History of wrist arthroscopy; excisional operations to repair and reconstruction
Arthroscopy was established initially in Japan by Professor Kenji Takagi of the University of Tokyo. In 1918, Professor Takagi inspected the cadaver knee using a bladder scope, and then he tried arthroscopic exploration in clinical cases of knees tuberculous arthritis in 1922. With the help of Professor Takagi, Dr Masaki Watanabe developed a clinically usable arthroscope and applied this not only to the knee but also to other joints. Watanabe performed clinical wrist arthroscopy in 1970 using a 1.7 mm diameter arthroscope. The first clinical wrist arthroscopy report in the literature was by Chen in 1979. The volar portal technique of the radiocarpal joint and dry arthroscopy for repairing intraarticular fractures of the radius were achieved in the first decade of the 21st century. Introduction of distal radioulnar joint (DRUJ) arthroscopy now has changed the treatment algorithm of triangular fibrocartilage complex (TFCC) lesions.
In the mid-1980s to the early 1990s, most of the arthroscopic surgeries were excisional procedures, such as arthroscopic synovectomy and arthroscopic partial resection of the TFCC. Approximately 30 years have passed since then, and many technological innovations and improved anatomical knowledge have been achieved.
Reported complications of wrist arthroscopy have been few. Severe complications, such as nerve and tendon laceration, local pain at the portals, skin burn due to radiofrequency or plasma device for synovectomy, cartilage damages on the radius or carpal bones, infection, and complex reginal pain syndrome have been reported. , Those complications may be due to the inexperience of the surgeons.
We now have technological developments, such as a 4K high-resolution monitor and radio frequency and plasma probes, but the most important achievement has been technical advancements. In this chapter, technical revolutions in wrist arthroscopy including arthroscopic bone graft for scaphoid fracture/nonunion, arthroscopic transosseous repair technique for foveal avulsion of the TFCC, arthroscopic reconstruction of the TFCC using palmaris longus (PL) tendon, arthroscopic reconstruction of the scapholunate (SL) ligament, and arthroscopic reconstruction of the lunotriquetral (LT) ligament are described by the world leaders of wrist arthroscopy.
Arthroscopic bone grafting in scaphoid nonunion (Pak-Cheong Ho)
The scaphoid is located radially in the wrist in a relatively superficial location. The scaphoid bears most of the load transmitted through the wrist and is a frequent site of injury. Therefore the location of the scaphoid allows an arthroscopic approach for both the evaluation and therapeutic interventions without harming its blood supply and ligamentous architecture. In 1998, the technique of arthroscopic bone grafting was introduced in four cases of scaphoid nonunion. Radiological union was achieved in three cases at an average of 3 months ( Fig. 7.1 ).
The technique
Evaluation of the scaphoid nonunion starts with standard radiocarpal joint arthroscopy with traction and without tourniquet to check for any degenerative changes, such as scaphoid nonunion advanced collapse (SNAC). Gravity-driven saline irrigation is set up to maintain a clear arthroscopic view. Stage 1 SNAC wrists can also be managed by this technique with additional arthroscopic radial styloidectomy.
The repair for the scaphoid nonunion is conducted through the midcarpal joint arthroscopic portal. The midcarpal ulnar portal is usually the viewing portal, and the midcarpal radial portal is used for instrument placement for resection of the fibrous nonunion and bone grafting for injuries in the proximal and waist portions. For the distal third nonunions, the scaphotrapeziotrapezoidal portal is often needed to access the nonunion site. Portals may be swapped to allow better visualization of different areas of the nonunion. The nonunion site is identified with a probe. Fibrous tissue interposed is debrided from the defect using the angled curette, punch, and shaver. T sclerotic bone surfaces are resected using a 2.9-mm arthroscopic burr until healthy cancellous bone is encountered. Without the tourniquet, the vascularity of both fragments can be appreciated, and curettage is finished when punctate bleeding is seen. Lack of bleeding from the proximal segment indicates a less favorable prognosis but does not preclude union.
It is key to adequately debride the surrounding soft tissue and fibrous tissue at the nonunion site, which makes the scaphoid fragments mobile and facilitates reduction. The dorsal intercalated segment instability (DISI) deformity is corrected by the closed Linscheid maneuver under fluoroscopic guidance. With passive flexion of the wrist, the radiolunate joint is realigned and transfixed with a 1.6-mm Kirschner [K] wire inserted percutaneously through the dorsal distal radius. In the presence of an intact SL ligament, this will realign the proximal scaphoid with the distal radius. Traction and manipulation by gentle passive ulnar deviation, hypersupination, and extension of the wrist realigns the distal fragment with the proximal one and restores the appropriate length and bony axis of the scaphoid.
The fracture is transfixed with a 1.1-mm K-wire inserted percutaneously from the scaphoid tubercle eccentrically across the volar and proximal aspects of the scaphoid. Cancellous bone chips are harvested from the iliac crest and densely packed into the fracture site through a 5-mm arthroscopic cannula using a flat-ended plunger. The dorsal and most proximal aspect of the nonunion site beneath the axial K-wire is the at-risk zone of inadequate graft filling and should be filled with a graft before the other areas are addressed. For proximal third nonunions, as the bone defect may communicate with the radiocarpal joint freely, a 6-French Foley catheter can be inserted from the 1–2 or 3–4 portal and inflated to block the radiocarpal space to avoid graft spillage. Fibrin glue is injected at the end to stabilize and seal the bone graft from synovial fluid and to protect the articular surfaces.
Fixation is completed either by inserting two additional K-wires or with a cannulated screw. K-wires are cut short and buried underneath the skin, and the wounds are closed with Steri-Strips without stitches. Early active mobilization is initiated 2 weeks after the procedure. The buried K-wires are removed under local anesthesia when union is evident, usually between 10 and 12 weeks after surgery ( Fig. 7.2 ).
Clinical outcomes
The author and a colleague reported the result in 69 patients of scaphoid nonunion and achieved an overall union incidence of 91% (62 unions among 69 scaphoids) in 2011. A larger group of patients was reviewed recently in our unit. This group included 128 wrists in 123 patients. The average age was 28 years (range: 14–66). There were 17 distal-third, 69 mid-third, and 42 proximal-third fractures. DISI deformity was presented in 49%. Seventy-four percent showed osseous bleeding from the proximal fragment, whereas 26% had poor bleeding. Seventy-six percent of cases were fixed with three K-wires, whereas 24% were fixed with the screw. The mean followup was 26 months (range, 3-216). Overall union incidence was 89% (114/128). Bleeding from proximal scaphoid fragment was the only statistically significant factor affecting union. The incidence of union dropped from 93% in the good bleeding group to 79% in the poor bleeding group. Other authors described similar techniques with the incidence of union ranging from 93% to 100% and union time from 9.7 weeks to 4 months.
Oh et al compared arthroscopic versus open grafting retrospectively and showed similar union incidence and clinical and radiological outcomes. Subgroup analysis of patients with carpal collapse showed better carpal alignment restoration in the open bone grafting group but no difference in clinical outcome.
Arthroscopic transosseous repair of the avulsed TFCC at the fovea (Toshiyasu Nakamura)
Arthroscopic exploration revealed that there are many types of TFCC lesion, such as intra-discal, peripheral, and foveal. Slit or flap-type tears in the triangular fibrocartilage (TFC) can be treated with arthroscopic partial resection. Arthroscopic capsular repair is indicated mostly for peripheral injuries at the medial margin of the TFC, which can be seen on radiocarpal arthroscopy. , , DRUJ arthroscopic exploration can reveal the condition of the proximal side of the TFCC, such as the proximal surface of the TFC or origin of the radioulnar ligament (RUL) at the fovea. When the TFCC is avulsed from the fovea of the ulna, which corresponds to an avulsion of the RUL, severe DRUJ instability is obvious. , Dry DRUJ arthroscopy can diagnose foveal lesions of the RUL. Arthroscopic transosseous repair is indicated for fresh foveal avulsions of the RUL. For chronic fovea avulsions, open repair or reconstruction using the PL tendon or a half-slip of the extensor carpi ulnaris (ECU) can be selected depending on the condition of the avulsed RUL. If the avulsed RUL can be retracted to the fovea without tear-out, open repair is possible, whereas fragile RUL requires the reconstruction either with ECU half-slip or PL tendon. In the case of more than 2 mm of positive ulnar variance, ulna shortening can be considered to neutralize the ulnar variance before repair, resulting in excellent clinical results.
Several teams have reported arthroscopic assisted transosseous repair techniques of the TFCC. Atzei et al explored the foveal lesion arthroscopically and used a mini-incision to insert a bone anchor at the fovea. Iwasaki and Minami used a 2.9-mm drill hole directed from the proximal ulnar cortex to the fovea under fluoroscopic control with a radiocarpal arthroscopically assisted suture of the TFCC to the periosteum of the ulna. A disadvantage of Iwasaki’s and Minami’s technique is the difficulty of reattaching the RUL because of the large-diameter drill hole. Nakamura et al described excellent clinical results with the arthroscopic pullout transosseous repair technique with parallel bone tunnels. This technique reattaches the TFCC to the fovea directly with minimum incision.
The technique
Under general anesthesia or brachial plexus block, the patient is supine with a pneumatic tourniquet on the upper arm. The forearm is held vertical with traction tower, and 2 to 3 kg of weight is applied on the upper arm for counter-traction.
Arthroscopic examination of the radiocarpal joint may demonstrate loss of trampoline effect as well as loss of peripheral tension in the TFC (hook test) in patients with foveal disruption, since the TFCC is incontinuously connected to the ulna. Those signs (loss of trampoline effect or positive hook test) may be indirect signs for foveal avulsion of the RUL.
DRUJ arthroscopy or open exploration can directly visualize the complete foveal rupture of the TFCC. Because open exploration is extensively invasive, DRUJ arthroscopic exploration is recommended. In the case of foveal detachment, the DRUJ joint space can be widely expanded because of the floating TFC so that the scope can be easily introduced. When the TFCC is attached completely to the ulna without any DRUJ instability, the fovea area is very tight and difficult to be visualized with DRUJ arthroscopy. When the ligament tissue can be seen in the avulsed RUL area, arthroscopic-assisted foveal reattachment is possible. When there is severe scarring in the fovea area or the RUL is missing, open exploration is recommended.
After foveal detachment of the TFCC is confirmed by DRUJ arthroscopic exploration, the original target device ( Fig. 7.3 ; Wrist Drill Guide, Arthrex, Naples, FL, USA) is placed through the 6R (preferred) or 4–5 portal. A 1-cm longitudinal incision is made on the medial side of the ulna 10 to 15 mm proximal to the tip of the ulnar styloid. The periosteum is elevated to create the bone tunnel entrance. The small spike on the target device is set on the ulnar half of the TFC.
With a 1.6-mm K-wire, two separate small holes are made from the medial cortex of the ulna to the medial half portion of the TFC using the parallel drill attachment of the Wrist Drill Guide ( Fig. 7.4 ). DRUJ arthroscopy may be helpful to confirm the avulsed RUL ( Fig. 7.5 A). A 21-gauge needle, in which the loop nylon 4-0 stitch is placed, is passed through one tunnel from the outside and then is repeated through the other bone tunnel. From the 6R or 4–5 portal, both loop stitches are pulled out by mosquito forceps simultaneously. One end of two absorbable 3-0 stitches (Vicryl, Ethicon, Cincinnati, OH, USA) is set inside one of the loops, and then two stitches are introduced from the RC joint to the ulnar cortex of the ulna by pulling the loop in one of the tunnels. The other end of the stitches is placed in the other loop. Pulling the loop draws the absorbable stitches into the second tunnel. Tying the two absorbable stitches at the ulna cortex creates an outside-in pullout suture of the TFCC to the fovea. The TFCC is tightly anchored to the ulnar fovea ( Fig. 7.5 B).
This technique requires at least one assistant. The surgeon creates the bone tunnels holding the drill in the right hand and the drill guide in the left hand with its spike on the ulnar corner of the TFC precisely. The assistant keeps the arthroscope and wrist-forearm position neutral. After the K-wires have passed the ulna, arthroscopic observation is helpful for precise hole-making through the fovea. The forearm should be neutral when the suture is tied.
Clinical outcomes
We started using this technique in 1997, and the author has treated 45 wrists with foveal avulsion of the TFCC with the arthroscopic transosseous repair technique. There were 28 male and 17 female patients. Ages ranged from 10 to 59 years with a mean age of 30. The injured side was 30 right and 15 left. All cases indicated ulnar detachment at the fovea via DRUJ arthroscopy. The time between the initial injury and operation averaged 8 months (range: 1 month to 4 years). Ulnar variance was +2 mm in six wrists, +1 mm in two, neutral in 35, and -1 mm in two. Follow-up averaged 4.5 years (range: 24–60 months). Pain was recognized in all 45 wrists preoperatively.
After the TFCC arthroscopic repair, 35 patients indicated no pain. Mild pain with motion was recognized in six wrists, and severe pain persisted in four. There was no loss of rotation preoperatively, but one wrist lacked 30 degrees of supination postoperatively. DRUJ instability was found in all 45 wrists, in which severe instability (no endpoint) was present in 34 wrists, moderate (obvious instability) in 9, and mild instability (compared with the contralateral side) in two. There was no DRUJ instability in 38 wrists postoperatively; however, moderate instability was noted in three wrists, and severe DRUJ instability in four. Final clinical results were 32 excellent, five good, four fair, and four poor results using the modified Mayo Wrist score. Fair and poor clinical results were noted in earlier cases with ulnar positive variance cases (more than 1 mm ulnar positive variance) and/or chronic cases (>6 months from initial injury).
DRUJ arthroscopic findings are key for this technique. When the avulsed ligament with sharp edges or ligament fibers can be seen, this technique is promising because of the robust healing potential of the RUL. This technique can allow earlier return to athletic activity. Earlier recovery was commonly seen in my patients. One of them obtained a gold medal in the 2021 Tokyo Olympic Games six months after the surgery. If aggressive scar formation at the fovea or absent RUL with synovial surrounding is seen through DRUJ arthroscopy, then a switch to open surgery is necessary.
Arthroscopic reconstruction of the TFCC (Andrea Atzei)
Arthroscopic findings provide the foundation for a treatment algorithm for TFCC peripheral tears. Over the years, the new concept of tear irreparability has been introduced, which is based on the arthroscopic assessment of the healing potential of the tear’s edges. Intraoperative tourniquet release confirms the vascularity of the debrided surfaces, indicating good healing potential. Conversely, for tears considered irreparable, such as primary massive rupture, wide gap formation after debridement of degenerated/sclerotic edges, frayed remnants unable to hold sutures, and elongated scar after failed suture, tendon graft reconstruction is necessary. ,
New arthroscopic techniques have been introduced to reduce surgical morbidity and to improve the quality of reconstruction ( Fig. 7.6 ) , These techniques reproduce the open Adams-Berger technique. The surgical details are given below.
The technique
Similar to the Adams-Berger reconstruction, the harvested PL tendon graft is passed through the tunnel made on the radius slightly radial to the sigmoid notch from dorsal to palmar. Fluoroscopic guidance should be used when creating the bone tunnel. Then the tendon is introduced from the 4–5 portal and the volar-ulnar portal into the joint. The PL tendon is passed over the palmar RUL in the interval between the ulnotriquetral and the ulnolunate ligaments to stabilize the ulnocarpal joint ( Fig. 7.6 A) The ulnar tunnel is made between the medial cortex of the ulna and the central fovea using the target device and fluoroscopy. Both ends of the PL tendon graft are introduced into the tunnel with forceps one by one. They are secured in the ulna tunnel using an interference screw ( Fig. 7.6 B). Along with the standard arthroscopic portals, three accessory mini-open incisions are required for tunnel preparation. These increase the risk of intraoperative injury of the nerve ( Fig. 7.6 C).
Clinical outcomes
Arthroscopic reconstruction obtained better clinical outcomes compared to the original open Adams-Berger technique. Recurrence of DRUJ instability is a main drawback of the Adams-Berger technique, ranging from 14% at a mean follow-up of 2.2 years to 22% at 9-year follow-up. Recurrent DRUJ instability with arthroscopic reconstruction was 7% and 9%. The overall failure incidence was 14% of 95 Adams-Berger reconstructions. Sixty percent of these required revision for DRUJ instability. At a median 39-month follow-up, the DRUJ was unstable in 5% of patients, and 34% had some residual laxity. Biomechanical studies indicated that the Adams-Berger technique was unable to fully restore DRUJ stability and forearm rotation. Elongation or rupture of the graft was related to poor matching of the radial tunnel openings with the origins of the RUL. Arthroscopic reconstruction may reroute the PL tendon passed on the TFC to reattach the total structure of the TFCC onto the ulnar tunnel over the fovea, and this may also tighten the palmar ulnocarpal ligaments, resulting in a less DRUJ-destabilizing ratio. , The original Adams-Berger technique only reconstructs the RUL.
The ulnar nerve may be at risk of injury during both open and arthroscopic reconstructions. In a series of 95 patients treated with the open Adams-Berger reconstruction, neuropraxia of the ulnar nerve area was reported in six patients, and another patient required excision of a painful neuroma. In a series of 28 cases of the arthroscopic reconstruction, three cases developed neuropraxia of the ulnar nerve due to entrapment by the tendon graft tendon in one case and forceful retraction in two cases. Even without any obvious paresthesia in the distribution of the dorsal superficial branch of the ulnar nerve, discomfort over the ulnar incision is another common complication of the arthroscopic technique, present in 11% to 46%. Since the classical loop around the ulnar neck method of graft fixation in the open reconstruction may cause tendon loosening, painful scalloping of the ulnar neck, or even some persistent ulnar pain, the arthroscopic technique introduced the use of an interference screw to secure the tendon graft to the ulnar tunnel. The interference screw caused one ulna fracture in the arthroscopic technique, which did not affect DRUJ stability at follow-up.
Paralleling a similar effort for the open technique to overcome its limitations, , the second generation of arthroscopic-assisted techniques was introduced in 2000s. Carratalà et al developed a technique that applies the two tendons separately set into either the dorsal and palmar side of the sigmoid notch of the radius, and they are fixed with the interference screw under arthroscopic guidance. Then a standard ulnar approach is used for out-in ulnar interference screw fixation. Early clinical experience indicates one excellent, two good, and one poor result at 6-month follow-up. The all-inside anatomic arthroscopic (3A) technique using the drill guide through a radial counter-incision creates converging tunnels exiting at the radial RUL origins. The 6U portal is used for inside-out drilling the foveal tunnel, and the interference screw fixed the graft tendon providing the stronger fixation ( Fig. 7.7 ).
