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New Advances in Wrist Arthroscopy

Gregory I. Bain, M.B.B.S., F.R.A.C.S., F.A.(Ortho)A., Justin Munt, M.B.B.S.,and Perry C. Turner, M.B.Ch.B., F.R.A.C.S.(Ortho)

Abstract: Wrist arthroscopy is a commonly used procedure that has undergone many modificationsand improvements since it was first described. The advent of new portals (both dorsal and volar)means that the wrist joint can be viewed from virtually any perspective (“box concept”). Indicationsfor wrist arthroscopy have continued to expand and include diagnostic and reparative procedures and,more recently, reconstructive, soft-tissue, and bony procedures. Arthroscopic grading of Kienböck’sdisease better describes articular damage compared with plain radiographs and can help guidesurgical treatment options. Triangular fibrocartilage complex injury diagnosis, classification, andtreatment can be performed arthroscopically, including distal ulna resection (wafer procedure).Assessment of fracture reduction of the distal radius and scaphoid is superior to that obtained withfluoroscopy, with the advantage of being able to look for associated soft-tissue and chondral injuries.Arthroscopic assessment of intercarpal ligament injuries and instability is now considered the goldstandard by many authors. Arthroscopy can also aid us in the management of post-traumatic capsularcontraction, resection of ganglia, and the relatively rare isolated ulna styloid impaction. Complica-tions of wrist arthroscopy are relatively uncommon. With the ever-expanding list of indications andprocedures that can be performed with this technique, it exists as an essential diagnostic andtherapeutic tool for the orthopaedic surgeon. Key Words: Wrist—Arthroscopy—Kienböck’sdisease—Fracture—Instability—Diagnosis.

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rofessor Kenji Takagi first reported large-jointarthroscopy in 1920.1 Hampered by large devices,

t would be another 50 years before advances in tech-ology allowed the design of small-joint instrumenta-ion. The first wrist arthroscopy was described byhen2 in 1979. In 1986 Roth et al.3 presented anInstructional Course Lecture” on wrist arthroscopy athe American Academy of Orthopaedic Surgeons meet-

From the University of Adelaide (G.I.B., J.M.), Royal Adelaideospital (G.I.B., J.M.), and Modbury Public Hospital (G.I.B., J.M.,.C.T.), Adelaide, Australia.The authors report no conflict of interest.Address correspondence and reprints requests to Gregory I.

ain, M.B.B.S., F.R.A.C.S., F.A.(Ortho)A., 196 Melbourne St,orth Adelaide, South Australia, 5006, Australia. E-mail: greg@regbain.com© 2008 by the Arthroscopy Association of North America0749-8063/08/2403-7400$34.00/0doi:10.1016/j.arthro.2007.11.002

Note: To access the supplementary video illustrations accom-

tpanying this report, visit the March issue of Arthroscopy atwww.arthroscopyjournal.org.

Arthroscopy: The Journal of Arthroscopic and Related S

ng, which brought wrist arthroscopy into mainstreamrthopaedic surgery. Since then, wrist arthroscopy hasontinued to evolve as an essential diagnostic andherapeutic tool.4 Wrist arthroscopy now has a wideange of indications, and these continue to be ex-ended as the principles of open surgical proceduresecome adapted to the arthroscope (Table 1). Theurpose of this article is to outline some of the newevelopments and current techniques in the field ofrist arthroscopy.

WRIST ARTHROSCOPY TECHNIQUE ANDPORTALS: THE BOX CONCEPT

Arthroscopic examination of the wrist should in-lude the radiocarpal and midcarpal joints. Multipleortals are now described (Fig 1).5,6 Traditionally, the-4, 4-5, 6R, and midcarpal portals have been used asiagnostic and working portals.5,7 With the advent ofew volar portals, it is now possible to have viewing andorking portals that encircle the wrist.5,8-10 This enables

he arthroscopic surgeon to view and instrument from all

355urgery, Vol 24, No 3 (March), 2008: pp 355-367

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irections (box concept) (Fig 2). The arthroscope andorking portals can be adjusted to suit whatever diag-ostic or therapeutic procedures are required.Our Surgical Technique: General or regional an-

sthesia is preferred. The patient is supine on theperating table with the shoulder along the edge of theable (Fig 3; Video 1, online only, available at www.rthroscopyjournal.org). A tourniquet is placed abovehe elbow and inflated to 250 mm Hg. The shoulder isbducted 70° to 90°, and the forearm is suspendedertically (by use of finger traps) from an articulatingrm attached to the operating table. A sling with 7 to0 lb of weight is placed over the tourniquet to pro-ide downward countertraction and thus distraction ofhe wrist joint. A 2.5-mm arthroscope is used with a0° viewing angle. A short bridge arthroscope (leverrm of 100 mm) allows for easier control. The wrist isxamined, and landmarks are palpated (Table 2). It isecommended that the anatomy and portals be drawnn until the surgeon is experienced in portal place-ent. The 3-4 portal is established in the soft spotcm distal to Lister’s tubercle. An 18-gauge needle is

nserted first and angled 10° volar to be parallel to theoint surface, thereby decreasing the risk of articularamage. The wrist is then distended with 5 to 7 mL ofaline solution. A vertical stab incision is made with a

TABLE 1. Indicatio

Soft Ti

iagnostic Wrist pain of unknown oSynovial biopsy

Ectomy” procedures Bacterial sampling, drainDorsal and volar gangliaIntraosseous ligamentsSynovectomyTFCC tearsArticular cartilage lesion

issue shrinkage Radiofrequency capsuleurgical release Volar capsular release

Dorsal capsular releaseepair procedures Dorsal radiocarpal ligam

Lunotriquetral instabilityScapholunate instabilityTFCC suture

econstructive procedures Scapholunate ligament reDistal radioulnar joint st

o. 15 scalpel blade. A blunt trocar is then introduced b

nto the joint. To maintain orientation, the thumb isept on Lister’s tubercle until the arthroscope has beenntroduced. Inflow (lactated Ringer’s solution) is grav-ty-fed (a pump is not required). Subsequent portalsre made by use of an outside-in technique where theeedle is introduced in the joint. The 6R portal is theommonly used radiocarpal portal. It is identifiedy use of transillumination and introduction of theeedle radial to the extensor carpi ulnaris (ECU)endon and distal to the triangular fibrocartilageomplex (TFCC). A mini-open approach is used forhe 1-2, 6U, and scaphoid-trapezoid-trapeziumSTT) portals because of the proximity of the cuta-eous nerves. An inside-out technique with an ex-hange rod for the volar radial portal is preferredVideo 2, online only, available at www.arthrosco-yjournal.org).8,10 The radial midcarpal portal is inhe soft spot 1 cm distal to the 3-4 portal. The ulnaridcarpal portal is introduced by use of the same

ransillumination technique.

OPERATIVE PROCEDURES

ienböck’s Disease

Historically, the radiologic classification of Kien-

Wrist Arthroscopy

Bone

Assessment of instabilityStaging of Kienböck’s diseaseStaging before limited wrist fusion

d joint lavage Distal pole of scaphoidDistal ulnar (wafer procedure)HamateLunateOs central carpiPisiformProximal pole of scaphoidProximal-row carpectomySTT debridementUlnar styloid

ent shrinkage

Distal radius fracturesPeri-lunate dislocationScaphoid fracturesScapholunate instability

uctionion

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357NEW ADVANCES IN WRIST ARTHROSCOPY

ssess the condition, although its reliability has beenhown to be poor.12 Arthroscopy provides direct vi-ualization and assessment of the pathology in theadiocarpal and midcarpal joints. The disparity be-ween radiographic assessment and arthroscopic as-essment has been highlighted by Ribak,13 who re-orted that plain radiographs were poorly correlatedith arthroscopic findings. This was reinforced byain and Begg,14 who reported that it was not uncom-on for plain radiographs to underscore the severity

f the articular involvement identified with arthros-opy.

Wrist arthroscopy has become a valuable assess-ent and primary treatment tool in the treatment ofienböck’s disease. The use of arthroscopy enables

he surgeon to specifically identify the nonfunctionaloints and tailor the surgical reconstructions to thenatomic findings. By specifically directing the treat-ent options to the findings identified, patient out-

omes can be optimized.We developed an arthroscopic classification system

or the assessment of Kienböck’s disease (Fig 4).14 A

IGURE 1. Wrist arthroscopy: Position of dorsal portals.5 Con-ention is to describe portals according to their anatomic location.he radiocarpal portals are numbered according to their relation to

he extensor compartments; for example, the 3-4 portal is situatedetween the third and fourth extensor compartments, and the 6Rompartment is on the radial side of the ECU tendon (sixth com-

artment). (A, artery; DRUJ, distal radioulnar joint; MCR, midcar-al radial; MCU, midcarpal ulnar.) (Reprinted with permission.5) F

ormal articular surface has a glistening appearanceith hard subchondral bone on palpation. Nonfunc-

ional articular surfaces will have any one of theollowing: extensive fibrillation, fissuring, articularartilage loss, loose floating articular cartilage pieces,r osteochondral fracture. The severity of the synovitis isot used as a specific grade but is an indication of theeverity of the chondral changes (Video 3, online only,vailable at www.arthroscopyjournal.org).

IGURE 2. Box concept. The wrist can be thought of as a box,hich can be visualized from almost every perspective. Through a

ombination of arthroscopic portals—2 dorsal (3-4 and 6R), 2olar (VR and VU), 1 radial (1-2), and 1 ulnar (6U)—it is nowossible to have viewing and working portals that encircle therist. This enables the arthroscopic surgeon to see and instrument

rom all directions. The arthroscope and working portals can bedjusted to suit whatever therapeutic procedures are required.

IGURE 3. Operating room setup for performing wrist arthroscopy.

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This grading system assists in classifying the sever-ty of the disease and better directs the surgeon towardhe reconstructive surgical options. A patient with arade 0 disorder could be treated with an extra-artic-lar procedure, such as a joint-leveling procedure orevascularization of the lunate. Patients with grade 1r 2a can be treated with a radio-scapho-lunate fusion.atients with grade 1 or 2b can be treated with aroximal-row carpectomy, whereas those with grade 3r 4 require salvage procedures (such as wrist arthro-esis or arthroplasty).14

Menth-Chiari et al.15 reported on the use of arthro-copic debridement for Kienböck’s disease. They re-

TABLE 2. Arthroscopic Wris

Portal Technique

orsal1-2 Inserted in the extreme dorsum of the snuffbox just

tendon to avoid the radial artery.5,6

3-4 The portal is 1 cm distal to Lister’s tubercle betweenthe third and fourth compartment.

4-5 Between the common extensor fourth compartment afifth compartment.

6R Located distal to the ulna head and radial to the ECUportal is established under direct vision of the arthof a needle. This avoids damage to the TFCC.

6U Established under direct vision similar to the 6R pordissection is always used to avoid the dorsal brancnerve.

DRUJ Forearm supinated to relax dorsal capsule. Arthroscointo axilla between radius and ulna underneath the

idcarpalMCR Soft depression palpated between proximal and dista

cm distal to the 3-4 portal along a line bordering tthe third metacarpal.

MCU Soft depression palpated between the proximal and d1 cm distal to the 4-5 portal in line with the fourth

STT Between EPL and ECRB in the midcarpal row. On tof the EPL tendon. Terminal branches of the radiaat risk.

olarVR 2-cm longitudinal incision overlying FCR on radial

proximal wrist crease. FCR retracted ulnarly. Radidentified with needle, then port expanded with ar

An inside-out technique can also be used here, betwLRL ligaments, staying to the radial side of the Favoid the median nerve.

VU 2-cm longitudinal incision. FCU identified and retracthe ulna nerve. Interval between FCU and commoNeedle inserted into joint, then expanded with arte

DRUJ Uses the same mini-open approach as for VU portalstay below the TFCC.

Abbreviations: EPL, extensor pollicis longus; EI, extensor indicislnar; ECRB, extensor carpi radialis brevis; FCR, flexor carpi radialnaris.

orted excellent pain relief and improved range of t

otion in all grades of patients with up to 2 years ofollow-up.

FCC Lesions

Injury to the TFCC is a common cause of ulnar-ided wrist pain. Wrist arthroscopy has become theold standard in the diagnosis and treatment of thesenjuries.16,17 Arthroscopy can assess the tear size andtability, as well as any associated synovitis and chon-ral or ligament lesions.The TFCC attaches to the sigmoid notch of the

istal radius and spans across the ulna head to attach

als: Technique and Comment

Comment

o the EPL Gives access to the radial styloid, scaphoid, lunate,and articular surface of the distal radius.

ndons of Main working portal. Gives a wide range ofmovement and view.

in the Usually the 6R portal is used in preference.

n. Thise by use

Main working portal.

ntthe ulna

6U and 6R portals allow visualization back towardthe radial side and access to the ulna-sidedstructures.

oduced.

Gives a view of the DRUJ articulation.

l rows 1ial edge of

Can be used to traverse to the STT joint,scapholunate articulation, and distal pole of thescaphoid.

arpal rowsarpal.

Allows visualization of distal lunate, lunotiquetral,and triquetral hamate articulation.

r marginry nerve

Used with the MCR portal for STT debridement.

volarl jointceps.RSC and

don to

Safe zone of 3 mm in all directions with respect topalmar cutaneous branch of median nerve(ulnarly) and radial artery (radially).

arly withr tendons.eps.

Both volar portals used to assist in reduction ofdistal radius fracture, with a view of the dorsalarticular surface and dorsal ligaments.

taken to Gives a view of the DRUJ and deep-sided TFCCtears.

J, distal radioulnar joint; MCR, midcarpal radial; MCU, midcarpal, radio-scapho-capitate; LRL, long radiolunate; FCU, flexor carpi

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359NEW ADVANCES IN WRIST ARTHROSCOPY

FCC is both to stabilize (distal radioulnar joint andlna-carpus) and to transmit load (20% of the totaload in ulna-neutral variance).19 Only the peripheral5% of the TFCC on the dorsal, volar, and ulnarargins is vascularized.20 The central and radial por-

ions remain avascular. Lesions in these areas do not

IGURE 4. Arthroscopic classification of Kienböck’s disease.14he grade for each wrist is dependent on the number of articularurfaces that are defined as nonfunctional. Grade 0 indicates aatient who has Kienböck’s disease identified on imaging, suchs a magnetic resonance imaging scan, and may have associatedynovitis identified on wrist arthroscopy but has intact articularurfaces. The usual progression of articular damage is from theroximal aspect of the lunate (grade 1) to the lunate facet of theadius (grade 2a). In those patients in whom there is a coronalracture in the lunate, there will be involvement of the proximalnd distal aspects of the lunate (grade 2b). In grade 3, there isurther progression that involves both the proximal and distalspects of the lunate and the lunate facet of the radius. Grade 4nvolves all 4 articular surfaces (including the proximal capi-ate). (Reprinted with permission.14)

TABLE 3. TFCC Injuries:

Type of Tear Description of Tear

raumatic1A Tear in horizontal or central portion of disk, often

with an unstable flap1B Tear from distal ulna insertion with or without

ulnar styloid fracture1C Tear with ulnocarpal ligaments disrupted

(ulnolunate and ulnotriquetral ligaments)1D Tear from insertion at radius

egenerative2A TFCC wear but no perforation2B TFCC wear but no perforation

Chondromalacia of lunate or ulnar head2C Central perforation of TFCC

Chondromalacia of lunate or ulnar head2D Central perforation of TFCC

Chondromalacia of lunate or ulnar headPerforation of LT ligament

2E Central perforation of TFCCPerforation of LT ligamentUlnocarpal arthritis

Abbreviations: FCU, flexor carpi ulnaris; LT, lunotriquetral.

ave the potential to heal and therefore are treatedith debridement. The dorsal and volar ligaments

peripheral 2 mm) maintain stability of the TFCC, andt is crucial that these be preserved.21

Palmer’s classification of TFCC injuries can besed to help guide treatment (Table 3).18 This dividesesions into type 1 (traumatic) and type 2 (degenera-ive). Type 1 lesions are classified according to theocation of the tear.

Central tears (type 1A) are managed with arthro-copic debridement of the TFCC tear, performed withhe arthroscope in the 6R portal and the instruments inhe 3-4 portal.5 The 3.5-mm oscillating resector re-

oves degenerative fibrocartilage and adjacent syno-itis. The outcomes from this limited debridement areewarding, with 80% to 85% of patients requiring nourther surgery and having a good to excellent re-ult.22,23 In those patients in whom there is a neutral oregative ulnar variance, arthroscopic debridement ofhe TFCC is all that is required. In patients who have

positive ulnar variance, additional procedures maye required (as described later).A peripheral tear in the TFCC (type 1B) can be

ifficult to detect. A normal TFCC has tension withints substance when a probe is applied across it, re-erred to as the “trampoline effect.” Loss of this nor-al trampoline effect would indicate that there is a

eripheral tear of the triangular fibrocartilage.24 Pa-

fication and Management18

Authors’ Management

al splinting with or without steroid injection; arthroscopicebridement of central torn portionroscopic repair; inside-out technique; with or without ECUeath open repairroscopic-augmented repair by use of a mini-open approach with

r without FCU augmentationridement of torn portion or reattachment to sigmoid notch

gnostic arthroscopy followed by open diaphyseal ulna shortening

roscopic TFCC debridement plus arthroscopic wafer procedurer open diaphyseal ulna shortening

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ients with a peripheral tear can be treated with eithern outside-in or inside-out repair technique.23,25 Newerechniques using slotted cannulae, suture welding, andini-incisions with arthroscopic assistance have also

een developed.4,26,27

Our Surgical Technique: We prefer to use thenside-out technique popularized by Poehling et al.25

ith the use of a 14-gauge Tuohy needle and No. 2olydioxanone sutures (Fig 5).23 When an unstableeripheral tear is associated with a fractured ulnartyloid, an open procedure must be performed to ad-ress the ulnar styloid fragment through either bonyeattachment or fragment excision and reattachment ofhe TFCC to the remaining distal ulna. The ECUendon sheath is intimately related to the dorsal aspectf the TFCC.28 A peripheral TFCC tear may be asso-iated with ECU subluxation and require open recon-truction in addition to any arthroscopic procedureserformed.Type 1C lesions involve disruption of the TFCC from

he ulnar extrinsic ligament complex. At arthroscopy,here will be laxity of the ulnar intrinsic ligaments, andhe pisiform may be unusually easy to see because thedjacent ligaments are torn. These injuries are lessommon but more complex to manage.4 Augmenta-ion with a flexor carpi ulnaris distally based stripwhich is then brought to the dorsal aspect of theriangular fibrocartilage) can also be performed.

Type 1D radial-sided tears have a poor chance ofealing. This is because of the relative avascularity ofhe radial side of the TFCC, as well as the fact that itttaches onto the articular cartilage of the sigmoidotch. Most of these tears are managed with arthro-copic debridement; however, a number of sutureechniques have previously been described in the lit-rature, with two thirds of patients having good toxcellent results.4,29,30

Type 2 TFCC lesions are degenerative tears that areften asymptomatic.31 Most symptomatic degenera-ive tears of the TFCC are related to chronic overload-ng of the ulnocarpal joint as a result of positive ulnarariance.4,32 The primary pathology in these cases isot limited to the TFCC itself but also to the sequelaef chronic ulnar impaction between the ulna and thearpus, with secondary damage to surrounding struc-ures such as the lunotriquetral ligament or articularurfaces of the lunate, triquetrum, and distal ulna.4,18

hen an arthroscopic debridement is being per-ormed, the TFCC, adjacent synovitis, and chondralhanges are all debrided. It is essential to preserve theeripheral 2 mm of the TFCC to maintain distal ra-

ioulnar joint stability. p

If there is ulnar positivity, shortening of the ulnaith either diaphyseal ulnar shortening or an arthro-

copic wafer procedure should be performed. The arthro-copic wafer procedure involves resection of the prom-nent distal ulna through the TFCC tear33-35 (Video 4,nline only, available at www.arthroscopyjournal.org).esection is continued until 2 to 3 mm of ulna is

emoved over the radial two thirds of the ulna tochieve an approximate �1.5 mm negative ulnar vari-nce. Wnorowski et al.36 recommended that the wafer

IGURE 5. Arthroscopic inside-out suture technique for repairingype 1B TFCC traumatic tears.23,25 By use of a “sewing machine”eedle technique, 2 to 3 sutures are inserted through the torn ulnardge of the TFCC, capsule, and skin. (A) A 14-gauge Tuohy needles inserted into the 3-4 portal and through the ulnar edge of theFCC, capsule, and skin. (B) The suture is advanced through theeedle, and the free end is held. The needle tip is withdrawn intohe wrist and again advanced through the TFCC. The suture re-ains in the lumen of the needle and is passed through the TFCCsecond time to complete the loop. (C) The free end is withdrawn

rom the needle to allow the ends to be tied. (D) The 2 ends of theuture are tied over the capsule with a mini-open incision. One tohree sutures can be inserted. (Reprinted with permission from theournal of Bone and Joint Surgery Inc.5)

rocedure be done to the level of the subchondral

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361NEW ADVANCES IN WRIST ARTHROSCOPY

one, because this will unload the head of the ulna.he forearm is rotated from pronation to supination toisualize and resect the full circumference of the ulnaead. Adequate resection is confirmed with fluoros-opy. Osterman35 reported pain relief in 73% of pa-ients and improvement in another 12% of patientsith this procedure (which is similar to the finding ofood results in 78% of wrists reported by Darrowt al.34 with ulnar shortening). The results of arthro-copic debridement of type 2 degenerative lesionsave yielded good to excellent results in 75% of casesith up to 5 years’ follow-up.37

lna Styloid Carpal Impaction

Ulna styloid carpal impaction is an uncommon con-ition that has traditionally been managed with openxcision of the ulna styloid.38 Arthroscopic techniquesan also be used to resect the ulna styloid.39 The longlna styloid can be easily identified at arthroscopyFig 6A). A fluoroscopy unit is used to confirm correctositioning of the bur, which is used to debride thelna styloid under arthroscopic vision (Fig 6B). TheFCC is not violated, which ensures a more rapid

ehabilitation.

istal Radius Fractures

Wrist arthroscopy is now a valuable adjunct in theanagement of intra-articular distal radius fractures,

oth in assessing associated intercarpal ligament in-ury and improving the quality of joint surface reduc-ion.40-44 It has been shown to be superior to intraop-rative fluoroscopy and plain radiography in assessingoint surface reduction.45 Distal radius fractures withrticular cartilage steps of less than 2 mm have lessisk of developing degenerative osteoarthritis.46,47 Pa-ients with arthroscopically assisted reduction of intra-rticular distal radial fractures have been shown toave superior clinical outcomes, better range of mo-ion, and improved radiologic variables (displacementnd angulation), as compared with those undergoinguoroscopically assisted reduction.44

Our Opinion: With the advent of fixed-angle plat-ng for the management of distal radius fractures,here has been a change in the utilization of wristrthroscopy. In the past some we treated distal radiusractures with comminution with arthroscopy, percu-aneous K-wires, and external fixators.47 These pa-ients would now preferentially be treated with axed-angle plating system because we believe that

his provides superior stability of the fracture. How-

ver, wrist arthroscopy still has a place in the man- r

gement of some complex fractures. We have used itn those cases in which there is some doubt (afteruoroscopic assessment) as to whether the screwsould be intra-articular. The arthroscope can be intro-uced by use of a volar portal with the use of thexisting open volar surgical approach. An assessmentf the articular reduction and associated soft-tissueigamentous injuries can also be performed (Video 5,nline only, available at www.arthroscopyjournal.rg). We still use arthroscopic-assisted reduction for-part radial styloid fractures to assist in articular

IGURE 6. (A) Radiologic appearance of ulna styloid impaction.he ulnar styloid impacts into the triquetrum with wrist ulnareviation. (B) Intraoperative radiologic confirmation of correctlacement of instruments before arthroscopic resection of ulnatyloid. (Reprinted with permission.39)

eduction and assessment of the scapholunate ligament,

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hich is often torn in this group of patients (Fig 7).47

ulp and Osterman48 reported good to excellent re-ults in 85% of patients with arthroscopically treatedadius fractures. They showed a mean grip strengthoss of 20% and a flexion-extension loss of 20°.

The association of soft-tissue injuries with dis-laced distal radius fractures has been reported by aumber of authors.43,49 These include tears of theFCC (43%) and scapholunate (32%) and lunotrique-

ral (15%) ligament tears. Scapholunate and lunotri-uetral tears are more common with intra-articularractures, and TFCC tears are more common withxtra-articular fractures.43

rthroscopic-Assisted Reduction ofcaphoid Fractures

Percutaneous fixation techniques have become in-reasingly popular for the management of scaphoidractures.50,51 The concept of using wrist arthroscopyo assist in the treatment of scaphoid fractures wasntroduced by Whipple52 and subsequently reportedy other authors.53,54 It is indicated for displaced buteducible scaphoid fractures and undisplaced but un-table fractures.53 The magnification provided by ar-hroscopy allows accurate assessment of fracture re-uction. In addition, arthroscopy allows assessment ofhe other injuries within the carpus, including injurieso the interosseous ligaments and triangular fibrocar-ilage and osteochondral fractures.55

It is our experience that arthroscopy is valuable innsuring that there is correct rotation of the fracture.e have seen a number of scaphoid fractures that we

onsidered to be simple and stable. However, whenhese were assessed arthroscopically, we have beenurprised to find instability and associated chondralnjuries. We find this to be one of the most technicallyemanding of the arthroscopic wrist procedures.Our Surgical Technique: The wrist is initially

xamined and imaged with fluoroscopy. The line ofhe scaphoid is marked on the skin in both the coronalnd sagittal planes (Fig 8).54 Attempted reduction ofhe fracture is performed (humpback deformity is re-uced with wrist supination and extension). The wrists then placed in the standard setup position. We findhat the ulnar midcarpal portal best visualizes theeduction, because the radial midcarpal portal raisesnd opens the fracture. The fracture is reduced by usef joysticks in the proximal and distal poles and withhe arthroscopic probe. A small volar incision is madet the distal end of the STT joint. The tuberosity of the

caphoid is identified through the volar approach, and i

he volar lip of the trapezium is excised with a rongeuro allow the correct line of access to the scaphoid. The-wire is advanced into the scaphoid in the preas-

essed planes and confirmed to be satisfactory onuoroscopy. It is common for the first K-wire to be

IGURE 7. Arthroscopic-assisted manipulation and percutaneous-wire fixation of intra-articular 2-part distal radius fractures using

he “London technique” (for London, Ontario, Canada). (A) Thetandard wrist arthroscopy setup is used. K-wires are inserted asoysticks into the radial styloid and lunate fragments. The articularurface is reduced under arthroscopic vision. (B) The Londonechnique involves advancing wires through the distal ulna intoubchondral bone of the distal radius. (C) The wires are withdrawnrom the radial side of the wrist so that they do not impinge on theistal radioulnar joint. (Reproduced with permission.47 Copyright000 British Editorial Society of Bone and Joint Surgery.)

ncorrectly positioned. The best method is to leave the

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363NEW ADVANCES IN WRIST ARTHROSCOPY

rst wire in place and to direct a second wire based onhe 2-plane fluoroscopy images. Advancing the tip ofhe threaded wire to the cortex of the proximal polef the scaphoid minimizes the chance of displacement.n extra derotation K-wire can be used if there is

onsiderable rotatory instability.Jigs can be used to stabilize the fracture and provide

ompression across the fracture before fixation.52-54 A-wire can be positioned with accuracy with a can-ulated screw insertion over the top. The other end ofhe jig is introduced through a 1-2 portal and posi-ioned directly adjacent to the scapholunate ligament.ompression of the jig will stabilize the scaphoid.owever, it is critical to assess whether reduction isbtained, because the jig may displace the fracture.Fractures of the proximal pole of the scaphoid can

lso be managed with dorsal percutaneous fixation.54

double-cut K-wire is advanced through the proxi-al pole of the scaphoid into the center of the circle

dentified on the fluoroscopy unit. It is advancedhrough the wrist to pierce the skin on the radial volarspect of the thumb. This wire will likely be within therapezium. The wire is withdrawn from the volar as-ect so that the wrist can be extended. The position ofhe fracture and wire can now be better assessed withuoroscopy and placed in the standard setup for wristrthroscopy. Once correct wire positioning is con-rmed, the wire is advanced from volar to dorsal.ver this wire, a cannulated headless screw is inserted

nto the scaphoid from the dorsal aspect.Wrist arthroscopy is also useful in a proportion of

caphoid nonunions. Slade et al.54 reported on the usef arthroscopy in the assessment and management ofelected scaphoid fibrous nonunions. Computed to-

IGURE 8. Scaphoid centralxis relative to wrist position.he central axis of the scaphoid

s visualized by pronating therist. Varying degrees of wristexion change the scaphoidhape from a “curved bean” tocylinder to a circle. (Reprintedith permission.54)

ography scan showed well-aligned fractures with t

inimal sclerosis (�1 mm) and no cyst formation.rthroscopy was used to confirm reduction and theresence of an intact cartilaginous envelope. The frac-ure was seen as a dark line on the articular cartilage,nd probing revealed firm fibrous union. These au-hors recommended percutaneous compression screwxation without bone grafting and had 100% union at4 weeks in this group of patients.Arthroscopic excision of the proximal pole of the

caphoid in patients with Preiser’s disease has beeneported.56 Ruch et al.57 reported on arthroscopic ra-ial styloidectomy and distal scaphoid excision forvascular necrosis of the proximal pole of the scaph-id with nonunion. There was improved pain andotion despite increased carpal collapse in their 3

atients.

hondral Lesions

Arthroscopic debridement of chondral lesions in therist has been described in a number of anatomic

ites. These include the STT joint, the radiocarpaloint in Kienböck’s disease, and the proximal pole ofhe scaphoid.56-58 Post-traumatic chondral lesions areot uncommon after wrist injuries including distaladius fractures. The patients who are most likely tobtain a good result with arthroscopic debridement arehose with mechanical symptoms.5

Patients with a type 2 lunate (with a second distalrticular facet to articulate with the hamate) are atncreased risk of degenerative osteoarthritis develop-ng at the proximal condyle of the hamate.59 This is aess common cause of ulnar-sided wrist pain. Theroximal condyle of the hamate can be debrided ar-

hroscopically through a midcarpal ulna portal.60

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ssessment of Carpal Instability

Radiologic methods for assessing carpal instabilitynclude plain radiography, fluoroscopy, arthrography,omputed tomography, and magnetic resonance imag-ng. Three-compartment arthrography will identifyerforations of the intercarpal ligaments, but it doesot provide accurate localization of the tears or thextent of instability.61 Arthroscopy has been showno be more sensitive than magnetic resonance im-ging in diagnosing intercarpal ligament and TFCCnjuries.62

Arthroscopy is now considered the gold standardor diagnosing carpal instability. It has the advantagef direct visualization of the scapholunate and lunotri-uetral ligaments63,64 (Video 6, online only, availablet www.arthroscopyjournal.org). The state of the lig-ment, the extent of the ligament injury, and whethert is a repairable ligament stump can be assessedirectly. Associated hemorrhage, synovitis, chondralamage, and degenerative changes (e.g., radial styloidegenerative osteoarthritis) can also be visualized.When infiltration into the midcarpal joint is being

erformed, a leakage of saline solution through theadiocarpal portals indicates that there must be a tearf the lunotriquetral ligament or scapholunate liga-ent. This is the same concept as that seen with an

rthrogram where the midcarpal joint is injected and aeakage of contrast is seen in the radiocarpal joint onollow-up radiographs.61,65,66

From the midcarpal joint, the degree of laxity be-ween the scapholunate interval can be assessed. Gei-sler et al.49 described a classification for assessmentf scapholunate instability (Table 4). This relies ondentifying whether an arthroscopic probe can belaced into the scapholunate interval, whether it cane rotated, or whether a 2.7-mm arthroscope can bedvanced between the scapholunate interval. In addi-ion, the presence of a step between the scaphoid andhe lunate can also be assessed. The functional signif-cance of the ligament injury can be assessed asell—that is, the presence of a tear with or without

ssociated significant instability (as identified in theidcarpal joint). Under the same anesthetic, a fluoro-

copic assessment of the wrist can be performed.64 Ifhis is performed before draping, then the oppositerist can be used for comparison. This examination

hould include placing the wrist in a neutral position,oving to full ulnar deviation, applying an axial load,

nd also applying traction across the wrist to deter-ine whether there is abnormal distal translation of

he scaphoid. l

The scapholunate instability test of Watson et al.67 cane performed under fluoroscopy or arthroscopic visionor both). Abnormal widening of the scapholunate inter-al and subluxation or dislocation of the scaphoid overhe dorsal rim of the distal radius can be identified.

Lunotriquetral instability can also be assessed byse of the same arthroscopic assessment techniquesnd specific provocation tests.68 Pressure is placedirectly onto the pisiform and on the dorsal aspect ofhe lunate. By squeezing the lunate volarly and theriquetrum dorsally, lunotriquetral instability is iden-ified. The wrist is taken through radial and ulnareviation with direct visualization of the lunotriquetralrticulation.

ost-traumatic Contractures

Verhellen and Bain69 reported on volar capsularelease for contractures of the wrist. They recom-ended performing capsular releases in those patientsho have restricted range of motion where the con-

racture is a result of the stiffness of the joint capsule.Luchetti et al.70 reported that pain and restricted

ange of motion after distal radius fractures can bemproved with arthroscopic debridement. This in-ludes excision of scar tissue on the volar aspect of theadial carpal joint, leveling of articular steps, andebridement of TFCC and interosseous ligament tears.ther authors have also reported improvement after

rthroscopic arthrolysis.71

Our Surgical Technique: The volar capsular re-

TABLE 4. Geissler’s Arthroscopic Classification ofCarpal Instability/Intercarpal Ligament Injuries

Grade Description

Attenuation/hemorrhage of interosseous ligament as seenfrom the radiocarpal joint. No incongruence of carpalalignment in the midcarpal space.

I Attenuation/hemorrhage of interosseous ligament as seenfrom the radiocarpal joint. Incongruence/step-off asseen from the midcarpal space. A slight gap (less thanwidth of a probe) between the carpal bones may bepresent.

II Incongruence/step-off of carpal alignment is seen in theradiocarpal and midcarpal space. The probe may bepassed through the gap between the carpal bones.

V Incongruence/step-off of carpal alignment is seen in theradiocarpal and midcarpal space. Gross instabilitywith manipulation is noted. A 2.7-mm arthroscopemay be passed through the gap between the carpalbones (so-called drive-through lesion).

Reprinted with permission.76

ease is performed via the 3-4 and 6R portals. Release

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365NEW ADVANCES IN WRIST ARTHROSCOPY

f the volar capsule must preserve at least part ofhe radio-scapho-capitate ligament to minimize thehance of ulnar translocation. Knowledge of the majoreurovascular structures is essential (Fig 9). To avoidausing injury, we do not instrument through the volareri-articular fat (Video 7, online only, available atww.arthroscopyjournal.org). The dorsal capsule is

lso released through the same portals, although theolar portals (radial and ulnar) may be of assistance inxamining the dorsal capsule. Because of the verylose proximity of the extensor tendons to the dorsalapsule, we recommend placing a nylon tape throughhe 3-4 portal and “railroading it” between the dorsalapsule and the extensor tendons (Fig 10). Traction onhis nylon tape then retracts the extensor tendons outf the way. Then, with the use of basket forcepsntroduced through the 3-4 portal, the dorsal capsulean be excised (Video 8, online only, available atww.arthroscopyjournal.org). We have used this

echnique in patients with post-traumatic capsularontractures (distal radius fractures and after openorsal ganglion excision).

rthroscopic Resection of Wrist Ganglia

The goal of arthroscopic ganglion resection is toeduce scarring and avoid any capsular wrist stiffnesshat may be associated with an open removal.72 Inddition, any underlying instability of the intrinsiccapholunate ligament, implicated as causative for aorsal ganglion, will be thoroughly assessed at theime of arthroscopy.4,73

IGURE 9. Cross-sectional anatomy of wrist with proximity of

Merves in relation to joint capsule. (UN, ulnar nerve; MN, medianerve; RA, radial artery.) (Reprinted with permission.69)

Our Surgical Technique: We use the technique aseported by Osterman and Raphael.72 The ganglionnd standard portal sites are outlined with a marker.he arthroscope is placed in the 6R portal and instru-entation in the 1-2 portal. The ganglion is resected

rom the dorsum of the scapholunate ligament. Oster-an and Raphael report that approximately two thirds

f patients will have a visible pearl-like gangliontalk. When such a stalk is not seen, the origin isssumed to be from the dorsal capsule, in which caseynovitis is usually noted. A needle placed through thekin and extended into the stalk is used. A ganglionortal, almost always equivalent to the standard 3-4ortal, is established. A full-radius resector or basketunch is used to resect a 1-cm-diameter portion oforsal capsule at the ganglion origin. Care should beaken to avoid injury to the scapholunate ligament andxtensor tendons. Dorsal synovitis, when present, isebrided. In one third of cases, the underlying exten-or tendons may be visible. The wrist is removed fromhe traction tower and re-examined. It is important tonsure that the extra-articular portion of the ganglionas been fully ruptured. Osterman and Raphael re-orted only 1 recurrence in their series of 150 patients.

COMPLICATIONS

Complications of wrist arthroscopy are uncommon,ith authors reporting rates of approximately 2%.7,74,75

IGURE 10. Nylon tape separating extensor tendons from dorsalrist capsule. Because of the very close proximity of the extensor

endons to the dorsal capsule, we recommend placing a nylon tapehrough the 3-4 portal and “railroading it” between the dorsalapsule and the extensor tendons. By placing traction on this nylonape, the extensor tendons are retracted out of the way.

ost complications are related to the size of the

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366 G. I. BAIN ET AL.

nstrumentation within a small joint space. Care muste taken with creation of portal sites because injury tohe extensor tendons, radial artery, and branches of theadial and ulna nerve have all been reported. Thextensor pollicis longus is the tendon most at riskuring wrist arthroscopy. Other reported complica-ions include infections and reflex sympathetic dystro-hy and those relating to implanted material, such asutures or K-wires.7,74,75 Skin lacerations on fingerraps have been reported, and the use of flexible nylonnger traps has been advocated in those patients withery friable skin (e.g., rheumatoid arthritis patients).

CONCLUSIONS

Wrist arthroscopy is a relatively safe procedure thatas undergone many advances since it was first de-cribed. It is now regarded as the gold standard in theiagnosis and treatment of a variety of conditions. Itslinical applications continue to expand, with moreomplex reparative, reconstructive, and salvage pro-edures now being performed. Further advances areikely to occur from adapting open reconstructive pro-edures into an arthroscopic model.

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New Advances in Wrist ArthroscopyWRIST ARTHROSCOPY TECHNIQUE AND PORTALS: THE BOX CONCEPTOur Surgical Technique

OPERATIVE PROCEDURESKienböck's DiseaseTFCC LesionsOur Surgical Technique

Ulna Styloid Carpal ImpactionDistal Radius FracturesOur Opinion

Arthroscopic-Assisted Reduction of Scaphoid FracturesOur Surgical Technique

Chondral LesionsAssessment of Carpal InstabilityPost-traumatic ContracturesOur Surgical Technique

Arthroscopic Resection of Wrist GangliaOur Surgical Technique

COMPLICATIONSCONCLUSIONSREFERENCES