Review of the clinical exam, radiologic findings and operative treatment of common wrist conditions treated with wrist arthroscopy Ομιλία στο Σεμινάριο Χειρουργικής του Χεριού, Ιωάννινα 30 Οκτ- 1 Νοε, 2014. "Ανασκόπηση της Αρθροσκόπησης στο Χέρι".

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

5. MRI 1,5T
• Fairly accurate in
interosseous lig. &
TFCC tears
• SL lig.:
– 70% sensitivity
– 90% specificity
– 85% accuracy
• TFCC: worse

6. MRI 3,0Τ
• Accuracy
improved but far
from excellent

7. 1.Diagnostic

8. 2.TFCC Lesions –
DRUJ instability

9. 3. Wrist Instability-
SL LT lesions

10. 4. Bony Procedures
Wafer- Styloidectomy- PCR

11. 5.Dorsal Ganglion
Resection

12. 6.Synovectomy-
Washout - Arthrolysis

13. 7. Fractures
Distal Radius- Scaphoid

14. #1. Radial-sided wrist pain

15. Radial-sided pain DD
Scaphoid fracture
SL lig. tear
Kienbock’s
AVN Scaphoid/ Preiser’s
CMC arthritis
Occult ganglion cyst
Metacarpal boss
Radiocarpal impingement

16. ScaphoLunate instability
Scapholunate ballottment test
Anatomic snuffbox synovial irritation
Watson’s test Wrist flexion- finger extension maneuver

17. Anatomic snuffbox= synovial irritation

18. Dorsal SL- lunate pain

19. Watson’s test

20. X-rays 1: True PA view
900 -900 position

21. X-rays 1: True PA view
• SL gap> 2-3mm
(static instability)
• “Shortened” scaphoid
• Cortical ring sing

22. X-rays 2: Pronated grip view
1. Dynamic SL diastasis
2. Ulnocarpal Impingement
3. Ulnar Variance measurements

23. X-rays 2: Pronated grip view
NEUTRAL GRIP
Dynamic SL instability

24. X-rays 3: Comparative
Dynamic SL instability

26. Radiocarpal Arthroscopy
• Always Probe the SL lig.

27. Geissler classification
Type I
L S

28. Geissler classification
Type II
L S

29. Geissler classification
Type III
L S

30. Geissler classification
Type IV
C
L S

31. Geissler classification
Type IV

32. Mid-carpal Arthroscopy
• Essential for accurate staging

33. Mid-carpal Arthroscopy
• Essential for accurate staging

34. SL lig. lesions
• Staging
• Management
•Δυναμική Αστάθεια
•Στατική Αστάθεια
•Αρθρίτιδα (SLAC)
3mo
ACUTE
Good Healing Potential
CHRONIC
Poor Healing Potential

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

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

37. E V O L V I N G C O N C E P T S
Acute, Geissler III, IV
C
L S L S
• Attempts at arthroscopically-assisted direct repair
Del Piñal, JHS(A) 2011

38. Chronic, Geissler I, II
L S L S
• Arthroscopic debridement & pinning

39. Chronic, Geissler I, II
• Thermal shrinkage & pinning
L S L S
Darlis & Sotereanos, JHS(A), 2005

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

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

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

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

44. #2. Ulnar-sided wrist pain

45. Ulnar-sided pain DD
TFCC tear
LT lig. tear
DRUJ arthritis
Fracture/ Non-union Ulnar styloid
Ulnocarpal Impaction Syndrome
ECU tendinitis/ instability
Fracture hamate
Pisiform arthritis
Unlar artery thrombosis
Ulnar n. compression Guyon’s
Superficial Ulnar n. neuritis

46. Fovea sign
TFCC lesion

47. TFCC lesion
TFCC impaction
test
Nakamura/ ulnocarpal stress test

48. Volar & Dorsal RU lig.- Foveal attachment

50. DRUJ instability: clinical exam unreliable
Radioulnar ballottement test
(Neutral- pronation- supination) DRUJ compression test
Piano- Key sign
ECU subluxiation in supination-ulnar
deviation

51. LT instability
LT ballottement/ Reagan’s test Kleinman’s shear test (LT)

52. X-rays : Pronated grip view

53. X-rays : Pronated grip view
•Unlocarpal impaction syndrome
•Ulnar variance measurements

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

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

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

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

58. 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

59. MRI

60. Arthroscopic Wafer procedure
• Preferred when modest shortening needed

61. Open Ulna Recession Procedures
• Several options…

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

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

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

65. Usual location of peripheral tears
Dorsal

66. Usual location of peripheral tears

67. The Iceberg Concept Atzei &Lucetti 2011

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

69. Foveal attachment involvement
• Clinical DRUJ instability
• Fracture through the fovea
• MRI findings
• Arthroscopic findings
– Positive Hook Test
– Direct Foveal Portal
Arthroscopy

70. Hook test

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

72. REPAIR TO CAPSULE

73. REPAIR TO CAPSULE

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

75. REATTACH TO FOVEA
2. All Arthroscopic, Knotless: Geissler

77. TFCC
ACC 6R
6R

78. TFCC
ACC 6R
6R

79. TFCC
ACC 6R
6R

81. TFCC
ACC 6R
6R

82. TFCC
ACC 6R
6R

84. 3. Distal Radius Fracture

85. Arthroscopically assisted reduction
• Consider in young, high demand patients
• Currently indicated in selected injuries:
– Radial styloid Fx
– Die Punch Fx
– Three & Four part Fx
–DRUJ instability or interosseous lig tear
• No metaphyseal comminution

86. 1. Radial styloid

87. 1. Radial styloid

88. 1. Radial styloid

89. 1. Radial styloid

90. 1. Radial styloid

91. 1. Radial styloid

92. 2. Die punch 2. die punch

93. 3. Three & Four part fractures

94. 3. Thr3e.e T &h rFeoeu r& p aFrotu frra pcaturrte fsractures

95. 3. Thr3e.e T &h rFeoeu r& p aFrotu frra pcaturrte fsractures

96. 3. Thr3e.e T &h rFeoeu r& p aFrotu frra pcaturrte fsractures

97. 3. Thr3e.e T &h rFeoeu r& p aFrotu frra pcaturrte fsractures

98. 3. Thr3e.e T &h rFeoeu r& p aFrotu frra pcaturrte fsractures

99. 3. Thr3e.e T &h rFeoeu r& p aFrotu frra pcaturrte fsractures

100. 3. Thr3e.e T &h rFeoeu r& p aFrotu frra pcaturrte fsractures

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

102. European Wrist
Arthroscopy Society

103. www.geap.org

104. Thank You
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