Revision Wrist Arthroscopy After Failed Primary Arthroscopic Treatment (SS-47)

Abstract

<h3>Introduction</h3> Arthroscopic treatment of ulnar-sided wrist pain is becoming increasingly prevalent; however, little is known about cases in which primary treatment fails to relieve symptoms. The purpose of this study was to identify common reasons for revision wrist arthroscopy. <h3>Methods</h3> Between March 1997 and July 2010, 23 non-staging revision wrist arthroscopies were performed by the senior author. Twelve patients with intercurrent relief of symptoms or traumatic injury were excluded. One was excluded based on concomitant neuropathy. The remaining eleven patients (5 male and 6 female; mean age 24 years) had symptoms that did not improve with primary arthroscopic treatment, requiring revision wrist arthroscopy at a mean of 14.7 months (4-38 months). Ten patients were originally diagnosed with triangular fibrocartilage complex (TFCC) tears; the remaining patient had no identifiable lesions. Data were collected through retrospective review of intraoperative and clinical findings. <h3>Results</h3> All 11 patients required revision procedures because of persistent wrist pain. In 5 of the 11 patients (45%), distal radial ulnar joint (DRUJ) instability was the major cause for revision. Revisions for all 5 patients revealed TFCC peripheral damage requiring repair (1 revision of an unstable repair, 4 previously treated with only debridement). One patient was lost to follow-up, but all 4 remaining (100%) had complete resolution of pain, regaining normal range of motion (ROM) with DRUJ stability. The chief cause for revision in 5 of the 11 patients (45%) was failure to treat ulnar abutment syndrome (UAS). Initially, 1 of these 5 patients presented with chronic ulnocarpal wrist pain, while 4 of the 5 had presented with pain following injury. These 4 were treated purely as traumatic TFCC tears in prior procedures, with no measures taken to correct ulnar positive variance. Notably, 2 of these patients showed ulnar neutral variance on plain films, but intraoperatively demonstrated lunate cartilaginous damage indicative of dynamic ulnar positive variance. All 5 patients were treated with an arthroscopic wafer ulnar shortening, regaining normal ROM in all cases (100%) and complete relief of pain in 4 (80%). One patient (11%) required revision for a previously undiagnosed scapholunate interosseous ligament (SLIL) tear. This was initially a traumatic case, presenting with ulnocarpal wrist pain that persisted after primary arthroscopic TFCC repair. Revision arthroscopy revealed a Grade-II SLIL tear, which was treated with radiofrequency capsular shrinkage, scaphoid reduction, and percutaneous scaphocapitate pinning. Overall, at an average of 7.3 months follow-up (3-35 months), 10 of 11 wrists (91%) exhibited full ROM, with 8 of the 10 also reporting complete resolution of ulnocarpal wrist pain, as seen in Table 1. <h3>Conclusion</h3> Careful attention to a number of key factors may reduce the incidence of revision arthroscopy. DRUJ instability can be better assessed with arthroscopic-assisted shuck testing, both before and after TFCC repair is performed. A thorough evaluation for UAS—both static and dynamic—in traumatic TFCC tears may reduce the recurrence of pain and revision procedures to address the underlying pathology. Finally, treatment outcomes for traumatic ulnocarpal wrist pain may be improved by identifying concurrent radial-side intercarpal ligament injuries.