Uses and abuses of wrist arthroscopy

Surgical Treatment of Scaphoid Fractures: Recommendations for Management

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

Arthroscopic Resection of Wrist Volar Synovial Cyst: Technique Description and Case Series

Background  Arthroscopy nowadays has become a widespread technique for the treatment of orthopaedic pathologies. Small-joint arthroscopy has evolved and, through direct visualization, enables diagnosis and immediate treatment of intra-articular lesions. The arthroscopic resection has become a minimally invasive alternative for the open technique. We intend to describe the technique, literature review, and results of arthroscopy for the surgical treatment of wrist volar synovial cysts. Methods  Thirty-nine patients submitted to arthroscopy for the treatment of wrist volar synovial cyst were included and assessed in this study, during the period of January 2015 to May 2017 with a complete assessment in minimum follow-up of 6 months. The technique was indicated for patients with pain and functional impairment for longer than 4 months, with no improvement with conservative measures, or for patients with cosmetic complaints, or those who presented the cyst for more than 3 months. Results  We demonstrated good outcomes in regard to pain, range of motion, and complications in arthroscopic resection of volar wrist ganglion. Conclusion  Arthroscopic resection of volar synovial is a useful and safe technique. It is a low-morbidity, minimally invasive procedure that carries few complications and is a good alternative to the open technique.

Artrhoscopic Resection of Volar Wrist Ganglion: Surgical Technique and Case Series

Objectives  To describe the technique and results of the arthroscopic surgical treatment of volar ganglion cyst of the wrist. Materials and Methods  The present study comprised 21 patients submitted to the arthroscopic treatment of volar ganglion cysts of the wrist from January 2015 to May 2017, with a full evaluation for at least 6 months. The technique was indicated for patients presenting pain and functional impairment for more than four months, with no improvement with the conservative treatment, or for those with cosmetic complaints and cyst present for more than three months. Results  The mean age of the patients was 43.6 years; 16 (76%) patients were female, and 5 (24%) were male. The mean follow-up time from surgery to the final assessment was of 10.9 months. A total of 2 (9.6%) patients complained of mild pain after the procedure, and another patient presented slight motion restrictions. The 18 (90.4%) remaining patients reported cosmetic improvement, complete functional recovery, and pain improvement. There were no recurrences or infections. No patient required further surgery. Conclusions  The arthroscopic resection of volar ganglion cysts is a useful and safe technique. It is a minimally-invasive procedure, with low morbidity and very few complications, representing a good alternative to the open technique.

Diagnostic Wrist Arthroscopy for Nonspecific Wrist Pain

Background: This study addresses the prevalence of discrete pathophysiology accounting for patients' symptoms during diagnostic wrist arthroscopy in individuals with wrist pain without a specific preoperative diagnosis. Secondarily, we determined the number and type of surgeries subsequent to diagnostic wrist arthroscopy. Methods: Between January 2000 and January 2015, 135 diagnostic wrist arthroscopies were performed by 12 surgeons in 3 urban academic hospitals. We recorded the diagnostic findings of diagnostic wrist arthroscopy and any subsequent surgeries. Results: One hundred and five patients had synovitis or a normal wrist (78%), 17 had likely age-appropriate changes (eg, central triangular fibrocartilage complex defects scapholunate changes) (13%), 8 (6%) were given uncommon diagnoses, and 5 (4%) had osteochondral defects. Sixteen patients (12%) had subsequent wrist surgery: 2 were for adverse events, 2 were carpal tunnel releases, and 12 were other surgeries. Conclusion: Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit.

A WORKING CLASSIFICATION FOR THE MANAGEMENT OF SCAPHO-TRAPEZIUM-TRAPEZOIDOSTEO-ARTHRITIS

Osteo-arthritis (OA) of the scapho-trapezium-trapezoid joint (STT) is the second most common involved joint after trapezium-metacarpal I OA in the wrist.

The possible aetiology causing or contributing to the development of STT OA is shortly discussed.

A working classification is then proposed, which assists in the management of STT OA.

Accuracy of sonographically guided and palpation guided scaphotrapeziotrapezoid joint injections

OBJECTIVES

The purpose of this study was to determine and compare the accuracies of sonographically guided and palpation guided scaphotrapeziotrapezoid (STT) joint injections in a cadaveric model.

METHODS

A clinician with 6 years of experience performing sonographically guided procedures injected 1.0 mL of a diluted latex solution into the STT joints of 20 unembalmed cadaveric wrist specimens using a palmar approach. At a minimum of 24 hours after injection, an experienced clinician specializing in hand care completed palpation guided injections in the same specimens using a dorsal approach and 1 mL of a different-colored latex. A fellowship-trained hand surgeon blinded to the injection technique then dissected each specimen to assess injection accuracy. Injections were graded as accurate if the colored latex was found in the STT joint, whereas inaccurate injections resulted in no latex being found in the joint.

RESULTS

All sonographically guided injections were accurate (100%; 95% confidence interval, 81%-100%), whereas only 80% of palpation guided injections were accurate (95% confidence interval, 61%-99%). Sonographically guided injections were significantly more accurate than palpation guided injections, as determined by the ability to deliver latex into the joint (P < .05).

CONCLUSIONS

Sonographic guidance can be used to inject the STT joint with a high degree of accuracy and is more accurate than palpation guidance within the limits of this study design. Clinicians should consider using sonographic guidance to perform STT joint injections when precise intra-articular placement is desired. Further clinical investigation examining the role of sonographically guided STT joint injections in the treatment of patients with radial wrist pain syndromes is warranted.

Anatomic course of the superficial branch of the radial nerve in the wrist and its location in relation to wrist arthroscopy portals: a cadaveric study

PURPOSE

The aim of this study was to assess the course of the superficial branch of the radial nerve (SBRN) at the level of the wrist and its branches in relation to wrist arthroscopy portals.

METHODS

Dissections were performed on 11 hands from 6 cadavers in the section starting from the point where the SBRN begins to emerge and ending at the terminal branches of the dorsal hand. The distribution of the SBRN, the distance from the superficial branch to the dorsal portals used in wrist arthroscopy, and the distance from the superficial branch to the anatomic determinants (styloid process of the radius, Lister tubercle) were studied.

RESULTS

At the level of the wrist, the nerve bifurcated into 2 branches in 8 of 11 wrists (73%) and into 3 branches in 3 of 11 wrists (27%). The mean distance from the SBRN where it was first detected proximal to the Lister tubercle was 73 mm. The mean distance between the styloids was 52 mm; the distance between the Lister tubercle and styloid process of the radius was 23 mm. At the wrist level, the distance from the branch closest to the radial side to the Lister tubercle was 28 mm (L-D1), 21 mm (L-D2/3), and 7 mm (RS-D1). The distance of the closest nerve branch to the 3-4 portal was 9 mm. The distances of the other portals were 5 mm (1-2RMC-D1), 8 mm (1-2RMC-D2/3), 8 mm (1-2P-D1), and 9 mm (1-2P-D2/3).

CONCLUSIONS

The limited size of the area where portals can be positioned and the anatomic variations between individuals are major obstacles in developing a guideline for reducing the risk of SBRN injury in wrist arthroscopy.

CLINICAL RELEVANCE

Great care must be taken when using the 1-2 portal. We suggest making a skin-only incision for this portal and then using blunt dissection to help prevent injury to the SBRN.

Identifying scapholunate ligamentous injury

The first purpose of this study was to develop a noninvasive clinical tool that could predict whether the scapholunate interosseous ligament and other secondary stabilizing ligaments are injured in the presence of suspected scapholunate instability. The second purpose of this study was to determine which of those ligaments or ligament groups have been injured. Kinematic and three-dimensional (3D) meaurements from 62 cadaver wrists moved in a wrist joint motion simulator were used to develop various neural network predictive models. One group of models was based on angular changes in scaphoid and lunate motion before and after ligament sectioning (representing scapholunate instability). A second group of models was based on changes in the minimum distance between the scaphoid and lunate as well as other 3D gap measurements. The models, based on the scaphoid and lunate angular data, could predict with a 93% accuracy rate whether the wrist ligaments were intact. These models could also predict whether it was the dorsal ligaments or the volar ligaments that were sectioned 84% of the time. The models worked best using data with the wrist in 10 to 30 degrees of wrist flexion. The viability of a CT-based predictive model has been demonstrated by obtaining high prediction rates, sensitivity, specificity, and kappa statistic values.

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.

Advances in arthroscopic surgery: indications and outcomes

PURPOSE OF REVIEW

To examine recent trends in the use of arthroscopic surgical techniques to address musculoskeletal problems. The review is particularly timely given the rapidly expanding range of indications for diagnostic and therapeutic arthroscopic procedures involving virtually every peripheral joint.

RECENT FINDINGS

We focus on arthroscopic approaches to problems of the hip, wrist, elbow and ankle. Hip arthroscopy is permitting novel, minimally invasive approaches to the management of femoral acetabular impingement, labral tears, loose bodies and chondral lesions. Wrist arthroscopy has provided novel approaches to ligament tears, synovitis and fractures. Ankle arthroscopy has been especially helpful with soft tissue impingement syndromes, synovitis and fracture. Elbow arthroscopy has been especially helpful in the management of synovitis and osteoarthritis due to osteophytosis. Complications of arthroscopic procedures occur very rarely. Virtually all the literature on arthroscopy outcomes comes from small uncontrolled studies.

SUMMARY

Arthroscopy provides a safe alternative to arthrotomy in the management of a wide range of clinical problems. The generally weak designs of studies performed to date compromises the strength of recommendations that can be made about the role of these procedures in clinical practice.