Wrist arthroscopy. Indications and clinical applications

Gender Disparities in Preoperative Resource Use for Wrist Arthroscopy

BACKGROUND

Although national efforts to minimize gender biases exist, gender differences in surgery persist. This study aims to investigate gender differences in preoperative resource use of patients undergoing wrist arthroscopy for nontraumatic wrist pain.

METHODS

Patients who underwent a wrist arthroscopy for nontraumatic pain from 2009 to 2015 were selected from the Truven MarketScan databases. Demographic and preoperative resource use data were recorded. Multivariable regression models were performed to examine the relationship between gender and preoperative resource use and to investigate the cost of these services.

RESULTS

A total of 8792 patients, 3805 men and 4987 women, met our inclusion criteria. Women were less likely to use imaging modalities preoperatively (OR, 0.08; 95 percent CI, 0.07 to 1.00; p = 0.02). However, women used more occupational therapy (OR, 1.2; 95 percent CI, 1.1 to 1.3; p = 0.002), nonnarcotic analgesia (OR, 1.2; 95 percent CI, 1.1 to 1.3; p = 0.001), and narcotic analgesia (OR, 1.6; 95 percent CI, 1.5 to 1.8; p < 0.001). Preoperative costs during the 12 months before surgery were similar between genders ($1308 versus $1367, respectively; p = 0.07). However, women accrued more costs from occupational therapy ($130 versus $93; p = 0.003), and nonnarcotic ($65 versus $46; p < 0.001) and narcotic medications ($568 versus $197; p < 0.001).

CONCLUSIONS

Significant gender differences exist in the preoperative care for patients undergoing wrist arthroscopy. Men use more imaging, implying more intense preoperative investigation for wrist pain, whereas women use more conservative measures, highlighting possible implicit provider biases in preoperative management and potential gender differences in disease presentation.

High-resolution MRI (3T-MRI) in diagnosis of wrist pain: is diagnostic arthroscopy still necessary?

INTRODUCTION

3T MRI has become increasingly available for better imaging of interosseous ligaments, TFCC, and avascular necrosis compared with 1.5T MRI. This study assesses the sensitivity and specificity of 3T MRI compared with arthroscopy as the gold standard.

PATIENTS AND METHODS

Eighteen patients were examined with 3T MRI using coronal T1-TSE; PD-FS; and coronal, sagittal, and axial contrast-enhanced T1-FFE-FS sequences. Two musculoskeletal radiologists evaluated the images independently. Patients underwent diagnostic arthroscopy.

RESULTS

The classifications of the cartilage lesions showed good correlations with the arthroscopy findings (κ = 0.8-0.9). In contrast to the arthroscopy, cartilage of the distal carpal row was very good and could be evaluated in all patients on MRI. The sensitivity for the TFCC lesion was 83%, and the specificity was 42% (radiologist 1) and 63% (radiologist 2). For the ligament lesions, the sensitivity and specificity were 75 and 100%, respectively, with a high interobserver agreement (κ = 0.8-0.9).

DISCUSSION

3T MRI proved to be of good value in diagnosing cartilage lesions, especially in the distal carpal row, whereas wrist arthroscopy provided therapeutic options. When evaluating the surgical therapeutical options, 3T MRI is a good diagnostic tool for pre-operatively evaluating the cartilage of the distal carpal row.

The use of thermal shrinkage for scapholunate instability

Scapholunate interosseous ligament (SLIL) instability is the most common form of carpal instability. There is a lack of consensus among hand surgeons as to the appropriate treatment of various stages. This article reviews the background and results of thermal treatment of predynamic instability of the SLIL. Case examples are discussed as well as a series of patients treated with our protocol for this injury.

Arthroscopic assessment of intra-articular distal radius fractures after open reduction and internal fixation from a volar approach

PURPOSE

The volar approach with locked plating is a common treatment for intra-articular distal radius fractures. The purpose of this study was to arthroscopically assess the articular surface after internal fixation through the volar approach as a means to evaluate the ability of an extra-articular reduction to anatomically restore the joint surface.

METHODS

Sixteen patients with intra-articular distal radius fractures were prospectively enrolled. A volar approach and internal fixation using a locked volar plate was performed. Using a visual analog scale (VAS), the fracture reduction was clinically graded on the quality of reduction of the visible metaphyseal fracture lines, fluoroscopically graded, and arthroscopic graded. Maximum step and gap deformity were recorded from arthroscopy and plain radiograph.

RESULTS

The mean VAS score for the fracture reduction based on extra-articular fracture lines was 7.4. The mean VAS score for the fluoroscopic reduction was 8.2. The mean VAS score for the arthroscopic reduction was 6.4. The arthroscopic VAS score was significantly lower than the VAS score for fluoroscopy but was not significantly different than the VAS score for metaphyseal reduction. Mean arthroscopic measurement of maximum step and gap deformity were 1 mm and 2 mm, respectively. Mean postoperative radiographic maximum step and gap deformity were both less than 1 mm. The arthroscopic step and gap deformities were significantly greater than the radiographic deformities.

CONCLUSIONS

A volar approach, indirect reduction, and locked plate fixation is a useful technique in restoring articular congruity after distal radius fracture. The number of fracture lines and presence of step and gap deformity can be adequately assessed using clinical and fluoroscopic assessment. However, the magnitude of step and gap deformity may be underestimated.

The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity

PURPOSE

Eliciting tenderness in the region of the ulnar fovea is a possibly useful clinical test for defining the source of ulnar-sided wrist pain. Until now, no reports of the clinical sensitivity and specificity of this test have been available. Based on anecdotal observations, a hypothesis was developed stating that ulnar fovea tenderness (positive "ulnar fovea sign") is sensitive and specific in detecting two ulnar-sided wrist conditions: foveal disruption of the distal radioulnar ligaments and ulnotriquetral (UT) ligament injuries.

METHODS

The clinical records of 272 consecutive patients with wrist arthroscopy performed by the senior author from 1998 through to 2005 were reviewed. Relevant clinical and surgical data were abstracted. The ulnar fovea sign test is executed by pressing the examiner's thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform. A positive ulnar fovea sign is designated when there is exquisite tenderness that the patient claims replicates their pain, with comparisons made with the contralateral side.

RESULTS

There were a total of 90 foveal disruptions and 68 UT ligament injuries diagnosed during wrist arthroscopy. The ulnar fovea sign was positive in 156 patients. The sensitivity of the fovea sign in detecting foveal disruptions and/or UT ligament injuries was 95.2%. Its specificity was 86.5%.

CONCLUSIONS

The hypothesis stating that the ulnar fovea sign is a useful clinical maneuver to detect foveal disruptions and UT ligament tears is supported. The conditions represent 2 common sources of ulnar-sided wrist pain. The differentiation between the 2 conditions may be made clinically, where UT ligament tears are typically associated with a stable distal radioulnar joint and foveal disruptions are typically associated with an unstable distal radioulnar joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Une nouvelle technique de ponction de l’articulation radio-carpienne

OBJECTIVE

Previous techniques for radiocarpal joint injection introduce the needle directly between the navicular and the radius. We propose here a new technique using the same puncture site for midcarpal and radiocarpal arthrograms without need for needle reinsertion.

MATERIALS AND METHODS

A prospective study of 85 radiocarpal injections for arthrography was performed. For each case, the needle tip was positioned at the medial part of the proximal scaphoid, under the mid carpal joint, and directed obliquely with a 45 degrees angle to the joint space to reach the radiocarpal joint. In case of midcarpal and radiocarpal arthrograms, a single puncture site was always used.

RESULTS

Injection of the radiocarpal joint was successful in 82 of the 82 cases.

CONCLUSION

The method proposed here is simple, efficient and uses a single site of puncture in cases requiring bi-compartmental injections.

[Wrist arthroscopy. Current indications and results]

Arthroscopy of the wrist is a recent technique but already validated for many indications. It rarely gives rise to complications but requires a learning curve just like any other endoscopic procedure. It allows complete visualization of the osseous, articular, synovial and ligamentous structures of the different joints comprising the wrist. There are two main indications for wrist arthroscopy: i) Diagnostic; when other investigations have proved inconclusive (assessment of carpal instabilities, osteochondral fractures and certain synovial pathologies...); ii) therapeutic; these have recently widened in terms of carpal pathology. Lesions of the triangular fibrocartilage complex (traumatic or degenerative) are best diagnosed and treated arthroscopically. Arthroscopic treatment is the least invasive, most effective and safest means of performing procedures such as debridement, TFCC reattachment, and ulna shortening. Other conditions can benefit greatly from wrist arthroscopy such as certain wrist ganglions, rheumatoid synovitis, radiocarpal fractures and some scaphoid fractures. Degenerative pathology of the wrist also presents opportunities for articular debridement ("shaving"), synovectomy or even various "ectomies".

Complications of wrist arthroscopy

PURPOSE

To determine the incidence and nature of complications after arthroscopy of the wrist joint.

METHODS

The outpatient records and surgical reports of 211 patients who had wrist joint arthroscopy were reviewed to determine type of procedure, type of anesthetic, portals used, and incidence and nature of postsurgical complications.

RESULTS

We identified a total of 11 complications in our patient group (5.2%). Of these, 2 patients (0.9%) developed major complications and 9 patients (4.3%) developed minor complications. Five complications 45% were identified in the immediate postsurgical period and 6 (55%) were delayed complications. All of the minor complications resolved at latest follow-up evaluation with conservative care.

CONCLUSIONS

Wrist arthroscopy is a safe procedure with a low rate of major and minor complications. In spite of its limitations wrist arthroscopy remains an invaluable tool in the diagnosis and treatment of wrist joint disorders.

Office-based arthroscopic synovectomy of the wrist in rheumatoid arthritis

We present an office-based technique for performing arthroscopic synovectomy of the wrist in patients with rheumatoid arthritis. Intra-articular anesthesia as well as subcutaneous portal anesthesia are used. Standard portals are used in the radial carpal and midcarpal joints. Standard instrumentation is used and the synovectomy is accomplished using a motorized shaver. We performed 30 procedures in 21 patients: 15 complete synovectomies, 3 radioulnar carpal synovectomies because of only limited disease, and 12 limited synovectomies because these patients were participants in a clinical trial and required only limited synovectomy for investigational purposes. There were no complications. Office-based arthroscopic synovectomy of the wrist in patients with refractory rheumatoid arthritis can be performed safety and effectively. This technique is useful in both a clinical as well as a research setting.

Diagnostic arthroscopy: indications and interpretation of findings

Many authors recommend arthroscopy for diagnostic or therapeutic purposes. Arthroscopy is a sophisticated investigation, which can cause damage requiring wrist fusion. It allows visualization of findings, but these are subtle and difficult, if not impossible to interpret, since the contralateral wrist cannot be used as a standard for comparison. Furthermore, not all intracarpal ligaments are directly and reliably visible through the arthroscope: for example the scaphoid-trapezial ligament which is essential for the stabilization of the distal part of the scaphoid. Therefore, it is questionable whether we can define arthroscopy as a gold standard of diagnosis just because it permits direct vision, as if what cannot be seen does not exist! Traction, mandatory for examination, induces particular stresses that may distort intracarpal motion and so-called dynamic evaluation. Each author tends to present a specific classification, rendering comprehension even more difficult. Accordingly, teaching and learning become a real challenge. Arthroscopy may be important in particular cases, but it remains only one component of a complex clinical assessment.

Magnetic resonance imaging of the wrist: diagnostic performance statistics

AIM

To review the published diagnostic performance statistics for magnetic resonance imaging (MRI) of the wrist for tears of the triangular fibrocartilage complex, the intrinsic carpal ligaments, and for osteonecrosis of the carpal bones.

MATERIALS AND METHODS

We used Medline and Embase to search the English language literature. Studies evaluating the diagnostic performance of MRI of the wrist in living patients with surgical confirmation of MR findings were identified.

RESULTS

We identified 11 studies reporting the diagnostic performance of MRI for tears of the triangular fibrocartilage complex for a total of 410 patients, six studies for the scapho-lunate ligament (159 patients), six studies for the luno-triquetral ligament (142 patients) and four studies (56 patients) for osteonecrosis of the carpal bones.

CONCLUSIONS

Magnetic resonance imaging is an accurate means of diagnosing tears of the triangular fibrocartilage and carpal osteonecrosis. Although MRI is highly specific for tears of the intrinsic carpal ligaments, its sensitivity is low. The diagnostic performance of MRI in the wrist is improved by using high-resolution T2* weighted 3D gradient echo sequences. Using current imaging techniques without intra-articular contrast medium, magnetic resonance imaging cannot reliably exclude tears of the intrinsic carpal ligaments. Hobby, J. L. (2001). Clinical Radiology, 56, 50-57.

Clinical diagnosis of triquetrolunate ligament injuries

The clinical diagnosis of peritriquetral injuries is difficult. We describe our diagnostic technique based on specific questions and three clinical tests. The accuracy of our diagnostic technique was compared prospectively with the definitive diagnosis made at arthroscopy. Preoperatively, 19 patients were diagnosed as having triquetrolunate dissociation. This was confirmed at arthroscopy in 17. Another five patients not diagnosed preoperatively were also diagnosed at arthroscopy as having mainly triquetrolunate dissociation. The sensitivity of our diagnostic protocol was 0.77 and the positive predictive value was 0.89.

A comparison of magnetic resonance imaging and arthroscopy in the investigation of chronic wrist pain

Forty-three patients with chronic wrist pain have been investigated prospectively with magnetic resonance imaging and arthroscopy. Pathology within the wrist joint was detected in 30 cases with magnetic resonance imaging and 32 cases with arthroscopy. The sensitivity and specificity of magnetic resonance imaging compared with arthroscopy were 0.8 and 0.7 for triangular fibrocartilage complex pathology, 0.37 and 1.0 for scapholunate ligament and 0 and 0.97 for lunotriquetral ligament. It is concluded that magnetic resonance imaging is unhelpful in the investigation of suspected carpal instability. In analysis of the triangular fibrocartilage complex, the results of magnetic resonance imaging should be interpreted with caution.

The role of arthroscopy in the investigation of wrist disorders

The findings at arthroscopy of the wrist in 48 consecutive cases carried out over a 4.5 year period have been retrospectively reviewed. In correlating the clinical and arthroscopic findings in the 36 patients with wrist instability and triangular fibrocartilage injuries we found concurrence in 28 of the cases. In the six patients in whom we were unable to make any provisional clinical diagnosis we did not find arthroscopy helpful. Arthroscopy usefully influenced the management in two of the six patients in whom the articular surface was assessed. We feel that a careful clinical examination of the wrist is the mainstay of diagnosis in wrist disorders. Arthroscopy remains useful in selected cases but has a limited specialized role which should continue to be provided from specialist centres.