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Löw S, Kiesel S, Spies CK, Erne H. [Arthroscopic reconstruction of scaphoid nonunions]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2022; 34:261-274. [PMID: 35394136 DOI: 10.1007/s00064-022-00765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/23/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Minimally invasive arthroscopically assisted reconstruction of scaphoid nonunions. INDICATIONS Delayed union or nonunion of the scaphoid with sclerosis and with indication for bone transplantation. Limited arthritic changes at the radial styloid. CONTRAINDICATIONS Severe humpback deformity with dorsal intercalated segment instability. Midcarpal arthritic changes. SURGICAL TECHNIQUE Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3 to 4 kg. Standard wrist arthroscopy via the 3-4 and the 4-5 portal and the midcarpal joint via the radial and ulnar portal, respectively, with sodium chloride as arthroscopy medium. Change of the optic to the ulnar midcarpal portal and opening of the nonunion with an elevator via the radial midcarpal portal. Resection of the sclerosis with a 3.0 mm burr while irrigating the joint. Harvesting of cancellous bone via the second extensor compartment. On the hand table, closed reduction by joy-stick K‑wires if needed and insertion of K‑wires for the scaphoid screw. Insertion of the screw without entering of the distal thread into the bone. Arthroscopic insertion of the bone transplant by a blunt drill sleeve via the radial portal with steady compression by the obturator. Complete insertion of the screw under arthroscopic control of the compression of the nonunion space with arthroscopic control of stability with the probe. POSTOPERATIVE MANAGEMENT Six weeks forearm cast including the thumb metacarpophalangeal joint, radiographic control and non-load bearing movements for two more weeks, CT scan in the oblique sagittal plane after 8 weeks, and increase of load, as well as physiotherapy on demand depending on the radiographic results. RESULTS To date, 17 patients with a mean age of the nonunion of 18 months were treated. In 14 patients, bony union was achieved after 8 weeks. In one patient, an extraosseous screw placement was corrected. In another patient with extraosseous screw placement, persisting nonunion was treated with an angular stable plate. One scaphoid demonstrated an asymptomatic tight nonunion after 14 months, while one scaphoid with sclerosis of the proximal pole did not heal.
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Affiliation(s)
- Steffen Löw
- Praxis für Handchirurgie und Unfallchirurgie, Ledermarkt 8-10, 97080, Bad Mergentheim, Deutschland.
| | - Sebastian Kiesel
- Klinik für Handchirurgie, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt, Deutschland
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Bakker D, Kortlever JT, Kraan GA, Mathijssen N, Colaris JW, Ring D. Treatment Recommendations for Suspected Scapholunate Ligament Pathology. J Wrist Surg 2022; 11:62-68. [PMID: 35127266 PMCID: PMC8807106 DOI: 10.1055/s-0041-1732411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
Background The diagnosis and treatment of scapholunate interosseous ligament (SLIL) pathology is debated and notably variable. This study assessed the influence of diagnostic arthroscopy on treatment recommendations and the interobserver reliability of the arthroscopic classification of SLIL pathology. Methods The influence of diagnostic arthroscopy on treatment recommendations and the reliability of the arthroscopic classification of SLIL pathology were tested in a survey-based experiment. Seventy-seven surgeons evaluated 16 scenarios of people with wrist pain with variation in symptoms, scaphoid shift, time of symptom onset, and MRI appearance of the SLIL. Participants were randomized to view or not to view diagnostic wrist arthroscopy. Factors associated with recommendation for repair, capsulodesis, or tenodesis were analyzed. Results Viewing arthroscopic videos was associated with both offering surgery and a more reconstructive option. Other factors independently associated with recommendation for surgery included greater pain intensity and activity intolerance, women surgeons, an asymmetric scaphoid shift, and a recent onset of symptoms. The interobserver reliability of SLIL classification was slight. Conclusions Diagnostic arthroscopy leads to more surgery, and more invasive surgery, in spite of unreliable assessment of pathology. Clinical Relevance This points to the need to measure the potential benefits and harms of diagnostic wrist arthroscopy among people with wrist pain and no clear diagnosis on interview, examination, and radiographs. Level of Evidence Not applicable.
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Affiliation(s)
- Daniel Bakker
- Department of Surgery and Perioperative Care, Dell Medical School – The University of Texas at Austin, Austin, Texas
- Department of Orthopaedic Surgery, Reinier de Graaf Groep, Delft, The Netherlands
| | - Joost T.P. Kortlever
- Department of Surgery and Perioperative Care, Dell Medical School – The University of Texas at Austin, Austin, Texas
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Gerald A. Kraan
- Department of Orthopaedic Surgery, Reinier de Graaf Groep, Delft, The Netherlands
| | - Nina Mathijssen
- Department of Orthopaedic Surgery, Reinier de Graaf Groep, Delft, The Netherlands
| | - Joost W. Colaris
- Department of Orthopaedic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School – The University of Texas at Austin, Austin, Texas
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Löw S, Erne H, Pillukat T, Mühldorfer-Fodor M, Unglaub F, Spies CK. Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy. J Hand Surg Eur Vol 2017; 42:357-362. [PMID: 28080158 DOI: 10.1177/1753193416684658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study examined the reliability of surgeons' estimations as to whether central lesions of the triangular fibrocartilage complex were traumatic or degenerative. A total of 50 consecutive central triangular fibrocartilage complex lesions were independently rated by ten experienced wrist surgeons viewing high-quality arthroscopy videos. The videos were reassessed after intervals of 3 months; at the second assessment surgeons were given the patient's history, radiographs and both, each in a randomized order. Finally, the surgeons assessed the histories and radiographs without the videos. Kappa statistics revealed fair interrater agreement when the histories were added to the videos. The other four modalities demonstrated moderate agreement, with lower Kappa values for the assessment without videos. Intra-rater reliability showed fair agreement for three surgeons, moderate agreement for two surgeons and substantial agreement for five surgeons. It appears that classification of central triangular fibrocartilage complex lesions depends on the information provided upon viewing the triangular fibrocartilage complex at arthroscopy. LEVEL OF EVIDENCE II.
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Affiliation(s)
- S Löw
- 1 Department of Orthopaedic and Trauma Surgery, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - H Erne
- 2 Department for Plastic Surgery and Hand Surgery, Technische Universität München, München, Germany
| | - T Pillukat
- 3 Clinic for Hand Surgery, Rhön-Klinikum AG, Bad Neustadt/Saale, Germany
| | - M Mühldorfer-Fodor
- 3 Clinic for Hand Surgery, Rhön-Klinikum AG, Bad Neustadt/Saale, Germany
| | - F Unglaub
- 4 Department of Hand Surgery, Vulpius Clinic, Bad Rappenau, Germany
| | - C K Spies
- 4 Department of Hand Surgery, Vulpius Clinic, Bad Rappenau, Germany
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Löw S, Spies CK, Unglaub F, van Schoonhoven J, Prommersberger KJ, Mühldorfer-Fodor M. Preventable Repeat Wrist Arthroscopies: Analysis of the Indications for 133 Cases. J Wrist Surg 2017; 6:33-38. [PMID: 28119793 PMCID: PMC5258130 DOI: 10.1055/s-0036-1584311] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
Abstract
Background Frequently, patients undergo repeated wrist arthroscopies for single wrist problems. Purpose The purposes of this study were to assess the indications for repeat wrist arthroscopies and to identify potentially preventable procedures. Methods For this retrospective, two-center study, the electronic patient records were examined for patients, who underwent repeat wrist arthroscopy in a 5-year period. The cases were sorted by the underlying pathologies and the causes that necessitated repeat arthroscopies. Results Ulnar-sided wrist pain accounted for 100 (77%) of all 133 revision arthroscopies: 67 of which due to suspected ulnar triangular fibrocartilage complex (TFCC) avulsions, 33 due to ulnar impaction syndromes. Cartilage was reassessed in 22 (17%) wrists. Thereby, insufficient preoperative diagnostics necessitated pure diagnostic before therapeutic arthroscopy in 49 (37%) wrists: 48 of which for TFCC pathologies, one for a scapholunate (SL) ligament lesion. The uncertainty of diagnosis despite previous arthroscopy necessitated 18 (14%) revision arthroscopies: 15 for ulnar TFCC avulsions, 1 for a central TFCC lesion, 2 to reevaluate the SL ligament. Inadequate photo or video documentation of the cartilage necessitated arthroscopic reassessment in 16 (12%) wrists. Conclusion In this series, two out of three revision arthroscopies could potentially have been prevented. Inadequate preoperative diagnostics with the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain. However, even arthroscopically, the diagnosis of ulnar TFCC avulsions or SL ligament lesions is not trivial. Surgical skills and experience are necessary to detect such lesions. Finally, adequate photo or video documentation may prevent repeated arthroscopic diagnostic procedures. Level of Evidence Level IV.
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Affiliation(s)
- Steffen Löw
- Section of Hand Surgery, Division of Trauma and Orthopedic Surgery, Caritas Krankenhaus, Bad Mergentheim, Germany
| | | | - Frank Unglaub
- Department of Hand Surgery, Vulpius Klinik, Bad Rappenau, Germany
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Andersson JK, Axelsson P, Strömberg J, Karlsson J, Fridén J. Patients with triangular fibrocartilage complex injuries and distal radioulnar joint instability have reduced rotational torque in the forearm. J Hand Surg Eur Vol 2016; 41:732-8. [PMID: 26701974 DOI: 10.1177/1753193415622342] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/17/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED A total of 20 patients scheduled for wrist arthroscopy, all with clinical signs of rupture to the triangular fibrocartilage complex and distal radioulnar joint instability, were tested pre-operatively by an independent observer for strength of forearm rotation. During surgery, the intra-articular pathology was documented by photography and also subsequently individually analysed by another independent hand surgeon. Arthroscopy revealed a type 1-B injury to the triangular fibrocartilage complex in 18 of 20 patients. Inter-rater reliability between the operating surgeon and the independent reviewer showed absolute agreement in all but one patient (95%) in terms of the injury to the triangular fibrocartilage complex and its classification. The average pre-operative torque strength was 71% of the strength of the non-injured contralateral side in pronation and supination. Distal radioulnar joint instability with an arthroscopically verified injury to the triangular fibrocartilage complex is associated with a significant loss of both pronation and supination torque. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- J K Andersson
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - P Axelsson
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - J Strömberg
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
| | - J Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - J Fridén
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
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Löw S, Erne H, Schütz A, Eingartner C, Spies CK. The required minimum length of video sequences for obtaining a reliable interobserver diagnosis in wrist arthroscopies. Arch Orthop Trauma Surg 2015; 135:1771-7. [PMID: 26423659 DOI: 10.1007/s00402-015-2339-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE To examine the relationship between video length for wrist arthroscopy and interobserver reliability. MATERIALS AND METHODS 100 consecutive wrist arthroscopies were documented by long and short videos of the radiocarpal and the midcarpal joints. The long videos were about twice as long as the short videos. They were presented randomly to two independent and blinded examiners. Their diagnoses were compared to the diagnoses made by the surgeon who performed the arthroscopies. Kappa coefficients were calculated. RESULTS Kappa statistics were inconsistent and did not show that the long video provided an obvious advantage over the short video. The Kappa coefficients of the two examiners for the assessment of the cartilage status were 0.524 and 0.700 for the long videos and 0.465 and 0.639 for the short videos, respectively. The examiners diagnosed twice as many false-positive cartilage lesions on short videos than on long videos. The assessment of ligament lesions was more accurate on long than on short videos. CONCLUSIONS The results confirmed the hypothesis that the reproducibility of diagnoses based on video documents was influenced by the length of the video sequences. Therefore, it may be advisable for video documentation to be done diligently. The video sequence of the radiocarpal joint should last about 60 s, and that of a midcarpal joint should last about 45 s. Videos of difficult joints should last appropriately longer. LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Steffen Löw
- Section of Hand Surgery, Division of Trauma and Orthopedic Surgery, Caritas Krankenhaus, Uhlandstraße 7, 97980, Bad Mergentheim, Germany.
| | - Holger Erne
- Department for Plastic and Hand Surgery, Klinikum rechts der Isar TUM, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Alexander Schütz
- Sporthopaedicum, Hildegard-von Bingen-Str. 1, 93053, Regensburg, Germany.
| | - Christoph Eingartner
- Section of Hand Surgery, Division of Trauma and Orthopedic Surgery, Caritas Krankenhaus, Uhlandstraße 7, 97980, Bad Mergentheim, Germany.
| | - Christian K Spies
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstrabe 29, 74906, Bad Rappenau, Germany.
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Kirchberger MC, Unglaub F, Mühldorfer-Fodor M, Pillukat T, Hahn P, Müller LP, Spies CK. Update TFCC: histology and pathology, classification, examination and diagnostics. Arch Orthop Trauma Surg 2015; 135:427-37. [PMID: 25575720 DOI: 10.1007/s00402-015-2153-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 02/09/2023]
Abstract
The TFCC is a crucial stabilizer of the DRUJ. Based on its superficial and deep fibers, the TFCC guarantees unrestricted pronation and supination which is essential for performing sophisticated tasks. The ability to perform complex movements is of uppermost importance for hand function. Therefore, a functional intact TFCC is a prerequisite in this context. The articular disc of the TFCC is a fibrocartilaginous extension of the superficial zone of hyaline articular cartilage which arises from the radius. The peripheral 10-40 % of the TFC is vascularized. Degeneration of the articular disc is common with increasing age. Even though the central part of the articular disc is avascular, potential regeneration of lesions could be detected. The Palmer and Atzei classifications of TFCC lesions are complementary. TFCC innervation is based on different nerves. There is a high variability. A diligent clinical examination facilitates specific tests which help to allocate symptoms to the pathology. Therefore, a thorough clinical examination is not dispensable. Wrist arthroscopy remains the "gold standard" for diagnosing TFCC pathologies despite technical progress in imaging modalities. MR arthrography may have the potential to become a real alternative to wrist arthroscopy for diagnosing TFCC pathologies with technical progress in the future.
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Affiliation(s)
- Michael C Kirchberger
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
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Spies CK, Hahn P, Unglaub F. Letter to the editor: how does ulnar shortening osteotomy influence morphologic changes in the triangular fibrocartilage complex? Clin Orthop Relat Res 2015; 473:397-8. [PMID: 25373937 PMCID: PMC4390974 DOI: 10.1007/s11999-014-4041-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 10/27/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Christian Karl Spies
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstr. 29, 74906 Bad Rappenau, Baden-Württemberg Germany
| | - Peter Hahn
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstr. 29, 74906 Bad Rappenau, Baden-Württemberg Germany
| | - Frank Unglaub
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstr. 29, 74906 Bad Rappenau, Baden-Württemberg Germany
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Springorum HR, Winkler S, Maderbacher G, Götz J, Heers G, Grifka J, Preissler P. [Wrist arthroscopy : challenging procedure of modern hand surgery]. DER ORTHOPADE 2014; 44:89-102. [PMID: 25527300 DOI: 10.1007/s00132-014-3059-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Arthroscopy of the wrist has developed in the shadow of arthroscopy of the large joints. Nowadays, wrist arthroscopy has a relevant importance in the diagnostics and therapy in hand surgery and is indispensable for serious surgery of the wrist. Special equipment and extensive knowledge of the surgeon are necessary for carrying out the procedure.
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Affiliation(s)
- H-Robert Springorum
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland,
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Löw S, Herold A, Eingartner C. [Standard wrist arthroscopy: technique and documentation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2014; 26:539-46. [PMID: 25452089 DOI: 10.1007/s00064-014-0311-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 05/17/2014] [Accepted: 06/03/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Minimally invasive approach to the wrist in order to diagnose and treat different wrist pathologies. INDICATIONS Diagnosis of unclear chronic pain syndromes, cartilage status, intra-articular ligament structures as well as post-traumatic and inflammatory conditions of the wrist. Treatment of ulnar impaction syndrome, dorsal ganglia and also in fracture treatment and various different wrist interventions. CONTRAINDICATIONS Soft tissue infections around the wrist, severe scarring may impede access to the joint. SURGICAL TECHNIQUE Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3-4 kg. Superficial stab incision, blunt preparation through joint capsule, insertion of optic through 3-4 portal and probe through 4-5 portal, and radial and ulnar midcarpal portals, respectively. Either sodium chloride, CO2 or air is used as arthroscopy medium. Diagnostic round with standardized examination of all parts of the joint. Standardized written and high quality photo and/or video documentation to facilitate understandability of the findings. POSTOPERATIVE MANAGEMENT Forearm cast for 1 week, limited load for 2 more weeks, then load is increased to normal.
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Affiliation(s)
- S Löw
- Sektion Handchirurgie, Klinik für Orthopädie und Unfallchirurgie, Caritas-Krankenhaus, Uhlandstr. 7, 97980, Bad Mergentheim, Deutschland,
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Affiliation(s)
- Frank Unglaub
- Department of Hand Surgery, Vulpius Klinik, Bad Rappenau, Germany
- Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Christian Spies
- Department of Hand Surgery, Vulpius Klinik, Bad Rappenau, Germany
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Löw S, Pillukat T, Prommersberger KJ, van Schoonhoven J. The effect of additional video documentation to photo documentation in wrist arthroscopies on intra- and interobserver reliability. Arch Orthop Trauma Surg 2013; 133:433-8. [PMID: 23254378 DOI: 10.1007/s00402-012-1670-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Indexed: 11/28/2022]
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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Affiliation(s)
- Steffen Löw
- Section of Hand Surgery, Clinic for Orthopaedic and Trauma Surgery, Caritas-Krankenhaus, Uhlandstraße 7, Bad Mergentheim, Germany.
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