Treatment of dynamic scaphoid instability

BACKGROUND: Chronic wrist pain attributable to scaphoid instability without fixed deformity (dynamic instability) presents a treatment dilemma. The diagnosis usually is delayed, missing the opportunity for direct repair. The intercarpal fusion, tenodesis, and capsulodesis procedures create a fixed deformity. This report presents an outcome study of a new treatment for dynamic scaphoid instability that spanned more than 5 years. METHODS: Arthroscopic evaluation was used to confirm the diagnosis for 105 wrists of 102 patients who had experienced wrist pain for an average of 24.4 months. The treatment for these patients involved transferring two thirds of the extensor carpi radialis longus through the distal pole of the reduced scaphoid volarly to the intact flexor carpi radialis. The postoperative follow-up period averaged 63 months. RESULTS: The average grip strength increased by 65%. The average active wrist extension-flexion increased by 9%, with an average radial deviation loss of 6 degrees. The overall results, as measured by the modified Green and O'Brien clinical wrist scale, were as follows: excellent (49%), good (24%), and fair (26%). Good to excellent results were reported by 85% of the patients. Pain relief was reported by 94% of the patients, and 93% of the patients would recommend the procedure to others. CONCLUSIONS: Scaphoid instability without fixed deformity is a complex problem. Conventional treatments have drawbacks. The new technique produced positive results that are quite promising for the management of dynamic scaphoid instability.     

Arthroscopic management of scapholunate instability

Scapholunate ligament tears cause chronic instability leading to SLAC. Wrist arthroscopy allows to see the lesions, even at an early stage, and to treat them with a simple K-Wires fixation in acute cases. Patients were treated on an outpatient basis with tourniquet and under regional anaesthesia. In acute cases, the scapholunate dissociation was reduced by external and internal manoeuvres. The fixation was done with pins under arthroscopic and fluoroscopic control. In chronic lesions, after wrist arthroscopy check, an electrothermal shrinkage can be performed in some cases. An arthroscopic classification was created with 4 grades. Wrist arthroscopy is the best technique for early diagnosis, and assures the best functional results.     

Arthroscopic management of multidirectional instability: pancapsular plication

Patients with multidirectional glenohumeral instability without a Bankart lesion represent a challenging group. Arthroscopic pancapsular plication affords the surgeon flexibility to correct the degree and direction of laxity in the multidirectionally unstable patient. This technique can be combined with suture anchors if needed to correct capsulolabral defects in patients with more advanced lesions. The mainstay of treatment for MDI remains conservative. In resistant cases, however, arthroscopic management can be performed safely and efficaciously, now with documented extended success in an active patient population.     

Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability

PURPOSE: For chronic dynamic scapholunate (SL) instability (>3 months after injury) open procedures (capsulodesis, limited intercarpal fusions, tenodesis, SL ligament reconstruction) have become popular in recent years but their long-term results have been suboptimal. We evaluated retrospectively the results of aggressive arthroscopic debridement of the SL ligament to bleeding bone in an effort to induce scar formation and closed pinning of the SL joint in patients unwilling to have an open procedure. METHODS: Eleven patients (mean age, 37 y) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with dynamic SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a Geissler grade III or IV SL tear) and treated. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results. RESULTS: The mean follow-up period was 33 months (range, 12-76 mo). Three patients had subsequent surgery 9 to 11 months after the procedure. Subsequent surgeries included a dorsal capsulodesis, a four-corner fusion, and a wrist arthrodesis. Of the 8 remaining patients there were 2 excellent, 4 good, 1 fair, and 1 poor result based on the Mayo wrist score. In these patients the mean range of motion was 65 degrees of extension to 59 degrees of flexion and the mean grip strength was 82% of the uninjured contralateral extremity. Although persistent radiographic SL gapping in grip views was noted in all 8 patients none progressed to static instability or dorsal intercalated segment instability. CONCLUSIONS: The results of this technique are suboptimal; however, it may be an option for patients unwilling to have more than an arthroscopic procedure or those requiring maintenance of wrist motion, provided they understand the risks and benefits of this approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Arthroscopic evaluation and treatment of scaphoid nonunion.

Scaphoid fractures are one of the most common carpal fractures and heal without complication in a majority of cases. Nonunion of the scaphoid, unfortunately, can occur secondarily to several reasons; namely, delay in treatment, delay in diagnosis, the intra-articular nature of the fracture, the precarious vascular supply of the scaphoid, and significant biomechanical stresses across the fractured scaphoid.     

Arthroscopic aided fixation of scaphoid fractures.

Acute nondisplaced scaphoid fractures have traditionally been managed with cast immobilization. Although cast immobilization may be successful in approximately 90% of cases, prolonged casting may lead to muscle atrophy, joint contracture, disuse osteopenia, and potential financial hardship. An athlete or worker may be inactive for 6 months or longer as the fracture heals. Arthroscopic assisted fixation offers a middle ground between traditional cast immobilization and open reduction for scaphoid fractures. These techniques reduce exposure and minimize soft tissue dissection with potential loss of vascularity, avoid division of the important radioscaphocapitate ligament, and allow for detection and management of any associated intracarpal soft tissue injuries. This article presents the indications and describes in detail the various applications for wrist arthroscopy in management of scaphoid fractures.     

Arthroscopic treatment of osteochondritis dissecans of the scaphoid

Osteochondritis dissecans of the carpal scaphoid has been reported only rarely in the literature. A 29-year-old, right-hand-dominant oil-field worker with symptomatic osteochondritis dissecans of the left carpal scaphoid was treated by arthroscopic debridement and drilling of the lesion. Preliminary follow-up at 9 months revealed a dramatic relief in his symptoms.     

Arthroscopic assessment of carpal instability

The evaluation, classification, and treatment of carpal instability continues to be one of the most controversial topics in hand surgery. One explanation is the lack of standardized findings and radiographic criteria. No good modality to date has been proposed to accurately aid in evaluating carpal instability. Wrist arthroscopy has become increasingly useful in the assessment of mechanical wrist pain. With this technology, specific patterns of injury can more accurately be identified by direct visualization. This will also aid in implementing a reproducible, less subjective means of describing wrist instability. The treatment can then be focused on management of the specific ligamentous injury responsible for the pattern of instability visualized. The following is an attempt to categorize these instability patterns as seen through arthroscopy and provide our proposed treatment options.Arthroscopy 1998 Oct;14(7):675-81     

Arthroscopic treatment of shoulder instability

Arthroscopic treatment of glenohumeral instability has become more common over the last years. Compared with open reconstruction which still is the gold standard in the treatment of glenohumeral instability the arthroscopic techniques show several advantages but also disadvantages that must be proved for every single case. Careful patient selection with regard of prognostic preoperative and intraoperative factors is substantial for successful treatment. When indicated using clinical, radiological and arthroscopic findings the results of arthroscopic stabilization could be improved over the last years and failure rates could be decreased.     

Arthroscopic treatment of glenohumeral instability

Arthroscopic treatment of glenohumeral instability using modern suture anchor techniques has reported recurrence rates equal to open techniques, even in high-demand contact athletes. Compared with open procedures, arthroscopic stabilization leads to less morbidity and less stiffness, leading to improved postoperative function, especially in overhead athletes. This article highlights the technical aspects of arthroscopic treatment of anterior glenohumeral instability.     

Radiocarpal articular contact characteristics with scaphoid instability

The relative importance of the three major periscaphoid ligament complexes in maintaining the normal radiocarpal articulation was assessed. Pressure-sensitive film recorded the changes in radioscaphoid and radiolunate articular contact that occurred with sequential ligament sectioning in 12 cadaver wrists. Alterations in the radiocarpal articular contact as a result of ligament disruption are evident in the absence of the recognizable static x-ray changes of carpal instability. The scapholunate interosseous ligament is essential in preventing scapholunate diastasis and dorsoradial subluxation of the proximal scaphoid. Rotatory subluxation of the scaphoid occurs when disruption of the scapholunate interosseous ligament is coupled with disruption of either the palmar intracapsular radiocarpal ligaments or the scaphotrapezial ligament complex. These data help explain the development of degenerative arthritis caused by carpal ligamentous instability.     

Arthroscopic treatment of anterior glenohumeral instability

Arthroscopic treatment of anterior shoulder instability is now well defined but its learning curve remains long. This technique should only be used for a certain kind of instability. Surgical gesture should be acquired such as the different devices that are proposed. Arthroscopic techniques are still in progress and results are improving with the selection of patient who could benefit by it.     

Arthroscopic treatment of multidirectional instability.

Multidirectional instability of the shoulder, described by Neer and Foster, has been treated surgically with the inferior capsular shift procedure. The small number of reports on mid-term outcomes indicate that good to excellent results have been obtained in 75% to 100% of cases. Arthroscopic treatment of multidirectional instability has been previously described. The purpose of this study was to review the results of the arthroscopic capsular shift procedure with a minimum follow-up of 2 years. A retrospective study was performed on 25 patients who underwent an arthroscopic capsular shift performed with the transglenoid technique between January 1990 and December 1993. All patients had earlier not responded to an extensive course of physical therapy. Excluded from the study were patients who had undergone a previous arthroscopic capsular shift or any other procedure, arthroscopic or open, for the shoulder. Average patient age was 26.4 years. There were 20 male and 5 female patients. Sixteen of the affected shoulders involved the dominant extremity. All patients had a history of asymptomatic subluxation that slowly progressed to symptomatic subluxation. Eleven patients had a history of dislocation. Thirteen patients were athletes who were symptomatic in their chosen sport, whereas the other patients were symptomatic in activities of daily living. All patients were examined while they were under anesthesia and had positive results on the sulcus test in abduction with associated anterior instability, posterior instability, or both. Follow-up evaluation was performed with patient interview and examination. All 25 patients were available for follow-up, which occurred an average of 60 months (range 36 to 80 months) after operation. Three patients had episodes of instability after the operation. The average Bankart score was 95 (range of 50 to 100). All but 1 patient had regained full symmetric range of motion by follow-up. Twenty-one (88%) patients had a satisfactory result according to the Neer system. Results of treatment with the arthroscopic capsular shift procedure for multidirectional instability of the shoulder appear to be comparable to those of the open inferior capsular shift.     

Operative management of ankle instability: reconstruction with open and percutaneous methods

Chronic ankle instability affects a large number of young patients. A thorough history and clinical examination are key to proper patient selection. Once the patient decides to undergo operative intervention, the appropriate procedure should be selected according to their physical and lifestyle demands. The surgeon should gain familiarity with the full range of procedures, from open to percutaneous, and anatomic to nonanatomic. With proper patient selection, functional outcomes are excellent, with success rates from 80% to 90%.     

Arthroscopic capsulorrhaphy for anterior shoulder instability

Surgical Principles Refixation of the detached labrum and anteroinferior glenohumeral ligament to the glenoid rim. Transscapular passage of the sutures placed from anterior and fixation over the infraspinatus fascia. Revised Version from: Operat. Orthop. Traumatol. 4 (1992), 1–10 (German Edition).     

Arthroscopic versus open ankle arthrodesis

Background

It is thought that arthroscopic ankle fusion offers improved outcomes over open fusion in terms of functional outcomes, time to fusion, length of stay and fewer complications. However, there are doubts about whether correction of established severe deformity can be achieved using the arthroscopic approach.