State-of-the-art in wrist arthroscopy use for SL and TFCC repair. Detailed outline of options, indications and techniques

1. Wrist Arthroscopy
Clinical applications
Nickolaos A. Darlis, MD, PhD
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3. Wrist Arthroscopy
Clinical applications
Nickolaos A. Darlis, MD, PhD
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4. 1.Diagnostic

5. 2.TFCC Lesions –
DRUJ instability

6. 3. Wrist Instability-
SL LT lesions

7. 4. Bony Procedures
Wafer- Styloidectomy- PCR

8. 5.Dorsal Ganglion
Resection

9. 6.Synovectomy-
Washout - Arthrolysis

10. 7. Fractures
Distal Radius- Scaphoid

11. ScaphoLunate lig.
managment

12. SL lig. lesions
• Acute
•Δυναμική Αστάθεια
• Chronic (>3 mo) •Στατική Αστάθεια
•Αρθρίτιδα (SLAC)
• Staging
• Management

13. Geissler classification
Type I
L S

14. Geissler classification
Type II
L S

15. Geissler classification
Type III
L S

16. Geissler classification
Type IV
C
L S

17. Geissler classification
Type IV

18. Acute, Geissler I L S
• Immobilize (in supination?)

19. Acute, Geissler II, III L S L S
• Arthroscopic reduction, K-wire stabilization

20. C
Acute, Geissler III, IV L S L S
• Open reduction, Repair

21. EVOLVING CONCEPTS C
Acute, Geissler III, IV L S L S
• Attempts at arthroscopically-assisted direct repair
Del Piñal, JHS(A) 2011

22. Chronic, Geissler I, II L S L S
• Arthroscopic debridement, thermal shrinkage
Darlis & Sotereanos, JHS(A), 2005

23. C
Chronic, Geissler III, IV L S L S
Dynamic Instability
• Open treatment: Capsulodesis, partial wrist arthrodesis,
tendodesis, ligament reconstruction

24. C
Chronic, Geissler III, IV L S L S
Dynamic Instability
• Aggressive arthroscopic debridement,
percutaneous pinning
Darlis & Sotereanos, JHS(A), 2006

25. C
Chronic, Geissler III, IV L S L S
Static Instability/Arthritis
• Open treatment: Capsulodesis, partial wrist arthrodesis,
tendodesis, wrist arthrodesis

26. C
Chronic, Geissler III, IV L S L S
Static Instability
• Arthroscopic Reduction and Association of the Scaphoid
and Lunate (RASL) Aviles et al, Arthroscopy, 2007

27. TFCC - Ulnocarpal Impaction
managment

28. TFCC 3-D structure Nakamoura T et al, 1996

29. The Hammoc paradigm
Nakamoura T et al 1996

31. Volar & Dorsal RU lig.-Deep bundle

32. The Iceberg Concept Atzei &Lucetti 2011

33. Palmer Classification
Class 1: Traumatic Injuries
A Central perforation of the disk proper
B Peripheral avulsion from the ulna
Without styloid fracture
With styloid fracture
C Distal avulsion from the carpus
D Radial avulsion
Without sigmoid notch fracture
With sigmoid notch fracture
Class 2: Degenerative Injuries
A TFCC wear
B TFCC wear + lunate and/or head chondromalacia
C TFCC perforation + lunate and/or head chondromalacia
D TFCC perforation + lunate and/or head chondromalacia +
lunotriquetral ligament perforation
E TFCC perforation + ulnocarpal arthritis

34. Palmer Classification
• Traumatic (Class 1)
• Degenerative (Class 2)- associated with
ulnocarpal impaction syndrome

35. Tear location
Radial tear Central tear
Peripheral tear)
Deep bundle
of TFCC
radius Volar radioulnar
ulna lig.
N.D

36. 1. Central TFCC lesions
• Poorly vascularized- healing potential minimal
• Arthroscopic debridement up to 2/3 of articular disc

37. 1. Central TFCC lesions
Arthroscopic TFCC debridement using radiofrequency probes
Darlis NA & Sotereanos DG, JHS(B)2005

38. 1. Central TFCC lesions
• Often degenerative and associated
with ulnocarpal impaction
syndrome
• Ulnar recession procedure to
prevent symptom recurrence

39. Ulnocarpal Impaction Syndrome
Clinical features:
• Ulnar sided wrist pain
• Associated degenerative changes:
– Ulnar side of the lunate
– Radial side of the ulnar dome
– TFCC central tear
– Triquetrum- LunoTriquetrum lig.
• Usually positive or neutral ulnar variance

40. Pronated Grip View Radiographs

41. MRI

42. Arthroscopic Wafer procedure
• Preferred when modest shortening needed

43. Open Ulna Recession Procedures
• Several options…

44. Open Ulna Recession Procedures
Another approach: Keep it simple…
• Step-Cut Ulnar Shortening Osteotomy
Darlis& Sotereanos JHS(A),
2005

45. 2. Radial TFCC tears
• Repair or debridement?

46. 2. Radial TFCC tears
• Repair if:
– VRUL or DRUL are involved
– DRUJ instability

47. 3. Peripheral (ulnar) TFCC tears
• Well vascularized
• Repairable

48. Usual location of peripheral tears
Dorsal

49. Common misconceptions
• TFCC tear ≠ DRUJ instability
– In fact: most tears do not have evident instability
• Ulnar styloid fracture ≠ DRUJ instability
– Styloid fractures may co-excist with TFCC tears

50. Timing of the repair
0 6 months 1 year
ACUTE SUBACUTE CHRONIC
Good Healing Potential Unpredictable Poor Healing Potential
3mo 6mo

51. 3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE OR REATTACH TO FOVEA
TFCC TFCC

52. 3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
OR
REATTACH TO FOVEA

53. REPAIR TO CAPSULE
• Arthroscopic or arthroscopic assisted repairs
– Inside-out
– Outside-in
– All inside
– Specialized Kits

54. REPAIR TO CAPSULE
• All inside repairs favored
– minimize risk of nerve or tendon injury

55. REPAIR TO CAPSULE
FasT-Fix® repair
© 2007 Arthroscopy Association of North America

56. REPAIR TO CAPSULE
6R
TFCC

57. REPAIR TO CAPSULE
6R
TFCC

58. REPAIR TO CAPSULE
6R
TFCC

59. REPAIR TO CAPSULE
6R
TFCC

60. REPAIR TO CAPSULE
6R
TFCC

61. REPAIR TO CAPSULE
6R
TFCC

62. REPAIR TO CAPSULE
6R
TFCC

63. REPAIR TO CAPSULE
6R
TFCC

64. REPAIR TO CAPSULE
6R
TFCC

65. REPAIR TO CAPSULE

66. REATTACH TO FOVEA
Indications:
• DRUJ instability
• Fracture through the fovea
• MRI findings
• Arthroscopic findings
– Positive Hook Test
– Direct Foveal Portal Arthroscopy

67. REATTACH TO FOVEA
1. Mini open: Sotereanos
Incision
EDM ECU
U
Chou, Sarris, Sotereanos, JHS(B), 2003
Chou, Sarris, Sotereanos JHS(B), 2003

68. REATTACH TO FOVEA
2.Mini open –Arthroscopic Assisted: Atzei- Luchetti

69. REATTACH TO FOVEA
2.Mini open –Arthroscopic Assisted: Atzei- Luchetti

70. REATTACH TO FOVEA
3. Arthroscopic Assisted (Transosseous): Nakamura
© 2011 Arthroscopy Association of North America

71. REATTACH TO FOVEA
4. All Arthroscopic, Knotless: Geissler

72. 1-2 3-4 4-5 6R ACC 6
R 6U

73. REATTACH TO FOVEA
ACC 6R
6R
TFCC

74. REATTACH TO FOVEA
ACC 6R
6R
TFCC

75. REATTACH TO FOVEA
ACC 6R
6R
TFCC

76. REATTACH TO FOVEA
ACC 6R
6R
TFCC

77. REATTACH TO FOVEA
ACC 6R
6R
TFCC

78. REATTACH TO FOVEA
ACC 6R
6R
TFCC

79. REATTACH TO FOVEA
ACC 6R
6R
TFCC

80. REATTACH TO FOVEA
ACC 6R
6R
TFCC

81. REATTACH TO FOVEA
ACC 6R
6R
TFCC

82. REATTACH TO FOVEA
ACC 6R
6R
TFCC

83. REATTACH TO FOVEA
ACC 6R
6R
TFCC

97. EVOLVING CONCEPTS
ASSH 2011
• Safe and effective in children (71 scopes)
• Common reasons for re-operation 14/237
– Unrecognized DRUJ instability (5)
– Unrecognized dynamic ulnar impaction (5)
– Unrecognized need for radial styloidectomy (2)
– Unrecognized SLl lig tear (2)

98. Wrist Arthroscopy complications
6% in 9185 procedures
Inability to complete procedure 20%
(ganglion excision, TFCC repair)
Nerve Lesions 10%
(Radial and Ulnar n. sensory branches)
Chondral lesions 9%
CRPS 8.5%
Traction- Potitioning 8.5%
(oedema, neurapraxia, stiffness)
Loose bodies 5%
2008, Caroline Leclercq, MD & the European Wrist Arthroscopy Society

99. European Wrist
Arthroscopy Society

100. Thank you
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