Wrist and Hand Arthroscopy

Radiocarpal Joint

The portals are named after the corresponding extensor tendon compartments and their relationship.

6U portal

The portal is established just ulnar and volar to the ECU tendon at the ulnar snuffbox. The portal points to the prestyloid recess and is used commonly as the outflow portal ( eFig. 17.8 ). It is also used to facilitate arthroscopic repair of type 1b TFCC peripheral tears. Precaution has to be taken to avoid injuring the DSBUN during portal development.

Midcarpal Joint

The midcarpal joint portals are named after their joint positions and include the following:

Distal Radioulnar Joint

Arthroscopy of the DRUJ was first described by Whipple in 1994. DRUJ arthroscopy is not commonly performed because of the intrinsic difficulty and a limit on what can be done therapeutically. Usually a smaller size of arthroscope such as 1.9 mm diameter is required to establish the portal. However, in rheumatoid arthritis, the portal tends to be easier to develop as the capsule is distended by the synovitis process. Similarly, if the TFCC is avulsed from the foveal region, the space distal to the ulnar head will also become more spacious. Portal location is best defined by direct palpation of the DRUJ with the forearm in fully supinated position with traction reduced. Two portals exist. The proximal DRUJ (PDRUJ) portal is located at the axilla between sigmoid notch and the ulnar head. The distal DRUJ (DDRUJ) portal is identified just proximal to the taut structure of the dorsal radioulnar ligament at the distal end of the DRUJ. It also lies slightly proximal to the 4-5 portal. In patients with perforated TFCC, the working portal for the DRUJ can be gained through the 4-5 or 6R portal, visualizing through the perforation.

Volar Portals

The volar portals are not standard portals commonly used by wrist arthroscopic surgeons. Most of the wrist joint areas can be reached using the dorsal portals. Nevertheless, these relatively newer portals provide visualization on specific areas of the wrist that are not easily accessible with the conventional dorsal portals and thus serve good complementary roles. Bain et al. described the possibility of having viewing and working portals that encircle the wrist as the “box concept.”

Two volar portals have been described in the radiocarpal joint to view the dorsal structures and the volar aspect of the interosseous ligaments.

Volar radial (VR) portal

The volar radial (VR) portal first described by Jantea et al. is made between the interval of the radioscaphocapitate (RSC) ligament and the long radiolunate (LRL) ligament. ^, This portal is most easily made by placing the arthroscope directly through that interligamentous interval with the scope in the 3-4 portal. The scope is removed from the cannula, and a blunt trocar or switching stick is then inserted into the cannula and gently passed through the volar capsule, tenting the skin on the volar aspect of the wrist near the radial artery. A small incision is then made in the skin, and the switching stick is bluntly eased through the skin incision. The cannula is removed from the dorsal portal and reinserted around the switching stick into the joint through the volar portal. Abe et al. reported the use of volar portal in 230 patients in Japan from 1992 to 2001. The portal was developed by an outside-in approach, just radial to the flexor carpi radialis (FCR) tendon at the level of proximal wrist flexion wrist ( eFig. 17.9 ). The radial artery and venae comitantes were retracted radially and the FCR tendon and median nerve retracted ulnarly. The volar capsule was exposed through the tendon sheath of FCR and a small 3-mm incision was made parallel to the capsular fibers. The portal was then opened between the LRL and RSC ligaments. This approach provided access to dorsal rim fragment of intraarticular fracture of distal radius, dorsal synovial proliferation of the rheumatoid wrist, and volar segment tear of the scapholunate and lunotriquetral ligaments. A similar approach was used by Verhellen and Bain in arthroscopic release for cases of capsular contracture.

Radiocarpal Joint

A typical radiocarpal joint examination starts at the 3-4 portal as the viewing portal. The 6U portal is commonly employed for outflow using an 18-gauge needle or plastic angiocatheter. It is important to adopt a systematic approach in evaluating all the major intraarticular capsuloligamentous structures and the articular surfaces. Typically from the 3-4 portal, the first structure being seen is the ligament of Testut, or the radioscapholunate ligament ( eFig. 17.11 ). This ligament originates at the volar margin of the intercondylar ridge of the distal radius and inserts on either side of the volar scapholunate (SL) ligament. It is an important landmark of the radiocarpal joint, though biomechanically it is not a true ligament but contains some fibrovascular tissue providing minor blood supply to the proximal scaphoid. Moving toward the radial styloid, the intracapsular LRL ligament and RSC ligaments are identified. The RSC ligament is the most radial extrinsic ligament that can be easily viewed. The LRL ligament is just ulnar to the RSC ligament and may be two to three times the width of the RSC ligament. ^, There is a clear sulcus between the two extrinsic ligaments ( eFig. 17.12 ). Following the proximal scaphoid and orientating the arthroscope dorsoradially along the curvature of the scaphoid, it is possible to reach the dorsal ridge of the scaphoid at the waist portion where capsular reflection is attached at the anatomical snuffbox region ( eFig. 17.13 ). Then returning the scope to the radiocarpal joint and looking downward, the articular cartilage of the radial styloid, proximal scaphoid, and distal radius scaphoid fossa are visible. The radial styloid should be examined for any sign of chondromalacia or synovitis, which is commonly seen in SLAC wrists ( eFig. 17.14 ). Part of the dorsal and proximal membranous portion of SL ligament between the scaphoid and the lunate is visualized when arthroscope is moved back to the dorsocentral part of radiocarpal joint ( eFig. 17.15 ). It should have a normal concave appearance between the two carpal bones ( eFig. 17.16 ). Loss of normal concave appearance of the SL ligament with hemorrhage can be seen in acute Geissler grade I and II tears and a torn ligament with a gap between scaphoid and lunate in Geissler grade III and IV tears. Tophaceous deposits on the SL ligament may help in the differential diagnosis of gout in patients presenting with acute wrist pain and inflammation, which can mimic traumatic disruption ( Video 17.3 ). In chronic injury, the normal concavity of the SL ligament may become a convex redundant mass of soft tissue due to tissue attenuation. It can also present as a complete disruption of the ligament with retracted fibrotic stumps that are not amendable for repair. Moving ulnarly, the proximal articular surface of the scaphoid fossa and lunate fossa of the distal radius, the interfacet ridge ( eFig. 17.17 ), and the corresponding articulating surface of proximal scaphoid and lunate can be seen. On the volar side of the lunate fossa, and often partly obscured by the radioscapholunate ligament, the short radiolunate (SRL) ligament may be identified with a rich synovial lining on the inside of the ligament facing the joint ( eFig. 17.18 ). This synovium-rich ligament explains the frequent observation of early bony erosion and destruction of the radiolunate joint in rheumatoid arthritis.

Further advancing the arthroscope in the ulnar direction, one can see the synovium covering the ulnocarpal ligament consisting of UL and UT ligament components ( eFig. 17.19 ), the radial insertion of TFCC over the sigmoid notch, and the central fibrocartilaginous disk, which amalgamates with the ulnar attachment of the dorsal and palmar radioulnar ligaments of the TFCC to the fovea of the ulnar head at the prestyloid recess. Any tear of the TFCC, articular wear, synovitis, or capsular injury should be thoroughly evaluated and documented. The prestyloid recess is located just dorsal to the ulnocarpal ligaments. This is a normal anatomic finding not to be confused with a peripheral tear of the TFCC. The 6U inflow cannula is normally placed in this recess. A probe hooking on the prestyloid recess will not lift up the tissue unless there is a proximal disruption of the TFCC, and hence a positive hook test as described by Ruch et al. ( Video 17.4 ). The arthroscope is then swapped from the 3-4 portal to the 4-5 portal where a better view can be obtained of the proximal membranous and dorsal part of lunotriquetral (LT) ligament, as well as the dorsal cartilage of lunate and triquetrum ( eFig. 17.20 ). Hemorrhage and gap between lunate and triquetrum are signs suggestive of LT ligament injury. Cartilage wear over ulnar proximal lunate and a central degenerative tear of the articular disk should raise the suspicion of ulnar impaction syndrome.

It is recommended that a working portal should not be established over the 4-5 or 6R site at the beginning of the procedure until the entire ulnocarpal joint area has been inspected through the 3-4 entry portal. This precaution helps to eliminate the dilemma of determining whether a dorsal capsular defect or synovial folding over the dorsoulnar corner commonly found at arthroscopy is a pathologic lesion or as a result of capsular intrusion by the arthroscopic trocar set. Occasionally it may be difficult for the arthroscope inserted at the 3-4 portal to negotiate through the narrowest portion of the radiocarpal joint at the convex proximal side of the lunate to reach the ulnocarpal area. A useful trick is to direct the scope dorsally where the capsular space is more roomy until the tip passes the lunate. The scope can then be glided gently into the ulnocarpal joint using the lunate as a “skid.” This can avoid the use of 4-5 or 6R portal at the very beginning which potentially violates the normal anatomy. However, the use of the 6R or 4-5 portal at the latter part of the procedure should be liberal as the LT ligament is usually not visible from the 3-4 portal. Moreover, probing through these portals is frequently required to assess the integrity of the extrinsic and interosseous ligaments, as well as the TFCC. The true extent of many apparently trivial intraarticular lesions can only be ascertained by careful probing. The author advises using the shoulder side rather than the tip of the probe to palpate intraarticular structures to avoid iatrogenic injury especially on the cartilage. In a typical case of a central TFCC tear, probing should be performed to assess the stability of the flap tear as well as the integrity of the radioulnar ligaments. Similarly, in many cases of a peripheral tear of the TFCC, the actual tear may be obscured by the overlying reactive synovial overgrowth, making diagnosis difficult to establish by simple visual examination alone. In these instances, the synovial overgrowth should be debrided first by using a shaver before probing the lesion. Finally, the loss of trampoline rebound feeling of the TFCC on probing is also an important sign of a destabilizing TFCC lesion at its peripheral insertion.

The pisotriquetral (PT) joint can often be assessed through the radiocarpal joint. From the 6R portal, the arthroscope can be swept distally and ulnarward past the lunate, the indentation of the LT joint and along the proximal surface of the triquetrum. As the arthroscope is being pushed further distally and volarward, the aperture of the PT joint can be located with or without a covering membrane ( Video 17.5 ). Cadaveric study by Arya and Compson et al. demonstrated four types of connection between radiocarpal joint and PT joint: Type I (27%), a thick synovial membrane covered the joint and precluding visualization; Type II (17%), a thin synovial membrane over the silhouette of the pisiform bone; Type III (8%), a synovial membrane covering the joint with a small fenestration, and Type IV (48%), a synovial membrane with a large fenestration or absence of membrane. The presence of the PT orifice needs to be distinguished from a peripheral tear of the TFCC or LT ligament.

Midcarpal Joint

For midcarpal joint examination, the recommended initial portal is the MCR portal which is usually the easiest to establish. It is the single most useful portal in the midcarpal joint as almost the entire joint is accessible. Outflow is established at the MCU portal which can be easily converted into working or probing portal as necessary. In cases where radial side pathology is more significant, such as in scaphoid nonunion, SLAC wrist or advanced rheumatoid arthritis, the MCR portal may become excessively tight and MCU portal will then become the preferred entry portal. Under any circumstances, extreme caution and patience should be exercised in developing the midcarpal joint portals as traumatic scraping and iatrogenic injury to the articular cartilage can occur.

With the arthroscope in MCR portal, the anatomic structures should be evaluated systematically. The first structures seen would be the confluence point between capitate, scaphoid, and lunate. On the volar aspect, the scaphocapitate portion of the RSC ligament can be seen ( eFig. 17.21 ). In conjunction with the ulnocapitate ligament on the ulnar side, the arcuate ligament is formed. Normally these ligaments are covered with synovial lining. The lining is particularly thickened on the ulnar side, forming a well-defined soft tissue projection at the volar junction of lunate and triquetrum, which sometimes can be confused with an osteochondral fracture. The Space of Poirier can be appreciated between the capitate and lunate interval where no ligament connection is found normally. From this point when the arthroscope is moved toward the radial side, the scaphocapitate joint and the STT joint are entered ( eFig. 17.22 ). Moving back, the SL joint can be seen, and the central, volar and dorsal aspects of the joint should be systematically assessed by rotating the lens ( eFig. 17.23 ). Further to the ulnar side, the “four corner” joint space between the lunate, triquetrum, capitate, and the hamate can be appreciated. The roundish appearance of the capitate and hamate when looking from the radial side gives rise to its description as a “baby’s buttock” ( eFig. 17.24 ). The integrity and stability of the SL and LT joint should then be assessed. In a normal wrist, there should be no or minimal gap between scaphoid and lunate or between the lunate and triquetrum articulations. Geissler developed a grading system to evaluate the stability of the wrist’s interosseous ligaments. (See section titled Carpal Instability.) The mere presence of gap in the SL or LT articulation does not necessarily imply pathology as the phenomenon is common in patients with generalized joint laxity. The arthroscopic findings have to be carefully matched with the clinical assessment. Another observation is that a “step-off” can often be seen over the LT articulation if the arthroscope is introduced from the MCR portal. This misinterpretation is due to the presence of a small, type II facet over the ulnar side of the lunate that articulates with the proximal pole of the hamate ( eFig. 17.25 ). Presence of a type II lunate can be clarified if the arthroscope is introduced through the MCU portal to directly visualize the LT joint space. Moving further ulnarward, the “helicoidal” appearance of the TH joint can be appreciated ( eFig. 17.26 ). Following the dorsal curvature of the hamate, the carpometacarpal joints can be visited, where synovitis in commonly seen in inflammatory arthritis ( eFig. 17.27 ). The STT portal is seldom required in routine diagnostic arthroscopy unless STT joint pathology is suspected or found.

Distal Radioulnar Joint

DRUJ examination is indicated only when joint pathology is suspected, as the risk of iatrogenic injury is much higher than in the rest of wrist joint due to its natural joint tightness. Longitudinal traction is ineffective in distending the joint space. Instead it may create more difficulty as the joint compression load would be increased upon axial traction. It is easier to approach the joint with the forearm in supinated position, as then it will relax the dorsal capsule, translate the ulnar head more anteriorly, and lift the central disk distally from the ulnar head. In addition, arthroscope of size larger than 2.0 mm should not be used to minimize potential morbidity. In DRUJ arthroscopy, it is possible to observe the cartilage condition of the sigmoid notch, the ulnar head, the proximal synovial recess of the DRUJ capsule, the undersurface of the TFCC, and the foveal insertion of the radioulnar ligament ( eFig. 17.28 ).

After most arthroscopic procedures, sutures are usually not required for the wounds. Instead, Steri-Strip opposition is sufficient for wound healing, which typically takes 8 to 10 days. The author routinely places a thin layer of water-resistant dressing on top in order to encourage the use of the hand in daily activities such as bathing and hand-washing in the early postoperative period. Compression bandage is applied for 2 to 3 days. Finger mobilization exercises are encouraged from day one. For simple diagnostic arthroscopy, wrist immobilization is not generally necessary. In experienced hands, a complete diagnostic arthroscopic examination of the radiocarpal and midcarpal joints can be accomplished within 20 minutes or less.

Lavage

The function of lavage mainly works through the elimination of inflammatory mediators, joint debris, and other synovial contaminants as a result of the wash-out process. Indications include pyogenic septic arthritis, gouty arthritis, and degenerative arthritis ( Video 17.6 ). Gravity-assisted fluid irrigation is usually sufficient for most situations. Typically, the 3-4 portal is used to visualize the radiocarpal joint. Joint lavage is delivered via the arthroscope. The 4-5 or 6R portal is used to insert a shaver to manage loculations and synovitis, as well as for joint fluid suction ( Video 17.7 ). An additional midcarpal and/or distal radioulnar portal can be placed as needed. Chow et al. reported the result of arthroscopic debridement of 15 septic wrists in 14 patients. All except 2 patients (85.7%) responded well to single arthroscopic treatment with no complication. Symptom duration of ≥5 days was associated with less improvement on quick-Disabilities of the Arm, Shoulder and Hand (DASH) at final follow-up. Similar results were obtained by Hariri et al. on 9 patients. Both advocated early arthroscopic intervention for better infection control and preservation of wrist function. Sammer and Shin compared the outcomes of arthroscopic and open treatment in isolated septic wrist and concluded that arthroscopic treatment resulted in less intervention and a shorter hospital stay.

Joint Debridement

The technique is employed in conditions where debris in the joint from various tissue origins contributes to symptoms directly or indirectly. Examples include degenerative arthritis, central TFCC tear, Kienböck disease, and partial interosseous ligament tear. Debridement of partial interosseous ligament tear has been shown to provide symptomatic relief in cases without carpal dissociation. Various instruments such as suction punch, motorized shaver, arthroscopic knife, and radiofrequency apparatus can be used in a partial excision of a central TFCC tear. Symptomatic improvement can be expected if ulnar variance of the wrist is neutral or minus. ^, For ulnar positive patients, an additional arthroscopic wafer procedure or open ulnar shortening (USO) may provide more durable relief. A systematic review by Saito and Chung on 550 patients in 18 studies reported nonstatistical improvements in grip strength, DASH score, and pain visual analog scale (VAS) score after debridement of TFCC tears. Average time to return to work was 4 month. At average 30-month follow-up, further surgery was required in 31% of patients with positive ulnar variance compared with only 1% in patients with neutral or negative ulnar variance, suggesting caution in performance of this procedure in patients with positive variance. Soreide and Haugstvedt reported the good long-term outcome of average 19 years of arthroscopic-assisted debridement of TFCC tears in 15 patients. Nishizuka and colleagues treated 66 patients with ulnar-sided wrist pain with either USO, TFCC repair, or arthroscopic debridement. While both the USO and TFCC repair groups had statistical improvements in Hand20 scores and pain, there was no improvement in any measured parameter in the arthroscopic debridement group (n = 14), even when ulnar-positive and TFCC detachment patients were excluded from the analysis.

Synovectomy

The procedure is best indicated for rheumatoid arthritis and other systemic arthritides involving the wrist joint. Adolfsson and Frisén first reported in 1997 the outcome of arthroscopic synovectomy in 18 patients with painful rheumatoid synovitis who failed medication and with only early radiographic changes. There was improved wrist motion and grip strength 6 months following synovectomy. The results were sustained in a longer-term follow-up at 3.8 years after surgery. Other studies with long-term follow-up of an average of 13 years showed good outcomes even in advanced diseases of Larsen grade III and IV arthritis, and no correlation was found between radiographic staging and clinical outcome. Recurrent cases could also benefit from a second arthroscopic synovectomy.

Arthroscopy also plays a prominent diagnostic role in inflammatory arthritis by offering a direct visualization and full access to almost all areas within the joint. Any abnormal synovitis and chondral damage can be detected in early phases. The morphology of the synovium may give a clue to the origin and diagnosis: villonodular in rheumatoid arthritis, seronegative arthritis, and psoriatic arthritis; tophaceous in gouty arthritis; fibrillated in osteoarthritis and posttraumatic arthritis, and fibrinoid in septic arthritis ( Fig. 17.7 ). Synovial biopsy can be obtained for histopathological and microbiological analysis, especially in monoarticular arthritis cases, where infection or pigmented villonodular synovitis (PVNS) need to be excluded.

Wrist Ganglionotomy

Osterman first described the technique of arthroscopic treatment for the typical dorsal wrist ganglion arising close to the SL joint in 1995. It is better to describe the procedure as “ganglionotomy” rather than “ganglionectomy” since the ganglion cyst is not excised structurally. The principle is to abolish the “check valve” phenomenon by creating a capsular defect at the stalk portion of the ganglion cyst where the cyst communicates with the wrist joint and therefore allowing spontaneous drainage, shrinkage, and resolution of the ganglion cyst. In the original study, the 6R portal was used as the viewing portal. The stalk could be identified in only 61% of the cases. A full radius resector was introduced from the 3-4 portal to resect a 1 cm defect from the dorsal capsule. The end point was to see a gush of mucinous fluid from the ganglion draining into the joint, followed by a complete disappearance of the ganglion externally. In Osterman’s series, complete resection was achieved in all of the 18 cases with no recurrence.

It is generally considered to be desirable to identify the stalk of the ganglion at the dorsal capsule-ligamentous junction of the SL joint. Arthroscopically it presents as a capsular bulging lesion with focal synovial hypertrophy. Ahsan and Yao used a color-aided technique of indigo carmine dye to visualize the stalks. However, the experience in identifying the stalks varies, and this might not be a significant factor contributing to success or recurrence. Because the stalk of dorsal wrist ganglion is not a constant finding arthroscopically, an alternative technique has been developed, including the use of an intrafocal portal through the cyst. ^, Wu et al. retrospectively compared the result of transcystic portal and cyst-sparing portal technique and found no difference in recurrence rate, complication, and clinical results at mean follow-up of 3 years. In general, the rate of recurrence varied from 0% to 29.7% in the literature. ^{, , ,} Systematic reviews and metaanalyses showed comparable recurrence and complication rate following open versus arthroscopic excision of wrist ganglions. ^,

Dorsal Wrist Ganglion

Indications

Arthroscopic dorsal wrist ganglionotomy is best indicated in a symptomatic patient with a dorsal wrist ganglion arising from the SL joint, as illustrated by the typical location just distal to the Lister tubercle of the distal radius. The ganglion is preferably a sessile one or one with short stalk pivoting at the SL interval ( Video 17.10 ). Tenosynovial cysts from the extensor tendons should be excluded. The nature of the cyst should be confirmed preoperatively either by aspiration to yield gelatinous content or by ultrasound scanning to show its cystic nature, as arthroscopic treatment of a solid soft tissue tumor is contraindicated. The latter can also help establish the capsular relationship of the ganglion with the wrist joint and the likely origin at the SL capsule-ligamentous junction. In general, ganglions larger than 1 cm diameter are preferable, as the surgical end point of treating an occult ganglion less than 1 cm may be illusive. Any wrist mass of uncertain nature should not be subjected to arthroscopic resection. The appearance of the surgical scar is often more favorable than open surgery for larger ganglions, especially in obese patients ( Fig. 17.9 ). Other indications include a dorsal wrist ganglion associated with wrist pain or signs of SL instability since the cause of the pain can be evaluated with wrist arthroscopy and appropriate treatment performed simultaneously. Recurrent ganglion can also be treated with this technique though with increased difficulty. Dorsal ganglions arising from other atypical sites of the wrist are generally treated with open excision, though there has been report on treating wrist ganglia arising from the LT joint with a similar technique and principles ( Fig. 17.10 ).

Removal of Loose Bodies

Loose bodies in the wrist are uncommon. Koh et al. reported loose bodies in 1.4% of the series of 707 wrist arthroscopy patients. Arthroscopy is considered as the best maneuver in removing an intraarticular chondral or osteochondral loose body that causes symptoms of locking or clicking. The causes can be due to osteoarthritis, articular fracture, cartilage nutrition disorders, and infection. Frequently the loose body is radiolucent but can be detected with the aid of CT scan or MRI. Mosquito graspers, straight and curved, are invaluable in retrieving loose body from within the joint ( eFig. 17.31 ). A hypodermic needle can be used to maneuver or skewer the loose body. Particular attention should be paid to potential recesses of the joint including the prestyloid recess, the recess between the radial styloid and palmar radiocarpal ligament, ulnar facet of the triquetral-hamate joint, and the STT joint region. The author had an experience of removing an unsuspected loose osteochondral fragment from the DRUJ in a female patient presented with locking of the forearm rotation after trivial ulnar styloid fracture. Katolik described an arthroscopic removal of loose body from the pisotriquetral joint following a low-energy trauma in a collegiate rower.

Capsular Release

Wrist stiffness is a debilitating condition often secondary to trauma or prolonged immobilization and may have intraarticular and extraarticular etiologies. Arthrofibrosis may be localized or diffuse. Arthroscopic arthrolysis is an effective treatment for restoring range of motion and reducing pain. Carpal instability is a potential contraindication for capsular release since release of the volar and/or dorsal extrinsic ligaments may exacerbate the condition. Presence of significant posttraumatic arthritis or osteoarthritis would limit any potential gain. Patients who cannot comply with postoperative dynamic–static progressive splinting and intensive rehabilitation program are not appropriate candidates.

Verhellen and Bain described the use of combined volar and dorsal portals in performing arthroscopic release in two cases of severe posttraumatic capsular fibrosis and stiff wrist. All volar capsular ligaments except the ulnocarpal ligament complex and the volar radioulnar ligament were divided completely with a shaver, RF probe, or arthroscopic knife, followed by gentle manipulation under anesthesia ( Video 17.14 ). The relationship of the major neurovascular structures to the volar capsule had been studied. The average distance from the radiocarpal joint capsule to the median nerve was 6.9 mm, 6.7 mm to the ulnar nerve and 5.2 mm to the radial artery. Release can also be performed for the dorsal radiocarpal ligament. However, risk to the closely related extensor tendons is significant. RF probe is contraindicated because of the risk of thermal injury to the overlying tendons. Arthroscopic knives need to be used with extreme caution even under experienced hands. The main difficulty in arthroscopic arthrolysis lies on the initial entry of the arthroscope and instrument into an already contracted joint space. The trick is to perform progressive gentle dilatation of the joint space using trocar of different sizes before the final introduction of the arthroscope. Also, a small-sized arthroscope of 1.9 mm facilitates the procedure. The joint usually becomes more spacious and visible after initial debridement of the intraarticular fibrosis. Luchetti et al. reported the result on 28 patients with postdistal radius fracture arthrofibrosis at an average follow-up of 28 months. Radiocarpal, midcarpal, and DRUJ portals were used under dry arthroscopy to avoid fluid extravasation into the soft tissues. Wrist flexion/extension increased from an average of 84 degrees to 99 degrees and mean pronosupination increased from 144 degrees to 159 degrees. Hattori et al. reported an improvement of 20 degrees in the flexion–extension arc of 11 patients after arthroscopic capsular release for a variety of posttraumatic arthrofibrotic conditions.

Osteotomy

Indications for arthroscopic bony resection include radial styloidectomy for rheumatoid and posttraumatic arthritis and the wafer procedure for ulnar impaction syndrome. Other useful clinical techniques include proximal row carpectomy for posttraumatic arthritis and advanced Kienböck disease, distal scaphoidectomy for symptomatic radioscaphoid joint arthritis in low demand patients, and total or subtotal scaphoidectomy as concomitant procedure for midcarpal arthrodesis in SLAC wrist, scaphoid nonunion advanced collapse (SNAC) wrist, as well as proximal hamate pole resection.