The role of arthroscopy in the treatment of wrist injuries in the athlete.

Wrist arthroscopy provides an ideal means of evaluating intraarticular soft-tissue injuries of the wrist. Many lesions such as tears of the triangular fibrocartilage complex can be treated by arthroscopic means as well. Reduction of articular fractures of the distal radius and pin fixation, reduction of scaphoid fractures and intramedullary fixation, and arthroscopic reduction and transcutaneous pin stabilization of acute carpal dissociation patterns can all be accomplished with minimally invasive techniques under arthroscopic control. These measures often provide the athlete with shorter periods of immobilization and earlier return to athletic competition. Wrist arthroscopy provides a very useful adjunct to the treatment armamentarium of all sports medicine physicians.

Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a multicenter study.

A multicenter study to assess arthroscopic reconstruction of the peripheral attachment of the triangular fibrocartilage complex was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Twenty-seven of the 45 wrists had associated injuries, including distal radius fracture (4), partial or complete rupture of the scapholunate (7), lunotriquetral (9), ulnocarpal (2), or radiocarpal (2) ligaments. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAC) wrist deformity. The peripheral tears were repaired using a zone-specific repair kit. The patients were immobilized in a munster cast, allowing elbow flexion and extension, but no pronation or supination for 4 weeks, followed by 2 to 4 weeks in a short arm cast or VersaWrist splint. All patients were reexamined independently 1 to 3 years postoperatively by a physician, therapist, and registered nurse. The results were graded according to the Mayo modified wrist score. Twenty-nine of the 45 wrists were rated excellent. 12 good, 1 fair, and 3 poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. One patient had chronic pain, and two patients had ulnar nerve symptoms, although motion was normal in all, and their grip strength was at least 75% of the opposite hand. Arthroscopic repair of peripheral tears of the triangular fibrocartilage complex (TFCC) is a satisfactory method of repairing these injuries.

A multicenter prospective review of 640 endoscopic carpal tunnel releases using the transbursal and extrabursal chow techniques.

A prospective study involving eight institutions was performed, incorporating 640 cases of carpal tunnel release using a dual portal endoscopic technique. The original transbursal technique described by Chow was used in 110 cases (17%), and the modified extrabursal technique was used in 530 cases (83%). An overall complication rate of 11% was found in the patients in whom the transbursal technique was used, compared with 2.2% in the patients in whom the extrabursal technique was used. The return-to-work status was followed in 291 cases (199 non-worker's compensation cases and 92 worker's compensation cases). The worker's compensation patients returned to work in an average of 57 days, compared with 22 days for non-worker's compensation patients. This study suggests the extrabursal dual portal endoscopic technique is associated with fewer complications than the transbursal approach, and patients covered by worker's compensation return to work later than non-worker's compensation patients.

The role of arthroscopy in athletic injuries of the wrist.

Arthroscopy has advanced our understanding of wrist dysfunction due to injuries sustained during participation in sports. Although the initial role of arthroscopy was primarily to facilitate diagnosis of specific injuries, technologic advances have allowed many of these entities to be managed arthroscopically. This minimally invasive surgery, which is used to treat cartilage lesions, ligament instability, synovitis, and other injuries, allows early and more specific diagnosis, satisfactory management, and early return to play or work. Arthroscopy should be considered a primary means of evaluation and management of athletic injuries of the wrist.

Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius.

Sixty patients who had a displaced intra-articular fracture of the distal end of the radius were managed with manipulative reduction and internal fixation performed under both fluoroscopic and arthroscopic guidance. According to the AO/ASIF classification system, seven fractures were type B1, two were type B2, three were type B3, thirteen were type C1, twelve were type C2, and twenty-three were type C3. Forty-one patients (68 per cent) had soft-tissue injuries of the wrist, including tears of the triangular fibrocartilage complex (twenty-six patients), the scapholunate interosseous ligament (nineteen), and the lunotriquetral interosseous ligament (nine). Thirteen patients had two soft-tissue injuries. Intracarpal soft-tissue injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface or the radius.

Avulsion of the femoral attachment of the anterior cruciate ligament in a 3-year-old boy.

The incidence of anterior cruciate ligament injury is rare in children. Deficient or absent cruciate ligaments have previously been described as the cause for congenital dislocation of the knee in newborns. We report a case of a 3-year-old boy who presented with a swollen left knee, which did not resolve over a 10-day period. He would not bear weight or extend the knee beyond 45 degrees, and had significant pain with passive extension. Arthroscopy revealed an anterior cruciate ligament that appeared to have been sheared off its attachment to the lateral femoral condyle. This is the youngest patient reported with traumatic disruption of the anterior cruciate ligament.

Stabilization of the fractured scaphoid under arthroscopic control.

All surgical procedures for the scaphoid are technically demanding. Nonunion, however, is associated with predictable adverse consequences, and union is predicated on effective fracture immobilization. The arthroscopically assisted approach to scaphoid fractures provides the combined advantages of internal fracture fixation and minimally invasive surgical technique (Fig. 5). Patients are receptive to the approach, and the new fixation device has proven to be extremely effective in the first 5 years of clinical usage.

The role of arthroscopy in the treatment of intra-articular wrist fractures.

Fractures of the distal radius and scaphoid are the two most common intra-articular fractures of the wrist. For the distal radius, visual inspection and lavage, reduction of fracture fragments, and pin fixation conducted under arthroscopic control more accurately restore the smooth articular surfaces than is possible using traditional closed manipulation and ligamentotaxis. A technique for arthroscopically assisted reduction and screw fixation for fractures of the scaphoid is described using a modified Herbert screw. These techniques have the combined advantages of more accurate fracture reduction, reduced surgical trauma, and earlier mobilization of the wrist.

The role of arthroscopy in the treatment of scapholunate instability.

Diagnosis of scapholunate instability is made using clinical provocative maneuvers such as the Watson test and a two-compartment arthrogram. The history of treatment options for this instability pattern is reviewed. A technique for arthroscopic treatment is described in which anatomic reduction and multiple pin fixation precipitate fibrous ankylosis to stabilize the joint. Best results were seen in patients with less than 3 months' symptom duration and less than 3-mm side-to-side gap difference. This treatment offers less loss of motion and minimal surgical surgical trauma to the wrist than other techniques currently in use.

Arthroscopy of the distal radioulnar joint. Indications, portals, and anatomy.

Carpal tunnel syndrome is defined as a clinical condition related to dysfunction of the median nerve specifically related to the carpal tunnel. This article reviews anatomy, current surgical treatment options, technique, indications and contraindications, efficacy, complications, and the author's own perspective on the subject.

Intraarticular abnormalities in association with posterior cruciate ligament injuries.

The effect of an isolated injury of the posterior cruciate ligament on the articular cartilage and menisci has not been extensively studied. Intraarticular abnormalities in 88 arthroscopically proven posterior cruciate ligament tears in symptomatic patients with straight unidirectional posterior instability were reviewed. There were 33 patients with acute injuries (range, 3 to 21 days; mean, 14) and 55 patients with chronic tears (range, 28 to 3650 days; mean, 786). Of the acute injuries, chondral defects occurred in 4 patients (12%) and meniscal tears in 9 patients (27%; 6 lateral and 3 medial). Chondral defects of both the lateral femoral condyles and patella were present in all 4 patients. Of the chronic injuries, chondral defects occurred in 27 (49%) and meniscal tears in 20 patients (36%) (7 lateral and 17 medial). Chondral defects of the medial femoral condyle were most common. The mechanism of injury resulting in an isolated injury of the posterior cruciate ligament is most likely to affect the lateral compartment or the articular cartilage of the patella. The incidence of articular defects and the incidence of meniscal tears increased in patients with chronic posterior cruciate ligament injuries; both lesions increased most in the medial compartment.

Anatomic relationships in the shoulder impingement syndrome.

Impingement syndrome of the shoulder may be produced by compression of the subacromial structures against the coracoacromial arch. The anterior tip of the acromion, the coracoacromial ligament, and the coracoid process have been implicated as sources of impingement. Anatomic specimens were examined to determine the anatomic sites on the coracoacromial arch that result in compression of the subacromial structures during specific shoulder motions that are known to produce impingement pain. The relationships of the supraspinatus tendon, the biceps tendon, and the greater tuberosity of the humerus with the coracoacromial arch were demonstrated through various arcs of shoulder motion in autopsy subjects. Biceps tendon impingement occurred predominantly against the lateral free edge of the coracoacromial ligament. Impingement of the supraspinatus tendon and greater tuberosity was demonstrated primarily against the acromial end of the coracoacromial ligament and the anterior tip of the acromion during arcs of flexion and internal rotation. The coracoacromial ligament was stretched by the greater tuberosity passing beneath it. This may explain the formation of traction osteophytes on the anterior acromion in patients with chronic impingement symptoms.

Arthroscopic management of wrist triangular fibrocartilage complex injuries in the athlete.

Wrist arthroscopy can facilitate early definitive diagnosis of debilitating soft tissue injuries in athletes. Many such injuries can be treated successfully with minimally invasive arthroscopic techniques, reducing the morbidity associated with surgical exposure and permitting earlier return to competition. The triangular fibrocartilage complex (TFCC) is vulnerable to injury from rotational forces or axial load applied to the hand. Under arthroscopic control, injuries to the central articular disk can be treated by excision of unstable tissue fragments; peripheral separation of the disk from the dorsal or volar ligaments can be repaired with sutures to achieve complete healing. Avulsion fractures from the dorsal ulnar margin of the sigmoid notch of the radius are better treated through a small arthrotomy after initial arthroscopic evaluation.

Arthroscopic treatment of triplane fractures of the ankle.

Failure to obtain and/or maintain adequate closed reduction of triplane ankle fractures is an indication for surgical reduction and internal fixation. Operative treatment requires anteromedial and/or anterolateral incisions for adequate visualization of fracture fragments. The added surgical trauma associated with operative treatment of these fractures can be minimized without loss of efficacy using minimally invasive techniques under arthroscopic control. Arthroscopic reduction and internal fixation (ARIF) of two-part triplane fractures provides the advantages of complete evacuation of fracture hemarthrosis, accurate and certain reduction of the articular surface, and secure fixation of fracture fragments. Two patients treated with ARIF demonstrated rapid and complete fracture healing without complication. Follow-up at 6-12 months showed no leg length discrepancy, angulation, swelling, persistent symptoms, or limitation of function. ARIF of triplane ankle fractures reduces surgical trauma, provides a method for accurate delineation of fracture fragment orientation, and ensures accurate reduction and joint congruity under direct visualization.

[The importance of arthroscopy for hand surgery today]. / Der Stellenwert der Arthroskopie für die Handchirurgie heute.

Wrist arthroscopy is a new approach to the diagnosis and treatment of chronic wrist pain and pathology, that could not be achieved by conventional diagnostic instruments. The arthroscopy allows detailed assessment to articular surfaces, chronic synovitis, triangular fibro-cartilage tears, lesions of the intercarpal and palmar ligaments, and intraarticular fractures of the radius. The technique is very demanding and should be performed only by experienced surgeons. The dorsal portals are located with relation to the six extensor compartments. Because of the limited space of the wrist joint, an arthroscope with an outermost diameter of 2.5 mm or less is necessary with a high-sensitivity, light-weight microchip video-camera and special mini-instrument. With this equipment, surgery can be performed within the radio-carpal- and midcarpal joint. Only few in Germany are experienced in wrist arthroscopy; looking to the USA, this technique has already shown its great potential.