Chapter 21 Arthroscopic Arthrolysis of the Wrist

10.1055/b-0035-121131

Chapter 21 Arthroscopic Arthrolysis of the Wrist

Introduction

Intra-articular wrist fractures (radius, scaphoid) and, occasionally, the repair of intrinsic ligaments (even arthroscopic ones) can lead to wrist stiffness due to intra-articular fibrosis, which is more severe in the radiocarpal than in the midcarpal joint. Open surgical arthrolysis itself produces postoperative fibrosis, which limits its effectiveness. Arthroscopy avoids this pitfall by cleaning out the joint without affecting the joint capsule and by enabling immediate recovery of the patient’s range of motion.

Operative Technique

Patient Preparation and Positioning

The procedure is performed under regional anesthesia. The range of flexion and extension is measured under regional anesthesia to verify the true nature of the stiffness. The arm is then secured to an arm board and upward traction of 5 to 7 kg is applied to the hand and forearm.

Debridement of the Medial Radiocarpal Joint

The 3–4 radiocarpal portal is used first. The sheath and scope are placed at a slightly medial angle toward the triangular fibrocartilage complex (TFCC). In most patients, the view of the joint is hampered by significant fibrosis. A needle is introduced through the 4–5 portal, and an attempt is made to find its distal tip at the end of the scope ( Fig. 21.1 ). A shaver is inserted through the 4–5 portal, and the position of the distal end is located without moving the scope. The view gradually improves as the intra-articular fibrosis is removed ( Fig. 21.2a, b ). This entire medial area is debrided to fully release the TFCC. In some patients, a secondary 6R portal may be needed.

Resection of the Fibrous Radiocarpal Wall

Once the medial part of the joint has been completely cleaned out, the scope is inserted into the 6R portal. In many patients, there will be a fibrous wall between the scapholunate ligament and the ridge separating the scaphoid and lunate facets of the radius. This wall can be very thick ( Fig. 21.3a, b ). The wall is cut away completely with Stevens tenotomy scissors from dorsal to volar ( Figs. 21.4a, b and 21.5 ).