**3. Outcomes**

Final evaluation was obtained from the radiological outcome, measurements of wrist and forearm motion, grip strength, the Mayo modified wrist score (Cooney et al., 1994) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Wrist flexion-extension was assessed with a goniometer. Forearm supination and pronation were assessed with the elbow flexed 90 degrees at the patient's side. Grip strength was measured with a calibrated Jamar dynamometer. The average of three trials for both hands was recorded for all strength measurements. We could recognize several advantages of arthroscopic surgery for DRF. During PART, anatomical reduction of the articular surface was achieved with fluoroscopy initially, and reduction was re-confirmed with arthroscopy. In this process, we can recognize the dissociation between fluoroscopic and arthroscopic reduction, and this dissociation was assessed. The frequency and severity of intraarticular soft tissue injury could also be evaluated using arthroscopy.

Surgical time ranged from 38 to 150 minutes (average 82 minutes). The case that needed 150 minutes included SLIL repair and TFCC debridement. One-hundred ten wrists were followed up for over 1 year so far (by May 2011). The follow-up period ranged from 12 to 48 months (average 18 months). At final follow-up, the mean palmar tilt was 5.6 degrees (-10 to 16 degrees), radial inclination 26.1 degrees (18 to 31 degrees), and ulnar variance 0.1mm (- 2mm to 5mm). The mean active extension of the wrist was 62.5 degrees (45 to 80 degrees, 92% on the uninjured side), and the mean flexion was 60.1 degrees (45 to 80 degrees, 88% on the uninjured side). The mean pronation of the forearm was 83.1 degrees (70 to 90 degrees, 96% on the uninjured side), and the mean supination was 86.5 degrees (75 to 95 degrees, 97% on the uninjured side). The mean grip strength was 88.2% (38% to 110% on the uninjured side).

In 118 wrists of intraarticular fractures, 108 wrists seemed to achieve reduction with fluoroscopy; however, there remained a gap or step-off of over 2mm in 38 cases (35.2%), confirmed arthroscopically. Among 155 wrists, SLIL injury was recognized in 44 wrists (28.9 %). According to Geissler's classification, 24 wrists were grade I, 4 were grade II, 13 were grade III and 3 were grade IV. Debridement for a torn ligament was performed in 4 wrists (grade I: 2, grade III: 2), scapholunate pinning was performed for 3 wrists of grade III, and 1 wrist of grade IV underwent reconstruction. LTIL injury was recognized in 23 wrists (14.8%). Nineteen wrists were grade I, 2 were grade II, 1 was grade III, and 1 was grade IV. Only 2 wrists of grade I were debrided for the torn ligament hung down. TFCC injury was recognized in 98 wrists (63.2%). Sixty-seven wrists were 1A tear, 5 were 1B, 1 was 1D, 7 were 1A+1B, 1 wrist was a foveal tear and 17 wrists were degenerative tear. Debridement was performed for 53 wrists (1A: 50, 1A+1B: 3), debridement and repair were performed in 1 wrist (1A+1B), repair was performed for one wrist of 1B tear and one foveal tear. Pinning was applied for one wrist of 1D tear.

The final results of 110 wrists according to the Mayo modified wrist score were 84 excellent, 24 good and 2 fair. The mean DASH score at final follow-up was 4.2 points (0 to 30). There were few complications: 3 re-dislocation of the distal fragment, 2 extensor pollicis longus rupture and 1 complex regional pain syndrome. The final results of these 6 cases were 4 good and 2 fair.

#### **4. Summary**

72 Modern Arthroscopy

Since the volar locking plate provides rigid fixation, early rehabilitation can be allowed. A dorsal splint is applied just after surgery, the splint is then removed during the daytime, and active wrist motion is started on the first day after surgery. From the second day, passive motion and grasping exercises are started with a therapist. The night splint is removed within 7 days after surgery. Forearm rotation exercises are prohibited in patients who have ulnar side injuries, such as distal ulna fracture, ulnar styloid fracture and TFCC

Final evaluation was obtained from the radiological outcome, measurements of wrist and forearm motion, grip strength, the Mayo modified wrist score (Cooney et al., 1994) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Wrist flexion-extension was assessed with a goniometer. Forearm supination and pronation were assessed with the elbow flexed 90 degrees at the patient's side. Grip strength was measured with a calibrated Jamar dynamometer. The average of three trials for both hands was recorded for all strength measurements. We could recognize several advantages of arthroscopic surgery for DRF. During PART, anatomical reduction of the articular surface was achieved with fluoroscopy initially, and reduction was re-confirmed with arthroscopy. In this process, we can recognize the dissociation between fluoroscopic and arthroscopic reduction, and this dissociation was assessed. The frequency and severity of intraarticular soft tissue injury

Surgical time ranged from 38 to 150 minutes (average 82 minutes). The case that needed 150 minutes included SLIL repair and TFCC debridement. One-hundred ten wrists were followed up for over 1 year so far (by May 2011). The follow-up period ranged from 12 to 48 months (average 18 months). At final follow-up, the mean palmar tilt was 5.6 degrees (-10 to 16 degrees), radial inclination 26.1 degrees (18 to 31 degrees), and ulnar variance 0.1mm (- 2mm to 5mm). The mean active extension of the wrist was 62.5 degrees (45 to 80 degrees, 92% on the uninjured side), and the mean flexion was 60.1 degrees (45 to 80 degrees, 88% on the uninjured side). The mean pronation of the forearm was 83.1 degrees (70 to 90 degrees, 96% on the uninjured side), and the mean supination was 86.5 degrees (75 to 95 degrees, 97% on the uninjured side). The mean grip strength was 88.2% (38% to 110% on the

In 118 wrists of intraarticular fractures, 108 wrists seemed to achieve reduction with fluoroscopy; however, there remained a gap or step-off of over 2mm in 38 cases (35.2%), confirmed arthroscopically. Among 155 wrists, SLIL injury was recognized in 44 wrists (28.9 %). According to Geissler's classification, 24 wrists were grade I, 4 were grade II, 13 were grade III and 3 were grade IV. Debridement for a torn ligament was performed in 4 wrists (grade I: 2, grade III: 2), scapholunate pinning was performed for 3 wrists of grade III, and 1 wrist of grade IV underwent reconstruction. LTIL injury was recognized in 23 wrists (14.8%). Nineteen wrists were grade I, 2 were grade II, 1 was grade III, and 1 was grade IV. Only 2 wrists of grade I were debrided for the torn ligament hung down. TFCC injury was recognized in 98 wrists (63.2%). Sixty-seven wrists were 1A tear, 5 were 1B, 1 was 1D, 7 were 1A+1B, 1 wrist was a foveal tear and 17 wrists were degenerative tear. Debridement was performed for 53 wrists (1A: 50, 1A+1B: 3), debridement and repair were performed in 1

**2.2 Postoperative management** 

repair until 3 weeks after surgery.

could also be evaluated using arthroscopy.

**3. Outcomes** 

uninjured side).

The theories of the treatment of peri- or intraarticular fractures are 1) recover alignment, 2) reduce intraarticular fragments, 3) treatment for intraarticular soft tissue injuries, 4) rigid fixation that allows early rehabilitation. Less invasive technique is recently advocated. Prognosis is generally less favorable for displaced, comminuted, intraarticular fractures. Treatment for DRF should also be performed according to these theories. Although various factors affect the prognosis of DRF, accurate reconstruction of the alignment of the radius with its carpal and ulnar articulations, articular surface and treatment of soft tissue injury of intracarpal lesions are the most important factors. Accurate reconstruction of the articular surface, with the goal of establishing anatomic congruency of that surface, is important to minimize the risk of late osteoarthritis. Knirk and Jupiter (1986) reported that displacement of 2 mm or more of the distal radial articular fragments resulted in traumatic osteoarthritis. Further investigation indicated that the critical tolerance for joint surface incongruity may be as little as 1mm (Fernandez & Geissler, 1991; Mehta et al., 2000; Trumble et al., 1994). We have experienced that reduction with a fluoroscopy is not always accurate compared to reduction with wrist arthroscopy. Dissociation between two reduction procedures was 35.2%. This rate is similar to other reports, such as 33% in Edwards (2001) and Lutsky's (2008).

If an associated carpal ligament or TFCC injury is suspected even in a nondisplaced DRF, adequate treatment is mandatory to prevent the development of carpal instability or ulnar side wrist pain. Geissler et al. (1996) demonstrated a considerable rate of soft tissue injuries associated with DRF. These soft tissue injuries have been thought to influence the functional outcome; however, the evaluations performed to date for intraarticular soft tissue injuries combined with DRF have not been sufficient. The causes of chronic wrist pain after DRF treatment were analyzed by Cheng et al. (2008): ulnocarpal abutment caused by mal-union, ulnar styloid non-union, intraarticular soft tissue injury and chondral lesion. Especially regarding the TFCC, some authors recommend acute arthroscopic repair of peripheral tear of TFCC in conjunction with distal radius fixation resulted in a highly satisfaction (Lindau et al., 2000; Ruch et al., 2003). Furthermore we have experienced over 10 cases of chronic wrist pain due to TFCC disk tear after healing of DRF with almost normal alignment. They were treated volar locking plate fixation without arthroscopic assessment or conservative treatment. For this reason, we consider that slit or flap tear of the disk should be debrided.

Wrist arthroscopy is an effective adjunct for this pathology; therefore, wrist arthroscopy may be indicated for all DRF. When volar plate fixation is indicated, the standard upright position makes it problematic to combine arthroscopy and plate fixation because traction has to be both applied and released; PART is able to solve this problem. An alternative is to use a traction table, which makes it possible to perform arthroscopy in a horizontal position (Culp & Osterman, 1995); however, this technique is sometimes more technically

Arthroscopic Treatment of Distal Radius Fractures 75

Chen NC, Jupiter JB. Current concepts review. Management of distal radial fractures. J Bone

Cheng HS, Hung LK, Ho PC et al.. An analysis of causes and treatment outcome of chronic

Chung KC, Watt AJ, Kotsis SV, et al. Treatment of unstable distal radial fractures with the volar locking plating system. J Bone Joint Surg. 2006; 88A: 2687-2694. Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg. 1994;

Culp RW, Osterman AL. Arthroscopic reduction and internal fixation of distal radius

Doi K, Hattori Y, Otsuka K, et al. Intra-articular fractures of the distal aspect of the radius:

Edwards CC II, Haraszti CJ, McGillivary GR, et al..Intra-articular distal radius fractures:

Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand

Freeland AE, Geissler WB. The arthroscopic management of intra-articular distal radius

Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an

Gruber G, Zacherl M, Giessauf C et al. Quality of life after volar plate fixation of articular fractures of the distal part of the radius. J Bone Joint Surg. 2010; 92A: 1170-1178. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J

Lindau T, Adlercruetz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage

Lozano-Calderon SA, Souer S, Mudgal C, et al. Wrist mobilization following volar plate

Lutsky K, Boyer MI, Steffen JA et al.. Arthroscopic assessment of intra-articular distal radius

Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the

Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius:

Osada D, Viegas SF, Shah MA, et al. Comparison of different distal radius dorsal and volar fracture fixation plates: a biomechanical study. J Hand Surg. 2003; 28: 94-104. Palmer AK. Triangular fibrocartilage complex lesions; a classification. J Hand Surg. 1989;

Arthroscopically assisted reduction compared with open reduction and internal

Arthroscopic assessment of radiographically assisted reduction. J Hand Surg. 2001;

intra-articular fracture of the distal end of the radius. J Bone Joint Surg. 1996; 78A:

complex cause distal radioulnar joint instability after distal radius fractures. J Hand

fixation of fractures of the distal part of the radius. J Bone Joint Surg. 2008; 90A:

fractures after open reduction and internal fixation from a volar approach. J Hand

wrist pain after distal radial fractures. 2008; 13: 1-10.

fractures. Orthop Clin North Am. 1995; 26: 739-748.

fixation. J Bone Joint Surg. 1999; 81A:1093-1110.

fractures. Hand Surgery. 2000; 5: 93-102.

Bone Joint Surg. 1986; 68A: 647-659.

distal radius. J Bone Joint Surg. 2000; 82B: 79-86.

a preliminary report. J Hand Surg. 2002; 27A: 205-215.

Joint Surg. 2007; 89: 2051-2062.

19A: 143-154.

26: 1036-1041.

357-365.

1297-1304.

14A: 594-606.

Surg. 1991; 16A: 375-384.

Surg. 2000; 25A: 464-468.

Surg. 2008; 33A: 476-484.

demanding and, using a volar and dorsal approach simultaneously, may be difficult in this position. Slade et al. (2005) reported provisional K-wire fixation of the fracture fragments of the radius after arthroscopic reduction and volar locking plate fixation; however, several cases where re-displacement of the fragments occurred when performing arthroscopy in this sequence were experienced in our series.

The volar locking plate system has been shown a reliable and satisfactory result for the DRF without arthroscopy in some chapters. Chung et al. (2006) reported the results of 87 patients, mean age of 48.9 years old, including 65% of intraarticular fracture. One year after surgery, mean grip strength was 78.7% of the contralateral side, mean flexion was 58.0 degrees, extension was 60.5 degrees, pronation was 78.6 degrees and supination was 79.6 degrees. Lozano-Calderón et al. (2008) reported the results of 60 patients treated with a single, fixed angle volar plate. They were classified into 2 groups of early motion group (range of motion was started within 2 weeks) and late motion group (range of motion was started at 6 weeks). Early motion group that was similar with our series, demonstrated 68 degrees of flexion, 56 degrees of extension, 90 degrees of pronation and 88 degrees of supination at 6 months after surgery. Grip strength was 78% of contralateral side and DASH score was 8.5. The report of 54 patients with intraarticular DRF and a mean age of 63 years by Gruber et al. (2010) demonstrated 58 degrees of flexion, 57 degrees of extension, 83 degrees of pronation, 68 degrees of supination, grasping power was 71% of contralateral side at 6 years after surgery. DASH score was 5 points at 2 years follow up. Our results were superior to those of these reports. Our results were considered to be derived from the several advantages of PART. A volar locking plate that seems to offer the most stable construct (Osada et al., 2003) enables early range of motion and grasping exercises. PART is possible with a small skin incision and preserving the pronator quadratus muscle. Arthroscopic management is less harmful to soft tissue around the wrist joint; therefore, early rehabilitation can also be indicated. Irrigation to remove fracture hematoma and debris potentially reduces the inflammatory reaction and improves the range of motion. In addition, initial treatment for concomitant SLIL injury and TFCC tear may contribute these satisfactory results.

In conclusion, wrist arthroscopy is a feasible adjunct for the treatment of DRF, especially as it can evaluate the reduction of intraarticular fragments and soft tissue injury. In recent years, volar locking plate fixation has become popular, and simultaneous arthroscopic procedures for reduction have become problematic because vertical traction has to be applied and released during surgery. A PART can overcome these difficulties, and this technique can be performed with a small skin incision, preserving the pronator quadratus muscle, and simplifies the combination of plating and arthroscopy, and achieves good final result.

#### **5. References**


demanding and, using a volar and dorsal approach simultaneously, may be difficult in this position. Slade et al. (2005) reported provisional K-wire fixation of the fracture fragments of the radius after arthroscopic reduction and volar locking plate fixation; however, several cases where re-displacement of the fragments occurred when performing arthroscopy in this

The volar locking plate system has been shown a reliable and satisfactory result for the DRF without arthroscopy in some chapters. Chung et al. (2006) reported the results of 87 patients, mean age of 48.9 years old, including 65% of intraarticular fracture. One year after surgery, mean grip strength was 78.7% of the contralateral side, mean flexion was 58.0 degrees, extension was 60.5 degrees, pronation was 78.6 degrees and supination was 79.6 degrees. Lozano-Calderón et al. (2008) reported the results of 60 patients treated with a single, fixed angle volar plate. They were classified into 2 groups of early motion group (range of motion was started within 2 weeks) and late motion group (range of motion was started at 6 weeks). Early motion group that was similar with our series, demonstrated 68 degrees of flexion, 56 degrees of extension, 90 degrees of pronation and 88 degrees of supination at 6 months after surgery. Grip strength was 78% of contralateral side and DASH score was 8.5. The report of 54 patients with intraarticular DRF and a mean age of 63 years by Gruber et al. (2010) demonstrated 58 degrees of flexion, 57 degrees of extension, 83 degrees of pronation, 68 degrees of supination, grasping power was 71% of contralateral side at 6 years after surgery. DASH score was 5 points at 2 years follow up. Our results were superior to those of these reports. Our results were considered to be derived from the several advantages of PART. A volar locking plate that seems to offer the most stable construct (Osada et al., 2003) enables early range of motion and grasping exercises. PART is possible with a small skin incision and preserving the pronator quadratus muscle. Arthroscopic management is less harmful to soft tissue around the wrist joint; therefore, early rehabilitation can also be indicated. Irrigation to remove fracture hematoma and debris potentially reduces the inflammatory reaction and improves the range of motion. In addition, initial treatment for concomitant

SLIL injury and TFCC tear may contribute these satisfactory results.

Arthroscopy. 2003; 19: 440-445.

In conclusion, wrist arthroscopy is a feasible adjunct for the treatment of DRF, especially as it can evaluate the reduction of intraarticular fragments and soft tissue injury. In recent years, volar locking plate fixation has become popular, and simultaneous arthroscopic procedures for reduction have become problematic because vertical traction has to be applied and released during surgery. A PART can overcome these difficulties, and this technique can be performed with a small skin incision, preserving the pronator quadratus muscle, and simplifies the combination of plating and arthroscopy, and achieves good final

Abe Y, Doi K, Hattori Y, et al. A benefit of the volar approach for wrist arthroscopy.

Abe Y, Doi K, Hattori Y, et al. Arthroscopic assessment of the volar region of the

Abe Y, Tsubone T, Tominaga Y. Plate presetting arthroscopic reduction technique for the distal radius fractures. Tech Hand Up Extrem Surg. 2008; 12: 136-143.

scapholunate interosseous ligament through a volar portal. J Hand Surg. 2003; 28A:

sequence were experienced in our series.

result.

**5. References** 

69-73.


**Part 3** 

**Arthroscopy of the Hip** 


**Part 3** 

**Arthroscopy of the Hip** 

76 Modern Arthroscopy

Ruch DS, Vallee J, Poehling GG, et al. Arthroscopic reduction versus fluoroscopic reduction

Ruch DS, Weiland AJ, Wolf SW, et al. Current concepts in the treatment of distal radial

Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular

Slade JF, Taksali S, Safanda J. Combined fractures of the scaphoid and distal radius: a

Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg. 1994; 19A: 325-340. Willis AA, Kutsumi K, Zobitz ME, et al. Internal fixation of dorsally displaced fractures of the distal part of the radius. J Bone Joint Surg. 2006; 88A: 2411-2417.

fractures. Instr Course Lect. 2004; 53: 389-401.

fractures. Arthroscopy. 2003; 19: 511-516.

Clin. 2005; 21: 427-441.

225-230.

in the management of intra-articular distal radius fractures. Arthroscopy. 2004; 20:

fibrocartilage complex injuries associated with intra-articular distal radius

revised treatment rationale using percutaneous and arthroscopic techniques. Hand

**5** 

*Spain* 

**Arthroscopy after Total Hip** 

*1University Hospital Donostia (San Sebastián)* 

Cuéllar Ricardo1, Ponte Juan2, Esnal Edorta3 and Tey Marc4

Hip arthroscopy has been available for some years. Although arthroscopy has not been as widely adopted in the hip joint as compared to its use in other joints, it is currently in a

This is mainly due to the description of femoroacetabular impingement syndrome, where hip arthroscopy has proven to be a precious diagnostic and therapeutic tool. The development and improvement of the technique together with the instrumentation has

The hip joint, is more difficult to access than other joints such as the knee and shoulder. This is due to its tight congruency, the degree of coverage of the ball and socket articular surfaces – the acetabulum extends beyond the equator of the femoral head - the powerful

These anatomical features restrict the manoeuvrability of the arthroscopic instruments

With the techniques for the knee and shoulder joints already well established, we have witnessed the development of arthroscopy for the diagnosis and treatment of hip disorders over the last decade (Johnston et al., 2008; Kelly et al., 2003; Larson et al., 2009; Lubowitz & Poehling, 2006). Arthroscopic techniques have improved, increasing the surgical indications and achieving better outcomes (Byrd, 2006; Byrd & Jones, 2009; Larson & Giveans, 2009; Philippon, 2007a, 2007b). This procedure is performed in children and in adults for both diagnostic and therapeutic purposes, (Kocher et al., 2005; McCarthy & Lee, 2006; Parisien, 1988; Philippon et al., 2007b; Roy et al., 2009; Sampson, 2006), the most commonly treated

The first publication concerning visualization of the hip joint was by Burman in 1931, who reported his experience in 20 hips using a 4-mm arthroscope and the use of water to achieve joint distension (Burman, 1931). He described the anterior peritrochanteric portal, concluding that this was the best option for visualizing the hip joint. He concluded that the hip joint was not suitable for arthroscopy due to the inability to access and visualize what nowadays is known as the central compartment. Although there were some other reports in the intervening years, it is considered that Gross, in 1977, was the first person to describe the

disorder being femoroacetabular impingement syndrome (Philippon et al., 2007b).

surrounding muscles and the proximity of important vessels and nerves.

making hip arthroscopy a more demanding technique.

**1. Introduction** 

phase of rapid development.

allowed broadening its indications.

**Replacement Surgery** 

*2Quirón Hospital (San Sebastián) 3Alto Deba Hospital (Mondragón) 4Dexeus University Hospital (Barcelona)* 
