Thank you for asking me to speak. So I don't have any conflicts of interest, but I just want to point out that I will be mentioning the European Wrist Arthroscopy Society at the end of the talk, and I actually paid them to be a member. So for any of you who may be getting tired of scoping shoulders, knees, elbows, I thought I'd talk a little bit about the wrist, that neglected joint, and just give you a little primer on wrist arthroscopy. So what makes it different from the other joints? Well, obviously, it's smaller, which affects the instrumentation that we use, also affects how we maneuver in a very tight space. It's actually made up of three distinct joints, and as demonstrated here, there are a lot of soft tissues, tendons, nerves, arteries, that we have to be cognizant of, especially when developing our portals, most of which are on the dorsal surface. As mentioned, the wrist is really three distinct joints. It's the radiocarpal joint, the midcarpal joint, and the DRUJ, and sometimes we have to individually scope all three of these in certain patients. I just want to remind you of the intrinsic ligaments that we need to be aware of during arthroscopy. Most important are the scapholunate interosseous ligament and the lunar traquitral ligament, and then some of the extrinsic volar capsular ligaments, including the radius scapho-capitate, long and short radiolunate, and then the ulnar carpal ligaments. As I mentioned, the arterial anatomy is also important for some of the more unique portals that we use, such as the 1-2 portal, as well as when performing thumb CMC arthroscopy, the ulnar portal. It's very close to the deep branch of the artery. So what are some of the indications for wrist arthroscopy? Well, some of the basic indications include chronic wrist pain, for which conservative treatment has been unsuccessful, and MRIs may be equivocal. Synovitis is shown here. This is great for washing out a septic wrist, and for some of the more common injuries, such as scapholunate and lunar traquitral tears, as well as TFCC injuries. Some more advanced techniques you can use in the wrist include treating distal radius and scaphoid fractures, managing both dorsal and volar ganglia. Arthrofibrosis is seen here after post-traumatic stiffness of the wrist, and some people are even using this for radial styloidectomies and proximal carpectomies for salvage procedures after slack and snack wrists. The arthroscopic portals are designed dorsally relative to the extensor compartments. There's also some mid-carpal portals, but the most important ones that we use are the 3-4 for viewing. Our workhorse for instrumentation is the 4-5, and then the mid-carpal portals, both ulnar and radial to the capitate. There are also some more discrete portals, such as the DREJ and some fuller portals that are occasionally used. We always use traction to distract the wrist about 10 to 12 pounds. Most of us will use just gravity irrigation rather than a pump. As a hand surgeon, I'm somewhat OCD, so I don't like a lot of fluid all over the floor, so we take care to control the outflow, use a tourniquet a lot of the time. And the instrumentation, we'll use a 30-degree, 2.7-millimeter scope for the majority of our cases, but sometimes a 1.9 scope for the smaller joints, as well as the standard manual and other equipment that you're used to for the larger joints. So just to take you briefly through the normal wrist joint, what you'd expect to see arthroscopically, this is a panoramic view of the radial carpal joint. You can see the radius approximately, the scaphoid and lunate distally, and in between a little concavity, which is the scapholunate interosseous ligament. You can also see some of the important volar carpal ligaments, such as the radioscaphocapitate, the long radiolunate, and the radioscapholunate ligament, which is really a vascular pedicle. The ulnar side of the wrist is dominated by the TFCC, which some has analogies to the meniscus in the knee. On the right side, you can see a probe, which we're using for the trampoline test to see if the TFCC is taut or if it's loose, which would indicate a tear. Mid-carpal arthroscopy, the capitate is distal, and this is the lunate and triquetral, and you can see a normal lunatriquetral joint. But in the same patient, we go over to the radial side against capitate and scaphoid and lunate, and you see a large gap between them because this is a complete scapholunate disruption. So I just want to talk about some of the pathology that we'll encounter with wrist arthroscopy. So again, I showed you the worst-case scenario of a complete disruption of the SL ligament, a Geissler 4. This is a Geissler 1. If you look at the scapholunate interosseous ligament, there's some redundancy, some pooching into the joint, and this is somebody with chronic radial-sided wrist pain. And in contrast to what's in the shoulder literature, this is successfully treated with electrothermal shrinkage. We had a small case series that we described about 15 years ago in a two-year follow-up. Ninety percent of patients were still pain-free and very functional. There have been some other authors since then who have published similar results. So it can be effective in the wrist joint in combination with immobilization for about four to six weeks afterwards. TFCC tears, again, very analogous to meniscal tears. This is an example of a linear central tear in the avascular portion of the TFCC. So again, it's not going to heal with any attempted repair. So in these cases, we'll debride that central tear. This is my favorite instrument, the suction punch, to really remove large portions of it and then finish it up with the shaver to create stable edges and reduce their pain about 85 percent of the time. And you can see the ulna just deep to that TFCC tear. Peripheral tears, again, do have vascularity and have a capacity to heal. So we treat these just as you would a peripheral meniscus. There are a couple of different techniques out there. But again, just an example of I actually use the meniscal repair kit and place a couple of PDS sutures to bring this back to the ulnar capsule and recreate the stability of the TFCC. And finally, dorsal ganglia have been spoken about a lot, but you can also treat volar ganglia through the scope. Here's an example of some synovitis. And once you debride that, you can get to the stalk between the long radial lunate ligament and radial scaphocapitate ligament. And once you put the scope in there, you can actually transluminate the ganglion from within the joint. And you resect the capsule in the origin of the stalk. As you can see on the left, once you've done an adequate resection, you can see the FPL tendon. Here's an example of a patient she had bilateral ganglia, both appearing similar to what's on her right hand. And we had resected the left arthroscopically about a year prior and doing well. So there's a wide spectrum of acute and chronic pathology that we treat with wrist arthroscopy. You can often visualize a lot of these structures better than with open arthrotomy. And if you're thinking of branching out and become a proficient wrist arthroscopist, you need to do a little preparation. Go to the cadaver lab, study the anatomy. And there are a number of courses both given in the U.S. And if you want an excuse to go to Europe, the European Wrist Arthroscopy Society does offer some advanced and basic workshops. Thank you very much.

wrist arthroscopy

ligaments

TFCC injuries

arthrofibrosis

preparation