Wrist arthroscopy
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| Wrist arthroscopy | |
|---|---|
 Wrist Arthroscopy |
Wrist arthroscopy can be used to look inside the joint of the wrist. It is a minimally invasive technique which can be utilized for diagnostic purposes as well as for therapeutic interventions. Wrist arthroscopy has been used for diagnostic purposes since it was first introduced in 1979. However, it only became accepted as diagnostic tool around the mid-1980s. At that time, arthroscopy of the wrist was an innovative technique to determine whether a problem could be found in the wrist. A few years later, wrist arthroscopy could also be used as a therapeutic tool.[1]
TFCC lesion
There are several therapeutic wrist arthroscopy indications, in this article the focus will be on the TFCC-lesion, the SL-lesion, the dorsal ganglion resection and the distal radius fracture.
The Triangular Fibrocartilage Complex (TFCC) is a fibrous structure covering both the radiocarpal and distal radioulnar joint. Tears in this ligament occur commonly after a person falls or secondary to a wrist fracture. Abnormalities in the TFCC are classified with the Palmer Classification, which divides the tears in a traumatic or degenerative stage.[2] Both stages of TFCC tears are treatable with an arthroscopic intervention, although the degenerative stage is operated according to the "Arthroscopic wafer procedure".[3] In this procedure, the surgeon debrides the TFCC and a limited part of the ulnar head. If the patient has a Class 1 TFCC tear, a different arthroscopic technique is used. Damaged tissue will be debrided until fresh edges are available for arthroscopic repair.[4] Good to excellent results have been reported on TFCC Class 1B repair for 85-90% of the patients. And 90% of the results for the Arthroscopic wafer procedure were good to excellent.[5]
Scapholunate and lunotriquetral instability
The initial treatment of patients with a suspected tear of the scapholunate and lunotriquetral interosseous ligament is a splint of the wrist. If the pain and instability persists, one could undergo an open surgery to reconstruct the scapholunate ligament. The lunotriquetral shear test may also be used. Arthroscopy is until today in an experimental stage but research suggest that in the near future it will be a reasonable alternative for open surgery due to faster recovery time.[6] For a tear in the lunotriquetral ligament, arthroscopic debridement is the prime treatment with a loss or reduction of symptoms of 78-100%.[7]
Dorsal ganglion resection
28 to 58% of the dorsal ganglia resolve spontaneously, still some patients choose to undergo cosmetic intervention for resection of the ganglion when non-operative treatment failed. Some examples of this non-operative treatment are immobilization through a splint or aspiration of the ganglion with or without injection of a steroid. In some cases the ganglia are associated with serious loss of wrist function or weakness in the affected finger, which makes a surgical intervention highly indicated.[8]
Resection of dorsal ganglion are still widely treated with open surgery. However, recent studies show that treatment with an arthroscopic intervention is a reasonable alternative. Arthroscopic intervention has the advantages of smaller incisions, faster recovery of wrist function and less pain postoperative. Overall outcome of arthroscopy is not superior to the outcome in open surgery. Recurrence rates and final wrist function are similar.[9]
Distal radius fracture
Distal radius fractures might occur when a person falls on an outstretched hand (FOOSH). Immediate pain, swelling and loss of wrist function are the most common symptoms. These fractures have wide variety of classification systems, but for arthroscopic intervention a difference is made between extra- or intra-articular fractures. Arthroscopy can be used to treat an intra-articular distal radius fracture and at the same time examine the Scapholunate ligament, Lunotriquetral ligament and articular disk.[5] The shifted bone segment is relocated, in necessary a bone autograft can be used to fill up the fracture. At the end the fracture is stabilized using percutane wires. Arthroscopy has good results as treatment for distal radius fracture, with over 85% of the patiënts showing good to excellent postoperative results.[10]
Diagnostic uses
Persistent pain in the wrist after conservative treatment is the major indication for a diagnostic wrist arthroscopy. Conservative treatment consists of wrist immobilization, oral NSAIDs and/or injection with corticoids.[11] Diagnostic wrist arthroscopy may also be indicated when other imaging techniques, such as MRI and ultrasonography, need confirmation on observed uncertainties or when other imaging techniques failed to establish a clear diagnosis. This makes arthroscopy an important diagnostic tool for some common anomalies around the wrist.[12] However, relying on arthroscopic findings in the setting of an unclear preoperative diagnosis yields limited diagnostic benefit. Therefore, its use should be limited to the cases with other objective clinical findings.[13]
| Diagnostic Indications | Explanation |
|---|---|
| Ganglion | A cavity in a joint capsule filled with thick fluid |
| SL-lesion | Tear of the Scapholunate ligament |
| LT-lesion | Tear of the Lunotriquetral ligament |
| TFCC-lesion | Tear in the TFCC. Classification according Palmer Classification in traumatic or degenerative lesion |
| Synovitis | Inflammation of the synovial membrane |
| Cartilage decrease | A short of cartilage can cause arthritis |
