Wrist arthroscopy: current concepts

Research hotspots and trend of wrist arthroscopy: A bibliometrics analysis from 2013 to 2023

BACKGROUND

Wrist arthroscopy technology is a surgical technology invented in recent years and widely used in clinical treatment of various wrist diseases. This study uses the methods of bibliometrics and visual analysis to understand the global research status, research hotspots, and future development trends of wrist arthroscopy.

METHODS

The relevant literature of global publications on wrist arthroscopy from 2013 to 2023 was extracted from the Web of Science Core Collection database, and the annual output, cooperation, hot spots, research status, and development trend of this field were analyzed by using the bibliometric software (VOSviewers, CiteSpace, and the R package "Bibliometrix").

RESULTS

A total of 635 articles were included, from 2013 to 2023, the number of publications related to wrist arthroscopy showed an overall upward trend, the USA, France, and China are the top 3 countries in terms of the number of publications, whereas Mayo Clinic is the institution with the highest number of publications, Ho PC holds a core position in this field, keyword analysis indicates that the research hotspots are the applications of wrist arthroscopy in triangular fibrocartilage complex injuries, scaphoid nonunion, and avascular necrosis of the lunate.

CONCLUSION SUBSECTIONS

Wrist arthroscopy has shown tremendous potential in treating various wrist diseases. However, there are still some challenges in its research domain. With continuous deep research, strengthened international collaboration, and ongoing technological advancements, wrist arthroscopy has the potential to become the standard treatment in hand surgery, offering more efficient and safer treatment options for patients worldwide.

Safe zones in dorsal portals for wrist arthroscopy: a cadaveric study

The standard dorsal portals are the most commonly used in wrist arthroscopy. This cadaveric study aims to determine safe zones, by quantitatively describing the neurovascular relationships of the dorsal wrist arthroscopy portals: 1-2, 3-4, midcarpal radial, midcarpal ulnar, 4-5, 6-radial and 6-ulnar. The neurovascular structures of twenty-one fresh frozen human cadaveric upper limbs were exposed, while the aforementioned portals were established with needles through portal sites. The minimum distance between portals and: dorsal carpal branch of radial artery, superficial branch of radial nerve, posterior interosseous nerve and dorsal branch of ulnar nerve, were measured accordingly with a digital caliper, followed by statistical analysis of the data. The median and interquartile range for each portal to structures at risk were determined and a safe zone around each portal was established. Free of any neurovascular structure safe zones surrounding 1-2, 3-4, midcarpal radial, midcarpal ulnar, 4-5, 6-radial and 6-ulnar portals were found at 0.46mm, 2.33mm, 10.73mm, 11.01mm, 10.38mm, 5.95mm and 0.64mm respectively. Results of statistical analysis from comparisons between 1-2, 3-4 and midcarpal radial portals, indicated that 1-2 was the least safe. The same analysis among 3-4, midcarpal radial, midcarpal ulnar and 4-5 portals indicated that midcarpal portals were safer, while 3-4 was the least safe. Results among midcarpal ulnar, 4-5, 6-radial and 6-ulnar portals indicated that 6-radial and specifically 6-ulnar were the least safe. This study provides a safe approach to the dorsal aspect of the wrist, enhancing established measurements and further examining safety of the posterior interosseous nerve.

Arthroscopic Dorsal Ligamentocapsulodesis in the Treatment of Occult Dorsal Wrist Ganglion Cysts Associated with Scapholunate Instability: Surgical Technique and Preliminary Clinical Results

Background: This study aimed to evaluate our preliminary results and experience with the arthroscopic dorsal ligamentocapsulodesis in managing occult dorsal wrist ganglion cysts (ODGCs) associated with scapholunate (SL) instability. Methods: All patients who underwent arthroscopic dorsal ligamentocapsulodesis due to an ODGC with concomitant SL ligament tear were retrospectively reviewed. In addition to demographic data and length of follow-up, outcomes data that included range of motion, grip strength, modified Mayo wrist score (MMWS), complications and radiographs were collected. Results: The study included 18 patients (18 wrists; 10 female and 8 male). The mean age was 32 years (range: 19-48) and the mean follow-up was 34 months (range: 24-48). The mean preoperative extension deficit decreased from 5.5° (range: 0°-20°) to 2.7° (range: 0°-15°) at the final follow-up (p = 0.004). The mean preoperative flexion deficits decreased from 4.4° (range: 0°-15°) to 2.2° (range: 0°-10°) postoperatively (p = 0.003). The mean hand grip strength significantly increased from 27.7 kg (range: 22-36) to 38.3 kg (range: 31-46) at the final follow-up assessment (p < 0.001). The mean MMWS improved from 46 (range: 25-65) pre-operatively to 91 (range: 70-100) at the final follow-up (p = 0.0002). No major intra- or postoperative complications were observed. Conclusions: SL instability may have an important role in the aetiology of ODGCs, and arthroscopic dorsal ligamentocapsulodesis can provide pain relief and functional improvement without recurrence at the short- to mid-term follow-up in the treatment of ODGCs. Level of Evidence: Level IV (Therapeutic).

Arthroscopic Resection Arthroplasty for Scapholunate Advanced Collapse Wrist

Purpose  Scapholunate advanced collapse (SLAC) wrist results from an untreated scapholunate dissociation and is the most common type of degenerative arthritis of the wrist. The most common surgical treatments for SLAC wrist are proximal row carpectomy and four-corner fusion with scaphoid excision. Arthroscopic surgical treatment for SLAC wrist has been reported; however, only limited data on functional outcomes are available. The purpose of this study is to report our 5-year follow-up clinical outcomes for arthroscopic treatment for SLAC wrist. Methods  Thirty-one consecutive cases of arthroscopic resection arthroplasty for SLAC wrist were reviewed. Preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, grip strength, and pain (on 0-10 scale) as well as postoperative satisfaction (0 = not satisfied, 5 = completely satisfied) were recorded. Grip and range of motion were measured by an occupational therapist. Results  The preoperative pain score was 7 and 0.18 postoperatively. The mean satisfaction at final follow-up was 4.8. Preoperative and final follow-up scores of the mean DASH was 48 and 3, respectively. The total arc of motion was 114 degrees preoperatively and 126.5 degrees postoperatively. Mean grip strength before surgery was 41 and 49 kg at final follow-up. Conclusion  Arthroscopic resection arthroplasty for SLAC wrist results in significant improvement in patient function as measured by DASH and pain scores. Type of Study/Level of Evidence  Therapeutic IV.

A study of clinical anatomy of the safe zone for the volar approach for wrist arthroscopy

OBJECTIVE

The current study was to perform an anatomical observation of the volar approach for wrist arthroscopy and to establish the safe zone for this approach.

METHODS

Eight preserved specimens and 2 fresh specimens were used to simulate the medial-to-lateral operation and to mark the volar approach. Based on anatomical measurements of the volar approach, the closest distances from the 1/2, 6R, 6U, VR, VR' and VU approaches to the adjacent important structures were established.

RESULTS

The closest distance from the 1/2 approach to the superficial branch of the radial nerve was 2.4±1.5mm. The closest distances from the 6U and 6R approaches to the dorsal carpal branch of the ulnar nerve were 16.2±1.3mm and 9.0±2.4mm, respectively. The closest distances from the VR and VR' approaches to the palmar cutaneous branch of the median nerve were 6.7±1.1mm and 2.8±0.9mm, respectively; the closest distances to the radial artery were 6.3±4.0mm and 10.0±3.4mm, respectively. Moreover, both of the two approaches passed through the base of the flexor carpi radialis tendon. The closest distance from the VU approach to the ulnar artery and flexor digitorum profundus tendon were 3.3±1.4mm and 0.3±2.5mm, respectively.

CONCLUSIONS

In conclusion, a safe zone could be located for the establishment of the volar approach for wrist arthroscopy.

LEVEL OF EVIDENCE

III; retrospective study with no control group.

Mycobacterium Tuberculosis infection of the wrist joint: A current concepts review

Background

Osteoarticular Tuberculosis (TB) of wrist joint is a rare, often misdiagnosed form of site affected by Mycobacterium Tuberculosis infection that can lead to severe disability and morbidity. This review aims to summarize the current literature on the diagnosis and management of Mycobacterium Tuberculosis infection of the wrist joint.

Materials and methods

A comprehensive search strategy using the PEO (Population, Exposure, Outcome) framework was conducted on PubMed, Google Scholar, and Web of Science databases from 1967 to 2022, excluding single case reports and correspondence articles. The keywords used for the search included 'Mycobacterium tuberculosis' 'osteoarticular' and 'wrist'. Clinical presentation, demographic details, complementary investigations undertaken, trends, and complications of different management interventions were recorded to generate this review.

Results

Osteoarticular Tuberculosis (TB) of the wrist joint accounts for fewer than 1% of all skeletal TB cases across a spectrum of age ranges. Magnetic Resonance Imaging (MRI) represents an excellent modality to reveal the extent of the disease at an early stage of the condition. Synovial fluid analysis has been recommended for microbiological diagnosis. Treatment options include anti-tubercular therapy (ATT), incision and drainage, debridement, synovectomy, and arthrodesis.

Conclusion

Early diagnosis and treatment of wrist tuberculosis is crucial for achieving good functional outcomes in patients with this uncommon condition. Polymerase Chain Reaction (PCR) and GeneXpert technology for the detection of Mycobacterium tuberculosis (MTB) have improved diagnostic accuracy in detecting MTB DNA and rifampicin resistance. Anti-Tubercular Therapy (ATT) regime remains a foundation pillar in the overall management of these patients with focused surgical interventions leading to improved clinical outcomes.

Is Wrist Arthroscopy Safer with the Nanoscope?

Background  Nanoscope, given its smaller size, may be safer when establishing dorsal wrist arthroscopy portals compared with the traditional 2.7 mm arthroscope. Case Description  Ten fresh frozen cadaver specimens were utilized. Dorsal radiocarpal portals were established with the Nanoscope and calipers were used to measure the distance between the portals and the surrounding anatomical structures. The only structure that was pierced during portal placement was the dorsal sensory branch of the ulnar nerve (DSUN) in one specimen when establishing the 6U portal. Our study did not note any tendon injuries. Literature Review  Traditional wrist arthroscopy may be performed with a 2.7 mm arthroscope. With its larger outer sheath cannula, this may place adjacent anatomical structures at risk of injury. Clinical Relevance  During wrist arthroscopy, the Nanoscope may be safer when creating portals to underlying structures. Level of Evidence  This is a Level IV study.

Functional Outcomes Are Similar After Arthroscopic Capsular Repair of Triangular Fibrocartilage Complex Tears Between Outside-In Technique and All-Inside Technique Using Pre-Tied Suture Device

PURPOSE

To compare outcomes of arthroscopic triangular fibrocartilage complex capsular repair at 2-year follow-up between outside-in and all-inside techniques.

METHODS

In total, 58 consecutive patients (wrists) with a Palmer 1B triangular fibrocartilage complex tear without symptomatic distal radioulnar joint instability underwent arthroscopic suture repair from 2011 to 2019 including 31 patients via the outside-in technique (group A) and 27 via the all-inside technique using a pre-tied needle device (group B). Two-year follow-up included visual analog scale (VAS) pain score, motion range, grip strength, Mayo Modified Wrist Score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and complication rate. Correlation between functional result and patient satisfaction was analyzed.

RESULTS

Score changes in VAS, wrist flexion-tension, supination-pronation, grip strength, MMWS, and QuickDASH at 2-year follow-up were not significantly different between group A (3.4 ± 0.8, 18.4 ± 17.5, 12.9 ± 13.3, 30.7 ± 11.2, 26.6 ± 7.9 and 19.4 ± 9.9 and group B (3.4 ± 1.0, 18.5 ± 18.3, 15.6 ± 13.7, 30.8 ± 11.4, 28.1 ± 8.6, and 7.6 ± 7.2) with P values of .400, .489, .223, .486, .240, and .223 respectively. Surgical time averaged 105 minutes (78 to 136) in group A and 94 minutes (61-126) in group B with significant difference (P = .012). Patient satisfaction averaged 1.1 (0-3.5) in group A and 1.0 (range 0-3.0) in group B. Satisfaction score was more strongly correlated with QuickDASH (coefficients: 0.863 in group A and 0.918 in group B) than with MMWS (-0.693 in group A and -0.465), grip strength (-0.619 in group A and -0.417 in group B) and VAS score (0.607 in group A and 0.222 in group B).

CONCLUSIONS

Both techniques achieved comparable outcomes with shorter surgical time in all-inside repair using pre-tied needle device. Patient satisfaction was strongly correlated with QuickDASH score.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic comparative investigation.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

Complications of Wrist and Hand Arthroscopy

Arthroscopy of the wrist continues to evolve and advance as a valuable clinical technique in hand surgery. This article aims to address safety of wrist arthroscopy and provide an overview of the known iatrogenic complications. Ultimately, the likelihood of associated injuries during wrist arthroscopy is dependent on the surgeon's ability and understanding of the equipment. Case volume and duration of experience directly correlate with mitigating iatrogenic injury and optimizing patient outcomes.

Diagnostic Wrist Arthroscopy

After reviewing this article, readers should have a comprehensive understanding of the indications for diagnostic arthroscopy, technical considerations in performing a systematic evaluation of the wrist, and limitations of this technique.

Arthroscopic Transplantation of Osteochondral Autograft for Treatment of Cartilage Defects in the Wrist

Focal chondral lesions are a common cause of chronic wrist pain, with no ideal treatment. The authors developed arthroscopic transplantation of osteochondral autograft from lateral femoral condyle to distal radius with satisfactory outcome in 4 consecutive patients between December 2006 and December 2010. In all cases, graft incorporation was completed by 3 months to 4 months postoperation. All patients showed improvement in wrist function with no pain at follow-up at an average of 70.5 months (range 24-116 months). Second-look arthroscopy in 3 patients confirmed the preservation of normal articular cartilage. Patient satisfaction was high with no complications.

WRIST ARTHROSCOPY: BASIC TIPS FOR DRY ARTHROSCOPIC EXPLORATION

Objective:

This article provides details and tips on the dry arthroscopic technique, based on our experience and its clinical applications.

Method:

The technique was applied to 65 patients (33 men and 32 women) aged between 20 and 62 years (average of 35.4 years) for treating: synovial cyst resection, scapholunate ligament injury repair, ulnocarpal impact correction, triangular fibrocartilage injury repair, and assisted reduction of distal radius fractures.

Results:

A minimally invasive intra-articular evaluation has been observed as a benefit, with low infection rate, small scars, and high rates of early recovery, without affecting intra-articular fluid use, reducing the risk of compartment syndrome and infiltrated soft tissues, in the case of need for associated open surgery. As for the difficulties, we report the surgeon’s view, which is commonly prevented by optical blurring or debris that hit the lens, and the need for radiofrequency care, since the heat generated is dissipated with greater difficulty than in the classical technique.

Conclusion:

Dry arthroscopy emerges as an effective choice to treat wrist pathologies, however, deep knowledge and ease with the classical technique, as well as a learning curve, are key to obtain a good outcome. Level of Evidence V, Expert Opinion.

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.

Complications of Wrist Arthroscopy: A Multicenter Study Based on 10,107 Arthroscopies

Background Wrist arthroscopy is now a routine procedure, regarded as safe. Complications are reported in the literature as being rare and mostly minor. Purpose The two goals of this study were to evaluate the incidence and nature of complications based on a very large multicenter retrospective study, and to investigate about a potential learning curve. Methods The authors sent a detailed questionnaire to all members of the European Wrist Arthroscopy Society (EWAS), inquiring about the number and types of complications encountered during their practice of wrist arthroscopy, and about their experience with the technique. Results A total of 36 series comprising 10,107 wrist arthroscopies were included in the study. There were 605 complications (5.98% of the cases), of which 5.07% were listed as serious and 0.91% as minor. The most frequent ones were failure to achieve the procedure (1.16%), and nerve lesions (1.17%). Cartilage lesions and complex regional pain syndrome each occurred in 0.50% cases. Other complications (wrist stiffness, loose bodies, hematomas, tendon lacerations) were less frequent. Breaking down of the data according to each surgeon's experience of the technique showed a significant relationship with the rate of complications, the threshold for a lower complication rate being approximately 25 arthroscopies a year and/or greater than 5 years of experience. Conclusion Although the global incidence of complications was in keeping with the literature, the incidence of serious complications was much higher than previously reported. There is a significant learning curve with the technique of wrist arthroscopy, both in terms of volume and experience.

Arthroscopic resection of occult dorsal wrist ganglia

INTRODUCTION

Arthroscopic resection of dorsal wrist ganglia has become a well-accepted practice. However, there is a paucity of results on occult ganglia in the literature. The purpose of this study is to evaluate the subjective outcomes of occult dorsal wrist ganglion cysts resected arthroscopically, and to identify and examine intraarticular findings and relate them to pre-operative MRI findings and histologies.

MATERIALS AND METHODS

In 39 patients, 40 wrists were treated with arthroscopic resection of an occult dorsal wrist ganglion. Radio-carpal arthroscopy and mid-carpal arthroscopy were performed, and a capsular window overlying both compartments at the level of the scapholunate interval was created. The motivation to undergo operation for all patients was pain at rest and on load. In a retrospective study by telephone interview, patients were asked for pain reduction and satisfaction with the operation. 30 patients could be reached after 28.5 months on average.

RESULTS

29 of the 30 patients were content with the operation. Reduction of pain at rest and on load was significant. MRI was performed pre-operatively in all the cases and could confirm the presence of a ganglion in 31 cases. Intraoperatively, ganglion structures were identified in 25 cases. Histology showed ganglion tissue or myxoid degeneration in 12 of 26 taken samples. Histology was positive in the cases without intraoperative visualization of typical ganglion structures and without confirmation by MRI.

CONCLUSION

The results of this study confirm that a high patient satisfaction can be achieved for arthroscopic treatment of occult dorsal wrist ganglia, which seem especially amenable for arthroscopic treatment. Furthermore, the results suggest that arthroscopic resection of a dorsal capsular window can be indicated if the complaints and the clinical findings are typical for dorsal wrist ganglion, even though MRI findings may be negative.

[Arthroscopic resection of dorsal wrist ganglion cysts]

OBJECTIVE

Pain relief and improvement of hand function by ganglion cyst resection and/or creation of a dorsal capsular window with partial synovectomy. In the case of visible ganglion cysts consideration of aesthetic aspects.

INDICATIONS

Visible and occult persisting dorsal wrist ganglion cysts, recurrent ganglion cyst after open or arthroscopic resection and intraosseous ganglion cyst with an extraosseous portion.

CONTRAINDICATIONS

Recent skin lesion of the wrist.

SURGICAL TECHNIQUE

Standard setting for wrist arthroscopy. Portals: radiocarpal 3‑4 and 6R, midcarpal radial (RMC) and midcarpal ulnar (UMC) portals. Start with arthroscopy in 3‑4 portal. If there is insufficient visualization of the dorsal capsular fold, change the arthroscope to the 6R portal. From here a tangential view onto the dorsal capsule at the level of the scapholunate (SL) ligament can be obtained. If a large ganglion overlying the 3‑4 portal or the RMC portal is present, UMC portals are primarily used. Intra-articular visualization of ganglion structures should always be attempted, especially for occult ganglion cysts. If the radiocarpal findings are inconspicuous, midcarpal arthroscopy from the UMC portal is performed to visualize the dorsal capsule at the SL ligament. Depending on the main localization of the visible alterations, ganglion or thickening of the capsule, a dorsal capsular window is created at the level of the SL ligament either radiocarpal or midcarpal or overlying both joints. Complete resection of the ganglion is controlled by palpation. Use of a 2.4 mm arthroscope with 30° angle of vision and 2.5 mm shaver (aggressive cutter). Low-suction drainage and soft padded dressing. An arthroscope with 70° angle of vision enables an even better view onto the dorsal capsule.

POSTOPERATIVE MANAGEMENT

Immediate wrist mobilization, avoidance of excessive loading for 3 weeks. Physiotherapy is necessary if wrist flexion is not regained 3  weeks postoperatively.

RESULTS

From 2007 to 2010 a total of 92 wrists from 88 patients were treated by arthroscopic ganglion cyst resection, 44 % for occult and 17 % for recurrent ganglia. At a mean follow-up of 78 % after 29.5 months a high patient satisfaction of 90 % was achieved. The only complication was a complex regional pain syndrome (CRPS) in one patient. The recurrence rate was 12.5 %.

Arthroscopic grading of common wrist disorders and its role in management

Palmer devised a classification system to guide treatment of triangular fibrocartilage complex tears in 1989. The main division is between traumatic Type I and atraumatic Type II tears. The wrist arthroscopy makes diagnosis and treatment of ulnar impaction syndrome possible in a less invasive way. Arthroscopy is the most valuable tool for diagnosis and treatment of acute scapholunate and lunotriquetral dissociation. Arthroscopic grading of Kienböck's disease better describes articular damage compared with plain radiographs and can help surgical treatment. The wrist arthroscopy generally makes it possible to make the diagnosis of the chondral lesion before they are visible by the usual imaging.

Update TFCC: histology and pathology, classification, examination and diagnostics

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.

Temperature in and around the scapholunate ligament during radiofrequency shrinkage: a cadaver study

PURPOSE

To investigate whether applied radiofrequency energy (RFE) for shrinkage of the scapholunate interosseus ligament reaches temperatures required for ligament shrinkage while leaving adjacent structures unaffected.

METHODS

Standard wrist arthroscopy was performed on 7 pairs of cadaveric limbs with continuous saline irrigation and gravity-assisted outflow through an 18-gauge needle. We subjected 14 scapholunate ligaments to treatment with monopolar (n = 7) or bipolar (n = 7) RFE for ligament shrinkage. Temperature was recorded simultaneously inside the dorsal part of the scapholunate interosseus ligament at a depth of 0.9 ± 0.1 mm and at 6 other sites in and around the wrist because thermal shrinkage starts at 60°C to 65°C.

RESULTS

We observed an increase in temperature corresponding to the time of energy application. The highest measured peak temperatures at the scapholunate ligament were 43°C (monopolar) and 32°C (bipolar). Mean temperatures at 30 seconds of application were 29°C ± 7°C (monopolar) and 28°C ± 3°C (bipolar).

CONCLUSIONS

Temperatures sufficiently high to induce ligament shrinkage were not reached with either monopolar or bipolar RFE. We did not monitor temperature levels responsible for damage on adjacent cartilage or immediately adjacent capsular tissue in this setting.

CLINICAL RELEVANCE

This study suggests that RFE for capsular shrinkage in the wrist is safe but ineffective.

RFE based chondroplasty in wrist arthroscopy indicates high risk for chrondocytes especially for the bipolar application

Background

The application of radiofrequency energy (RFE) has become widespread for surgical performed chondroplasty especially due to the anticipated sealing effect, however the safety of this procedure in the wrist remains unclear. The purpose of this study was to investigate the subchondral temperature during radiofrequency energy (RFE) application simulating chondroplasty in an arthroscopic setting of the wrist.

Methods

A chondroplasty of the lunate fossa was performed during an arthroscopy setting on 14 cadaver arms using monopolar or biopolar RFE. The temperature was recorded simultaneously from 7 predefined anatomical landmarks.

Results

The mean temperature for both application modes did not exceed more than 30°C at all measured points, except for the lunate fossa. The highest subchondral measured peak temperature was 49.35°C (monopolar) and 69.21°C (bipolar) in the lunate fossa. In addition, the temperature decreased for both radiofrequency (RF) devices depending on the distance of the sensors to the RF-probe.

Conclusion

It remains to be questionable how safe RFE can be used for chondroplasty in wrist arthroscopy under continuous irrigation and constant movement to obtain the desired sealing effect. However, the bipolar device should be applied with more caution since peak temperature in the lunate fossa almost reached 70°C even under continuous irrigation.

Arthroscopic Resection Arthroplasty of the Radial Column for SLAC Wrist

Background Symptomatic advanced scapholunate advanced collapse (SLAC) wrists are typically treated with extensive open procedures, including but not limited to scaphoidectomy plus four-corner fusion (4CF) and proximal row carpectomy (PRC). Although a minimally invasive arthroscopic option would be desirable, no convincing reports exist in the literature. The purpose of this paper is to describe a new surgical technique and outcomes on 14 patients who underwent arthroscopic resection arthroplasty of the radial column (ARARC) for arthroscopic stage II through stage IIIB SLAC wrists and to describe an arthroscopic staging classification of the radiocarpal joint for patients with SLAC wrist. Patients and Methods Data were collected prospectively on 17 patients presenting with radiographic stage I through III SLAC wrist who underwent ARARC in lieu of scaphoidectomy and 4CF or PRC. Fourteen patients (12 men and 2 women) subject to 1-year follow-up were included. The average age was 57 years (range 41 to 78). The mean follow-up was 24 months (range 12 to 61). Arthroscopic resection arthroplasty of the radial column is described for varying stages of arthritic changes of the radioscaphoid joint. Midcarpal resection was not performed. Results The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 66 preoperatively and 28 at final follow-up. The mean satisfaction (0 = not satisfied, 5 = completely satisfied) at final follow-up was 4.5 (range 3 to 5). The pain level (on 0-10 scale) improved from 6.6 to 1.3. The total arc of motion changed from 124° preoperatively to 142° postoperatively following an ARARC. Grip was 16 kg preoperatively and 18 kg postoperatively. Radiographic stages typically underestimated arthroscopic staging. Although four of our patients appeared to be radiographic stage I, all were found to have arthritis involving some or all of the radioscaphoid articulation at the time of arthroscopy. Clinical Relevance Pain relief is rapid and remains consistent over time following ARARC. ARARC may be a viable surgical option for patients with SLAC wrist who desire a minimally invasive procedure. Radiographic stages underestimate the degree of arthritic change. Accurate staging requires arthroscopy. The indications and long-term outcome are not well defined; continued surveillance is warranted. Level of Evidence Level IV, Therapeutic study.

Arthroscopic osteochondral grafting for radiocarpal joint defects

Background Focal chondral lesion is a common cause of chronic wrist pain. The best treatment remains unknown. We have developed a technique of arthroscopic transplantation of an osteochondral autograft from the knee joint to the distal radius with satisfactory clinical results. Materials and Methods Between December 2006 and December 2010, four patients (average age 31 years) with posttraumatic osteochondral lesions over the dorsal lunate fossa were treated with arthroscopic osteochondral grafting. Pre- and postoperative motion, grip strength, wrist functional performance score, pain score, and return to work status were charted. Postoperative computed tomography (CT) scan, magnetic resonance imaging (MRI), and second-look arthroscopy were performed to assess graft incorporation. Description of Technique With the arthroscope in the 3-4 portal, synovitis over the dorsal lunate fossa was débrided to uncover the underlying osteochondral lesion. We employed the 6-mm trephine of the Osteoarticular Transfer System (OATS) to remove the osteochondral defect. Osteochondral graft was harvested from the lateral femoral condyle and delivered into the wrist joint arthroscopically. Results In all cases, grafts incorporation was completed by 3-4 months postoperative. All patients showed improvement in the wrist performance score (preoperative 27.5, postoperative 39 out of 40) with no pain on final follow-up at average 48.5 months (range 24-68 months). Grip strength improved from 62.6 to 98.2% of the contralateral side. Motion improved from 115.5 to 131.3°. X-ray images showed preserved joint space. Patient satisfaction was high with no complication. Conclusion An arthroscopic-assisted transfer of an osteochondral graft is a viable treatment option for chondral defects of the distal radius.

Wide-Awake Wrist Arthroscopy and Open TFCC Repair

The wide-awake approach to hand surgery entails the use of local infiltration anesthesia using lidocaine with epinephrine and no tourniquet. The technique provides practitioners with an option to perform advanced hand surgical care in an ambulatory setting, without the need for general or regional anesthetics. We present our results using wide-awake approach in wrist surgery, both open and arthroscopic. Between June and August 2011, the wide-awake approach was used in nine elective wrist surgery cases; three arthroscopic procedures, four open triangular fibrocartilage complex (TFCC) repairs, and two combined arthroscopy/open surgery (eight men/one woman). The arthroscopic patients were anesthetized using dorsal infiltration of lidocaine with epinephrine (20 mL) with an additional intra-articular 5 mL injection 30 minutes before surgery. The open surgery patients received 40 mL of lidocaine with epinephrine around the ulnar aspect of the forearm, from 8-cm proximal to 3-cm distal to the distal radioulnar joint. Standard diagnostic radio- and midcarpal arthroscopies were performed, where one patient had a loose body removed and two patients underwent TFCC debridements due to central TFCC tears. The six open cases were all due to TFCC foveal disruptions, which were reinserted using osteosutures in the distal ulna. Following placement of the ligament sutures, a preliminary knot allowed active and passive motion testing of pronosupination, to determine the adequate amount of tension in the ligaments. The wide-awake approach to wrist surgery is a plausible and reliable technique that eliminates the need for general anesthesia, removes the need of a tourniquet, and provides a cost-efficient and safe approach to wrist surgery. The ability to control ligament reconstructions using active motion may additionally enhance the rehabilitation of these patients, both through early proprioceptive awareness and adequate tensioning of soft tissues.

Wrist arthroscopy in children and adolescents: a single surgeon experience of thirty-four cases

PURPOSE

The purpose of this study was to report our experience of wrist arthroscopy in children and adolescents with chronic wrist pain in a retrospective single surgeon series. Therefore, technical differences or obstacles compared to standard wrist arthroscopy in adults, and complications were highlighted.

METHODS

A retrospective data review of all patients undergoing wrist arthroscopy between 2002 and 2011 was performed. The basic inclusion criteria was chronic, therapy refractory wrist pain for more than three months in children and adolescents aged 18 years and younger. In total, 34 arthroscopies in 27 girls and six boys were reviewed. The mean age at time of arthroscopic exploration was 14.6 years (range, 9.8-17.9 years).

RESULTS

A total of 28 wrists showed a triangular fibrocartilage complex (TFCC) tear (82.4%). In 26 of 34 (76.5%) inspected wrist joints additional pathologies besides TFCC tears were documented. As a consequence, 14 arthroscopic TFCC resections, two arthroscopic TFCC repairs and seven open resection arthroplasties were performed. Other concomitant procedures (e.g., ulna shortening) were performed in 25 patients (26 wrists) because of predisposing malformations. No intraoperative or postoperative complications related to the arthroscopies were observed. No relevant technical differences to wrist arthroscopy in adults were experienced apart from cases of major anatomical malformations.

CONCLUSIONS

Wrist arthroscopy has been shown to be a safe procedure to detect and treat paediatric wrist disorders. Nevertheless, we believe that this procedure should only be carried out by well-trained, experienced hand surgeons.