This document discusses wrist arthroscopy techniques and indications. It covers management of scapholunate ligament injuries, triangular fibrocartilage complex tears, and distal radius fractures. Key points include: - Arthroscopic debridement and repair are used for acute vs chronic scapholunate ligament injuries. - Central triangular fibrocartilage complex tears are debrided while peripheral tears can be repaired arthroscopically or openly. - Ulnocarpal impaction syndrome is treated with wafer resection or ulna shortening osteotomy. - Arthroscopy can aid reduction and detection of injuries for some distal radius fractures.

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

2. Current indications

3. Current indications

4. Current indications

5. Current indications

6. Current indications

7. Current indications

8. Current indications

9. Current indications

10. SL lig. management
TFCC management
Ulnocarpal impaction
Distal Radius Fractures

11. SL lig. lesions
• Acute
•Δυναμική Αζηάθεια
• Chronic (>3 mo)
•Σηαηική Αζηάθεια
•Αρθρίηιδα (SLAC)
• Staging
• Management

12. Geissler classification
Type I
L S

13. Geissler classification
Type II
L S

14. Geissler classification
Type III
L S

15. Geissler classification
Type IV
C
L S

16. Geissler classification
Type IV

17. Acute, Geissler I L S
• Immobilization

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

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

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

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

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

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

24. SL lig. management
TFCC management
Ulnocarpal impaction
Distal Radius Fractures

25. TFCC
• Load transmission across
ulnar wrist
• DRUJ stabilization

26. TFCC and wrist arthroscopy

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

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

29. TFCC tears
Pre-styloid recess

30. EVOLVING CONCEPTS
Volar & Dorsal RadioUlnar lig.
1. VRUL, DRUL major contributors to DRUJ stability

31. EVOLVING CONCEPTS
Deep Bundle
2. Deep bundle of TFCC attaching to ulnar fovea crucial
for DRUJ stability

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

33. 1. Central TFCC lesions

34. 1. Central TFCC lesions
• Head of ulna should be visible through the defect
• Remove all residual tissue attaching to the radius
Arthroscopic TFCC
debridement using
radiofrequency probes
Darlis NA & Sotereanos
Darlis & Sotereanos, JHS(A), 2005 DG, JHS(B)2005

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

36. 2. Peripheral (ulnar) TFCC tears
• Well vascularized
• Repairable

37. 2. Peripheral TFCC tears
Often associated with DRUJ instability: repair
• Arthroscopic
• Open

38. 2. Peripheral TFCC tears
• Arthroscopic repair (to capsule)
– Inside-out
– Outside-in
– All inside
– Specialized Kits

39. EVOLVING CONCEPTS
Peripheral TFCC tears
FasT-Fix® repair
© 2007 Arthroscopy Association of North America

40. 2. Peripheral TFCC tears
• Open Repair
– to capsule
– “Anatomic” reattachement to ulnar fovea
currently favored if DRUJ instability
Incision
EDM ECU
U
Chou & Sotereanos
JHS(B), Chou, Sarris, Sotereanos, JHS(B), 2003
2003

41. EVOLVING CONCEPTS
Peripheral TFCC tears
Arthroscopic-assisted anatomic repair
© 2011 Arthroscopy Association of North America

42. 3. Radial TFCC tears
• Repair or debridement?

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

44. 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

45. Pronated Grip View Radiographs

46. MRI

47. Arthroscopic Wafer procedure
• Preferred when modest shortening needed

48. Open Ulna Recession Procedures
• Several options…

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

50. Technique
SL lig. management
TFCC management
Ulnocarpal impaction
Distal Radius Fractures

51. Wrist arthroscopy in distal radius Fx
Concomitant lesions increasingly recognized:
• ΤFCC ≈60% (43-78%)
• SL lig.≈ 40% (32-75%)
• LT lig. ≈20% (15-61%)
• Chondral lesions ≈20% (19-32%)

52. Arthroscopically assisted reduction
• Currently indicated in selected injuries
– Radial styloid Fx
– Die Punch Fx
– Three & Four part Fx
– DRUJ instability
Especially in young, high demand patients

53. 1. Radial styloid

54. 2. die punch

55. 3. Three & Four part fractures

56. Arthroscopically assisted reduction
• better results than both ORIF and fluoroscopically
assisted fixation in the mid-term
Doi et al, JBJS(A), 1999
Ruch et al, Arthroscopy 2004
Varitimidis et al, JBJS(B), 2008

57. Arthroscopically assisted reduction
• Attribute results to better reduction or early
detection of lig. & TFCC lesions?
• Long term effect on post-traumatic arthritis
still unknown
• Need for routine TFCC repair unproven

58. Arthroscopically assisted reduction
TFCC repair if:
• DRUJ unstable
• Young active patient

59. EVOLVING CONCEPTS
“Dry” arthroscopy
Courtesy: Francisco del Piñal, MD

60. EVOLVING CONCEPTS
Dorsal ganglion cysts
• Technique
– 6R viewing portal
– Current trends away from portal
through the ganglion
• Direct stalk visualization rare; New aids
– Dye for stalk identification
– Combined ultrasound & arthroscopy
• Mathulin: 114 cases with min f-up of 2 years
– recurrence rate 12.3%

61. 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)

62. 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

63. European Wrist
Arthroscopy Society

64. www.geap.org

65. Thank you