CHAPTER SYNOPSIS:

Arthroscopy of the wrist allows extensive visualization of the radiocarpal and midcarpal articular surfaces with minimal disruption of the soft tissues or ligaments, thus allowing reduced pain and faster recovery. Wrist arthroscopy is a diagnostic or “staging” tool, but it also provides therapeutic options including joint debridement, synovectomy, and loose body removal.

IMPORTANT POINTS:

Wrist arthroscopy has an expanding role in the diagnosis and treatment of wrist arthritis.

Wrist arthroscopy provides more information on the condition of the articular surface than imaging modalities including magnetic resonance imaging (MRI).

Arthroscopy is a safe procedure, when performed correctly, with minimal complications.

CLINICAL/SURGICAL PEARLS:

Wrist arthroscopy can be used for evaluation of the articular surface and ligamentous structures of the wrist to help determine the optimal reconstructive or salvage procedure.

From a therapeutic standpoint, debridement of synovitis and unstable chondral lesions and removal of loose bodies can be done to temporize, but usually not cure, the painful wrist.

Early mobility will reduce postoperative wrist stiffness.

CLINICAL/SURGICAL PITFALLS:

When performing radial stylectomy:

Damage to the volar ligaments may lead to ulnar translocation of the carpus

Amount of resection should be checked using fluoroscopy with the traction removed to confirm there is no impingement

Failure to use blunt dissection and spread technique will lead to damage of surrounding structures and articular cartilage

VIDEO:

N/A

INTRODUCTION

Arthroscopy of the smaller joints was slow to develop because of technical challenges and was not popularized until 1979 by Chen, who reported on 90 arthroscopic procedures of the wrist and finger joints in 43 patients using the Wantanabe 24 arthroscope. Since then, wrist arthroscopy has been refined, and its indications continue to evolve. As better equipment and new techniques are developed, it is likely that wrist arthroscopy will have an even greater role in the diagnosis and treatment of wrist arthritis.

This chapter will briefly review the current indications and advantages of using wrist arthroscopy as part of a comprehensive treatment strategy in dealing with the challenges of wrist arthritis.

INDICATIONS

Several indications for arthroscopy in wrist arthritis are outlined in Box 2-1 . One of the main advantages of arthroscopy of the wrist is that it allows for extensive visualization of the articular surfaces of the distal radius and carpal bones without disruption of the soft tissues or ligaments. This leads to faster recovery without compromising care of the patient. Mutimer and colleagues performed a comparison of magnetic resonance imaging (MRI) and wrist arthroscopy. Twenty patients with wrist pain were investigated over a 1-year period with both MRI and wrist arthroscopy. Only a fair correlation (K = 0.38) was seen between the two methods. The authors concluded that wrist arthroscopy provided more information on the condition of the articular surface and was a powerful tool in the evaluation and treatment of the painful degenerative wrist. In addition to an obvious diagnostic role, wrist arthroscopy offers potential therapeutic benefit as well. Arthroscopic debridement or limited excision of arthritic joint surfaces and synovitis and the extraction of loose bodies can be done with minimal or no collateral damage to the soft tissue envelope—an obvious advantage over analogous open techniques.

RADIOCARPAL JOINT

Scapholunate Disorders

The distal radius articulates with the scaphoid and lunate carpal bones. Normally, the scaphoid’s flexion torque is balanced by the triquetral’s extension torque via the “intercalating” lunate. When this balance is lost by disruption of the bones or connecting ligaments of the proximal row, the result is abnormal kinematics and redistribution of forces across the radiocarpal joint leading to progressive degenerative changes known as scapholunate advanced collapse (SLAC) , in the case of scapholunate interosseous ligament disruption, or scaphoid nonunion advanced collapse (SNAC) in the case of displaced scaphoid nonunion. As outlined in Table 2-1 , joint surface destruction proceeds in a predictable pattern ( Fig. 2-1 ). Similarly, a scaphoid fracture not only can disrupt carpal mechanics leading to a similar wrist arthrosis, but the “ragged” fracture edge also can damage the capitate surface. Treatment options include radial styloid excision, partial wrist fusion, proximal row carpectomy, and total wrist fusions, as outlined elsewhere in this text. This “decision tree” depends significantly on which joint surfaces are salvageable. Because patient counseling will be different for each of these surgical options, an accurate knowledge of the state of the articular surfaces is crucial. Imaging studies, although helpful, are inferior to the direct visualization allowed by modern arthroscopy techniques.

TABLE 2-1

Classification of SLAC Wrist

Stage	Definition
I	Arthritis localized to radial styloid
II	Radioscaphoid arthritis ( Fig. 2-2 )
III	Capitolunate arthritis with migration of capitate into scapholunate junction ( Fig. 2-3 )

 

Data from Watson HK, Ryu J: Evolution of arthritis of the wrist. Clin Orthop Relat Res 202:57–67, 1986.

Scapholunate advanced collapse wrist Stages I, II, and III. In Stage I changes are limited to the radial styloid. In Stage II the scaphoid fossa is involved. In Stage III the capitolunate joint is additionally narrowed and sclerotic.

(Adapted from Krakauer JD, Bishop AT, Cooney WP: Surgical treatment of scapholunate advanced collapse. J Hand Surg 19A:751, 1994. Copyright © Mayo Clinic.)

Other procedures that can be performed arthroscopically during “staging” include radial styloidectomy for short-term pain relief of the symptoms of impingement and to delay more aggressive procedures such as proximal row carpectomy and wrist arthrodesis. This procedure is usually reserved for the earlier stages of radiocarpal arthritis (e.g., SLAC Stages 1-2 and in low-demand patients with good wrist range of motion). It may also be used as an adjunct to other more aggressive procedures such as soft tissue or bony stabilization of the unstable scaphoid to prevent/delay progression of disease.

For SNAC wrist, arthroscopic debridement or excision of the distal pole of the scaphoid is indicated for chronic disease without advanced degenerative changes of the radiocarpal surface when obtaining scaphoid union is unlikely and as a temporizing procedure until a salvage procedure is needed. This procedure may be combined with an arthroscopic radial styloidectomy.

KIENBÖCK’S AND PREISER’S DISEASE

Avascular necrosis of the lunate was described by Robert Kienböck in 1910. It is more common in males and presents between the ages of 20 and 40 years. The clinical presentation includes wrist pain, tenderness localized over the region of the dorsal lunate, restricted range of motion, and grip weakness.

The etiology of Kienböck’s disease is likely multifactorial and may be the result of mechanical load or shear forces leading to vascular compromise. Other theories involve interruption of blood supply from repetitive trauma or ligamentous damage or venous congestion from local or systemic diseases such as sickle cell disease, gout, or corticosteroid use. The role of negative ulnar variance leading to abnormal forces across the lunate as suggested by Hulten is controversial. Other authors have suggested that anatomic risk factors for Kienböck’s disease include a smaller more radially inclined lunate compared to patients without Kienböck’s disease.

The diagnosis is usually made with imaging modalities such as plain x-rays or MRI. Classification traditionally has been done by radiographs using the Lichtman classification ( Table 2-2 ).

Plain anteroposterior (AP) and lateral radiographs showing changes in SLAC 2 wrist. Note the increased scapholunate space and the sclerosis of the radioscaphoid joint. Early osteophytes are clearly seen on the radial border of the scaphoid. The lateral view shows dorsal osteophytes and the dorsally angled lunate.

Plain AP and lateral radiographs showing degenerative changes in Stage 3 SLAC wrist.

Although this radiologic classification has high reliability and reproducibility, recently Ribak emphasized the discrepancy between radiographic and arthroscopic assessment of Kienböck’s disease. Bain and Begg have used arthroscopy to assess and classify ( Fig. 2-4 ) Kienböck’s disease based on the number of articular surfaces of the lunate and adjacent articulations, which are nonfunctional and arthritic. They stated that surgery is aimed at debridement of the joint, classifying the degree of arthritis, which will help direct the definitive procedure to be performed, therefore improving patient care. If the articular surfaces are intact, an arthroscopic synovectomy may still be a useful adjunct to a proximal radial shortening, if indicated. Although lunate fragmentation can be identified on imaging studies, the state of lunate facet may be less obvious. The decision to proceed with a proximal row carpectomy can be determined following arthroscopic confirmation of intact cartilage there. Involvement of the proximal lunate and lunate facet, with preservation of the midcarpal joint, however, may lead to the decision to perform a radioscapholunate fusion. More extensive involvement of the joint would require a wrist arthrodesis. Bain and colleagues concluded that arthroscopy provides a valuable assessment and subsequent classification of Kienböck’s disease. In their study, arthroscopy alone was performed for patients with Grade 0 or those with Grade III-IV disease who did not yet want a wrist arthrodesis.

Arthroscopic classification of Kienböck’s disease. The grade for each wrist is dependent on the number of articular surfaces that are defined as nonfunctional. Grade 0 indicates a patient who has Kienböck’s disease identified on imaging, such as a magnetic resonance imaging scan, and may have associated synovitis identified on wrist arthroscopy but has intact articular surfaces. The usual progression of articular damage is from the proximal aspect of the lunate (Grade I) to the lunate facet of the radius (Grade IIa). In those patients in whom there is a coronal fracture in the lunate, there will be involvement of the proximal and distal aspects of the lunate (Grade IIb). In Grade III there is further progression that involves both the proximal and distal aspects of the lunate and the lunate facet of the radius. Grade IV involves all four articular surfaces (including the proximal capitate).

(Adapted from Bain GI, Munt J, Turner PC: New advances in wrist arthroscopy. Arthroscopy 24(3):355–367, 2008.)

Atraumatic avascular necrosis of the scaphoid or Preiser’s disease is an uncommon disorder that presents with swelling and pain to the dorsum of the wrist over the scaphoid. It is also characterized by decreased grip strength and range of motion. The etiology is unknown but thought to be multifactorial and similar to the etiology of Kienböck’s disease of the lunate. The natural history of this disease is degeneration of the radiocarpal joint again as a result of altered joint mechanics and increased abnormal contact between the scaphoid and radiocarpal joint. Unlike SLAC or SNAC wrists and even Kienböck’s, however, the pattern of progression is much less predictable. For Preiser’s, joint visualization as provided by arthroscopy may be even more helpful in determining salvage options.

MIDCARPAL JOINT

Proximal Pole of Hamate Arthritis

Proximal pole of hamate arthritis is a common cause of ulnar-sided wrist pain. It is usually seen in individuals who take part in sports requiring ulnar deviation of the wrist, such as golf. Proximal pole of hamate arthritis has been associated with patients with lunotriquetral instability/tears. Harley and colleagues found that 91% of their patients had some degree of lunotriquetral instability and thought that arthrosis of this joint may be part of the spectrum of ulnar-sided wrist degeneration. They proposed the acronym HALT (Hamate Arthrosis Lunotriquetral ligament Tear). Proximal pole of hamate arthritis is typically associated with Type 2 lunates because the hamate does not articulate with Type 1 lunates. Loading between the hamate and the medial facet of Type 2 lunates associated with repetitive forceful ulnar deviation seems to lead to arthrosis of this joint. Of patients with Type II lunates, 44% have this form of arthritis as opposed to 2% in Type 1 lunates ( Fig. 2-5 ).

MRI illustrating Type 1 lunate with single facet for the articulation of the capitate (A) and Type 2 lunate showing extra facet for the articulation of the hamate (B) .

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Ulnar Impaction Syndrome Distal Interphalangeal Joint Arthritis Total Wrist Arthrodesis and Total Wrist Arthroplasty Metacarpophalangeal Arthritis Elbow Arthrodesis Ulnohumeral Arthroplasty

Stay updated, free articles. Join our Telegram channel

Join