Arthroscopic Debridement Alone for Intercarpal Ligament Tears

Arthroscopic Debridement Alone for Intercarpal Ligament Tears Arnold-Peter C. Weiss, MD, Kavi Sachar, MD, Keith A. Glowacki, MD, Providence, RI This study examined the role of arthroscopic debridement alone for complete and incomplete intercarpal ligament tears of the wrist. Forty-three wrists underwent arthroscopic evaluation for persistent wrist pain and were identified as having isolated scapholunate or lunotriquetral ligament tears treated by arthroscopic debridement alone of the torn ligament edges. At follow-up examination at an average of 27 months, 29 (66%) wrists having a complete scapholunate ligament tear and 36 (85%) wrists having a limited scapholunate ligament tear had either complete symptom resolution or improved symptomatology. Thirty-three (78%) wrists with a complete lunotriquetral ligament tear and 43 (100%) wrists having a limited lunotriquetral ligament tear had complete symptom resolution or improvement. No wrists were noted to have static intercarpal instability pattern changes on follow-up radiographs. Grip strength improved 23% postoperatively. These findings suggest that intercarpal ligament tears, in a majority of patients, may be treated from a symptomatic standpoint by debridement alone for at least several years. The long-term ability of this approach to maintain a pain-free wrist has yet to be determined. No statistically significant difference was noted in the symptomatic improvement rate of scapholunate compared to lunotriquetral ligament debridement. (J Hand Surg 1997;22A:344-349.)

Chronic wrist pain represents a serious clinical problem in young productive patients and is frequently refractory to conservative management. Attempts at immobilization, functional splinting, injections, and therapy modalities have all met with limited success. 1 Recently, wrist arthroscopy has been an aid in attempts to determine the cause of occult wrist pain in patients who for whom conservative management has failed and who have persistent symptoms despite prolonged conservative treatment. 2-5 Patients with chronic wrist pain are commonly evaluated by wrist arthrography and magnetic resonance imaging (MRI) to determine whether intercarpal ligament or triangular fibrocartilage complex (TFCC) injuries were present. 6,7 The sensitivity, specificity, and accuracy of these techniques in determining From the Department of Orthopaedic Surgery, Brown University School of Medicine, Rhode Island Hospital, Providence, RI. Received for publication April 24, 1995; accepted in revised form Aug. 15, 1996. No benefits in any from have been received or will be received from a commercial party related directly or indireclty to the subject of this article. Reprint requests: Arnold-Peter C. Weiss, MD, University Orthopedics, Inc., 2 Dudley Street, 2nd floor, Providence, RI 02905.

344 The Journal of Hand Surgery

the presence of these lesions has recently been called into question. 8,9 Tears of the TFCC can be successfully treated either arthroscopically or by open repair; reports have demonstrated symptom improvement after debridement of central TFCC tears.~O,U Patients with positive arthrographic or MRI findings consistent with an intercarpal ligament tear are frequently offered a limited wrist arthrodesis, or ligament reconstruction if the wrist pain persists. However, limited wrist arthrodeses often require prolonged immobilization and carry with them the risk on nonunion and loss of wrist motion. 12-~4 Ligament reconstruction of the intercarpal ligaments has an unpredictable outcome, requires prolonged immobilization, and often results in loss of wrist motion. 15-19 In addition, arthrography can determine only whether a break in the continuity of the intercarpal ligaments exists, not the magnitude of the tear present. Therefore, these reconstructive procedures are often recommended without specific knowledge of the injury severity. Wrist arthroscopy has allowed the evaluation of the intercarpal ligaments prior to undertaking any open surgical treatment to determine the magnitude of the tears themselves. A better understanding of the

The Journal of Hand Surgery / Vol. 22A No. 2 March 1997

natural history of the tears if left untreated or treated by relatively simple means would be advantageous in discussing treatment outcome with patients. It is theoretically possible that arthroscopic debridement of the torn ligament ends would incite a scar and a "healing" reaction, providing some stability to the carpus and symptom improvement. Alternatively, this procedure may represent some form of denervation of the wrist, providing the noted symptom improvement. It is unknown whether limited forms of treatment for intercarpal ligament tears, such as arthroscopic debridement, would alter the natural progression of these injuries if left untreated; this question is beyond the scope of our study. Nevertheless, improvement in symptoms alone by limited treatment may well pro.vide improved function and abilities. The purpose of this study was to determine whether arthroscopic debridement alone of identified intercarpal ligament (scapholunate or lunotriquetral) tears improved patient symptoms postoperatively.

Materials and Methods Over a 2.5-year period, 127 patients with persistent wrist pain refractory to conservative management underwent wrist arthroscopy for evaluation of possible internal derangement of the wrist. Conservative management included splint immobilization, local intra-articular injection of corticosteroid medication, and different hand therapy modalities. Only patients for whom at least 6 weeks of conservative treatment failed (no symptom improvement) and who had no radiographic evidence of wrist arthrosis were offered arthroscopic evaluation. All patients had a preoperative clinical carpal instability examination consisting of a scaphoid shift test and a lunotriquetral shear test and underwent triple-injection cinearthrography preoperatively as part of a separate prospective clinical study, followed by subsequent wrist arthroscopy (using multiple standard portals) performed by a hand surgeon (A-P. C. W,). 9,20,21 The findings of clinical examination and wrist arthrography were not used in defining outcomes from this study after arthroscopic debridement. Although not a specific aim of this study, wrist arthrography compared less than optimally to arthroscopy in defining intercarpal ligament lesions (accuracy for detecting all lesions= 60%) as previously reported in part. 9 After either general or regional anesthesia, traction to the wrist is provided by longitudinal pull to the index and middle fingers through fingertraps attached

345

to a 10-lb. (4.5 kg) weight via a pulley. Countertraction is provided to the distal humerus, with the elbow at 90 ~ by a soft cuff attached to a 10-lb. (4.5 kg) weight via a second pulley. The arm is positioned horizontally on a hand table extension. Inflow irrigation to the wrist joint is provided by a 14-gauge barbed plastic catheter placed in the 6U portal (just volar to the extensor carpi ulnaris tendon and distal to the distal ulna). A 2.9-mm arthroscope with a 25 ~ visual offset is introduced into the 3-4 portal (between the third and fourth dorsal compartments just distal to Lister's tubercle of the distal radius) via a sheathed trocar. A probe is placed in the 4-5 portal (between the fourth and fifth dorsal compartments just distal to the distal radius), then radiocarpal joint examination is conducted. Examination of the midcarpal joint is undertaken via the midcarpal radial and ulnar portals (at the midcarpal joint, radial and ulnar to the fourth compartment). All lesions noted at arthroscopy were treated, as per the protocol, by debridement alone of the torn area by an oscillating cutter blade or suction punch using the 4-5 portal. Patients were excluded if they had preoperative symptoms consistent with ulnar impingement or isolated TFCC tears. Similarly, patients were excluded if they had TFCC tears alone, large TFCC tears with a minor defect of an intercarpal ligament, and symptoms relating only to the TFCC region, or substantial osteochondral defects or arthrosis. All patients underwent splint immobilization postoperatively for 14 days and then began a hand therapy protocol concentrating on range of motion (ROM) and strengthening. Ligament tears were defined arthroscopically as being complete (without any intercarpal ligament, either volar or dorsal, remaining) or limited (the extreme volar or dorsal portion of the intercarpal ligament remaining intact, although a full-thickness disruption of the majority of the volar or dorsal ligament was present) (Fig. 1). Initial and follow-up examinations included sequential posteroanterior/latera]/power grip wrist radiographs, ROM testing, strength measurements, and symptom query (degree of pain in wrist with activity and overall influence of wrist pain on inhibiting daily use of hands; rated as mild, moderate, or severe). Forty-three patients (43 wrists) out of the 127patient cohort were identified arthroscopically as having isolated scapholunate or lunotriquetral ligament tears or predominant scapholunate or lunotriquetral ligament tears (patients with clinical symptoms and physical examination findings consistent

346

Weiss et al. / Debridement Alone for Ligament Tears

A B Figure 1. A 26-year-old patient had a 9-month history of persistent wrist pain. (A) Arthroscopic evaluation demonstrated a redundant but completely torn scapholunate ligament off the lunate edge. (B) The arthroscope could be passed between the scaphoid and lunate so that the capitate head could be visualized (S, scaphoid; C, capitate; L, lunate). This patient had arthroscopic debridement of the ligament edges alone and is completely asymptomatic, including during heavy manual labor activities, at 1.5 years after surgery.

with the injury identified, yet also having a minor secondary problem, such as a small TFCC tear-without TFCC symptoms noted at arthroscopy). The selected cohort contained 20 women and 23 men. Sixteen patients were covered by workers' compensation insurance and 2 were involved in a liability claim. Patient age averaged 32 years. Average symptom duration prior to arthroscopy was 8 months (range, 2-24 months). Thirty wrists were noted to have positive findings on scaphoid shift tests at preoperative physical examination; of these, 26 had pain centered at the scapholunate interval. Twelve wrists were noted to have positive findings on lunotriquetral shear tests; all of these had pain in the ulnar side of the carpus. Five wrists had pain that could not be localized. Preoperative posteroanterior and lateral radiographs of the wrist demonstrated a scapholunate gap of 3 mm or less in 26 wrists. Two wrists had scapholunate gaps of 4 and 5 mm. The scapholunate angle measured below 55 ~ in all patients (range, 39~176 With power grip radiographs, eight wrists were noted to have scapholunate gaps of greater than 3 mm (all of these patients had positive findings on scaphoid shift tests). Preoperative posteroanterior, lateral, and power grip radiographs demonstrated no gaps of greater than 3 mm at the lunotriquetral joint.

Fourteen patients rated preoperative wrist pain with activity as severe, 27 patients as moderate, and 2 as mild. Nineteen patients rated the ability of their preoperative wrist pain to interfere with daily activities as severe, 18 as moderate, 3 as mild, and 3 as none. Statistical analysis was performed using InStat 2.0 software (Graphpad Software, San Diego, CA).

Results The average period to follow-up examination was 27 months. At arthroscopic evaluation, 15 patients were noted to have complete scapholunate ligament tears, with 10 of these patients reporting, at final follow-up examination, complete resolution of symptoms or only occasional symptoms with heavy-use activities. Six patients in this group had small central TFCC tears; 3 were believed to be degenerative and 3 traumatic. All patients had had radial-sided wrist pain with tenderness over the scapholunate interval and had no ulnar-sided wrist pain. Five patients had persistent pain and required either scapholunate ligament reconstruction, proximal row carpectomy, or limited intercarpal arthrodesis; all 5 were involved in workers' compensation claims. Thirteen patients were noted to have limited scapholunate ligament tears, with 11 of these reporting, at final follow-up examination, complete resolution of symptoms or


only occasional symptoms with heavy activities. Three of these patients had small central TFCC tears; 1 was thought to be degenerative and 2 were thought to be traumatic. Two patients had persistent pain and required scapholunate ligament reconstructions secondarily; 1 patient had filed a workers' compensation claim and the other, a liability claim. Nine patients were noted to have a complete lunotriquetral ligament tear, with 7 patients noting, at final follow-up evaluation, complete resolution of symptoms or only occasional symptoms. Both patients with persistent pain were treated by lunotriquetral arthrodesis covered under workers' compensation insurance. Six patients were noted to have limited lunotriquetral ligament tears, and all 6 patients noted complete resolution of symptoms or only occasional symptoms with heavy-use activities. Four of these patients had small central TFCC tears, all of which were believed to be traumatic; 2 were covered by workers' compensation insurance. At arthroscopy, one patient was noted to have both a limited scapholunate and a complete lunotriquetral tear. In 17 of 24 patients (71%) with complete scapholunate and/or lunotriquetral ligament tears, symptom resolution or only occasional symptoms were noted at final follow-up evaluation. None of these patients was noted to have any evidence of a static intercarpal instability (dorsal intercalated segment instability, volar intercalated segment instability, joint gap, or scaphoid rotation) on follow-up radiographs. All patients with a complete scapholunate or lunotriquetral ligament tear were noted to have active gapping of the involved joint on both radiocarpal and midcarpal joint examination. Eleven of these 24 wrists were noted to have some stepoff at the joint involved at the midcarpal space; this finding was occasionally dynamic, requiring a probe to elicit via a ballottement maneuver of the lunate. At final follow-up evaluation, 17 of 19 patients (89%) who had limited scapholunate and/or lunotriquetral ligament tears noted symptom resolution or only occasional symptoms. A summary of the results is given in Table 1.

Postoperatively, 5 patients rated wrist pain with activity as severe, 4 as moderate, 2 as mild, and 32 as not present. Four patients rated the ability of their postoperative wrist pain to interfere with daily activities as severe, 3 as moderate, 3 as mild, and 33 as not present. Statistical analysis demonstrated a significant improvement in both pain with activity (p < .01) and pain inhibiting daily activities (p < .01) when comparing preoperative to postoperative symptoms. A summary of the results as compared to preoperative data is given in Table 2. Follow-up radiographic findings demonstrated on posteroanterior and lateral radiographs a scapholunate gap of 3 mm or less in 27 wrists and of 5 mm in 1. The scapholunate angle measured below 57 ~ in all patients (range, 41 ~176 With power grip radiographs, 5 wrists were noted to have scapholunate gaps greater than 3 ram. No lunotriquetral joint gaps of greater than 3 mm were noted with any radiographic view. No statistically significant differences in pre- and postoperative radiographic findings were noted (p = .98). All 9 patients who had persistent symptoms requiring secondary wrist ligament reconstruction, limited intercarpal arthrodesis, or proximal row carpectomy were involved in either workers' compensation or liability claims. None of these 9 patients with persistent pain had evidence of static intercarpal instability on follow-up radiographs. No statistical difference in follow-up examination interval for any of the 4 injury types with regard to patients with and without pain following arthroscopic debridement was noted (range, p = .32-.67). Grip strength measurements (Jamar dynamometer) improved 23% postoperatively from 70 to 86 lb. ROM measurements were statistically unchanged by arthroscopic surgery. Extension went from an average of 82 ~ to 70 ~ flexion from 80 ~ to 78 ~ radial deviation from 13~ to 14~ ulnar deviation from 27 ~ to 26 ~ and pronation/supination from 72o/86 ~ to 70~ ~ Statistical analysis using the chi-square test demonstrated no differences in symptom resolution

Table 1. Summary of Postoperative Symptom Results Type of Lesion Scapholunate ligament Complete Limited Lunotriquetral ligament Complete Limited

347

No. of Cases

Symptoms Resolved~Improved

15 13

10 11

67 85

9 6

7 6

78 100

% Improvement

348

Weiss et al. / Debridement Alone for Ligament Tears

Table 2. Summary of Symptom Query Results Preoperative Symptom Level

Severe Moderate Mild None

Postoperative

Pain With Activity

Pain Inhibits Daily Activities

Pain With Activity

Pain Inhibits Daily Activities

14 27 2 0

19 18 3 3

5 4 2 32

4 3 3 33

between all scapholunate and lunotriquetral ligament tears (p = .67) and between complete scapholunate and lunotriquetral ligament tears (p = .46). Preoperative physical examination findings and symptom localization were compared to the eventual findings noted at arthroscopy (Table 3).

Discussion With the advent of diagnostic tools such as wrist arthrography, MRI, and wrist arthroscopy, the diagnosis of intercarpal ligament tears in individuals with chronic wrist pain has become much more common. 22 Although many of these wrists respond to conservative treatment, there is a subset that continues to have chronic pain and disability. 23 Arthroscopy offers not only diagnostic capabilities for determining both whether a lesion is present and what the magnitude of that lesion is but also a potential treatment for intercarpal ligament tears. Arthroscopic debridement alone of complete or partial intercarpal ligament injuries can provide considerable symptom relief for patients with chronic wrist pain. Our findings regarding the effectiveness of debridement for partial intercarpal ligament injuries are similar to those noted by other authors. 24 Surprisingly, we also found substantial improvement in overall symptoms in patients who had complete ligament tears and underwent arthroscopic debridement alone. The data in this study suggest that complete intercarpal ligament tears may not respond as well as

incomplete ones to arthroscopic debridement alone from a symptom resolution standpoint. The long-term benefit of this form of treatment alone remains to be seen because it seems difficult to postulate that any reconsfitufion of the intercarpal ligament occurs after debridement of the completely tom ligament ends alone. It is possible that secondary carpal collapse may occur in these patients. Patients with limited intercarpal ligament tears may have enough continuity of the remaining ligament for the ligament to theoretically reconstitute by fibrous tissue if debridement stimulates fresh, bleeding tissue edges to heal. The results of this study suggest that all wrists that have a complete or incomplete intercarpal ligament injury and undergo arthroscopic debridement do not follow a uniform course, with a minority possibly developing secondary static carpal collapse and persistent pain, although most may never develop these secondary problems. It has been recently documented that a large number of patients who have distal radius fractures also have concomitant scapholunate ligament tears. 25 After 6-8 weeks of cast immobilization for the wrist fracture alone, the vast majority of these patients never have secondary symptoms in their wrist related to the ligament injury and their wrists do not show evidence of carpal collapse at long-term followup evaluation. These findings would support the argument that the presence of an intercarpal ligament tear alone does not necessarily, in and of itself, predispose to a poor result and may be appropriately treated with

Table 3. Correlation of Examination and Symptom Location to Arthroscopic Findings Examination Type of Lesion

Scapholunate Complete Incomplete Lunotriquetral ligament Complete Incomplete

Scaphoid Shift

Symptom Location

Lunotriquetral Shear

Scapholunate Junction

Ulnar

Diffuse

15 11

0 0

14 10

1 0

0 3

2 2

8 4

1 1

6 5

2 0


less aggressive means than ligament reconstruction or limited wrist arthrodesis. Long-term follow-up evaluation of these patients is required before any definitive treatment recommendations can be made.

References 1. Brown DE, Lichtman DM. The evaluation of chronic wrist pain. Orthop Clinic North Am 1984;15:183-192. 2. North ER, Meyer S. Wrist injuries: correlation of clinical and arthroscopic findings. J Hand Surg 1990;15A: 915-920. 3. Ruch DS, Siegel D, Chabon SJ, Koman LA, Poehling GG. Arthroscopic categorization of intercarpal ligamentous injuries of the wrist. Orthopaedics 1993; t 6:1051-1061. 4. Hanker GJ. Diagnostic and operative arthroscopy of the wrist. Clin Orthop 1991;293:165-174. 5. Whipple TL. The role of arthroscopy in the treatment of wrist injuries in the athlete. Clin Sports Med 1992; 11: 227-238. 6. Zinberg EM, Palmer AK, Coren AB, Levinsohn EM. The triple injection wrist arthrogram. J Hand Surg 1988;13A: 803-809. 7. Berger RA, Linscheid RL, Berquist TH. Magnetic resonance imaging of the anterior radiocarpal ligaments. J Hand Surg 1994; 19A:295-303. 8. Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy, and arthrotomy. J Hand Surg 1993;18A: 815-822. 9. Weiss APC, Akelman E, Lambiase R. Comparison of the findings of triple injection cine-arthrography of the wrist with those of arthroscopy. J Bone Joint Surg 1996;78A: 348-356. 10. Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg 1994;19A:143-154. 11. Palmer AK, Werner FW, Glisson RR, Murphy DJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg 1988;13A:391-394. 12. Nelson DL, Manske PR, Pruitt DL, Gilula LA, Martin RA. Lunotriquetral arthrodesis. J Hand Surg 1993;18A: 1113-1120.

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13. McAuliffe JA, Dell PC, Jaffe R. Complication of intercarpal arthrodesis. J Hand Surg 1993;18A:1121-1128. 14. Kleinman WB. Long-term study of chronic scapholunate instability treated by scapho-trapezium-trapezoid arthrodesis. J Hand Surg 1989;14A:429-445. 15. Pin VG, Young VL, Gilula LA, Weeks PM. Management of chronic lunotriquetral ligament tears. J Hand Surg 1989; 14A:77-83. 16. Lavernia CJ, Cohen MS, Taleisnik J. Treatment of scapholunate dissociation by ligamentous repair and capsulodesis. J Hand Surg 1992;17:354-359. 17. Blatt G. Capsulodesis in reconstructive hand surgery: dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clin 1987;3:81-102. 18. Almquist EE, Bach AW, Sack JT, Fuhs SE, Newman DM. Four-bone ligament reconstruction for treatment of chronic, complete scapholunate separation. J Hand Surg 199 t ;322-327. 19. Glickel SZ, Millender LH. Ligamentous reconstruction for chronic intercarpal instability. J Hand Surg 1984;9A: 514-527. 20. Botte MJ, Cooney WE Linscheid RL. Arthroscopy of the wrist: anatomy and technique. J Hand Surg 1989;14A: 313-316. 21. Whipple TL. Arthroscopic surgery: the wrist. Philadelphia: JB Lippincott, 1992. 22. Weiss APC, Akelman E. Diagnostic imaging and arthroscopy for chronic wrist pain.- Orthop Clin North Am 1995 ;26:759-767. 23. Maitin EC, Bora FW, Osterman AL. Lunotriquetral instability: a cause of chronic wrist pain. J Hand Surg 1988; 13A:309. 24. Ruch DS, Poehling GG. Arthroscopic management of partial scapholunate and lunotriquetral injuries of the wrist. J Hand Surg 1996;21A:412~17. 25. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg 1996;78A:357-365.