Wrist and Elbow Arthroscopy A Practical Surgical Guide to

Techniques, 2nd Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/wrist-and-elbow-arthroscopy-a-practical-surgical-gui
de-to-techniques-2nd-edition/

Click Download Now

William B. Geissler
Editor

Wrist and Elbow Arthroscopy

A Practical Surgical Guide to Techniques

Second Edition
Editor
William B. Geissler, MD
Alan E. Freeland Chair of Orthopedic Hand Surgery
Professor and Chief, Division of Hand and Upper Extremity Surgery
Chief, Section of Arthroscopic Surgery and Sports Medicine
Department of Orthopedic Surgery and Rehabilitation
University of Mississippi Medical Center
Jackson, MS, USA

Videos for this book can be accessed at http://www.springerimages.com/videos/978-1-4614-1595-4

ISBN 978-1-4614-1595-4 ISBN 978-1-4614-1596-1 (eBook)

DOI 10.1007/978-1-4614-1596-1
Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2014951507

© Springer Science+Business Media New York 2015

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically
for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work.
Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the
Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions
for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution
under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of publication, neither
the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may
be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Preface

It has been my pleasure to edit the second edition to Wrist and Elbow Arthroscopy textbook.
Arthroscopic surgery has continued to revolutionize the practice of orthopedics by providing
the technical ability to examine and treat intra-articular abnormalities under bright light and
magnified conditions. Wrist arthroscopy has continued to significantly advance our knowledge
and understanding of this complex joint with its multiple articulations and ligaments all within
a 5 cm interval. Since the previous textbook, there has been continued considerable growth in
the indications and techniques for wrist arthroscopy. As more surgeons are exposed to wrist
arthroscopy, newer techniques continue to be developed, which helps our patients. This is evi-
dent by the growth of this textbook to 34 chapters compared to the previous edition.
As before, this is truly an international text. Recognized experts from around the world
from four continents have contributed the latest techniques and advances in wrist arthroscopy.
The goal for the authors was to describe their arthroscopic techniques in detail to include their
tips and tricks to make the procedures easier for all of us to perform. There are many new top-
ics and additions with the second edition. This includes multiple chapters on management of
scapholunate instability, arthroscopic proximal row carpectomy, and arthroscopic staging
management of Kienbock disease. In addition, dry arthroscopy has continued to grow in popu-
larity. A chapter is dedicated specifically to these newer techniques. Small joint arthroscopy
has continued to make several gains and multiple chapters are included describing these tech-
niques and applications for the smaller joints of the hand.
Lastly, I am pleased that the second edition has been expanded to include the field of elbow
arthroscopy, which continues to grow in popularity. This can be a very difficult joint for
arthroscopic surgical techniques and leaders from around the world have contributed their
techniques and pearls for this newest edition. Arthroscopic management of complex topics
including elbow arthritis, contractures, and instability are included in this edition.
First, I want to acknowledge and thank the international group of experts who committed
their time and expertise to author these chapters. Their tips and tricks are invaluable and they
all have advanced the field of wrist and elbow arthroscopy.
I want to acknowledge my early mentors in hand surgery including Terry L. Whipple, M.D.,
who initially exposed me to the wonderful techniques of wrist arthroscopy. He particularly
demonstrated to me how precise and delicate arthroscopic surgery is of the wrist to be well
performed. I want to acknowledge and thank Alan E. Freeland, M.D., my mentor, friend, and
colleague who instructed me in hand surgery and guided my career. I certainly want to acknowl-
edge and thank my wife, Susan, and daughter, Rachel Leigh, who provided tireless support and
understanding throughout my career.
I want to thank my nurses, Tracy Wall, R.N., and Janis Freeland, R.N., who work tirelessly
behind the scenes, but really run the show. Finally, Sheila Steed, my administrative assistant,
who has always been there and somehow always keeps me pointed in the right direction.

Jackson, MS, USA William B. Geissler, MD

v
Contents

1 Arthroscopic Wrist Anatomy and Setup .............................................................. 1

Nicole Badur, Riccardo Luchetti, and Andrea Atzei
2 Evaluation of the Painful Wrist ............................................................................. 29
Enrique Pereira
3 Lasers and Electrothermal Devices ....................................................................... 37
Daniel J. Nagle
4 Anatomy of the Triangular Fibrocartilage Complex ........................................... 47
Jared L. Burkett and William B. Geissler
5 Management of Type 1A TFCC Tears .................................................................. 59
Laith Al-Shihabi, Robert W. Wysocki, and David S. Ruch
6 Arthroscopic Management of Peripheral Ulnar Tears of the TFCC ................. 67
William B. Geissler
7 Management of Type 1D Tears .............................................................................. 81
Fernando Corella, Miguel Del Cerro, and Montserrat Ocampos
8 Management of Ulnar Impaction .......................................................................... 93
Megan Anne Meislin and Randy Bindra
9 Kinematics and Pathophysiology of Carpal Instability ....................................... 101
Alan E. Freeland and William B. Geissler
10 Management of Scapholunate Ligament Pathology ............................................ 119
Mark Ross, William B. Geissler, Jeremy Loveridge, and Gregory Couzens
11 Arthroscopic Scapholunate Reconstruction ......................................................... 139
Christophe L. Mathoulin and Abhijeet L. Wahegaonkar
12 Arthroscopic Management of Lunotriquetral Ligament Tears .......................... 151
Michael J. Moskal and Felix H. Savoie III
13 Arthroscopic Management of Dorsal Capsular Lesions ..................................... 159
David J. Slutsky
14 Arthroscopic Arthrolysis ........................................................................................ 165
Duncan Thomas McGuire, Riccardo Luchetti, Andrea Atzei,
and Gregory Ian Bain
15 Wrist Arthritis: Arthroscopic Techniques of Synovectomy,
Abrasion Chondroplasty, Radial Styloidectomy,
and Proximal Row Carpectomy of the Wrist ....................................................... 177
Kevin D. Plancher, Michael L. Mangonon, and Stephanie C. Petterson

vii
viii Contents

16 Arthroscopic Proximal Row Carpectomy ............................................................. 189

Noah D. Weiss and Aaron H. Stern
17 Arthroscopic Partial Wrist Fusion ........................................................................ 195
Pak-cheong Ho
18 Arthroscopic Management of Distal Radius Fractures ....................................... 239
Tommy Lindau and Kerstin Oestreich
19 Arthroscopic Management of Scaphoid Fractures and Nonunions ................... 251
William B. Geissler
20 Arthroscopic Assessment and Management of Kienböck’s Disease................... 261
Duncan Thomas McGuire and Gregory Ian Bain
21 Arthroscopic Excision of Dorsal Ganglions .......................................................... 269
Meredith N. Osterman, Joshua M. Abzug, and A. Lee Osterman
22 Arthroscopic Management Volar Ganglions ........................................................ 275
Carlos Henrique Fernandes and Cesar Dario Oliveira Miranda
23 Dry Arthroscopy and Its Applications .................................................................. 283
Francisco del Piñal
24 Thumb CMC Arthroscopic Electrothermal Stabilization
(Without Trapeziectomy) ....................................................................................... 297
John M. Stephenson and Randall W. Culp
25 Partial Trapeziectomy and Soft Tissue Interposition .......................................... 303
Tyson K. Cobb
26 Suture-Button Suspensionplasty for the Treatment
of Thumb Carpometacarpal Joint Arthritis ......................................................... 313
John R. Talley and Jeffrey Yao
27 Small Joint Arthroscopy ......................................................................................... 321
Alejandro Badia
28 Endoscopic Carpal Tunnel Release ....................................................................... 341
Steven M. Topper
29 Elbow Arthroscopy: Anatomy, Setup, Portals, and Positioning ......................... 349
Sonya M. Clark
30 Arthroscopic Management of Elbow Contractures ............................................. 357
Erich M. Gauger and Julie E. Adams
31 Arthroscopic Management of Elbow Arthritis .................................................... 365
Roger P. van Riet
32 Lateral Epicondylitis .............................................................................................. 375
Mark Steven Cohen
33 Arthroscopic and Open Radial Ulnohumeral Ligament
Reconstruction for Posterolateral Rotatory Instability of the Elbow ................ 381
Michael J. O’Brien, Felix H. Savoie III, and Larry D. Field
34 Arthroscopic Management of Osteochondritis Dissecans
of the Capitellum ..................................................................................................... 389
Noah C. Marks and Larry D. Field
35 Arthroscopic Treatment of Elbow Fractures........................................................ 399
Michael R. Hausman and Steven M. Koehler

Index ................................................................................................................................. 415

Contributors

Joshua M. Abzug, MD Department of Orthopaedics, University of Maryland School of

Medicine, Timonium, MD, USA
Julie E. Adams, MD Department of Orthopaedic Surgery, University of Minnesota,
Minneapolis, MN, USA
Laith Al-Shihabi, MD Department of Orthopaedic Surgery, Rush University Medical Center,
Chicago, IL, USA
Andrea Atzei, MD Fenice HSRT Hand Surgery and Rehabilitation Team, Centro di Medicina,
Treviso, Italy
Policlinico San Giorgio, Pordenone, Italy
Alejandro Badia, MD Badia Hand to Shoulder Center, Doral, FL, USA
Nicole Badur, MD Hand Surgery and Surgery of Peripheral Nerves, University Hospital
Bern, Freibugstrasse, Bern, Switzerland
Gregory Ian Bain, MBBS, FRACS, FA (Orth) A, PhD Upper Limb Surgeon, Professor of
Upper Limb and Research, Department of Orthopaedic Surgery, Flinders University of South
Australia, Flinders Drive, South Austalia, Australia
Randy Bindra, MD Department of Orthopaedic Surgery, Griffith University and Gold Coast
University Hospital, Southport, QLD, Australia
Jared L. Burkett, MD Alabama Orthopaedic Clinic, Mobile, AL, USA
Miguel Del Cerro, MD Hand Surgery Unit, Beata María Hospital, Madrid, Spain
Sonya M. Clark, DO Upstate Hand Center, Spartanburg, SC, USA
Tyson K. Cobb, MD Orthopaedic Specialists, Bettendorf, IA, USA
Mark Steven Cohen, MD Department of Orthopaedic Surgery, Rush University Medical
Center, Chicago, IL, USA
Fernando Corella, PhD Section of Hand Surgery, Orthopaedic and Trauma Department,
Infanta Leonor University Hospital and Beata María Hospital, Madrid, Spain
Gregory Couzens, MBBS, FRACS (Orth) Brisbane Hand and Upper Limb Research
Institute, Brisbane, QLD, Australia
Randall W. Culp, MD, FACS Department of Orthopaedics, Thomas Jefferson University
Hospital, The Philadelphia Hand Center, King of Prussia, PA, USA
Carlos Henrique Fernandes, MD Department of Orthopedic Surgery, Universidade Federal
de São Paulo, São paulo, SP, Brazil
Larry D. Field, MD Upper Extremity, Mississippi Sports Medicine and Orthopaedic Center,
Jackson, MS, USA

ix
x Contributors

Alan E. Freeland, MD Department of Orthopaedic Surgery and Rehabilitation, University of

Mississippi Medical Center, Brandon, MS, USA
Erich M. Gauger, MD Department of Orthopaedic Surgery, University of Minnesota,
Minneapolis, MN, USA
William B. Geissler, MD Department of Orthopaedic Surgery, University of Mississippi
Medical Center, Jackson, MS, USA
Michael R. Hausman, MD Department of Orthopaedic Surgery, Mount Sinai Medical
Center, New York, NY, USA
Pak-cheong Ho, MBBS, FRCS, FHKCOS, FHKAM (Ortho) Department of Orthopaedic
and Traumatology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
SAR, China
Steven M. Koehler, MD Department of Orthopaedic Surgery, Mount Sinai Medical Center,
New York, NY, USA
Tommy Lindau, MD, PhD The Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK
Jeremy Loveridge, MD, MBBS, FRACS (Orth) Brisbane Hand and Upper Limb Research
Institute, Brisbane, QLD, Australia
Riccardo Luchetti, MD Private Activity, Rimini Hand and Rehabilitation Center,
Rimini, Italy
Michael L. Mangonon, DO Plancher Orthopaedics and Sports Medicine, New York,
NY, USA
Noah C. Marks, MD Mississippi Sports Medicine and Orthopaedic Center, Jackson, MS, USA
Christophe L. Mathoulin, FMD, FMH Institut De La Main, Clinique Jouvenet, Paris, France
Duncan Thomas McGuire, MBCHB, FC (Orth) (SA), MMed Department of Orthopaedic
Surgery, Groote Schuur Hospital, Cape Town, South Africa
Megan Anne Meislin, MD Department of Orthopaedics, Loyola Univesity Medical Center,
Maywood, IL, USA
Cesar Dario Oliveira Miranda, MD Department of Hand Surgery, Hand Surgery Institute
Salvador, Salvador, Bahia, Brazil
Michael J. Moskal, MD Orthopaedic Surgery Department, University of Louisville,
Sellersburg, IN, USA
Daniel J. Nagle, MD, FAAOS, FACS Department of Orthopedics, Northwestern University
Feinberg School of Medicine, Chicago, IL, USA
Michael J. O’Brien, MD Department of Orthopaedics, Tulane University School of Medicine,
New Orleans, LA, USA
Montserrat Ocampos, MD Section of Hand Surgery, Orthopaedic and Trauma Department,
Infanta Leonor University Hospital and Beata María Hospital, Madrid, Spain
Kerstin Oestreich, MD, MSc Department of Plastic Surgery, Birmingham Childrens
Hospital, Birmingham, UK
A. Lee Osterman, MD The Philadelphia Hand Center, P.C., King of Prussia, PA, USA
Meredith N. Osterman, MD Department of Orthopedic Surgery, Thomas Jefferson
University Hospital, Philadelphia, PA, USA
Contributors xi

Enrique Pereira, MD Department of Hand Surgery, Penta Institute of Traumatology and

Rehabilitation, Martinez, Buenos Aires, Argentina
Stephanie C. Petterson, MPT, PhD Research Department, Orthopaedic Foundation,
Stamford, CT, USA
Francisco del Piñal, MD Unit of Hand-Wrist and Plastic Surgery, Private Practice and,
Hospital Mutua Montañesa, Santander, Spain
Kevin D. Plancher, MD Plancher Orthopaedics and Sports Medicine, New York, NY, USA
Roger P. van Riet, MD, PhD Department of Orthopedics and Traumatology, Monica
Hospital, Erasme University Hospital, Antwerp, Belgium
Mark Ross, MBBS, FRACS (Orth) Brisbane Hand and Upper Limb Research Institute,
Brisbane, QLD, Australia
David S. Ruch, MD Duke University Medical Center, Durham, NC, USA
Felix H. Savoie III, MD Department of Orthopaedics, Tulane University School of Medicine,
New Orleans, LA, USA
David J. Slutsky, MD The Hand and Wrist Institute, Torrance, CA, USA
John M. Stephenson, MD Department of Orthopaedic Surgery, University of Arkansas for
Medical Sciences, Little Rock, AR, USA
Aaron H. Stern, BA Weiss Orthopaedics, Sonoma, CA, USA
John R. Talley, MD Division of Plastic Surgery, Department of Surgery, Stanford University
Medical Center, Palo Alto, CA, USA
Steven M. Topper, MD Colorado Hand Center, Colorado Springs, CO, USA
Abhijeet L. Wahegaonkar, MD, FACS, MCh (Orth) Department of Hand and Microvascular
Reconstructive Surgery, Brachial Plexus and Peripheral Nerve Surgery, Sancheti Institute for
Orthopaedics and Rehabilitation, Pune, Maharashtra, India
Noah D. Weiss, MD Weiss Orthopaedics, Sonoma, CA, USA
Robert W. Wysocki, MD Department of Orthopedic Surgery, Rush University, Chicago, IL,
USA
Jeffrey Yao, MD Department of Orthopedic Surgery, Stanford University Medical Center,
Redwood City, CA, USA
 Arthroscopic Wrist Anatomy
and Setup 1
Nicole Badur, Riccardo Luchetti, and Andrea Atzei

The wide list of indications for wrist arthroscopy is

Introduction continuously growing and includes basic treatment of soft
tissue pathologies as synovitis, ganglia, fibrosis, stiffness,
Arthroscopy, first described in 1918 in a cadaver knee joint management of triangular fibrocartilage complex (TFCC)
and 1962 successfully as an operative procedure [1], has tears, scapholunate- and lunotriquetral ligament lesions and
equipped the orthopedic surgeon with an excellent tool to removal of loose bodies. Osseous procedures include partial
assess and treat intra-articular pathologies. After successful bone resections in ulnocarpal- or ulnostyloid impaction syn-
application on large joints, the technique has been progres- drome and scaphotrapeziotrapezoid (STT) or triquetroham-
sively extended onto smaller sized joints as the shoulder, the ate (TH) arthritis [6]. The method has also gained wider
hip, the ankle, the elbow and the wrist. Wrist arthroscopy acceptance in more sophisticated procedures as assisting
was reported first in 1979 for diagnostic purposes [2]. From reduction of intra-articular distal radius fractures [7–13], or
the late 1980s through the 1990s arthroscopy has become an scaphoid fractures [14, 15] and in posttraumatic sequelae.
important means in the armory of a hand surgeon and wrist Arthroscopically assisted osteotomy in intra-articular distal
arthroscopy the so-called golden standard for diagnosing radius malunions [16, 17], treatment of scaphoid nonunions
intra-articular lesions in the wrist. Since then it has contin- [15] and arthroscopic arthrolysis has been described [18].
ued to evolve not only as a diagnostic, but also therapeutic Arthroscopic decompression of the lunate for Kienböck’s
tool and indications have steadily grown. Iatrogenic compli- disease [19], arthroscopic proximal row carpectomy [20] and
cations from open wrist surgery as capsular fibrosis resulting arthroscopically assisted partial wrist fusions have been
in stiffness are reduced by arthroscopic surgery [3, 4]. Wrist described [21].
arthroscopy is now an established procedure for treating Dedicated miniaturized instrumentation meeting the needs
many intra-articular wrist pathologies with chronic wrist of a small joint, a thorough knowledge of wrist anatomy and
pain and in acute wrist trauma [5]. the anatomic landmarks [22] as well as careful and skilled
surgical technique are required to allow a safe and appropri-
ate arthroscopic treatment of disorders in the wrist joint.
Electronic supplementary material: Supplementary material is available
in the online version of this chapter at 10.1007/978-1-4614-1596-1_1.
Videos can also be accessed at http://www.springerimages.com/
videos/978-1-4614-1595-4. Setup and Equipment
N. Badur, M.D.
Hand Surgery and Surgery of Peripheral Nerves, University Setup
Hospital Bern, Freiburgstrasse, Bern 3010, Switzerland
e-mail: [email protected] Wrist arthroscopy requires standard arthroscopic equipment.
R. Luchetti, M.D. (*) An arm table, arthroscopy tower system with monitor, video
Private Activity, Rimini Hand & Rehabilitation Center, recorder and printer, a scope with a camera attached, light
Via Pietro da Rimini 4, Rimini 47924, Italy source with fiber-optic cable, motorized shavers, radiofre-
e-mail: [email protected]
quency ablators, an image intensifier and a traction system
A. Atzei, M.D. have become the standard of care. Digital systems allow data
Fenice HSRT Hand Surgery and Rehabilitation Team, Centro di
Medicina, Via Repubblica, 10/B Villorba, Treviso 31050, Italy transfer to a USB stick.
The intervention is frequently carried out under regional
Policlinico San Giorgio, Via Gemelli 10, Pordenone 33170, Italy
e-mail: [email protected] anesthesia (axillary block) or general anesthesia under sterile

W.B. Geissler (ed.), Wrist and Elbow Arthroscopy: A Practical Surgical Guide to Techniques, 1
DOI 10.1007/978-1-4614-1596-1_1, © Springer Science+Business Media New York 2015
2 N. Badur et al.

Fig. 1.1 Different traction systems. Vertical traction tower designed by rod position. Vertical and horizontal position of the wrist is possible (b).
Whipple (Linvatec®, Largo, FL, USA). Wrist positions can be adjusted Wrist tower designed by Geissler (Acumed®, Hillsboro, Oregon, USA)
through a ball-and-socket joint. The central rod position hinders intra- that can be modified allowing different angles in wrist position and
operative X-ray views (a). Traction tower designed by Borelli (Micai®, vertical or horizontal traction positioning without interference with
Genova, Italy), allowing free dorsal and volar approach to the wrist, intraoperative X-ray (c)
rotation of the wrist and easy image intensifier access with the eccentric

conditions in an aseptic operation theater. Although wrist the metal of the tower, and are then stabilized to the tower.
arthroscopy has also been described without exsanguination Different models of traction towers exist (Fig. 1.1).
[15], the use of a pneumatic tourniquet placed at the upper Vertical traction is then applied by suspending the fingers
arm is generally recommended. with sterile finger traps and applying counter-traction
The patient is positioned supine on the operation table through a gearing mechanism at the tower that allows precise
with the affected arm on a hand table. The arm is abducted modulation. To visualize the radiocarpal joint, the finger
90° and the elbow flexed 90° allowing a vertical position of traps are preferably placed on the index- and middle-finger
the forearm, wrist and hand. In this position the wrist is kept or the index-, middle- and ring finger. Other traction devises
in neutral prono-supination. Horizontal wrist arthroscopy allowing traction to all fingers are also used (Fig. 1.2). The
has been described [23, 10], however, we prefer the vertical applied traction varies between 3.5 and 7 kg in patients. For
position to maintain a neutral rotation of the wrist and visualization of the STT joint traction can be applied by sus-
360-degree access to the wrist. Traction is usually recom- pending only the thumb.
mended to distend the wrist and improve intra-capsular Advantages of traction towers as the Whipple-, Borelli- or
vision [1]. Vertical traction across the wrist is preferably Geissler traction tower are that they provide good stability
achieved using a traction tower. The arm and forearm need to that can be crucial for certain interventions as arthroscopic
be padded with towels, preventing direct skin contact with assisted reduction of distal radius fractures. Further they can
1 Arthroscopic Wrist Anatomy and Setup 3

Fig. 1.2 Vertical traction is applied using Chinese finger traps at the from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up,
index- and middle finger (a). Traction on all fingers, the thumb included portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25
if needed, can be applied by special traction hands (e.g., Arthrex®, Suppl 1:S131-44. French. With permission from Elsevier]
Naples, FL, USA) (b) and standard suspension systems (c) [Modified

Fig. 1.3 Unconventional vertical overhead traction systems allowing rotation of the wrist and 360° access (a and b). A counter-traction band is
placed around the arm proximal to the elbow. The tension can be adjusted by adding weights (c)

be sterilized. For some interventions, however, we need a If a traction tower is not available a simple traction method
free pronosupination as for arthroscopic stabilization of can be used: a shoulder traction holder can provide overhead
TFCC lesions and the stability provided by the tower can suspension with a counter traction band around the arm
hinder. Also the central bar of some towers can interfere with proximal to the elbow. The tension can be adjusted by adding
the intraoperative use of an image intensifier. The fact that weights (Fig. 1.3). Those systems are easy to set up and
traction towers need to be sterilized can be a hassle if there is allow undisturbed intra-operative X-ray access as well as
only one available and more wrist arthroscopies are per- more freedom of motion than a traction tower while provid-
formed within the same operating session. ing less stability (Fig. 1.4).
4 N. Badur et al.

Equipment

The most important instrument is the arthroscope (Fig. 1.6).

Because of the size of the joint, arthroscopes for wrist arthros-
copy are smaller in diameter than traditional arthroscopes.
Different diameters of the optic are used in wrist arthroscopy,
ranging from 1.9 to 2.7 mm, with either a 30-degree- or less
common a 70-degree-viewing-angle to meet the needs of the
different articulations in the wrist. The light source cable is
also smaller in diameter. The smaller the diameter of the
arthroscope, the higher is the risk of bending and damaging
the fiber-optic in the cannula. Short cannulas (5–8 cm) and
scopes (lever arm of 100 mm) are long enough and allow
easier handling and control [24]. The 2.7 or 2.4 mm optic is
Fig. 1.4 Undisturbed intra-operative X-rays access is possible by sim- ideal for the exploration of the radiocarpal- and midcarpal
ple overhead suspension of the wrist while providing less stability joint as the arthroscopic vision field is bigger, but too bulky
for exploration of the distal radioulnar joint (DRUJ), the sca-
photrapeziotrapezoid (STT) joint and in patients with a small
wrist. In those cases the use of an arthroscope with a diameter
of 1.9 mm or smaller is more appropriate.
A blunt trocar with a trocar sleeve is important to estab-
lish the viewing and working portals of the joints to be
inspected without damaging the articular cartilage.
Numerous instruments, appropriate to meet the criteria of
diagnosing and treating wrist pathologies have been devel-
oped. The probe is probably the simplest but most useful
diagnostic tool in wrist arthroscopy, serving as an extension
of the surgeon’s finger [1]. For some interventions the use of
a stronger probe as used in shoulder arthroscopy that does
not bend is beneficial [16]. A variety of differently angled
punches, baskets with or without the option of incorporating
a suction mechanism and grasping forceps in various sizes
are useful in removing loose bodies and excising pieces of
soft tissue. Small arthroscopy knives with differently shaped
and retrograde blades aid in excising unstable chondral por-
tions of the carpal bones. A freer elevator, pins and a variety
of small differently shaped osteotomes are useful tools in
arthroscopically assisted correction of mal-united distal
Fig. 1.5 Positioning of the patient, the surgical and anesthetic staff and radius fractures [17].
the arthroscopic equipment Differently aggressive and sized motorized shavers and
differently sized burrs ranging from 2.0 to 4.5 mm with inte-
grated finger-controlled suction mechanism are powered
Anesthesia is positioned on the side of the uninvolved instruments for debriding synovium or resecting bone, e.g.,
extremity or at the patient’s head, the surgeon on the side that when performing a resection of the distal pole of the scaph-
is awaiting surgery, at the patient’s head. The arthroscopy oid for STT arthritis or a radial styloidectomy for beginning
tower and video monitor are placed at the patient’s feet, usu- radiocarpal arthritis as in stage 1 of scaphoid nonunion
ally on the opposite side of the patient. An image intensifier advanced collapse (SNAC I). Shavers and burrs can be oper-
is positioned in the operating theater so that it is not in the ated with a foot pedal or by finger control and allow continu-
way of the surgeon and rolled into the operating field as ous or oscillating cutting.
needed. The assistant and scrub nurse can position them- Radiofrequency probes allow efficient soft tissue debride-
selves depending on the intervention and the surgeon’s needs ment and ligament- or capsular shrinkage [25], but because
which may differ in diagnostic and interventional wrist of the risk of thermal injury adequate fluid control must be
arthroscopies (Fig. 1.5). carefully managed [26].
1 Arthroscopic Wrist Anatomy and Setup 5

Fig. 1.6 Wrist arthroscopy

equipment

Traditionally wrist arthroscopy has been carried out with differences outside and inside the wrist and to avoid closeness
constant joint irrigation for distension and improvement of of the scope and motorized instruments, thus preventing
intra-articular vision [27]. Lactated Ringer’s solution is used splashing. The arthroscope can be cleaned by rubbing its tip
for irrigation because it is rapidly reabsorbed from the soft carefully at the local soft tissue [30].
tissues [8]. Electric fluid pumps that regulate fluid volume to However, dry arthroscopy also has its limits. For example
avoid extravasation and decrease intraoperative bleeding may when radiofrequency ablators are used, water is necessary as
be used but pure gravitational force is generally sufficient for milieu conductor and to prevent temperature peaks and pos-
the irrigation of the wrist joint. Outflow is provided via the sible joint damage. Also when using a burr the aspiration
port of the cannula with the camera or a separate needle may be blocked by small cartilage and bone fragments and
placed into the ulnar side of the wrist or the successively water facilitates the aspiration.
established portals. While the classic (wet) wrist arthroscopy The equipment is completed by different utensils for
bears the disadvantage of cumbersome extra-articular water specified arthroscopic procedures as ligament repair, from
leakage into the soft tissue and the risk of serious complica- simple needles or longer Tuohy needles [31] to more sophis-
tions as development of compartment syndrome [7, 8, 28, ticated, commercially available ligament repair kits [32].
29], the wrist joint can easily be inspected without the use of
water, referred to as “dry arthroscopy” [30]. Synovial villi or
ruptured ligament parts do not interfere with the intra-articu- Surgical Technique
lar vision as they do not float into the field of vision and
remain at their origins. In the usual joint there is mucous fluid Certain rules need to be respected in order to obtain a good
that does not impede vision. However, depending on the pro- intra-articular vision and to avoid complications. It is very
cedure to be performed, an initial washout of the joint may be important that all external anatomic landmarks and portals
useful, e.g., evacuation of hematoma in acute intra-articular must be marked after the traction to the wrist is applied but
distal radius fractures. Debris can be cleared by injecting before starting the arthroscopic procedure so that the rela-
10–20 ml of saline through the side valve of the scope fol- tionship of surface landmarks are not altered [28]. The fol-
lowed by aspirating with the shaver. The wrist joint can also lowing landmarks can be palpated if the wrist is not too
be dried with small neurosurgical patties inserted with a swollen (Fig. 1.7):
grasper. Other helpful maneuvers to keep a clear vision in dry Osseous landmarks:
arthroscopy are to immerse the tip of the scope into warm • Dorsal: Lister’s tubercle, distal radial edge, dorsal ulnar
water to prevent condensation (fog effect) due to temperature head, index-, middle-, (ring-) and small metacarpals.
6 N. Badur et al.

Fig. 1.7 Osseous and tendinous landmarks of the wrist from dorsal (a), extensor digitorum communis, ECU extensor carpi ulnaris, FCU flexor
volar (b) and ulnar (c). RS radial styloid, L Lister’s tubercle, UH ulnar carpi ulnaris, FCR flexor carpi radialis. The numbers 1–6 represent the
head, US ulnar styloid, P pisiform, DS distal pole of the scaphoid, APL extensor compartments. Volar incisions for the establishment of the VR
abductor pollicis longus, ECRL extensor carpi radialis longus, ECRB and VM joint (black line), for the VU and V-DRUJ (red line) and for the
extensor carpi radialis brevis, EPL extensor pollicis longus, EDC 6-U and DF portal (blue line)

• Radial: radial styloid process, trapezium, base of the first

metacarpal.
• Ulnar: ulnar styloid, triquetrum, base of the fifth metacarpal.
• Volar: pisiform and distal pole of the scaphoid.
Tendinous landmarks:
• Dorsal: extensor carpi radialis longus (ECRL) tendon,
extensor pollicis longus (EPL) tendon, extensor digito-
rum communis (EDC) tendon, extensor carpi ulnaris
(ECU) tendon.
• Radial: abductor pollicis longus (APL) tendon.
• Ulnar: extensor carpi ulnaris (ECU) tendon.
• Volar: flexor carpi radialis (FCR) tendon, flexor carpi
ulnaris (FCU) tendon.
Not all palpable surface landmarks need to be drawn onto
the skin as orientation for establishing the portals, we mark
the key structures as needed for each intervention (Fig. 1.8).
Standard wrist arthroscopy includes the assessment of the
radiocarpal- and ulnocarpal joint, the midcarpal- and STT
joint and the distal radioulnar joint (DRUJ). Numerous
arthroscopic dorsal and palmar approaches have been
described and are routinely used. The most commonly used Fig. 1.8 Preoperative marking of the landmarks and dorsal portals for
dorsal radiocarpal portals are named relative to the extensor performing a standard wrist arthroscopy. Abbreviations are according
compartments between which they are located. to the previous figure
The first portal to be established in almost every wrist
arthroscopy is the 3-4 radiocarpal portal. It can be identified
by simple palpation of the “soft spot” just distal of the dorsal Two other circles of the same dimension are drawn just distal
rim of the radius in a vertical line with Lister’s tubercle. Two to the first one in a vertical line with Lister’s tubercle. The
methods of localizing the entry point for the 3-4 portal are third circle is located directly over the soft spot that is the
used. The first method is called the “3 circle method” entry point of the 3-4 portal [33]. The second method is
(Fig. 1.9). A circle is drawn around Lister’s tubercle. called the “rolling thumb method” (Fig. 1.10). The thumb