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1 Wrist Arthroscopy Background: Why Do Wrist Arthroscopy? Ramesh C. Srinivasan Hand & Upper Extremity Surgeon Director of Research The Hand Center of San Antonio Associate Master Instructor, AANA Wrist and Elbow Arthroscopy Course Outline Background What pathology can be addressed? Set-up Portal Anatomy Diagnostic Arthroscopy Case Examples Complications Conclusions Background: Why Do Wrist Arthroscopy? Less invasive/minimize scarring

2 Background: Why Do Wrist Arthroscopy? Less invasive/minimize scarring You can see better You can see better L You can see better You Can See better Midcarpal Lu Lu Radiocarpal

3 Arthroscopy vs. MRI MRI, decreased sensitivity: TFCC, SL, LT, etc. Arthroscopy: Gold Standard What pathology can be addressed? Ligament tears: SL, LT, etc. Arthritis: Radiocarpal, Midcarpal, CMC Ganglions Chondral defects TFCC tears Synovitis Fractures: Distal Radius, aphoid, etc. Arthroscopy vs. MRI MRI, poor sensitivity: TFCC, SL, LT, etc. Arthroscopy: Gold Standard ****Persistent wrist pain without findings on X-ray or MRI, diagnostic wrist arthroscopy can be considered Pre-op Evaluation of patient Surgeon may identify anatomic abnormalities Difficult to differentiate b/w asx degenerative findings and pathologic findings wrist pain

4 Pre-op Evaluation of patient Traction / Suspension Surgeon may identify anatomic abnormalities Difficult to differentiate b/w asx degenerative findings and pathologic findings wrist pain ***Preoperative H+P are critical!!! Accumed Traction Tower Basic equipment 15 blade 22 gauge needle, 18 gauge needle Fine dissecting hemostat 2.5mm, 30 o small joint scope probe (1.5mm tip) 2.0 or 3.0 Shaver Arthroscopy Tower 4 finger traps Traction / Suspension

5 Anatomy of Portals Standard Portals are Dorsal 3-4, 4-5, 6R, MCR, MCU 1-2, 6U EPL Superficial radial and ulnar nerves at risk EDC EPL

6 ECU EDC EPL ECU EDC EPL ECU EDC 3-4 EPL 6R ECU EDC EPL

7 ECU 6R MCR EPL EDC EPL SRN MCR MCU 6R 3-4 EPL 4-5 ECU EDC EPL 1-2 SRN

8 VR DCUN ECU VR DCUN 6U ECU DCUN 6U ECU

9 RSL LRL RSC Rad

10 RSC SLIO RSL LRL Rad RSL LRL RSC Lu SLIO Rad

11 UTL ULL Cap TFCC Lunate aphoid Ulna Cap Trapezoid Trapezium Lunate SL aphoid aphoid

12 Capitate Capitate Capitate Lunate Triquetrum aphoid Lunate aphoid Triquetrum Lunate Triquetrum Capitate Capitate Hamate Triquetrum Lunate aphoid Triquetrum LT Lunate Triquetrum

13 Case Ex #1: Radial Styloidectomy 62 yo F s/p distal radius fx, tx closed Pain w/ wrist extension/radial deviation (picking up her grandchildren) Case Ex #1: Radial Styloidectomy Case Ex #1: Radial Styloidectomy RSC RSC Rad

14 Case Ex #1: Radial Styloidectomy Case Ex #2: Ganglion Case Ex #1: Radial Styloidectomy

15 * Stalk Rad Ext Ext

16 Cap Lu Ext

17 Dry Technique Dry Technique

18 Dry Technique Case Ex. #3: TFCC repair 48 yo m, FOOSH ulnar-sided wrist pain X-rays: Ulnar neutral variance MRI: TFCC tear Case Ex. #3: TFCC repair

19 Case Ex. #3: TFCC repair Case Ex. #3: TFCC repair Case Ex. #3: TFCC repair

20 Case Ex. #3: TFCC repair CMC Arthroscopy What else can be done? CMC Arthroscopy CMC arthritis Ulnar shortenings Wrist contracture releases Kienbock s dz PIP and MPJ (UCL, etc.)

21 CMC Arthroscopy Complications of Wrist Arthroscopy Infection Tendon rupture Chondrolysis Arthrofibrosis Neuropraxia Skin burns Ganglion at portal CMC Arthroscopy Conclusions Important Diagnostic Modality Therapeutic Applications are expanding Relatively Safe

22 What else can be done? CMC arthritis Ulnar shortenings Wrist contracture releases Kienbock s dz SL Dorsal Wrist Syndrome

23 Pressure: 30 mm Hg Avoid bubbles!!! Fluids Getting Started