David J. Slutsky


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3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

Office hours: M-F, 9am – 5 pm

Worker’s compensation, Medicare and most insurance plans accepted.

In September 2008, we will be moving to a beautiful new 4,400 sq ft, state of the art dedicated hand center located at 2808 Columbia Ave in Torrance, CA., which will feature onsite nerve conduction studies, occupational hand therapy and digital x-ray.
 


PROCEDURES

WRIST ARTHROSCOPY

Wrist arthroscopy has revolutionized the treatment of wrist disorders, just as knee arthroscopy revolutionized the treatment of knee injuries. The ability to visualize the intra-articular wrist anatomy in nearly microscopic detail has led to a heightened ability in defining the origins of wrist pain. On occasion it may be difficulty differentiating normal anatomy from abnormal pathology. In addition, the pathological findings may not always correlate with the clinical symptoms.

Although wrist arthroscopy was first reported in 1979, it was popularized starting in 1985 when a number of investigators developed standardized methods for viewing wrist anatomy. Wrist arthroscopy requires use of a smaller arthroscope and smaller instrumentation than the knee. The arthroscope is introduced through a number of portals or openings on the dorsum (back) of the wrist. Anatomical cadaver studies performed by the author has lead to the use of two volar wrist portals(/publications/volar_portals.pdf) (i.e. palmar surface of the wrist) which have increased the diagnostic yield and aided in the treatment of scapholunate and lunotriquetral ligament tears. The portals are safe areas that have been worked out between the tendons where there is minimal risk of injuring an artery or nerve. The portals are numbered based on their position relative to the extensor tendon compartments. The standard portal is between the 3rd extensor compartment (the long thumb extensor tendon) and the 4th extensor compartment (the finger extensors), and is called the 3,4 portal. Similarly the 4,5 portal is between the finger extensors and the extensor digiti minimi tendon to the small finger. A catheter is inserted on the ulnar side of the wrist for outflow drainage, and irrigation fluid is introduced through the arthroscope. The wrist is kept in traction to distract the joint and allow an easier visualization of the wrist anatomy.

The wrist consists of 2 anatomically separate compartments, the radiocarpal joint, which is the space between the radius and the proximal row of carpal bones i.e. the scaphoid, lunate and triquetrum, and the midcarpal joint, which is the space between the distal row of carpal bones i.e. the capitate and hamate. There are two portals available for viewing the midcarpal joint.

Wrist Pain
In general, wrist pain is initially investigated with a thorough history and physical exam, followed by plain x-rays. If the pain is not controllable with conservative measures then an arthrogram or an MRI with contrast, may be performed. This consists of injecting dye into the two separate wrist compartments and watching for abnormal leakage of the dye under fluoroscopy. Any leakage may be suggestive of a torn ligament between two of the wrist bones i.e. the scapholunate and lunotriquetral ligaments. A tear or stretching injury of the scapholunate ligament (link to SL ligament figure) is a common cause of persistent pain on the radial or “thumb side” of the wrist, but this will not show up on an MRI or arthrogram since there is no actual tear or hole in the ligament substance. Similarly synovitis can only be detected arthroscopically (link to synovitis figure). With severe ligament tears arthroscope can be inserted in the gap to view directly from the midcarpal to the radiocarpal joint (link to SL gap figure). The pain often worsens with wrist extension such as performing a push up, but may also cause pain during gripping and lifting. Pain on the ulnar side or “small finger” side of the wrist is commonly due to a tear of the triangular fibrocartilage (TFC), which is triangular shaped structure that supports the ulnar wrist bones. This may be associated with a tear of the lunotriquetral ligament as well (link to LT tear figure).

The Bone scan is a fairly nonspecific screening test and has largely been replaced by the MRI. The MRI is an excellent diagnostic test for specific lesions especially avascular necrosis of the lunate (Kienböck’s disease) but it still lags behind an MRI of other joints in establishing the diagnosis of a torn intracarpal ligament or a torn TFC. Arthroscopy has transformed the treatment of these ligament injuries which may not be detected by an MRI and /or arthrogram. Up to 65% of the time, pathology may be visualized arthroscopically that was not detected by x-ray or MRI.

By directly viewing the ligaments between the scaphoid, lunate and triquetrum, partial ligament tears and ligament instability can be directly assessed (link to diagnostic wrist arthroscopy video). Partial ligament tears can be successfully treated with debridement i.e. removing the frayed edges which cause impingement with joint motion, or with thermal shrinkage, which tightens up stretched ligaments. Previously undiagnosed injuries to the cartilage of the carpal bones in particular cannot be detected by any other means (link to cartilage defect figure). TFC tears are preferentially diagnosed arthroscopically since the arthrogram cannot accurately localize the site of the tear. Tears on the periphery of the triangular cartilage can be successfully repaired (link to TFCC tear 1-3). since the periphery has a vigorous blood supply which will allow healing by scar (link to TFCC repair video). The central portion of the TFC has no blood supply and is usually treated by debriding the tear so that the jagged edges will not cause symptoms by impinging on the carpal bones (link to TFCC debride 1,2). If the ulnar head is longer than the radius (ulna plus variance) then the ulna itself is shortened to decrease the load across the TFC (link to wafer 1,2). This can also be performed arthroscopically, and is called a “wafer resection” (link to wafer resection video). Removal of loose bodies and synovectomies can also be performed without opening the wrist joint (link to loose body figure).

Through the use of the volar portals, the author has reported on tears of the dorsal radiocarpal ligament (DRCL) which is one of the important secondary wrist stabilizers, located on the dorsal (back) part of the wrist. (link to DRCL tear ) (link to dorsal radiocarpal ligament paper). This injury was previously unknown and is surprisingly common. In a review of 64 patients who underwent wrist arthroscopy by the author, 35 of these patients were found to have a DRCL tear! (link to DRCL incidence paper). Of this group 6 patients were found to have an isolated DRCL tear that was solely responsible for their wrist pain. The author devised an arthroscopic repair method which consists of placing a suture through the torn ligament (link to DRCL 1-3) (link to DRCL repair video). All of the patients with an isolated DRCL tear had complete relief of their pain and returned to their previous occupation and recreational activities. DRCL repairs when combined with other wrist pathology however had mixed results, which are largely dependent on the results of treatment of the associated ligament injuries.

Procedures
The number of arthroscopic procedures continues to grow. Arthroscopic removal of a wrist ganglion has become commonplace and has the advantage of allowing one to examine the wrist ligaments at the same time (link to ganglion 1,2). The scaphoid is a frequently fractured wrist bone in young adults that is now often treated with percutaneous screw fixation. Arthroscopy allows one to directly visualize the fracture site to ensure an anatomic reduction (link to scaphoid 1,2). Guide wires are placed through the skin and checked by x-ray. A specially designed cannulated screw is then passed down the guide wire (link to scaphoid ARIF video). The screw can be inserted either from the palmar or dorsal surface of the wrist depending upon which part of the scaphoid is fractured and then the fracture is visualized arthroscopically to ensure an anatomic reduction (link to scaphoid 3 - 6). With longstanding scaphoid fractures that have failed to heal i.e. “a scaphoid nonunion”, bone graft can be harvested with a bone biopsy needle from the iliac crest and injected in to the fracture site, or alternatively demineralized bone matrix can be used (link to scaphoid 7,8). Scaphoid fractures and nonunions typically heal much faster following percutaneous techniques as compared to an open screw insertion and may not require casting, although full time splinting is necessary until fracture site healing is demonstrated by a CT scan.

Arthroscopic assisted fixation of distal radius fractures has been shown to yield superior results as compared to open procedures (link to radius ARIF video). The amount of fragmentation or “comminution” is usually underestimated by x-rays (link to radius 1 - 3). The fracture can then be reduced by introducing instruments through small skin incisions under fluoroscopy (link to radius 4-6). The fracture fragments are also viewed directly arthroscopically and initially held with percutaneous k-wires (link to radius 7-9). In many cases a nonbridging external fixator can be applied which allows immediate wrist motion, also in a percutaneous manner (link to radius 10). The final result can be quite gratifying and does not leave any implanted metal (link to radius 11).

In general, the recovery time following wrist arthroscopy is in the range of 4 weeks following v.s. 8-12 weeks for open procedures on the wrist. In addition, the risk of postoperative loss of wrist motion is greatly diminished.

Work Considerations
The type of procedure will determine the return to work.

Dorsal Radiocarpal Ligament Repair

The wrist is immoblized in a short arm cast for 6 weeks followed by therapy for wrist motion up to 12 weeks. Light clerical duty may be tolerated at 8 weeks but heavy manual labor may not be possible until between 4-6 months.

Scapholunate or Lunotriquetal Ligament / Triangular fibrocartilage debridement

most people can perform one-handed work activity by the 2nd week followed by light duty including clerical work at 6-8 weeks. Heavy manual labor can often be resumed by 8 -12 weeks.

Arthroscopic Scapholunate reduction and pinning

The k-wires are typically removed at 6-8 weeks followed by a removal splint and protected range of motion for up to 12 weeks. Light clerical duty may be tolerated at 12 weeks but heavy manual labor may not be possible until between 4-6 months.

Triangular fibrocartilage repair

The wrist is immoblized in a long arm splint for 6-8 weeks followed by therapy for wrist motion up to 12 weeks. Light clerical duty may be tolerated at 12 weeks but heavy manual labor may not be possible until between 4-6 months. The patient may not reach maximal improvement for up to 1 year hence long term activity modification is often needed.