three common clinical scenarios leading to wrist arthroscopy
DESCRIPTION
Three common clinical scenarios leading to wrist arthroscopy Ομιλία στο 20ο Συνέδριο της Ελληνικής Εταιρείας Χειρουργικής του Χεριού, 4-6 Σεπ, Αλεξανδρούπολη,TRANSCRIPT
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
#1. Radial-sided wrist pain
Radial-sided pain DD
Scaphoid fracture
SL lig. tear
Kienbock’s
AVN Scaphoid/ Preiser’s
CMC arthritis
Occult ganglion cyst
Metacarpal boss
Radiocarpal impingement
ScaphoLunate instability
Scapholunate ballottment test
Watson’s test Wrist flexion- finger extension maneuver
Anatomic snuffbox synovial irritation
Anatomic snuffbox= synovial irritation
Dorsal SL- lunate pain
Watson’s test
X-rays 1: True PA view
900 -900 position
X-rays 1: True PA view
• SL gap> 2-3mm (static instability)
• “Shortened” scaphoid
• Cortical ring sing
X-rays 2: Pronated grip view
1. Dynamic SL diastasis
2. Ulnocarpal Impingement
3. Ulnar Variance measurements
X-rays 2: Pronated grip view
NEUTRAL GRIP
Dynamic SL instability
X-rays 3: Comparative
Dynamic SL instability
Radiocarpal Arthroscopy• Always Probe the SL lig.
Geissler classification
Type I
L S
Geissler classification
Type II
L S
Geissler classification
Type III
L S
Geissler classification
Type IV
SL
C
Geissler classificationType IV
Mid-carpal Arthroscopy• Essential for accurate staging
Mid-carpal Arthroscopy• Essential for accurate staging
SL lig. lesions
• Staging
• Management •Δυναμική Αστάθεια
•Στατική Αστάθεια
•Αρθρίτιδα (SLAC)
3mo
ACUTEGood Healing Potential
CHRONICPoor Healing Potential
Acute, Geissler II, III
• Arthroscopic reduction, K-wire stabilization
L S L S
Acute, Geissler III, IV
• Open reduction, Repair
L S SL
C
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
Chronic, Geissler I, II
• Arthroscopic debridement & pinning
L SL S
Chronic, Geissler I, II
• Thermal shrinkage & pinningDarlis & Sotereanos, JHS(A), 2005
L SL S
Chronic, Geissler III, IVDynamic Instability
• Open treatment: Capsulodesis, partial wrist arthrodesis, tendodesis, ligament reconstruction
L S SL
C
Chronic, Geissler III, IVDynamic Instability
• Aggressive arthroscopic debridement,
percutaneous pinningDarlis & Sotereanos, JHS(A), 2006
L S SL
C
Chronic, Geissler III, IVStatic Instability/Arthritis
• Open treatment: Capsulodesis, partial wrist arthrodesis, tendodesis, wrist arthrodesis
L S SL
C
Chronic, Geissler III, IVStatic Instability
• Arthroscopic Reduction and Association of the Scaphoid and Lunate (RASL) Aviles et al, Arthroscopy, 2007
L S SL
C
#2. Ulnar-sided wrist pain
Ulnar-sided pain DD
TFCC tear
LT lig. tear
DRUJ arthritis
Fracture/ Non-union Ulnar styloid
Ulnocarpal Impaction Syndrome
ECU tendinitis/ instability
Fracture hamate
Pisiform arthritis
Unlar artery thrombosis
Ulnar n. compression Guyon’s
Superficial Ulnar n. neuritis
Fovea sign
TFCC lesion
TFCC impaction
test
Nakamura/ ulnocarpal stress test
TFCC lesion
Volar & Dorsal RU lig.- Foveal attachment
DRUJ instability: clinical exam unreliable
Radioulnar ballottement test
(Neutral- pronation- supination) DRUJ compression test
Piano- Key sign
ECU subluxiation in supination-
ulnar deviation
LT instability
LT ballottement/ Reagan’s test Kleinman’s shear test (LT)
X-rays : Pronated grip view
•Unlocarpal impaction syndrome
•Ulnar variance measurements
X-rays : Pronated grip view
Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle of TFCC
Volar radioulnar lig.radius
ulna
1. Central TFCC lesions
• Poorly vascularized- healing potential minimal
• Arthroscopic debridement up to 2/3 of articular disc
Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005
1. Central TFCC lesions
1. Central TFCC lesions
• Often degenerative and associated with ulnocarpal impaction syndrome
• Ulnar recession procedure to prevent symptom recurrence
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
MRI
Arthroscopic Wafer procedure
• Preferred when modest shortening needed
Open Ulna Recession Procedures• Several options…
Open Ulna Recession Procedures
Another approach: Keep it simple…
• Step-Cut Ulnar Shortening Osteotomy
Darlis& Sotereanos JHS(A), 2005
2. Peripheral (ulnar) TFCC tears
• Well vascularized
• Repairable
Timing of the repair
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 6 months 1 year
3mo 6mo
Usual location of peripheral tears
Dorsal
Usual location of peripheral tears
The Iceberg Concept Atzei &Lucetti 2011
REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears
• Clinical DRUJ instability
• Fracture through the fovea
• MRI findings
• Arthroscopic findings
– Positive Hook Test
– Direct Foveal Portal Arthroscopy
Foveal attachment involvement
Hook test
REPAIR TO CAPSULE
REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
REPAIR TO CAPSULE
1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA
2. All Arthroscopic, Knotless: Geissler
REATTACH TO FOVEA
TFCC
6R
ACC 6R
TFCC
6R
ACC 6R
TFCC
6R
ACC 6R
TFCC
6R
ACC 6R
TFCC
6R
ACC 6R
3. Distal Radius Fracture
• 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
1. Radial styloid
1. Radial styloid
1. Radial styloid
1. Radial styloid
1. Radial styloid
1. Radial styloid
2. die punch2. Die punch
3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
European Wrist Arthroscopy Society
www.geap.org
Thank you
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