Saturday, September 15, 2007

Wrist Arthroscopy

· Abrams, RA, Petersen, M, and Botte, MJ: Arthroscopic Portals of the Wrist: An Anatomic Study. J Hand Surg 19A:940-944, 1994.

o Study which relates the position of portals relative to nerve and tendon structures on the wrist. The perilous portals are the 1,2 and ECU portals (6U and 6R) because of distance to radial artery and dorsal nerves. Advocated a longitudinal incision through skin, with blunt dissection to capsule for all portals.

· Koman, LA, Poehling, GD, Toby, EB, and Kammire, G: Chronic Wrist Pain: Indications for Wrist Arthroscopy. Arthroscopy 6(2):116-119, 1990.

· Cooney, WP: Evaluation of Chronic Wrist Pain by Arthrography, Arthroscopy, and Arthrotomy. J Hand Surg 18A:815-822, 1993.

o Prospective study of 20 patients with chronic wrist pain. Aims to compare double-contrast wrist arthrography to arthroscopy and open arthrotomy. Accuracy varied with about ~50% accuracy in arthrography. It was particularly bad at intercarpal ligament pathology but good at diagnosing TFCC pathology with 100% accuracy for tears.

o The results of arthrography are much less sensitive and specific than arthroscopy. This may be one of the reason why there are few arthrography studies performed anymore. There are tons of false positives and negatives secondary to small fenestrations (50% in 50 yo, 60% at 60 yo and etc.) The small fenestrations likely don’t mean anything clinically. Bottom line, the state of arthrography was not the same after this article.

· Potter, HG Asnis-Ernberg, A and Weiland, AJ et al: The Uitility of High-Resolution Magnetic Resonance Imaging in the Evaluation of the Triangular Fibrocartilage Complex of the Wrist – JBJS 79:1675-1984, 1997.

o MRI is really good at defining the actual problem in the wrist and correlates well with the diagnostic results of arthroscopy. Gradient Echo sequence is used appears to be the sequence of choice. Interesting conversational notes are that these studies were likely interpreted by experts in the field of musculoskeletal radiology and likely performed on the very best magnets. The MRIs that frequently accompany patients to the clinic are of lower quality and likely do not yield the same results. There may be a study here comparing the diagnostic accuracy of different quality wrist MRI as sort of a validation of this work.

· Weiss, AC, Akelman, E and Lambiase, R: Comparison of the Findings of Triple-Injection Cinearthrography of the Wrist with Those of Arthroscopy. JBJS 78-A(3):348-356, 1996.

o Prospective evaluation of 50 patients comparing triple injection arthrography to arthroscopy for SL LT and TFCC tears. Arthrography had 56 percent sensitivity, 83 percent specificity, and 60 percent accuracy compared to arthroscopy. Therefore, a negative arthrogram does not rule out a full-thickness tear of the SL ligament, LT ligament or TFC.

o This is part of a two-part study and the balance of the work is suggestive of this overall theme that arthroscopy is a reasonable newer alternative to the previous arthrogram based approach.

o One unrelated point is to note that there are a fair amount of studies that aimed to justify the use of arthroscopy for diagnosis and treatment. It is my opinion that these studies sometimes had obvious short comings.

· Geissler, WB and Freeland AE: Arthroscopically Assisted Reduction of Intraarticular Distal Radial Fractures. Clin Orthop. 327:125-134, 1996.

o This article describes the technique of percutaneous and limited open reduction in combination with wrist arthroscopy for displaced distal radius fractures. Technical tips can be found for arthroscopy. The authors also present an arthroscopic classification of wrist interosseous ligament instability graded I-IV. It is this classification that may be the most lasting legacy of this article. Still years after the publication, this is standard ways of describing arthroscopic ligamentous lesions in the wrist. Treatment recommendations are made based on this scheme. Data on associated ligamentous injuries are presented in a prospective series of 60 patients.

· Whipple TL: The Role of Arthroscopy in the Treatment of Scapholunate Instability. Hand Clinics, Vol. II(1):37-40, 1995.

o This is an older study done in the setting of treatments of SL instability treated with K-wire fixation. This is a technique article so that if you have a patient with Geissler 1 or 2 ligament issue – you can do a chondrodesis…..this smells like a predecessor to a RASL procedure.

· Hofmeister, EP Daoo, KD et al: The Role of Midcarpal Arthroscopy in the Diagnosis of Disorders of the Wrist. Journal of Hand Surgery 26A: 407-414, 2001

o Paper aims to answer the question of whether midcarpal arthroscoy is useful or not. It seems to always help to refine the diagnosis. There is no independent confirmation of the value of midcarpal arthroscopy. That is to say that authors were not blind to the results of radiocarpal arthroscopy when performing the midcarpal examination. I am forced to believe that midcarpal arthroscopy is important but since it refines more than it diagnoses, a more properly designed experiment might be in order.

· Weiss, A.P.C., Sachar, K., Glowacki, K.A.: Arthroscopic Debridement Alone for Intercarpal Ligament Tears. J Hand Surg 22A:344-349, 1997.

o This study aims to answer a rather critical question: What happens if you just debride out a torn wrist ligament? Ligaments are divided into either complete or partial tears on the basis of an initial arthroscopic examination. Only patients with SL or LT tears are included and they are divided into partial and complete as above. Forty-three patients were included in the study with good to excellent results in 71 percent of patients with complete tears versus 89 percent good to excellent results in those with partial tears. Nine patients required further surgery, and all were either workers’ compensation or liability claims.

o Although above is factually correct, it may misrepresent reality. The paper aims to describe a hither-to unheard of way of treating these tears in the wrist – namely debride them. It would be truly earth shattering if debriding scapholunate tears (complete ones) really does work…..alas, it does not one third of the time. If the idea that debridement alone is to be advocated, it should be based on a pool patients with only SL tears. It seems like the statements become stronger with LT and SL tears are lumped together. Bottom line, partial tears can be debrided with a reasonable expectation of complete symptom resolution. Full tears are unpredictable when treated in this fashion. The workers compensation statements aim to suggest that those full tears which did poorly were comp claims. They do not mention the number of those that did well which were comp claims for comparison. Last word, 71 percent improvement for full tear debridement is true only when both SL and LT data are lumped. The individual figures for LT tears (7/9 doing well) compared with SL tears (10/15 doing well) seem to suggest different outcomes. Not sure there are grounds for combining those two groups together.

OPTIONAL:

· North ER and Meyer S: Wrist Injuries: Correlation of clinical and arthroscopic findings. J Hand Surg 15A:915-920, 1990.

· Whipple TL, Cooney WP, III, Osterman, AL and Viegas SF: Wrist Arthroscopy. Chap. 10.

REVIEW:

· Geissler, W.B., Freeland, A.E., Weiss, APC and Chow J.C.Y.: Techniques of Wrist Arthroscopy. J Bone and Joint Surg. 81-A:1184-1197, 1999.

HONORABLE MENTION:

· Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 1990;6(2):120-124.

o Early article on the indications, findings and results of a prospective series of over 50 patients treated with wrist arthroscopy. Notably, they treated TFCC tears with debridement and over one quarter of debrided patients underwent limited resection of the ulnar head by arthroscopic means. G2E in 85 percent of patients.

· Osterman AL, Seidman GD. The role of arthroscopy in the treatment of lunatotriquetral ligament injuries. Hand Clinics 1995;11(1):41-50.

o This investigates the LT tear with arthroscopy. There is ample discussion of anatomy, kinematics and pathophysiology of LT ligament injuries. Good results in a group of 20 patients with LT tears treated with debridement and percutaneous pinning of the LT joint.

· Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg 1997;22A:57-65.

o Traumatic TFCC tears (1B-D). G2E in almost 90% with fair results in the rest. There is also technical points in this paper.

· Berger RA. Arthroscopic anatomy of the wrist and distal radioulnar joint. Hand Clin 1999;15(3):393-413.

o Review article describes wrist anatomy specifically as pertains to portals. Key features are the arthroscopic illustrations and pearls.

· Ruch DS, Poehling G. Arthroscopic management of partial scapholunate and lunotriquetral injuries of the wrist. J Hand Surg 1996;21A:412-417.

o Fourteen patients with partial tears underwent arthroscopic debridement. The Thirteen patients were satisfied and 11 had complete relief.

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