Arthroscopy of the Small Joints of the Hand

CHAPTER 27 Arthroscopy of the Small Joints of the Hand






Introduction


The past 25 years have been witness to a virtual explosion of interest and application of arthroscopy in the orthopedic surgeon’s armamentarium. Beginning as a diagnostic tool, largely for conditions in large joints such as the knee and shoulder, the arthroscope soon developed into a therapeutic tool for a procedure with well–documented advantages over open procedures. Next, intermediate–size joints (such as the wrist and elbow) became amenable to arthroscopic procedures—due in large part to the reduction in size of arthroscopic tools. This, too, followed the pattern of diagnostic procedures followed by therapeutic applications. With further reduction in the dimensions of arthroscopic equipment, we now have the capability to enter very small joints—such as the carpometacarpal and metacarpophalangeal joints of the hand.13 Although largely limited to diagnostic procedures, innovations are currently emerging in the use of the arthroscope for therapeutic intervention. Only time will tell if true advantages can be found in the application of arthroscopic technology to these small joints.


As a note of practicality, safety, and integrity, it must be emphasized that common sense must prevail with these techniques. Just because we have the capability to perform small–joint arthroscopy does not mean there is a universal indication that we must do so. In the large number of lectures and courses the author has participated in, and to each of the residents and fellows he has had the privilege to teach, he has stressed (1) how relatively seldom he actually employs arthroscopy in regard to these small joints and (2) the necessity of being convinced that there is a distinct advantage in performing arthroscopy over open procedures before considering using it.


These are decisions each surgeon must ask in an environment of personal honesty, resisting the urge to follow trends and to succumb to pressures from patients who have read about this procedure or the other on the Internet and want what is most modern. If a surgeon can get better results with an open procedure than with an arthroscopic procedure, they owe it to the patient to perform the procedure in the manner that gets the best results or to refer the patient to someone who is getting superior results with the other procedure.



First Carpometacarpal Joint


Arthroscopy of the first carpometacarpal (CMC) joint was developed and described nearly 10 years ago.1,2 The first CMC joint is particularly attractive as a joint available for arthroscopic evaluation because of its relative depth, highly curved articular surfaces, and the nearly circumferential nature of the stabilizing ligaments. Each of these factors makes complete viewing of the joint difficult with arthrotomy, unless highly destructive capsulotomies are carried out through these vital ligaments. As such, the use of the arthroscope was initially proposed for a diagnostic joint evaluation (if nothing more).


Early on it became quite clear, however, that the arthroscope could be a useful tool to help visualize the adequacy of reduction of fractures involving the articular surfaces of the trapezium or the base of the first metacarpal (such as with a Bennett’s fracture)—as well as for the debridement of an arthrotic joint. With miniaturization of thermocouple probes, a technique for an arthroscopically guided shrinkage of the joint capsule for the treatment of pain due to joint capsule laxity was developed—as well as arthroscopically guided arthroplasty for the treatment of end–stage arthrosis.





Regional Anatomy


The skin overlying the first CMC joint is glabrous only on the palmar surface. Immediately deep to the skin and superficial to the deep fascia are numerous veins, including the principal tributaries forming the cephalic vein system. Within the periadventitial tissue of these tributaries are the major volar (S1) and major dorsal (S2) divisions of the superficial radial nerve, which are found just deep to the veins (Figure 27.1).



Several muscles and tendons cross the joint, beginning anteriorly with the abductor pollicis brevis—which originates from the anterior surface of the trapezium (Figure 27.1). Just lateral to this is the tendon of abductor pollicis longus, inserting into the posterior base of the first metacarpal. The tendon of extensor pollicis brevis passes distally just posterior to the abductor pollicis longus. Just superficial to the posterior joint capsule of the first CMC joint is the deep division of the radial artery, crossing the first CMC joint deep to the extensor pollicis longus tendon before coursing anteriorly between the proximal metaphases of the first and second metacarpals. Between the proximal epiphyses of the first and second metacarpals is the intermetacarpal ligament, which is entirely extracapsular.



Joint Anatomy


The first CMC joint is a bi–sellar—a double saddle joint formed by the distal articular surface of the trapezium and the base of the first metacarpal. The articular surface along the major axis of the trapezium is concave in the medial–lateral direction and the articular surface along the minor axis is convex in the antero–posterior direction. The converse relationship is found with the base of the first metacarpal, where the articular surface is concave in the antero–posterior direction and convex in the medial–lateral direction. Although a joint capsule surrounds the entire joint, only 3/4 is reinforced by capsular ligaments.4,5


The anterior edge of the first CMC joint is reinforced by the anterior oblique ligament (AOL) complex, which is composed of superficial and deep divisions (Figure 27.2). The superficial division (AOLs) spans nearly the entire anterior edge of the joint and attaches to the anterior surface of the trapezium just proximal to the articular surface and just distal to the articular surface of the base of the fist metacarpal. The deep division (AOLd) is a well–demarcated thickening of the superficial band found just medial to the midline of the superficial division.



Often there is a distinct medial edge separating the AOLd from the AOLs. It is the deep division of the AOL that is often referred to as the “beak” ligament. The orientation of the fibers of the AOLs is slightly oblique, passing proximal to distal from lateral to medial. The fiber orientation of the AOLd is essentially proximal to distal. The extreme lateral (ulnar) surface of the joint is reinforced by the ulnar collateral ligament (UCL), which has fibers oriented in a proximal to distal direction (Figure 27.2). The lateral 30% of the posterior surface of the joint capsule is reinforced by the posterior oblique ligament (POL) (Figure 27.3). The fiber orientation of the POL is slightly oblique, passing from proximal and medial to distal and lateral.



The remaining posterior joint capsule is reinforced by the dorsoradial ligament (DRL) (Figure 27.3). The fiber orientation of the DRL is generally proximal to distal. The joint capsule immediately deep to the tendon of abductor pollicis longus is not reinforced by a ligament. Although there is a distinct border between the AOLs and AOLd, there are no reliable demarcations between the remaining ligaments.




Technique


The patient is positioned supine on the operating table, with either regional or general anesthesia. Parenteral antibiotics may be administered and a pneumatic tourniquet is typically applied to the arm. A single finger trap is secured to the thumb and between 5 and 8 pounds of longitudinal traction is applied. Using a 22–gauge hypodermic needle, the location of either the 1–R or 1–U portal is scouted by advancing the needle directly ulnarly. The needle should be angled approximately 20 to 30 degrees distally due to the curved nature of the joint surface. If there is any difficulty in passing the needle into the joint or if there is any concern about the proper identification of the joint, intraoperative radiographs or fluoroscopy may be used to verify the level of the needle prior to proceeding.


Once the proper level of the joint portals has been identified, small stab wounds are created with a scalpel—either transversely or longitudinally. The author advocates making the incisions for both portals at the beginning of the procedure. This facilitates switching portals during the operation without disturbing the cadence of the procedure. Subcutaneous tissues are dissected bluntly to the joint capsule level to be certain that underlying neurovascular tissues are displaced from harm’s way. The arthroscope sheath is then introduced with a tapered trocar in one portal and a small probe is introduced in the other portal. It is rare that an outflow device is needed, particularly with judicious control of inflow fluid volume and rate. If an outflow tract is necessary, however, a large–bore hypodermic needle may be introduced—or a shaver may be used to evacuate excess or cloudy fluid. It may also be necessary to debride excess synovial tissue in order to visualize the joint surfaces and the ligaments. This may be accomplished with either a small shaver or a suction punch.


The author typically orients the camera and angles the arthroscope lens in a manner that places the image of the base of the first metacarpal at the top and the trapezium at the bottom. A comprehensive inspection of the articular surfaces is carried out. Next, the intra–articular appearance of the capsular ligaments is noted. It is best to use the probe to validate the integrity of these structures, rather than simply relying on their visual appearance.


The dorsoradial ligament, posterior oblique ligament, ulnar collateral ligament, and deep portion of the anterior oblique ligament can typically be visualized from the 1–R portal (Figure 27.4a through d). The superficial and deep portions of the anterior oblique ligament, ulnar collateral ligament, and posterior oblique ligament can be visualized through the 1–U portal (Figure 27.4a through d).


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Jun 22, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Arthroscopy of the Small Joints of the Hand

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