Background
Surgical visualization by means of arthroscopy has revolutionized orthopedics by allowing direct treatment of intra-articular pathology. Wrist arthroscopy evolved from the successful application of arthroscopy in larger joints.
The wrist is a complex joint that continues to challenge clinicians. This joint consists of eight carpal bones, multiple articular surfaces with extrinsic and intrinsic ligaments, and a triangular fibrocartilage complex (TFCC)—all within a 5-cm interval. Surgeons who use wrist arthroscopy are able to directly visualize cartilage, synovial tissue, and ligaments under bright illumination and magnification.
Most acute wrist sprains in which radiographic findings are normal resolve after conservative measures. However, the evaluation of the patient who does not improve after such treatment is controversial. [1]
Historically, tricompartmental wrist arthrography has been the criterion standard for the detection of intra-articular pathology. Wrist arthroscopy, which can be used simultaneously to detect and treat wrist injuries, and magnetic resonance imaging (MRI) have changed the way in which wrist pathology is treated. [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13] A study by Cheriex et al concluded that cineradiography also has a high success rate in detecting scapholunate dissociation. [14] Plain x-rays and computed tomography (CT) arthrography are insufficient diagnostic tools. [15]
Wrist arthroscopy is growing in popularity as a feasible adjunct in the management of disorders of the wrist. [16, 17] The procedure enables evaluation and detection of carpal structures under bright magnifying conditions with minimal morbidity as compared with arthrotomy. Improved wrist arthroscopic techniques continue to emerge as more surgeons are exposed to wrist arthroscopy and new instrumentation is developed. Despite short-term follow-up, the results of one study add another technique, arthroscopic resection arthroplasty, to the treatment algorithm of the very common pantrapezial arthritis. [18]
For patient education resources, see Wrist Injury and Carpal Tunnel Syndrome.
Indications
The indications and applications for wrist arthroscopy continue to expand as new techniques and instrumentation evolve. Diagnostically, wrist arthroscopy can allow for assessing interosseous ligament tears and determining whether the tears are partial or complete, evaluating the TFCC, inspecting for chondral defects in the carpal and midcarpal space, and evaluating chronic wrist pain of unknown etiology.
Therapeutically, operative intervention is indicated for treatment of intra-articular fractures of the distal radius and scaphoid, wrist lavage, synovectomy (ie, rheumatoid arthritis), ganglionectomy, distal ulnar shortening, detection and removal of loose bodies, debridement of degenerative arthritis, debridement and repair of the TFCC, resection arthroplasty (proximal-row carpectomy), management of septic arthritis (arthroscopic incision and drainage), [19] and stabilization of interosseous ligaments, as well as other conditions (eg, Kienböck disease [20] ).
Technical Considerations
Anatomy
The TFCC is a homogeneous structure comprising the following components [21] :
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Articular disk
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Dorsal and volar radioulnar ligaments
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Ulnar collateral ligament
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Sheath of the extensor carpi ulnaris
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Meniscal homologue
The TFCC acts as an extension of the articular surface of the radius to support the proximal carpal row, and it also provides stability to the distal radioulnar joint (DRUJ). The volar carpal ligaments assist in limiting wrist extension and radial deviation, as well as assist in stabilizing the volar-ulnar aspect of the carpus. Approximately 20% of the load of the forearm is transferred through the ulnar side of the wrist and the TFCC. [21]
The articular disk has thickening of the volar and dorsal margins, which are known as the volar and dorsal radioulnar ligaments. These ligaments assist in providing stability to the DRUJ. Palmer proposed a classification system for TFCC tears, which divided the injuries into two categories: traumatic (class I) and degenerative (class II). (See Technique.) [21] For more information, also see Wrist Joint Anatomy.
Outcomes
Sammer and Shin, in their study of 36 patients with septic arthritis of the wrist, found arthroscopic irrigation and debridement (n = 19) to be effective in patients with isolated disease; arthroscopy was associated with fewer operations and a shorter hospitalization than open treatment (n = 17). However, these benefits were not seen in patients who had multiple sites of infection. [19]
In a study of 55 patients who underwent arthroscopic resection for dorsal wrist ganglion cysts, Edwards et al noted a significant increase in function and a significant decrease in pain within 6 weeks after the procedure. [22] At 2 years after surgery, all patients had wrist motion that was within 5º of preoperative motion; there were no recurrences. The authors noted that recurrent ganglion cysts originating from the midcarpal joint are not contraindications for arthroscopic resection, that assessment of the midcarpal joint is necessary for complete resection of most ganglion cysts, and that identification of a discrete stalk is an uncommon finding and is not necessary for successful resection.
Adolfsson used arthroscopy to examine 144 patients who had posttraumatic wrist pain but normal findings on standard radiographs. [23] During the procedure, ligamentous changes were observed in 75 patients, TFCC lesions (including lunotriquetral instability) in 61, and degrees of scapholunate instability in 14.
The results of one small study found that arthroscopic proximal-row carpectomy can be a safe and reliable alternative to the open procedure. Range of motion and grip strength compared favorably, and mobilization of the wrist was improved over the open technique. [24]
Noback et al studied 13 patients with stage 2 or 3 SLAC wrist treated with arthroscopic wrist debridement and radial styloidectomy and concluded that the procedure relieved pain but did not necessarily avoid the need for future procedures. [25]
Soreide et al studied 15 patients with a median follow-up duration of 20 years. Their findings show that arthroscopically assisted resection of selected TFCC lesions is safe and efficient. [26, 27]
Trehan et al, in a study assessing outcomes of arthroscopic TFCC surgery in 43 pediatric and adolescent patients (44 wrists), found that at final follow-up, the mean QuickDASH score was 4, the Patient-Rated Wrist Evaluation was 8, and patient and parent satisfaction scores were both 9/10. [28]
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Traction tower after draping.
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Wrist is suspended in traction tower, and portals are drawn with associated landmarks on extensor surface of wrist.
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Wrist is suspended in traction tower, and portals are drawn with associated landmarks on extensor surface of wrist.
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Arthroscopic image of radial radiocarpal joint. Radioscaphocapitate ligament is most volar radial extrinsic wrist ligament. Adjacent and ulnar to radioscaphocapitate ligament, long radiolunate ligament is depicted. Note that long radiolunate ligament is larger. Scaphoid is depicted above.
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Short radiolunate ligament appears as vascularized tuft. It is ulnar to long radiolunate ligament.
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Trampoline test. Similar to trampoline, disk of triangular fibrocartilage complex should be taut when probed.
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Lunotriquetral ligament, as depicted from 4-5 portal in radiocarpal space.
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Grade III scapholunate tear, as depicted from midcarpal space. Note that gap allows passage of 1-mm probe.
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Grade IV scapholunate tear, as depicted from the midcarpal space. A 2.7-mm arthroscope may be freely passed through the tear.
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Posteroanterior radiograph of wrist. Abnormal widening between scaphoid and lunate is present, indicating complete scapholunate tear.
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Electrothermal shrinkage performed in patient with dynamic carpal instability. Careful use of probe is required to avoid damage to critical structures.
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Class IA tear of triangular fibrocartilage complex. Probe points at tear.
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Arthroscopic debridement in class IA tear. Flap has been debrided, and arthroscope is used to smooth remaining disk.
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Class 1B tear, as depicted from 3-4 portal. Reactive synovitis may cover tear.
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Repair of class IB tear with outside-in technique. Small longitudinal incision incorporates 6-R portal.
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Arthroscopic image of cannulated needle piercing articular disk in class IB repair.
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Arthroscopic view reveals retrieval of suture with small-joint grasper.
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Sutures placed before being tied in class IB tear.
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Class ID tear. Avulsion of disk from sigmoid notch is depicted.
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Arthroscopic image of rim of the sigmoid notch, which is debrided to bleeding bone bed before reattachment of disk.
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Class IIC tear of triangular fibrocartilage complex. Note chondromalacia of ulna.
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Radiocarpal view after arthroscopic removal of ganglion stalk.
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Arthroscopic view demonstrating articular stepoff in distal radius fracture. Hematoma and debris are removed for optimal visualization.
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Radiograph of wrist after arthroscopic-assisted pinning of intra-articular distal radius fracture.
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Before scaphoid is pinned, wrist is flexed at 45 degrees, which places scaphoid in 90 degrees flexion.
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Fluoroscopic image demonstrates reaming of scaphoid in proximal-to-distal fashion after arthroscopic reduction and percutaneous pinning.
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Anteroposterior radiograph after reduction and fixation with headless screw.
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Lateral radiograph after reduction and fixation with headless screw.
Tables
Grade |
Description |
Management |
I |
Attenuation and/or hemorrhage of the interosseous ligament as observed from the radiocarpal joint. No incongruence of carpal alignment in midcarpal space. |
Immobilization |
II |
Attenuation and/or hemorrhage of the interosseous ligament, as observed from the radiocarpal joint. Incongruence and/or stepoff, as observed from the midcarpal space. A slight gap (less than the width of a probe) between the carpals may be present. |
Arthroscopic reduction and pinning |
III |
Incongruence and/or stepoff of the carpal alignment are observed in both the radiocarpal and midcarpal space. The probe may be passed through a gap between the carpals. |
Arthroscopic reduction and/or open reduction and pinning |
IV |
Incongruence and/or stepoff of the carpal alignment are observed in both the radiocarpal and midcarpal space. Gross instability with manipulation is noted. A 2.7-mm arthroscope may be passed through the gap between the carpals. |
Open reduction and repair |
