Education in wrist arthroscopy: past, present and future.

PURPOSE: Arthroscopy has assumed an important place in wrist surgery. It requires specific operative skills that are now mainly acquired in the operating room. In other fields of endoscopic surgery, e-learning and virtual reality (VR) have introduced new perspectives in teaching skills. This leads to the following research question: Could the current way of teaching wrist arthroscopy skills be supported using new educational media, such as e-learning and simulator training? METHOD: The literature was searched for available methods of teaching endoscopic skills. Articles were assessed on the evidence of validity. In addition, a survey was sent to all members of the European Wrist Arthroscopy Society (EWAS) to find out whether hand surgeons express a need to embrace modern educational tools such as e-learning or simulators for training of wrist arthroscopy skills. RESULTS: This study shows that the current way of teaching wrist arthroscopy skills can be supported using new educational media, such as e-learning and simulator training. Literature indicates that e-learning can be a valuable tool for teaching basic knowledge of arthroscopy and supports the hypothesis that the use of virtual reality and simulators in training enhances operative skills in surgical trainees. This survey indicates that 55 out of 65 respondents feel that an e-learning program would be a valuable asset and 62 out of the 65 respondents are positive on the additional value of wrist arthroscopy simulator in training. CONCLUSION: Study results support the need and relevance to strengthen current training of wrist arthroscopy using e-learning and simulator training. LEVEL OF EVIDENCE: V.

Joint-sparing arthroscopic management of avascular necrosis of the capitate.

Avascular necrosis of the proximal pole of the capitate is an exceedingly rare pathology with few therapeutic solutions. The largest published series concerned a cohort of 6 cases over 10 years. The present case concerns our experience with avascular necrosis of the capitate in a 20-year-old woman. Due to her age and high functional demand, we opted for a minimally invasive solution using arthroscopy. We performed an X-shaped palmaris longus tendon interposition arthroplasty at the midcarpal joint between the capitate and the lunate. We here report 2 years' follow-up.

Effectiveness of early versus delayed motion in patients with distal radius fracture treated with volar locking plate: A systematic review and meta-analysis.

The aim of this study was to determine the effectiveness of early versus delayed motion on the functional outcomes in patients with distal radius fracture (DRF) treated with a volar locking plate. A systematic review and meta-analysis of randomized clinical trials was performed. An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria included randomized clinical trials that compared the effect of early versus delayed motion on wrist and/or upper limb function, pain, grip strength, and wrist range of motion in subjects older than 18 years with DRF treated with a volar locking plate. Five clinical trials were included that met the eligibility criteria for the quantitative synthesis. At 6 weeks, the PRWE questionnaire showed a mean difference (MD) of -10.6 points (p < 0.001), the MD was -11.1 points for the DASH questionnaire (p < 0.001), -0.56 cm for pain on VAS (p = 0.01), 5.0 kg for grip strength (p = 0.01), 12.5 degrees for wrist flexion (p = 0.07), and 12.8 degrees for wrist extension (p = 0.05). All differences favored the early motion treatment. At 3 months of follow-up, only the DASH, pain on VAS, and grip strength showed significant differences in favor of early motion. At 1 year of follow-up, none of the variables studied were different between groups. In the short term, there was moderate to high evidence of clinically and statistically significant differences in the functional outcomes in favor of early versus delayed motion in patients with DRF treated with a volar locking plate. But these differences were not observed at 1 year of follow-up. PROSPERO registration no.: CRD42020158706.

COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

[Comparison of two arthroscopic classifications for scapholunate instability]. / Comparaison de deux classifications arthroscopiques pour l'instabilité scapholunaire dissociative.

The W. Geissler's and G. Dautel's arthroscopic classifications for scapholunate instability have been compared in a prospective, multicentric study. Physical, radiographic and arthroscopic data from 50 patients were reported by eight operators working in eight different institutions. Two questions were asked for each study case: Which classification seemed to be the more easy to use? Which classification seemed to give the best treatment algorithm? The good and bad points of each classification are presented. Neither of these two classifications is ideal, so the authors propose a classification incorporating the important points gleaned from the study. The proposed classification is simple, reproducible and precise, especially in terms of scapholunate ligament status.

[Arthroscopic management of intra-articular fractures of the distal radius]. / Traitement des fractures articulaires du radius distal sous contrôle arthroscopique: technique opératoire et choix thérapeutiques.

The use of arthroscopy in the management of intra-articular fractures of the distal radius has become established over the last ten years, but the operative technique is not yet standardised. We report our experience with this technique and give a stage by stage description of the operative procedure. The arthroscopic part of the procedure consists firstly of an evaluation of the bony, cartilaginous and ligamentous injuries and secondly direct visual control of the reduction. The choice of bone fixation depends on the individual preferences of the surgeon but may be influenced by the configuration of the fracture. A literature review reiterates the advantages of arthroscopic assistance in managing these fractures without revealing any disadvantages. However, mastery of the arthroscopic techniques is vital before the full advantages of this type of management can be realised.

Indications, techniques, and outcomes of arthroscopic repair of scapholunate ligament and triangular fibrocartilage complex.

This review includes updated understanding of the roles of intrinsic and extrinsic carpal ligaments in scapholunate instability and details the author's experience of indications, arthroscopic repair methods, and outcomes of treating the instability. A classification on triangular fibrocartilage complex injuries is reviewed, followed by author's indications, methods, and outcomes of arthroscopic repair of triangular fibrocartilage complex injuries.

[Therapeutic interest of wrist arthroscopy: about 1000 cases]. / Intéret thérapeutique de l'arthroscopie du poignet: à propos de 1000 cas.

Wrist arthroscopy is a relatively recent procedure because it was described in the 70's. During the first period of 80's it became an indisputable technique of diagnosis. Since the 90's many therapeutic procedure were described by several authors all over the world. This technique increase a lot the understanding of wrist pathologies and ameliorate significantly the results for patients. We report our experience about 1000 wrist arthroscopy between 1998 and 2005. The patients were always operated on outpatient basis under local regional anaesthesiology. The arm was laid on the table and the hand on in-line traction (5-7 kg). We used a 2.4 mm arthroscope, 30 degree angled. The both joints, radiocarpal and midcarpal, were systematically explored. The small portals were not closed. In our experience, only 42 arthroscopies (4%) were without surgical procedure. We separated the indications in 7 chapters: (1) arthoscopic assistance for fractures treatment (distal radius and scaphoid: 7%; (2) TFCC tears (17%); (3) treatment of intrinsic ligaments tears (scapholunate and lunotriquetral: 21%); (4) ectomy (radial styloidectomy, wafer, carpal boss 13%); (5) resection of wrist ganglia (21%); (6) partial prosthesis (2.5%); (7) others techniques (arthrolysis, synovectomy 14.5%).

[Percutaneous fixation of scaphoïd fractures with arthroscopic assistance]. / Ostéosynthèse percutanée des fractures du scaphoïde carpien avec assistance arthroscopique.

We report the results of a series of 37 recent fractures of the scaphoid treated by percutaneous screwing under X-ray control with systematic realization of a wrist arthroscopy. In 22 cases the factures were undisplaced and we had 15 displaced fractures. In all the cases the wrist arthroscopy allows to check the quality of the reduction, the good positioning of the screws and the correct reduction of fragments. Union was obtained in all cases with an average of 62 days (range 45-80). The functional recovery of the operated wrists was good with an early return to work on average 21 days (between 0 days and 3 months). The systematic association of wrist arthroscopy to the percutaneous screwing secures the procedure which can be proposed to motived patients interested by a fast return to the active life. The quality and the stability of the reduction are controlled and avoid complications due to bad positioning of the material. The possibility of treating in the same time the associated intra carpal ligaments tears lesions is possible.

[Arthroscopic distal ulna resection after post traumatic ulno carpal abutment]. / Résection arthroscopique distale de l'ulna dans les conflits.

Ulno carpal abutments secondary to the sequels of a fracture of the radius are often due to the inversion of the distal radio ulnar index by shortening relative to the radius. This positive ulnar variance eventually leads to an abutment between the head of the ulnar and the proximal articular face of the lunate with alteration of the cartilaginous carpal surfaces. The wrist arthroscopy makes diagnosis and treatment possible in a less invasive way. The patients are operated on as outpatients under local regional anaesthetic using a pneumatic tourniquet. The arthroscope is positioned using the 3-4 radio carpal opening permitting exploration of the joint. The surgical treatment is performed by arthroscopy using a burr and going in through the 6R radio carpal opening. In this way we use the technique of partial resection of the distal ulna. We have a series of 62 patients who have benefited from the technique of partial resection of the ulnar head by arthroscopy. There were 30 men and 32 women. The average age was 66 years old (between 45 and 82). Our average follow-up is 32 months (between 12 and 60 months). Recovery of mobility was immediate in all cases with persistent pain in the radio ulnar joint in 8 cases. Arthroscopic treatment of ulno carpal abutment has proved itself effective and innocuous. It should nevertheless be reserved for operations on small sized inversions of the distal radio ulnar index (less than 5 mm). In the event of larger ulnar variances we prefer ulnar shortening osteotomy. The other techniques will be restricted to cases where the distal radio ulnar joint has been impaired.

[Arthroscopic management of articular cartilage defect]. / Traitement arthroscopique des lésions cartilagineuses au poignet.

The chondral changes of the carpus are frequent, often after trauma but also being able to be secondary with degenerative disease. The wrist arthroscopy generally makes it possible to make the diagnosis of these lesions, before they are visible by the usual paraclinic examinations. It will make it possible to withdraw foreign body, cartilage or osseous fragments free in the articulation at the origin of pains. It will also allow the abrasion of small size area of chondral change. Lastly, it will be an essential tool for a secondary conventional treatment. The installation of partial implants in necrosis of proximal pole by arthroscopy is a recent technique very well adapted.

[Arthroscopic treatment of osteoarthritis of scaphotrapezotrapezoid joint]. / Traitement arthroscopique de l'arthrose scaphotrapézotrapézoïdienne (STT).

Osteoarthritis of scaphotrapezotrapezoid joint corresponds to 13% of wrist arthritis. It is seldom isolated. The arthroscopic treatment associates a radial mid carpal portal and a STT portal called 1-2 midcarpal portal. Between 2002 and 2005, we carried out 13 resection isolated from the distal pole of the scaphoid. There were only women whose average age was 58 years. The improvement was real on the level of the pain, mobility and the muscular force. In same time, we operated on 13 patients by associating an implant in pyrocarbone as interposition after resection. The average age was 67 years. The average follow-up was 20 months. We had two implant dislocations for technical errors. The quality of the results helped by the invasive initially mini-approach and the arthroscopy can make it possible to select some indications.

Treatment of dynamic scapholunate instability dissociation: Contribution of arthroscopy.

Scapholunate (SL) ligament injuries generally result from trauma to an extended, supinated wrist, leading to chronic instability that progresses toward osteoarthritis. They can occur together with distal radius fracture. These injuries can be difficult to diagnose, especially early on. Treating chronic SL ligament injuries before the onset of osteoarthritis is still a challenge for surgeons. Until recently, the recommended treatments consisted of open SL ligament reconstruction or repair procedures that reduce pain and improve pinch strength but also lead to wrist stiffness. The introduction of arthroscopy has completely changed our understanding of these injuries and how to treat them. We review here the treatment approach through the eyes of three specific groups of surgeons: the "pioneers" who first analyzed these injuries; the "specialists" who explored various stabilization techniques to compensate for the torn SL ligament; and the most recent group, the "anatomists" who, based on recent arthroscopy findings, sought to reconstruct the anatomical structures as accurately as possible and who developed the concept of the SL complex.

Assessment of the structures at risk during wrist arthroscopy: a cadaveric study and systematic review.

UNLABELLED: We assessed the proximity of neurological structures to arthroscopic portals in a cadaveric study and through a systematic review. Arthroscopy was performed on ten cadaveric wrists. Subsequently the specimens were dissected to isolate the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the posterior interosseous nerve and the extensor tendons. We measured the distances from the nerves to common portals. For the systematic review Pubmed and EMBASE were searched on the 31 May 2014 for cadaveric studies reporting the proximity of neurological structures to any arthroscopic wrist portal. In the cadaveric study, partial injuries were seen to six extensor tendons and one posterior interosseous nerve; it was assumed this was due to creation of the portals. Seven published studies were included in the systematic review. The dorsal sensory branch of the ulnar nerve was found to be at risk by performing the 6 Ulnar, 6 Radial and ulnar midcarpal portals, the sensory branch of the radial nerve by the 1-2 and 3-4 portals and the posterior interosseous nerve by the 3-4 and 4-5 portals. LEVEL OF EVIDENCE: V.

Further experience with the index metacarpal vascularized bone graft.

We report our experience in the use of a vascularized bone graft harvested from the head of the index metacarpal to treat scaphoid nonunion after failure of other techniques. Only 15 patients were treated between 1988 and 1994, showing the scarcity of indications for the operation. Union was obtained in 14 cases but the functional results were acceptable in ten cases only. This was due to previously unnoticed degenerative lesions.

Vascularized bone graft from the palmar carpal artery for treatment of scaphoid nonunion.

We report the use of a bone graft harvested from the palmar and ulnar aspect of the distal radius and vascularized by the palmar carpal artery for the treatment of scaphoid nonunion in 17 patients, ten of whom had already had unsuccessful surgery. Union was obtained in all cases at an average of 60 days (range, 45-90 days). The average follow-up was 16 months (range, 12-36 months). There were no failures.

Arthroplasty of the proximal interphalangeal joint using the Sutter implant for traumatic joint destruction.

We report the functional results in a series of 21 Sutter arthroplasties for post-traumatic arthritis with an average follow-up of more than 2 years. The dorsal approach was used in every case. Pain was always present preoperatively and mobility was reduced to an average range of motion of 15 degrees. Postoperatively, pain was absent in 18 cases. The average active range of motion was 55 degrees. There were two fractures of implants. Although the follow-up is limited, the Sutter arthroplasty has given results that are similar to, or better than, those reported for other techniques.

Vascular anatomy of the palmar surfaces of the distal radius and ulna: its relevance to pedicled bone grafts at the distal palmar forearm.

The potential for harvesting vascularized bone grafts from the palmar surface of the distal radius has been studied in 40 arms of fresh cadavers which had previously been injected with coloured latex solution. It was found that vascularized grafts can be pedicled on the radial part of the palmar carpal arterial arch. If a longer pedicle is required, the bone graft can be pedicled on the anterior branch of the anterior interosseous artery with retrograde flow occurring from the palmar carpal arch.

[Skin complications of stonefish envenomation in 6 travellers returning from the Indo-Pacific maritime region]. / Complications cutanées des envenimations par poisson-pierre chez 6 voyageurs au retour de la région maritime indo-pacifique.

Stonefish (Synanceja verrucosa) sting has been known for a long time to be a medical hazard. It is a common cause of severe marine envenomation. Immediate complications (collapsus, pulmonary oedema) have been described extensively. Late complications (oedema, tissue necrosis) have not been studied in details although they are common and a cause of invalidity and pain. We have observed six travellers with complications of stonefish sting over a 10 year-period in our department. All the patients were coming back from the Indo-Pacific maritime region. They presented with cutaneous abcess (in one) or necrotic complications (foot ulcers in two, cellulitis in three) associated with painfull oedema in two and lymphangitis in three. Surgery has been performed in four patients, two of them undergoing many operations. Two had long term sequelae. Such complications could be avoided. Appropriate initial treatment (i.e., neutralization of the venom by hot water, disinfection, antivenom and antibioprophylaxis) seems to be able to reduce late complications. Antivenom is indicated in severe systemic manifestations which are life threatening and in case of crucial pains. Prevention is the most important part of therapy and relies on appropriate information of the travellers.

[Free transfer of the vascularized fibula in pseudarthrosis and femoral bone loss]. / Transfert libre de péroné vascularisé dans les pseudarthroses et pertes de substance fémorale.

The authors report their experience of femoral reconstruction by free fibular graft transfer. Twenty eight patients were operated on between 1977 and 1988. The average follow-up was 7 years and 3 months. The etiology of most of the cases was a post traumatic lesion (70 per cent). Loss of substance was found in 19 cases. 60 per cent of these were septic. The approach was usually posterior and vessels from the sciatic nerve were used. Union was obtained in 89 per cent of the cases. In 65 per cent of the cases union occurred in less than 1 year. In 1 out of 4 cases graft thickening was necessary and achieved by secondary bone grafts. The comparison of this technique with standard treatments evidenced a definite superiority of vascularized bone grafts in cases of septic pseudarthrosis and significant losses of bone.