Wrist Arthroscopy

Abstract

This article is dedicated to our special interest in hand surgery - arthroscopy. We are the initiators of the wrist arthroscopy in our clinic as well as in country. In this chapter we can only sketch some aspects of this fascinating, intriguing and specific direction of hand surgery. Indications for arthroscopic surgery and application in different wrist conditions including novel techniques. There is a short historical review at the beginning - names and contribution of the pioneers of the wrist arthroscopy, development of instruments and surgical possibilities. This is followed by arthroscopic anatomy of the portals and structures accessible via these portals. The most common arthroscopic procedures in our practice are listed and described, such as arthroscopic treatment of ganglions and bone cysts, intercarpal ligament or TFCC tears, application of the arthroscopy in treatment of the articular distal radius fractures, scaphoid fractures and nonunions The text is supplemented with photos of our patients.

1. Introduction

Since wrist arthroscopies for diagnostical purposes were first reported and described in 1979, it has become an important diagnostic and therapeutic tool in the hands of trained specialists during the last decades. Nowadays it is widely used in the treatment of acute wrist injuries as well as different chronic conditions and degenerative diseases. Arthroscopy has assumed an important place in wrist surgery. The wide list of indications for wrist arthroscopy is continuously growing and requires specific operative skills and specialized training before entering the operating room for real surgery. At this point it’s necessary to highlight the huge investment of International Wrist Arthroscopy Society (IWAS) and Asia Pacific Wrist Association (APWA) in training programs, courses and workshops all around the world. Today arthroscopic methods are proposed in the treatment of almost all soft tissue and osseous problems of the wrist. They include synovitis, fibrosis, stiffness, triangular fibrocartilage complex (TFCC) problems, ganglion cysts, scapholunate- (SLIL) and lunotriquetral ligament (LTIL) tears, intra-articular distal radius fracture (DRF) and nonunion treatment, arthroscopic arthrolysis, treatment of scaphoid fractures and nonunions, arthroscopic treatment of Kienböck’s disease, arthroscopically assisted partial wrist fusions, etc. We can be grateful to the industry, that they have been able to listen to our wishes and create the tools needed for our surgeries. Since authors have been limited in the size of the manuscript as well as many well illustrated books on this topic have already been published, we will address only the most frequent problems of wrist arthroscopy in our practice.

2. History of the wrist arthroscopy

Early arthroscopic explorations mostly focused on a knee joint, but M. Burman in the early thirties experimented with a use of arthroscopy in other joints, including the wrist joint. In 1970, the 1.7 mm No. 24 arthroscope was developed, allowing a wide angle of vision and clear focus utilizing a small diameter. M. Watanabe, who started to use arthroscopy in 1950s and developed the famous No. 21, used this scope to examine 21 wrists in 1970–1972. He developed dorsal approaches on the ulnar side of the extensor pollicis longus tendon to access the radiocarpal joint. Watanabe reported on 67 wrist arthroscopies, including visualization of the distal radioulnar joint. He also included 39 arthroscopies of the thumb carpometacarpal joint and metacarpophalangeal joints as well as 9 interphalangeal joint arthroscopies [1]. Y.C. Chen was an another enthusiast and pioneer of the wrist arthroscopy in 1970s. In 1979 he published an article about 90 arthroscopies of the wrist and finger joints in 34 clinical cases and 2 amputed arms with No.24 arthroscope. Eighty-four wrist and finger joints of four cadavers and two amputated arms were also dissected for macroscopic observation. This article was also illustrated with some color photographies taken with arthroscope [2].

In 1986 Terry Whipple published paper on wrist artrhroscopy technics and described the safe wrist artrhroscopy portals which are still used today [3]. The first wrist arthroscopy course was organized by Terry Whipple, Gary Poehling and James Roth in Winston-Salem, North Carolina, USA in 1986. The first textbook dedicated to the wrist arthroscopy was published in 1992 by T. Whipple. During the next decades the popularity of the wrist arthroscopy has grown, new indications and techniques have been developed. In 1997 P.C.Ho organized the 1st Hong Kong Wrist Arthroscopy course. With growing international interest in wrist arthroscopy, Christophe Mathoulin founded the European Wrist Arthroscopy Society (EWAS) in 2005 and the first EWAS cadaveric wrist arthroscopy course was organized in Strasbourg. In 2015 P.C. Ho and G. Bein developed the Asian Pacific Wrist Association (APWA). Both of them are wrist-specific international educational organizations with worldwide network of wrist arthroscopy courses and workshops (Figure 1). In 2019, EWAS evolved into the IWAS – International Wrist Arthroscopy Society.

Figure 1.

Authors attending their first wrist arthroscopy course in Rotterdam in 2009 – Uldis Krustins (left), Janis Krustins (right).

3. Setup and equipment

Wrist arthroscopy requires standard arhroscopic equipment – arthroscopy column with monitor, video camera, video and photo recordingdevice, light source with fiber optic cable which nowadays can be integrated in one small box motorized shavers, radiofrequency ablators and X-Ray C arm and traction system. The patient is positioned supine on the operation table with the affected arm on a hand table. The arm is abducted 90° and the elbow flexed 90° allowing a vertical position of the forearm, wrist and hand. In this position the wrist is kept in neutral prono-supination. The surgeon is positioned at the head of the patient with the assistant beside or facing the surgeon. The arthroscopy column may be on the other side of the patient facing the surgeon (Figure 1). X-ray C arm is used when necessary and is not in the way of the staff all the time (Figures 2 and 3).

Figure 2.

Standard setup and position of the staff during the wrist arthroscopy.

Figure 3.

Use of C arm during the surgery.

Arthroscopic wrist procedures usually are performed under the regional block anesthesia with a pneumatic tourniquet placed on the upper arm, but there are surgeons who propose to do wrist arthroscopies under portal site local anesthesia (PSLA) without tourniquet [4]. Traditionally wrist arthroscopies were performed using irrigation, but it can be easily inspected and treated also in “dry technique” [5]. However, dry arthroscopy also has its limits. For example when radiofrequency ablators are used, water is necessary as milieu conductor and to prevent temperature peaks and possible joint damage. Also when using a burr the aspiration may be blocked by small cartilage and bone fragments and water facilitates the aspiration [6].

Arthroscopic manipulations in wrist require vertical traction to separate bones and create space for instruments and scope. The traction applied is usually 3.5 to 7 kg for wrist joint and 2 to 3 kg for the thumb [6, 7]. There are different types of wrist vertical traction towers – with Chinese finger traps or special traction hands for all fingers. Authors use K.L.Martin and Smith & Nephew wrist traction towers (Figure 4a, b).

Figure 4.

Different finger traps and traction devices (4a - K.L.Martin; 4b -Smith & Nephew).

4. Instruments

The most important instrument, of course, is the scope. In wrist small arthroscopes, between 1.9 mm and 2.7 mm, with camera angulated at 30°, are usually used Arthroscopes are shorter (60 to 80 mm), too. The second most important tool is a probe which helps to explore the joint and serves as an extension of the surgeon’s finger [8]. A variety of differently angled punches, baskets with or without the option of incorporating a suction mechanism and grasping forceps in various sizes are useful for specific manipulations (Figure 5). A motor is fitted with abrasive instruments, such as shavers or burrs of appropriate sizes: 2 to 3 mm in diameter and 6 to 8 cm long. Basic instruments also include a shaver for synovial resection and a burr for bony resection. A special electric bipolar diathermy machine is used for efficient tissue resection by vaporization. An irrigation system is used for joint cleaning. The equipment can be completed by different instruments or kits for specific arthroscopic procedures.

Figure 5.

Set of manual instruments for wrist arthroscopy.

5. Wrist arthroscopy portals

The map of safe wrist arthroscopy portals was first designed by Terry L. Whipple and co-authors in 1986 after anatomical studies of fresh cadaveric wrists which were arthroscoped an then tediously dissected to determine the relationship of each portal to the closest neurovascular and tendinous structures [3]. Seven dorsal wrist portals were identified - five portals for radio-carpal joint with relation to the six extensor compartments (1-2; 3-4; 4-5; 6R and 6 U), one for midcarpal joint – distally from the 3-4 portal and the seventh portal for DRUJ. Anatomical studies proved that 1-2,6 U and 6R portals are the most perilous due the proximity of the radial artery and dorsal radial and ulnar sensory nerve branches. The midcarpal, 3-4,4-5 and DRUJ portals are relatively safe, since neurovascular structures are usually remote [9]. Later additional portals for midcarpal and radio-carpal joint, DRUJ as well as portals and techniques for small joint arthroscopy were described [9, 10, 11, 12, 13, 14].

Localization of portals first has to be checked by palpation with fingertip, then standard intramuscular injection needle can be inserted to determine the exact orientation of the portal. Small and shallow horizontal incisions using no. 15 blade are recommended. Then skin, subcutaneous tissues and join capsule can be dissected using mosquito clip to push away any important structures without injuring them. It’s suggested to use a curved mosquito clip which can easily slip over the curve of the dorsal rim of the radius or proximal carpal bones.

The normal inclination of the dorsal radius and lunate must be taken into consideration when entering the joints with trocar and never use sharp trocars. The insertion angle usually is about 10° proximally to parallel of the dorsal joint axis, to match the distal articular curves of the bones (Figure 6).

Figure 6.

Insertion angle of the instruments.

Volar portals can be used for visualization of the dorsal capsular structures like dorsal radiocarpal ligament (DRCL), palmar aspects of the carpal ligaments or as occasional accessory portals in arthroscopic assisted surgeries of the distal radius fractures or carpal injuries [13, 14, 15].

Localization, function of radiocarpal portals and structures at risk are presented in Table 1 and for midcarpal portals in Table 2.

Portal	Localization and function	Structures at risk
1-2	Between APL and ECRB tendons at the dorsal aspect of the anatomical snuffbox. Used rarely, mostly to reach the radial styloid process and radial part of the joint, as well as for removal of the volar ganglion cysts or washout of the joint.	Radial artery, superficial sensory branch of the radial nerve
3-4	1 cm distally from the Lister`s tubercle, between the EPL and EDC tendons. Always used as a primary portal for visualization of the joint. Almost a complete panoramic view of the volar radiocarpal joint.	EPL and EDC tendons
4-5	Axis of the 4^th metacarpal, between the EDC and EDM tendons. Portal for instrumentation and visualization of the TFCC.	EDC and EDM tendons
6R	At the radial aspect of the ECU tendon. Additional portal for instrumentation or visualization or reconstruction of the TFCC	Dorsal branch of the ulnar nerve
6U	At the ulnar aspect of the ECU tendon. Additional portal for instrumentation, visualization of the reposition of DRF fragments or for reconstruction of the ulnar part of the TFCC	Dorsal branch of the ulnar nerve
VR	2 cm long incision parallel to FCR tendon. Used for evaluation of the DRCL and volar part of the SLIL or fixation of the DRF fragments	Palmar cutaneous branch of the radial nerve, radial artery and volar cutaneous branch of the median nerve
VU	2 cm long incision parallel to ulnar margin of the flexor tendons. Used for the evaluation of the volar part of the LTIL and dorsal ulnar capsule.	Ulnar artery, ulnar nerve and distal palmar branch of the ulnar nerve

Table 1.

Radiocarpal portals.

APL – m. abductor pollicis longus, DRCL – dorsal radio-carpal ligament, ECRB – m. extensor carpi radialis, ECRL – m. extensor carpi radialis longus, ECU – m. extensor carpi ulnaris, EDC – m. extensor digitorum communis, EDM – m. extensor digiti minimi, EPL – m. extensor pollicis longus, FCR – m. flexor carpi radialis, DRF – distal radius fracture, LTIL – luno-triquetral interosseus ligament, SLIL - scapho-lunate interosseus ligament, TFCC – triangular fibrocartilage complex, VR – volar radial portal, VU – volar ulnar portal.

Portals	Localization and function	Structures at risk
MCR	Localized 1 cm distally from the 3-4 portal, between ECRB and EDC tendons. Visualization of the scapho-lunate, scapho-capitate and scapho-trapezium-trapezoideum joints.	ECRB and EDC tendons
MCU	Localized 1 cm distally from the 4-5 portal, on the axis of the 4^th metacarpal bone, between EDC and EDM tendons. Visualization of the luno-triquetral, luno-capitate and. triquetro-hamate joints	EDC and EDM tendons
STT	Localized on the axis of the 2^nd metacarpal bone, ulnary from the EPL tendon, at the level of the scapho-trapezio-trapezoidal joint. Used for instrumentation and resection of the distal scaphoid in STT arthritis	Radial artery, EPL, ECRB and ECRL tendons, terminal branches of the sensory branch of the radial nerve
STT-R	Localized radially to APL tendon at the same level as STT portal. Used for resection of the distal pole of the scaphoid	APL tendon, terminal branches of the sensory branch of the radial nerve

Table 2.

Midcarpal portals.

APL – m. abductor pollicis longus, ECRB – m. extensor carpi radialis, ECRL – m. extensor carpi radialis longus, EDC - m. extensor digitorum communis, EDM – m. extensor digiti minimi, EPL – m. extensor pollicis longus, MCR – midcarpal radial portal, MCU – midcarpal ulnar portal, STT - scapho-trapezio-trapezoidal portal, STT-R - scapho-trapezio-trapezoidal radial portal.

6. Structures which can be identified via dorsal radiocarpal portals

The images below (Figures 7–18) illustrate the anatomical structures of the wrist that can be identified from different standard portals.

Figure 7.

Standard dorsal portals of the wrist. MCR – midcarpal radial portal, MCU – midcarpal ulnar portal, STT - scapho-trapezio-trapezoidal portal, DDRU – dorsal distal radioulnar joint portal, PDRU – proximal distal radioulnar joint portal, ECU – m. extensor carpi ulnaris, EDC – m. extensor digitorum communis, EDM – m. extensor digiti minimi, EPL – m. extensor pollicis longus, 1/2;, 3/4;, 4/5;, 6R;, 6 U – radiocarpal portals.

Figure 8.

Standard volar radiocarpal portals. RVP – radial volar portal, UVP – ulnar volar portal.

Figure 9.

Straight/radial view from 3 to 4 portal. SC – scaphoid, RSC – radioscaphocapitate ligament, LRL – long radiolunate ligament.

Figure 10.

Straight view from 3 to 4 portal. SC – scaphoid, RLT – radiolunotriquetral ligament, Lu – lunate, LRL – long radiolunat ligament, SLIL – scapholunate interosseous ligament.

Figure 11.

Straight/ulnar view from 3 to 4 portal - Lu – lunate, SC – scaphoid, UL – ulnolunate ligament, UT – ulnotriquetral ligament, SLIL - scapholunate interosseous ligament.

Figure 12.

Ulnar view from 3 to 4 portal over the scaphoid ridge, radial part of TFCC accessible.

Figure 13.

Ulnar view from 3 to 4 portal – TFCC, proximal part of Triquetrum and ulnar recess. 6 U – possible location of 6 U portal.

Figure 14.

Degenerative central tear of TFCC in “ulna +” variation.

Figure 15.

Rupture of the dorsal SLIL. View from 6R portal. SLIL - scapholunate interosseous ligament.

Figure 16.

View of STT joint from MCR portal. STT – Scaphotrapeziotrapezoidal joint, MCR – midcarpal radial portal.

Figure 17.

View of scapholunate joint from MCR portal.

Figure 18.

View of lunotriquetral joint from MCR portal.

There are four described arthroscopy portals in the distal radio-ulnar joint. The anatomy of the DRUJ is complex because ulna articulates with both radius and proximal carpal row. Stability of the DRUJ is provided by TFCC with its volar and dorsal distal radioulnar ligaments, connecting at the fovea of the ulnar head. Even in normal wrists DRUJ is a quite narrow place for visualization and instrumentation, therefore it’s suggested to use 1.9 mm scope, reduce the traction of the arm and introduce the scope in the DRUJ when the wrist is fully supinated [16, 17, 18]. Localization of the DRUJ portals, their functions and structures of the risk are described in Table 3.

Portals	Localization and function	Structures at risk
D-DRUJ	Localized 5-8 mm proximally from the 6R portal, between EDM and ECU tendons. Visualization of the ulnar head, undersurface of the TFCC, sigmoid notch, insertion of the volar and dorsal radioulnar ligaments in ulnar fovea	TFCC, articular cartilages of the sigmoid notch and ulnar head
P-DRUJ	Localized 1 cm proximal to the D-DRUJ portal, between EDM and ECU tendons. Visualization of the sigmoid notch, head of ulna and volar capsule,	TFCC, articular cartilages of the sigmoid notch and ulnar head
V-DRUJ	2 cm long incision parallel to ulnar margin of the flexor tendons – the same as for VU portal or can be created by pushing the blunt trocar from 6U portal towards the anterior ulnocarpal capsule between UL and UT ligaments, exiting ulnar to the flexor tendons, where small skin incision can be made.; Visualization of the dorsal radioulnar ligament, possibility to proceed an arthroscopic wafer procedure when TFCC is intact	Ulnar artery, ulnar nerve and distal palmar branch of the ulnar nerve, flexor tendons
DF	Localized 1 cm proximally to the 6U portal between ECU tendon and ulnar styloid dorsally and FCU tendon volarly. Forearm must be fully supinated.; Visualization of the ulnar fovea region, this portal is used as a dedicated working portal for fixation of the TFCC to the ulnar fovea in proximal TFCC lesions	Dorsal branch of the ulnar nerve, ECU and FCU tendons

Table 3.

DRUJ portals.

ECU – m. extensor carpi ulnaris, EDC – m. extensor digitorum communis, EDM – m. extensor digiti minimi, FCU – m. flexor carpi ulnaris, DF – dorsal foveal portal, D-DRUJ – dorsal distal radioulnar portal, P-DRUJ – proximal distal radioulnar portal, V-DRUJ – volar distal radioulnar portal, TFCC – triangular fibrocartilage complex, VU – volar ulnar portal.

7. Small joint arthroscopy portals

There mostly are two standard portals for STT, first carpometacarpal joint (CMC), metacarpophalangeal (MCP), proximal interphalangeal joint (PIP) and distal interphalangeal joint (DIP). Arthroscopical access to pisotriquetral (PT) [19, 20] and fourth or fifth CMC joints also are described while usefulness of these procedures is limited or not yet established [10].

First CMC portals are localized approximately 1 cm distally from STT portals on both sides of the first dorsal compartment. Accessory dorsal portal (the dorsal ulnar portal) can be used as necessary for better viewing the radial side of the joint by placing a trocar into the volar portal, across the CMC or the STT joint and out the dorsum of the hand (Figure 19) [21].

Figure 19.

CMC and STT portals. a – localization on the skin, b – verification with fluoroscope.

There are two portals – radial and ulnar for MCP, PIP and DIP joint arthroscopies, the naming of them is related to relationship with extensor tendons and they were established by Chen [2]. MCP joint arthroscopies can be successfully used in the rheumatoid conditions when synovectomy and thermal shrinkage can be performed [22, 23, 24], or in traumatic cases such as gamekeepers injury [10, 25], collateral ligament ruptures and reduction of the intraarticular metacarpal head fractures as well as in cases of complex MCP joint dislocations [26, 27]. Indications of the MCP joint arthroscopy include also chronic cases of instability, removal of the loose bodies as well as in cases of joint stiffness caused by intraarticular fibrosis or even cases of septic arthritis [18, 28].

Arthroscopy of the PIP and DIP joints has not been widely accepted because of the limited indications and technical limitations. The main indications are inflammatory or septic arthritis as well as removal of foreign bodies. Several authors suggest horizontal placement of the hand instead of using a traction tower, as it is important to be able to flex the joint freely [29, 30]. Cobb reported several cases of the DIP arthroscopic arthrodesis [10]. Since authors have no personal experience in finger joint arthroscopy, further discussion on this topic will not be continued in this chapter.

Many years the use of intra-articular fluid for wrist arthroscopy was considered essential. Francisco del Piñal et al. described a technique for dry arthroscopy in 2007 [5].

8. Arthroscopic treatment of ganglion cysts

Ganglion cysts are the most common benign soft-tissue tumors of the wrist. Dorsal cysts are more common than volar and surgical treatment is indicated for painful ganglions or large ones for cosmetic purposes. These ganglions usually appear in the dorsal scapholunate region which consists of three anatomical structures – the dorsal segment of scapholunate (SL) ligament, the dorsal intercarpal ligament (DICL) and the dorsal capsuloscapholunate septum (DCSS) [31]. The extra-articular part of the cyst can vary in size and location as well as in relation to dorsal ligaments. Surgical treatment of the so called “occult” ganglion cysts, who are small, intracapsular and can be very painful, is challenging by conventional methods. Arthroscopic treatment of such ganglion cysts is a method of a choice.

There are two different arthroscopical techniques for resection of the dorsal ganglia. The one is an access via radiocarpal joint and the other is through the ganglion and via the midcarpal joint [32, 33]. Some authors describe the necessity to combine radiocarpal and midcarpal portals, thus enabling a complete resection [34].

In the 2nd edition of Wrist Arthroscopy Techniques by C. Mathoulin different techniques of the dorsal ganglion artrhroscopic resections using only midcarpal portals are described and well-illustrated [35]. In our hands the midcarpal approach works perfect in most cases, except if ganglions are located very proximally (Figure 20). It provides also a good cosmetic result with only two almost invisible scars on the dorsal aspect of the wrist, which is important especially in younger females.

Figure 20.

Dorsal ganglion, view from MCU portal, a – visualization of ganglion cyst after synovectomy, b – ganglion removed, clean extensor tendons visible.

Aftertreatment – patients have to be encouraged to start early movements. In some cases, if patients have low pain malaise, short arm cast or wrist splint is recommended for first week after surgery. Recurrence rate for dorsal wrist ganglions treated arthroscopically is from 3 to 12% [34, 36, 37, 38]. Complications are rare and they are less common than in open surgeries. Most common complications reported are some stiffness (less than with open surgery), neurapraxia, extensor tenosynovitis and complex regional pain syndrom [39]. In meta-analysis presented by Head et al. in 2015, mean complication rate for arthroscopic surgical excision was 4%, and recurrence rate 6% [40]. Complication rate reported for open surgeries was 14% and recurrence rate 21%.

Volar wrist ganglions are less common than dorsal ganglions (about 20%) and they mainly occur in the radiocarpal joint, especially in the radial corner of the volar aspect. Volar ganglions in the midcarpal joint are very rare ant mostly they occur as a result of STT arthritis. The most common appearance is below FCR and FPL tendons. The technique of the arthroscopic volar ganglion resection was first described by P.C.Ho et al. in 2003 [41]. The origin and stalk of the ganglion usually locates between radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. It becomes visible by gently pushing with finger on the ganglion while scope is positioned in 3-4 portal. Shaver is inserted in the 1-2 portal and ganglion has to be removed gently to avoid injuries of the neurovascular structures and flexor tendons (Figure 21) [39, 42].

Figure 21.

Volar ganglion of the wrist, a – ganglion detected in volar radial corner of the wrist, b – ganglion removed.

Aftertreatment is similar to that one for dorsal ganglions. In a systemic review presented by Fernandes et al. in 2014 mean complication rate for arthroscopic volar ganglion surgeries was 6% and recurrence rate 6.9% [43]. Reported complications are increased cyst site volume during the immediate postoperative period, radial artery injuries, neuropraxia of the dorsal radial nerve, partial lesions of the median nerve [39, 43, 44].

9. Arthroscopic bone grafting of the intraosseus carpal ganglion cysts

Intraosseus ganglions (IOG) can affect all carpal bones but mostly they affect the lunate, capitate and scaphoid [45]. In patients who have dorsal wrist ganglions, the prevalence of IOGs is reported to be almost 50% [46]. Most of them are asymptomatic and can be found during the routine radiographs or CT scans because of the different complains. Surgical treatment is recommended for the symptomatic IOGs and include the curettage of the damaged bone and bone grafting.

Arthroscopically assisted treatment of the intraosseus ganglions of the lunate was first described by Ashwood and Bain in 2003 with the aim of reducing the morbidity that has been seen with open techniques [47].

Surgeries can be performed via routine radiocarpal or midcarpal portals – depending of the localization of the ganglion cyst. Usually the ganglion cyst cannot be visualized by arthroscope, because they still remain covered by the articular cartilage. The location of the drill hole has to be determined by the preoperative radiographic investigations. Once the ganglion is removed with the arthroscopic cutter and the hole is debrided with curette and shaver, it can be filled with bone grafts from the distal radius or iliac crest, which can be harvested via small incision and then delivered into the bone through a trocar under the arthroscopic visualization (Figure 22).

Figure 22.

Arthroscopic debridement of the scaphoid cyst, a – defect of the bone after debridement, b – defect closed with autologous bone graft (ABG).

Aftetreatment includes immobilization for 10 to 14 days and patients are advised not to return to light duties until 6 weeks after the surgery, and heavy manual labor is avoided for a minimum of three months [18].

10. Arthroscopic treatment of the scapholunate ligament tears

Scapholunate interosseus ligament (SLIL) should be considered as a key stone of the intercarpal stability. It is U shaped in the sagittal plane and has three components – dorsal, volar and proximal [48]. The dorsal segment is the strongest portion with a tensile strength of 260 - 300 N and approximate thickness of 3 mm [32]. The proximal component is the weakest and avascular, The volar part has a tensile strength of 120- 150 N and approximate thickness of 1 mm. The palmar and dorsal segments work collectively to prevent rotational translation between scaphoid and lunate, whereas the intermediate segment has little role in stability [49, 50, 51].

Scapholunate stability is effectively ensured by a complex associating the dorsal and volar portions of the SLIL, the dorsal intercarpal (DIC) ligament, the dorsal radiocarpal (DRC) ligament, the radioscaphocapitate (RSC) ligament, the scaphotrapezial (ST) ligament, and the dorsal capsulo-scapholunate septum (DCSS). The integrity of these various stabilizers is taken into account while determining the arthroscopic classification of “predynamic” scapholunate instability [52].

When the SLIL is injured, the scaphoid tends to move into volarflexion, while the lunate, which is still fixed to the triquetrum, is forced, due to carpal kinematics, to follow the triquetrum into dorsal extension. The opposite happens with time when the LT interosseous ligament (LTIL) is injured. This static instability is often referred to radiologically as dorsal intercalated segment instability (DISI), following an SLIL injury and volar intercalated segment instability (VISI) following a LTIL injury [53].

The first arthroscopic classification of SLIL tears was presented in 1996 by Geissler et al. [54] using a 4-stage grading system (Table 4) (Figures 23 and 24).

Grade	Description
I	Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space.; No incongruency of carpal alignment in mid-carpal space.
II	Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space.; Incongruency or step-off of carpal space.; There may be slight gap (less than width of probe) between carpal bones.
III	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space.; Probe may be passed through gap between carpal bones.
IV	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space.; There is gross instability with manipulation.; 2.7-millimeter arthroscope may be passed through gap between carpal bones (“drive thru sign”).

Table 4.

Geissler’s arthroscopic classification of SLIL tears.

Figure 23.

Geissler grade II tear – attenuation an hemorrhage (*) of SLIL.

Figure 24.

Geissler grade IV tear – arrow shows gap between scaphoid and lunate. Scope easily passes between bones and slides into midcarpal joint.

In 2013 Messina et al. published the European Wrist Arthroscopy Society (EWAS) Classification of Scapholunate tears which was based on anatomical arthroscopic study and is an evolution of Geissler’s classification (Table 5) [55].

Arthroscopic stage (EWAS)	Arthroscopic testing of SLIOL from MC joint	AP findings
I	No passage of the probe	Not found in cadaver specimens
II lesion of membranous SLIL	Passage of the tip of the probe in the SL space without widening (stable)	Lesion of proximal/membranous part of SLIL
III A partial lesion involving the volar SLIL	Volar widening on dynamic testing from MC joint (anterior laxity)	Lesion of anterior and proximal part of SLIL with or without lesion of RSC- LRL
III B partial lesion involving the dorsal SLIL	Dorsal SL widening on dynamic testing (posterior laxity)	Lesion of proximal and posterior part of SLIL with partial lesion of DIC
III C complete SLIL tear, joint is reducible	Complete widening of SL space on dynamic testing, reducible with removal of probe	Complete lesion of SLIL (anterior, proximal, posterior), complete lesion of one extrinsic ligament (DIC lesion or RSC/ LRL)
IV complete SLILwith SL gap	SL gap with passage of the arthroscope from MC to RC joint No radiographic abnormalities	Complete lesion of SLIL (anterior, proximal, posterior), lesion of extrinsic ligaments ( DIC, and RSC/ LRL)
V	Wide SL gap with passage of the arthroscope through SL joint Frequent X Ray abnormalities such as an increased SL gap, DISI deformity	Complete lesion of SLIL, DIC, LRL, RSC, involvement of one or more other ligaments (TH, ST, DRC)

Table 5.

Arthroscopic EWAS (European Wrist Arthroscopy Society) Classification and corresponding anatomo-pathological (AP) findings in cadaver specimens.

SLIL: scapholunate interosseous ligament. MC: midcarpal. RC: radiocarpal. RSC: radio-scapho-capitate. LRL: long radiolunate. DIC: dorsal intercarpal ligament. SL: scapholunate. TH: triquetro-hamate. ST: scaphotrapezial. DRC: dorso radiocarpal. DISI: dorsal intercalated segmental instability.

The existing classifications, however, describe the dynamic instability of the scapholunate joint but do not distinguish the site of ligament attenuation or tear, particularly in its volar portion.

The choice of the procedure for SLIL injuries in the absence of arthritis depends on the extent of the lesion, quality of the ligament remnants and reducibility of the joint [53].

Garcia-Elias et al. [56] developed a set of 6 questions that provide a useful framework for developing stage-based treatment algorithms. By answering these questions in terms of yes or no, each case can be placed into one of seven categories (Table 6). As expected, the increasing number of negative answers indicates a progression of the dysfunction from minimal (Stage 1) to maximal (Stage 7). In general, all instabilities from the same stage will be treated similarly.

Stage	1	2	3	4	5	6	7
Is the dorsal SL ligament intact?	YES	NO	NO	NO	NO	NO	NO
If repaired, has it good chances of healing?	YES	YES	NO	NO	NO	NO	NO
Is the radioscaphoid angle normal?	YES	YES	YES	NO	NO	NO	NO
Is the lunate uncovering index normal?	YES	YES	YES	YES	NO	NO	NO
Is the misalignment easily reducible?	YES	YES	YES	YES	YES	NO	NO
Are the joint cartilages normal all over the wrist?	YES	YES	YES	YES	YES	YES	NO

Table 6.

Six questions by Marc Garsia-Elias.

Detailed description of indications and treatment methods depending on the time after injury, the stage of SLIL disruption and stability or instability of the carpus is presented in the report of the IFSSH Committee On Carpal Instability in 2016 (part 2: Management of scapho-lunate dissociation [57].

Since this book is oriented to the arthroscopic methods of treatment further discussion on open surgical procedures will not be proceeded.

In acute injuries, arthroscopy can be used to determine the extent of scapholunate interosseous ligament injury. Partial tears may be treated by percutaneous pinning of the scaphoid and lunate, thus allowing for the possibility of primary healing or fibrosis.

Predynamic or occult SL injury results from an incomplete tear of the SL ligament. In selected cases with reducible scapholunate instability (Garcia-Elias stages 2, 3 and 4) where the ligament is partially (Figure 25) or completely ruptured, and where the scaphoid is well aligned or can be reduced, Mathoulin et al. proposed the arthroscopic dorsal capsuloplasty, which may be combined with K-wire fixation of the scapholunate and the scaphocapitate joints [58, 59].

Figure 25.

Partial, reparable rupture of SLIL, a- view from MCU portal, yellow arrow shows the step off between articular surfaces od scaphoid and lunate, red arrow points detachment of SLIL from lunate, b- The same patient – normal SLIL in RC joint, view from 3 to 4 portal.

This technique can be performed only in cases when ligament stumps remain attached to the scaphoid and lunate. This technique includes synovectomy of midcarpal and radiocarpal joints. Then the scope is introduced into the 6R portal to inspect the gap between the lunate and the dorsal capsule (Figure 26).

Figure 26.

View from 6R portal with detached dorsal capsule and injured dorsal capsuloligamentous scapholunate septum (DCSS).

An absorbable monofilament suture is passed through a needle. This needle is inserted through the skin via the 3–4 portal, then shifted slightly distally so as to cross the joint capsule (Figure 27).

Figure 27.

Needle inserted via 3-4 portal and shifted distally to enter the midcarpal joint.

The needle is located inside the joint through the scope and then pushed through the SLIL stump on the scaphoid side. The needle is oriented dorsal to volar and angled proximal to distal, allowing it to enter the midcarpal joint (Figure 28). A second needle and suture are then inserted parallel to the first into the SLIL stump attached to the lunate. The scope is returned to the MCU portal. The two needles are located inside the midcarpal joint, after they have passed between the scaphoid and lunate. Both sutures are externalized via MCR portal with hemostat and the knot is tied outside the joint. Then the knot is pulled back into the midcarpal joint (Figure 29).

Figure 28.

View from the UMP - needle in the midcarpal joint and suture is knotted by twisting of the needle.

Figure 29.

The inner knot of both sutures at the level of SL joint.

At this point the traction of the wrist is released to reduce the gap between scaphoid and lunate. Transfixation of the scapholunate and scaphocapitate joints with K-wires can be performed if reduction is insufficient. The final knot is tied after the wrist is released from traction and positioned in slight extension [52].

After treatment includes 8 weeks of immobilization and an adequate rehabilitation.

There are several other, more complicated arthroscopic SLIL repair procedures described, but the indications of these techniques are limited to predynamic and dynamic SL instability.

P.C.Ho et al. in 2002 designed an arthroscopic assisted box reconstruction of scapholunate ligament with palmaris longus (PL) tendon graft [60]. It enables simultaneous reconstruction of the dorsal and palmar SL ligaments anatomically with the use tendon graft in a boxlike structure. With the assistance of arthroscopy and intraoperative imaging as a guide, a combined limited dorsal and volar incision exposed the dorsal and palmar SL interval without violating the wrist joint capsule. Bone tunnels of 2.4 mm are made on the proximal scaphoid and lunate. A palmaris longus tendon graft is delivered through the wrist capsule and the bone tunnels (Figure 30) to reduce and connect the two bones in a boxlike fashion.

Figure 30.

A palmaris longus tendon graft deliverd through the lunate and both capsules.

Once the joint diastasis is reduced and any DISI malrotation corrected, the tendon graft is knotted and sutured on the dorsal surface of the SL joint extra-capsularly in a shoe-lacing manner (Figure 31a, and b). Additional suture anchors can be placed at the dorsal bone tunnels for the scaphoid and lunate for additional graft fixation. The RL pin is removed at the beginning of the third week. The cast is then changed to a thumb spica splint for an additional 2 weeks, at which time gentle wrist mobilization is allowed out of the splint. The SC pins are removed after 8 weeks. The potential risk of ischemic necrosis of the carpal bone is minimized by preservation of the scaphoid blood supply [52, 60].

Figure 31.

Tightened tendon graft, view from volar (a) and dorsla (b) side.

Corella et al. in 2011 published a novel all arthroscopic technique for scapholunate instability [61]. They developed the BTT ligamentoplasty - Bone (base of second metacarpal bone), Tendon (flexor carpi radialis graft), Tenodesis (in the scaphoid and lunate). This technique aims to reproduce the tripple tenodesis technique proposed by Garcia-Elias et al. in 2006 [56], but with an arthroscopic approach reducing soft tissue trauma. It reconstructs both the dorsal and volar portion of the SL ligament with a 3-mm graft of the FCR tendon, which is fixed to the scaphoid and lunate tunnels with interference screws. Graft resistance and strength can be increased with the use of a 1.3 mm SutureTape. The SutureTape is passed and fixed with the screws along with the tendon graft. After the graft is fixed to the scaphoid bone with the anchor, the volar portion of the SutureTape that exits from the lunate tunnel is sutured to the portion that exits from the scaphoid tunnel. It’s recommended to start early postoperative wrist mobilization with this technique – dart-throwing motion from the 3rd week and flexion/extension movements from the 5th week after surgery [62].

11. Arthroscopy in the treatment of articular distal radius fractures (DRF)

Hand surgeons began applying wrist arthroscopy to the surgical treatment of the DRF in the late 90’s of the last century. Arthroscopic reduction of intraarticular fragments, as opposed to conventional methods, may improve outcomes regardless of the method of fixation, volar locking plates or external fixator and K-wires [63, 64, 65, 66, 67, 68, 69]. Failure to reduce intra-articular fractures of the distal radius predisposes to pain, restricted movement and degenerative arthritis. The functional results of treatment for articular DRF’s are determined by alignment of fragments of extraarticular fracture, by restoring bone shape, length and fold, anatomical reposition of joint surface, prevention of additional damage to soft tissue, as well as potential post-operative complications [70, 71, 72, 73, 74]. Fluoroscopy alone provides an image that has poorer resolution than that of the magnified camera used for direct arthroscopic visualization, whereas even a small degree of displacement is obvious arthroscopically [75]. It is obvious that optical visualization of the articular space gives an opportunity to detect a greater number of soft tissue lesions more often, than only fluoroscopic and clinical evaluation or surgeon’s mistrust about the possibilities of such injuries [76]. Wrist arthroscopy is currently recommended for the treatment of any articular distal radius fracture (Figure 32a, and b), but some possible contraindications have been identified. As one of these are elderly and low-active patients, open fractures and polytrauma patients, particularly at the early stage of treatment, since this procedure can significantly increase the duration of surgery. As another major objection to the use of arthroscopic treatment, is a lack of technical equipment and surgeon’s experience [64, 77, 78].

Figure 32.

Dorsally displaced articular fracture of the distal radius.

There are two controversial fracture fixation techniques. In cases of volar plating, standard flexor carpi radialis approach can be used. Once the fracture is preliminarily fixed with the volar locking plate (VLP) (Figure 33), the wrist joint is assessed arthroscopically using the 3-4 and 4-5, 6R, 6 U or 1-2 portals to remove blood clots, small articular fragments or to make an additional reposition and fixation with K-wires. Distal screws can be inserted only after arthroscopic inspection of the radiocarpal joint and a fluoroscopic confirmation of the correct position for the screws (Figures 34a,b and 35a,b).

Figure 33.

Preliminary fixation of the volar plate before arthroscopic part of the surgery.

Figure 34.

Additional fragment reposition and fixation.

Figure 35.

Final fluoroscopic image of the surgery.

After treatment includes 2 weeks in short plaster cast and early mobilization can be allowed as volar locking plate provides rigid fixation.

In cases of comminuted fractures when fixation with VLP is impossible, arthroscopically assisted fracture reposition and fixation with K-wires and external fixator is recommended (Figures 36a–c and 37a,b). This surgery is commenced with a primary closed reduction and fixation with several K-wires, under fluoroscopic guidance. Following fixation in a traction tower, the articular surfaces are assessed using the standard arthroscopic technique. Further fragment reductions are performed, if required, using a probe or K-wires as joysticks through elongated 3-4, 4-5, 1-2 and in some cases, volar portals. Additional K-wire fixation is used as required. Once satisfactory reposition is achieved, the bridging external fixator can be applied. The external fixator is removed 4 weeks after surgery. K-wires are usually removed between 4 and 6 weeks after surgery.

Figure 36.

Position of the monolateral external fixator over the wrist joint. a and b - Comminuted volar, distal, articular fracture of the radius.

Figure 37.

Final x-ray after the application of external fixation and K-wires.

The associated soft tissue lesions can be found from 30 to 66% of DRFs, but not all of them require surgical treatment [79, 80, 81]. In cases of associated soft tissue injuries like SLIL and LTIL acute ruptures or TFCC lesions, arthroscopically guided, debridement of the injured ligaments or TFCC is advised, as well as trans-articular fixation of the scapholunate and/or lunotriquetral joints with K-wires, or application of peripheral sutures for TFCC tears.

Authors have never experienced severe complications as tendon ruptures or infection but we have found that the more extensive use of K-wires in reduction and/or fixation during external fixation and K-wire fixation is more likely to result in nerve damage. Furthermore, the complication of subsequent loss of position of fragments also occurred in patients treated with K-wires and external fixator [81].

In last two decades several minimally invasive plate osteosynthesis (MIPO) techniques using volar locking plates on DRF are presented [82, 83, 84]. In cases of comminuted articular DRF’s this technique can be supplemented with an arthroscopic visualization. After all, two major lines of MIPO techniques evolved and got new promoters: single longitudinal incision and double transverse incision, leading to the creation of new special volar plates setups adapted to each technique’s pitfalls and benefits [85, 86]. Unfortunately authors do not have any personal experience with MIPO technique.

12. Arthroscopic arthrolysis

Arthroscopic wrist arthrolysis is indicated in situations of posttraumatic wrist rigidity. It can be performed in radiocarpal joint, midcarpal joint and even in DRUJ. The most frequent clinical pathological conditions are adhesive capsulitis and arthrofibrosis of the wrist. Capsulitis is due to ligament and/or capsule contractures, and wrist arthrofibrosis is usually due to osseous band fibrosis of the radius and/or first row carpal bone(s) from a radius articular fracture. These two conditions can be associated in the same case [87]. The technique of the arthroscopic arthrolysis of the wrist was presented by R. Luchetti et al. in 2006. In radiocarpal joint almost all possible portals, including volar portals must be used during this surgery. It could be difficult to orient in the joint and to triangulate instruments because of the fibrotic adhesions inside the joint. Once they are removed (Figure 38a, and b), but the range of motion (ROM) is still insufficient, resection of the volar and dorsal radiocarpal ligaments is recommended. This can be done with miniblade, laser or radiofrequency cutter. It’s also recommended to leave dorsal and volar ulnar ligaments intact. The midcarpal joint also has to be inspected in the same manner but ligament resection is not recommended. Wrist stiffness is much more rarely attributable to the midcarpal joint, and any fibrosis in this joint is rarely significant [88]. Arthroscopic arthrolysis of the DRUJ is technically very challenging, because visualization of this joint is already problematic in the normal conditions and requires good arthroscopic skills of the surgeon. But once it can be done, patients achieve an improvement of prono/supination movements. If the arthroscopic arthrolysis of the DRUJ cannot be performed because of the technical difficulties it can be conversed to open surgery. Rehabilitation is started immediately after the surgery.

Figure 38.

Intraarticular adhesions (a) after removal (b).

Complications – in cases when osteochondral lesions of various severity are present during the procedure of the arthrolysis, it is quite common for fibrotic bridges to reform in a few months and provoke partial or complete radiocarpal ankylosis. The use of articular instruments and motorized instruments can cause unwanted osteoarticular lesions (chondral scuffing, ligament injuries etc.) that can manifest themselves postoperatively in the form of pain or wrist instability [87, 89].

13. Arthroscopic treatment of scaphoid fractures

The incidence of acute scaphoid fractures is about 70% of all carpal fractures and 11% of all wrist fractures. Young men in the 2nd and 3rd decade of life are the main target population of this injury. Two-thirds of all scaphoid fractures occur in the waist area and 60 – 85% are non-dislocated fractures. Distal third is affected in 25% of cases, but proximal third in 5-10% of fractures [90]. Two morphological bone types are identified: type I or full scaphoids and type II or slender scaphoids. Type I possess more robust internal vascular network than type II scaphoids which may prove to be related to development of nonunion, avascular necrosis or Preiser disease [91]. Indications for surgical treatment are: displacement greater than 1 mm, commination, open fracture, scaphoid fracture with perilunate dislocation, associated carpal instability – scapholunate angle greater than 60°, radiolunate angle greater than 15°, as well as angulation of the scaphoid – intrascaphoid angle greater than 35° and height to length ratio greater than 0.65 [92].

In cases when volar approach with retrograde screw insertion is chosen, arthroscopic treatment of scaphoid fracture has to be started with a small, anterior volar incision through which a 1-mm K-wire is inserted into the scaphoid under fluoroscopy control. This step can be the most difficult one of the entire procedure. If a rolled-up drape is placed under the wrist to extend it to 60°, the K-wire will be about 45° to horizontal. The K-wire is angled from the distal tubercle toward the middle of the carpus. The second stage includes an arthroscopic evaluation when the wrist is placed in vertical traction. Usually midcarpal portals (MCU) are used to visualize the fracture site. If the additional reposition is required, the K-wire can be removed from the proximal pole and manual maneuvers as well as hook probe can be used to achieve the correct position. Then cannulated headless compression screw can be inserted when wrist is released from traction. After the compression of the fracture fragments it’s recommended to make a final arthroscopic evaluation of the midcarpal and radiocarpal joints, to verify the compression and length of the screw [93, 94]. The alternative is a dorsal approach. It provides direct unobstructed access to the proximal scaphoid pole permitting the placement of a central axis guide-wire for antegrade screw implantation [95, 96].

Active wrist motion exercises are initiated immediately or within 10 days after surgery. Strengthening exercises were delayed until healing was well established on X-rays of the scaphoid, usually 3 to 4 months after surgery [93, 97].

14. Arthroscopic management of scaphoid nonunion

Acute scaphoid fractures are often missed and patients return with pain when delayed union or nonunion manifests (Figure 39a).

Figure 39.

(a) X-ray of scaphoid nonunion, (b) shaver in the nonunion site, (c) defect of the scaphoid after removal of debris, (d) fixation of the scaphoid with K-wires, (e) defect filled with bone graft, (f) final x-ray after the surgery.

The natural history of untreated scaphoid nonunions is progression to carpal collapse resulting in wrist arthritis and chronic painful disability [98, 99]. Osteoarthritis at the scaphoid-radial styloid joint is significantly associated with dorsiflexed intercalated segment instability (DISI) deformity. An overall incidence of DISI deformity of the wrist is about 56%, and the frequency of DISI pattern increased with longer duration of non-union [100]. Arthroscopic management of scaphoid nonunions without severe deformities or arthritis is effective [101]. This simplifies postoperative recovery, reduces complications, and preserves the wrist’s capsule-ligament complex—and, thus, the scaphoid’s precarious vascularization [102]. Arthroscopic management of scaphoid nonunion is based on the following ideas: that scaphoid vascularity can be preserved because of the minimally invasive nature of arthroscopic surgeries; and that direct visualization with magnification can facilitate accurate debridement of the nonunion site, identify fibrous union and punctate bleeding from fracture site and aid perfect reduction [103].

Principles of the arthroscopic treatment of the scaphoid nonunions are the same as with other surgical techniques: excision of pseudrthrosis, correction of humpback deformity, restoration of the length of the bone, bone grafting and a stable fixation.

Surgical technique includes inspection of the radiocarpal joint via standard portals, synovectomy and arthroscopically guided styloidectomy, if necessary. Arthroscopic treatment of the nonunion is performed via midcarpal portals. The scope is inserted in MCU portal and instruments in MCR, accessory portal (close to the nonunion) or STT portal. If a frank bony defect is encountered, it is curetted with a fine-angled curette or motorized shaver (Figure 39b), until all fibrotic tissue and sclerotic bone are removed.

If the tourniquet is used, at this point it has to be released, to assess the vascularity of the bones. Any humpback and DISI deformity should be identified and corrected. Once the deformity of the scaphoid is corrected, fragments have to be transfixed with K-wires from the tubercle of the scaphoid to the proximal pole for provisional scaphoid fixation (Figure 39c and d).

This process is controlled under arthroscopic and fluoroscopic guidance. The bone graft is taken from the ipsilateral distal radius or iliac crest depending on the amount needed for filling the defect. The bone graft is inserted into a trocar and then the end of the trocar is placed at the nonunion site. The graft is pushed into the trocar with a blunt guide wire until the nonunion site is filled (Figure 39e and f).

Some surgeons recommend to add fibrin glue to protect the graft but others claim that once the scaphoid is fixed and the traction released, the capitate’s native anatomical position will provide sufficient graft stabilization [102, 104]. The fragments are stabilized with screw(s) and/or K-wires. Recorded union rate with this procedure is 86 – 100% [105, 106, 107]. Arthroscopically treated patients achieve faster healing despite shorter time to surgery in the percutaneous group. Local bone grafting is considered as the main reason for this outcome [108].

15. Arthroscopic treatment of thumb carpometacarpal (CMC) osteoarthritis

Thumb CMC joint pain, instability and progressive arthritis is a common problem affecting many patients, especially middle-aged women. Once present, the symptoms of thumb CMC osteoarthritis are typically progressive and may lead to significant functional disability. There are two classifications for thumb CMC osteoarthritis: Eaton – Litter classification which is based on radiological changes [109] (Table 7) and arthroscopic classification developed by [110] (Table 8). He also presented an algorithm for management of the CMC osteoarthritis incorporating arthroscopical stages into radiological classification and subsequent treatment decision-making. Treatment methods depend on the stage of the radiologic and arthroscopic findings and can contain detriment, thermal shrinkage, correctional osteotomy of the 1st metacarpal base as well as arthroscopic resection with different interposition arthroplasties or suspensionplasties.

Class	Description
I	Synovitis phase.; Subtle carpometacarpal joint space widening
II	Slight carpometacarpal joint space narrowing, sclerosis, and cystic changes with osteophytes or loose bodies < 2 mm
III	Advanced carpometacarpal joint space narrowing, sclerosis, and cystic changes with osteophytes or loose bodies > 2 mm
IV	Arthritic changes in the carpometacarpal joint as in Stage III with scaphotrapezial arthritis

Table 7.

Eaton-Litter radiological classification of 1st CMC arthritis.

Stage	Arthroscopic changes
I	Intact articular cartilage; Disruption of the dorsoradial ligament and diffuse synovial hypertrophy.; Inconsistent attenuation of the anterior oblique ligament (AOL)
II	Frank eburnation of the articular cartilage on the ulnar third of the base of first metacarpal and central third of the distal surface of the trapezium.; Disruption of the dorsoradial ligament + more intense synovial hypertrophy.; Constant attenuation of the AOL
III	Widespread, full-thickness cartilage loss with or without a peripheral rim on both articular surfaces.; Less severe synovitis.; Frayed volar ligaments with laxity

Table 8.

A. Badia arthroscopic classification of 1st CMC arthritis.

With recent advances in arthroscopic techniques, partial trapezectomy with or without different soft tissue or implant interposition has been reported with good results [111, 112, 113, 114]. Theoretical advantages over open procedures include a decreased risk of neurovascular injuries, smaller incisions decreased postoperative pain and shorter overall recovery time. On the other side, this technique has several disadvantages, including increased setup and operative procedure time, increased surgical training, increased equipment cost and additional x-ray fluoroscopy time [115].

There is growing evidence that techniques involving use of no interposition result in a high rate of satisfactory outcomes [116, 117]. Cobb et al. in 2015 compared outcomes of patients treated with or without tendon interposition and found no difference in outcomes.

Another promising technique is an arthroscopic hemitrapeziectomy and suture button suspensionplasty [118, 119].

Authors have their own small experience (6 patients) with arthroscopic hemitrapezectomy and interposition arthroplasty with RegJoint™ implant (Figure 40a–e). The follow up is 12 to 36 months without any severe complications. Marcuzzi et al. in 2020 published long-term results with open technique [120]. They found dissapointing radiological results with an almost complete collapse of the metacarpal base on the distal pole of scaphoid in more than 80% of patients. However the results did not correspond with clinical outcomes that were very satisfactory. We hope that arthroscopical technique preserving the dorsal capsule will improve the outcomes, but further investigations are necessary.

Figure 40.

(a) preopertive x-ray of 1st CMC arthritis, (b) CMC portals connected with skin incison, (c) Regjoint Scaffold sutured before insertion via elongated CMC portal, (d) Implant pulled in and positioned in the site, (e) transfixation of the bones and implant with K-wire.

Complication rate with arthroscopic CMC arthroplasties is about 4% and include as follows: CRPS, ulnar or radial sensory nerve neuropathy, transitory numbness near the portal, prolonged hematoma, FPL tendon rupture and superficial skin necrosis [121].

16. Arthroscopic evaluation and treatment of the triangular fibrocatilage complex (TFCC) injuries

The development of our understanding and management of TFCC tears has been developed with important contributions including Palmer’s classification of TFCC tears (Table 9), G. Poehling’s inside-out suture technique, F. Del Piñal’s all inside suture technique [122], A. Atzei’s and R. Luchetti’s TFCC tear classification (Figure 41), T. Nakamura’s anatomical and clinical studies [123] and J.R. Haugstvedt’s developed techniques for the TFCC tears and lunotriquetral tears as well as studies about DRUJ functional anatomy and pathomechanics [1, 124].

Class or subclass	Description
Class 1	Traumatic
1A	Central slit
1B	Ulnar avulsion with or without distal ulnar fracture
1C	Distal avulsion(carpal attachement)
1D	Radial avulsion with or without sigmoid notch fracture
Class 2	Degenerative
2A	TFCC wear
2B	TFCC wear, lunate or ulnar chondromalacia
2C	TFCC perforation, lunate or ulnar chondromalacia
2D	TFCC perforation, lunate or ulnar chondromalacia, lunotriquetral ligament tear
2E	TFCC perforation, lunate or ulnar chondromalacia, lunotriquetral ligament tear, ulnocarpal osteoarthritis

Table 9.

Palmer’s classification of TFCC tears.

Figure 41.

A. Atzei’s and R. Luchetti’s classification of TFCC tears (reprinted by permission).

TFCC – is one of the instrinsic ligaments of the wrist, with load bearing function between the lunate, triquetrum and ulnar head. TFCC acts as stabilizer for the ulnar aspect of the wrist joint [125].

TFCC consists of five parts: fibrocartilaginous disc and the meniscal homolog, volar ulnocarpal ligaments (ulnolunate and ulno-triquetral), dorsal and volar radioulnar ligaments (each with a superficial and deep part), ulnar collateral ligament as well as the floor of the fibrous 5th and 6th extensor compartments [125, 126].

Palmer had a two-dimensional view of the TFCC [127]. Nakamura described it as a three dimensional structure, and separated TFCC in three components: the distal component which acted like a hammock to suspend the carpus, the triangular ligament as the proximal component which stabilized the radius to the ulna, and the UCL as the ulnar component which stabilized the carpus to the ulna [128, 129]. Atzei and Luchetti updated previous “hammock” concept to the novel “iceberg” concept [130]. In analogy with the iceberg, during arthroscopy of the radiocarpal joint (RCJ) the TFCC shows its “emerging” tip. The tip of the iceberg represents that part of the TFCC that functions as a shock absorber. This part is much more smaller than “submerged” part which can be seen only in case of the DRUJ arthroscopy. The submerged TFCC represents the foveal insertions of the TFCC and functions as the stabilizer of the DRUJ and of the ulnar carpus. The larger size of the submerged portion of the iceberg corresponds to its greater functional importance.

TFCC biomechanics:

• TFCC stabilizes DRUJ and ulnocarpal joint

• TFCC allows the transmission and distribution of forces from wrist onto ulna and provides a gliding surface for the carpus during complex movements of the wrist.

• The central disc works as the distribution mechanism for the mechanical stress onto proximal triquetrum and the lunate

Clinical assessment of TFCC tears:

• The ulnar fovea sign is the most reliable clinical sign [131], where the patient has the point of tenderness over the ulnar capsule in the area between extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU) tendons.

• The ballotment test evaluates DRUJ stability. This is a simple and reliable to determine DRUJ laxity [132].

Imaging assessment of TFCC tears:

• Radiographs – of limited value for TFCC injury diagnostics, but very important for acute and chronic wrist pain. The presence of ulnar styloid fracture alone or with distal radius fracture is of some importance for the diagnosis of the TFCC tear [133]. The Galeazzi fracture-subluxation is a particular condition that is associated with a TFCC tear [134].

• MRI and MRI arthrogram. MRI is more useful to exclude associated pathologies of the ulnar compartment. Comparing specificity and sensitivity of MRI, MRI arthrography and artroscopy for diagnosis of the TFCC tear, confirm the arthroscopy as the gold standard for diagnosis [135, 136].

Arthroscopic examination of TFCC. Three arthroscopic tests are used to check the type of TFCC injury:

• The “trampoline sign” – the loss of elasticity of the TFCC – seen in complete avulsion injuries of the proximal and distal portions of the TFCC

• The “hook sign”– positive in complete tears of the TFCC and negative in other cases. The hook test is more accurate than the trampoline test to detect foveal tears of the TFCC of the wrist [137]

• The “ghost sign” – reverse ““trampoline sign”. This indicates an avulsion of the deep fibers of the TFCC. The sign is negative in distal lesions and positive in isolated proximal lesions.

Atzei’s/Luchetti’s classification also shows the stability/instability of the DRUJ joint and possible surgical treatment to corresponding TFCC tear.

An algorithm of treatment according to Atzei’s/Luchetti’s classification:

CLASS 0 – isolated styloid fracture without TFCC tear. Frequently associated with distal radial fractures. DRUJ is stable. If isolated treatment is wrist splinting for 3 weeks.

CLASS 1 – periferal tear of the TFCC distal component, the DRUJ may be slightly lax. Hook test negative. Small tear requires 4 weeks of wrist immobilization followed by two weeks splinting. A larger tears requires arthroscopic TFCC suture.

CLASS 3 – periferal tear of the TFCC proximal component. Mild to severe laxity of the DRUJ joint. Hook test is positive. TFCC foveal reattachment is required by transosseus sutures or a suture anchor.

CLASS 4 – nonrepairable peripheral TFCC tear due to the massive defect or poor healing potential. This condition requires reconstruction with tendon graft.

CLASS 5 – DRUJ arthritis following peripheral TFCC tear. Arthroscopy shows significant degenerative or traumatic cartilage defect. Suggested treatment – arthroplasty or prosthetic replacement.

In cases of peripheral repairable TFCC tears, authors use debridement and synovectomy to detect and refresh the site of the rupture. Usually 6R portal is used for shaver and 3-4 portal for visualization. Occasionally 6 U portal can be used if tears are localized more volarly. Once the size of tear is recognized, portal can be elongated to vizualise extensor tendons by transillumination of the capsule. Needle with suture loop is passed a little bit proximally from the margin to the TFCC to capture capsule together with the TFCC. Once recognized in the joint, suture is captured with mosquito forceps and one part of it passed via the portal or, in cases if several sutures necessary, via extra holes in the capsule. Location of the extensor tendons is evaluated to avoid capture of them in the suture and knots are tightened extra-articulary (Figure 42a–c). The reattachment can be performed with an inside-out, outside-in, or all-inside technique, providing good to excellent results, which tend to persist over time, in 60–90% of cases [138].

Figure 42.

Periferal, reconstructable TFCC tear. (a) tear after the debridement, (b) sutures passed the TFCC and capsule, (c) sutures tightened extra-articulary via 6R portal.

In cases of proximal reparable TFCC foveal detachment, we prefer to use the transosseus refixation of the TFCC described by T. Nakamura [139]. We use the original Arthrex target device through 6R portal and an approximately 1 cm longitudinal incision on the ulnar side of the ulnar cortex, 10–15 mm proximal from the tip of the ulnar styloid. Then target device is set on the TFCC and two parallel channels with original 1.6 mm K-wires are made from the ulnar cortex through the head of ulna and TFCC. Then follows a manipulation with needles, suture loops and main suture, where different techniques of the suture insertion are possible (Figure 43a–c).

Figure 43.

Proximal reparable detachement of TFCC. (a) Arthrex targeting device over the foveal area, view from 4-5 portal, (b) sutures passed through the TFCC and head of ulna, (c) sutures tightened and TFCC reattached to foveal region.

After the main suture is passed through the bone channels to make outside-in pullout suture of the TFCC to the fovea and tensed with knot over the cortex. Another option is to hide the knot inside the ulna and tense with a push-lock anchor.

After treament includes 2-3 weeks in long arm plaster cast, following 3 weeks in short cast with following rehabilitation after the cast is removed.

In cases of unrepearable TFCC injuries or degenerative tears, an anatomic reconstruction with free tendon graft is recommended. The arthroscopic reconstruction is a mini invasive option of the Adams-Berger procedure [140], but it requires an experience in arthroscopic surgery. Nowadays tendon grafts can be fixed in the bone channel with interference screw, instead of the original procedure where tendons were wrapped around the bone and sutured together. Nevertheless, when well done, this technique provides good stabilization of the DRUJ, while maintaining good mobility of the wrist in all directions [141].

A systemic review by Liu et al. about the surgical repair of TFCC tears confirms that arthroscopic techniques achieve overall better outcomes compared with open repair technique. For foveal tears, transosseous sutures achieve overall better functional outcomes compared with suture anchors. Current evidence demonstrates that TFCC repair achieves good clinical outcomes, with low complication rates [142].

17. Discussion

During the last 4 decades wrist arthroscopy has turned from the diagnostic tool of some enthusiasts to the widely used therapeutical complex for treatment of different wrist pathologies. Evolution of the wrist arthroscopy equipment as well as skills of the surgeons has allowed us to improve our knowledge of the wrist anatomy and biomechanics. Wrist arthroscopy is especially valuable for evaluation of intra-articular soft tissue pathologies. Furthermore - arthroscopic classification systems have been described for TFCC, SLIL and LTIL lesions, Kienböck disease, 1st CMC joint, etc.

Wrist arthroscopy techniques have proved superiority over the open techniques with lower complication rates and recurrence rates. For example in wrist ganglion surgery open surgical excision had a mean recurrence of 21%, compared with a recurrence rate of 59% for aspiration. The lowest rate was observed with arthroscopic excision, with a recurrence of 6% across all studies [40].

Arthroscopic scapho-lunate ligamentous repair is now considered the less damaging and denervating than open repair [143]. Although several arthroscopic SLIL reconstruction methods as well as arthroscopic reconstruction technique for LTIL tears have been described, these surgeries are challenging, therefore different modalities and variations of open procedures are still actual and used. Some arthroscopic techniques require a long learning curve and years of practice.

A systematic review about arthroscopic vs. open TFCC surgeries shows comparable results between open and arthroscopic procedures, in terms of DRUJ re-instability and functional outcome scores. There is insufficient evidence to recommend one technique over the other in clinical practice [144]. However arthroscopic procedures are less aggressive and may allow quicker recovery, especially in athletes [145]. In combination with a TFCC procedure, the ulnar variance can readily be assessed. Ulnar abutment or impingement can be directly visualized through dynamic assessment. Whilst ulnar shortening is an extra-articular procedure, the arthroscopic wafer procedure allows for intra-articular treatment without the need for hardware. This overcomes the issues of hardware prominence and circumvents non-union rates of about 10%, while also allowing for a quicker return to work [145, 146].

Wrist arthroscopy is beneficial also in the treatment of distal radius articular fractures, because it helps to visualize articular gaps and step-offs unrecognized with the fluoroscope alone. Although arthroscopically assisted DRF surgeries have superior long-term outcomes in several parameters [76], the advantage of this procedure, however, is the recognition of associated soft tissue lesions which can be prevented if recognized.

The next aspect is professional training and experience of the surgeon. Leclercq et al. in the multicenter study organized by EWAS found that surgeons who perform less than 25 wrist arthroscopies per year have a complication rate of 12.06%, whereas among the surgeons who perform more than 75 wrist arthroscopies per year, the complication rate is 3.95%. Surgeon with less than 5 years of practice in wrist arthroscopy have complication rate 13.6%, whereas surgeons who had 15 or more years of practice complication rate is only 2.3%. Surgeons with longer practice and greater amount of wrist artrhroscopies performed per year, more often are doing therapeutical arthroscopies. This ratio is up to 87% of procedures comparing to less experienced colleagues who perform therapeutical procedures in about 60.5% of cases [147].

18. Conclusions

Arthroscopy has assumed an important place in wrist surgery. It requires specific operative skills, training, technical equipment and patience, because these surgeries sometimes take more time than expected, even if you think, you are trained enough (my personal experience). Minimally invasive surgery is a trend of our century and arthroscopic treatment of wrist pathologies has already demonstrated promising outcomes and it’s superiority over open surgical procedures.