Arthroscopy of large joints such as the knee and shoulder is very common, however the use of the procedure to treat the wrist is a much more recent development with indications and techniques continuing to evolve.
From the 1980s to 1990s, wrist arthroscopy gained popularity primarily as a diagnostic tool and was soon acknowledged as the gold standard in the diagnosis of a number of intra-articular wrist pathologies. With more recent advances in technology and the development of joint-specific and technique-specific instrumentation, the number of therapeutic arthroscopic wrist techniques described continues to expand.
Arthroscopy can provide a number of benefits over traditional open surgery for several conditions in and around the wrist.
It is less invasive and the incidence of post-operative capsular contracture is reduced. Much like in larger joints, the amount of joint surface that can be examined is actually increased thanks to the small size of the instrumentation and angled nature of the scope, essentially allowing the surgeon to ‘look around corners’.
While commonly operated under general anaesthesia, wrist arthroscopy can also be performed utilising a peripheral block, with newer techniques described using just local anaesthetic in a wide-awake patient to allow intra-operative dynamic assessment.
Some of the well-established techniques in wrist arthroscopy include:
Removal of Ganglion Cysts
Ganglion cysts arise from a stalk that communicates with the wrist joint, forming a one-way valve that allows fluid to be pushed into to the cyst, but not return into the wrist joint. Most commonly a dorsal wrist ganglion will arise from the dorsal aspect of the scapholunate interval, the origins of volar wrist ganglions are more variable. Arthroscopy allows assessment of the wrist joint and scapholunate ligament, which has been shown to be injured in 30% of cases of dorsal ganglion. A surgeon can then confidently identify the stalk of the ganglion and excise this area of wrist capsule, removing the one-way valve effect and effectively draining the ganglion cyst. Recurrence rates following arthroscopic ganglion excision (0-10%) have been found to be equivalent or improved compared to open excision.
Removal of Loose Bodies
Loose bodies can arise in the wrist for a number of reasons and lead to mechanical symptoms such as catching, locking and pain. Arthroscopy is the gold standard for removal of loose bodies from the wrist, allowing simple and minimally invasive removal of the loose bodies as well as a comprehensive assessment of the wrist joint.
Treatment of TFCC Injuries and Ulnar-Sided Wrist Pain
Arthroscopy allows thorough assessment of the TFCC (triangular fibrocartilage complex) as well as the ability to perform repairs of certain types of tears. It is not uncommon to debride a degenerate pattern of TFCC tear in combination with an open ulnar-shortening procedure in patients with ulnocarpal impaction. Scapholunate and Lunotriquetral Ligament Injuries Although an MRI is very sensitive for detecting these ligament injuries and newer imaging techniques such as a 4D CT can demonstrate carpal instability, arthroscopic assessment allows confirmation of the degree of injury as well as suitability for repair or reconstruction. Newer techniques of arthroscopic-assisted scapholunate ligament reconstruction allow dynamic assessment of the accuracy and tension of the reconstruction as it is performed.
Treatment of Intra-Articular Fractures
Most distal radius and scaphoid fractures treated with internal fixation are done so using intra-operative fluoroscopy. Arthroscopic-assisted reduction can also be performed to ensure accurate restoration for articular cartilage surfaces and exclude intra-articular metalwork. More recently, techniques for arthroscopic bone grafting and fixation of scaphoid non-unions have been described with promising results.
New techniques are being developed rapidly. Arthroscopic procedures for base-of-thumb arthritis are now well described although long-term outcome data is not yet available. Arthroscopically assisted partial wrist fusions have also being described along with a number of procedures for addressing early wrist arthritis.
Wrist arthroscopy is an exciting and dynamic field of upper limb orthopaedic surgery. As technology continues to develop, further techniques will evolve allowing surgeons to address more conditions using a minimally invasive arthroscopic approach.
Dr Justin Alexander (pictured with Dr PC Ho (Course Director) at the most recent Advanced Wrist Arthroscopy Workshop in Hong Kong) is a specialist in wrist arthroscopy and upper limb surgery. If you would like to make an appointment with Dr Alexander, contact 08 8130 1239.