Wrist arthroscopy: principles and clinical applications.

With the development of better and smaller equipment, arthroscopy of the wrist offers the same benefits achievable with arthroscopy of the knee, shoulder, or elbow - not only diagnostic information but also a therapeutic option. Standardized techniques of performing wrist arthroscopy have been developed to evaluate the treat various wrist disorders, such as lesions of the triangular fibrocartilage complex, intra-articular distal radius fractures, and scaphoid fractures. Arthroscopy is now performed in the treatment of dorsal-wrist ganglion cysts and interosseous ligament disruptions, as well as for bone incisions, such as radial styloidectomy, distal ulnar excision (wafer procedure), and proximal-row carpectomy. Compared with other techniques, arthroscopic procedures, such as repair of the triangular fibrocartilage complex, demonstrate better results and improved localization of the injury with a low complication rate. In addition, arthroscopic procedures involve lesssurgical dissection, less postoperative pain, a shorter recovery time, and an earlier return to work for the patient.     

桡骨远端骨折合并腕关节韧带损伤的关节镜观察

目的 介绍桡骨远端骨折时,腕关节韧带(舟月骨间韧带、月三角韧带和三角纤维软骨复合体)损伤的关节镜观察.方法 对27例桡骨远端骨折,采用腕关节镜辅助治疗,观察舟月骨间韧带、月三角韧带和三角纤维软骨复合体的损伤情况,通过Gsssler腕部韧带损伤等级分型方法和Palmer方法记录损伤级别.采用卡方检验,分析腕关节韧带损伤程度与骨折类型之间的关系.结果 27例腕关节镜下观察均出现舟月骨间韧带、月三角韧带损伤,损伤为Ⅰ～Ⅱ级;25例有三角纤维软骨复合体损伤,损伤大多为Ⅰa型;腕部韧带损伤的程度与骨折的分型无显著关系.结论 桡骨远端骨折时,腕部韧带损伤率较高,采用腕关节镜辅助治疗有利于准确发现腕部韧带的损伤.

Abstract：

Objective To report te incidence and extent of injuries of the scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL) and triangular fibrocartilage complex (TFCC)observed under wrist srthroscope during treatment of distal radius fractures.Methods Twenty-seven cases of distal radius fractures were treated with wrist arthroscopic assistance.Distal radius fractures were categorized using AO classification.Injuries of SLIL and LTIL were viewed and graded by Geissler's arthroscopic classification of carpal instability/intercarpal ligament injuries.TFCC lesions were recorded by Palmer's classification.Chi square statistical analysis was used to analyze the relationship between the extent of these ligament injuries and the types of distal radius fractures.Results All 27 cases had SLIL and LTIL injuries of grade Ⅰ to grade Ⅱ.25 cases had type Ⅰa TFCC lesions.There was no significant correlation between ligament injuries and the types of fractures.Conclusion There is a high incidence of ligament injury accompanying distal radius fractures.Wrist arthroscope assisted treatment of distal radius fractures can enhance the accurate detection of these carpal ligament injuries.     

The incidence of dorsal radiocarpal ligament tears in patients having diagnostic wrist arthroscopy for wrist pain

PURPOSE: The goal of this study was to examine the incidence of dorsal radiocarpal ligament (DRCL) tears in patients having diagnostic arthroscopy for chronic wrist pain. METHODS: A chart review was performed of 64 patients who had diagnostic wrist arthroscopy for chronic wrist pain that was refractory to conservative measures. For each case, interosseous ligament instability/tears were graded according to the Geissler classification. Tears of the triangular fibrocartilage complex and the presence or absence of a DRCL tear were noted. RESULTS: There were 35 of 64 wrists (in 64 patients) with DRCL tears. The average duration of wrist pain prior to treatment was 20 months. Only 10 patients could recall a specific injury. Five patients had an isolated DRCL tear. A scapholunate interosseous ligament injury was identified in 13 patients, of whom 7 had a concomitant DRCL tear. A lunotriquetral interosseous ligament injury was present in 7 patients, of whom 2 had a concomitant DRCL tear. Two patients had a capitohamate ligament tear: 1 of these patients had a DRCL tear. There were 7 patients with a solitary triangular fibrocartilage complex tear: 6 of 7 were in association with a DRCL tear. One patient had a chronic ulnar styloid nonunion and a DRCL tear. Two or more lesions were present in 23 patients; DRCL tears were present in 12. CONCLUSIONS: DRCL tears are commonly seen with injuries to the primary wrist stabilizers. Recognition of this condition and further research into treatment methods are needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.     

Distal radioulnar joint arthroscopy and the volar ulnar portal

Pain on the ulnar side of the wrist remains poorly understood. As attention has shifted toward the myriad causes of ulnar-sided wrist pain, the utility of viewing the wrist from a volar ulnar (VU) perspective has emerged. Lunotriquetral ligament tears have been implicated in the pathogenesis of volar intercalated segmental instabilities. They often originate in the palmar subregion, which is most important for maintaining stability. These tears are difficult to visualize through the 4, 5, or 6R portals. They are well seen through a VU portal, and the direct line of sight facilitates debridement. The VU portal has potential use in the arthroscopic diagnosis and treatment of patients with injuries to the ulnar sling mechanism. It aids in triangular fibrocartilage repairs especially those involving the dorsal aspect between the ulnar styloid and the radial insertion, because the proximity of the 4, 5, and 6R portals makes triangulation of the instruments difficult. Although arthroscopy of the dorsal aspect of the distal radioulnar joint has been well described, it has largely remained a curiosity, with few clinical indications. Recent biomechanical studies have highlighted the importance of the deep attachment of the triangular fibrocartilage complex in maintaining distal radioulnar joint stability. The volar distal radioulnar portal is useful for assessing the foveal attachment. It may be used where there is the suspicion of a peripheral triangular fibrocartilage detachment due to a loss of its normal tension despite the lack of a visible tear during radiocarpal arthroscopy. The judicious use of these portals deserves consideration for inclusion as part of a thorough arthroscopic examination of selected patients with ulnar-sided wrist pain.     

关节镜治疗创伤后慢性腕关节疼痛

目的：探讨关节镜在创伤后慢性腕关节疼痛的治疗效果。方法：回顾分析2007年2月至2010年6月收治的12例创伤后慢性腕关节疼痛的病例,男9例,女3例,年龄19～47岁,平均35.6岁,经查体及MR检查有异常者行关节镜检查和治疗。其中8例三角纤维软骨复合体（TFCC）中央型部分撕裂,行镜下边缘部分切除;2例腕骨间韧带部分损伤后松弛者行射频皱缩;1例下尺桡关节不稳行腕关节清理后克氏针横穿远端尺桡骨于前臂旋转中立位,长臂石膏固定6周;1例尺骨撞击综合征行腕关节清理,三角软骨盘边缘修整后,磨钻部分切除远端尺骨。用改良Mayo腕关节评分进行疗效评价。结果：术后平均随访10个月,Mayo腕关节评分术前平均（51.67±15.27）分（25～75分）,术后平均（77.92±10.54）分（65～95分）,术后评分高于术前。11例恢复原来工作。结论：对创伤后慢性腕关节疼痛病例,关节镜可以明确诊断并行镜下治疗,疗效良好。     

A comparison of the findings of wrist arthroscopy and magnetic resonance imaging in the investigation of wrist pain

Between 1996 and 1999, 54 patients with wrist pain had magnetic resonance imaging performed using a 1.5 Tesla scanner without a wrist coil. Wrist arthroscopy was performed using a standard technique. The findings were then compared. Magnetic resonance imaging had a low sensitivity for the detection of triangular fibrocartilage complex injuries (0.44) and scapholunate ligament injuries (0.11) when wrist arthroscopy was used as the standard of reference.We conclude that when a magnetoresonance technique that does not employ a dedicated wrist coil is used, a negative magnetic resonance imaging scan does not exclude these two significant injuries.     

腕关节镜技术在腕部损伤中的临床应用

目的 探讨腕关节镜技术在腕部损伤中的的临床应用及疗效.方法 自2005年1月至2009年1月采用腕关节镜技术治疗89例腕部损伤患者,男51例,女38例;年龄11～78岁,平均45.8岁.术中根据病损情况,在关节镜下进行清理、桡骨远端骨折和舟骨骨折复位内固定、腕骨间韧带修复、三角纤维软骨复合体的修复等手术.术后对患者进行随访,观察疗效,了解并发症的发生情况,采用肩、臂、手功能丧失量表(DASH)进行评分.结果 术后5例患者出现小指尺侧麻木,其中4例观察3周恢复至正常,另1例3个月才得以恢复.所有患者对腕背小创口愈合外观非常满意.83例患者术后获13个月至3年(平均16个月)随访.所有患者均顺利进行了腕关节镜检查,桡骨远端骨折的关节面骨折台阶复位到1 mm以下,间隙明显变小;舟状骨骨折,关节镜通过腕中关节观察,新鲜骨折达到完全复位.DASH评分平均为(12.5±18.4)分.结论 在腕部创伤性疾病的诊断与治疗方面,采用腕关节镜技术比较可行,微创、直观,可以获得较好的修复效果.

Abstract：

Objective To report our experience of treating wrist traumatic disorders with arthroscopy. Methods From January 2005 to January 2009,89 patients with wrist traumatic disorder were diagnosed and treated in our department with wrist arthroscopy.They were 51 men and 38 women,aged from 11 to 78 years (average,45.8 years).After arthroscopic debribment,fractures of the distal radius and the scaphoid were reduced and fixed,and injuries to the interosseous ligaments and triangular fibrocartilage complex were repaired.The Disability of Arm,Shoulder and Hand (DASH) questionnaire was used to investigate functional recovery of the wrist.Complaints,symptoms and signs of the patients were recorded at the postoperative follow-up. Results The patients obtained a mean follow-up of 16 months (from 13 months to 3 years) .Intra-articular distal radius fractures obtained a reduction of less than one mm and scaphoid fractures achieved complete reduction.Follow-ups revealed fine functional recovery.No obvious complications of the blood vessel,tendon and nerve were observed.The mean DASH score was 12.5 ± 18.4 points.Conclusion Because of minimally invasion and direct visualization,wrist arthroscopy can be an effective treatment for wrist traumatic disorders.     

Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings

PurposeThe triangular fibrocartilage complex is one of the most important stabilizers of the wrist and a defect in its anatomical structure is a possible cause of ulnar sided wrist pain. The aim of this study is to compare the diagnostic accuracy between conventional MRI and MR arthrography (MRA) in the depiction of triangular fibrocartilage complex (TFCC) tears.Methods-materialsA total of 60 patients with clinical findings that suggested TFCC tears underwent wrist MRI and MRA. All the MRI and MRA results were compared with the arthroscopic findings.Results40 tears were confirmed by arthroscopy. 38/40 tears were identified by MRA while MRI identified 26/40 tears. There were also 8 false positives and 13 false negative results identified by MRI. Two false negative results were identified by MRA. No false positive results were identified.ConclusionMR arthrography is more sensitive and specific method in terms of the diagnosis of TFCC tears compared to conventional wrist MRI. There was no difference in the diagnostic accuracy between wrist arthroscopy and MRA.     

Evaluation of chronic wrist pain: Arthroscopy superior to arthrography: Comparison in 39 patients

39 patients with chronic wrist pain underwent arthrography and arthroscopy to reveal disruptions of the triangular fibrocartilage complex (TFCC) and/or interosseous ligaments. TFCC disruption was diagnosed arthroscopically in 15 cases of which arthrography revealed the disruption in only 7. in 3 other patients, arthrography showed rupture of the TFCC: however, arthroscopy showed no defects. Rupture of an interosseous ligament was diagnosed arthroscopically in 6 patients in all of whom it was also revealed by arthrography. in 6 other patients, arthrography showed disruption of an interosseous ligament not verified by arthroscopy.

We conclude that arthroscopy is superior to arthrography for diagnosing chronic wrist pain.     

腕关节镜下Outside-in褥式缝合治疗PalmerⅠB型三角纤维软骨复合体损伤

目的探讨腕关节镜下Outside-in褥式缝合治疗PalmerⅠB型三角纤维软骨复合体损伤的长期临床疗效。方法对2018年5月-2019年8月收治的PalmerⅠB型三角纤维软骨复合体损伤患者37例给予腕关节镜下Outside-in褥式缝合。随访观察并比较术前术后患者腕关节的活动度、患肢握力、影像学MRI、腕关节VAS疼痛评分、腕关节的功能评分(改良Mayo评分)。结果所有患者术后随访6~18个月,平均(12.60±3.10)个月。末次随访时37例患者腕关节疼痛较术前均有改善,患肢握力基本与健侧一致,能满足生活工作要求;术后复查腕关节MRI,见三角纤维软骨复合体信号强度及形态均提示其连续性恢复;腕关节尺侧疼痛较术前明显缓解(P<0.05);术后腕关节的功能评分(改良Mayo评分)较术前明显提高(P<0.05)。结论腕关节镜下采用Outside-in褥式缝合方式治疗PalmerⅠB型三角纤维软骨复合体损伤是一种微创、安全、有效的方式,末次随访结果满意,可作为治疗PalmerⅠB型三角纤维软骨复合体损伤的可选方式。     

腕关节镜辅助下Kapandji技术整复桡骨远端Die-punch塌陷型骨折

目的探讨腕关节镜辅助下Kapandji技术整复桡骨远端Die-punch塌陷型骨折的治疗效果。方法自2012年1月至2018年12月,我们共收治31例桡骨远端Die-punch塌陷型骨折患者,骨折均经CT检查确诊,术中在腕关节镜视下用克氏针撬拨复位桡骨远端塌陷骨折块,达到关节软骨面基本平整,进一步检查腕关节内韧带,特别是舟月韧带、月三角韧带和三角纤维软骨复合体的损伤情况,并修复相应韧带损伤。本组骨折均用克氏针结合外固定支架固定。结果术中发现合并舟月韧带损伤5例、月三角韧带损伤2例、三角纤维软骨复合体损伤10例。术后患者伤口均Ⅰ期愈合,并获得随访,时间为6~24个月,平均11.3个月。骨折愈合时间为6?8周,平均7周。术后X线片测量掌倾角6°~17°,尺偏角15°~23°。腕关节功能按Gartland-Werley标准评定:优22例,良7例,可2例,优良率为93.5%。结论腕关节镜辅助下Kapandji技术整复桡骨远端Die-punch塌陷型骨折可准确复位塌陷的关节面,可减少创伤性骨关节炎并发症,又能明确腕关节内韧带和三角纤维软骨复合体等结构的损伤程度,便于早期处理,以防遗留慢性腕关节痛或不稳定。     

Wrist arthroscopy

Wrist arthroscopy allows complete visualization under magnification, and its purpose is to establish an anatomic diagnosis and, if feasible, provide treatment for the anatomic lesion. Current indications, though numerous and potentially expanding, are also controversial. Wrist arthroscopy will continue to expand as new techniques and instrumentation evolve, and it has now become the gold standard for the diagnosis of intra-articular pathology and triangular fibrocartilage lesions. The present review focuses on the current applications of arthroscopy in the management of intra-articular fractures of the distal radius, triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts.     

Evaluation of chronic wrist pain: Arthroscopy superior to arthrography: Comparison in 39 patients

39 patients with chronic wrist pain underwent arthrography and arthroscopy to reveal disruptions of the triangular fibrocartilage complex (TFCC) and/or interosseous ligaments. TFCC disruption was diagnosed arthroscopically in 15 cases of which arthrography revealed the disruption in only 7. in 3 other patients, arthrography showed rupture of the TFCC: however, arthroscopy showed no defects. Rupture of an interosseous ligament was diagnosed arthroscopically in 6 patients in all of whom it was also revealed by arthrography. in 6 other patients, arthrography showed disruption of an interosseous ligament not verified by arthroscopy.

We conclude that arthroscopy is superior to arthrography for diagnosing chronic wrist pain.     

Triangular fibrocartilage complex lesions: a classification

Based on anatomic and biomechanical studies and review of our clinical experience of the past 10 years, a classification of injuries to the triangular fibrocartilage complex is presented. This classification is based on the clinical examination, routine x-ray films, wrist arthrograms, wrist arthroscopy, and wrist arthrotomy. The classification recognizes both traumatic and degenerative lesions. Traumatic lesions are classified according to their location. Degenerative lesions are classified by the location and severity of degenerative changes of the triangular fibrocartilage complex, ulnar head, ulnocarpal bones and lunotriquetral ligament.     

腕关节镜下射频皱缩治疗腕骨间韧带部分损伤合并TFCC损伤

目的 采用腕关节镜辅助射频皱缩技术治疗腕骨间韧带部分损伤合并TFCC(triangular fibrocartilage complex,三角纤维软骨复合体)损伤,并初步评估其治疗效果.方法 对8例腕关节疼痛的患者,关节镜检查发现腕骨闻韧带部分损伤合并TFCC损伤,予清创后利用射频器对腕骨间韧带和TFCC残缘进行射频皱缩.术后观察其疼痛情况,关节各项活动度,握、捏力,并用改良Mayo腕关节评分及DASH量表评分评估其功能情况.结果 术后随访时间平均为10个月(6～12个月).3例疼痛完全消失,4例疼痛明显减轻,1例尚无明显好转.按改良Mayo腕关节评分:术前平均51.3(30～70),术后平均78.1(45～95).按DASH量表评分:术前平均39.3(18.3～49.3),术后平均19.2(8.8～28.7).两种评分术后均较术前有明显改善.术后无关节炎、手背神经损伤等并发症表现.结论 关节镜下射频皱缩对腕骨间韧带部分损伤合并TFCC损伤是一种有效的治疗手段.     

Arthroscopic repair of triangular fibrocartilage complex injuries

The triangular fibrocartilage complex is a functionally and anatomically intricate group of structures located at the ulnar aspect of the wrist. Injury to this structure affects the biomechanics of the wrist and makes functional restoration difficult. This article reviews the anatomy, biomechanics, diagnosis, and arthroscopic treatment of triangular fibrocartilage complex injuries.     

腕关节骨间韧带射频紧缩术对韧带形态及生物力学特性的影响

目的 探讨射频紧缩对腕关节骨间韧带解剖形态和生物力学性能的影响. 方法以新鲜冷冻成年男性腕关节标本为材料,对其腕骨间韧带进行射频紧缩治疗.分别在射频处理前、后观察和测量舟月掌、背侧韧带(SL-v,SL-d)、月三角背侧韧带(LT)、小多角骨-头状骨背侧韧带(TC)、头钩背侧韧带(CH)以及第2腕掌关节背侧韧带(CMC-2)的长度和厚度,并用生物力学试验机对射频处理后的韧带进行拉伸力学测定,分别记录断裂强度和断裂形变,对所测数据进行统计学分析.结果腕骨间韧带经射频处理后,韧带的长度都有不同程度的缩短,但仅有CH差异有统计学意义(t=-2.898,P=0.016);韧带均有增厚,其中SL-v,sL-d,LT,CH和CMC-2差异均有统计学意义(t值分别为-7.617,-2.241,-4.559,-3.971,-7.883,P<0.05).韧带的断裂强度有所增强,仅SL-d差异有统计学意义(t=-4.481,P=0.001),所有韧带的断裂形变都有显著性地增加. 结论 经射频处理的正常腕关节骨间韧带基本保持了原有的解剖形态,但韧带的厚度和粘弹性得到了显著地增强.     

Functional outcome of arthroscopic assisted fixation of distal radius fractures

Background:

Many studies in literature have supported the role of wrist arthroscopy as an adjunct to the stable fixation of unstable intraarticular distal radial fractures. This article focuses on the surgical technique, indications, advantages, and results using wrist arthroscopy to assess articular reduction and evaluates the treatment of carpal ligament injuries and triangular fibrocartilage complex (TFCC) injuries in conjunction with the stable fixation of distal radial fractures.

Materials and Methods:

We retrospectively evaluated 27 patients (16 males and 11 females), who underwent stable fixation of intraarticular distal radial fractures with arthroscopic evaluation of the articular reduction and repair of associated carpal injuries. As per the AO classification, they were 9 C 1, 12 C2, 2 C3, 3 B 1, and 1 B2 fractures. The final results were evaluated by modified Mayo wrist scoring system. The average age was 41 years (range: 18-68 years). The average followup was of 26 months (range 24-52 months).

Results:

Five patients needed modification of the reduction and fixation after arthroscopic joint evaluation. Associated ligament lesions found during the wrist arthroscopy were TFCC tears (n=17), scapholunate ligament injury (n=8), and luno-triquetral ligament injury (n=1). Five patients had combined injuries i.e. included TFCC tear, scapholunate and/or lunotriquetral ligament tear. There were 20 excellent, 3 good, and 4 fair results using this score.

Conclusion:

The radiocarpal and mid carpal arthroscopy is a useful adjunct to stable fixation of distal radial fractures.     

Dry Wrist Arthroscopy: Technique and Rationale

Wrist arthroscopy has been established as a useful, minimally invasive tool for diagnosing and treating many different wrist conditions. The standard portals are located on the dorsum of the hand and wrist and are named for their relation to the extensor compartments. They include the radiocarpal and midcarpal portals. The radiocarpal portals are 3-4, 4-5, 6R, 6U, and 1-2. The midcarpal portals are STT (scaphotrapeziotrapezoidal), MCR (midcarpal radial), and MCU (midcarpal ulnar). Traditionally, wrist arthroscopy is performed with constant inflow of saline solution for joint insufflation and visualization. Dry wrist arthroscopy (DWA) is a technique that allows for arthroscopic exploration and instrumentation without infusing any fluid into the joints. Some advantages of DWA include lack of fluid extravasation, less obstruction by floating synovial villi, decreased risk of compartment syndrome, and the ability to perform concomitant open procedures more easily than with a wet technique. Additionally, the risk of fluid displacing carefully laid bone graft is much less without constant flow. DWA can be used in the assessment and management of triangular fibrocartilage complex (TFCC) and scapholunate interosseous ligament tears and other ligamentous injuries. DWA can also be used in fracture fixation to assist with reduction and restoration of articular surfaces. Moreover, it is used in more chronic settings to diagnose scaphoid nonunions. DWA does have its disadvantages such as generation of heat through the use of burrs and shavers and clogging of these instruments during debridement of tissue. DWA is a technique that can be used to manage multiple orthopaedic conditions including soft-tissue and osseous injuries. With a minimal learning curve for surgeons who already perform wrist arthroscopy, DWA can be a useful addition to their practice.     

腕关节镜辅助下重建陈旧性桡尺远侧韧带

目的 探讨腕关节镜辅助下重建陈旧性桡尺远侧韧带的方法.方法 对14例陈旧性桡尺远侧韧带损伤者,在腕关节镜辅助下,重建桡尺远侧韧带(取掌长肌肌腱作移植肌腱).结果 术后14例均获得5～16个月的随访,术后与术前比较腕关节稳定性、活动幅度均有明显提高,疼痛无力症状明显缓解.按照改良Mayo腕功能评分标准评定:优9例,良4例,可1例.结论 腕关节镜辅助下重建陈旧性桡尺远侧韧带,虽然对手术器械及技术要求较高,但该术式重建的桡尺远侧韧带更加接近生理解剖结构,手术创伤小,功能恢复满意.