Diagnostic Wrist Arthroscopy

Soft Flexible Skin Conformable Nanocomposites as a Platform for Electroceutical and Orthopedic Applications

Designing biomimetic substrates and electrodes for bioelectronic devices with the necessary mechanical, electrical, and biological properties is critical considering the potential mismatch between soft tissue and rigid electronics, where incompatibility leads to decreased device performance, delamination, inflammation, and discomfort. There is an unmet engineering and clinical need for epidermal bioelectronics that are bioinert, can emulate host tissue mechanical properties, demonstrate low bulk resistivity, and are flexible and scalable. To address this shortcoming, this work describes innovations pertaining to the development of a hydrophilic, biocompatible nanocomposite comprised of carbon black (CB), polyvinyl alcohol (PVA), and glycerol for neuro-muscular and rehabilitative applications. We find that this materials platform (herein referred to as CB-AFTIDerm), comprised of 3 wt% PVA and 5 wt% glycerol, demonstrated superior biocompatibility (cytotoxic grade of 0), high flexibility (maximum of 140% stretchability and as low as 1% ∆R/Ro at 3.5-cm bending diameter), low electrical resistivity (as low as 0.6 Ω.cm), and electrical stability over a long-term duration (at 235 Ω in the lateral direction and between 300 Ω and 400 Ω in the transverse direction for a 24 h period). We find that the optimal CB concentration for our material platform is at 50% CB. We present examples for use in electroceutical therapy of chronic wounds and in orthopedic rehabilitation for monitoring joint angles. Achieving such results from a material, mechanics, biological, and electrical perspective facilitates the translational potential of this materials platform for the digital health and wearable technologies community to improve patient outcomes.

Front-to-Back Arthroscopic Repair of Complete Lunotriquetral Ligament Injuries: A Case Presentation and Algorithm for Arthroscopic Management of Intercarpal Ligament Injuries

The lunotriquetral intercarpal ligament (LTIL) is an important structure that equalizes the forces on the lunate imparted through the scapholunate intercarpal ligament. The extension moment of the triquetrum balances the flexion force of the scaphoid, positioning the lunate for efficient load transfer from the hand to the wrist. In contrast to the scapholunate intercarpal ligament, the LTIL is strongest volarly, with the most critical region being associated with the volar ulnocapitate ligament. Injury to the LTIL is less well understood in comparison to the scapholunate intercarpal ligament but is thought to arise from a fall on a radially deviated, flexed, and pronated wrist, or through attenuation related to ulnar impaction. The uncommon nature of this pathology has resulted in sparse literature, but it should always be considered in ulnar sided wrist pain. Arthroscopy is the gold standard tool for diagnosis, but treatments have been limited to thermal shrinkage or debridement, with reparative interventions classically being performed using an open approach. With advances in arthroscopic techniques, repairs and reconstructions are becoming possible and confer advantages such as less soft tissue stripping and accurate intra-articular joint evaluation. We demonstrate an arthroscopic repair of the volar and dorsal LTIL and propose a treatment methodology to incorporate arthroscopy into the treatment of these injuries.

Reliability of Wrist Arthroscopy in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Tears

PURPOSE

Wrist arthroscopy is considered the gold standard for diagnosis of intra-articular wrist conditions including triangular fibrocartilage complex (TFCC) tears; however, the ability to reliably diagnose TFCC pathology during wrist arthroscopy is unclear. The purpose of this study was to assess the reliability of the diagnosis of TFCC tears on wrist arthroscopy videos.

METHODS

Five hand surgeons reviewed 43 cases on a secure web-based platform at two time points separated by 4-6 weeks. Each case included a deidentified clinical vignette and wrist radiographs with ulnar variance measurements and an arthroscopy video of ulnar wrist pathology, averaging 42 seconds. Surgeons were queried on the presence of TFCC tear and Palmer and Atzei classifications. Interobserver/intraobserver reliabilities were determined using kappa coefficients.

RESULTS

The interobserver reliability regarding the presence/absence of TFCC tear was fair-good, with kappa coefficients of 0.596 in the first round of case review and 0.708 in the second round. The overall intraobserver reliability for the presence/absence of TFCC tear was also fair-good, with a kappa coefficient of 0.567. For cases with central TFCC tears, the interobserver reliability regarding the presence of TFCC tear was perfect, with a kappa coefficient of 1.0. When central tears were excluded, the kappa coefficients decreased to 0.322 and 0.368 in each round. The interobserver reliability for the Palmer and Atzei classifications was low, with kappa coefficients of 0.220 and 0.121 in the first round and 0.222 and 0.123 in the second round.

CONCLUSIONS

Experienced wrist arthroscopy surgeons demonstrated fair-good interobserver reliability for the diagnosis of TFCC tear on wrist arthroscopy. However, when central TFCC tears were excluded, interobserver reliability was poor. These findings demonstrate a need for a focus on education for wrist arthroscopy anatomy.

CLINICAL RELEVANCE

This investigation demonstrated poor agreement in surgeon identification and classification of TFCC tears, aside from central TFCC tears. The low reliability has a direct bearing on treatment considerations for TFCC tears.

Needle Arthroscopy Versus Conventional Arthroscopy in the Evaluation of Carpal Pathology: A Comparative Study

BACKGROUND

The needle scope is a less invasive intervention to evaluate carpal pathology. We hypothesize that there is no difference in the evaluation and diagnostic capability of the needle scope versus the conventional wrist arthroscope.

METHODS

Twenty patients indicated for wrist arthroscopy were prospectively enrolled. Prior to insertion of the 2.7-mm arthroscope, the needle scope evaluated for synovitis; cartilage damage (location and modified Outerbridge classification); integrity of the volar, scapholunate (SL), and lunotriquetral ligaments; and the triangular fibrocartilage complex (TFCC). Following needle scope evaluation, the surgeon completed a survey regarding the visualization and diagnosis. The 2.7-mm arthroscope was then inserted, and the surgeon completed the second portion of the survey. Statistical analysis was then completed to determine statistical significance.

RESULTS

Twelve patients were female (60%), and the mean age was 39.8 years (±11.8 years). Eleven patients underwent arthroscopy for TFCC pathology, 4 patients for SL tearing, and 5 patients for extensive synovitis. There was no difference between the needle scope and wrist arthroscopy diagnosis. There was no difference between radiocarpal and midcarpal visualization. Surgeon-rated ease of use and diagnostic confidence were the same between two groups. The needle scope was better able to visualize the scapho-trapezium-trapezoid and carpometacarpal joints; however, the image was of marginally decreased quality.

CONCLUSION

In this study, there was no difference between radiocarpal or midcarpal visualization and surgeon-rated ease of use, while diagnostic confidence was the same between two groups.

LEVEL OF EVIDENCE

II (prospective cohort study)-Diagnostic.

Postoperative Benefits of Soft Tissue Wrist Arthroscopy: Retro- and Prospective Analyses of Outcome Measures

Background: Elective soft-tissue-only wrist arthroscopy is a standard procedure in hand surgery for the diagnosis and treatment of wrist pain. A number of pathologies can be treated arthroscopically, with the aim of pain reduction and improved wrist mobility. A postinterventional evaluation of the treatment using objective and patient-reported outcome measures (PROMs) allows for an evidence-based statement about the benefits of soft-tissue-only wrist arthroscopy. Methods: A dual-center study combining retro- and prospective clinical analyses of patient outcomes after soft-tissue-only wrist arthroscopies was performed. The data were collected at two hospitals with departments specializing in hand surgery. The outcome was measured by assessing the range of motion of the wrist and its manual strength, as well as PROMs, including Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: A total of 154 soft interventions met the study criteria and could be included. Seven months after the elective soft-tissue-only wrist arthroscopies, mobility improved significantly for active extension and flexion, as well as the ulnar and radial abduction of the wrist. The grip strength also improved significantly, by an average of 6 kg, during this period. The DASH score improved significantly, from 35 points to 14 points. Additionally, wrist pain at rest was reduced significantly. Conclusions: After elective soft-tissue-only wrist arthroscopy, patients showed an overall functional improvement in their wrist, with a significant reduction in pain and improvement of mobility and grip strength. This study emphasizes the importance of wrist arthroscopy as a successful treatment option for soft tissue pathologies of the wrist.

Research hotspots and trend of wrist arthroscopy: A bibliometrics analysis from 2013 to 2023

BACKGROUND

Wrist arthroscopy technology is a surgical technology invented in recent years and widely used in clinical treatment of various wrist diseases. This study uses the methods of bibliometrics and visual analysis to understand the global research status, research hotspots, and future development trends of wrist arthroscopy.

METHODS

The relevant literature of global publications on wrist arthroscopy from 2013 to 2023 was extracted from the Web of Science Core Collection database, and the annual output, cooperation, hot spots, research status, and development trend of this field were analyzed by using the bibliometric software (VOSviewers, CiteSpace, and the R package "Bibliometrix").

RESULTS

A total of 635 articles were included, from 2013 to 2023, the number of publications related to wrist arthroscopy showed an overall upward trend, the USA, France, and China are the top 3 countries in terms of the number of publications, whereas Mayo Clinic is the institution with the highest number of publications, Ho PC holds a core position in this field, keyword analysis indicates that the research hotspots are the applications of wrist arthroscopy in triangular fibrocartilage complex injuries, scaphoid nonunion, and avascular necrosis of the lunate.

CONCLUSION SUBSECTIONS

Wrist arthroscopy has shown tremendous potential in treating various wrist diseases. However, there are still some challenges in its research domain. With continuous deep research, strengthened international collaboration, and ongoing technological advancements, wrist arthroscopy has the potential to become the standard treatment in hand surgery, offering more efficient and safer treatment options for patients worldwide.

The access route through the anatomical snuffbox in ultrasound-guided synovial biopsy of the wrist allows for a safe and effective collection of tissue samples in inflammatory arthritis

BACKGROUND

A proof-of-concept study to evaluate the feasibility and safety of minimally invasive ultrasound (US)-guided synovial biopsy of the radiocarpal (RC) joint using the anatomical snuffbox as an access route.

METHODS

Twenty consecutive patients with active chronic arthritis of the wrist underwent minimally invasive US-guided synovial biopsy of the RC joint using the anatomical snuffbox as the access route. Samples were retrieved from 3 predetermined biopsy target sites of the RC synovia (proximal, vault, and distal site), aiming for a minimum of 12 samples. The procedure's feasibility was evaluated based on the number and histological quality of retrieved tissue fragments tested on pre-defined histometric parameters. The safety and tolerability of the procedure were assessed through 1-week and 1-month follow-up clinical evaluations.

RESULTS

A median number of 17 fragments (≥ 1 mm diameter size at macroscopic evaluation) per procedure was processed for histopathology (range 9-24) and dedicated to the study. At the histopathologic evaluation, a gradable tissue (visible lining layer and ≥ 4 fragments with IST) was recognized in 19/20 biopsies (95%), and all pre-defined histometric parameters were judged applicable and successfully measured in 19/19 gradable biopsies. All three biopsy target sites showed sampling accessibility. The entire procedure was generally well tolerated. At the 1-month follow-up, no patients showed infectious complications.

CONCLUSIONS

The access route through the anatomical snuff box in US-guided synovial biopsies of the RC joint allows for a safe and targeted collection of adequate tissue samples. This modification of the traditional access route may allow easier, repeatable, and safer sampling of anatomically distinct areas of the wrist in the course of arthritis.

Efficacy of perioperative antibiotic prophylaxis in elective soft-tissue-only wrist arthroscopy

Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy. A clinical ambispective dual-centre study was performed to determine whether PAP reduces postoperative infection rates after soft tissue-only wrist arthroscopies. Retrospective and prospective data was collected at two hospitals with departments specialized in hand surgery. During the study period, 464 wrist arthroscopies were performed, of these 178 soft-tissue-only interventions met the study criteria and were included. Signs of postoperative infection and possible adverse drug effects (ADEs) of PAP were monitored. Additionally, risk factors for surgical site infection (SSIs), such as diabetes mellitus and BMI, were obtained. The overall infection rate of SSI was zero. Neither in the PAP group (n = 69) nor in the control group (n = 109) were signs of postoperative infection observed. Observed symptoms of ADEs were three-times higher in the PAP group when compared to the control-group (16.3 vs 5.5%; p = 0.043). No major ADEs were observed, but one in ten patients in the PAP group reported mild to severe intestinal or hypersensitivity symptoms. We demonstrate that the number needed to treat (NNT) with PAP to prevent one postoperative infection in soft-tissue arthroscopies of the wrist is > 109. Conversely, symptoms of ADEs were reported by one out of ten patients given PAP. Considering the high NNT to prevent postoperative infection and the large number of ADEs caused by PAP, we recommend not to use PAP routinely in soft-tissue arthroscopies of the wrist. Subsequent large-scale studies should be conducted to substantiate these results.

The training of wrist arthroscopy

The wrist is a complex joint that bridges the hand to the forearm. Patients with wrist disorders increasingly prefer minimally invasive procedures for wrist joint diagnosis and treatment. Wrist arthroscopy offers direct visualization of the structures of the joint anatomy and existing disease processes while causing minimal damage to surrounding soft tissue. However, it requires a high level of technical ability for wrist arthroscopy practitioners. Therefore, an improved focus on wrist arthroscopy training combining new educational media and traditional practice should aid in the development of novel wrist arthroscopy training mode. This article aims to describe the status of wrist training and evaluation systems and introduce a new progressive wrist training system.

Radiographic Landmarks for Ideal Port Placement in Wrist Arthroscopy

Background  The placement of wrist arthroscopy portals is traditionally performed using distances from anatomic landmarks. We sought to evaluate the safety of traditional portal placement and determine if radiographic landmarks could provide an additional method of identifying tendon intervals. Methods  Six cadaveric specimens were used to evaluate the accuracy of portal placement based on anatomic and radiographic landmarks. Fluoroscopic images were used to document the location of previously described surface landmarks. Soft tissue was dissected away to identify the relationship between the transcutaneously placed portals and the extensor tendons. With soft tissue removed, tendon intervals were identified in relationship to anatomic carpal bone landmarks, and interval distances measured. Portals were then placed under radiographic imaging on the final three specimens and accuracy was examined by the removal of overlying soft tissue to confirm accurate interval placement Results  The 3,4 portal was safely placed using only surface anatomic landmarks, however the 4,5 and midcarpal ulnar (MCU) portal sites were not consistently placed in the intended tendon interval, especially in larger wrists. Radiographic interval targets for the 3,4 portal were identified at the ulnar aspect of the scaphoid and the 4,5 portal at the ulnar one-third of the lunate. The radiographic site for the MCR was located at the inferior radial one-third of the capitate and the MCU portal was located at the radial aspect of the hamate. The 6R portal radiographic landmark is at the radial aspect of the triquetrum and 6U at the ulnar aspect of the triquetrum. Conclusion  Portal placement in wrist arthroscopy based on anatomic landmarks alone can be unreliable in larger wrists. Radiographic imaging based on carpal bone landmarks provides an additional tool for consistent placement of portals in wrist arthroscopy and may limit unintended injury to extensor tendons. Level of Evidence  This is a Level VI study.

Is Midcarpal Arthroscopy for Suspected Scapholunate Pathology Associated With Greater Interobserver Agreement and More Frequent Offer of Surgery?

PURPOSE

This study compared the interobserver agreement of arthroscopic classification of suspected scapholunate interosseous ligament (SLIL) pathology with and without midcarpal arthroscopy to help inform diagnostic strategies. It also measured the association of midcarpal arthroscopy with recommendations for reconstructive surgery. The association of midcarpal arthroscopy with the type of surgery recommended was also studied.

METHODS

Fourteen consecutive videos of diagnostic radiocarpal and midcarpal wrist arthroscopy for suspected SLIL pathology were selected. An international survey-based experiment was conducted among upper extremity surgeons of the Science of Variation Group. Participants were randomized to view either radiocarpal arthroscopic videos or radiocarpal and midcarpal videos. Surgeons rated SLIL pathology according to the Geissler classification and recommended surgical or nonsurgical treatment. If surgical treatment was recommended, they indicated the type of procedure.

RESULTS

The interobserver agreement for the Geissler classification was slight/fair for observers who reviewed midcarpal and radiocarpal videos and for those who viewed radiocarpal videos only. Viewing midcarpal videos was associated with higher pathology grades, the recommendation for reconstructive surgery, and a preference for tenodesis over scapholunate ligament repair.

CONCLUSIONS

Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement.

CLINICAL RELEVANCE

The pursuit of a pathology that accounts for wrist symptoms in a nonspecific interview and examination and normal radiographs is understandable; however, the low reliability of the scapholunate pathology of diagnostic arthroscopy might be associated with more potential harm than benefit.

Prevalence of Ganglion Cyst Formation After Wrist Arthroscopy: A Retrospective Longitudinal Analysis of 2420 Patients

BACKGROUND

Dorsal wrist ganglion cysts arise from the leakage of synovial fluid through tears in the scapholunate ligament and/or dorsal wrist capsule. An analogous disruption of the dorsal capsule is created with routine portal placement during wrist arthroscopy. We hypothesized that wrist arthroscopy would predispose to wrist ganglions.

METHODS

Using the Truven MarketScan Outpatient Services Database from 2015 to 2016, patients who underwent wrist arthroscopy and developed an ipsilateral wrist ganglion were identified. Exclusion criteria included ganglion diagnosis preceding arthroscopy and bilateral pathology. Postoperative ganglion diagnosis was modeled with logistic regression. Predictor variables included age, gender, comorbidities, and arthroscopic procedure.

RESULTS

In all, 2420 patients underwent wrist arthroscopy. Thirty (1.24%) were diagnosed with an ipsilateral wrist ganglion at a mean time of 4.0 months (standard deviation: 2.4, range: 0.2-9.0). Significant predictors of ganglion diagnosis included female gender (odds ratio [OR]: 4.0, P < .01) and triangular fibrocartilage complex and/or joint debridement (OR: 0.13, P < .01). By comparison, among all 24,718,751 outpatients who had not undergone wrist arthroscopy, 39,832 patients had a diagnosis of a wrist ganglion cyst (0.16%).

CONCLUSIONS

Wrist arthroscopy is associated with a postoperative rate of ganglion cyst formation that is nearly 8 times the rate in the general population. Additional studies are needed to investigate techniques that minimize the risk of this complication.

Cartilage Injuries and Posttraumatic Osteoarthritis in the Wrist: A Review

OBJECTIVE

Focal cartilage injuries, and posttraumatic osteoarthritis (OA) in the wrist are likely common and a cause of wrist pain. To estimate the incidence of cartilage lesions and to understand the pathomechanisms leading to wrist cartilage injuries and OA, a literature review on the subject was performed combined with a presentation of one of the authors' own experience.

DESIGN

This study includes a literature review of the topic. As a comparison to the review findings, the observations of one of the authors' consecutive 48 wrist arthroscopies, were assessed. PubMed, Scholar, and Cochrane databases were searched using the keywords "cartilage injury AND wrist AND treatment" and "wrist AND cartilage AND chondral AND osteochondral AND degenerative OA."

:RESULT

A total of 11 articles, including 9 concerning chondral and osteochondral repair and treatment and 2 regarding posttraumatic OA, were retrieved. The cartilage repair treatments used in these articles were drilling, osteochondral autograft, juvenile articular cartilage allograft, and chondrocyte implantation. One article displayed concomitant cartilage injuries in displaced distal radius fractures in 32% of the patients. The review of our findings from a 1-year cohort of wrist arthroscopies showed 17% cartilage injuries.

CONCLUSION

There is a lack of knowledge in current literature on cartilage injuries and treatment, as well as posttraumatic OA in the wrist. Cartilage injuries appear to be common, being found in 17% to 32% of all wrist arthroscopies after trauma, but no guidelines regarding conservative or surgical treatment can be recommended at the moment. Larger prospective comparative studies are needed.

Bare bones: Fundamentals of diagnostic wrist arthroscopy

Diagnostic wrist arthroscopy is an essential component of the modern orthopaedic wrist surgeon's skill set. Fundamental elements of diagnostic wrist arthroscopy include pre-operative planning and consent, operative set up, surface anatomy, a systematic approach and applied clinical anatomy, and closure. These fundamentals are described, including options and preferences for implementation. A sound understanding of these elements is key to lay the foundations for successful clinical procedures.

Comparative study between open and arthroscopic techniques for scaphoid excision and four-corner arthrodesis

This study presents our technique of arthroscopic scaphoid excision and four-corner arthrodesis and compares the clinical and radiological outcomes with those achieved with the open method. Twenty-seven patients (14 in arthroscopy group and 13 in open group) were included. Bone union was achieved in 13 of 14 patients in the arthroscopy group and in all 13 patients in the open group. In the open group, severe stiffness (flexion-extension arc was 10°) occurred in one patient after surgery. The mean postoperative flexion-extension arc was 75° and 51° in the arthroscopy group and open group, respectively. The pain, clinical scores, and radiological indices were improved in both arthroscopy and open groups. Arthroscopic and open scaphoid excision and four-corner arthrodesis did not show significant differences in clinical outcomes and bone union rates. The arthroscopic method provided a superior range of motion.Level of evidence: III.