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INTRODUCTION
Wrist arthroscopy has grown steadily from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. A thorough wrist examination is integral to any arthroscopic assessment. Although wrist arthroscopy can identify an anatomic abnormality, it cannot be used to differentiate between an asymptomatic degenerative condition and a pathologic lesion that is the cause of wrist pain.
ANATOMY
The standard portals for wrist arthroscopy are mostly dorsal ( Fig. 40-1 A–B). This is partly due to the relative lack of neurovascular structures on the dorsum of the wrist as well as the initial emphasis on assessing the volar wrist ligaments. The dorsal portals are named in relation to the extensor compartments. One anatomic study determined that branches of the superficial radial nerve (SRN) pass within 3 mm (range 1 to 6 mm) of the 1-2 portal. The radial artery was found an average of 3 mm radial to the portal (range 1 to 5 mm). Either partial or complete overlap of the lateral antebrachial cutaneous nerve (LABCN) with the SRN occurs up to 75% of the time. Steinberg and colleagues recommended placing this portal no more than 4.5 mm dorsal to the first extensor compartment and within 4.5 mm of the radial styloid. Branches of the SRN that were radial to the 3-4 portal were located at a mean distance of 16 mm and were generally remote from the 4-5 portal. Branches of the SRN were found radial to the midcarpal radial portal at a mean of 7.2 mm. The dorsal cutaneous branch of the ulnar nerve (DCBUN) passes within 2.5 mm of the 6R portal and 17.5 mm from the dorsal distal radioulnar portal.
In an anatomic study of the volar radial (VR) portal performed by the author, there was a safe zone constituting the width of the flexor carpi radialis (FCR) tendon plus at least 3 mm or more in all directions at the level of the proximal wrist crease, which was free of any neurovascular structures. There was no true safe zone for the volar ulnar (VU) portal; hence careful dissection and wound spread technique should be observed. Table 40-1 describes the typical field of view as seen through a 2.7-mm arthroscope under ideal conditions.
| Portal | Radial | Central | Volar | Dorsal/Distal | Ulnar |
|---|---|---|---|---|---|
| 1-2 | Scaphoid and lunate fossa, dorsal rim of radius | Proximal and radial scaphoid, proximal lunate | Oblique views of RSC, LRL, SRL | Oblique views of DRCL | TFCC poorly visualized |
| 3-4 | Scaphoid and lunate fossa, volar rim of radius | Proximal scaphoid and lunate, dorsal and membranous SLIL | RSC, RSL, LRL, ULL | Oblique views of the DRCL insertion onto the dorsal SLIL | TFCC radial insertion, central disk, ulnar attachment, PRUL, DRUL, PSO, PTR |
| 4-5 | Lunate fossa, volar rim of radius | Proximal lunate, triquetrum, dorsal and membranous LTIL | RSL, LRL, ULL | Poorly seen | TFCC radial insertion, central disk, ulnar attachment, PRUL, DRUL, PSO, PTR |
| 6R | Poorly seen | Proximal lunate, triquetrum, dorsal and membranous LTIL | ULL, ULT | Poorly seen | TFCC radial insertion, central disk, ulnar attachment, PRUL, DRUL, PSO, PTR |
| 6U | Sigmoid notch | Proximal triquetrum, membranous LTIL | Oblique views of ULL, ULT | Oblique views of DRCL | TFCC oblique views of the radial insertion, central disk, ulnar attachment, PRUL, DRUL |
| VR | Scaphoid and lunate fossa, dorsal rim of radius | Scaphoid and lunate fossa, dorsal rim of radius | Palmar scaphoid and lunate, palmar SLIL | Oblique views of RSL, LRL ULL | Oblique views of the radial insertion, central disk, ulnar attachment, PRUL, DRUL |
| Midcarpal radial | STT joint, distal scaphoid pole | SLIL joint, distal scaphoid, distal lunate | Radial limb of arcuate ligament, i.e., continuation of the RSC ligament | Proximal capitate, CHIL, oblique views of proximal hamate | LTIL joint, partial triquetrum |
| Midcarpal ulnar | Distal articular surface of the lunate and triquetrum and partial scaphoid | SLIL joint | Volar limb of arcuate ligament, i.e., continuation of the triquetrocapitolunate | Oblique views of proximal capitate, CHIL, proximal hamate | LTIL joint, triquetrum |
| Dorsal DRUJ | Sigmoid notch, radial attachment of TFCC | Ulnar head | Palmar radioulnar ligament | Proximal surface of articular disk | Limited view of deep DRUL |
| Volar DRUJ | Sigmoid notch, radial attachment of TFCC | Ulnar head | Dorsal radioulnar ligament | Proximal surface of articular disk | Foveal attachment of deep fibers of TFCC, i.e., DRUL, PRUL |
METHODOLOGY
The patient is positioned supine under general anesthesia with the arm abducted under tourniquet control. A 2.7-mm 30°-angled scope along with a camera attachment is used along with some method of overhead traction. The structures that should be visualized as part of a standard examination include the articular surface of the radius, the proximal scaphoid and lunate, the volar carpal ligaments, the scapholunate interosseous ligament (SLIL), the lunotriquetral interosseous ligament (LTIL), and the triangular fibrocartilage complex (TFCC). The author’s practice is to establish the dorsal portals first and then start the arthroscopic examination with the VR portal to visualize the palmar SLIL and the dorsal radiocarpal ligament (DRCL) to minimize artifact secondary to iatrogenic trauma to the dorsal capsular structures. If the patient has ulnar-sided wrist pain, the VU portal is used to assess the palmar LTIL and the dorsal radioulnar ligament (DRUL), extensor carpi ulnaris (ECU) subsheath, and radial TFCC attachment. The scope is then inserted in the 3-4 portal followed by various combinations of the 4-5 portal and 6R portal. The 6U portal is used mostly for outflow, but it may be used for instrumentation when debriding palmar LTIL tears.
Midcarpal arthroscopy is performed next to assess the integrity of the intercarpal ligaments and to inspect for chondral lesions or loose bodies in the midcarpal joint. The special use portals such as the dorsal and volar distal radioulnar joint (DRUJ) portals and the 1-2 portal are used as needed.
3-4 Portal
The surgeon is initially seated facing the dorsal surface of the wrist. The concavity overlying the lunate between the extensor pollicis longus (EPL) and the extensor digitorum communis (EDC) is located just distal to Lister’s tubercle, in line with the second web space. The radiocarpal joint is identified with a 22-gauge needle that is sloped 10 degrees palmar to account for the volar inclination of the radius. The joint is injected with 5 mL saline. A shallow skin incision is made to prevent injury to small branches of the SRN or superficial veins. Tenotomy scissors or blunt forceps are then used to spread the soft tissue and pierce the dorsal capsule. This technique is repeated for each portal. The vascular tuft of the radioscapholunate (RSL) ligament is directly in line with the 3-4 portal. Superior to the radioscapholunate ligament is the membranous portion of the SLIL. The insertion of the dorsal capsular attachment can often be visualized by rotating the scope dorsally while looking ulnarward. The radioscapholunate and the long radiolunate ligaments are radial to the portal and can be probed with a hook in the 4-5 portal. The LTIL, TFCC, and ulnolunate (ULL) and ulnotriquetral (ULT) ligaments are ulnar to the portal.
4-5 Portal
The interval for the 4-5 portal is identified with a 22-gauge needle inserted between the extensor digitorum communis tendons and the extensor digiti minimi (EDM), in line with the ring metacarpal. Because of the normal radial inclination of the distal radius, this portal lies slightly proximal and about 1 cm ulnar to the 3-4 portal. Views of the ulnar half of the lunate are obtained by moving the scope radially, whereas the triquetrum is seen by angling the scope in a superior and ulnar direction. The LTIL is often difficult to differentiate from the carpal bones without probing. The ULL and ULT can be seen on the far end of the joint. Proximally, the radial insertion of the TFCC blends imperceptibly with the sigmoid notch of the radius, but it can be palpated with a hook probe in either the 3-4 portal or the 6R portal. The peripheral insertion of the TFCC slopes upward into the ulnar capsule. The volar and dorsal radioulnar ligaments can be probed for laxity/tears, but they are not seen as distinct structures, since they blend with the TFCC. The pisotriquetral orifice (PTO) is just distal and anterior to the prestyloid recess and is found within the substance of the ULT just anterior to the proximal articular surface of the triquetrum.
6R and 6U Portals
The 6R portal is identified on the radial side of the ECU tendon just distal to the ulnar head. The scope should be angled 10 degrees proximally to avoid hitting the triquetrum. The TFCC is immediately below the entry site. The LTIL is located radially and superiorly, whereas the ulnar capsule is immediately adjacent to the scope. The 6U portal is located ulnar to the ECU tendon. This portal can be used to view the dorsal rim of the TFCC or for instrumentation when debriding the palmar LTIL.
Midcarpal Portals
The midcarpal radial (MCR) portal is found 1 cm distal to the 3-4 portal. The scaphotrapeziotrapezoid (STT) joint lies radially and can be seen by rotating the scope dorsally. The scapholunate (SL) articulation, which is proximal to this portal, can be probed for instability or stepoff. By moving the scope in an ulnar direction, the lunotriquetral (LT) articulation comes into view. Superiorly, the proximal surface of the capitate, the interosseous ligament, and the hamate are seen. The midcarpal ulnar (MCU) portal is located 1 cm distal to the 4-5 portal or 1.5 cm ulnar and slightly proximal to the MCR portal, in line with the ring metacarpal axis. Normally, there is very little stepoff between the distal articular surfaces. When in doubt, the traction should be released, and the SL joint should be viewed with the scope in the MCU, whereas the LT joint should be viewed with the scope in the MCR portal.
Volar Portals
To establish the VR portal, the surgeon is seated facing the volar aspect of the wrist. A 2-cm transverse or longitudinal incision is made in the proximal wrist crease overlying the FCR tendon. It is not necessary to specifically identify the adjacent neurovascular structures, provided that the anatomic landmarks are adhered to. The tendon sheath is divided, and the FCR tendon is retracted ulnarly. The radiocarpal joint space is identified with a 22-gauge needle and distended with 5 mL of saline. Tenotomy scissors or forceps are used to pierce the volar capsule. A blunt obturator and trocar are then introduced followed by the arthroscope.
The midcarpal joint can be accessed through the same skin incision by angling the trocar 1 cm distally and approximately 5 degrees ulnarward. A hook probe is inserted through the 3-4 portal and used to assess the palmar aspect of the SLIL and the DRCL. A useful landmark when viewing from the VR portal is the intersulcal ridge between the scaphoid and lunate fossae. The origin of the DRCL is seen immediately ulnar to this ridge, just proximal to the lunate. The VU portal is established via a 2-cm longitudinal incision centered over the proximal wrist crease along the ulnar edge of the finger flexor tendons. The tendons are retracted to the radial side, and the radiocarpal joint space is identified with a 22-gauge needle. Blunt tenotomy scissors or forceps are used to pierce the volar capsule, followed by insertion of a cannula and blunt trocar, then the arthroscope. The ulnar nerve is protected by use of the cannula and a more radial entry site. The median nerve is protected by the adjacent flexor tendons. The palmar region of the LTIL can usually be seen slightly distal and radial to the portal. A hook probe is inserted through the 6R or 6U portal.
Distal Radioulnar Joint Portals
The dorsal aspect of the DRUJ can be accessed through a proximal and distal portal. The proximal portal is mostly for outflow and can be identified by inserting a 22-gauge needle horizontally at the neck of the distal ulna. The distal portal (DDRUJ) is identified just proximal to the 6R portal underneath the dorsal radioulnar ligament. This portal can be used for outflow drainage or for instrumentation. It lies on top of the ulnar head but underneath the TFCC.
The topographic landmarks and establishment of the volar distal radioulnar (VDRU) portal are identical with those of the VU portal. The capsular entry point lies 5 to 10 mm proximally. There is more room on the volar ulnar aspect of the DRUJ for insertion of an arthroscope with relatively unimpeded views of the proximal articular disk and the foveal attachments. The VDRU portal is accessed through the VU skin incision. A 1.9-mm small joint arthroscope can be used because gaining access to the DRUJ can be difficult, especially in a small wrist, but a standard 2.7-mm scope provides a better field of view. It is useful to leave a needle or cannula in the ulnocarpal joint for reference. The DRUJ is located by angling a 22-gauge needle 45 degrees proximally and then injecting the DRUJ with saline. Once the correct plane is identified, the volar DRUJ capsule is pierced with tenotomy scissors followed by a cannula with a blunt trocar and then the arthroscope. Alternatively, a probe can be placed in the DDRUJ portal and advanced through the palmar incision to help locate the joint space. It can then be used as a switching stick over which the cannula is introduced.
Initially, the DRUJ space appears quite confined, but over the course of 3 to 5 minutes the fluid irrigation expands the joint space, which improves visibility. A burr or thermal probe can be substituted for the 3-mm hook probe through the DDRUJ as necessary.
PROCEDURES
The number of conditions that are amenable to arthroscopic treatment continues to grow. Many arthroscopic procedures are now commonplace. Table 40-2 provides a partial list of the more standard procedures that are discussed in the following text.
| Synovial biopsy and synovectomy |
| Chondroplasty and loose body removal |
| Staging and debridement of avascular necrosis |
| Ganglion resection: Volar and dorsal |
| Release of wrist contracture |
| Dorsal radiocarpal ligament repair |
| Evaluation/treatment of carpal instability: scapholunate, lunotriquetral, midcarpal |
| Triangular fibrocartilage tears: repair versus debridement |
| Arthroscopic wafer resection |
| Arthroscopic bone resection: Hamate pole resection, radial styloidectomy, distal scaphoid resection, proximal row carpectomy |
| Arthroscopic reduction and internal fixation of distal radius fractures |
| Arthroscopic-guided fixation of scaphoid fractures |
| Arthroscopic shrinkage of the trapeziometacarpal joint |
| Arthroscopic hemiresection of the trapeziometacarpal joint with/without interposition substance |
| Arthroscopic scaphotrapezial debridement/resection |
Synovial Biopsy and Synovectomy
Synovial biopsy is mostly indicated in inflammatory conditions in which a tissue sample is required to aid in the diagnosis. These include inflammatory arthritis, gout, sarcoidosis, and granulomatous infections. Synovial biopsy is also of use when quantitative analysis of the inflammatory response in a rheumatoid patient is indicated for prognostic reasons. It is most efficient to take the sample directly, using arthroscopic forceps; however, a full radius resector and arthroscopic scalpel may be of use.
Arthroscopic synovectomy is mostly indicated in rheumatoid arthritis patients with a stable wrist joint and well-preserved articular surfaces who have not responded to 6 months of appropriate medical management. It is also beneficial in patients who have juvenile rheumatoid arthritis, systemic lupus erythematosus, or postinfectious arthritis, but arthroscopic synovectomy is not recommended in psoriatic arthropathy. Preoperatively, magnetic resonance imaging (MRI) of the wrists in patients with early rheumatoid arthritis can help to predict the future course. The synovectomy is performed systematically with a 3.5-mm shaver and thermal ablator, starting on the radial side of the wrist and then moving to the ulnocarpal and midcarpal joints. Synovitis is especially localized around the radial styloid, radioscaphocapitate (RSC) ligament, the prestyloid recess, and the ECU subsheath. Early motion with protective splinting is instituted postoperatively to limit adhesions. Adolfsson interviewed 18 patients 12 to 15 years after arthroscopic synovectomy and noted a long period of comfort after the synovectomy with only one patient requiring additional surgery.
Chondroplasty and Loose Body Removal
Articular cartilage damage is a common cause of wrist pain and may result from osteochondral fractures or chronic carpal instability, or idiopathically. Loose bodies are common sequelae of osteoarthritis. They may also be seen in avascular necrosis (AVN) due to sloughing of a cartilage defect. Loose bodies give rise to pain and locking, which is relieved after arthroscopic removal ( Fig. 40-2 ). Articular defects often go undetected by preoperative imaging studies, and they are best seen at the time of arthroscopy. Culp and colleagues have provided a modified Outerbridge classification for chondral lesions in the wrist in which grade I represents softening of the hyaline surface, grade II consists of fibrillation and fissuring, grade III represents a fibrillated lesion of varying depth in the articular surface, and grade IV involves a full-thickness defect down to bone. Grades I to III lesions are treated with debridement and localized synovectomy. Localized grade IV lesions can be treated with abrasion chondroplasty and subchondral drilling.
Surgical Technique
Once a focal area of chondral damage is identified, an arthroscopic burr or 0.62-inch Kirschner (K) wire is used to make perforations into the subchondral bone plate. These perforations are made 1 to 2 mm apart while maintaining an adequate bony bridge ( Fig. 40-3 ). Chondroplasty is not indicated when there is widespread cartilage loss. Bain and Roth noted improvement in 83% of patients with 1 degree chondral defects that were treated with debridement. Whipple stated that patients often have relief after abrasion arthroplasty if the defect is less than 5 mm.
Arthroscopy and Avascular Necrosis
Bain and Begg described an arthroscopic classification for Kienböck’s disease based on the number of articular surfaces. In grade 0, all articular surfaces are normal; hence an extra-articular unloading procedure may be indicated. Grade 1 consists of one nonfunctional proximal lunate surface, which can be treated with a proximal row carpectomy (PRC), radioscapholunate fusion or lunate excision and scaphocapitate (SC) fusion ( Fig. 40-4 ). In grade 2, the proximal and distal lunate surfaces are nonfunctional, which requires a proximal row carpectomy or scaphocapitate fusion. Grades 3 and 4 require total wrist fusion or arthroplasty. Menth-Chiari and colleagues used arthroscopic debridement alone of the necrotic lunate in seven patients with Lichtman stage IIIA–IIIB. All patients reported significant improvement in pain relief and complete relief of mechanical symptoms at an average of a 19-month follow-up. There are scant reports on arthroscopic treatment of Preiser’s disease, but the same investigators reported good pain relief and improved wrist motion in a patient after debridement of a necrotic scaphoid at a 31-month follow-up.
Arthroscopic Wrist Ganglionectomy
Osterman and Raphael pioneered the arthroscopic resection of dorsal wrist ganglia and reported on 150 procedures with only one recurrence. Volar wrist ganglia that originate from the radiocarpal joint are amenable to arthroscopic resection, but ganglia that arise from the STT joint are not.
Indications
The indications for arthroscopic removal of a dorsal ganglion are similar to those for an open method. An ideal indication is for patients with concomitant wrist pain and a positive scaphoid shift test in whom evaluation of any associated SLIL instability is desirable. The occult ganglion that is entirely intracapsular and cannot be visualized during open surgery is another good indication. Preoperative x-rays should be performed to rule out intraosseous communication or other carpal pathology. It is important to ensure that the lesion is a ganglion either with transillumination, MRI, or needle aspiration. Allen’s test should be performed with volar ganglia to ensure adequate hand perfusion from the ulnar artery in the event of radial artery perforation and to rule out an aneurysm masquerading as a cyst.
Contraindications
Previous scarring in the area owing to previous injury or surgery for recurrence may distort the anatomy and make it difficult to establish the portals.
Surgical Technique
Dorsal Ganglionectomy
Since the ganglion overlies the 3-4 portal, it is the author’s preference to view the ganglion through the VR portal, which provides a direct line of sight and allows one to rule out a tear of the DRCL. Alternatively, the 1-2 or 6R portal can be used. A shaver is then introduced into the ganglion through the 3-4 portal to perforate the ganglion and resect the stalk. The intra-articular ganglion is completely debrided along with a 1-cm area of surrounding dorsal capsule. The extensor tendons may be visible through the defect. Midcarpal arthroscopy should be performed to debride any midcarpal extension of the ganglion and to assess the status of the SL and LT joints ( Fig. 40-5 ).
Volar Ganglionectomy
The ganglion is amenable to arthroscopic resection only when it arises from the radiocarpal joint, which can be determined by injecting the cyst with dye intraoperatively under fluoroscopy. The joint is surveyed in the standard fashion starting with the 3-4 portal. When a volar ganglion is present, there may be an outpouching in the sulcus between the RSC and the long radiolunate. Volar pressure on the cyst can deliver it into the joint space. A resector is placed through the VR, 1-2, or 4-5 portal to resect the ganglion and 1 cm of surrounding capsule until the FCR tendon is seen. Postoperatively, the wrist is splinted for 1 week for comfort followed by protected range of motion. Loss of wrist flexion after dorsal ganglia excision or loss of wrist extension with volar ganglia can be treated with dynamic splinting at 6 to 8 weeks.
Results
Rizzo and coauthors performed an arthroscopic resection of 41 dorsal ganglia. At 2 years, patients demonstrated improved wrist motion and grip strength, excellent pain relief, and only two recurrences. Mathoulin and colleagues performed an arthroscopic resection on 32 patients with volar ganglia using a 1-2 portal, with no recurrences at the 26-month follow-up. Good results are not invariable in patients with associated intracarpal pathology, however. Povlsen and Tavakkolizadeh noted an abnormal SL joint in 10 of 16 patients and an abnormal LT joint in 2 of 16 patients. At 5-year follow-up, only 1 patient remained pain-free.
Arthroscopic Release of Wrist Contracture
Indications
Patients lacking a functional arc of wrist motion who have failed a trial of dynamic/static progressive splinting are candidates for this procedure. Lee and colleagues devised a classification system based on pathologic anatomic location. Type I represents intrinsic adhesions, which are subdivided into radiocarpal (A), midcarpal (B), DRUJ (C), and combined (D). Type II represents extrinsic contracture, which can be dorsal (A), volar (B), DRUJ (C), or combined (D). The operative approach should be wrist arthroscopy for types IA (radiocarpal adhesions) and IB (midcarpal adhesions) in which intra-articular adhesions are present. Types IC (DRUJ adhesions) and IIC (DRUJ capsular contracture) are best approached in an open manner in which dorsal and palmar capsulectomies of the DRUJ are performed. For types IIA, IIB, and IID (dorsal, palmar, and combination extrinsic contracture, respectively), both open and arthroscopic methods are used.
Contraindications
A frank carpal instability pattern is a contraindication to arthroscopic release of wrist contracture, since release of the volar and/or dorsal extrinsic ligaments would likely exacerbate this condition. Similarly, significant post-traumatic osteoarthritis limits any ultimate gains. Division of the RSC, long radiolunate, and short radiolunate (SRL) ligaments should be performed with caution in patients who are at risk for ulnar translocation, such as those with rheumatoid arthritis and those who have undergone previous radial styloidectomies. Patients who cannot comply with postoperative dynamic/static progressive splinting because of low pain threshold or psychological disorder are not appropriate candidates.
Surgical Technique
Volar Capsulotomy
A blunt trocar and cannula are initially inserted in the 3-4 portal and used in a sweeping fashion to clear a path. A full radius resector is used to clear adhesions. The radial artery passes within 5.2 mm, the median nerve within 6.9 mm, and the ulnar nerve within 6.7 mm of the volar capsule, which should be kept in mind. An arthroscopic knife is introduced through a cannula in the 4-5 portal. The RSC ligament is gently divided until the volar capsular fat and/or the FCR tendon is seen. The ULL (ulnolunate) and ULT (ulnotriquetral) should not be released in the presence of LT joint instability, since in sectioning studies this combination results in a volar intercalated segmental instability (VISI) pattern, especially when the dorsal radiocarpal ligament is also released.
Dorsal Capsulotomy
The author’s preference is to view through the VR portal, although the 1-2 portal may be substituted. In patients with a partial or complete SLIL tear, sectioning the DRCL should be done with caution, since it may exacerbate any preexisting SL instability. An arthroscopic knife is introduced through a cannula placed in the 3-4 portal. The dorsal capsule and the DRCL are gently sectioned until the dorsal capsular fat and/or the extensor tendons can be seen. Bain and colleagues use an umbilical tape to retract and protect the extensor tendons. If it is desirable to release the dorsoulnar capsule, it is necessary to establish a VU portal or to view through the 6U portal. The adhesions are cleared by using the 4-5 and 6R portals, and then a capsulotomy is performed in a similar fashion. Postoperatively, the patient is placed in a bulky splint for 2 to 3 days to reduce hematoma formation followed by aggressive wrist mobilization.
Results
Osterman described his experience with 23 patients with an average preoperative wrist flexion of 5 degrees and extension of 15 degrees. At a 2-year follow-up flexion improved to 48 degrees and extension to 58 degrees. Hattori and colleagues noted an average increase of 22 degrees in their series of 11 patients. Luchetti and colleagues reported on 28 patients. Radiocarpal, midcarpal, and distal radioulnar portals were used. At a mean of 28 months, wrist flexion/extension increased from an average of 84 degrees to 99 degrees, and mean pronation/supination increased from 144 degrees to 159 degrees.
INTEROSSEOUS LIGAMENT INJURIES
Arthroscopy has perhaps influenced the diagnosis and treatment of interosseous ligament injuries more than any other type of carpal disorder. Geissler and colleagues proposed an arthroscopic grading scale of interosseous ligament instability that has gained wide acceptance ( Table 40-3 ). This classification quantifies the resultant instability and not the actual size of the tear. In Geissler grades I and II lesions, there is no to minimal instability owing to ligament attenuation, but no tearing ( Fig. 40-6 A). Grades III and IV lesions ( Fig. 40-6 B) represent partial and complete tears with greater degrees of carpal instability.
| Grade | Radiocarpal Joint | Midcarpal Instability | Stepoff |
|---|---|---|---|
| I |
| None | None |
| II |
| Slight gap (less than width of 3-mm probe) | Midcarpal only |
| III |
| Probe can be passed between carpal bones | Midcarpal and radiocarpal |
| IV |
|
| Midcarpal and radiocarpal |
Scapholunate Ligament Injuries
Indications
Arthroscopic assessment of the SLIL is indicated in any patient with radial-sided wrist pain with a positive scaphoid shift test who has not responded to conservative measures. It is also indicated when there is an SL gap without a dorsal intercalated segmental instability (DISI) deformity. It then guides the subsequent treatment by allowing staging of the degree of injury and the severity of instability.
Contraindications
Complete and repairable SLIL tears as well as static carpal instabilities are best managed with open techniques. Rosenwasser and associates have treated complete but nonrepairable ligament tears with the RASL procedure (reduction and association of the scaphoid and lunate), which uses a cannulated Herbert screw to create a stable pseudarthrosis. Hausman has reported favorable results with an arthroscopic version of the RASL.
Surgical Technique
Arthroscopic Debridement
Arthroscopic debridement alone is indicated for acute or chronic Geissler I and II lesions. Palmar tears are best seen through the VR portal. The tear is debrided to stable margins while preserving any intact fibers by switching the arthroscope and resector between the VR, 3-4, and 4-5 portals. Early wrist motion is instituted postoperatively.
Thermal Shrinkage
The indications for thermal shrinkage are the same as for debridement, but thermal shrinkage may have some use when there is an associated dynamic instability. The dorsal SLIL is treated using a thermal probe in the 4-5 portal. The palmar SLIL can be treated with the probe in the 3-4 portal while viewing through the VR portal. It is important to use rapid irrigation to limit possible thermal damage to the cartilage. The probe is applied using multiple strokes like a paintbrush for only a few seconds at a time. In the midcarpal joint, the distal continuation of the RSC ligament (or the radial limb of the arcuate ligament) is seen at the palmar junction of the scaphoid and lunate. Short bursts of thermal energy to this tissue tighten the SL and scapholunocapitate articulations. When midcarpal examination reveals SL joint congruency without gapping, the thermal shrinkage is complete. K-wire fixation is often used after shrinkage for 8 weeks, followed by wrist motion.
Arthroscopic-Assisted Percutaneous K-Wire Fixation
In patients with partial tears without carpal malrotation, temporary K-wire fixation may improve SL stability. If necessary, individual K wires can be inserted dorsally into the lunate and the distal scaphoid and used as joysticks to derotate the scaphoid and lunate. The K wires should be introduced in a safe zone that is no more than 4.5 mm dorsal to the first extensor compartment and within 4.5 mm of the radial styloid. A second K wire is inserted between the distal scaphoid and the capitate. The reduction is checked with both fluoroscopy and arthroscopy.
Lunotriquetral Ligament Injuries
Indications
LTIL tears often coexist with a TFCC tear and an ulnar-positive variance. An LTIL debridement may be combined as necessary with TFCC debridement and a wafer resection or an open ulnar-shortening osteotomy.
Contraindications
Patients with static carpal instability may be staged arthroscopically, but they usually require an open procedure for definitive treatment.
Surgical Technique
The 4-5 portal is the usual working portal for LT ligament injuries, but superior views of the LTIL can be obtained through the 6R and 6U portals. Palmar tears of the LTIL are best seen through the VU portal ( Fig. 40-7 ). They can also be seen obliquely through the 6U. Occasionally, tears of the ulnar limb of the arcuate ligament (i.e., the triquetro-hamate-capitate ligament) are evident on the midcarpal examination ( Fig. 40-8 ). Grade I tears are debrided. Grade II tears are treated with arthroscopic reduction, thermal shrinkage, and K-wire fixation for 8 weeks. Acute grade III tears are treated in a similar fashion to that of grade II injuries, but consider open treatment for injuries more than 6 months old. Grade IV acute tears may be pinned in selected circumstances, but chronic injuries are usually beyond arthroscopic management.
Results
O’Meeghan and colleagues demonstrated that milder grades of instability do not necessarily culminate in a static carpal instability. At 7-year follow-up, 11 patients with untreated Geissler I or II SLIL injuries still showed no radiologic signs of instability, but they continued to experience considerable pain, loss of motion, and functional limitation. In Whipple’s series of 40 patients treated with arthroscopic reduction and pinning, 85% of patients with a less than 3 mm side-to-side SL gap and symptoms of less than 3 months’ duration maintained comfort and stability at 2 to 7 years. Only 53% of patients with a side-to-side SL gap of more than 3 mm or with symptoms for more than 3 months were symptom-free at 1 to 3 years. This supports the concept that both the chronicity of the lesion and the degree of instability impact the eventual outcomes.
If there is no instability, debridement alone can be successful. Ruch and Poehling reported the relief of mechanical symptoms in 13 of 14 patients treated for membranous flap tears of the SLIL and LTIL with no progression of instability at 34 months. In their study of 43 patients, Weiss and colleagues noted symptom improvement at 27 months with no evidence of a carpal instability pattern in 85% of patients with an incomplete SLIL tear versus 66% with a complete tear. Similarly, 100% of patients with a partial LTIL tear had symptom resolution compared with 78% with a complete tear. Darlis and colleagues found that athroscopic debridement and pinning provide inconsistent results with more advanced degrees of ligamentous instability. They treated 11 patients with Geissler III or IV SLIL instability with aggressive debridement down to bleeding bone and percutaneous pinning for 4 to 8 weeks. Three patients failed within the first year and required a partial carpal fusion. At the 3-year follow-up, only 6 of 11 patients achieved a good result without further revision surgery.
Thermal shrinkage seems to hold promise in the treatment of partial wrist ligament injuries. Sixteen patients (mean age 34 years) with Geissler I or II SLIL injuries of an average 5-month duration underwent debridement and shrinkage followed by 2 weeks of immobilization. At 19 months postprocedure, there were 14 excellent to good results and 2 fair to poor results using the modified Mayo wrist score. Hirsh and associates treated 10 patients (mean age 37 years) with Geissler II SLIL injuries with shrinkage and 4 to 6 weeks of immobilization. Symptom duration was more than 6 months in eight patients. At 28 months, the pain had resolved in 9 of 10 patients. Similarly, Shih and Lee studied 19 patients (mean age 23 years) with symptomatic dynamic and predynamic SL instability of 17 months’ duration. At 28 months after thermal shrinkage, 15 of 19 patients were fully satisfied with the results and returned to their preinjury activity. Four patients had recurrent laxity of the SL joint. The loss of wrist motion averaged 5 degrees.
Battistella and colleagues divided 120 patients into four groups. Group A consisted of 20 patients with Geissler I SLIL instability. They were treated with thermal shrinkage alone. Group B consisted of 20 patients with a grade I instability treated with debridement alone. Group C consisted of 40 patients with a grade II or III instability treated with thermal shrinkage and pinning for 6 weeks. Group D consisted of 40 patients with a grade II or III instability treated with debridement and pinning for 6 weeks. At an average 24-month follow-up, patients treated with thermal shrinkage with and without pinning had superior modified Mayo scores and less pain compared with the debridement groups.
Arthroscopic Dorsal Radiocarpal Ligament Repair
In most series, the DRCL is overlooked during the standard arthroscopic examination, since it is difficult to visualize through the standard dorsal portals. The DRCL is best viewed through the VR portal because of the straight line of sight. An arthroscopic classification of DRCL tears is outlined in Table 40-4 .
| Stage | Description |
|---|---|
| 1 | Isolated DRCL tear |
| 2 | DRCL with associated SLIL or LTIL (Geissler I/II) or TFCC tear or midcarpal instability |
| 3A | DRCL tear with associated SLIL and/or LTIL (Geissler III) and/or TFCC tear |
| 3B | DRCL tear with SLIL and/or LTIL (Geissler IV) and/or TFCC tear |
| 4 | DRCL with chondromalacia or widespread degenerative changes |
∗ The ligament with the highest Geissler grade determines the stage.
Indications
Isolated DRCL tears respond favorably to repair. Repairs may also be considered in cases in which the associated interosseous ligament tear or TFCC tear can be treated arthroscopically. Guidelines for treatment are listed in Table 40-5 .
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Management of Soft Tissue Contractures Around the Distal Radioulnar Joint
Lunotriquetral Ligament Instability/Tear: Acute and Chronic
Arthroscopic Resection of Distal Scaphoid and Tendon Interposition for Isolated Scaphotrapeziotrapezoid Arthritis
Bone Tumors of the Hand and Wrist
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