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Comparative Outcome Analysis of Arthroscopic-Assisted Versus Open Reduction and Fixation of Trans-scaphoid Perilunate Fracture Dislocations
Comparative Outcome Analysis of ArthroscopicAssisted Versus Open Reduction and Fixation of Trans-scaphoid Perilunate Fracture Dislocations Won-Taek Oh, M.D., Yun-Rak Choi, M.D., Ph.D., Ho-Jung Kang, M.D., Ph.D., Il-Hyun Koh, M.D., Ph.D., and Kyung-Han Lim, M.D.
Purpose: To compare union rates and clinical and radiological outcomes of arthroscopic-assisted reduction and fixation with those of open reduction and fixation in patients with trans-scaphoid perilunate fracture dislocations. Methods: This retrospective study included consecutive patients with trans-scaphoid PLFDs who underwent arthroscopic-assisted reduction and fixation (group A) or open reduction and fixation (group O), and who were followed up for a minimum of 2 years between May 2005 and March 2013. We excluded initially missed patients. Each different surgeon who was on call had performed each experienced operation. These clinical outcomes were assessed: range of motion, grip strength, Mayo wrist score, and Disabilities of Arm, Shoulder, and Hand (DASH) score. For radiologic outcomes, the scapholunate angle, radiolunate angle, and lunotriquetral distance were measured. Results: The total number of included patient was 20 (11 in group A and 9 in group O). Scaphoid union occurred in all patients except 1 individual (11 of 11 in group A, and 8 of 9 in group O). At the last follow-up, the mean flexion-extension arc was significantly greater in group A (125.0 ) than in group O (105.6 ) (P ¼ .028). The mean grip strength was 81.1% that of the contralateral side in group A and 80.9% in group O (P ¼ .594). The mean Mayo wrist score was 85.5 in group A and 79.4 in group O (P ¼ .026), and the mean DASH score was 10.6 in group A and 20.8 in group O (P ¼ .001); however, only the DASH score showed a minimum clinically important difference. The mean scapholunate angle, radiolunate angle, and lunotriquetral distance were similar between the 2 groups: 47.2 , 1.7 , and 2.0 mm in group A and 48.8 , 5.6 , and 2.1 mm in group O, respectively. Conclusions: Although both arthroscopic and open techniques achieved stability of the injured wrists in patients with trans-scaphoid PLFDs, it is shown that the arthroscopic-assisted technique showed a clinically meaningful better DASH score and greater flexion-extension arc with other parameters being similar. Level of Evidence: Level III, retrospective comparative study.
T
rans-scaphoid perilunate fracture dislocations (PLFDs) are among the most complex carpal injuries and involve severe disruption of carpal bone alignment.1-3 Early treatment of these injuries is necessary to prevent devastating complications, such as chronic carpal instability and eventual post-traumatic arthritis. Although closed treatment was historically advocated, several studies have reported that closed reduction and immobilization alone results in From the Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received January 27, 2016; accepted July 11, 2016. Address correspondence to Yun-Rak Choi, M.D., Ph.D., Department of Orthopedic Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/1677/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.07.018
nonunion of the scaphoid, intercalary segmental instabilities, and unfavorable wrist arthritis.4-6 Although studies comparing conservative treatment with open treatment have shown consistently better results with operative fixation,7,8 the trend has been toward anatomic reduction and repair of the ligamentous and osseous structures with early open reduction and internal fixation.1,4,9-11 Despite the superiority of open treatment over closed treatment for trans-scaphoid PLFDs, diminished wrist function seems to be inevitable.3,9,12 Previous studies have shown that the flexion-extension arc of the effected wrist decreased to between 57% and 75% compared with the contralateral side.1,4,9-11,13,14 This may be attributed to fibrosis of the injured joint being promoted by the addition of surgical trauma to the severely injured capsular and ligamentous structures.3,11,12 Recently, arthroscopic-assisted reduction and fixation of trans-scaphoid PLFDs has been used as an alternative to open surgery, introducing the potential advantages
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of minimal invasiveness. Several authors have shown that the arthroscopic method allows anatomical reduction of intercarpal alignments, maintains carpal stability, and results in more than 80% wrist motion compared with the contralateral wrist.12,15 However, there are lack of studies comparing arthroscopicassisted surgery with open surgery. The purpose of the current study was to compare union rates and clinical and radiological outcomes of arthroscopic-assisted reduction and fixation with those of open reduction and fixation in patients with transscaphoid PLFDs. The authors hypothesized that arthroscopic-assisted repair would achieve better wrist motion and function postoperatively than open anatomical repair.
Methods We retrospectively reviewed the records of all patients who met the following criteria between May 2005 and March 2013: (1) acute (<1 week) trans-scaphoid PLFD who underwent arthroscopic-assisted or open reduction and fixation; and (2) followed up for a minimum of 2 years. Patients fulfilling the following criteria were excluded: (1) initially missed trans-scaphoid PLFDs; (2) trans-scaphoid, transcapitate PLFDs; (3) concomitant fractures or dislocations of the ipsilateral elbow or shoulder; (4) major central or peripheral nervous system injury at the time of injury; (5) any previous surgery on the involved wrist; and (6) inadequate follow-up (<24 months). One of the 2 surgeons (Y-R.C., H-J.K.) who was on call had performed an operation in turn. Both of them were experts in the field of the hand surgery. One of them (Y-R.C.) had experience in arthroscopic-assisted reduction and fixation, and he had performed arthroscopic surgery during the study period. The other (H-J.K.) had experience in open reduction and fixation, and he had carried out open surgery during the same period. The patients who underwent arthroscopicassisted surgery were classified as group A, and those who underwent open surgery were classified as group O. Our institutional review board approved the study and waived the requirement for informed consent. Surgical Technique The closed reduction was attempted and successful in the emergency department using the technique described by Jones.16 In the operation room, however, these injuries were so unstable that closed reduction should be repeated immediately before operation in cases of the redislocation. All operations were conducted while the patients were receiving general anesthesia. With the patient in the supine position, the arm was prepped and draped on a hand table. A pneumatic tourniquet and Esmarch bandage were used to exsanguinate the arm.
In group A of arthroscopic-assisted reduction and fixation (Fig 1), the patient’s arm was suspended in an Arc Wrist Tower (Acumed, Hillsboro, OR) with 5 to 8 kg of traction after placing the index, middle, and ring fingers in finger traps. A 3-4 portal, 6-R portal, and midcarpal ulnar portal were created sequentially, and a 1.9-mm video arthroscope was introduced through each portal. While using the midcarpal ulnar portal as the viewing portal, a scaphotrapeziotrapezoidal portal or midcarpal radial portal (depending on the level of the scaphoid fracture) was created under direct vision as the working portal to facilitate the approach. Bone or cartilage fragments, as well as frayed edges of torn intrinsic or extrinsic ligaments that interrupted reduction, if present, were thoroughly debrided or removed to facilitate reduction of the scaphoid fracture or lunotriquetral joint. After releasing longitudinal traction, the scaphoid fracture was reduced with manipulation of the distal fragment using a probe or percutaneous joystick K-wire, under guidance from the arthroscopic and fluoroscopic images. Subsequently, a K-wire was inserted from the scaphoid tubercle and passed through the fracture site for temporary fixation. After the arthroscopy switched into the scaphotrapeziotrapezoidal or midcarpal radial portal, the lunotriquetral joint was reduced using the same method and pinned percutaneously from the ulnar side of the wrist, starting at a point dorsal to the pisiform and aiming in a slight proximal direction. To insert a guidewire for headless screw fixation of the scaphoid fracture, the arthroscope was introduced into the 6-R portal. The guidewire, inserted through a 15-G needle, was inserted percutaneously, proximal and ulnar to the 3-4 portal, to target the ideal starting point at the most proximal tip of the scaphoid pole, immediately adjacent to the insertion of the scapholunate interosseus ligament along the long axis of the scaphoid.17 After removal of the provisional K-wire, a 5-mm transverse incision was then made at the point of the prepositioned guidewire. A sharp straight hemostat was used to spread the soft tissue and pierce the dorsal capsule (proximal 3-4 portal). After reaming, a headless compression screw (either an HCS 3.0 [Synthes, Paoli, PA] or Acutrak mini screw [Acumed, Hillsboro, OR] system) was inserted over the guidewire to fix the scaphoid fracture. In group O of open reduction and fixation (Fig 2), a 5-cm longitudinal incision was created on the dorsal aspect of the wrist in line with Lister’s tubercle. Skin flaps were raised radially and ulnarly, and the incision was extended down to the extensor retinaculum. The retinaculum was divided in line with the third dorsal compartment, and the extensor pollicis longus tendon was identified distally and retracted radially. Only the distal 1 cm of the third compartment was released. The second and fourth compartments were then reflected
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Fig 1. Arthroscopic-assisted reduction and fixation for trans-scaphoid perilunate fracture dislocation (PLFD). (A) Posteroanterior and lateral views of the preoperative radiographs of a 29-year-old man showing a dorsal trans-scaphoid PLFD of the right wrist. (B, C) On the radial midcarpal view, the scaphoid fracture is shown after debridement of hematoma and interposed tissue (arrowhead), and anatomical reduction is performed (arrow). (D, E) On the scaphotrapeziotrapezoidal view, the lunotriquetral joint is reduced and transarticular K-wires are inserted. (F) The postoperative radiographs show proper fixation and normal carpal alignment. (Lu, lunate; Sc, scaphoid; Tq, triquetrum.)
off the dorsal capsule. A capsulotomy was created and extended longitudinally. Bone or cartilage fragments were removed from the joint and the joint was irrigated to remove any hematoma or other debris. The scaphoid fracture was reduced using percutaneous joystick K-wires, and the guidewire for headless screw fixation was introduced along the long axis of scaphoid. After reaming, a headless compression screw (either an HCS 3.0 [Synthes] or a Herbert mini screw [Zimmer, Warsaw, IN] system) was inserted over the guidewire. Then, the lunotriquetral joint was reduced and pinned percutaneously from the ulnar side of the wrist. The capsulotomy incision was closed with absorbable 2-0 or 3-0 sutures in an interrupted fashion. The retinaculum was repaired, leaving the extensor pollicis longus free distally but still within its compartment proximally. The skin was then closed with nylon sutures. After the operation, a sugar-tong splint was placed, with the wrist and forearm in the neutral position. All patients were encouraged to initiate immediate digital
exercises to reduce swelling. At the first postoperative visit 2 weeks after surgery, a well-molded short arm cast that held the wrist in a functional position was fashioned and worn for 6 to 8 additional weeks. The short arm cast and K-wires transfixing the lunotriquetral joint were removed at 6 to 8 weeks postoperatively and then active-assisted wrist movement exercises were encouraged. Clinical and Radiologic Assessments The preoperative evaluation consisted of plain radiographs of the wrist, including true posteroanterior, lateral, posteroanterior with ulnar deviation, and oblique with 45 pronation views. Postoperatively, all patients underwent regular follow-up visits in our outpatient clinic at 2 weeks, 8 to 10 weeks, 6 months, and 1 year after surgery, and then annually thereafter. The same 4 radiographic views of the wrist as in the preoperative evaluation were obtained at each followup visit.
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Fig 2. Open reduction and fixation for trans-scaphoid perilunate fracture dislocation (PLFD). (A) Posteroanterior and lateral views of the preoperative radiographs of a 46-year-old man showing a dorsal trans-scaphoid PLFD of the left wrist. (B) Approaching on the dorsal aspect of the wrist, the extensor pollicis longus tendon (asterisk) is retracted radially, and the scaphoid fracture is shown with a displacement (arrow). (C) The postoperative radiographs show proper fixation and normal carpal alignment. (D-F) The radiological measurements after 2 years postoperatively identify (D) 2.0 mm of lunotriquetral distance, (E) 56.0 of scapholunate angle, and (F) 4.6 of radiolunate angle. (Sc, scaphoid.)
One observer (K-H.L.) who was not involved in the treatment performed all of the clinical and radiological assessments. Bony union was determined by disappearance of the discontinuity and gap in the scaphoid on plain radiographs, and resolution of tenderness on physical examination. Clinical outcomes were evaluated by active range of motion (ROM) of the wrists, grip strength, Modified Mayo Wrist Score (MWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score. Active flexion extension arc (FEA) and radial and ulnar deviation arc were measured using a hand-held goniometer. Grip strength was measured using a JAMAR hydraulic dynamometer (Asimov Engineering, Los Angeles, CA). MWS is a commonly used wrist rating system.14 The total score ranges from 0 to 100 points, with higher scores indicating a better result. This system consists of 4 categories: pain (25 points), active FEA as a percentage of the opposite side (25 points), grip strength as a percentage of the opposite side (25 points), and the ability to return to regular employment or
activities (25 points); depending on the number of points scored, the outcome is classified as excellent (91-100), good (80-90), fair (65-79), or poor (<65). The DASH questionnaire, a self-reported questionnaire introduced by Davis et al.,18 contains 30 items: 21 questions that assess difficulties with specific tasks, 5 questions that evaluate symptoms, and 4 questions that evaluate social function, work function, sleep, and confidence. The DASH score ranges between 0 and 100, with higher scores representing greater upper extremity disability. For the radiologic assessment, the scapholunate angle (SLA), radiolunate angle (RLA), and lunotriquetral distance (LTD) were measured on radiographs obtained immediately after surgery and at the last follow-up. The SLA was defined as the angle between the scaphoid axis drawn tangentially to the volar proximal and distal borders of the scaphoid and the lunate axis drawn perpendicularly to a line connecting the volar and dorsal poles of the lunate. The RLA was defined as the angle between the lunate axis
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Results
52.4 ) in group O, and mean extension was 64.5 10.4 (95% CI, 64.3 to 64.7 ) in group A and 53.3 10.9 (95% CI, 53.1 to 53.5 ) in group O. The FEA was 125 17.5 in group A and 105.6 18.8 in group O. Patients in group A exhibited significantly better flexion, extension, and FEA at the last follow-up than patients in group O (P ¼ .047, P ¼ .03, and P ¼ .028, respectively) (Table 2). The mean MWS and DASH score were 85.5 5.7 (95% CI, 84.5-86.5) and 10.6 5.0 (95% CI, 10.5-10.7), respectively, at the last follow-up in group A and 79.4 5.3 (95% CI, 79.3-79.5) and 20.8 5.4 (95% CI, 20.7-20.9), respectively, in group O. The MWS and DASH score of group A were significantly better than those of group O (P ¼ .026 and P ¼ .001, respectively) (Table 2). Radiologic values of SLA, RLA, and LTD were similar between the 2 groups. Four patients in group A and 3 patients in group O exhibited midcarpal arthritis on radiographs at the last follow-up; the rates did not differ between the 2 groups (Table 2). However, patients with or without arthritis had similar FEA, MWS, and DASH scores at the last follow-up (P ¼ .874, .432, and .777, respectively).
Thirty-three patients underwent arthroscopic-assisted or open reduction and fixation for acute trans-scaphoid PLFDs at 2 different tertiary hospitals between May 2005 and March 2013. Thirteen patients were excluded based on exclusion criteria; thus 20 patients were included in the study: 11 underwent arthroscopicassisted reduction and fixation (group A) and 9 underwent open reduction and fixation (group O). All patients included in this study were male. The mean time from injury to operation was 1.1 days (range, 0-3 days) in group A and 1.0 day (range, 0-3 days) in group O. The mean age at the time of surgery was 30.1 years (range, 20-39 years) in group A and 32.1 years (range, 24-38 years) in group O. The mean follow-up period after surgery was 50 months (range, 24-72 months) in group A and 44.7 months (range, 24-90 months) in group O. The surgery involved the dominant arm in 54.5% (6 of 11) of the group A patients and 44.4% (4 of 9) of the group O patients (Table 1). The scaphoid fractures united in 95% (19 of 20) of the patients after surgery. One patient in group O failed to achieve union and eventually underwent cancellous bone grafting and fixation with 2 headless compression screws 5 years after the initial surgery (the delay was due to the patient being lost to follow-up postoperatively). This later procedure was successful, resulting in union. The overall union rate did not differ significantly between group A (100%; 11 of 11) and group O (89%; 8 of 9) (Table 2). At the last follow-up evaluation, mean flexion was 60.5 8.2 (95% confidence interval [CI], 60.3 to 60.7 ) in group A and 52.2 9.1 (95% CI, 52.0 to
Our study showed that the FEA, MWS, and DASH score were statistically significant better outcomes after arthroscopic-assisted reduction and fixation for patients with acute trans-scaphoid PLFDs than those after open reduction and fixation at the last follow-up; however, union rate, grip strength, and radiographic values (SLA, RLA, LTD, and midcarpal arthritis) were similar. Although anatomic reduction and repair of the ligamentous and osseous structures with early open reduction and internal fixation is the current trend for treating trans-scaphoid PLFDs,1,4,9-11 diminished wrist function seems to be a common consequence after this treatment.3,9,12 Recently, arthroscopic-assisted reduction and fixation, with its potential benefits of minimal invasiveness, has shown promising results with respect to wrist motion and function in patients with transscaphoid PLFDs.12,15 However, data comparing arthroscopic-assisted surgery with open surgery are lacking. The purpose of this study was to compare union rates and clinical and radiological outcomes in patients with the trans-scaphoid PLFDs treated with either open reduction and fixation or arthroscopicassisted reduction and fixation. Our results showed that the arthroscopic-assisted technique appears to produce better joint movement and function in patients with trans-scaphoid PLFDs, although both techniques achieved stability of the injured wrists. Previous studies have reported differing union rates after operative treatment of trans-scaphoid PLFDs. In a retrospective study of perilunate dislocations (PLDs) or PLFDs treated by closed repair with external fixation
and the longitudinal axis of the radius.19 Midcarpal arthritis and radiocarpal arthritis were identified on the radiographs according to the system of Knirk and Jupiter.20 Operation-related complications (nerve injury, postoperative infection, etc.) were also reviewed and recorded. No patient was recalled to our institution specifically for this study, as all data were obtained from the medical records. There were no missing data. Statistical Analysis Data are presented as mean standard deviation unless otherwise indicated. Statistical analysis was performed using R software (Version 3.2.2; R Foundation for Statistical Computing, Vienna, Austria). The Wilcoxon rank-sum test or Cochran-Armitage trend test was applied for between-group comparisons of continuous or ranked data, such as ROM, grip strength, MWS, and DASH scores. The Fisher exact test was used to compare categorical data, such as demographic data or the presence of complications, between groups. Statistical significance was set at P < .05.
Discussion
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Kim et al.12 reported that in their retrospective study of arthroscopic reduction and fixation of 20 patients with a PLD or PLFD, the union rate was 83% (10 of 12) in the patients with trans-scaphoid PLFD, and all nonunion cases were fixed with K-wires. In the current study, we used headless compression screws to fix the scaphoid fractures regardless of the surgical technique, and we achieved scaphoid union in 95% of our patients with trans-scaphoid PLFD. This suggests that accurate reduction and stable fixation, rather than the method of surgery (arthroscopic-assisted or open approach), seem to be the key factors determining scaphoid union. Our union rate (95%) was higher than previous studies (71% to 83%). It is because we included only transscaphoid PLFDs excluding other types of PLFDs (transradial styloid, transcapitate, transtriquetrum, etc.), and we also excluded initially missed and delayed cases because of the study design. In addition, we used a headless compression screw instead of K-wires to achieve stable fixation of the scaphoid in both arthroscopic and open groups. The progressive development of headless compression screws, such as upgrade to the cannulated type, double threaded type, or small size preserving the same intensity, could affect better results. According to previous studies, arthroscopic-assisted surgery for trans-scaphoid PLFDs seemed to produce better range of flexion and extension in the injured wrist than open surgery. Souer et al.21 reported that the
Table 1. Patient Demographics Variables Age, yr Male/female, n Dominant/nondominant, n Injury mechanism, n Fall during sports Fall from a height Traffic accident Time from injury to operation, d Period of follow-up, mo
Group A (n ¼ 11) 30.1 6.8 11/0 6/5
Group O (n ¼ 9) 32.1 4.3 9/0 4/5
8 2 1 1.1 1.0
7 1 1 1.0 1.0
.873
50.0 16.0
44.7 24.6
.565
P Value* .449 1.000 1.000 1.000
NOTE. Continuous values are mean standard deviation. Group A: arthroscopic-assisted reduction and fixation; group O: open reduction and fixation. *P values are calculated using the Fisher test for categorical variables and the Wilcoxon rank sum test for continuous variables.
and percutaneous K-wires, Savvidou et al.6 reported a union rate of 71% (5 of 7 patients) for trans-scaphoid PLFDs. Souer et al.21 treated 18 patients with transscaphoid PLFDs by open methods, with K-wire fixation in 9 patients and screw fixation in the others. The union rate was 78% (7 of 9 patients) after screw fixation, and loss of stable reduction occurred in 78% (7 of 9 patients) in the K-wire fixation group. In their retrospective study of 30 patients with a PLD or PLFD treated by closed or open methods, Krief et al.9 reported a 77% (10 of 13) union rate for trans-scaphoid PLFDs.
Table 2. Clinical and Radiologic Outcomes at the Last Follow-up Variables Union, n Union time, wk Range of motion, Flexion Extension Radial deviation Ulnar deviation Flexion-extension arc, % Radial-ulnar deviation arc, % Grip strength, % MWS Excellent Good Fair Poor DASH score SLA, RLA, LTD, mm Arthritis, n
Group A 11/11 11.6 2.7
Group O 8/9 12.8 3.0
MD or OR (95% CI) e 0.3 (3.8 to 4.4)
8.2y 10.4y 6.9 3.8 7.8y 13.8 8.5 5.7y 6 4 1 0 10.6 5.0y 47.2 6.7 1.7 0.7 2.0 0.3 4/11
52.2 53.3 12.8 21.1 69.6 64.8 80.9 79.4
9.1 10.9 3.6 4.2 12.2 15.5 5.8 5.3 1 4 4 0 20.8 5.4 49.8 6.4 5.6 5.3 2.1 0.3 3/9
8.2 11.2 1.8 3.0 12.4 6.5 0.3 6.0
60.5 64.5 14.5 24.1 82.0 71.3 81.1 85.5
10.2 2.6 3.8 0.1 1.1
(0.1-16.3) (1.2-21.2) (3.3 to 6.9) (0.7 to 6.7) (3.0-21.9) (3.8 to 15.5) (6.1 to 7.9) (0.8-11.2) e e e e (5.3-15.1) (3.6 to 8.9) (0.4 to 10.4) (0.2 to 0.4) (0.1-11.1)
P Value* .450 .781 .047 .030 .833 .110 .013 .161 .594 .026 .023
.001 .391 .357 .433 1.000
NOTE. Continuous values are mean standard deviation. Percentage values are percentage of contralateral side. CI, confidence interval; DASH, Disabilities of Arm, Shoulder, and Hand; LTD, lunotriquetral distance; MD, mean difference; MWS, Mayo wrist score; OR, odds ratio; RLA, radiolunate angle; SLA, scapholunate angle. *P values are calculated by the Wilcoxon rank sum test for continuous values and by the Fisher test or the Cochran-Armitage trend test for categorical values. y P < .05.
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mean FEA was 71% of the contralateral side after open reduction and fixation in 9 patients with trans-scaphoid PLFDs. In Hildebrand et al.’s3 series, 22 patients with a PLD or PLFD achieved 57% of the contralateral FEA after open surgery. By contrast, Kim et al.12 reported that the mean FEA was 79% of the contralateral side after arthroscopic reduction and fixation. Similarly, Jeon et al.15 found in their retrospective study of arthroscopic surgery for 4 trans-scaphoid PLFDs that the mean FEA was 126 . The results of our current study support the impression obtained from previous reports, because the mean FEA in the arthroscopic group (125 , 82% of the contralateral side) was greater than that in the open group (105.6 , 70% of the contralateral side). Trans-scaphoid PLFDs are complex wrist injuries with severe disruption of surrounding soft tissues, such as capsules and interosseous ligaments. The open approach could add surgical injuries to these severely damaged soft tissues and thus aggravate capsular fibrosis, resulting in worse ROM than with the arthroscopic approach. Previous studies of arthroscopic surgery by Kim et al.12 and Jeon et al.15 reported the mean MWS values of 79 and 76, respectively. After open surgery, Souer et al.21 and Hildebrand et al.3 reported the mean MWS values of 66 and 71, respectively. Similarly, Krief et al.9 reported a mean MWS value of 70 at a minimum of 15 years of follow-up after open surgery. However, functional outcomes after open surgery varied from 63 to 81.14,22-24 In the current study, the mean MWS was significantly better after arthroscopic surgery (85.5) than after open surgery (79.4). DASH scores also showed significantly better outcomes after arthroscopic surgery (10.6) than after open surgery (20.8). These statistically significant differences in the MWS and DASH score between the 2 types of surgery seem to be at least partly based on the differences in mean ROM at the wrist joints between the 2 groups. However, as regards the minimum clinically important difference (MCID), only the DASH score showed a clinically significant difference. The MCID in DASH scores has been reported to range from 7 to 13.5,25-27 but there has been no report defining the MCID for MWS. The mean MWS after arthroscopic surgery of our study (85.5) was higher than those of previous studies (76-79). It is because we included only trans-scaphoid PLFDs excluding other types of PLFD, and these studies actually enrolled too small number of patients to discuss which shows better outcome than other. A remarkable thing is that results of studies of arthroscopic-assisted surgery generally presented better MWS than those of open surgery. On the basis of this trend of MWS and the clinical important difference of the DASH score, we speculated that arthroscopicassisted surgery shows better functional outcome than open surgery.
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Our radiologic results were within the normal range immediately after surgery and at the last follow-up, and these results are in close agreement with those of numerous other authors. In their study of closed methods, Savvidou et al.6 reported that the mean SLA was 49 (range, 48 to 64 ) and LTD was 1.8 mm (range, 1.3-2.2 mm) at the last follow-up. In Souer et al.’s21 study of surgery with repair of the lunotriquetral ligament, the mean SLA was 49 (range, 36 to 76 ) in the K-wire fixation group and 64 (range, 48 to 77 ) in the screw fixation group, at a mean follow-up of 44 months. In Krief et al.’s9 study of 30 patients with PLD or PLFD, 28 individuals underwent open surgery and 6 of the 28 open operations involved repair of the lunotriquetral ligament. The mean SLA, RLA, and LTD were 64 , 11 , and 1.6 mm, respectively, at a minimum of 15 years of follow-up. In the study of arthroscopic surgery by Kim et al.,12 the mean SLA was 55 (range, 48 to 64 ) and LTD was 1.8 mm (range, 1.3-2.2 mm). In trans-scaphoid PLFDs, the scapholunate interosseous ligament is usually preserved, so repairing this ligament seems to be unnecessary.1,12 By contrast, most clinicians believe that repair of the lunotriquetral interosseous ligament is required to maintain the stability of the proximal carpal row.1,8,28 However, we performed open or arthroscopic surgery without repair of the lunotriquetral interosseous ligament, and the joint was maintained by fixation with 1 or 2 transarticular Kwires. At the last follow-up, we detected no instability of the carpal row, and the radiologic outcomes of SLA, RLA, and LTD were within the normal range. Other studies of arthroscopic management for PLFDs, in which the lunotriquetral ligament was not repaired, also showed excellent outcomes, without carpal instability.12,15 These results suggest that with an acute injury of the lunotriquetral ligament, anatomical reduction and transarticular K-wire fixation without open repair might be sufficient to produce stable healing. In earlier studies of open surgery, the incidence of carpal arthritis ranged from 18% to 22% within 3 years after surgery and increased to 50% to 100% with follow-up periods of 6 to 13 years.3,4,9,13,21 In patients who underwent arthroscopic surgery, Kim et al.12 reported no carpal arthritis at a mean follow-up of 31.2 months. In our study, carpal arthritis was noted by radiologic examination after a mean follow-up period of 4 years in 36% of patients in the open surgery and 33% in the arthroscopic surgery; these rates were not significantly different between groups. Nevertheless, radiologic degenerative changes do not seem to be correlated with clinical outcomes. Hildebrand et al.3 found no statistical relation between the presence of midcarpal arthritis and clinical scores at the last followup. Likewise, Martinage et al.23 reported no correlation between radiologic and clinical outcomes. In the
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current study, we also found no correlation between radiologic carpal arthritis and clinical outcomes, and no secondary operation (such as carpectomy or arthrodesis) was required by any patient. However, longer follow-up is required to evaluate this issue because arthritis could worsen over time and eventually correlate with deteriorating clinical outcomes. Potential complications after wrist arthroscopy include local infection, injury to neurovascular structures (e.g., dorsal sensory branches of the radial and ulnar nerves or radial arteries), injury to extensor tendons and iatrogenic tendinopathy, and the development of a ganglion or complex regional pain syndrome. Previous complication rates ranged from 1.2% to 4.7%.29-31 Although we found no complications after arthroscopic management of trans-scaphoid PLFDs, our number of patients was too small to adequately assess the rates of relatively uncommon complications. Although complications during or after arthroscopic wrist surgery might be unusual, surgeons should be aware of these potential complications, to try to reduce their occurrence. Limitations Our study has several limitations. First, it included a small number of patients and had a low statistical power. That means this study had a chance of type II error with regard to the angles measured on radiographs and grip strength. Second, the selection bias of patient enrollment on each surgical technique could be raised. In our institution, 2 hand surgeons had equal duty days for emergency call and each patient was allocated based on which surgeon was on call. In addition, there could be another confounding factor for the experience of 2 different surgeons; however, they were fellowship trained and well experienced in the field of the hand surgery. Third, the follow-up period seems to be insufficient to determine whether there is a relation between the development of midcarpal arthritis and functional outcomes after surgery; long-term follow-up is required to evaluate this, as noted above. Fourth, all of our patients were male, although similar results may occur with females. Fifth, the design of this study was retrospective, and a prospective, randomized study comparing arthroscopy-assisted reduction and fixation with open reduction and fixation of trans-scaphoid PLFDs should be performed to confirm the efficacy of arthroscopy-assisted surgery. Sixth, we could not descript inter- and intraobserver reliability, because the radiographic values were measured by one observer. However, he was also an orthopeadic surgeon who was trained over 6 years.
Conclusions Although both arthroscopic and open techniques achieved stability of the injured wrists in patients with
trans-scaphoid PLFDs, it is shown that the arthroscopicassisted technique showed a clinically meaningful better DASH score and greater flexion-extension arc with other parameters being similar.
References 1. Weil WM, Slade JF III, Trumble TE. Open and arthroscopic treatment of perilunate injuries. Clin Orthop Relat Res 2006;445:120-132. 2. Green DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop Relat Res 1980;149:55-72. 3. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations: Questionnaire, clinical, and radiographic evaluation. J Hand Surg Am 2000;25: 1069-1079. 4. Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracturedislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl 1997;275:55-59. 5. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res 1982;164: 199-207. 6. Savvidou OD, Beltsios M, Sakellariou VI, Papagelopoulos PJ. Perilunate dislocations treated with external fixation and percutaneous pinning. J Wrist Surg 2015;4:76-80. 7. Moran SL, Ford KS, Wulf CA, Cooney WP. Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability. J Hand Surg Am 2006;31:1438-1446. 8. Herzberg G, Forissier D. Acute dorsal trans-scaphoid perilunate fracture-dislocations: Medium-term results. J Hand Surg Br 2002;27:498-502. 9. Krief E, Appy-Fedida B, Rotari V, David E, Mertl P, MaesClavier C. Results of perilunate dislocations and perilunate fracture dislocations with a minimum 15-year follow-up. J Hand Surg Am 2015;40:2191-2197. 10. Forli A, Courvoisier A, Wimsey S, Corcella D, Moutet F. Perilunate dislocations and transscaphoid perilunate fracture-dislocations: A retrospective study with minimum ten-year follow-up. J Hand Surg Am 2010;35:62-68. 11. Budoff JE. Treatment of acute lunate and perilunate dislocations. J Hand Surg Am 2008;33:1424-1432. 12. Kim JP, Lee JS, Park MJ. Arthroscopic reduction and percutaneous fixation of perilunate dislocations and fracture-dislocations. Arthroscopy 2012;28:196-203.e192. 13. Herzberg G. Acute dorsal trans-scaphoid perilunate dislocations: Open reduction and internal fixation. Tech Hand Up Extrem Surg 2000;4:2-13. 14. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987;214:136-147. 15. Jeon IH, Kim HJ, Min WK, Cho HS, Kim PT. Arthroscopically assisted percutaneous fixation for transscaphoid perilunate fracture dislocation. J Hand Surg Eur Vol 2010;35:664-668. 16. Jones RW. Carpal semilunar dislocations and other wrist dislocations with associated nerve lesions. Proc R Soc Med 1929;22:1071-1086.
SURGICAL OPTIONS FOR TRANS-SCAPHOID PLFDS 17. Slutsky DJ, Trevare J. Use of arthroscopy for the treatment of scaphoid fractures. Hand Clin 2014;30:91-103. 18. Davis AM, Beaton DE, Hudak P, et al. Measuring disability of the upper extremity: A rationale supporting the use of a regional outcome measure. J Hand Ther 1999;12:269-274. 19. Chung DW, Han CS, Lee JH, Kwon BK, Park JS. Surgical treatment of scaphoid nonuniondFactors of influencing outcome. J Korean Soc Surg Hand 2007;12:105-113. 20. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68:647-659. 21. Souer JS, Rutgers M, Andermahr J, Jupiter JB, Ring D. Perilunate fracture-dislocations of the wrist: Comparison of temporary screw versus K-wire fixation. J Hand Surg Am 2007;32:318-325. 22. Komurcu M, Kurklu M, Ozturan KE, Mahirogullari M, Basbozkurt M. Early and delayed treatment of dorsal transscaphoid perilunate fracture-dislocations. J Orthop Trauma 2008;22:535-540. 23. Martinage A, Balaguer T, Chignon-Sicard B, Monteil MC, Dreant N, Lebreton E. [Perilunate dislocations and fracture-dislocations of the wrist, a review of 14 cases]. Chir Main 2008;27:31-39 [in French]. 24. Laporte M, Michot A, Choughri H, Abi-Chahla ML, Pelissier P. [Perilunate dislocations and fracture-dislocations
25.
26.
27.
28.
29. 30.
31.
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of the wrist, a review of 17 cases]. Chir Main 2012;31:62-70 [in French]. Franchignoni F, Vercelli S, Giordano A, Sartorio F, Bravini E, Ferriero G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). J Orthop Sports Phys Ther 2014;44:30-39. Kim JK, Park ES. Comparative responsiveness and minimal clinically important differences for idiopathic ulnar impaction syndrome. Clin Orthop Relat Res 2013;471: 1406-1411. Malay S, SUN Study Group, Chung KC. The minimal clinically important difference after simple decompression for ulnar neuropathy at the elbow. J Hand Surg Am 2013;38:652-659. Lowdon IM, Simpson AH, Burge P. Recurrent dorsal trans-scaphoid perilunate dislocation. J Hand Surg Br 1984;9:307-310. Ahsan ZS, Yao J. Complications of wrist arthroscopy. Arthroscopy 2012;28:855-859. De Smet L, Dauwe D, Fortems Y, Zachee B, Fabry G. The value of wrist arthroscopy. An evaluation of 129 cases. J Hand Surg Br 1996;21:210-212. Nagle DJ, Benson LS. Wrist arthroscopy: Indications and results. Arthroscopy 1992;8:198-203.
Purpose: To compare union rates and clinical and radiological outcomes of arthroscopic-assisted reduction and fixation with those of open reduction and fixation in patients with trans-scaphoid perilunate fracture dislocations. Methods: This retrospective study included consecutive patients with trans-scaphoid PLFDs who underwent arthroscopic-assisted reduction and fixation (group A) or open reduction and fixation (group O), and who were followed up for a minimum of 2 years between May 2005 and March 2013. We excluded initially missed patients. Each different surgeon who was on call had performed each experienced operation. These clinical outcomes were assessed: range of motion, grip strength, Mayo wrist score, and Disabilities of Arm, Shoulder, and Hand (DASH) score. For radiologic outcomes, the scapholunate angle, radiolunate angle, and lunotriquetral distance were measured. Results: The total number of included patient was 20 (11 in group A and 9 in group O). Scaphoid union occurred in all patients except 1 individual (11 of 11 in group A, and 8 of 9 in group O). At the last follow-up, the mean flexion-extension arc was significantly greater in group A (125.0 ) than in group O (105.6 ) (P ¼ .028). The mean grip strength was 81.1% that of the contralateral side in group A and 80.9% in group O (P ¼ .594). The mean Mayo wrist score was 85.5 in group A and 79.4 in group O (P ¼ .026), and the mean DASH score was 10.6 in group A and 20.8 in group O (P ¼ .001); however, only the DASH score showed a minimum clinically important difference. The mean scapholunate angle, radiolunate angle, and lunotriquetral distance were similar between the 2 groups: 47.2 , 1.7 , and 2.0 mm in group A and 48.8 , 5.6 , and 2.1 mm in group O, respectively. Conclusions: Although both arthroscopic and open techniques achieved stability of the injured wrists in patients with trans-scaphoid PLFDs, it is shown that the arthroscopic-assisted technique showed a clinically meaningful better DASH score and greater flexion-extension arc with other parameters being similar. Level of Evidence: Level III, retrospective comparative study.
T
rans-scaphoid perilunate fracture dislocations (PLFDs) are among the most complex carpal injuries and involve severe disruption of carpal bone alignment.1-3 Early treatment of these injuries is necessary to prevent devastating complications, such as chronic carpal instability and eventual post-traumatic arthritis. Although closed treatment was historically advocated, several studies have reported that closed reduction and immobilization alone results in From the Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received January 27, 2016; accepted July 11, 2016. Address correspondence to Yun-Rak Choi, M.D., Ph.D., Department of Orthopedic Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/1677/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.07.018
nonunion of the scaphoid, intercalary segmental instabilities, and unfavorable wrist arthritis.4-6 Although studies comparing conservative treatment with open treatment have shown consistently better results with operative fixation,7,8 the trend has been toward anatomic reduction and repair of the ligamentous and osseous structures with early open reduction and internal fixation.1,4,9-11 Despite the superiority of open treatment over closed treatment for trans-scaphoid PLFDs, diminished wrist function seems to be inevitable.3,9,12 Previous studies have shown that the flexion-extension arc of the effected wrist decreased to between 57% and 75% compared with the contralateral side.1,4,9-11,13,14 This may be attributed to fibrosis of the injured joint being promoted by the addition of surgical trauma to the severely injured capsular and ligamentous structures.3,11,12 Recently, arthroscopic-assisted reduction and fixation of trans-scaphoid PLFDs has been used as an alternative to open surgery, introducing the potential advantages
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of minimal invasiveness. Several authors have shown that the arthroscopic method allows anatomical reduction of intercarpal alignments, maintains carpal stability, and results in more than 80% wrist motion compared with the contralateral wrist.12,15 However, there are lack of studies comparing arthroscopicassisted surgery with open surgery. The purpose of the current study was to compare union rates and clinical and radiological outcomes of arthroscopic-assisted reduction and fixation with those of open reduction and fixation in patients with transscaphoid PLFDs. The authors hypothesized that arthroscopic-assisted repair would achieve better wrist motion and function postoperatively than open anatomical repair.
Methods We retrospectively reviewed the records of all patients who met the following criteria between May 2005 and March 2013: (1) acute (<1 week) trans-scaphoid PLFD who underwent arthroscopic-assisted or open reduction and fixation; and (2) followed up for a minimum of 2 years. Patients fulfilling the following criteria were excluded: (1) initially missed trans-scaphoid PLFDs; (2) trans-scaphoid, transcapitate PLFDs; (3) concomitant fractures or dislocations of the ipsilateral elbow or shoulder; (4) major central or peripheral nervous system injury at the time of injury; (5) any previous surgery on the involved wrist; and (6) inadequate follow-up (<24 months). One of the 2 surgeons (Y-R.C., H-J.K.) who was on call had performed an operation in turn. Both of them were experts in the field of the hand surgery. One of them (Y-R.C.) had experience in arthroscopic-assisted reduction and fixation, and he had performed arthroscopic surgery during the study period. The other (H-J.K.) had experience in open reduction and fixation, and he had carried out open surgery during the same period. The patients who underwent arthroscopicassisted surgery were classified as group A, and those who underwent open surgery were classified as group O. Our institutional review board approved the study and waived the requirement for informed consent. Surgical Technique The closed reduction was attempted and successful in the emergency department using the technique described by Jones.16 In the operation room, however, these injuries were so unstable that closed reduction should be repeated immediately before operation in cases of the redislocation. All operations were conducted while the patients were receiving general anesthesia. With the patient in the supine position, the arm was prepped and draped on a hand table. A pneumatic tourniquet and Esmarch bandage were used to exsanguinate the arm.
In group A of arthroscopic-assisted reduction and fixation (Fig 1), the patient’s arm was suspended in an Arc Wrist Tower (Acumed, Hillsboro, OR) with 5 to 8 kg of traction after placing the index, middle, and ring fingers in finger traps. A 3-4 portal, 6-R portal, and midcarpal ulnar portal were created sequentially, and a 1.9-mm video arthroscope was introduced through each portal. While using the midcarpal ulnar portal as the viewing portal, a scaphotrapeziotrapezoidal portal or midcarpal radial portal (depending on the level of the scaphoid fracture) was created under direct vision as the working portal to facilitate the approach. Bone or cartilage fragments, as well as frayed edges of torn intrinsic or extrinsic ligaments that interrupted reduction, if present, were thoroughly debrided or removed to facilitate reduction of the scaphoid fracture or lunotriquetral joint. After releasing longitudinal traction, the scaphoid fracture was reduced with manipulation of the distal fragment using a probe or percutaneous joystick K-wire, under guidance from the arthroscopic and fluoroscopic images. Subsequently, a K-wire was inserted from the scaphoid tubercle and passed through the fracture site for temporary fixation. After the arthroscopy switched into the scaphotrapeziotrapezoidal or midcarpal radial portal, the lunotriquetral joint was reduced using the same method and pinned percutaneously from the ulnar side of the wrist, starting at a point dorsal to the pisiform and aiming in a slight proximal direction. To insert a guidewire for headless screw fixation of the scaphoid fracture, the arthroscope was introduced into the 6-R portal. The guidewire, inserted through a 15-G needle, was inserted percutaneously, proximal and ulnar to the 3-4 portal, to target the ideal starting point at the most proximal tip of the scaphoid pole, immediately adjacent to the insertion of the scapholunate interosseus ligament along the long axis of the scaphoid.17 After removal of the provisional K-wire, a 5-mm transverse incision was then made at the point of the prepositioned guidewire. A sharp straight hemostat was used to spread the soft tissue and pierce the dorsal capsule (proximal 3-4 portal). After reaming, a headless compression screw (either an HCS 3.0 [Synthes, Paoli, PA] or Acutrak mini screw [Acumed, Hillsboro, OR] system) was inserted over the guidewire to fix the scaphoid fracture. In group O of open reduction and fixation (Fig 2), a 5-cm longitudinal incision was created on the dorsal aspect of the wrist in line with Lister’s tubercle. Skin flaps were raised radially and ulnarly, and the incision was extended down to the extensor retinaculum. The retinaculum was divided in line with the third dorsal compartment, and the extensor pollicis longus tendon was identified distally and retracted radially. Only the distal 1 cm of the third compartment was released. The second and fourth compartments were then reflected
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Fig 1. Arthroscopic-assisted reduction and fixation for trans-scaphoid perilunate fracture dislocation (PLFD). (A) Posteroanterior and lateral views of the preoperative radiographs of a 29-year-old man showing a dorsal trans-scaphoid PLFD of the right wrist. (B, C) On the radial midcarpal view, the scaphoid fracture is shown after debridement of hematoma and interposed tissue (arrowhead), and anatomical reduction is performed (arrow). (D, E) On the scaphotrapeziotrapezoidal view, the lunotriquetral joint is reduced and transarticular K-wires are inserted. (F) The postoperative radiographs show proper fixation and normal carpal alignment. (Lu, lunate; Sc, scaphoid; Tq, triquetrum.)
off the dorsal capsule. A capsulotomy was created and extended longitudinally. Bone or cartilage fragments were removed from the joint and the joint was irrigated to remove any hematoma or other debris. The scaphoid fracture was reduced using percutaneous joystick K-wires, and the guidewire for headless screw fixation was introduced along the long axis of scaphoid. After reaming, a headless compression screw (either an HCS 3.0 [Synthes] or a Herbert mini screw [Zimmer, Warsaw, IN] system) was inserted over the guidewire. Then, the lunotriquetral joint was reduced and pinned percutaneously from the ulnar side of the wrist. The capsulotomy incision was closed with absorbable 2-0 or 3-0 sutures in an interrupted fashion. The retinaculum was repaired, leaving the extensor pollicis longus free distally but still within its compartment proximally. The skin was then closed with nylon sutures. After the operation, a sugar-tong splint was placed, with the wrist and forearm in the neutral position. All patients were encouraged to initiate immediate digital
exercises to reduce swelling. At the first postoperative visit 2 weeks after surgery, a well-molded short arm cast that held the wrist in a functional position was fashioned and worn for 6 to 8 additional weeks. The short arm cast and K-wires transfixing the lunotriquetral joint were removed at 6 to 8 weeks postoperatively and then active-assisted wrist movement exercises were encouraged. Clinical and Radiologic Assessments The preoperative evaluation consisted of plain radiographs of the wrist, including true posteroanterior, lateral, posteroanterior with ulnar deviation, and oblique with 45 pronation views. Postoperatively, all patients underwent regular follow-up visits in our outpatient clinic at 2 weeks, 8 to 10 weeks, 6 months, and 1 year after surgery, and then annually thereafter. The same 4 radiographic views of the wrist as in the preoperative evaluation were obtained at each followup visit.
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Fig 2. Open reduction and fixation for trans-scaphoid perilunate fracture dislocation (PLFD). (A) Posteroanterior and lateral views of the preoperative radiographs of a 46-year-old man showing a dorsal trans-scaphoid PLFD of the left wrist. (B) Approaching on the dorsal aspect of the wrist, the extensor pollicis longus tendon (asterisk) is retracted radially, and the scaphoid fracture is shown with a displacement (arrow). (C) The postoperative radiographs show proper fixation and normal carpal alignment. (D-F) The radiological measurements after 2 years postoperatively identify (D) 2.0 mm of lunotriquetral distance, (E) 56.0 of scapholunate angle, and (F) 4.6 of radiolunate angle. (Sc, scaphoid.)
One observer (K-H.L.) who was not involved in the treatment performed all of the clinical and radiological assessments. Bony union was determined by disappearance of the discontinuity and gap in the scaphoid on plain radiographs, and resolution of tenderness on physical examination. Clinical outcomes were evaluated by active range of motion (ROM) of the wrists, grip strength, Modified Mayo Wrist Score (MWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score. Active flexion extension arc (FEA) and radial and ulnar deviation arc were measured using a hand-held goniometer. Grip strength was measured using a JAMAR hydraulic dynamometer (Asimov Engineering, Los Angeles, CA). MWS is a commonly used wrist rating system.14 The total score ranges from 0 to 100 points, with higher scores indicating a better result. This system consists of 4 categories: pain (25 points), active FEA as a percentage of the opposite side (25 points), grip strength as a percentage of the opposite side (25 points), and the ability to return to regular employment or
activities (25 points); depending on the number of points scored, the outcome is classified as excellent (91-100), good (80-90), fair (65-79), or poor (<65). The DASH questionnaire, a self-reported questionnaire introduced by Davis et al.,18 contains 30 items: 21 questions that assess difficulties with specific tasks, 5 questions that evaluate symptoms, and 4 questions that evaluate social function, work function, sleep, and confidence. The DASH score ranges between 0 and 100, with higher scores representing greater upper extremity disability. For the radiologic assessment, the scapholunate angle (SLA), radiolunate angle (RLA), and lunotriquetral distance (LTD) were measured on radiographs obtained immediately after surgery and at the last follow-up. The SLA was defined as the angle between the scaphoid axis drawn tangentially to the volar proximal and distal borders of the scaphoid and the lunate axis drawn perpendicularly to a line connecting the volar and dorsal poles of the lunate. The RLA was defined as the angle between the lunate axis
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Results
52.4 ) in group O, and mean extension was 64.5 10.4 (95% CI, 64.3 to 64.7 ) in group A and 53.3 10.9 (95% CI, 53.1 to 53.5 ) in group O. The FEA was 125 17.5 in group A and 105.6 18.8 in group O. Patients in group A exhibited significantly better flexion, extension, and FEA at the last follow-up than patients in group O (P ¼ .047, P ¼ .03, and P ¼ .028, respectively) (Table 2). The mean MWS and DASH score were 85.5 5.7 (95% CI, 84.5-86.5) and 10.6 5.0 (95% CI, 10.5-10.7), respectively, at the last follow-up in group A and 79.4 5.3 (95% CI, 79.3-79.5) and 20.8 5.4 (95% CI, 20.7-20.9), respectively, in group O. The MWS and DASH score of group A were significantly better than those of group O (P ¼ .026 and P ¼ .001, respectively) (Table 2). Radiologic values of SLA, RLA, and LTD were similar between the 2 groups. Four patients in group A and 3 patients in group O exhibited midcarpal arthritis on radiographs at the last follow-up; the rates did not differ between the 2 groups (Table 2). However, patients with or without arthritis had similar FEA, MWS, and DASH scores at the last follow-up (P ¼ .874, .432, and .777, respectively).
Thirty-three patients underwent arthroscopic-assisted or open reduction and fixation for acute trans-scaphoid PLFDs at 2 different tertiary hospitals between May 2005 and March 2013. Thirteen patients were excluded based on exclusion criteria; thus 20 patients were included in the study: 11 underwent arthroscopicassisted reduction and fixation (group A) and 9 underwent open reduction and fixation (group O). All patients included in this study were male. The mean time from injury to operation was 1.1 days (range, 0-3 days) in group A and 1.0 day (range, 0-3 days) in group O. The mean age at the time of surgery was 30.1 years (range, 20-39 years) in group A and 32.1 years (range, 24-38 years) in group O. The mean follow-up period after surgery was 50 months (range, 24-72 months) in group A and 44.7 months (range, 24-90 months) in group O. The surgery involved the dominant arm in 54.5% (6 of 11) of the group A patients and 44.4% (4 of 9) of the group O patients (Table 1). The scaphoid fractures united in 95% (19 of 20) of the patients after surgery. One patient in group O failed to achieve union and eventually underwent cancellous bone grafting and fixation with 2 headless compression screws 5 years after the initial surgery (the delay was due to the patient being lost to follow-up postoperatively). This later procedure was successful, resulting in union. The overall union rate did not differ significantly between group A (100%; 11 of 11) and group O (89%; 8 of 9) (Table 2). At the last follow-up evaluation, mean flexion was 60.5 8.2 (95% confidence interval [CI], 60.3 to 60.7 ) in group A and 52.2 9.1 (95% CI, 52.0 to
Our study showed that the FEA, MWS, and DASH score were statistically significant better outcomes after arthroscopic-assisted reduction and fixation for patients with acute trans-scaphoid PLFDs than those after open reduction and fixation at the last follow-up; however, union rate, grip strength, and radiographic values (SLA, RLA, LTD, and midcarpal arthritis) were similar. Although anatomic reduction and repair of the ligamentous and osseous structures with early open reduction and internal fixation is the current trend for treating trans-scaphoid PLFDs,1,4,9-11 diminished wrist function seems to be a common consequence after this treatment.3,9,12 Recently, arthroscopic-assisted reduction and fixation, with its potential benefits of minimal invasiveness, has shown promising results with respect to wrist motion and function in patients with transscaphoid PLFDs.12,15 However, data comparing arthroscopic-assisted surgery with open surgery are lacking. The purpose of this study was to compare union rates and clinical and radiological outcomes in patients with the trans-scaphoid PLFDs treated with either open reduction and fixation or arthroscopicassisted reduction and fixation. Our results showed that the arthroscopic-assisted technique appears to produce better joint movement and function in patients with trans-scaphoid PLFDs, although both techniques achieved stability of the injured wrists. Previous studies have reported differing union rates after operative treatment of trans-scaphoid PLFDs. In a retrospective study of perilunate dislocations (PLDs) or PLFDs treated by closed repair with external fixation
and the longitudinal axis of the radius.19 Midcarpal arthritis and radiocarpal arthritis were identified on the radiographs according to the system of Knirk and Jupiter.20 Operation-related complications (nerve injury, postoperative infection, etc.) were also reviewed and recorded. No patient was recalled to our institution specifically for this study, as all data were obtained from the medical records. There were no missing data. Statistical Analysis Data are presented as mean standard deviation unless otherwise indicated. Statistical analysis was performed using R software (Version 3.2.2; R Foundation for Statistical Computing, Vienna, Austria). The Wilcoxon rank-sum test or Cochran-Armitage trend test was applied for between-group comparisons of continuous or ranked data, such as ROM, grip strength, MWS, and DASH scores. The Fisher exact test was used to compare categorical data, such as demographic data or the presence of complications, between groups. Statistical significance was set at P < .05.
Discussion
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Kim et al.12 reported that in their retrospective study of arthroscopic reduction and fixation of 20 patients with a PLD or PLFD, the union rate was 83% (10 of 12) in the patients with trans-scaphoid PLFD, and all nonunion cases were fixed with K-wires. In the current study, we used headless compression screws to fix the scaphoid fractures regardless of the surgical technique, and we achieved scaphoid union in 95% of our patients with trans-scaphoid PLFD. This suggests that accurate reduction and stable fixation, rather than the method of surgery (arthroscopic-assisted or open approach), seem to be the key factors determining scaphoid union. Our union rate (95%) was higher than previous studies (71% to 83%). It is because we included only transscaphoid PLFDs excluding other types of PLFDs (transradial styloid, transcapitate, transtriquetrum, etc.), and we also excluded initially missed and delayed cases because of the study design. In addition, we used a headless compression screw instead of K-wires to achieve stable fixation of the scaphoid in both arthroscopic and open groups. The progressive development of headless compression screws, such as upgrade to the cannulated type, double threaded type, or small size preserving the same intensity, could affect better results. According to previous studies, arthroscopic-assisted surgery for trans-scaphoid PLFDs seemed to produce better range of flexion and extension in the injured wrist than open surgery. Souer et al.21 reported that the
Table 1. Patient Demographics Variables Age, yr Male/female, n Dominant/nondominant, n Injury mechanism, n Fall during sports Fall from a height Traffic accident Time from injury to operation, d Period of follow-up, mo
Group A (n ¼ 11) 30.1 6.8 11/0 6/5
Group O (n ¼ 9) 32.1 4.3 9/0 4/5
8 2 1 1.1 1.0
7 1 1 1.0 1.0
.873
50.0 16.0
44.7 24.6
.565
P Value* .449 1.000 1.000 1.000
NOTE. Continuous values are mean standard deviation. Group A: arthroscopic-assisted reduction and fixation; group O: open reduction and fixation. *P values are calculated using the Fisher test for categorical variables and the Wilcoxon rank sum test for continuous variables.
and percutaneous K-wires, Savvidou et al.6 reported a union rate of 71% (5 of 7 patients) for trans-scaphoid PLFDs. Souer et al.21 treated 18 patients with transscaphoid PLFDs by open methods, with K-wire fixation in 9 patients and screw fixation in the others. The union rate was 78% (7 of 9 patients) after screw fixation, and loss of stable reduction occurred in 78% (7 of 9 patients) in the K-wire fixation group. In their retrospective study of 30 patients with a PLD or PLFD treated by closed or open methods, Krief et al.9 reported a 77% (10 of 13) union rate for trans-scaphoid PLFDs.
Table 2. Clinical and Radiologic Outcomes at the Last Follow-up Variables Union, n Union time, wk Range of motion, Flexion Extension Radial deviation Ulnar deviation Flexion-extension arc, % Radial-ulnar deviation arc, % Grip strength, % MWS Excellent Good Fair Poor DASH score SLA, RLA, LTD, mm Arthritis, n
Group A 11/11 11.6 2.7
Group O 8/9 12.8 3.0
MD or OR (95% CI) e 0.3 (3.8 to 4.4)
8.2y 10.4y 6.9 3.8 7.8y 13.8 8.5 5.7y 6 4 1 0 10.6 5.0y 47.2 6.7 1.7 0.7 2.0 0.3 4/11
52.2 53.3 12.8 21.1 69.6 64.8 80.9 79.4
9.1 10.9 3.6 4.2 12.2 15.5 5.8 5.3 1 4 4 0 20.8 5.4 49.8 6.4 5.6 5.3 2.1 0.3 3/9
8.2 11.2 1.8 3.0 12.4 6.5 0.3 6.0
60.5 64.5 14.5 24.1 82.0 71.3 81.1 85.5
10.2 2.6 3.8 0.1 1.1
(0.1-16.3) (1.2-21.2) (3.3 to 6.9) (0.7 to 6.7) (3.0-21.9) (3.8 to 15.5) (6.1 to 7.9) (0.8-11.2) e e e e (5.3-15.1) (3.6 to 8.9) (0.4 to 10.4) (0.2 to 0.4) (0.1-11.1)
P Value* .450 .781 .047 .030 .833 .110 .013 .161 .594 .026 .023
.001 .391 .357 .433 1.000
NOTE. Continuous values are mean standard deviation. Percentage values are percentage of contralateral side. CI, confidence interval; DASH, Disabilities of Arm, Shoulder, and Hand; LTD, lunotriquetral distance; MD, mean difference; MWS, Mayo wrist score; OR, odds ratio; RLA, radiolunate angle; SLA, scapholunate angle. *P values are calculated by the Wilcoxon rank sum test for continuous values and by the Fisher test or the Cochran-Armitage trend test for categorical values. y P < .05.
SURGICAL OPTIONS FOR TRANS-SCAPHOID PLFDS
mean FEA was 71% of the contralateral side after open reduction and fixation in 9 patients with trans-scaphoid PLFDs. In Hildebrand et al.’s3 series, 22 patients with a PLD or PLFD achieved 57% of the contralateral FEA after open surgery. By contrast, Kim et al.12 reported that the mean FEA was 79% of the contralateral side after arthroscopic reduction and fixation. Similarly, Jeon et al.15 found in their retrospective study of arthroscopic surgery for 4 trans-scaphoid PLFDs that the mean FEA was 126 . The results of our current study support the impression obtained from previous reports, because the mean FEA in the arthroscopic group (125 , 82% of the contralateral side) was greater than that in the open group (105.6 , 70% of the contralateral side). Trans-scaphoid PLFDs are complex wrist injuries with severe disruption of surrounding soft tissues, such as capsules and interosseous ligaments. The open approach could add surgical injuries to these severely damaged soft tissues and thus aggravate capsular fibrosis, resulting in worse ROM than with the arthroscopic approach. Previous studies of arthroscopic surgery by Kim et al.12 and Jeon et al.15 reported the mean MWS values of 79 and 76, respectively. After open surgery, Souer et al.21 and Hildebrand et al.3 reported the mean MWS values of 66 and 71, respectively. Similarly, Krief et al.9 reported a mean MWS value of 70 at a minimum of 15 years of follow-up after open surgery. However, functional outcomes after open surgery varied from 63 to 81.14,22-24 In the current study, the mean MWS was significantly better after arthroscopic surgery (85.5) than after open surgery (79.4). DASH scores also showed significantly better outcomes after arthroscopic surgery (10.6) than after open surgery (20.8). These statistically significant differences in the MWS and DASH score between the 2 types of surgery seem to be at least partly based on the differences in mean ROM at the wrist joints between the 2 groups. However, as regards the minimum clinically important difference (MCID), only the DASH score showed a clinically significant difference. The MCID in DASH scores has been reported to range from 7 to 13.5,25-27 but there has been no report defining the MCID for MWS. The mean MWS after arthroscopic surgery of our study (85.5) was higher than those of previous studies (76-79). It is because we included only trans-scaphoid PLFDs excluding other types of PLFD, and these studies actually enrolled too small number of patients to discuss which shows better outcome than other. A remarkable thing is that results of studies of arthroscopic-assisted surgery generally presented better MWS than those of open surgery. On the basis of this trend of MWS and the clinical important difference of the DASH score, we speculated that arthroscopicassisted surgery shows better functional outcome than open surgery.
7
Our radiologic results were within the normal range immediately after surgery and at the last follow-up, and these results are in close agreement with those of numerous other authors. In their study of closed methods, Savvidou et al.6 reported that the mean SLA was 49 (range, 48 to 64 ) and LTD was 1.8 mm (range, 1.3-2.2 mm) at the last follow-up. In Souer et al.’s21 study of surgery with repair of the lunotriquetral ligament, the mean SLA was 49 (range, 36 to 76 ) in the K-wire fixation group and 64 (range, 48 to 77 ) in the screw fixation group, at a mean follow-up of 44 months. In Krief et al.’s9 study of 30 patients with PLD or PLFD, 28 individuals underwent open surgery and 6 of the 28 open operations involved repair of the lunotriquetral ligament. The mean SLA, RLA, and LTD were 64 , 11 , and 1.6 mm, respectively, at a minimum of 15 years of follow-up. In the study of arthroscopic surgery by Kim et al.,12 the mean SLA was 55 (range, 48 to 64 ) and LTD was 1.8 mm (range, 1.3-2.2 mm). In trans-scaphoid PLFDs, the scapholunate interosseous ligament is usually preserved, so repairing this ligament seems to be unnecessary.1,12 By contrast, most clinicians believe that repair of the lunotriquetral interosseous ligament is required to maintain the stability of the proximal carpal row.1,8,28 However, we performed open or arthroscopic surgery without repair of the lunotriquetral interosseous ligament, and the joint was maintained by fixation with 1 or 2 transarticular Kwires. At the last follow-up, we detected no instability of the carpal row, and the radiologic outcomes of SLA, RLA, and LTD were within the normal range. Other studies of arthroscopic management for PLFDs, in which the lunotriquetral ligament was not repaired, also showed excellent outcomes, without carpal instability.12,15 These results suggest that with an acute injury of the lunotriquetral ligament, anatomical reduction and transarticular K-wire fixation without open repair might be sufficient to produce stable healing. In earlier studies of open surgery, the incidence of carpal arthritis ranged from 18% to 22% within 3 years after surgery and increased to 50% to 100% with follow-up periods of 6 to 13 years.3,4,9,13,21 In patients who underwent arthroscopic surgery, Kim et al.12 reported no carpal arthritis at a mean follow-up of 31.2 months. In our study, carpal arthritis was noted by radiologic examination after a mean follow-up period of 4 years in 36% of patients in the open surgery and 33% in the arthroscopic surgery; these rates were not significantly different between groups. Nevertheless, radiologic degenerative changes do not seem to be correlated with clinical outcomes. Hildebrand et al.3 found no statistical relation between the presence of midcarpal arthritis and clinical scores at the last followup. Likewise, Martinage et al.23 reported no correlation between radiologic and clinical outcomes. In the
8
W-T. OH ET AL.
current study, we also found no correlation between radiologic carpal arthritis and clinical outcomes, and no secondary operation (such as carpectomy or arthrodesis) was required by any patient. However, longer follow-up is required to evaluate this issue because arthritis could worsen over time and eventually correlate with deteriorating clinical outcomes. Potential complications after wrist arthroscopy include local infection, injury to neurovascular structures (e.g., dorsal sensory branches of the radial and ulnar nerves or radial arteries), injury to extensor tendons and iatrogenic tendinopathy, and the development of a ganglion or complex regional pain syndrome. Previous complication rates ranged from 1.2% to 4.7%.29-31 Although we found no complications after arthroscopic management of trans-scaphoid PLFDs, our number of patients was too small to adequately assess the rates of relatively uncommon complications. Although complications during or after arthroscopic wrist surgery might be unusual, surgeons should be aware of these potential complications, to try to reduce their occurrence. Limitations Our study has several limitations. First, it included a small number of patients and had a low statistical power. That means this study had a chance of type II error with regard to the angles measured on radiographs and grip strength. Second, the selection bias of patient enrollment on each surgical technique could be raised. In our institution, 2 hand surgeons had equal duty days for emergency call and each patient was allocated based on which surgeon was on call. In addition, there could be another confounding factor for the experience of 2 different surgeons; however, they were fellowship trained and well experienced in the field of the hand surgery. Third, the follow-up period seems to be insufficient to determine whether there is a relation between the development of midcarpal arthritis and functional outcomes after surgery; long-term follow-up is required to evaluate this, as noted above. Fourth, all of our patients were male, although similar results may occur with females. Fifth, the design of this study was retrospective, and a prospective, randomized study comparing arthroscopy-assisted reduction and fixation with open reduction and fixation of trans-scaphoid PLFDs should be performed to confirm the efficacy of arthroscopy-assisted surgery. Sixth, we could not descript inter- and intraobserver reliability, because the radiographic values were measured by one observer. However, he was also an orthopeadic surgeon who was trained over 6 years.
Conclusions Although both arthroscopic and open techniques achieved stability of the injured wrists in patients with
trans-scaphoid PLFDs, it is shown that the arthroscopicassisted technique showed a clinically meaningful better DASH score and greater flexion-extension arc with other parameters being similar.
References 1. Weil WM, Slade JF III, Trumble TE. Open and arthroscopic treatment of perilunate injuries. Clin Orthop Relat Res 2006;445:120-132. 2. Green DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop Relat Res 1980;149:55-72. 3. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations: Questionnaire, clinical, and radiographic evaluation. J Hand Surg Am 2000;25: 1069-1079. 4. Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracturedislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl 1997;275:55-59. 5. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res 1982;164: 199-207. 6. Savvidou OD, Beltsios M, Sakellariou VI, Papagelopoulos PJ. Perilunate dislocations treated with external fixation and percutaneous pinning. J Wrist Surg 2015;4:76-80. 7. Moran SL, Ford KS, Wulf CA, Cooney WP. Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability. J Hand Surg Am 2006;31:1438-1446. 8. Herzberg G, Forissier D. Acute dorsal trans-scaphoid perilunate fracture-dislocations: Medium-term results. J Hand Surg Br 2002;27:498-502. 9. Krief E, Appy-Fedida B, Rotari V, David E, Mertl P, MaesClavier C. Results of perilunate dislocations and perilunate fracture dislocations with a minimum 15-year follow-up. J Hand Surg Am 2015;40:2191-2197. 10. Forli A, Courvoisier A, Wimsey S, Corcella D, Moutet F. Perilunate dislocations and transscaphoid perilunate fracture-dislocations: A retrospective study with minimum ten-year follow-up. J Hand Surg Am 2010;35:62-68. 11. Budoff JE. Treatment of acute lunate and perilunate dislocations. J Hand Surg Am 2008;33:1424-1432. 12. Kim JP, Lee JS, Park MJ. Arthroscopic reduction and percutaneous fixation of perilunate dislocations and fracture-dislocations. Arthroscopy 2012;28:196-203.e192. 13. Herzberg G. Acute dorsal trans-scaphoid perilunate dislocations: Open reduction and internal fixation. Tech Hand Up Extrem Surg 2000;4:2-13. 14. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987;214:136-147. 15. Jeon IH, Kim HJ, Min WK, Cho HS, Kim PT. Arthroscopically assisted percutaneous fixation for transscaphoid perilunate fracture dislocation. J Hand Surg Eur Vol 2010;35:664-668. 16. Jones RW. Carpal semilunar dislocations and other wrist dislocations with associated nerve lesions. Proc R Soc Med 1929;22:1071-1086.
SURGICAL OPTIONS FOR TRANS-SCAPHOID PLFDS 17. Slutsky DJ, Trevare J. Use of arthroscopy for the treatment of scaphoid fractures. Hand Clin 2014;30:91-103. 18. Davis AM, Beaton DE, Hudak P, et al. Measuring disability of the upper extremity: A rationale supporting the use of a regional outcome measure. J Hand Ther 1999;12:269-274. 19. Chung DW, Han CS, Lee JH, Kwon BK, Park JS. Surgical treatment of scaphoid nonuniondFactors of influencing outcome. J Korean Soc Surg Hand 2007;12:105-113. 20. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68:647-659. 21. Souer JS, Rutgers M, Andermahr J, Jupiter JB, Ring D. Perilunate fracture-dislocations of the wrist: Comparison of temporary screw versus K-wire fixation. J Hand Surg Am 2007;32:318-325. 22. Komurcu M, Kurklu M, Ozturan KE, Mahirogullari M, Basbozkurt M. Early and delayed treatment of dorsal transscaphoid perilunate fracture-dislocations. J Orthop Trauma 2008;22:535-540. 23. Martinage A, Balaguer T, Chignon-Sicard B, Monteil MC, Dreant N, Lebreton E. [Perilunate dislocations and fracture-dislocations of the wrist, a review of 14 cases]. Chir Main 2008;27:31-39 [in French]. 24. Laporte M, Michot A, Choughri H, Abi-Chahla ML, Pelissier P. [Perilunate dislocations and fracture-dislocations
25.
26.
27.
28.
29. 30.
31.
9
of the wrist, a review of 17 cases]. Chir Main 2012;31:62-70 [in French]. Franchignoni F, Vercelli S, Giordano A, Sartorio F, Bravini E, Ferriero G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). J Orthop Sports Phys Ther 2014;44:30-39. Kim JK, Park ES. Comparative responsiveness and minimal clinically important differences for idiopathic ulnar impaction syndrome. Clin Orthop Relat Res 2013;471: 1406-1411. Malay S, SUN Study Group, Chung KC. The minimal clinically important difference after simple decompression for ulnar neuropathy at the elbow. J Hand Surg Am 2013;38:652-659. Lowdon IM, Simpson AH, Burge P. Recurrent dorsal trans-scaphoid perilunate dislocation. J Hand Surg Br 1984;9:307-310. Ahsan ZS, Yao J. Complications of wrist arthroscopy. Arthroscopy 2012;28:855-859. De Smet L, Dauwe D, Fortems Y, Zachee B, Fabry G. The value of wrist arthroscopy. An evaluation of 129 cases. J Hand Surg Br 1996;21:210-212. Nagle DJ, Benson LS. Wrist arthroscopy: Indications and results. Arthroscopy 1992;8:198-203.