Current Innovations in Wrist Arthroscopy
Hand and Wrist Institute, Torrance, CA 90503, USA. The Journal of hand surgery
(Impact Factor: 1.67).
09/2012; 37(9):1932-41. DOI: 10.1016/j.jhsa.2012.06.028
It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.
Available from: Isam Atroshi
- "Although arthroscopy of upper extremity joints was initially introduced mainly for diagnostic purposes it is being increasingly used for therapeutic interventions . For example, wrist interventions performed through arthroscopy include, among others, excision of wrist ganglia, treatment of acute fractures and of non-unions, ligament repair and reconstructions, repair or debridement of the triangular fibrocartilage complex, ulnar head resection, partial or total removal of carpal bones, and joint fusions [1,2]. A recent study on musculoskeletal upper extremity ambulatory surgery in the United States estimated that 272,148 rotator cuff repairs, 257,541 shoulder arthroscopies excluding those for cuff repairs, 3686 elbow arthroscopies, and 25,250 wrist arthroscopies were performed in 2006 . "
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Although arthroscopy of upper extremity joints was initially a diagnostic tool, it is increasingly used for therapeutic interventions. Randomized controlled trials (RCTs) are considered the gold standard for assessing treatment efficacy. We aimed to review the literature for intervention RCTs involving wrist and shoulder arthroscopy.
We performed a systematic review for RCTs in which at least one arm was an intervention performed through wrist arthroscopy or shoulder arthroscopy. PubMed and Cochrane Library databases were searched up to December 2012. Two researchers reviewed each article and recorded the condition treated, randomization method, number of randomized participants, time of randomization, outcomes measures, blinding, and description of dropouts and withdrawals. We used the modified Jadad scale that considers the randomization method, blinding, and dropouts/withdrawals; score 0 (lowest quality) to 5 (highest quality). The scores for the wrist and shoulder RCTs were compared with the Mann–Whitney test.
The first references to both wrist and shoulder arthroscopy appeared in the late 1970s. The search found 4 wrist arthroscopy intervention RCTs (Kienböck’s disease, dorsal wrist ganglia, volar wrist ganglia, and distal radius fracture; first 3 compared arthroscopic with open surgery). The median number of participants was 45. The search found 50 shoulder arthroscopy intervention RCTs (rotator cuff tears 22, instability 14, impingement 9, and other conditions 5). Of these, 31 compared different arthroscopic treatments, 12 compared arthroscopic with open treatment, and 7 compared arthroscopic with nonoperative treatment. The median number of participants was 60. The median modified Jadad score for the wrist RCTs was 0.5 (range 0–1) and for the shoulder RCTs 3.0 (range 0–5) (p = 0.012).
Despite the increasing use of wrist arthroscopy in the treatment of various wrist disorders the efficacy of arthroscopically performed wrist interventions has been studied in only 4 randomized studies compared to 50 randomized studies of significantly higher quality assessing interventions performed through shoulder arthroscopy.
Available from: Alejandro Badia
- "Arthroscopic evaluation is a minimally invasive procedure that proves to be the best modality to assess the joint surface and residual step-offs once reduction and fixation have been obtained, when compared to radiographs and fluoroscopy.3567121314 Wrist arthroscopy for distal radius fractures is indicated in young adults and high demand middle-aged patients, especially with intraarticular involvement secondary to high energy trauma, where there is a suspicion of associated soft tissue injuries.4789101119 The classic Colle's fracture, in an elderly and low-demand patient with osteopenic bone, does not require joint evaluation.9 "
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ABSTRACT: Many studies in literature have supported the role of wrist arthroscopy as an adjunct to the stable fixation of unstable intraarticular distal radial fractures. This article focuses on the surgical technique, indications, advantages, and results using wrist arthroscopy to assess articular reduction and evaluates the treatment of carpal ligament injuries and triangular fibrocartilage complex (TFCC) injuries in conjunction with the stable fixation of distal radial fractures.
We retrospectively evaluated 27 patients (16 males and 11 females), who underwent stable fixation of intraarticular distal radial fractures with arthroscopic evaluation of the articular reduction and repair of associated carpal injuries. As per the AO classification, they were 9 C 1, 12 C2, 2 C3, 3 B 1, and 1 B2 fractures. The final results were evaluated by modified Mayo wrist scoring system. The average age was 41 years (range: 18-68 years). The average followup was of 26 months (range 24-52 months).
Five patients needed modification of the reduction and fixation after arthroscopic joint evaluation. Associated ligament lesions found during the wrist arthroscopy were TFCC tears (n=17), scapholunate ligament injury (n=8), and luno-triquetral ligament injury (n=1). Five patients had combined injuries i.e. included TFCC tear, scapholunate and/or lunotriquetral ligament tear. There were 20 excellent, 3 good, and 4 fair results using this score.
The radiocarpal and mid carpal arthroscopy is a useful adjunct to stable fixation of distal radial fractures.
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ABSTRACT: INTRODUCTION: The reproducibility of diagnoses based on photo documents in wrist arthroscopies is limited and is expected to improve through the addition of video documents. AIM: The purpose of this study was to determine the effect of additional video documentation to photo documentation on intra- and interobserver reliability in wrist arthroscopies. MATERIALS AND METHODS: Sixty consecutive arthroscopies were documented by photographs of at least eight standard views and videos of the radiocarpal and midcarpal joints. After 3 months, the photographs and then the photographs together with the videos were reevaluated by the surgeon and by two hand surgeons to determine intra- and interobserver reliability. Percentage agreement and kappa coefficients were calculated. RESULTS: Using videos along with the photographs did not improve reproducibility in general. The assessments of the cartilage status were even worse. Some of the videos were criticized as being too short to allow adequate assessment of the cartilage. Lesions of the TFCC as well as its tension were assessed notably better by the videos, whereas assessment of SL and LT ligaments was not improved by the videos. Intraobserver reliability was better than interobserver reliability. CONCLUSION: As long as videos do not meet further quality criteria, they are not able to improve reliability in general. Nevertheless, videos should be used for documentation of the TFCC.
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