Clara Wing-yee Wong

Arthroscopic-Assisted Combined Dorsal and Volar Scapholunate Ligament Reconstruction with Tendon Graft for Chronic SL Instability.

Background Both the dorsal and the volar portion of the scapholunate interosseous ligament (SLIL) are major stabilizers of the scapholunate (SL) joint. Most reconstruction methods to restore SL stability do not address the volar constraints and frequently fail to reduce the SL gapping. Wrist arthroscopy allows a complete evaluation of the SL interval, accompanying ligament status, and associated SL advanced collapse (SLAC) wrist changes. It enables simultaneous reconstruction of the dorsal and palmar SL ligaments anatomically with the use tendon graft in a boxlike structure. Materials and Methods From October 2002 to June 2012, the treatment method was applied in 17 patients of chronic SL instability of average duration of 9.5 months (range 1.5-18 months). There were three Geissler grade 3 and 14 grade 4 instability cases. The average preoperative SL interval was 4.9 mm (range 3-9 mm). Dorsal intercalated segment instability (DISI) deformity was present in 13 patients. Six patients had stage 1 SLAC wrist change radiologically. Concomitant procedures were performed in four patients. Description of Technique With the assistance of arthroscopy and intraoperative imaging as a guide, a combined limited dorsal and volar incision exposed the dorsal and palmar SL interval without violating the wrist joint capsule. Bone tunnels of 2.4 mm were made on the proximal scaphoid and lunate. A palmaris longus tendon graft was delivered through the wrist capsule and the bone tunnels to reduce and connect the two bones in a boxlike fashion. Once the joint diastasis is reduced and any DISI malrotation corrected, the tendon graft was knotted and sutured on the dorsal surface of the SL joint extra-capsularly in a shoe-lacing manner. The scaphocapitate joint was transfixed with Kirschner wires (K-wires) to protect the reconstruction for 6-8 weeks. Results The average follow-up was 48.3 months (range 11-132 months). Thirteen returned to their preinjury job level. Eleven patients had no wrist pain, and six had some pain on either maximum exertion or at the extreme of motion. The average total pain score was 1.7/20 compared with the preoperative score of 8.3/20. The postoperative average total wrist performance score was 37.8/40, with an improvement of 35%. The average extension range improved for 13%, flexion range 16%, radial deviation 13%, and ulnar deviation 27%. Mean grip strength was 32.8 kg (120% of the preoperative status, 84% of the contralateral side). The average SL interval was 2.9 mm (range 1.6-5.5 mm). Recurrence of a DISI deformity was noted in four patients without symptoms. Ischemic change of proximal scaphoid was noted in one case without symptoms or progression. There were no major complications. All patients were satisfied with the procedure and outcome. Conclusion Our method of reconstructing both the dorsal and volar SL ligament, in a minimally invasive way, is a logical and effective technique to improve SL stability. The potential risk of ischemic necrosis of the carpal bone is minimized by preservation of the scaphoid blood supply, the small size of the bone tunnels created, and the inclusion of the capsule at the reconstruction site.

Imaging of radial wrist pain. Part II: pathology

Pain on the radial side of the wrist is a common clinical presentation. Such wrist pain may provide a diagnostic challenge for radiologists, in view of the small size of the anatomic structures, the occasional subtlety of the imaging findings, the diversity of potential etiologies, as well as the non-infrequent occurrence of incidental asymptomatic findings in this area. This review discusses the imaging findings in both the more common and less common causes of radial-sided wrist pain, concentrating particularly on the detection of early disease and less readily apparent abnormalities.

Imaging of radial wrist pain. I. Imaging modalities and anatomy

Radial wrist pain is a common clinical complaint. The relatively complex anatomy in this region, combined with the small size of the anatomical structures and occasionally subtle imaging findings, can pose problems when trying to localize the exact cause of pain. To fully comprehend the underlying pathology, one needs a good understanding of both radial-sided wrist anatomy and the relative merits of the different imaging techniques used to assess these structures. In part I of this review, these aspects will be discussed.

Wrist Arthroscopy under Portal Site Local Anesthesia (PSLA) without Tourniquet

UNLABELLED Purpose wrist arthroscopy is typically performed under general or regional anesthesia with the aid of a tourniquet to maintain a bloodless field. We have been using portal site local anesthesia (PSLA) for wrist arthroscopy without a tourniquet since 1998. The aim of the study was to assess the efficacy, safety, and complications of PSLA and whether this can be recommended for routine wrist arthroscopy. Method We conducted a retrospective study, identifying 111 consecutive cases of wrist arthroscopies performed from January 2007 to December 2009. All cases were performed under PSLA. The effectiveness of PSLA was assessed by analyzing whether the procedure required adjuvant forms of anesthesia. The subjective effectiveness was assessed via phone questionnaires. Results Sixty-eight male and 43 female patients were identified. The average age was 43.2 (range 16-77). The indications included chronic wrist pain of unknown origin (30), posttraumatic arthritis (27), rheumatoid arthritis (5), ganglion (30), triangular fibrocartilage complex (TFCC) injury (14), infectious (1), and carpal instability (4). The average duration of the procedures was 73 minutes (range 20-255 minutes). Therapeutic procedures were performed in all 111 cases in addition to a routine diagnostic assessment. These included arthroscopic debridement (82) synovectomy (6), ganglionectomy (30), TFCC repair (3), TFCC debridement (11), radial styloidectomy (2), wafer procedure (4), thermal shrinkage (2), distal scaphoidectomy (1), and synovial biopsy (4). All procedures could be completed uneventfully. Most patients tolerated the procedure well throughout the operation, and the satisfaction level was high. No complication was encountered. Discussions We concluded that PSLA technique is a feasible mode of anesthesia in selected patients. LEVEL OF EVIDENCE Level IV.

Do We Need to Repair the Nerves When Replanting Distal Finger Amputations

Distal replantation is an excellent model to study the results of nerve repair. We aim to demonstrate differences in aesthetic, sensory, and functional outcomes in fingertip replantation, with and without nerve repair. We recruited 28 fingers in 28 patients, who had successful distal replantation in 5 years. Half of the fingers had nerves repaired. Mean follow-up was 39 months. Symptoms of pain, numbness, cold intolerance, scar hypersensitivity, pulp atrophy, and weakness were reported. Nail width, pulp length, 2-point discrimination, Semmes-Weinstein test, and power were evaluated. We used chi-square tests of independence to examine association between nerve repair and symptoms, and independent T tests and Mann-Whitney U tests to analyze difference between replantation with and without nerve repair according to objective results. Chi-square tests reviewed no significant association between nerve repair and symptoms. Mann-Whitney U tests showed no significant difference between the groups, with and without nerve repair. All fingers showed mean 2-point discrimination of 5.6 mm, and Semmes-Weinstein test results of green in 3 fingers and blue in 17. There was no significant difference in overall outcomes in repairing nerve or not in distal finger replantation. Both groups had satisfactory outcomes. Possibly, spontaneous neurotization is present, and nerve repair is not necessary, which may help to shorten the operation time and decrease extensiveness of surgeries.

MR imaging of the traumatic triangular fibrocartilaginous complex tear

Triangular fibrocartilage complex is a major stabilizer of the distal radioulnar joint (DRUJ). However, triangular fibrocartilage complex (TFCC) tear is difficult to be diagnosed on MRI for its intrinsic small and thin structure with complex anatomy. The purpose of this article is to review the anatomy of TFCC, state of art MRI imaging technique, normal appearance and features of tear on MRI according to the Palmars classification. Atypical tear and limitations of MRI in diagnosis of TFCC tear are also discussed.

How to Teach Concepts of Surgical Skills and Strategy of Designing a Programme

In recent years, there has been rapid development of arthroscopic skills application in various anatomical regions. In order to set a standard training programme to facilitate the training of surgeons, it is important that the basic concept of arthroscopy skill acquisition is coupled with a well-designed programme. Arthroscopic training should be centred on a cadaveric model in a well-developed wet lab setting. Apart from cadaveric model training, there are emerging technologies in virtual training centre without the use of cadaver. As the learning procedure is complicated and involves extensive equipment, expertise and provision of human tissues, it is recommended to observe the regulations accredited by the International Organisation for Standardisation (ISO). Since human tissues are involved, it is important to pay attention to the procedures of procurement of the tissues, the regulations regarding handling of the tissues and the final dissemination of the remains to authorized centres. An arthroscopic training course should include basic didactic lectures of video, hands-on cadaveric demonstration and practice, live surgery, a full clinical round up with problem case discussion, and feedback from trainees. Special anatomical regions may entail specific requirements pertaining to the unique clinical condition and skill training that matches the need to handle these conditions.

Palmer Midcarpal Instability: An Algorithm of Diagnosis and Surgical Management

Background Palmar midcarpal instability (PMCI) is an uncommon form of nondissociative carpal instability. However, it is an important cause of chronic ulnar wrist pain. Diagnosis can be difficult and high index of suspicion is mandatory. Pathomechanics and optimal treatment of PMCI remain uncertain. We propose an algorithm of clinical diagnosis and evaluate the outcome of our management. Materials and Methods Between 2000 and 2011, 16 patients, including 7 males and 9 females, of a mean age of 33.9 diagnosed with PMCI were reviewed for their clinical, radiologic, and arthroscopic features. All patients presented with ulnar wrist pain in their dominant hands except in one. Initial management included a disease‐specific anticarpal supination splint. Refractory cases were evaluated by arthroscopy and treated by arthroscopic thermal shrinkage using radiofrequency appliance as an interim or definite surgical intervention. Shrinkage was targeted at the ulnocarpal ligament at the radiocarpal joint and triquetrohamate ligament at the midcarpal joint. Nonresponsive or recurrent cases were managed by a novel technique of dorsal radiocarpal ligament reconstruction procedure using a pisiform‐based split flexor carpi ulnaris (FCU) tendon graft. Results In all cases, the midcarpal clunk test was positive with pain. Other common clinical features included lax ulnar column, carpal supination, volar sagging of the wrist, increased pisostyloid distance, wrist pain aggravated by passive hand supination and not by passive forearm supination, and increased wrist pain upon resisted pronation, which could be partially alleviated by manually supporting the pisostyloid interval. Common arthroscopic findings were excessive joint space at triquetrohamate interval and reactive synovitis over the ulnar compartments. Nine patients (56.3%) responded well to splinting alone at an average follow‐up of 3.3 years. Arthroscopic thermal shrinkage was performed in five patients with recurrence in two patients. Five patients received split FCU tendon graft for ligament reconstruction. All patients showed improvement in the wrist performance score (preop 21.0, postop 36.6 out of 40) and pain score (preop 10.0, postop 2.2 out of 20) at the final follow‐up of average 86 months (range: 19‐155 months). Grip strength improved from 66.9 to 82.0% of the contralateral side. Wrist motion slightly decreased from a flexion/extension arc of 132 to 125 degrees. Three patients were totally pain free, one had mild pain, and one had moderate fluctuating pain. All patients returned to their original works. X‐ray showed no arthrosis. Conclusion PMCI is an uncommon but significant cause of chronic ulnar wrist pain. We have developed a clinical algorithm for diagnosis of the condition. The natural history seems to favor a benign course. Conservative treatment with an anticarpal supination splint is recommended as the initial management. Surgical options for resistant cases include arthroscopic thermal shrinkage or soft tissue reconstruction. The reconstruction of the dorsal radiocarpal ligament using a pisiform‐based split FCU tendon graft provides reliable restoration of the carpal stability with good long‐term outcome and few complications. This should be considered a viable alternative to limited carpal fusion.

Arthroscopic Management of Thumb Carpometacarpal Joint Arthritis

The thumb carpometacarpal joint (CMCJ1) is born to have good freedom of motion. However, the excellent mobility at this joint also predisposes attenuation of capsuloligamentous structures, joint incongruity, instability, and osteoarthritis. The prevalence of radiographic CMCJ1 arthritis is high. There is no single ideal surgery for all stages of CMCJ1 arthritis, and for all kinds of patients. The arthroscopic approach seems to provide a better alternative with rewarding preliminary results. It includes arthroscopic synovectomy/debridement/thermal shrinkage, arthroscopic partial trapeziectomy and suture button suspensionplasty, and arthroscopic CMCJ1 excision/suture button suspensionplasty/K-wire fixation.

Comparison of treatment effects on lateral epicondylitis between acupuncture and extracorporeal shockwave therapy

Background Lateral epicondylitis is one of the most common overuse injuries, and has been reported to reduce function and affect daily activities. There is no standard therapy for lateral epicondylitis. In Hong Kong, acupuncture and extracorporeal shockwave therapy (ESWT) have been popular in treating lateral epicondylitis in recent years. Objective This study is to compare the treatment effects of acupuncture and ESWT on lateral epicondylitis. Methods In this study, we evaluated 34 patients (34 elbows) with lateral epicondylitis. Seventeen patients were treated by 3-week ESWT, one session per week. Another 17 were treated by 3-week acupuncture therapy, two sessions per week. The outcome measures included pain score by visual analogue scale, maximum grip strength by Jamar dynamometer, and level of functional impairment by disability of arms, shoulders, and hands questionnaire. Participants were assessed at three time points: baseline; after treatment; and 2-week follow-up. Results The two treatments showed no significant difference at any assessment time-point. Both treatment groups had significant improvement in pain score in longitudinal comparisons. No significant difference was found in maximum grip strength and functional impairment in either treatment group, but a trend of improvement could be observed. In addition, improvement in pain relief stopped when treatment ended for either groups. Conclusions The treatment effects of acupuncture and ESWT on lateral epicondylitis were similar. The pain relief persisted for at least two weeks after treatment.