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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.
www. manoegomito.ch
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