Terry L. Whipple

Intracarpal Soft-Tissue Lesions Associated with an Intra-Articular Fracture of the Distal End of the Radius*

Sixty patients who had a displaced intra-articular fracture of the distal end of the radius were managed with manipulative reduction and internal fixation performed under both fluoroscopic and arthroscopic guidance. According to the AO/ASIF classification system, seven fractures were type B1, two were type B2, three were type B3, thirteen were type C1, twelve were type C2, and twenty-three were type C3. Forty-one patients (68 per cent) had soft-tissue injuries of the wrist, including tears of the triangular fibrocartilage complex (twenty-six patients), the scapholunate interosseous ligament (nineteen), and the lunotriquetral interosseous ligament (nine). Thirteen patients had two soft-tissue injuries. Intracarpal soft-tissue injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface or the radius.

Neurovascular anatomy and elbow arthroscopy: Inherent risks

Five cadaver elbows were examined arthroscopically. Detailed dissections of superficial cutaneous nerves and of deeper neurovascular structures were carried out either before or after arthroscopic examination. Normal neurovascular anatomy and variants were defined in relation to standard portal placement. The danger of neurovascular injury is emphasized due to inappropriate portals, direction of entry, or elbow position. A safe, reliable, and reproducible technique is defined.

Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist : A multicenter study

A multicenter study to assess arthroscopic reconstruction of the peripheral attachment of the triangular fibrocartilage complex was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Twenty-seven of the 45 wrists had associated injuries, including distal radius fracture (4), partial or complete rupture of the scapholunate (7), lunotriquetral (9), ulnocarpal (2), or radiocarpal (2) ligaments. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAC) wrist deformity. The peripheral tears were repaired using a zone-specific repair kit. The patients were immobilized in a munster cast, allowing elbow flexion and extension, but no pronation or supination for 4 weeks, followed by 2 to 4 weeks in a short arm cast or VersaWrist splint. All patients were reexamined independently 1 to 3 years postoperatively by a physician, therapist, and registered nurse. The results were graded according to the Mayo modified wrist score. Twenty-nine of the 45 wrists were rated excellent. 12 good, 1 fair, and 3 poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. One patient had chronic pain, and two patients had ulnar nerve symptoms, although motion was normal in all, and their grip strength was at least 75% of the opposite hand. Arthroscopic repair of peripheral tears of the triangular fibrocartilage complex (TFCC) is a satisfactory method of repairing these injuries.

The role of arthroscopy in the management of tibial plateau fractures.

The value of arthroscopy in the management of tibial plateau fractures was evaluated in a series of 29 patients from 1979 to 1984. It was determined that arthroscopy is of value in the management of these fractures; acute fractures and associated soft tissue injuries can be precisely defined, allowing for timely management decisions; based on direct arthroscopic observation, selected fractures can be reduced and stabilized, and appropriate postoperative management determined; and healed but symptomatic fractures may benefit from arthroscopic surgery.

Anatomic relationships in the shoulder impingement syndrome

Impingement syndrome of the shoulder may be produced by compression of the subacromial structures against the coracoacromial arch. The anterior tip of the acromion, the coracoacromial ligament, and the coracoid process have been implicated as sources of impingement. Anatomic specimens were examined to determine the anatomic sites on the coracoacromial arch that result in compression of the subacromial structures during specific shoulder motions that are known to produce impingement pain. The relationships of the supraspinatus tendon, the biceps tendon, and the greater tuberosity of the humerus with the coracoacromial arch were demonstrated through various arcs of shoulder motion in autopsy subjects. Biceps tendon impingement occurred predominantly against the lateral free edge of the coracoacromial ligament. Impingement of the supraspinatus tendon and greater tuberosity was demonstrated primarily against the acromial end of the coracoacromial ligament and the anterior tip of the acromion during arcs of flexion and internal rotation. The coracoacromial ligament was stretched by the greater tuberosity passing beneath it. This may explain the formation of traction osteophytes on the anterior acromion in patients with chronic impingement symptoms.

Intraarticular abnormalities in association with posterior cruciate ligament injuries

The effect of an isolated injury of the posterior cruciate ligament on the articular cartilage and menisci has not been extensively studied. Intraarticular abnormalities in 88 arthroscopically proven posterior cruciate ligament tears in symptomatic patients with straight unidirec tional posterior instability were reviewed. There were 33 patients with acute injuries (range, 3 to 21 days; mean, 14) and 55 patients with chronic tears (range, 28 to 3650 days; mean, 786). Of the acute injuries, chondral defects occurred in 4 patients (12%) and meniscal tears in 9 patients (27%; 6 lateral and 3 medial). Chondral defects of both the lateral femoral condyles and patella were present in all 4 patients. Of the chronic injuries, chondral defects occurred in 27 (49%) and meniscal tears in 20 patients (36%) (7 lateral and 17 medial). Chondral defects of the medial femoral condyle were most common. The mechanism of injury resulting in an isolated injury of the posterior cruciate ligament is most likely to affect the lateral compartment or the articular cartilage of the patella. The incidence of articular defects and the incidence of meniscal tears increased in patients with chronic posterior cruciate ligament injuries; both lesions increased most in the medial compartment.

ARTHROSCOPIC MANAGEMENT OF WRIST TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES IN THE ATHLETE

Wrist arthroscopy can facilitate early definitive diagnosis of debilitating soft tissue injuries in athletes. Many such injuries can be treated successfully with minimally invasive arthroscopic techniques, reducing the morbidity associated with surgical exposure and permitting earlier return to competition. The triangular fibrocartilage complex (TFCC) is vulnerable to injury from rotational forces or axial load applied to the hand. Under arthroscopic control, injuries to the central articular disk can be treated by excision of unstable tissue fragments; peripheral separation of the disk from the dorsal or volar ligaments can be repaired with sutures to achieve complete healing. Avulsion fractures from the dorsal ulnar margin of the sigmoid notch of the radius are better treated through a small arthrotomy after initial arthroscopic evaluation.

Arthroscopy-assisted fracture fixation.

PurposeThe purpose of this article was to systematically analyze the results of published studies in the literature which evaluated the use of arthroscopically assisted techniques in intra-articular fracture fixation.MethodsPublished investigations to date were analyzed by classifying them according to joints that were involved with intra-articular fractures including: knee, ankle, hip, shoulder, elbow, and wrist joints. The results were studied to assess the feasibility, efficiency, and outcomes of arthroscopy-assisted fracture fixation.ResultsArthroscopy-assisted techniques have been used successfully for the treatment of fractures of the tibial plateau, tibial eminence, malleoli, pilon, calcaneus, femoral head, glenoid, greater tuberosity, distal clavicle, radial head, coronoid, distal radius, and scaphoid. The major advantages of arthroscopic fracture fixation over open methods are direct visualization of the intra-articular space, decreased invasiveness, and the possibility for multitask interventions through which fixation of the fracture, and repair of the soft tissues and the cartilage can be performed simultaneously. The time-consuming and technically demanding nature of the procedures with a prolonged learning curve and limited fixation alternatives are the main disadvantages of this technique.ConclusionArthroscopic fixation is increasingly utilized for certain intra-articular fracture types due to the minimally invasive nature of the procedures and high accuracy. Randomized controlled trials are needed to justify wider use of arthroscopy-assisted techniques for treatment of intra-articular fractures.

A multicenter prospective review of 640 endoscopic carpal tunnel releases using the transbursal and extrabursal chow techniques

A prospective study involving eight institutions was performed, incorporating 640 cases of carpal tunnel release using a dual portal endoscopic technique. The original transbursal technique described by Chow was used in 110 cases (17%), and the modified extrabursal technique was used in 530 cases (83%). An overall complication rate of 11% was found in the patients in whom the transbursal technique was used, compared with 2.2% in the patients in whom the extrabursal technique was used. The return-to-work status was followed in 291 cases (199 non-workers compensation cases and 92 workers compensation cases). The workers compensation patients returned to work in an average of 57 days, compared with 22 days for non-workers compensation patients. This study suggests the extrabursal dual portal endoscopic technique is associated with fewer complications than the transbursal approach, and patients covered by workers compensation return to work later than non-workers compensation patients.

Laser Energy in Arthroscopic Meniscectomy

Rationale and technique are discussed for performing arthroscopic meniscectomy with a carbon dioxide laser, including presentation of findings in limited rabbit and human studies.