Holmium: Yag laser-assisted wrist arthroscopy: experience with 51 cases

Holmium: Yag laser-assisted wrist arthroscopy: experience with 51 cases

36 Discussion Associated ligamentous tears are more common in fracture of the distal radius than expected and may be of importance in the outcome of ...

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Discussion Associated ligamentous tears are more common in fracture of the distal radius than expected and may be of importance in the outcome of treatment of these fractures.

T H E J O U R N A L OF H A N D SURGERY VOL. 21B S U P P L E M E N T 1

cuff of fibrous tissue to be displaced distally from the ulnar sling and impact against the ulnar-sloped edge of the triquetrum. The resulting impingement on the triquetrum causes hyperemia, periosteitis, and softening of the bone.

Patients and methods

Holmium:Yag laser-assisted wrist arthroscopy: experience with 51 cases D. J. Nagle

Northwestern University Medical School, Department of Orthopaedic Surgery Assistant Professor of Clinical Orthopaedic Surgery, Chicago, IL, USA Wrist joint debridement has traditionally been carried out using a combination of arthroscopic knives and punches and motorized debriders. These devices are often bulky and present a risk to the articular surfaces of the relatively tight radiocarpal and mid-carpal joints. The Holmium:Yag laser probes, which are less than 1 nun in diameter, lend themselves particularly well to use in small joints. The pulsed Holmium:Yag laser allows precise delivery of energy, permitting the surgeon to sculpt and ablate tissue. We report our experience using the Holmium:Yag laser in 51 cases. The laser was used for synovectomy, ablation of chondral flaps, triangular fibrocartilage debridement, osteophyte debridement, and arthroscopic ulnar head shortening. The average age of our patients was 38 years. Sixty-eight per cent were workmen's compensation cases. There were no intraoperative complications. There were no postoperative infections. No significant joint effusions were noted postoperatively. The patients regained their ranges of motion and responded to their surgical procedures as anticipated. The use of the Holmium:Yag laser in this group of patients demonstrated its feasibility and its usefulness. The Holmium: Yag laser is ideally suited for ablation of tissues in the wrist joint, particularly in regard to triangular fibrocartilage tear debridement with avoidance of transarticular passage of basket punches for the debridement of the ulnar aspect of the triangular fibrocartilage. It is also ideally suited for the arthroscopic ulnar shortening with rapid ablation of chondral tissue. The ability to control the amount of energy delivered allows precise and safe ablation of tissues with minimal danger to adjacent tissues. Appropriate training is recommended in the use of the laser.

Triquetral impingement ligament tear

We conducted a retrospective review of 32 patients surgically treated for TILT between 1989 and 1995. Group I contained 16 patients with TILT only and a mean age of 32 years. Group II contained 16 patients with TILT and associated injuries/ surgeries and a mean age of 33 years. In each case, the injury was usually the result of an occupation or sports (mostly tennis or golf) mishap involving the dominant extremity. All patients presented with marked tenderness and swelling along the ulnar aspect of the triquetrum with decreased grip strength. Interestingly, 7 (44%) patients (Group II) had previously undergone a matched ulnar resection; this may be one cause of TILT syndrome.

Technique of TILT repair The wrist is surgically approached through an ulnar transverse incision, the capsule opened, and the triquetrum inspected. The triquetrum is usually markedly hyperemic with very soft, spongy cortex in the region of impingement from the distally displaced ulnar sling. The sling traversing this area is resected along with the soft cortex along the ulnar aspect of the triquetrum. The LT joint and TFCC are evaluated and preserved intact.

Results Follow-up was available for 21 patients with a mean of 6.7 months post-operatively (range 2-25 months). Subjectively, rest pain and activity pain at the triquetral region both improved significantly in all patients except one. Objectively, Group I demonstrated an average loss of 8.1%, extension, 15.2% flexion, 5.9% radial deviation, 9.4% ulnar deviation, 27.5% grip strength, and 12.2% key pinch strength. Group II demonstrated an average loss of 7.1% extension, 19.9% flexion, 7.2% radial deviation, 10.4% ulnar deviation, 11.6% grip strength, and 13.2% key pinch strength. There were no differences in pronation or supination between any of the groups. All patients were able to resume occupational and recreational activities.

Ligamentoplasty for chronic dislocations of the distal radio-ulnar joint according to the procedure of Hui and Linscheid

J. Weinzweig, H. K. W a t s o n

D. Della Santa, D. Savioz, C. S r n r c h a u d

Hartford Hospital, University of Connecticut Medical Center, Hartford, Connecticut, USA

Unitd de Chirurgie de la Main, Hdpital Universitaire, Genbve, Switzerland

Objective Ulnar wrist pain is a complex problem whose etiology often remains elusive. The finding of tenderness directly over the triquetrum may indicate another etiology of ulnar wrist pain. When accompanied by mild-to-moderate swelling along the ulnar aspect of the wrist, limited wrist motion, decreased grip strength, a history of a wrist hyperflexion injury, and normal radiographs, localized triquetral pain is most likely attributable to a syndrome we have termed triquetral impingement ligament tear (TILT). The mechanism of injury causes an ulnar

The treatment of dislocation of the distal radio-ulnar joint (DRUJ) is controversial. Recent instabilities may be treated by simple immobilization of the forearm in a position of reduction or by repair of the triangular fibrocartilage complex (TFCC). On the other hand inveterate arthritic dislocations require a more or less complete ulnar head resection, a solution which is not always satisfactory. Many different methods have been suggested for the treatment of pure chronic DRUJ dislocation. In 1992, Hui and Linscheid proposed a ligamentoplasty stabilizing the carpus to the ulna. This procedure was used in a short series of 10 cases