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Wrist arthroscopy using the holmium-YAG laser: technical considerations
SESSION 9
SESSION 9: FREE PAPERS Wrist arthroscopy using the holmium-YAG laser: technical considerations W. Jaeck, K. Schiitz, M. Infanger, V. E. Meyer
Zurich, Switzerland
47
its insertion on the palmar aspect of the triquetrum. The avutsed part of the meniscus can drop into the ulnocarpal joint, causing an impingement phenomenon. In all of our patients the meniscus-fragments have been arthroscopically removed either by means of a shaver or a holmium-YAG laser. All of the 15 patients with isolated meniscus lesion followed for 12 to 18 months had either complete relief of pain (50%) or their symptoms had been substantially improved. The authors conclude that the ulnocarpal meniscus lesion is a separate group within the TFCC lesions and arthroscopy is the procedure of choice for its diagnosis and treatment.
The holmium-YAG laser has been found to be a safe and efficient tool for precise arthroscopic removal of intra-articular tissue. Especially in small articular compartments as in the wrist joint the thin handpieces are much easier to manoeuvre around the surfaces of the joint than other bulky instruments. We present here the initial experience in our first 40 cases of laser application in wrist arthroscopy. Laser was mainly used for treatment of symptomatic lesions of the TFCC. The excision of unstable class IA, ID and class II (Palmer) tears of the discus triangularis is performed by introducing the laser tip through the 4-5 portal or 6-R portal under visualization with the scope through the standard 3-4 portal. The laser is then used at middle energy setting of about 1.0 Joule per pulse and a pulse rate setting of about 10/s. The required time for this procedure is reduced compared with mechanical shaver techniques. In order to protect the optical system from damage by the laser beam, treatment of dorsoulnar impingement caused by lesions of the meniscus and dtbridement of ulnocarpal synovitis needs modified approaches to the joint. In addition to the laser we continue in such cases to use shavers or other resecters as well, depending on the individual situation. The haemostatic effect of the holmium laser is a great advantage especially for synovectomy. Exuberant and impinging scar tissue from previous capsulo-ligamentous damage are easily resected with the laser. We also rarely used the laser at lower energy to reshape the cartilaginous surface in grade II chondromalacia. As complications we have observed one small local skin burn, healing without complication, and one laser-damaged scope. This presentation demonstrates, with the support of video sequences, the feasibility, technique and efficiency of holmium-YAG laser dgbridement in wrist arthroscopy.
Osteoid osteoma (OO) is a benign osteoblastic tumour uncommonly affecting the hand and wrist. The purpose of this study was to investigate the clinical features, the diagnostic examinations and treatment of OO in this region.
Isolated lesions of the ulnocarpal meniscus: prime candidates for arthroscopic treatment
Results
K. E. Schtitz, W. Jaeck, V. E. Meyer
Zurich, Switzerland In a consecutive series of 212 arthroscopies of painful wrists, a lesion of the ulnocarpal meniscus was found in 30 patients. In 15 patients (50%) no other pathology was evident in the wrist. All complained of ulnar wrist pain evoked by axial load in extension. Two-thirds of these patients had evidence of an injury in their history. The preoperative physical examination showed marked ulnodorsal tenderness on palpation and the examiner could feel crepitation by passive motion in a radialulnar direction. The ulnocarpal meniscus represents a longitudinally oriented part of the triangular fibrocartilage complex (TFCC). Despite an improved spatial resolution, magnetic resonance imaging (MRI) fails to differentiate between articular disc and ulnocarpal meniscus lesion. In contrast the two structures are clearly identifiable by arthroscopy especially if there is a tear through the meniscus or even a complete avulsion from
Osteoid osteoma of hand and wrist M. D. Recchioni, R. Busa, A. Marcuzzi, G. Pancaldi, A. Caroli
Modena, Italy Objective
Methods In the period 1985 to 1996, 11 cases of OO were treated. Average age was 27 years (range: 15-33 years). Seven lesions were in the right (64%) and four in the left (36%) upper extremity. Three of the lesions occurred in the metacarpal bones, three in the phalanges, two in the scaphoid, one in the lunate and two in the distal radius. In all cases the main clinical features were pain, swelling and decreased range of motion. Six of these patients obtained partial pain relief from aspirin. A history of trauma before the onset of symptoms was present in seven patients. Diagnosis was obtained by X-ray examination, bone scans with radioactive Technetium, CT and MRI. All patients were surgically treated by "en bloc" resection. Bone grafting was done in six patients. Histological examination confirmed the pre-operative diagnosis in all cases. Mean follow-up was 39 months (range: 6-89 months). Recurrence was evident in one case (third metacarpal head, subchondral involvement) 8 months after surgery. This patient underwent a new wider resection, and metacarpophalangeal implant arthroplasty. Ten months after the second resection the patient does not have any clinical and radiological signs of recurrence. All the patients had no pain and tenderness, with complete recovery of motion.
Conclusions The hand is an infrequent site for OO. Clinical features can simulate arthritis or synovitis. The X-ray examination gives in most cases non-specific information which may delay diagnosis. In our study seven patients had an initially negative X-ray examination. Bone scan is highly sensitive for OO, but should be associated with CT examination to facilitate adequate surgical excision. MRI can show the tissue reaction around the tumour. Surgical excision is necessary and should be sufficiently wide to avoid recurrences.
SESSION 9: FREE PAPERS Wrist arthroscopy using the holmium-YAG laser: technical considerations W. Jaeck, K. Schiitz, M. Infanger, V. E. Meyer
Zurich, Switzerland
47
its insertion on the palmar aspect of the triquetrum. The avutsed part of the meniscus can drop into the ulnocarpal joint, causing an impingement phenomenon. In all of our patients the meniscus-fragments have been arthroscopically removed either by means of a shaver or a holmium-YAG laser. All of the 15 patients with isolated meniscus lesion followed for 12 to 18 months had either complete relief of pain (50%) or their symptoms had been substantially improved. The authors conclude that the ulnocarpal meniscus lesion is a separate group within the TFCC lesions and arthroscopy is the procedure of choice for its diagnosis and treatment.
The holmium-YAG laser has been found to be a safe and efficient tool for precise arthroscopic removal of intra-articular tissue. Especially in small articular compartments as in the wrist joint the thin handpieces are much easier to manoeuvre around the surfaces of the joint than other bulky instruments. We present here the initial experience in our first 40 cases of laser application in wrist arthroscopy. Laser was mainly used for treatment of symptomatic lesions of the TFCC. The excision of unstable class IA, ID and class II (Palmer) tears of the discus triangularis is performed by introducing the laser tip through the 4-5 portal or 6-R portal under visualization with the scope through the standard 3-4 portal. The laser is then used at middle energy setting of about 1.0 Joule per pulse and a pulse rate setting of about 10/s. The required time for this procedure is reduced compared with mechanical shaver techniques. In order to protect the optical system from damage by the laser beam, treatment of dorsoulnar impingement caused by lesions of the meniscus and dtbridement of ulnocarpal synovitis needs modified approaches to the joint. In addition to the laser we continue in such cases to use shavers or other resecters as well, depending on the individual situation. The haemostatic effect of the holmium laser is a great advantage especially for synovectomy. Exuberant and impinging scar tissue from previous capsulo-ligamentous damage are easily resected with the laser. We also rarely used the laser at lower energy to reshape the cartilaginous surface in grade II chondromalacia. As complications we have observed one small local skin burn, healing without complication, and one laser-damaged scope. This presentation demonstrates, with the support of video sequences, the feasibility, technique and efficiency of holmium-YAG laser dgbridement in wrist arthroscopy.
Osteoid osteoma (OO) is a benign osteoblastic tumour uncommonly affecting the hand and wrist. The purpose of this study was to investigate the clinical features, the diagnostic examinations and treatment of OO in this region.
Isolated lesions of the ulnocarpal meniscus: prime candidates for arthroscopic treatment
Results
K. E. Schtitz, W. Jaeck, V. E. Meyer
Zurich, Switzerland In a consecutive series of 212 arthroscopies of painful wrists, a lesion of the ulnocarpal meniscus was found in 30 patients. In 15 patients (50%) no other pathology was evident in the wrist. All complained of ulnar wrist pain evoked by axial load in extension. Two-thirds of these patients had evidence of an injury in their history. The preoperative physical examination showed marked ulnodorsal tenderness on palpation and the examiner could feel crepitation by passive motion in a radialulnar direction. The ulnocarpal meniscus represents a longitudinally oriented part of the triangular fibrocartilage complex (TFCC). Despite an improved spatial resolution, magnetic resonance imaging (MRI) fails to differentiate between articular disc and ulnocarpal meniscus lesion. In contrast the two structures are clearly identifiable by arthroscopy especially if there is a tear through the meniscus or even a complete avulsion from
Osteoid osteoma of hand and wrist M. D. Recchioni, R. Busa, A. Marcuzzi, G. Pancaldi, A. Caroli
Modena, Italy Objective
Methods In the period 1985 to 1996, 11 cases of OO were treated. Average age was 27 years (range: 15-33 years). Seven lesions were in the right (64%) and four in the left (36%) upper extremity. Three of the lesions occurred in the metacarpal bones, three in the phalanges, two in the scaphoid, one in the lunate and two in the distal radius. In all cases the main clinical features were pain, swelling and decreased range of motion. Six of these patients obtained partial pain relief from aspirin. A history of trauma before the onset of symptoms was present in seven patients. Diagnosis was obtained by X-ray examination, bone scans with radioactive Technetium, CT and MRI. All patients were surgically treated by "en bloc" resection. Bone grafting was done in six patients. Histological examination confirmed the pre-operative diagnosis in all cases. Mean follow-up was 39 months (range: 6-89 months). Recurrence was evident in one case (third metacarpal head, subchondral involvement) 8 months after surgery. This patient underwent a new wider resection, and metacarpophalangeal implant arthroplasty. Ten months after the second resection the patient does not have any clinical and radiological signs of recurrence. All the patients had no pain and tenderness, with complete recovery of motion.
Conclusions The hand is an infrequent site for OO. Clinical features can simulate arthritis or synovitis. The X-ray examination gives in most cases non-specific information which may delay diagnosis. In our study seven patients had an initially negative X-ray examination. Bone scan is highly sensitive for OO, but should be associated with CT examination to facilitate adequate surgical excision. MRI can show the tissue reaction around the tumour. Surgical excision is necessary and should be sufficiently wide to avoid recurrences.