Arthroscopy: todaythe gold-standard in wrist joint surgery

Ivan TamiSwiss Medical Network

MusculoskeletalConference, Bern

March 31, 2017

«…great men …founded schools.To be remembered, they must spread

their knowledge.»Ivo Pitanguy, M.D., 1923-2016

Wrist ganglion cyst

Wrist ganglion cyst

Wrist ganglion cyst

Wrist ganglion cyst

Imaging: sonography

Imaging: MRI

Treatment: - aspiration of fluid- injection of corticosteroid

Recurrence 1:2

Treatment: open surgery

Treatment: surgeryGanglio cyst

PedicleScaphoid

Lunate

Ligament

Treatment: arthroscopy

Treatment: arthroscopy

Treatment: arthroscopy

After surgery

- Cast - 1°-2°weeks day and night- 3°-6° weeks only at night

- Hand Therapy- from the beginning assisted

mobilisation- start with strengthening after 6

weeks

Rehabilitation

Injury of the Triangular FibroCartilage

Complex (TFCC)

Clinical presentation

• Ulnar-sided– wrist pain– snapping– clunking

• grip strength• Impaired function

– P/S

Clinical examination

• DRUJ instability– ulnar fovea sign

• DRUJ instability– ulnar fovea sign

Clinical examination

• DRUJ instability– ulnar fovea sign– distal ulna ballottment test

Imaging for TFCC

Imaging: MRI”complete TFCC tear”

Courtesy of F. Del Grande, EOC CH-Lugano

Diagnosis: arthroscopy

Gold standard

Diagnosis: arthroscopy

Diagnosis: arthroscopy

• Hook test1,2

– positive TFCC tear– negative No tear

Arthroscopic Management of Ulnar Pain. F. del Piñal et al.

Diagnosis: arthroscopy

• Hook test1,2

– positive TFCC tear– negative No tear

1Atzei A et al. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. JHS Eur 2009

2Atzei A et al. Foveal TFCC tear classification and treatment. Hand Clin 2011

Diagnosis: arthroscopy

Arthroscopic Management of Ulnar Pain. F. del Piñal et al.

• Trampoline test1

– positive TFCC tear– negative No tear

Diagnosis: arthroscopy

• Trampoline test1

– positive TFCC tear– negative No tear

1Hermansdorfer JD et al. Management of chronic peripheral tears of the TFCC. JHS Am 1991

Palmer classification of TFCC Lesions1

• I Traumatic injury– A: central perforation– B: ulnar avulsion– C: distal avulsion– D: radial avulsion

• II Degenerative injury

1Palmer AK. Triangular fibrocartilage complex lesions: a classification. JHS Am 1989

Atzei-EWAS classification of TFCC1

Palmer Class IB

Palmer Class II1Atzei A. New Trends in arthroscopic management of 1-B TFCC injuries with DRUJ instability. JHS Eur 2009

Atzei-EWAS classification of TFCC

Acute injuries

Atzei Class I:suture ligament-to-capsule

Surgical treatment: suture (ligament-to-capsule)

Surgical treatment: suture (ligament-to-capsule)

• Repair: suture ligament-to-capsule

Atzei-EWAS classification of TFCC

Atzei Class II and III:foveal refixation

Surgical treatment: foveal refixation

• Repair: foveal refixation

Nakamura T. et al. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011

Surgical treatment: foveal refixation

Open versus arthroscopic repair

Marc Garcia-EliasInstitut Kaplan, Barcelona

Lucchetti R. Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability. JHS Eur 2014

Rehabilitation• 1-3° weeks

– long-arm cast– neutral rotation– elbow F/E

• 4-6° weeks– short cast– start wrist F/E– assisted forearm rotation

• 7-10° weeks– Short cast at night– resume daily activities

Sport and heavy works tasks > 3 months

The author declares that the research for and communication of this independent body of work does not constitute any financial or other conflict of interest.

Take home message

• Clinical assessment• MRI +/- arthrography• Arthroscopic repair• 3-6 months rehabilitation

Distal radius fractures

Decision making

Imaging for decision making

Imaging for decision making

N. Bizzotto, I. Tami et al. 3D Printing of bone fractures: a new tangible realistic way for preoperative planning and education. Surg. Innov. 2015

N. Bizzotto, I. Tami et al. 3D Printed models of distal radius fractures. Injury 2016  

Titanium

Anatomical design

2 distal rows

Multidirectionalangle system

Implants

Courtesy of Medartis

Implants

Implants

• Fracture reduction

Del Piñal et al. Arthroscopic Management of Distal Radius Fracture. 2010

Surgery

Japan

Don’t give up…just

wash out the joint and

clean it of blood!

Surgery

Surgery

• Bone grafting

Del Piñal et al. Arthroscopic Management of Distal Radius Fracture. 2010

Surgery

• Bone grafting

Surgery

• Bone grafting

Surgery

• Treatment of the associated ulnar‐sided lesions

K. Kasapinova et al. The correlation of initial radiographic characteristics of distal radius fractures and injuries of the triangular fibrocartilage complex. J Hand Surg Eur. 2016

Surgery

• Treatment of the associated ulnar‐sided lesions

T. Westphal et al. Unrepaired fracture of the styloid process of the ulna: not a bad treatment result at distalradius fracture. Unfallchirurg. 2011

Surgery

• Treatment of the associated ulnar‐sided lesions

Surgery

Arthroscopically assisted osteosynthesis

Rehabilitation

Sometimes doing less is more…but

sometimes you can do more with less!

Del Piñal et al. Arthroscopic Management of Distal Radius Fracture. 2010

Take home message

Thank you for your attention!

The author declares that the research for and communication of this independent body of work does not constitute any financial or other conflict of interest.

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