Introduction. The wrist arthroscopy has been performed since 1979. With the advances in technology and surgical expertise, wrist arthroscopy has become third commonest procedure after knee and shoulder joint. Wrist arthroscopy has become a gold standard for diagnosing TFCC pathologies and other intercarpal disorders. Our aim was to compare the clinical, MRI and arthroscopic findings while treating various wrist pathologies. Materials/Method. In retrospective trial, 30 patients (19 male and 11 female) with clinical evidence of wrist lesions were evaluated with MRI followed by wrist arthroscopy. The mean age of the patients at the time of outpatient appointment was 44 years with an average waiting time of 6.6 months. Inclusion criteria: all patients undergoing wrist surgery. Exclusion criteria: septic arthritis, acute distal radius fractures. Kappa analysis was used to compare the three methods of wrist pathology assessment. The total 30 patients were assessed for clinical findings, MRI report and corresponding arthroscopic findings. Results. According to the clinical findings, 22 patients (68% of all patients) were diagnosed with suspected TFCC injury. In 21 patients, the MRI showed TFCC tear (partial to complete) and this was confirmed by arthroscopy in 22 patients. There was a correlation of clinical, MRI and arthroscopy in detecting TFCC lesions in 95% cases. Sensitivity 93%, specificity 90%, positive predictive value 89% and negative predictive value 94%. The Scapho-lunate ligament tear was suspected in 8 (28% of all patients). In 6 patients, MRI showed scapho-lunate tear and this was confirmed by wrist arthroscopy in 10 patients. Correlation with wrist arthroscopy was 80%, sensitivity 94%, specificity 92%, positive predictive value 90% and negative predictive value 93%. 15 patients (50% of all patients) showed signs of moderate to severe cartilage wear and 12 patients had confirmation with MRI. Correlation with wrist arthroscopy was 75%, Sensitivity 90%, Specificity 91%, positive predictive value 89% with negative predictive value 92%. However clinical examination and MRI had poor correlation with wrist arthroscopy in diagnosing synovitis. Discussion. The MRI and wrist arthroscopy has fair correlation, though MRI sensitivity approaches that of arthroscopy, it cannot replace it at the moment. However, it is a potent additional tool for wrist diagnosis if intra-articular contrast is used. It can facilitate diagnosis and indications for surgery of the wrist. It may make arthroscopic and more invasive interventions for diagnostic purposes avoidable in future. Our results showed clinical examination is crucial for diagnosing wrist pathologies, MRI can be used as an adjunct but the wrist arthroscopy still remains the gold standard tool for diagnosis and therapeutic interventions

Chauffeur fractures or isolated radial styloid fractures (IRSF) are known to be associated with scapholunate ligament (SL) injuries. Diagnosis without arthroscopic confirmation is difficult in acute fractures. Acute management of this injury with early repair may prevent the need for more complex reconstructive procedures for chronic injuries. We investigated if all IRSF should be assessed arthroscopically for concomitant SL injuries. We performed a prospective cohort study on patients above the age of 16, presenting to the Gold Coast University Hospital with an IRSF, over 2 years. Plain radiographs and computerized tomography (CT) scans were performed. All patients had a diagnostic wrist arthroscopy performed in addition to an internal fixation of the IRSF. Patients were followed up for at least 3 months post operatively. SL repair was performed for all Geissler Grade 3/4 injuries. 10 consecutive patients were included in the study. There was no radiographic evidence of SL injuries in all patients. SL injuries were identified arthroscopically in 60% of patients and one third of these required surgical stabilisation. There were no post operative complications associated with wrist arthroscopy. We found that SL injuries occurred in 60% of IRSF and 20% of patients require surgical stabilisation. This finding is in line with the literature where SL injuries are reported in up to 40-80% of patients. Radiographic investigations were not reliable in predicting possible SL injuries in IRSF. However, no SL injuries were identified in undisplaced IRSF. In addition to identifying SL injuries, arthroscopy also aids in assisting and confirming the reduction of these intra-articular fractures. In conclusion, we should have a high index of suspicion of SL injury in IRSF. Arthroscopic assisted fixation should be considered in all displaced IRSF. This is a safe additional procedure which may prevent missed SL injuries and their potential sequelae

Physical examination is critical to formation of a differential diagnosis in patients with ulnar-sided wrist pain. Although the specificity and sensitivity of some of those tests have been reported in the literature, the prevalence of positive findings of those provocative maneuvers has not been reported. The aim of the study is to find the prevalence of positive findings of the most commonly performed tests for ulnar sided wrist pain in a population presenting to UE surgeon clinics, and to correlate those findings with wrist arthroscopy findings. Patients with ulnar sided wrist pain were identified from a prospective database of patients presented with wrist pain from September 2014. Prevalence of positive findings for the following tests were gathered: ECU synergy test, ECU instability test (Ice cream and Fly Swatter), Lunotriquetral ballottement, Kleinman shear, triquetrum tenderness, triquetrum compression test, triquetral-hamate tenderness, pisotriquetral shuck test, ulnar fovea test, ulnocarpal impaction (UCI) maneuver, UCI maneuver with fovea pressure (ulnar carpal plus test), piano key sign. A subgroup was then created for those who underwent wrist arthroscopy, and analysis of the sensitivities, the specificities and the predictive values of these provocative tests was carried out with correlation to arthroscopic finding. Prevalence of ECU instability tests was t 1.13% (ice cream scoop) and 1.5% (fly swatter). Lunotriquetral ballottement test's positive findings range from 4.91% (excessive laxity) to 14.34% (pain reproducing symptoms. The Kleinman shear test yielded pain in 13.58% of patients, and instability in only 2.26%. Triquetrum compression test reproduces pain in 32.83% of patients, and triquetral-hamate tenderness reproduced pain in 13.21%. Pisotriquetral grind test yields 15.85% positive findings for pain, and 10.57% for crepitus with radioulnar translation. The ulnar fovea test revealed pain in 69.05% of cases. The UCI maneuver yielded pain in 70.19%. The UCI maneuver plus ulnar fovea test reproduced pain in 80.38% of cases. Finally, the piano key sign yields positive finding in 2.64% of cases. For patients who underwent surgery, sensitivities, specificities and predictive values were calculated based on arthroscopic findings. The lunotriquetral ballottement test has 59.6% sensitivity, 39.6% specificity, 20.3% positive predictive value and 85.4% negative predictive value. The sensitivity of Kleinman test was 62.4%, the specificity was 41.3%, the positive predictive value was 23.5%, and the negative predictive value was 83.2%. The sensitivity of fovea test was 94.3%, the specificity was 82.5%, the positive predictive value was 89.5% and the negative predictive value was 92.3%. The UCI maneuver plus ulnar fovea test has 96.5% sensitivity, 80.7% specificity 86.4% positive predictive value, and 95.3% negative predictive value. Among the provocative tests, the prevalence of positive findings is low in the majority of those maneuvers. The exceptions are the fovea test, the UCI maneuver, and the UCI plus maneuver. With regard to the sensitivity and the specificity of those tests, the current study reproduces the numbers reported in the literature. Of those patients who underwent wrist arthroscopy, the tests are better at predicting at the absence of injury rather than at predicting its presence

Introduction. We reports the accuracy of direct Magnetic Resonance Arthrography (MRA) in detecting Triangular Fibrocartilage Complex (TFCC), Scapho-Lunate Ligament (SLL) and Luno-Triquetral Ligament (LTL) tears using wrist arthroscopy as the gold standard. Methods. We reviewed the records of all patients who underwent direct wrist MRA and subsequent arthroscopy over a 4-year period between June 2007 and March 2011. Demographic details, MRA findings, arthroscopy findings and the time interval between MRA and arthroscopy were recorded. The scans were performed using a 1.5T scanner and a high resolution wrist coil. All scans were reported by a musculoskeletal radiologist. Sensitivity, specificity, positive and negative predictive values (PPV & NPV) were calculated. Results. Two hundred and thirty four (234) MRA were performed over the study period. Fifty patients (50), who subsequently underwent 51 wrist arthroscopies (one bilateral), were included. The mean age was 35 years (range 16–64 years). The average delay between MRA and arthroscopy was 4.8 months (median 4 months, range 17 days–18 months). All patients were symptomatic with wrist pain. At arthroscopy, 26 TFCC tears, 7 SLL tears and 3 LTL tears were found. For TFCC, sensitivity was 96%, specificity 88%, PPV 89% and NPV 96%. For SLL, the values were 57%, 66%, 21% and 91% respectively. For LTL, 67%, 79%, 17% and 97%, respectively. Receiver Operating Characteristic (ROC) curve analysis showed that MRA only reliably differentiates between patients with and without TFCC tears (Area Under Curve AUC = 0.92, p < 0.0001) but not SLL (AUC = 0.62, p=0.28) or LTL (AUC = 0.73, p=0.17) tears. Conclusion. MRA is a sensitive and specific imaging modality for diagnosing TFCC tears. However, the diagnostic accuracy for SLL and LTL tears was not satisfactory. Wrist arthroscopy remains the gold standard if there is a clinical suspicion of inter-carpal ligament tears

The management of scapho-lunate (SL) instability remains controversial. Since 2001, the senior author has used a modified Brunelli tenodesis to achieve soft tissue stabilization in patients presenting with dynamic or static SL instability. From 2001 to 2009, 13 patients were prospectively studied. All patients complained of painful clicking in the wrist, inability to use the wrist for loading activities, and all had a positive scaphoid shift test (Kirk Watson). Wrist arthroscopy was performed to confirm the diagnosis and to confirm the absence of degenerative change in all cases. Data collection pre-operatively included, range of motion, grip strength, DASH score and pain score. All patients had wrist immobilisation in a forearm cast for six weeks post operatively. Physiotherapy commenced at that stage and clinical assessment was performed at 3 months, six months and 12 months post surgery. Patients were discharged from follow-up after 12 months. A significant improvement in grip strength and DASH score was documented at the 12 month post operative assessment. The range of wrist flexion was decreased in all patients. The majority returned to their original employment. All patients reported that their wrist instability symptoms were improved. Conclusion. Scapho-lunate ligament reconstruction using a split flexor carpi radialis tendon graft to achieve soft tissue stabilization, provided satisfactory results in patients with chronic SL instability. Improvement in DASH score and grip strength were documented at one year follow-up

There is a difference of opinion regarding the usefulness of MR Imaging as a diagnostic tool for triangular fibrocartilage complex (TFCC) tears in the wrist. Our aim was to determine the accuracy of direct magnetic resonance arthrography (MRA) in the diagnosis of triangular fibrocartilage complex (TFCC) tears of the wrist in a district general hospital setting. In a retrospective review of 21 patients who presented with complains of wrist pain and following a clinical examination, all had direct MR arthrography of the wrist in our hospital in a 1.5Tesla scanner. All had a diagnostic arthroscopy within 2-4 months of the MR scan. All patients had chronic ulnar sided wrist pain, although only two had a definite history of trauma. The findings of each diagnostic method were compared, with arthroscopy considered the gold standard. Twenty-one patients were studied (10 male: 11 female), mean age 42 years (range 27-71) years). Seventeen TFCC tears were diagnosed on arthroscopy. For the diagnosis of TFCC tears MRA had a sensitivity, specificity and accuracy of 67%. Our results echoed the opinion of some of the previous investigators with an unacceptable sensitivity or specificity for a diagnostic tool. MR arthrography needs to be further refined as a technique before it can be considered to be accurate enough to replace wrist arthroscopy for the diagnosis of TFCC tears. Other centres have reported better accuracy, using more advanced MRI technology. Until this iswidely available at all levels of healthcare the results of MRI for the diagnosis of TFCC tears should be interpreted with caution

Skills simulation is increasingly used as a training tool in postgraduate surgical training. Trainee's perception of the value of this experience has not previously been investigated. Our aim was to investigate the value of surgical simulation training delivered by an arthroscopy skills course. We constructed a subject-specific, self-assessment questionnaire based around the ISCP Peer Assessment Tool. The questionnaire was administered to candidates before and after attending the Plymouth Arthroscopy Skills Course. Participant demographic data was recorded. Questionnaire data was interrogated to give an overview of the course, as well as the benefit of site-specific skills stations. Statistical analysis showed the data to be normally distributed. The paired T-test was used to compare mean values. Twelve surgical trainees attended the course – CT2 trainees (n=4); ST3 trainees (n=7); ST4 trainee (n=1). 11 candidates completed both administered questionnaires giving a 92% response rate. The global mean score at the beginning of the course was 2.39. The global mean score at the end of the course was 3.90. The mean improvement was 1.51 (p<0.01; 95% CI = 0.96–2.07). Skill station specific scores all showed improvement with the greatest effect in wrist arthroscopy. CT trainees had a lower mean score compared to ST trainees. Both groups completed the course with similar mean scores. This study shows that arthroscopy simulation improves trainee-reported ratings of surgical skill. It also shows that less experienced candidates derived the greatest benefit from the training. Further research is required to compare self-assessed performance against objective benchmarks using validated assessment tools

Skills simulation is increasingly used as a training tool in postgraduate surgical training. Trainee's perception of the value of this experience has not previously been investigated. The aim of this investigation was to investigate the value of surgical simulation training delivered by an arthroscopy skills course. We constructed a subject-specific, self-assessment questionnaire based around the ISCP Peer Assessment Tool. The questionnaire was administered to candidates before and after attending the Plymouth Arthroscopy Skills Course. Participant demographic data was recorded. Questionnaire data was interrogated to give an overview of the course, as well as the benefit of site-specific skills stations. Statistical analysis showed the data to be normally distributed. The paired T-test was used to compare mean values. Twelve surgical trainees attended the course – CT2 trainees (n=4); ST3 trainees (n=7); ST4 trainee (n=1). 11 candidates completed both administered questionnaires giving a 92% response rate. The global mean score at the beginning of the course was 2.39. The global mean score at the end of the course was 3.90. The mean improvement was 1.51 (p<0.01; 95% CI= 0.96-2.07). Skill station specific scores all showed improvement with the greatest effect in wrist arthroscopy. CT trainees had a lower mean score compared to ST trainees. Both groups completed the course with similar mean scores. This study shows that arthroscopy simulation improves trainee-reported ratings of surgical skill. It also shows that less experienced candidates derived the greatest benefit from the training. Further research is required to compare self-assessed performance against objective benchmarks using validated assessment tools

Introduction. Midcarpal instability is an uncommon but troublesome problem. Patients have loss of dynamic control of the wrist in pronation and ulnar deviation due to laxity of the volar wrist ligaments that is often congenital or due to minor trauma. For those in whom conservative measures fail, open ligament reconstruction or fusions have been described. Aim. We prospectively studied a series of fourteen patients who underwent arthroscopic thermal capsular shrinkage for midcarpal instability. Methods. All patients were assessed clinically and by fluoroscopy and arthroscopy to confirm the diagnosis. Wrist arthroscopy with four portals was performed and monopolar radiofrequency capsular shrinkage was performed using a 2.3mm probe. Post-operatively the wrist was immobilised in a splint for 6 weeks. Results. Fourteen wrists in eleven patients were treated. Mean length of follow-up was 44 months. Symptoms of instability never occurred in three wrists and rarely occurred in eleven. The patient's subjective overall assessment of the wrist was ‘much better’ in ten wrists, ‘better’ for one wrist and ‘worse’ for three wrists. These three cases had persistent pain but improvement of instability symptoms. Two of these cases belonged to the same patient who had Ehlers Danlos syndrome. All patients were satisfied with the outcome and would have the same procedure again. The mean pre-operative DASH score was 35.2 and 17.1 at the most recent follow-up. Mean flexion decreased by 25% and mean extension by 17%. There were no significant complications. Conclusion. Capsular shrinkage is an effective procedure for midcarpal instability. Although there are some concerns regarding deterioration of results over time as seen in shoulder instability, these mid-term results show that this is currently not a problem