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Current Concepts in Wrist Arthroscopy
Current Concepts
Current Concepts in Wrist Arthroscopy George D. Chloros, M.D., Ethan R. Wiesler, M.D., and Gary G. Poehling, M.D.
Abstract: The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction–internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy. Key Words: Arthroscopy—Wrist—Distal radius fractures—Triangular fibrocartilage complex—Ganglia—Wrist ligaments.
W
rist arthroscopy is a continuously expanding field, bringing up new controversies and challenges. This review focuses on the current status of arthroscopy in the treatment of distal radius fractures (DRFs), triangular fibrocartilage complex (TFCC) in-
From the Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A. The authors report no conflict of interest. Address correspondence and reprints requests to George D. Chloros, M.D., Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2403-5323$34.00/0 doi:10.1016/j.arthro.2007.10.006
juries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. DISTAL RADIUS FRACTURE As first shown by Knirk and Jupiter1 in 1986 and subsequently by multiple studies,2,3 an articular stepoff of 1 to 2 mm may lead to the development of degenerative changes, and therefore accurate articular reduction is warranted. Studies show that compared with arthroscopy, fluoroscopy has been unsatisfactory in the evaluation of the status of the articular surfaces.4,5 Several authors report the presence of soft-tissue injuries occurring with both extra- and intra-articular DRFs (Fig 1). The reported incidence of TFCC tears
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 3 (March), 2008: pp 343-354
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FIGURE 1. (A) Anteroposterior radiograph. Note the apparent widening of the scapholunate interval (arrow). Also note that the scaphoid is foreshortened and the most distal portion of the lunate is quadrangular. This suggests that the scaphoid is flexed and the lunate and triquetrum are extended. (B) Lateral radiographs of a DRF are inconclusive regarding the extent of the injury. The scaphoid is slightly flexed as compared with the lunate. (C) The sagittal computed tomography scan shows a dorsally angulated articular fragment and radial styloid impaction (arrow). (D) MR image showing the intra-articular DRF and simultaneous scapholunate ligament injury (asterisk). (Reprinted with permission.92)
occurring with DRFs ranges from 10% to 84%, and scapholunate interosseous (SLIO) ligament injuries range from 7% to 86% of fractures, lunotriquetral
interosseous (LTIO) ligament injuries range from 0% to 60%, and chondral injuries range from 15% to 42%.6-15 The question that arises is whether treating
CURRENT CONCEPTS IN WRIST ARTHROSCOPY the associated tissue injuries results in any benefit to the final outcome of DRFs.2,3,16,17 Lindau et al.9 studied 43 patients with DRFs who had TFCC injuries proven arthroscopically but were left untreated, and at 1 year postoperatively, they found distal radioulnar joint instability in 19 patients, which was painful in 13. Ruch et al.13 acutely treated 13 TFCC injuries occurring with DRFs with arthroscopy. None of the patients reported ulnar-sided wrist pain, range of motion and grip strength were good, and the Gartland and Werley scores18 were excellent in 12 patients. Peicha et al.12 followed up 7 patients with arthroscopically proven SLIO ligament tears with DRFs who were treated with temporary SLIO ligament arthrodesis at 3 years postoperatively and found good to excellent results in all patients. These nonrandomized, uncontrolled studies show that there may be a benefit in acutely addressing the associated injuries occurring with DRFs. Results of Treatment To date, there has been only 1 prospective randomized study, performed by Doi et al.19 in 1999, which compared the outcome in 34 DRFs treated with arthroscopically assisted reduction (AAR) with 48 fractures treated with open reduction–internal fixation. At a minimum of 2 years’ follow-up, the patients in the AAR group had better outcomes according to the Mayo wrist score20 and Gartland and Werley score18 and better range of motion, grip strength, and radiographic results. Other nonrandomized studies have shown that AAR restores articular congruity and yields good to excellent outcomes. Ruch et al.14 compared the outcomes of fluoroscopic reduction (15 patients) versus arthroscopic reduction (15 patients) in 30 intra-articular DRFs with a step-off of greater than 2 mm after closed reduction and found improved range of motion in the arthroscopic group. Shih et al.15 reported on 33 patients with displaced intra-articular DRFs with AAR with a minimum follow-up of 24 months. They found and treated associated lesions in 22 of 33 patients, and the results were excellent in 11 patients and good in 22 according to the Mayo wrist score.20 Mehta et al.11 evaluated the results of AAR in 25 patients with intra-articular DRFs and addressed all TFCC, SLIO ligament, LTIO ligament, and osteochondral lesions simultaneously. At a mean follow-up of 19 months, the results were excellent in 88% of patients according to the New York Orthopaedic Hospital score,21 whereas according to the Gartland and Werley score,18 the results were good to excellent in
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70% of patients. Evaluation of articular congruency by use of plain radiographs revealed no articular stepoff in 65% of cases and a step-off of less than 1 mm in 31% of cases. Chen et al.6 studied the outcome of 20 intra-articular DRFs at a minimum of 12 months’ follow-up and found good to excellent results in 90% of patients according to the Mayo wrist score.20 Hardy et al.8 treated 18 intra-articular DRFs in a young population, and at a minimum follow-up of 9 months, according to the Mayo wrist score,20 72% of patients had good to excellent results. Kamano et al.22 treated 15 young patients with AO/ASIF C3.2 DRFs with AAR and palmar plating with autologous bone graft and found good results in 15 and excellent results in 5 according to the Gartland and Werley score.18 However, despite the absence of radiographic step-off, 10 patients had grade 1 osteoarthritis. In 2 recent reviews regarding the role of arthroscopy in DRFs, Chloros et al.2 and Wiesler et al.3 emphasized that there are no currently established rigid indications regarding the treatment of DRFs. The authors’ preferred indications for AAR of DRFs were fractures of the radial styloid, die-punch injuries, and intra-articular DRFs with suspected associated ligament or TFCC injury. Other valid indications included 3- or 4-part DRFs with articular displacement of greater than 2 mm after failure of closed reduction. The authors stated that there are multiple management approaches for each type of fracture, indicated that the basic principles of fracture treatment should be followed, and insisted on the importance of an individualized approach to treatment of DRFs (Fig 2). Techniques and indications for the arthroscopic management of DRFs are evolving. Lindau10 successfully performed wrist arthroscopy in 17 patients using a horizontal technique with standard arthroscopic equipment. The rationale was to maintain the traction and the arthroscopically reduced position of the wrist when performing additional procedures (e.g., plating), thus avoiding the risk of loss of arthroscopic reduction. Wiesler et al.23 have recently reported on an arthroscopic fixation technique for the management of DRFs with a volar lunate facet component. The fragments are disimpacted by use of a freer elevator introduced dorsally, and subsequently, the volar lunate facet is reduced with a nerve hook. del Piñal et al.24 have reported a technique for dry arthroscopy of the wrist. Luchetti et al.25 have reported good preliminary results with arthroscopic wrist arthrolysis to remedy wrist stiffness after fracture. It can therefore be concluded that (1) wrist arthroscopy is advantageous in providing accurate as-
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FIGURE 2. DRF case example. (A) Anteroposterior radiograph showing widening of scapholunate ligament and intra-articular fracture. (B) Arthroscopic view of displaced fracture. (C) Arthroscopic view of fracture after reduction and pinning. Note that there remains very little displacement. (D) This postoperative radiograph shows a well-reduced central fragment with pins across the scapholunate ligament and the DRF supported by a radiolucent external fixator. (Reprinted with permission.93)
sessment of the status of the articular surfaces and in detecting concomitant soft-tissue injuries, (2) the techniques and indications are expanding, and (3) nonrandomized studies of AAR of DRFs show satisfactory results. There is only 1 prospective randomized outcome study comparing AAR with open reduction– internal fixation that shows the benefits of arthroscopy.1
nosis and staging of TFCC lesions. Triple-injection arthrography has a low sensitivity and specificity compared with arthroscopy, as shown by Weiss et al.,30 whereas recent literature shows that high-resolution magnetic resonance imaging (MRI)31 and magnetic resonance (MR) arthrography32 are also not entirely satisfactory. Arthroscopy is advantageous in both the diagnosis and treatment of TFCC injuries.
ARTHROSCOPY IN TREATMENT OF TFCC INJURIES
Traumatic Injuries: Palmer Type 1 Type 1A: In 80% to 85% of patients with neutral or negative ulnar variance, the outcomes of debridement of Palmer type 1A TFCC tears (Fig 4) yield excellent to good results, with no requirement for further surgery.33,34 Type 1B: Type 1B lesions occur in the peripheral, well-vascularized portion of the TFCC, and therefore healing is increased. Several arthroscopic techniques have been reported, including the inside-out technique (Poehling and colleagues35 [Tuohy needle]), the out-
Injuries to the TFCC are commonly classified according to the Palmer classification (Table 1, Fig 3).26 However, a recent study by Estrella et al.27 found 18 dorsal TFCC lesions that could not be classified according to Palmer. The use of volar portals as described by Slutsky28 and Chen et al.29 may allow better ease of access for dorsal TFCC lesions. Wrist arthroscopy is the gold standard for the diag-
TABLE 1.
Palmer’s Classification of TFCC Injuries26 Description
Type 1: Traumatic TFCC lesions 1A 1B 1C 1D Type 2: Degenerative TFCC lesions 2A 2B 2C 2D 2E
Isolated central disk perforation Peripheral ulnar-sided tear of TFCC (with or without ulnar styloid fracture) Distal TFCC disruption (i.e., disruption from distal ulnocarpal ligaments) Radial TFCC disruption (with or without sigmoid notch fracture) TFCC wear TFCC wear with lunate or ulnar chondromalacia (or both) TFCC perforation with lunate or ulnar chondromalacia (or both) TFCC perforation with lunate or ulnar chondromalacia (or both) and with lunotriquetral ligament perforation TFCC perforation with lunate or ulnar chondromalacia (or both) and with lunotriquetral ligament perforation and ulnocarpal arthritis
CURRENT CONCEPTS IN WRIST ARTHROSCOPY
FIGURE 3. Palmer classification of TFCC traumatic injuries: (A) vertical tear 2 to 3 mm from radial border, (B) peripheral TFCC tear recognized by loss of tension of ligament, (C) tear of ulnocarpal ligaments, and (D) tear across TFCC at level of radius. There usually is a piece of bone left attached to the TFCC. (R, radius; U, ulna; L, lunate; T, triquetrum.) (Courtesy of Dr. Anastasios Papadonikolakis.)
side-in technique (Whipple and Geissler36 and Zachee et al.37), and the all-inside technique described by Bohringer et al.38 The results of the TFCC repair of type 1B lesions have been rewarding. In a multicenter study, Corso et al.39 found good to excellent results in 41 of 45 wrists (91%) repaired with an outside-in technique. Degreef et al.40 found minimal or absent
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pain in 47 of 52 cases at a minimum of 6 months’ follow-up. In a recent study Estrella et al.27 repaired 35 peripheral tears of the TFCC, including 11 type 1B tears, and found good to excellent results in 74% according to the Mayo wrist score20 whereas secondlook arthroscopy showed healing in 7 of 9 patients. Of note, dorsal sensory ulnar neuritis occurred in 17% of patients. Ruch and Papadonikolakis41 found that agerelated changes in the wrist, loss of grip strength, positive ulnar variance, and decreased supination are factors associated with a poorer outcome of TFCC repairs. Type 1C: In cases of isolated fraying, debridement may be used to remove any mechanical source of pain, whereas in cases of frank ulnar ligamentous disruption, either open or arthroscopic repair is the recommended treatment.42 Miwa et al.43 treated 7 type 1C tears with arthroscopic debridement and found an overall success rate of 88%. Shih et al.,44 in a series of 37 patients, including 10 patients with type 1C tears arthroscopically repaired with sutures, reported good to excellent results in 92% of patients overall. Type 1D: There is controversy regarding the management of type 1D lesions with complete avulsion of the TFCC off the distal radius, which is done by either debridement or repair. There are several techniques for repair, as described by Sagerman and Short,45 Trumble et al.,46 and Jantea et al.47 After the study of open repair of peripheral TFCC
FIGURE 4. (A) Suction biter debriding a central TFCC tear. The arthroscope is in the 3-4 portal, and the suction basket is in the 6R portal. This position allows debridement of the volar and radial sides of the tear. (B) After debridement of type 1A tear, with preservation of peripheral attachments. (R, radius; L, lunate; U, ulna.) (Reprinted with permission.92)
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injuries by Cooney et al.48 in 1994, good clinical results have been shown in several other studies with repair of the type 1D injury.45,46 In 13 patients with type 1D TFCC tears repaired arthroscopically by Trumble et al.,46 at a minimum of 2 years, 11 had complete pain relief and 2 had slight discomfort. Arthrography, MRI, and arthroscopy showed an intact TFCC at the latest follow-up in 10 patients. Miwa et al.,43 treated 17 type 1D injuries with arthroscopic suturing (12 cases) or debridement (5 cases). The results were good to excellent in 92% in the suture group and 80% in the debridement group. It may be concluded that in type 1D TFCC tears, which involve the distal radioulnar joint stabilizing the volar or dorsal radioulnar ligaments (or both), arthroscopic reattachment has been a reliable and successful management option, including objective evidence of healing. Degenerative Injuries: Palmer Type 2 Ulnar impaction syndrome results from chronic overloading of the ulnar side of the wrist and has been depicted in type 2 injuries of the Palmer classification.26 In 1996 Minami et al.49 showed that simple TFCC debridement with positive ulnar variance was unsuccessful and further concluded that osseous decompression of the ulnar side of the wrist should be performed. Patients with positive ulnar variance or Palmer type 2C, 2D, or 2E tears may be candidates for unloading of the ulnar side of the wrist, either by an ulnar shortening osteotomy (USO)50-52 or by a wafer procedure.53,54 A recent cadaveric study showed that the arthroscopic wafer procedure reduces the ulnar load in all conditions of ulnar variance.55 Tomaino and Weiser53 reviewed the outcome of the arthroscopic wafer procedure combined with an arthroscopic TFCC debridement in TFCC tears associated with positive ulnar variance in 12 patients. At final follow-up, 8 patients were pain-free and 4 had minimal symptoms. Neutral ulnar variance was restored in all patients. The results of USO have also been satisfactory.56 There have been 2 comparison outcome studies of USO versus the wafer procedure, by Constantine et al.57 and Bernstein et al.50 They concluded that although both the USO and wafer procedures provide similar pain relief and restoration of function, the latter is associated with fewer secondary procedures and tendinitis as compared with USO. Recently, Tatebe et al.58 performed second-look arthroscopies in 32 patients who had undergone USO who had a central TFCC tear documented on the first
arthroscopy. In 50% of the cases, the TFCC was found to be spontaneously repaired, showing that the avascular zone of the TFCC has some potential to repair. Intercarpal Ligament Injuries Prompt diagnosis in the acute setting may achieve primary ligament healing and possibly avoid later reconstructive procedures. Tricompartmental arthrography, as shown by Weiss et al.,30 has a low sensitivity, specificity, and accuracy in the detection of tears of either the SLIO ligament, the LTIO ligament, or the TFCC compared with arthroscopy. Hobby et al.59 reviewed 6 studies reporting the performance of MRI for SLIO ligament tears and 6 studies for LTIO ligament tears and found that MRI cannot reliably exclude tears of these ligaments. The technique was more sensitive for SLIO ligament tears than for LTIO ligament tears. MR wrist arthrography has been introduced to improve the accuracy of MRI. Meier et al.60 found 100% specificity and 72% sensitivity of MR arthrography compared with arthroscopy. It can be concluded that arthroscopy is the gold standard of imaging of SLIO and LTIO ligament injuries, currently surpassing arthrography, MRI, and MR arthrography (Fig 5). Furthermore, the utility of volar portals in the evaluation of the volar segments of the SLIO and LTIO ligaments has been shown in a recent study of 230 patients.61 A recent study by Abe et al.62 showed that wrist arthroscopy could identify various degrees of SLIO ligament tear as the main cause of radial-sided wrist pain in 11 wrists with inconclusive plain radiograph and MRI findings. The arthroscopic classification of carpal instability of Geissler et al.7 (Table 2) is commonly used as a guide to the diagnosis and management of interosseous ligament injuries. There is currently no arthroscopic procedure described to directly repair SLIO or LTIO ligament injuries; however, indirect procedures, including debridement, may be beneficial. In partial tears of the SLIO or LTIO ligament, excellent results have been reported with arthroscopic debridement. Weiss et al.63 reported the outcome of arthroscopic debridement alone for complete and incomplete SLIO or LTIO ligament tears in 43 wrists at a mean of 27 months’ follow-up. In the SLIO ligament group they found complete resolution or improved symptoms in 66% and 85% of complete and incomplete tears, respectively. The corresponding figures for the LTIO ligament group were 78% and 100%, respectively. Ruch and Poehling64 studied the outcome of arthroscopic debridement of isolated partial SLIO
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FIGURE 5. (A) The 3-4 portal allows visualization of the SLIO ligament; the ligament is flat and often hard to perceive. (B) Ulnocarpal ligaments seen through 6R portal. The LTIO ligament is seen as a concave structure between the lunate and the triquetrum. (C) Arthroscopic view of SLIO ligament tear looking from 3-4 portal into the midcarpal joint. (D) Partial tear of LTIO ligament. Note the irregular ligament behind the LTIO ligament. (SL, scapholunate ligament; LT, lunotriquetral ligament; UT, ulnotriquetral ligament; UL, ulnolunate ligament; S, scaphoid; L, lunate; C, capitate; T, triquetrum; R, radius.) (Reprinted with permission.94)
and LTIO ligament tears for a minimum of 2 years’ follow-up and found excellent results in 13 of 14 cases. Whipple65 treated SLIO ligament tears with AAR and percutaneous pinning, comparing patients TABLE 2.
with symptoms of less than 3 months’ duration and a scapholunate gap of less than 3 mm versus those with symptoms of more than 3 months’ duration and a scapholunate gap of more than 3 mm. At final follow-
Geissler’s Classification of Interosseous Ligament Injury7
Grade
Description
I II
Radiocarpal arthroscopy shows attenuation/hemorrhage of interosseous ligament. Midcarpal arthroscopy shows no incongruence. Radiocarpal arthroscopy shows attenuation/hemorrhage of interosseous ligament. Midcarpal arthroscopy shows incongruence or step-off; possible presence of gap between carpal bones that is less than the width of the probe. Incongruence/step-off of carpal alignment shown by both radiocarpal and midcarpal arthroscopy; probe can pass between carpal bones. Incongruence/step-off of carpal alignment shown by both radiocarpal and midcarpal arthroscopy; there is gross instability as shown by a 2.7-mm arthroscope being able to pass between carpal bones.
III IV
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up, 83% and 53% of patients were symptom-free, respectively. For the former group, a subsequent 2- to 7-year follow-up showed successful results in 85%. This important study shows that chronic tears of the SLIO ligament lose their intrinsic ability to heal and therefore highlights the significance of early diagnosis and management when there is still healing potential in the ligaments. Westkaemper et al.34 used arthroscopic debridement alone to treat 23 patients with SLIO ligament tears (21 partial and 2 complete) and 5 patients with LTIO ligament tears. The results were excellent or good in 87% of patients with SLIO ligament tears, whereas 4 of 5 patients with LTIO ligament tears had poor results. Osterman and Seidman66 reported the outcome of arthroscopic debridement and pinning of the scapholunate interval in 20 patients with LTIO ligament tears. At a mean follow-up of almost 3 years, 80% of the patients had complete relief of pain. Although wrist flexion and extension were reduced by 17% and 25%, respectively, the postoperative grip strength improved to 90%. In his series of 21 patients with tears of the dorsal radiocarpal ligament (DRCL), Slutsky67 repaired the DRCL with an outside-in technique using a volar radial portal. He showed that an isolated DRCL tear may have been solely responsible for wrist pain in 4 patients and that its repair had good results with no or mild pain. In case of a DRCL tear in combination with an SLIO ligament, LTIO ligament, or TFCC tear, the prognosis after treatment is poorer, and he concluded that further research into treatment methods is warranted. Earp et al.68 studied the outcome of arthroscopic management of chronic wrist pain that failed to respond to conservative measures at a minimum of 2 years’ follow-up in 32 children and adolescents (mean age, 13 years). There were 30 Geissler grade II tears and 2 Geissler grade III tears. Additional injuries included 7 partial tears of the short radiolunate ligament, 12 TFCC injuries (type 1B and 1D), and 27 chondral injuries, which were also addressed. There was significant improvement in the postoperative modified Mayo wrist score,20 showing that arthroscopy may provide a long-term benefit in patients with Geissler grade II tears in this patient population. It can therefore be concluded that simple debridement of the flaps in partial SLIO and LTIO ligament tears yields an excellent outcome, whereas the results of debridement are less satisfactory in cases of complete tears. Arthroscopic debridement of unstable segments of ligaments and pinning in the acute setting comprise a satisfactory option in the latter case, yield-
ing good results. Early diagnosis is important so that treatment may be undertaken when there is still healing potential in the ligaments. Further study is needed to address the problem of DRCL injuries. Use of Electrothermal Devices (Lasers and Radiofrequency Probes) in Wrist Arthroscopy Debridement of TFCC tears may be done either mechanically or with the use of laser or radiofrequency (RF) devices.51,69-71 In addition, ulnar shortening has been performed with the use of lasers, because RF probes cannot resect bone.70 The currently used laser device is the holmium:yttrium-aluminumgarnet (Ho:YAG) laser.69,70 Although there have been concerns because of the reports of 4 cases of avascular necrosis of the femoral condyle,72 in a subsequent review of 504 laser-assisted knee arthroscopies by Janecki et al.,73 there were no cases of avascular necrosis. Likewise, Gerber et al.74 have concluded that there is no acoustic trauma related to the vaporization of water at the tip of the Ho:YAG device. Similarly to the larger joints, the use of electrothermal devices remains controversial in the wrist. Nagle70 has reported no laser-related complications and no increase in postoperative wrist effusion or pain in over 250 laser-assisted wrist arthroscopies. Blackwell et al.69 reported a good to excellent response overall in 68% of patients among 35 cases of laserassisted arthroscopic debridement for a Palmer type 1A tear. Arthroscopic ulnar shortening for the treatment of ulnar impaction syndrome may also be accomplished with the use of the Ho:YAG laser. Nagle and Bernstein51 reviewed 11 patients with a mean follow-up of 31 months and found excellent or good results in 81% overall. Complications included ulnocarpal scar formation, transient tendinitis, and 1 portal-site erythema. Practically all patients returned to work. Further studies are warranted to compare laser-assisted methods with mechanically arthroscopic ulnar shortening. Regarding the use of RF probes, Darlis et al.71 reported the preliminary results in 20 patients (14 Palmer type 1A TFCC tears, 4 type 1D, and 4 type 2) who underwent debridement with RF probes with a mean follow-up of 22 months. There was substantial pain relief in 17 patients and no change in pain in 3, with no perioperative complications. However, Pell and Uhl75 retrospectively reviewed 47 wrist arthroscopies in which RF probes were used and found 3 patients (9%) with serious RF-related complications, including tendon ruptures in all 3 cases and a 5 ⫻
CURRENT CONCEPTS IN WRIST ARTHROSCOPY 10 –mm full-thickness skin burn in 1. This raises concerns over the safety of RF probes, and further studies are warranted to confirm their safety. Electrothermal shrinkage of the dorsal and palmar portions of the SLIO ligaments in patients with mild SLIO ligament instability has been reported. Darlis et al.76 reported on arthroscopic debridement and thermal shrinkage using RF probes for 16 partial SLIO ligament injuries (Geissler grade I or II) with a mean follow-up of 19 months. The outcomes were excellent or good in 88% of patients overall according to the Mayo wrist score.20 Similarly, Hirsh et al.77 reported that 9 of 10 patients with Geissler grade II injuries to the SLIO ligament with a mean follow-up of 28 months were asymptomatic and had returned to their preinjury function. Shih et al.78 reported a 79% success rate at a minimum of 2 years’ follow-up in 19 wrists with SLIO ligaments treated with electrothermal shrinkage. It can be concluded that the electrothermal shrinkage may play a role in the management of partial tears of the SLIO ligament. To date, its use is controversial, and most studies have a short follow-up.
GANGLIA Arthroscopic Resection of Dorsal Wrist Ganglia The dorsal wrist ganglia are the most frequent (60% to 70%) of all hand and wrist ganglia.79 Management options include benign neglect, because spontaneous resolution has been reported; aspiration, with or without cortisone infusion; and excision. Arthroscopy offers minimal scar formation, better visualization and accurate tracing of the ganglion’s pedicle for excision, and evaluation of concomitant intra-articular lesions. The rate of recurrence in open surgery has been variable and has been reported to be as high as 40%.79-81 In the arthroscopic studies published to date, it ranges from 4% to 7%,82-86 with the exception of the study by Chassat et al.,87 who report a 30% recurrence rate. It may be concluded that arthroscopy may prove to be of substantial benefit with respect to recurrences; however, further arthroscopic studies are warranted to confirm or dismiss the results of Chassat et al. An important issue is the association between the SLIO ligament instability and open ganglionectomy. Damage to the SLIO ligament after open surgery is rare but has been reported88,89; in the arthroscopic series published to date, there has been no evidence of postoperative SLIO ligament instability.82,84-87,90 This may be because the arthroscopic technique allows for
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FIGURE 6. Arthroscopic view of dye in volar ganglion extravasating into joint through volar ligament defect between RSC and radio-lunotriquetral ligament. (S, scaphoid; R, radius; RSC, radio-scapho-capitate ligament.) (Reprinted with permission.92)
a more controlled separation of the ganglion’s stalk from the ganglion proper. Associated injuries to the wrist joint have been documented in patients undergoing arthroscopic ganglion removal. Mathoulin et al.84 found associated lesions in 25% of 96 cases, whereas Shih et al.90 reported associated lesions in 38% of their 32 patients. Arthroscopy has the advantage of evaluating and treating any associated lesions, such as TFCC, cartilage, and ligament injuries. The results of arthroscopic resection of dorsal ganglia are rewarding. Rizzo et al.86 found significantly improved pain, range of motion, and grip strength in 41 patients with a minimum of 2 years’ follow-up. Mathoulin et al.,84 in a series of 96 patients, showed excellent results, with all patients being pain-free, with full range of motion and grip strength. Rocchi et al.83 reported excellent results in 27 of 30 cases of dorsal wrist ganglia. There was 1 recurrence, 1 postsurgical hematoma, and 1 axonotmesis of the sensory branch of the radial nerve. These arthroscopic outcomes compare favorably with open ganglionectomy. Arthroscopic Resection of Volar Wrist Ganglia There have been a limited number of reports regarding arthroscopic resection of volar wrist ganglia (Fig 6). Mathoulin et al.84 reported on 32 patients with excellent results, all pain-free, with full range of motion and grip strength and absence of complications or recurrences. Similarly, Ho et al.91 reported excellent results in 6 cases. Rocchi et al.83 reported excellent results in
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12 of 17 cases. However, among the 4 cases of the uncommon volar midcarpal ganglia, there were 3 complications that required open procedures: 1 injury to a radial arterial branch, 1 injury to the sensory branch of the radial nerve, and 1 arthroscopic technical difficulty. For volar midcarpal ganglia, an open approach is preferable.83,91 It can be concluded that the results from the preliminary arthroscopic studies treating volar wrist ganglia are encouraging; however, further studies are needed to evaluate the safety and efficacy of arthroscopic techniques.
CONCLUSIONS The range of treatments using wrist arthroscopy is expanding and brings new controversies and challenges. Its role in the treatment of DRFs is controversial and should be individualized according to patient and surgeon. Wrist arthroscopy is the gold standard in the diagnosis and treatment of TFCC injuries. Excellent outcomes have been obtained with debridement in partial SLIO and LTIO ligament tears, whereas in complete tears, debridement and pinning are satisfactory. The use of the newer electrothermal devices is promising; however, further investigation is warranted to better define their efficacy and safety. Arthroscopic results of dorsal ganglia resection show excellent results, and further studies are required to evaluate the role of arthroscopy in the management of volar ganglia.
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8. Hardy P, Gomes N, Chebil M, Bauer T. Wrist arthroscopy and intra-articular fractures of the distal radius in young adults. Knee Surg Sports Traumatol Arthrosc 2006;14:1225-1230. 9. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg [Am] 2000;25:464-468. 10. Lindau T. Wrist arthroscopy in distal radial fractures using a modified horizontal technique. Arthroscopy 2001;17:5e. Available online at www.arthroscopyjournal.org. 11. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach. J Bone Joint Surg Br 2000;82:79-86. 12. Peicha G, Seibert F, Fellinger M, Grechenig W. Midterm results of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures. Knee Surg Sports Traumatol Arthrosc 1999;7:327-333. 13. Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures. Arthroscopy 2003;19:511-516. 14. Ruch DS, Vallee J, Poehling GG, Smith BP, Kuzma GR. Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fractures. Arthroscopy 2004;20:225-230. 15. Shih JT, Lee HM, Hou YT, Tan CM. Arthroscopically-assisted reduction of intra-articular fractures and soft tissue management of distal radius. Hand Surg 2001;6:127-135. 16. Lindau T. Treatment of injuries to the ulnar side of the wrist occurring with distal radial fractures. Hand Clin 2005;21:417425. 17. Geissler WB. Intra-articular distal radius fractures: The role of arthroscopy? Hand Clin 2005;21:407-416. 18. Gartland JJ Jr, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg Am 1951;33:895-907. 19. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intraarticular fractures of the distal aspect of the radius: Arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg Am 1999;81:10931110. 20. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987:136-147. 21. Seitz WH Jr, Putnam MD, Dick HM. Limited open surgical approach for external fixation of distal radius fractures. J Hand Surg [Am] 1990;15:288-293. 22. Kamano M, Koshimune M, Kazuki K, Honda Y. Palmar plating for AO/ASIF C3.2 fractures of the distal radius with arthroscopically assisted reduction. Hand Surg 2005;10:71-76. 23. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg 2006;10:139-144. 24. del Piñal F, García-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: Surgical technique. J Hand Surg [Am] 2007;32:119-123. 25. Luchetti R, Atzei A, Fairplay T. Arthroscopic wrist arthrolysis after wrist fracture. Arthroscopy 2007;23:255-260. 26. Palmer AK. Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 1989;14:594-606. 27. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007;23: 729-737.e1. Available online at www.arthroscopyjournal.org. 28. Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Up Extrem Surg 2007;11:38-44. 29. Chen AC, Hsu KY, Chang CH, Chan YS. Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal. Arthroscopy 2005;21:1406.e1-1406.e4. Available online at www.arthroscopyjournal.org.
CURRENT CONCEPTS IN WRIST ARTHROSCOPY 30. Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg Am 1996;78:348-356. 31. Tanaka T, Yoshioka H, Ueno T, Shindo M, Ochiai N. Comparison between high-resolution MRI with a microscopy coil and arthroscopy in triangular fibrocartilage complex injury. J Hand Surg [Am] 2006;31:1308-1314. 32. Joshy S, Lee K, Deshmukh SC. Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fibrocartilage complex tears of the wrist. Int Orthop. 2007 Jan 11; [Epub ahead of print]. 33. Husby T, Haugstvedt JR. Long-term results after arthroscopic resection of lesions of the triangular fibrocartilage complex. Scand J Plast Reconstr Surg Hand Surg 2001;35:79-83. 34. Westkaemper JG, Mitsionis G, Giannakopoulos PN, Sotereanos DG. Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries. Arthroscopy 1998; 14:479-483. 35. de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 1996;12:699-703. 36. Whipple TL, Geissler WB. Arthroscopic management of wrist triangular fibrocartilage complex injuries in the athlete. Orthopedics 1993;16:1061-1067. 37. Zachee B, De Smet L, Fabry G. Arthroscopic suturing of TFCC lesions. Arthroscopy 1993;9:242-243. 38. Bohringer G, Schadel-Hopfner M, Petermann J, Gotzen L. A method for all-inside arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy 2002;18: 211-213. 39. Corso SJ, Savoie FH, Geissler WB, Whipple TL, Jiminez W, Jenkins N. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: A multicenter study. Arthroscopy 1997;13:78-84. 40. Degreef I, Welters H, Milants P, Van Ransbeeck H, De Smet L. Disability and function after arthroscopic repair of ulnar avulsions of the triangular fibrocartilage complex of the wrist. Acta Orthop Belg 2005;71:289-293. 41. Ruch DS, Papadonikolakis A. Arthroscopically assisted repair of peripheral triangular fibrocartilage complex tears: Factors affecting outcome. Arthroscopy 2005;21:1126-1130. 42. Tomaino MM. Management of type C TFCC tears. In: Geissler WB, ed. Wrist arthroscopy. New York: Springer, 2005; 50-54. 43. Miwa H, Hashizume H, Fujiwara K, Nishida K, Inoue H. Arthroscopic surgery for traumatic triangular fibrocartilage complex injury. J Orthop Sci 2004;9:354-359. 44. Shih JT, Lee HM, Tan CM. Early isolated triangular fibrocartilage complex tears: Management by arthroscopic repair. J Trauma 2002;53:922-927. 45. Sagerman SD, Short W. Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy 1996;12: 339-342. 46. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: Management by early arthroscopic repair. J Hand Surg [Am] 1997;22:57-65. 47. Jantea CL, Baltzer A, Ruther W. Arthroscopic repair of radialsided lesions of the triangular fibrocartilage complex. Hand Clin 1995;11:31-36. 48. Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg [Am] 1994;19:143-154. 49. Minami A, Ishikawa J, Suenaga N, Kasashima T. Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg [Am] 1996;21:406-411. 50. Bernstein MA, Nagle DJ, Martinez A, Stogin JM Jr, Wiedrich TA. A comparison of combined arthroscopic triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex
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72. Garino JP, Lotke PA, Sapega AA, Reilly PJ, Esterhai JL Jr. Osteonecrosis of the knee following laser-assisted arthroscopic surgery: A report of six cases. Arthroscopy 1995;11:467-474. 73. Janecki CJ, Perry MW, Bonati AO, Bendel M. Safe parameters for laser chondroplasty of the knee. Lasers Surg Med 1998; 23:141-150. 74. Gerber BE, Asshauer T, Delacretaz G, Jansen T, Oberthur T. Biophysical bases of the effects of holmium laser on articular cartilage and their impact on clinical application technics. Orthopade 1996;25:21-29 (in German). 75. Pell RF, Uhl RL. Complications of thermal ablation in wrist arthroscopy. Arthroscopy 2004;20:84-86 (suppl 2). 76. Darlis NA, Weiser RW, Sotereanos DG. Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage. J Hand Surg [Am] 2005;30:908-914. 77. Hirsh L, Sodha S, Bozentka D, Monaghan B, Steinberg D, Beredjiklian PK. Arthroscopic electrothermal collagen shrinkage for symptomatic laxity of the scapholunate interosseous ligament. J Hand Surg [Br] 2005;30:643-647. 78. Shih JT, Lee HM. Monopolar radiofrequency electrothermal shrinkage of the scapholunate ligament. Arthroscopy 2006;22: 553-557. 79. Angelides AC, Wallace PF. The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg [Am] 1976;1:228-235. 80. McEvedy BV. Cystic ganglia; their pathology, natural history and treatment. Med Illus 1955;9:425-428. 81. Zachariae L, Vibe-Hansen H. Ganglia. Recurrence rate elucidated by a follow-up of 347 operated cases. Acta Chir Scand 1973;139:625-628. 82. Luchetti R, Badia A, Alfarano M, Orbay J, Indriago I, Mustapha B. Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. J Hand Surg [Br] 2000;25:38-40. 83. Rocchi L, Canal A, Pelaez J, Fanfani F, Catalano F. Results
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and complications in dorsal and volar wrist Ganglia arthroscopic resection. Hand Surg 2006;11:21-26. Mathoulin C, Hoyos A, Pelaez J. Arthroscopic resection of wrist ganglia. Hand Surg 2004;9:159-164. Nishikawa S, Toh S, Miura H, Arai K, Irie T. Arthroscopic diagnosis and treatment of dorsal wrist ganglion. J Hand Surg [Br] 2001;26:547-549. Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: Results with a minimum 2-year follow-up period. J Hand Surg [Am] 2004;29:59-62. Chassat R, Nourissat G, Chaumeil G, Dumontier C. Arthroscopic treatment of dorsal ganglion cyst at the wrist. About 54 cases. Chir Main 2006;25:146-151 (in French). Crawford GP, Taleisnik J. Rotatory subluxation of the scaphoid after excision of dorsal carpal ganglion and wrist manipulation—A case report. J Hand Surg [Am] 1983;8:921-925. Duncan KH, Lewis RC Jr. Scapholunate instability following ganglion cyst excision. A case report. Clin Orthop Relat Res 1988:250-253. Shih JT, Hung ST, Lee HM, Tan CM. Dorsal ganglion of the wrist: Results of treatment by arthroscopic resection. Hand Surg 2002;7:1-5. Ho PC, Lo WN, Hung LK. Arthroscopic resection of volar ganglion of the wrist: A new technique. Arthroscopy 2003;19: 218-221. Koman LA, ed. Wake Forest University School of Medicine Orthopaedic Manual 2006. Winston-Salem, NC: Orthopaedic Press, 2006. Koman LA, ed. Wake Forest University School of Medicine Orthopaedic Manual 2007. Winston-Salem, NC: Orthopaedic Press, 2007. Koman LA, ed. Wake Forest University School of Medicine Orthopaedic Manual 1997. Winston-Salem, NC: Orthopaedic Press, 1997.
Current Concepts in Wrist Arthroscopy George D. Chloros, M.D., Ethan R. Wiesler, M.D., and Gary G. Poehling, M.D.
Abstract: The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction–internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy. Key Words: Arthroscopy—Wrist—Distal radius fractures—Triangular fibrocartilage complex—Ganglia—Wrist ligaments.
W
rist arthroscopy is a continuously expanding field, bringing up new controversies and challenges. This review focuses on the current status of arthroscopy in the treatment of distal radius fractures (DRFs), triangular fibrocartilage complex (TFCC) in-
From the Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A. The authors report no conflict of interest. Address correspondence and reprints requests to George D. Chloros, M.D., Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2403-5323$34.00/0 doi:10.1016/j.arthro.2007.10.006
juries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. DISTAL RADIUS FRACTURE As first shown by Knirk and Jupiter1 in 1986 and subsequently by multiple studies,2,3 an articular stepoff of 1 to 2 mm may lead to the development of degenerative changes, and therefore accurate articular reduction is warranted. Studies show that compared with arthroscopy, fluoroscopy has been unsatisfactory in the evaluation of the status of the articular surfaces.4,5 Several authors report the presence of soft-tissue injuries occurring with both extra- and intra-articular DRFs (Fig 1). The reported incidence of TFCC tears
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FIGURE 1. (A) Anteroposterior radiograph. Note the apparent widening of the scapholunate interval (arrow). Also note that the scaphoid is foreshortened and the most distal portion of the lunate is quadrangular. This suggests that the scaphoid is flexed and the lunate and triquetrum are extended. (B) Lateral radiographs of a DRF are inconclusive regarding the extent of the injury. The scaphoid is slightly flexed as compared with the lunate. (C) The sagittal computed tomography scan shows a dorsally angulated articular fragment and radial styloid impaction (arrow). (D) MR image showing the intra-articular DRF and simultaneous scapholunate ligament injury (asterisk). (Reprinted with permission.92)
occurring with DRFs ranges from 10% to 84%, and scapholunate interosseous (SLIO) ligament injuries range from 7% to 86% of fractures, lunotriquetral
interosseous (LTIO) ligament injuries range from 0% to 60%, and chondral injuries range from 15% to 42%.6-15 The question that arises is whether treating
CURRENT CONCEPTS IN WRIST ARTHROSCOPY the associated tissue injuries results in any benefit to the final outcome of DRFs.2,3,16,17 Lindau et al.9 studied 43 patients with DRFs who had TFCC injuries proven arthroscopically but were left untreated, and at 1 year postoperatively, they found distal radioulnar joint instability in 19 patients, which was painful in 13. Ruch et al.13 acutely treated 13 TFCC injuries occurring with DRFs with arthroscopy. None of the patients reported ulnar-sided wrist pain, range of motion and grip strength were good, and the Gartland and Werley scores18 were excellent in 12 patients. Peicha et al.12 followed up 7 patients with arthroscopically proven SLIO ligament tears with DRFs who were treated with temporary SLIO ligament arthrodesis at 3 years postoperatively and found good to excellent results in all patients. These nonrandomized, uncontrolled studies show that there may be a benefit in acutely addressing the associated injuries occurring with DRFs. Results of Treatment To date, there has been only 1 prospective randomized study, performed by Doi et al.19 in 1999, which compared the outcome in 34 DRFs treated with arthroscopically assisted reduction (AAR) with 48 fractures treated with open reduction–internal fixation. At a minimum of 2 years’ follow-up, the patients in the AAR group had better outcomes according to the Mayo wrist score20 and Gartland and Werley score18 and better range of motion, grip strength, and radiographic results. Other nonrandomized studies have shown that AAR restores articular congruity and yields good to excellent outcomes. Ruch et al.14 compared the outcomes of fluoroscopic reduction (15 patients) versus arthroscopic reduction (15 patients) in 30 intra-articular DRFs with a step-off of greater than 2 mm after closed reduction and found improved range of motion in the arthroscopic group. Shih et al.15 reported on 33 patients with displaced intra-articular DRFs with AAR with a minimum follow-up of 24 months. They found and treated associated lesions in 22 of 33 patients, and the results were excellent in 11 patients and good in 22 according to the Mayo wrist score.20 Mehta et al.11 evaluated the results of AAR in 25 patients with intra-articular DRFs and addressed all TFCC, SLIO ligament, LTIO ligament, and osteochondral lesions simultaneously. At a mean follow-up of 19 months, the results were excellent in 88% of patients according to the New York Orthopaedic Hospital score,21 whereas according to the Gartland and Werley score,18 the results were good to excellent in
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70% of patients. Evaluation of articular congruency by use of plain radiographs revealed no articular stepoff in 65% of cases and a step-off of less than 1 mm in 31% of cases. Chen et al.6 studied the outcome of 20 intra-articular DRFs at a minimum of 12 months’ follow-up and found good to excellent results in 90% of patients according to the Mayo wrist score.20 Hardy et al.8 treated 18 intra-articular DRFs in a young population, and at a minimum follow-up of 9 months, according to the Mayo wrist score,20 72% of patients had good to excellent results. Kamano et al.22 treated 15 young patients with AO/ASIF C3.2 DRFs with AAR and palmar plating with autologous bone graft and found good results in 15 and excellent results in 5 according to the Gartland and Werley score.18 However, despite the absence of radiographic step-off, 10 patients had grade 1 osteoarthritis. In 2 recent reviews regarding the role of arthroscopy in DRFs, Chloros et al.2 and Wiesler et al.3 emphasized that there are no currently established rigid indications regarding the treatment of DRFs. The authors’ preferred indications for AAR of DRFs were fractures of the radial styloid, die-punch injuries, and intra-articular DRFs with suspected associated ligament or TFCC injury. Other valid indications included 3- or 4-part DRFs with articular displacement of greater than 2 mm after failure of closed reduction. The authors stated that there are multiple management approaches for each type of fracture, indicated that the basic principles of fracture treatment should be followed, and insisted on the importance of an individualized approach to treatment of DRFs (Fig 2). Techniques and indications for the arthroscopic management of DRFs are evolving. Lindau10 successfully performed wrist arthroscopy in 17 patients using a horizontal technique with standard arthroscopic equipment. The rationale was to maintain the traction and the arthroscopically reduced position of the wrist when performing additional procedures (e.g., plating), thus avoiding the risk of loss of arthroscopic reduction. Wiesler et al.23 have recently reported on an arthroscopic fixation technique for the management of DRFs with a volar lunate facet component. The fragments are disimpacted by use of a freer elevator introduced dorsally, and subsequently, the volar lunate facet is reduced with a nerve hook. del Piñal et al.24 have reported a technique for dry arthroscopy of the wrist. Luchetti et al.25 have reported good preliminary results with arthroscopic wrist arthrolysis to remedy wrist stiffness after fracture. It can therefore be concluded that (1) wrist arthroscopy is advantageous in providing accurate as-
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FIGURE 2. DRF case example. (A) Anteroposterior radiograph showing widening of scapholunate ligament and intra-articular fracture. (B) Arthroscopic view of displaced fracture. (C) Arthroscopic view of fracture after reduction and pinning. Note that there remains very little displacement. (D) This postoperative radiograph shows a well-reduced central fragment with pins across the scapholunate ligament and the DRF supported by a radiolucent external fixator. (Reprinted with permission.93)
sessment of the status of the articular surfaces and in detecting concomitant soft-tissue injuries, (2) the techniques and indications are expanding, and (3) nonrandomized studies of AAR of DRFs show satisfactory results. There is only 1 prospective randomized outcome study comparing AAR with open reduction– internal fixation that shows the benefits of arthroscopy.1
nosis and staging of TFCC lesions. Triple-injection arthrography has a low sensitivity and specificity compared with arthroscopy, as shown by Weiss et al.,30 whereas recent literature shows that high-resolution magnetic resonance imaging (MRI)31 and magnetic resonance (MR) arthrography32 are also not entirely satisfactory. Arthroscopy is advantageous in both the diagnosis and treatment of TFCC injuries.
ARTHROSCOPY IN TREATMENT OF TFCC INJURIES
Traumatic Injuries: Palmer Type 1 Type 1A: In 80% to 85% of patients with neutral or negative ulnar variance, the outcomes of debridement of Palmer type 1A TFCC tears (Fig 4) yield excellent to good results, with no requirement for further surgery.33,34 Type 1B: Type 1B lesions occur in the peripheral, well-vascularized portion of the TFCC, and therefore healing is increased. Several arthroscopic techniques have been reported, including the inside-out technique (Poehling and colleagues35 [Tuohy needle]), the out-
Injuries to the TFCC are commonly classified according to the Palmer classification (Table 1, Fig 3).26 However, a recent study by Estrella et al.27 found 18 dorsal TFCC lesions that could not be classified according to Palmer. The use of volar portals as described by Slutsky28 and Chen et al.29 may allow better ease of access for dorsal TFCC lesions. Wrist arthroscopy is the gold standard for the diag-
TABLE 1.
Palmer’s Classification of TFCC Injuries26 Description
Type 1: Traumatic TFCC lesions 1A 1B 1C 1D Type 2: Degenerative TFCC lesions 2A 2B 2C 2D 2E
Isolated central disk perforation Peripheral ulnar-sided tear of TFCC (with or without ulnar styloid fracture) Distal TFCC disruption (i.e., disruption from distal ulnocarpal ligaments) Radial TFCC disruption (with or without sigmoid notch fracture) TFCC wear TFCC wear with lunate or ulnar chondromalacia (or both) TFCC perforation with lunate or ulnar chondromalacia (or both) TFCC perforation with lunate or ulnar chondromalacia (or both) and with lunotriquetral ligament perforation TFCC perforation with lunate or ulnar chondromalacia (or both) and with lunotriquetral ligament perforation and ulnocarpal arthritis
CURRENT CONCEPTS IN WRIST ARTHROSCOPY
FIGURE 3. Palmer classification of TFCC traumatic injuries: (A) vertical tear 2 to 3 mm from radial border, (B) peripheral TFCC tear recognized by loss of tension of ligament, (C) tear of ulnocarpal ligaments, and (D) tear across TFCC at level of radius. There usually is a piece of bone left attached to the TFCC. (R, radius; U, ulna; L, lunate; T, triquetrum.) (Courtesy of Dr. Anastasios Papadonikolakis.)
side-in technique (Whipple and Geissler36 and Zachee et al.37), and the all-inside technique described by Bohringer et al.38 The results of the TFCC repair of type 1B lesions have been rewarding. In a multicenter study, Corso et al.39 found good to excellent results in 41 of 45 wrists (91%) repaired with an outside-in technique. Degreef et al.40 found minimal or absent
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pain in 47 of 52 cases at a minimum of 6 months’ follow-up. In a recent study Estrella et al.27 repaired 35 peripheral tears of the TFCC, including 11 type 1B tears, and found good to excellent results in 74% according to the Mayo wrist score20 whereas secondlook arthroscopy showed healing in 7 of 9 patients. Of note, dorsal sensory ulnar neuritis occurred in 17% of patients. Ruch and Papadonikolakis41 found that agerelated changes in the wrist, loss of grip strength, positive ulnar variance, and decreased supination are factors associated with a poorer outcome of TFCC repairs. Type 1C: In cases of isolated fraying, debridement may be used to remove any mechanical source of pain, whereas in cases of frank ulnar ligamentous disruption, either open or arthroscopic repair is the recommended treatment.42 Miwa et al.43 treated 7 type 1C tears with arthroscopic debridement and found an overall success rate of 88%. Shih et al.,44 in a series of 37 patients, including 10 patients with type 1C tears arthroscopically repaired with sutures, reported good to excellent results in 92% of patients overall. Type 1D: There is controversy regarding the management of type 1D lesions with complete avulsion of the TFCC off the distal radius, which is done by either debridement or repair. There are several techniques for repair, as described by Sagerman and Short,45 Trumble et al.,46 and Jantea et al.47 After the study of open repair of peripheral TFCC
FIGURE 4. (A) Suction biter debriding a central TFCC tear. The arthroscope is in the 3-4 portal, and the suction basket is in the 6R portal. This position allows debridement of the volar and radial sides of the tear. (B) After debridement of type 1A tear, with preservation of peripheral attachments. (R, radius; L, lunate; U, ulna.) (Reprinted with permission.92)
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injuries by Cooney et al.48 in 1994, good clinical results have been shown in several other studies with repair of the type 1D injury.45,46 In 13 patients with type 1D TFCC tears repaired arthroscopically by Trumble et al.,46 at a minimum of 2 years, 11 had complete pain relief and 2 had slight discomfort. Arthrography, MRI, and arthroscopy showed an intact TFCC at the latest follow-up in 10 patients. Miwa et al.,43 treated 17 type 1D injuries with arthroscopic suturing (12 cases) or debridement (5 cases). The results were good to excellent in 92% in the suture group and 80% in the debridement group. It may be concluded that in type 1D TFCC tears, which involve the distal radioulnar joint stabilizing the volar or dorsal radioulnar ligaments (or both), arthroscopic reattachment has been a reliable and successful management option, including objective evidence of healing. Degenerative Injuries: Palmer Type 2 Ulnar impaction syndrome results from chronic overloading of the ulnar side of the wrist and has been depicted in type 2 injuries of the Palmer classification.26 In 1996 Minami et al.49 showed that simple TFCC debridement with positive ulnar variance was unsuccessful and further concluded that osseous decompression of the ulnar side of the wrist should be performed. Patients with positive ulnar variance or Palmer type 2C, 2D, or 2E tears may be candidates for unloading of the ulnar side of the wrist, either by an ulnar shortening osteotomy (USO)50-52 or by a wafer procedure.53,54 A recent cadaveric study showed that the arthroscopic wafer procedure reduces the ulnar load in all conditions of ulnar variance.55 Tomaino and Weiser53 reviewed the outcome of the arthroscopic wafer procedure combined with an arthroscopic TFCC debridement in TFCC tears associated with positive ulnar variance in 12 patients. At final follow-up, 8 patients were pain-free and 4 had minimal symptoms. Neutral ulnar variance was restored in all patients. The results of USO have also been satisfactory.56 There have been 2 comparison outcome studies of USO versus the wafer procedure, by Constantine et al.57 and Bernstein et al.50 They concluded that although both the USO and wafer procedures provide similar pain relief and restoration of function, the latter is associated with fewer secondary procedures and tendinitis as compared with USO. Recently, Tatebe et al.58 performed second-look arthroscopies in 32 patients who had undergone USO who had a central TFCC tear documented on the first
arthroscopy. In 50% of the cases, the TFCC was found to be spontaneously repaired, showing that the avascular zone of the TFCC has some potential to repair. Intercarpal Ligament Injuries Prompt diagnosis in the acute setting may achieve primary ligament healing and possibly avoid later reconstructive procedures. Tricompartmental arthrography, as shown by Weiss et al.,30 has a low sensitivity, specificity, and accuracy in the detection of tears of either the SLIO ligament, the LTIO ligament, or the TFCC compared with arthroscopy. Hobby et al.59 reviewed 6 studies reporting the performance of MRI for SLIO ligament tears and 6 studies for LTIO ligament tears and found that MRI cannot reliably exclude tears of these ligaments. The technique was more sensitive for SLIO ligament tears than for LTIO ligament tears. MR wrist arthrography has been introduced to improve the accuracy of MRI. Meier et al.60 found 100% specificity and 72% sensitivity of MR arthrography compared with arthroscopy. It can be concluded that arthroscopy is the gold standard of imaging of SLIO and LTIO ligament injuries, currently surpassing arthrography, MRI, and MR arthrography (Fig 5). Furthermore, the utility of volar portals in the evaluation of the volar segments of the SLIO and LTIO ligaments has been shown in a recent study of 230 patients.61 A recent study by Abe et al.62 showed that wrist arthroscopy could identify various degrees of SLIO ligament tear as the main cause of radial-sided wrist pain in 11 wrists with inconclusive plain radiograph and MRI findings. The arthroscopic classification of carpal instability of Geissler et al.7 (Table 2) is commonly used as a guide to the diagnosis and management of interosseous ligament injuries. There is currently no arthroscopic procedure described to directly repair SLIO or LTIO ligament injuries; however, indirect procedures, including debridement, may be beneficial. In partial tears of the SLIO or LTIO ligament, excellent results have been reported with arthroscopic debridement. Weiss et al.63 reported the outcome of arthroscopic debridement alone for complete and incomplete SLIO or LTIO ligament tears in 43 wrists at a mean of 27 months’ follow-up. In the SLIO ligament group they found complete resolution or improved symptoms in 66% and 85% of complete and incomplete tears, respectively. The corresponding figures for the LTIO ligament group were 78% and 100%, respectively. Ruch and Poehling64 studied the outcome of arthroscopic debridement of isolated partial SLIO
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FIGURE 5. (A) The 3-4 portal allows visualization of the SLIO ligament; the ligament is flat and often hard to perceive. (B) Ulnocarpal ligaments seen through 6R portal. The LTIO ligament is seen as a concave structure between the lunate and the triquetrum. (C) Arthroscopic view of SLIO ligament tear looking from 3-4 portal into the midcarpal joint. (D) Partial tear of LTIO ligament. Note the irregular ligament behind the LTIO ligament. (SL, scapholunate ligament; LT, lunotriquetral ligament; UT, ulnotriquetral ligament; UL, ulnolunate ligament; S, scaphoid; L, lunate; C, capitate; T, triquetrum; R, radius.) (Reprinted with permission.94)
and LTIO ligament tears for a minimum of 2 years’ follow-up and found excellent results in 13 of 14 cases. Whipple65 treated SLIO ligament tears with AAR and percutaneous pinning, comparing patients TABLE 2.
with symptoms of less than 3 months’ duration and a scapholunate gap of less than 3 mm versus those with symptoms of more than 3 months’ duration and a scapholunate gap of more than 3 mm. At final follow-
Geissler’s Classification of Interosseous Ligament Injury7
Grade
Description
I II
Radiocarpal arthroscopy shows attenuation/hemorrhage of interosseous ligament. Midcarpal arthroscopy shows no incongruence. Radiocarpal arthroscopy shows attenuation/hemorrhage of interosseous ligament. Midcarpal arthroscopy shows incongruence or step-off; possible presence of gap between carpal bones that is less than the width of the probe. Incongruence/step-off of carpal alignment shown by both radiocarpal and midcarpal arthroscopy; probe can pass between carpal bones. Incongruence/step-off of carpal alignment shown by both radiocarpal and midcarpal arthroscopy; there is gross instability as shown by a 2.7-mm arthroscope being able to pass between carpal bones.
III IV
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up, 83% and 53% of patients were symptom-free, respectively. For the former group, a subsequent 2- to 7-year follow-up showed successful results in 85%. This important study shows that chronic tears of the SLIO ligament lose their intrinsic ability to heal and therefore highlights the significance of early diagnosis and management when there is still healing potential in the ligaments. Westkaemper et al.34 used arthroscopic debridement alone to treat 23 patients with SLIO ligament tears (21 partial and 2 complete) and 5 patients with LTIO ligament tears. The results were excellent or good in 87% of patients with SLIO ligament tears, whereas 4 of 5 patients with LTIO ligament tears had poor results. Osterman and Seidman66 reported the outcome of arthroscopic debridement and pinning of the scapholunate interval in 20 patients with LTIO ligament tears. At a mean follow-up of almost 3 years, 80% of the patients had complete relief of pain. Although wrist flexion and extension were reduced by 17% and 25%, respectively, the postoperative grip strength improved to 90%. In his series of 21 patients with tears of the dorsal radiocarpal ligament (DRCL), Slutsky67 repaired the DRCL with an outside-in technique using a volar radial portal. He showed that an isolated DRCL tear may have been solely responsible for wrist pain in 4 patients and that its repair had good results with no or mild pain. In case of a DRCL tear in combination with an SLIO ligament, LTIO ligament, or TFCC tear, the prognosis after treatment is poorer, and he concluded that further research into treatment methods is warranted. Earp et al.68 studied the outcome of arthroscopic management of chronic wrist pain that failed to respond to conservative measures at a minimum of 2 years’ follow-up in 32 children and adolescents (mean age, 13 years). There were 30 Geissler grade II tears and 2 Geissler grade III tears. Additional injuries included 7 partial tears of the short radiolunate ligament, 12 TFCC injuries (type 1B and 1D), and 27 chondral injuries, which were also addressed. There was significant improvement in the postoperative modified Mayo wrist score,20 showing that arthroscopy may provide a long-term benefit in patients with Geissler grade II tears in this patient population. It can therefore be concluded that simple debridement of the flaps in partial SLIO and LTIO ligament tears yields an excellent outcome, whereas the results of debridement are less satisfactory in cases of complete tears. Arthroscopic debridement of unstable segments of ligaments and pinning in the acute setting comprise a satisfactory option in the latter case, yield-
ing good results. Early diagnosis is important so that treatment may be undertaken when there is still healing potential in the ligaments. Further study is needed to address the problem of DRCL injuries. Use of Electrothermal Devices (Lasers and Radiofrequency Probes) in Wrist Arthroscopy Debridement of TFCC tears may be done either mechanically or with the use of laser or radiofrequency (RF) devices.51,69-71 In addition, ulnar shortening has been performed with the use of lasers, because RF probes cannot resect bone.70 The currently used laser device is the holmium:yttrium-aluminumgarnet (Ho:YAG) laser.69,70 Although there have been concerns because of the reports of 4 cases of avascular necrosis of the femoral condyle,72 in a subsequent review of 504 laser-assisted knee arthroscopies by Janecki et al.,73 there were no cases of avascular necrosis. Likewise, Gerber et al.74 have concluded that there is no acoustic trauma related to the vaporization of water at the tip of the Ho:YAG device. Similarly to the larger joints, the use of electrothermal devices remains controversial in the wrist. Nagle70 has reported no laser-related complications and no increase in postoperative wrist effusion or pain in over 250 laser-assisted wrist arthroscopies. Blackwell et al.69 reported a good to excellent response overall in 68% of patients among 35 cases of laserassisted arthroscopic debridement for a Palmer type 1A tear. Arthroscopic ulnar shortening for the treatment of ulnar impaction syndrome may also be accomplished with the use of the Ho:YAG laser. Nagle and Bernstein51 reviewed 11 patients with a mean follow-up of 31 months and found excellent or good results in 81% overall. Complications included ulnocarpal scar formation, transient tendinitis, and 1 portal-site erythema. Practically all patients returned to work. Further studies are warranted to compare laser-assisted methods with mechanically arthroscopic ulnar shortening. Regarding the use of RF probes, Darlis et al.71 reported the preliminary results in 20 patients (14 Palmer type 1A TFCC tears, 4 type 1D, and 4 type 2) who underwent debridement with RF probes with a mean follow-up of 22 months. There was substantial pain relief in 17 patients and no change in pain in 3, with no perioperative complications. However, Pell and Uhl75 retrospectively reviewed 47 wrist arthroscopies in which RF probes were used and found 3 patients (9%) with serious RF-related complications, including tendon ruptures in all 3 cases and a 5 ⫻
CURRENT CONCEPTS IN WRIST ARTHROSCOPY 10 –mm full-thickness skin burn in 1. This raises concerns over the safety of RF probes, and further studies are warranted to confirm their safety. Electrothermal shrinkage of the dorsal and palmar portions of the SLIO ligaments in patients with mild SLIO ligament instability has been reported. Darlis et al.76 reported on arthroscopic debridement and thermal shrinkage using RF probes for 16 partial SLIO ligament injuries (Geissler grade I or II) with a mean follow-up of 19 months. The outcomes were excellent or good in 88% of patients overall according to the Mayo wrist score.20 Similarly, Hirsh et al.77 reported that 9 of 10 patients with Geissler grade II injuries to the SLIO ligament with a mean follow-up of 28 months were asymptomatic and had returned to their preinjury function. Shih et al.78 reported a 79% success rate at a minimum of 2 years’ follow-up in 19 wrists with SLIO ligaments treated with electrothermal shrinkage. It can be concluded that the electrothermal shrinkage may play a role in the management of partial tears of the SLIO ligament. To date, its use is controversial, and most studies have a short follow-up.
GANGLIA Arthroscopic Resection of Dorsal Wrist Ganglia The dorsal wrist ganglia are the most frequent (60% to 70%) of all hand and wrist ganglia.79 Management options include benign neglect, because spontaneous resolution has been reported; aspiration, with or without cortisone infusion; and excision. Arthroscopy offers minimal scar formation, better visualization and accurate tracing of the ganglion’s pedicle for excision, and evaluation of concomitant intra-articular lesions. The rate of recurrence in open surgery has been variable and has been reported to be as high as 40%.79-81 In the arthroscopic studies published to date, it ranges from 4% to 7%,82-86 with the exception of the study by Chassat et al.,87 who report a 30% recurrence rate. It may be concluded that arthroscopy may prove to be of substantial benefit with respect to recurrences; however, further arthroscopic studies are warranted to confirm or dismiss the results of Chassat et al. An important issue is the association between the SLIO ligament instability and open ganglionectomy. Damage to the SLIO ligament after open surgery is rare but has been reported88,89; in the arthroscopic series published to date, there has been no evidence of postoperative SLIO ligament instability.82,84-87,90 This may be because the arthroscopic technique allows for
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FIGURE 6. Arthroscopic view of dye in volar ganglion extravasating into joint through volar ligament defect between RSC and radio-lunotriquetral ligament. (S, scaphoid; R, radius; RSC, radio-scapho-capitate ligament.) (Reprinted with permission.92)
a more controlled separation of the ganglion’s stalk from the ganglion proper. Associated injuries to the wrist joint have been documented in patients undergoing arthroscopic ganglion removal. Mathoulin et al.84 found associated lesions in 25% of 96 cases, whereas Shih et al.90 reported associated lesions in 38% of their 32 patients. Arthroscopy has the advantage of evaluating and treating any associated lesions, such as TFCC, cartilage, and ligament injuries. The results of arthroscopic resection of dorsal ganglia are rewarding. Rizzo et al.86 found significantly improved pain, range of motion, and grip strength in 41 patients with a minimum of 2 years’ follow-up. Mathoulin et al.,84 in a series of 96 patients, showed excellent results, with all patients being pain-free, with full range of motion and grip strength. Rocchi et al.83 reported excellent results in 27 of 30 cases of dorsal wrist ganglia. There was 1 recurrence, 1 postsurgical hematoma, and 1 axonotmesis of the sensory branch of the radial nerve. These arthroscopic outcomes compare favorably with open ganglionectomy. Arthroscopic Resection of Volar Wrist Ganglia There have been a limited number of reports regarding arthroscopic resection of volar wrist ganglia (Fig 6). Mathoulin et al.84 reported on 32 patients with excellent results, all pain-free, with full range of motion and grip strength and absence of complications or recurrences. Similarly, Ho et al.91 reported excellent results in 6 cases. Rocchi et al.83 reported excellent results in
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12 of 17 cases. However, among the 4 cases of the uncommon volar midcarpal ganglia, there were 3 complications that required open procedures: 1 injury to a radial arterial branch, 1 injury to the sensory branch of the radial nerve, and 1 arthroscopic technical difficulty. For volar midcarpal ganglia, an open approach is preferable.83,91 It can be concluded that the results from the preliminary arthroscopic studies treating volar wrist ganglia are encouraging; however, further studies are needed to evaluate the safety and efficacy of arthroscopic techniques.
CONCLUSIONS The range of treatments using wrist arthroscopy is expanding and brings new controversies and challenges. Its role in the treatment of DRFs is controversial and should be individualized according to patient and surgeon. Wrist arthroscopy is the gold standard in the diagnosis and treatment of TFCC injuries. Excellent outcomes have been obtained with debridement in partial SLIO and LTIO ligament tears, whereas in complete tears, debridement and pinning are satisfactory. The use of the newer electrothermal devices is promising; however, further investigation is warranted to better define their efficacy and safety. Arthroscopic results of dorsal ganglia resection show excellent results, and further studies are required to evaluate the role of arthroscopy in the management of volar ganglia.
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