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3 Common Clinical Scenariosleading to
Wrist ArthroscopyNickolaos A. Darlis, MD, PhD
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I am here to convince you that
Clinical Exam + Plain X-rays=80% of the indications for wrist arthroscopy
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#1. Radial-sided wrist pain
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Radial-sided pain DD
Scaphoid fractureSL lig. tearKienbock’sAVN Scaphoid/ Preiser’sCMC arthritisOccult ganglion cystMetacarpal bossRadiocarpal impingement
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ScaphoLunate instability
Scapholunate ballottment test
Watson’s test Wrist flexion- finger extension maneuver
Anatomic snuffbox synovial irritation
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Anatomic snuffbox= synovial irritation
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Dorsal SL- lunate pain
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Watson’s test
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X-rays 1: True PA view
900 -900 position
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X-rays 1: True PA view
• SL gap> 2-3mm (static instability)
• “Shortened” scaphoid• Cortical ring sing
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X-rays 2: Pronated grip view
1. Dynamic SL diastasis2. Ulnocarpal Impingement3. Ulnar Variance measurements
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X-rays 2: Pronated grip view
NEUTRAL GRIP
Dynamic SL instability
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X-rays 3: Comparative
Dynamic SL instability
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Radiocarpal Arthroscopy• Always Probe the SL lig.
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Geissler classification
Type I
L S
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Geissler classification
Type II
L S
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Geissler classification
Type III
L S
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Geissler classification
Type IV
SL
C
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Geissler classificationType IV
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Mid-carpal Arthroscopy• Essential for accurate staging
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Mid-carpal Arthroscopy• Essential for accurate staging
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SL lig. lesions
• Staging• Management
• Δυναμική Αστάθεια• Στατική Αστάθεια• Αρθρίτιδα (SLAC)
3mo
ACUTEGood Healing Potential
CHRONICPoor Healing Potential
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Acute, Geissler II, III
• Arthroscopic reduction, K-wire stabilization
L S L S
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Acute, Geissler III, IV
• Open reduction, Repair
L S SL
C
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E V O L V I N G C O N C E P T S
Acute, Geissler III, IV
• Attempts at arthroscopically-assisted direct repairDel Piñal, JHS(A) 2011
L S SL
C
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Chronic, Geissler I, II
• Arthroscopic debridement & pinning
L SL S
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Chronic, Geissler I, II
• Thermal shrinkage & pinningDarlis & Sotereanos, JHS(A), 2005
L SL S
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Chronic, Geissler III, IVDynamic Instability
• Open treatment: Capsulodesis, partial wrist arthrodesis, tendodesis, ligament reconstruction
L S SL
C
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Chronic, Geissler III, IVDynamic Instability
• Aggressive arthroscopic debridement, percutaneous pinning
Darlis & Sotereanos, JHS(A), 2006
L S SL
C
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Chronic, Geissler III, IVStatic Instability/Arthritis
• Open treatment: Capsulodesis, partial wrist arthrodesis, tendodesis, wrist arthrodesis
L S SL
C
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Chronic, Geissler III, IVStatic Instability
• Arthroscopic Reduction and Association of the Scaphoid and Lunate (RASL) Aviles et al, Arthroscopy, 2007
L S SL
C
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#2. Ulnar-sided wrist pain
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Ulnar-sided pain DD
TFCC tearLT lig. tearDRUJ arthritisFracture/ Non-union Ulnar styloidUlnocarpal Impaction SyndromeECU tendinitis/ instabilityFracture hamatePisiform arthritisUnlar artery thrombosisUlnar n. compression Guyon’sSuperficial Ulnar n. neuritis
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Fovea sign
TFCC lesion
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TFCC impaction test
Nakamura/ ulnocarpal stress test
TFCC lesion
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Volar & Dorsal RU lig.- Foveal attachment
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DRUJ instability: clinical exam unreliable
Radioulnar ballottement test
(Neutral- pronation- supination) DRUJ compression test
Piano- Key sign
ECU subluxiation in supination- ulnar deviation
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LT instability
LT ballottement/ Reagan’s test Kleinman’s shear test (LT)
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X-rays : Pronated grip view
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• Unlocarpal impaction syndrome • Ulnar variance measurements
X-rays : Pronated grip view
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Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle of TFCC
Volar radioulnar lig.radiusulna
N.D
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1. Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of articular disc
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Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005
1. Central TFCC lesions
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1. Central TFCC lesions
• Often degenerative and associated with ulnocarpal impaction syndrome
• Ulnar recession procedure to prevent symptom recurrence
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Ulnocarpal Impaction Syndrome
Clinical features:• Ulnar sided wrist pain • Associated degenerative changes:
– Ulnar side of the lunate– Radial side of the ulnar dome– TFCC central tear– Triquetrum- LunoTriquetrum lig.
• Usually positive or neutral ulnar variance
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MRI
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Arthroscopic Wafer procedure• Preferred when modest shortening needed
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Open Ulna Recession Procedures• Several options…
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Open Ulna Recession Procedures
Another approach: Keep it simple…• Step-Cut Ulnar Shortening Osteotomy
Darlis& Sotereanos JHS(A), 2005
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2. Peripheral (ulnar) TFCC tears• Well vascularized• Repairable
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Timing of the repair
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 6 months 1 year
3mo 6mo
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Usual location of peripheral tears
Dorsal
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Usual location of peripheral tears
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The Iceberg Concept Atzei &Lucetti 2011
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REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears
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• Clinical DRUJ instability• Fracture through the fovea• MRI findings• Arthroscopic findings
– Positive Hook Test– Direct Foveal Portal
Arthroscopy
Foveal attachment involvement
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Hook test
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REPAIR TO CAPSULE
REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears
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REPAIR TO CAPSULE
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REPAIR TO CAPSULE
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1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA
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2. All Arthroscopic, Knotless: Geissler
REATTACH TO FOVEA
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TFCC
6R
ACC 6R
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TFCC
6R
ACC 6R
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TFCC
6R
ACC 6R
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TFCC
6R
ACC 6R
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TFCC6R
ACC 6R
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3. Distal Radius Fracture
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• Consider in young, high demand patients
• Currently indicated in selected injuries:– Radial styloid Fx– Die Punch Fx– Three & Four part Fx– DRUJ instability or interosseous lig tear
• No metaphyseal comminution
Arthroscopically assisted reduction
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1. Radial styloid
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1. Radial styloid
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1. Radial styloid
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1. Radial styloid
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1. Radial styloid
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1. Radial styloid
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2. die punch2. Die punch
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3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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European Wrist Arthroscopy Society
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www.geap.org
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