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.

Robot-assisted transosseous repair of triangular fibrocartilage complex: a cadaver study.

The feasibility and accuracy of robot-assisted bone tunnel construction in the transosseous repair of the triangular fibrocartilaginous complex (TFCC) were compared with those of freehand arthroscopic repair. A total of 20 cadaveric specimens were randomized into robotic-assisted and arthroscopy-guided groups. Three bone tunnels were constructed in the ulnar foveal region in each specimen. The discrepancy between the planned and actual tunnel exits was determined in the robot-assisted group by merging images. The success rate of tunnel construction, time consumption and number of drilling attempts were compared between groups. The median planned/actual exit discrepancy was 0.8 mm in the robot-assisted group, with 90% of tunnel exits successfully placed in the footprint region, compared to 63.3% in the arthroscopy-guided group. The robot-assisted group spent less time and required fewer drilling attempts to construct bone tunnels. These results indicated that the robot-assisted technique can accurately construct multiple bone tunnels in the foveal region and reduce the difficulty of TFCC transosseous repair.Level of evidence: III.

Hamatolunate impingement, a differential diagnosis of ulnar-sided wrist pain.

Ulnar-sided wrist pain (USWP) is a diagnostic challenge. Although most of the etiologies are associated with the triangular fibrocartilage complex, the distal radioulnar joint, ulnocarpal impingement, or extensor carpi ulnaris (ECU) tendinopathy, other differential diagnoses should be suggested during propaedeutics. Carpal anatomical variations, specifically the hamatolunate joint, may be responsible for USWP. The purpose of this case report is to highlight the diagnostic approach to USWP and discuss an infrequent differential diagnosis and its surgical management. We present a 44-year-old male patient, a waiter, with USWP and work difficulties. After careful clinical investigation and radiologic studies (magnetic resonance imaging and dynamic fluoroscopy), it was observed the hamatolunate joint impingement. The patient underwent arthroscopy with inspection of the midcarpal joint through the midcarpal radial portal, revealing joint degradation of both articular surfaces. The proximal pole of the hamate was removed. The patient evolved well and returned to work two months later. Function and pain scores were satisfactory at the one-year follow-up.

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.

Arthroscopic Debridement for Treatment of Chronic Dynamic Scaphoid Instability.

Background There is a paucity of information on minimal surgical intervention for the treatment of chronic dynamic scaphoid instability (CDSI) that will achieve an acceptable mid-term result. Purpose We hypothesize that by following a debride-first-then-wait protocol, some patients with CDSI can be treated with arthroscopic debridement alone and avoid a reconstructive procedure. Patients and Methods We performed a retrospective, longitudinal study from January 2008 to December 2018 of all patients diagnosed with CDSI and treated with arthroscopic debridement of the scapholunate interosseous ligament. In all cases, a debride-first-then-wait protocol was followed that included a predetermined wait period after arthroscopic debridement, giving the patient a chance to experience possible symptom improvement. This approach integrated the patient's perceived wellness into the decision-making process. All wrists that remained symptomatic or experienced recurrence of symptoms were treated with a reconstructive procedure. The wrists were divided into two groups: arthroscopic debridement only (ADO) and reconstructive procedure (RP). Results Seventy-nine wrists (72 patients) of 191 consecutive wrist arthroscopies met the inclusion criteria. The ADO group consisted of 43 wrists (54%). An average of 6.3 years later (range: 2-11 years), these patients remained satisfied with the results of the arthroscopic debridement and did not want further treatment. The RP group included 36 wrists (46%) with 91.7% of reconstructive surgeries occurring within 6 months of the arthroscopy. With a mid-term follow-up, 75% of Geissler grade II ligament tears, 48% of grade III tears, and 39% of grade IV tears were successfully treated with arthroscopic debridement alone and avoided a reconstructive surgery. Conclusion By adopting a debride-first-then-wait protocol, some patients with CDSI can be treated with a more limited intervention, arthroscopic debridement. In this series, 54% of wrists with CDSI avoided a reconstructive surgery for an average of 6.3 years. Type of Study / Level of Evidence Case Series, Level IV.

Arthroscopical Reinforcement of an Isolated Insufficiency of the Radioscaphocapitate Ligament to Treat Dynamic Radioscaphoid Instability: A Case Report.

The radioscaphocapitate ligament is part of the stabilizatory complex of the scaphoid. Isolated injury resulting in persistent radioscaphoid instability is rarely reported. The authors propose a technique for arthroscopic reinforcement. Magnetic resonance, dynamic fluoroscopy, and wrist arthroscopy will confirm the elongation of radioscaphocapitate ligament. Under arthroscopic control, an anchor can be drilled into the radial aspect of the scaphoid to tension the ligament toward the anchor. An arthroscopic reinforcement of the radioscaphocapitate ligament may resolve a persistent radioscaphoid instability due to elongation.

The Effect of Arthroscopic Triangular Fibrocartilage Repair on Accompanying Extensor Carpi Ulnaris Tendinitis and Synovitis in Triangular Fibrocartilage Tears.

Purpose Management of ulnar-sided wrist pain is difficult due to the complexity of the anatomy and the similarity of the signs and symptoms of possible diagnoses. The study's main purpose is to examine the effect of arthroscopic triangular fibrocartilage (TFC) repair on untreated extensor carpi ulnaris (ECU) tendinitis and synovitis. Methods Thirteen patients who underwent arthroscopic TFC repair in our clinic and preoperatively demonstrated ECU tendon pathology with magnetic resonance imaging (MRI) were included in the retrospective study. Pre- and postoperative visual analog scale (VAS), pre- and postoperative tendinitis and synovitis, postoperative Mayo and patient-rated wrist evaluation score, postoperative grip strength of the operated and control sides, short and long diameters of the ECU tendon in ultrasonography were recorded. Results The mean age of 13 patients (9 females and 4 males) was 39.54 ± 13.54, and the mean follow-up period was 26 ± 7.25 months. While there was no significant difference between pre- and postoperative tendinitis or synovitis levels, VAS decreased significantly (8.46 ± 1.33 vs. 3.00 ± 2.31, p = 0.0016). While the grip strength was 21.78 ± 7.83 on the control side, it was 18.28 ± 7.51 on the surgery side, being significantly lower ( p = 0.0252). Ulnar variance did not affect tendinitis or synovitis. Short and long diameters of ECU were similar for the operated and control sides. While the short diameter did not affect the synovitis-tendinitis score, the bigger the long diameter, the higher the synovitis score (rho = 0.5162). Conclusion In the presence of ECU, tendon pathologies accompanying TFC lesions, additional surgical interventions are mandatory as arthroscopic TFC repair has no significant effect on the healing of ECU. Level of evidence : 4.

Enhancing wrist arthroscopy: artificial intelligence applications for bone structure recognition using machine learning.

INTRODUCTION: Wrist arthroscopy is a rapidly expanding surgical discipline, but has a long and challenging learning curve. One of its difficulties is distinguishing the various anatomical structures during the procedure. Although artificial intelligence has made significant progress in recent decades, its potential as a valuable tool in surgery training is largely untapped. MATERIALS AND METHODS: The objective of this study was to develop an algorithm that could accurately recognize the anatomical bone structures of the wrist during arthroscopy. We prospectively included 20 wrist arthroscopies: 10 in patients and 10 in cadavers. For each surgery, we extracted and labeled images of the various carpal bones. These images were used to create a database for training, validating and testing a structure recognition algorithm. The primary criterion used was a Dice loss detection and categorization score for structures of interest, with a threshold greater than 80%. RESULTS: The database contained 511 labeled images (4,088 after data augmentation). We developed a Deeplabv3+ classification algorithm with a U-Net architecture. After training and testing our algorithm, we achieved an average Dice loss score of 89% for carpal bone recognition. CONCLUSION: This study demonstrated reliable detection of different carpal bones during arthroscopic wrist surgery using artificial intelligence. However, some bones were detected more accurately than others, suggesting that additional algorithm training could further enhance performance. Application in real-life conditions could validate these results and potentially contribute to learning and improvement in arthroscopic wrist surgery. LEVEL OF EVIDENCE: IV.

A modified partial wedge-shaped metaphyseal ulnar osteotomy for the treatment of ulnar impaction syndrome with reverse oblique sigmoid notch.

We describe a modified metaphyseal ulnar osteotomy to treat ulnar impaction syndrome with a reverse oblique sigmoid notch. Based on a computational analysis of radiographs, a modified wedge metaphyseal ulnar osteotomy was devised with its apex positioned at the ulnar styloid base to avoid impaction between the sigmoid notch and ulnar head. Subsequently, nine patients with ulnar impaction syndrome and a reverse oblique sigmoid notch underwent this operation, combined with arthroscopic exploration and transosseous triangular fibrocartilage complex repair. The mean follow-up was 14 months. All patients achieved bone union within 5 weeks, with no degenerative changes being observed during the follow-up assessments. The final follow-up assessments revealed decreases in ulnar variance and in the scores for Visual Analogue Scale, Quick Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Wrist Evaluation. All patients achieved excellent or good grades on the Modified Mayo Wrist Score. This technique is effective in treating the ulnar impaction syndrome with a reverse oblique sigmoid notch.Level of evidence: IV.

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.

The Medial Triquetrohamate Portal: A New Portal in Wrist Arthroscopy. Anatomical Study.

Introduction Continuing advances in wrist arthroscopy and better understanding of carpal conditions have created the need to design new wrist access portals that facilitate the implementation of new surgical techniques. The aim of this study was to define and verify the safety of the medial triquetrohamate (MTH) portal. Description of the technique The MTH portal is located about 5-10 mm ulnar and 2-3 mm distal to the midcarpal ulnar portal, ulnar to the extensor digitorum communis (EDC) tendon of the fourth and fifth fingers, and radial to the extensor digiti quinti (minimi) (EDQ) tendon. Methods An anatomical study was performed on 15 upper limb specimens from 15 human cadavers. Iatrogenic injuries to potentially at-risk neurovascular and tendinous structures were assessed, and the distance from the portal to these structures was measured. Results There were no iatrogenic injuries to the structures at risk. Mean distances from the MTH portal to the EDC tendon of the fourth and fifth fingers and to the EDQ tendon were 4.67 ± 0.35 mm and 7.27 ± 0.18 mm, respectively. No differences were observed between the left and right wrists. The distance from the MTH portal to the dorsal sensory branch of the ulnar nerve was 15.07 ± 0.44 mm. The structure with the highest risk of injury was the EDC tendon of the fourth and fifth fingers, with a distance of less than 5 mm. Conclusions The MTH portal is safe, reproducible and facilitates the implementation of various techniques related to midcarpal pathology.

The "Bubble Test" in the Arthroscopic Diagnosis of Triangular Fibrocartilage Central Lesion: Description and Relevance to Treatment.

Background Ulnarly sided wrist pain is a common and challenging symptom. Arthroscopy has become a safe and effective tool for the correct diagnosis and treatment, proving to be better than all other clinical and imaging diagnostic methods. Some tests have been described for the diagnosis of triangular fibrocartilage (TFC) lesions, such as the trampoline test for peripheral lesions and the hook, ghost, and suction tests for foveal detachments. In tears at the disc level, when they affect all layers of the TFC (complete lesion) at the same point, testing with the probe will usually suffice for the diagnosis. However, in some apparently partial lesions, the probe cannot pass through all layers because the proximal and distal sites of the lesion are not aligned. There has been no arthroscopic test described for such cases. Case Description We describe a simple and practical test that we have called the "bubble test" in a typical case to diagnose TFC central injuries, aiming to discriminate partial from complete lesions, which are eventually hard to differentiate through direct vision and arthroscopic probing, leading to a direct influence onto the treatment. The bubble test is performed with external compression of the distal radioulnar joint (DRUJ) aspect, with the thumb on the back of the DRUJ and the index and middle fingers onto the volar aspect. The abrupt compression of this region causes the passage of air mixed with synovial fluid from the DRUJ to the radiocarpal joint, generating bubble formation. Clinical Relevance The bubble test should correlate to physical examination and imaging (magnetic resonance imaging [MRI]) findings and is particularly useful in central and degenerative (Type II) TFC lesions in patients complaining of chronic pain on the ulnar region of the wrist, with no history of trauma and with inconclusive MRI findings. Once the diagnosis is confirmed, arthroscopic treatment consists of wide debridement of the lesion with resection of the injured tissue and the local inflammatory reaction. Thus, it is essential for the correct treatment to define the exact location of the lesion and to know whether the disc injury is complete.

Review and update on the management of triangular fibrocartilage complex injuries in professional athletes.

Triangular fibrocartilage complex injuries are common in amateur and professional sports. These injuries are mainly caused by acute or chronic repetitive axial loads on the wrist, particularly on the ulnar side and in association with rotations or radial/ulnar deviations. In order to treat professional athletes, a detailed specific knowledge of the pathology is needed. Moreover, the clinician should fully understand the specific and unique environment and needs of the athletes, their priorities and goals, the type of sport, the time of the season, and the position played. An early diagnosis and appropriate management with the quickest possible recovery time are the uppermost goals for both the athlete and the surgeon. A compromise between conservative vs surgical indications, athletes' needs and expectations, and financial implications should be achieved. Arthroscopic procedures should be timely planned when indicated as they could allow early diagnosis and treatment at the same time. Conservative measures are often used as first line treatment when possible. Peripheral lesions are treated by arthroscopic repair, whilst central lesions are treated by arthroscopic debridement. Further procedures (such as the Wafer procedure, ulnar osteotomies, etc.) have specific indications and great implications with regard to rehabilitation.

Arthroscopic Volar Capsuloligamentous Reattachment and Reinforcement to Bone.

Background: Injuries of the volar ligaments of the wrist are not uncommon, but their arthroscopic treatment presents a significant challenge. The objective of this paper is to introduce a technique for reattaching (in acute injuries) or reinforcing (in chronic injuries) various volar wrist ligaments to the bone, using standard wrist arthroscopic dorsal and volar portals. Methods: There are three common steps for all the arthroscopic volar capsuloligamentous reattachments or reinforcements Step 1 - Volar Portal Establishment: volar radial, volar ulnar and volar central portals are used depending on which structure needs to be reattached or reinforced. Step 2 - Anchor Placement: the anchor is positioned at the site where the ligament has been detached. Step 3 - Capsuloligamentous Suture and Knotting: a knot pusher is introduced inside the joint from the dorsal portal and advanced inside the volar portal where the threads of the anchor are located. The knot pusher is loaded with the threads and retrieved to the dorsal portal. A 16G Abbocath, loaded with a loop is used to pierce the volar ligaments. The loop of the Abbocath is captured from the dorsal portal and loaded with the threads. Both threads are taken to the volar portal and knotted after releasing the traction. This way the knot is placed out of the wrist and the ligaments are reattached or reinforced to the bone. Result: This technique has been used to reinforce and reattach the scapholunate and lunotriquetral ligaments and to reattach the radiocarpal ligaments and the Poirier space. Since this procedure has been performed in various conditions and in conjunction with other ligament treatments (such as perilunate injuries, carpal bone fractures, distal radius fractures, and reinforcement or reattachment of the dorsal portions of intrinsic ligaments), specific results are not presented. Conclusions: The described technique enables the reattachment and reinforcement of most volar ligaments to the bone using standard wrist arthroscopic portals. It can be performed in conjunction with the treatment of the dorsal portion of intrinsic ligaments or other wrist injuries.

Complications after arthroscopic triangular fibrocartilage complex (TFCC) surgery.

Wrist arthroscopy is a valuable and widely utilized tool in the treatment of triangular fibrocartilage complex (TFCC) injuries. These procedures include synovectomy alone, peri-capsular or transosseous repair, and arthroscopic-assisted reconstruction, and each are associated with specific complications. This review describes the types of complications and their rates in different types of arthroscopic TFCC surgery reported in the literature and in our centre. Across the spectrum of arthroscopic TFCC surgery, complication rates and the learning curve increase with surgical complexity. Relevant anatomy, prevention and management of complications including nerve injury and irritation, extensor tendon injury and tendinitis, fracture, stiffness, and persistence of symptoms or instability are discussed. Vigilance to anatomical details and careful dissection can help to reduce complications that may result in disturbing pain and functional loss.

Arthroscopic management of scapholunate complex injuries associated with distal radius fractures.

Scapholunate complex injuries are the most frequent lesions associated with distal radius fractures and the treatment algorithm according to the stage of the instability remains controversial. However, there is an admitted consensus around the necessary treatment of the associated high-grade instabilities. They occur frequently in young patients after high energy trauma, and not treated, they can lead to chronic wrist pain and eventually to scapholunate advanced collapse. The routine use of the arthroscopy provides an accurate intraoperative staging of the lesions and allows a tailored treatment depending on the severity of the scapholunate instability.

The Hook Test Is Not Pathognomonic for Foveal Detachment of the Triangular Fibrocartilage.

Background The integrity of the foveal insertion of the triangular fibrocartilage complex (TFCC) is currently assessed by inference using the hook test. Using dry arthroscopic techniques, the primary author observed that many patients with painful distal radioulnar joint (DRUJ) instability and a positive hook test had an intact foveal insertion. This study was performed to determine whether a positive hook test is a reliable index of a tear of the foveal insertion. Technique The hook test is performed using a probe to elevate the TFCC off the ulna head toward the articular surface of the lunate. In this study, the hook test was considered positive if the TFCC could be elevated to bridge more than 80% of the space between the TFCC and the articular surface of the lunate. Patients and Methods A retrospective study was performed using the medical records and arthroscopic videos of 113 patients who had clinical signs of DRUJ instability and underwent arthroscopic surgery performed by the primary author in 2020. It was documented whether the hook test was positive or negative, whether the foveal insertion was intact, abnormal or absent, and whether there were peripheral (dorsal or volar) tears of the TFCC. Sensitivity and specificity were calculated using arthroscopic findings as the reference standard. Results The sensitivity of the hook test was found to be 100%, and the specificity was 7.0%. The positive predictive value for foveal pathology was found to be 12.3% and the negative predictive value 100%. The diagnostic accuracy of the hook test in determining the presence of foveal tears was found to be 17.7%. The diagnostic accuracy of the hook test in determining the presence of a TFCC abnormality was 99.1%. Conclusions A positive hook test is indicative of a tear of the TFCC, but it is not anatomically specific for a tear of the foveal insertion. To reliably assess the foveal insertion, it must be visualized and probed using dry arthroscopic techniques.

All-Arthroscopic Foveal Triangular Fibrocartilage Complex Tendon Reconstruction.

Background In symptomatic chronic injury of ulnar-sided tear of the triangular fibrocartilage complex, reconstruction techniques involving foveal reconstruction with palmaris longus tendon graft using the method described by Bain have been described with good outcomes. Description of Technique With increasing popularity of wrist arthroscopy to address various wrist pathologies, we present our technique of arthroscopic foveal reconstruction. We also include a step-by-step description of the procedure with illustrations, with aims to aid surgeons in executing it Conclusion Unlike other arthroscopic techniques described, this involves single osseous ulnar tunnel and performed completely arthroscopically, allowing an end result similar to Bain's open technique.

Validation of the Clenched Fist View in Detecting Scapholunate Ligamentous Injury.

BACKGROUND: The purpose of this study was to determine the predictive value of the clenched fist stress views in identifying scapholunate ligament injuries. METHODS: An institutional review board-approved retrospective chart review was conducted of adult patients who underwent diagnostic arthroscopy with a ligamentous wrist injury from 2015 to 2020. Standard posteroanterior, lateral, and clenched fist stress radiographs were reviewed and scapholunate ligament gaps recorded. RESULTS: A total of 124 patients were included, of which 88 had normal standard radiographs and clenched fist radiographs. The positive predictive value of the clenched fist view was 69%, whereas the negative predictive value was 58%. The sensitivity of the clenched fist view was 40%, while the specificity was 82%. Of those patients with a negative clenched fist view, 42% were found to have an arthroscopic Geissler classification of 3 or higher scapholunate ligament injury. CONCLUSIONS: Despite the emphasis on stress radiographic views, a normal stress clenched fist view does not preclude arthroscopic findings of a Geissler class 3 or greater injury in symptomatic patients. The sensitivity of a clenched fist view is only 40%. These findings question the utility of stress radiographs when assessing for scapholunate ligament injuries.

Volar Wrist Arthroscopy Portals Using the NanoScope Are Safer than Traditional Arthroscopy.

BACKGROUND: The NanoScope, given its smaller size, may be further from critical structures when establishing volar wrist arthroscopy portals compared to the traditional 2.7-mm arthroscope. METHODS: Ten fresh-frozen latex-injected cadaver specimens were utilized. The volar radial (VR) and volar ulnar (VU) portals were created using an inside-out approach. The volar radial midcarpal (VR-MC) and volar ulnar midcarpal (VU-MC) portals were created using an inside-out approach. The arm was then dissected under 3.5-mm loupe magnification. Digital calipers were used to measure the distance between the portals and the surrounding anatomic structures by two fellowship-trained hand surgeons. RESULTS: The median nerve was on average 1.6, 7.2, 1.8, and 5.6 mm away from the trochar for the VR, VU, VR-MC, and VU-MC, respectively. The median nerve fascia was pierced by the VR portal in one specimen. The radial artery, ulnar artery, and ulnar nerve were not pierced in any specimen. Compared to historical controls, for the VR-MC portal, the NanoScope was further from all critical structures, aside from the radial artery, and did not pierce any neurovascular structures. For the VU-MC portal, the NanoScope was further from the ulnar artery and median nerve and did not pierce any neurovascular structures. CONCLUSION: In developing volar portals, after placing the cannula through the volar capsule from an inside-out approach, we recommend making a volar incision and dissecting the local anatomic structures to guard against injury. Compared to historical controls, the NanoScope was typically further from neurovascular structures.