New Frontiers in HandArthroscopy

Tyson K. Cobb, MDa,*, Stacey H. Berner, MDb,Alejandro Badia, MDc

KEYWORDS

� Small joint arthroscopy � Trapeziometacarpal arthroscopy� Thumb carpometacarpal arthroscopy� Metacarpophalangeal arthroscopy� Proximal interphalangeal joint arthroscopy� Pisotriquetral joint arthroscopy� Distal interphalangeal joint arthroscopic arthrodesis� Metacarpophalangeal joint

This article covers new and emerging techniquesin small joint arthroscopy in the hand. Recentimprovement in the quality of small joint scopesand advancement in techniques have allowed formany new small joint arthroscopic procedures inthe hand. The arthroscopic classification for thumbcarpometacarpal (CMC) arthritis as well as treat-ment of each stage are covered. Findings forarthroscopic treatment of pantrapezial arthrosisare reviewed. Metacarpophalangeal (MCP) ar-throscopy for the treatment of synovitis, arthritis,fractures, and gamekeeper injuries is discussed,as is arthroscopy of the proximal interphalangeal(PIP), pisotriquetral (PT), fourth and fifth CMC,and distal interphalangeal (DIP) joints.

ARTHROSCOPIC STAGING OF THUMBCMC JOINT

Arthroscopy allows for a true assessment of thejoint status. Although thumb CMC arthritis hastraditionally been staged by simple radiographicmeans,1 this does not represent an accurateassessment of articular status. This observationis particularly true in the early stages of osteoar-thritis, when symptoms are frequently worse than

The authors have nothing to disclose.a Orthopaedic Specialists, Davenport, IA, USAb Advanced Centers for Orthopaedic Surgery and Sports MMD 21117, USAc Badia Hand to Shoulder Center, Miami, FL, USA* Corresponding author.E-mail address: tysoncobbmd@gmail.com

Hand Clin 27 (2011) 383–394doi:10.1016/j.hcl.2011.06.0040749-0712/11/$ – see front matter � 2011 Elsevier Inc. All

the radiographs suggest; an arthroscopic jointevaluation depicts the process.2

In arthroscopic stage I there is a diffuse synovitisbut with minimal, if any, articular cartilage wear.Ligamentous laxity, particularly the volar liga-ments, is a frequent finding. If the patient presentsearly enough, an arthroscopic synovectomy canbe performed, using a full-radius resector and a ra-diofrequency probe, followed by shrinkage capsu-lorraphy if capsular redundancy is present. Thejoint is then protected in a thumb spica cast forseveral weeks depending on the extent of capsularlaxity. A greater degree of joint instability requiresa more aggressive capsulorraphy and longerimmobilization to achieve joint stability and slowthe progression of articular cartilage degeneration.

In arthroscopic stage II there is focal wear of thearticular surface on the central to dorsal aspect ofthe trapezium and the deep palmar aspect of themetacarpal base. This situation does suggest thata progressive arthritic process is under way andrequires a joint modifying procedure to alter thebiomechanics of the joint. After an arthroscopicsynovectomy, debridement, and frequent loosebody removal, the joint is evaluated for any insta-bility or laxity. A shrinkage thermal capsulorraphy

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Cobb et al384

is performed in many cases. The arthroscope isthen removed and one of the portals is extendeddistally to approach the metacarpal base. Adorsoradial closing wedge osteotomy, akin toWilson’s original technique,3 is then performed toplace the thumb in an extended and abductedposition.4 This procedure is to minimize thetendency for metacarpal subluxation and tochange the contact points of the worn articularcartilage, effectively centralizing the metacarpal.The osteotomy is usually stabilized by a single ob-lique K-wire that is also placed across the firstCMC joint. Pinning allows for healing of the osteot-omy in the correct position but also corrects themetacarpal subluxation that is often seen in thiscritical stage. Correction of the subluxation mayarrest the arthritic process but there are no datato support this. A thumb spica cast protects themetacarpal during healing and the wire is removed5 to 6 weeks after the operation. An arthroscopicstaging is used to determine the ideal indicationsfor this osteotomy, because it is difficult to deter-mine which joints have early focal trapezial wearby any imaging modality. Metacarpal osteotomyhas had good results in past studies, includinga more recent paper by Tomaino.5 Late follow-upof thesepatients has confirmed that themetacarpalremains centralized. The role of capsular shrinkageversus the alteration of force vectors by the use ofosteotomy likely both play a role in changing thejoint biomechanics.In arthroscopic stage III there is diffuse trapezial

articular cartilage loss. The metacarpal base mayalso show significant cartilage loss to varyingdegrees. The arthroscopic findings indicate thatthis is not a joint that is salvageable and a simpledebridement or osteotomy does not provide anacceptable long-term result. An arthroscopicpartial trapeziectomy is then performed by burringaway the remaining articular cartilage and re-moving the subchondral bone down to a bleedingsurface. This procedure functions not only to in-crease the joint space but to allow for cancellousbone bleeding, which forms a thrombus, becominga fibrous tissue interposition. One might augmentthis procedure by inserting an interposition mate-rial, although superior results have not been provenwith interposition.Stage III can also be treated by a traditional

open excisional arthroplasty, arthrodesis. ortotal joint replacement depending on surgeonpreference. However, it has been our experiencethat the minimally invasive nature of arthro-scopic resection arthroplasty has largely obvi-ated open surgery, which is inherently morepainful, more complication ridden, and limitsfuture options.

Although arthroscopic management of Badiastage 1, 2, and 3 is an acceptable standard formany surgeons, patients with pantrapezial ar-throsis have traditionally been treated with openprocedures. Recently we have completed a studyof 35 cases of arthroscopic resection arthroplastyperformed at the scaphotrapeziotrapezoidal (STT)joint and the CMC for pantrapezial arthrosis withgood results.6

Indications

Surgical indications include pain localized at boththe CMC and STT joints, radiographic changesconsistent with arthrosis, and full-thickness wide-spread cartilage loss of both joints found at thetime of arthroscopy.

Contraindications

Contraindications include active infection andinstability in patients who desire correction. Inthe authors’ experience most patients are satisfiedwith pain relief despite persistent instability at theCMC and MCP joints.

Surgical Technique

The arm is suspended using 2.3 to 4.5 kg (5–10pounds) of finger-trap traction on only the thumb.When indicated, diagnostic arthroscopy is per-formed with a 1.9-mm arthroscope. An arthro-scopic resection arthroplasty is performed usinga 2.3-mm or 2.7-mm arthroscope. Volar (1R) anddorsal (1U) portals are used for CMC arthroscopy.STT arthroscopy is performed through volar (1R)and dorsal (1U) portals, which are placed approx-imately 1 cm proximal to the corresponding CMCportals. An additional dorsal portal is used whennecessary by placing a blunt probe through thevolar portal across the STT or CMC joint and outthe dorsum of the hand (Fig. 1).Two to 3 mm of bone is removed from each side

of both the CMC and STT joints with a 3.0-mm or4.0-mm barrel bur (Fig. 2). Graft Jacket (WrightMedical Technology Inc, Arlington, TN, USA) wasused as interposition material in 23 of the cases.The patients are typically immobilized for 1 to 3weeks. The current protocol includes a postopera-tive splint for 1 week followed by a removablehand-based Orthoplast splint.Preoperative data collected included a 2-point

self-reported pain scale, disabilities of arm, shoul-der and hand (DASH) outcome measure, range ofmotion, grip strength, and pinch strength.Pain score (0–10) improved from 7 (range 5–10)

preoperatively to 1 (range 0–6) at 1 year postoper-atively (P<.0005) (Fig. 3). DASH score improvedfrom 46 preoperatively to 19 at 1 year (Fig. 4).

Fig. 1. Pantrapezial arthrosis: portal access across STTand CMC.

Fig. 3. Pantrapezial arthrosis: pain score improvementfrom preoperatively to 1 year postoperatively.

New Frontiers in Hand Arthroscopy 385

Thumb range of motion did not change signifi-cantly. All but one patient reached the base of thefifth digit at 1-year follow-up. The mean improve-ment in key pinch was 1.3 kg (2.9 pounds) (95%confidence internal [CI] 0.84–5.00) (P 5 .0008).The mean improvement in grip strength was 4.3 kg(9.52 pounds) (95% CI 1.467–17.56) (P 5 .023).

Complications

Two patients developed postoperative infections.One was superficial and resolved with outpatientantibiotics, and 1 deep infection required arthro-scopic irrigation and debridement. Three patientsdeveloped a flexor carpi radialis tendonitis, 2 ofwhich resolved with conservative treatment and

Fig. 2. Arthroscopic view of the distal aspect of theSTT joint following arthroscopic resection.

1 of which required surgical release. Two patientswith persistent pain underwent open revision sur-gery. Five patients reported paresthesias in thedistribution of the superficial branch of the radialnerve, all of which resolved by the third postoper-ative month.

MCP ARTHROSCOPY

The MCP joint is ideally suited for arthroscopicevaluation and treatment.7–10 The neurovascularstructures are not close to the arthroscopic portals.The bony and tendinous landmarks are generallyeasy to identify. The MCP joint represents a singlecompartment. Therefore, visualization and naviga-tion of the joint are easily accomplishedwith a shortlearning curve. The indications, equipment, andtechnique associated with MCP arthroscopy arediscussed in the next sections, supportedwith clin-ical case examples.

MCP arthroscopy is a useful diagnostic and ther-apeutic entity. There are several reports in therheumatology literature of diagnostic staging ofinflammatory arthropathy.11–16 Synovectomy maybe a useful adjunct in this patient population aswell, with short-term improvement in symptoms.However, long-term benefits have not yet beenestablished.14 In addition, debridement, removalof loose bodies, and chondroplasty can be useful

Fig. 4. Pantrapezial arthrosis: pinch and grip frompre-operatively to 1 year postoperatively.

Fig. 5. MCP: scope set-up.

Cobb et al386

in the posttraumatic setting.10 Minimally invasivelavage and debridement can be performed inselected cases of intra-articular sepsis.Arthroscopy can be useful for assessment and

treatment of fractures, dislocations, and ligamentinjuries. Intra-articular fractures can be treated byarthroscopic and arthroscopically assisted means.Adequacy of reduction of the articular surface canbe readily verified arthroscopically. SuccessfulreductionofStener lesionsandarthroscopically as-sisted repair of collateral ligament injuries of theulnar collateral ligament (UCL) of the thumb MCPjoint have been reported within the literature.17–22

Expanded applications include arthrofibrectomyand arthroscopically assisted arthrodesis of thumbMCP joints. Current analysis of the feasibility of ar-throscopically assisted arthroplasty may holdpromise for the future.7

Equipment:

� Small joint arthroscope� Traction apparatus� Fluid management system� Motorized shaver� Small joint punch, grasper, biopsy forceps.

Optional:

� Currettes/osteotomes� Fluoroscopy unit� Wire driver� Suture anchors� Radiofrequency probe� Headless screws.

Review of the literature reveals reports usingvarious sizes and types of arthroscopes. The1.0-mm needle arthroscope has been used forbiopsy and staging procedures.11,13 More com-monly, the 1.7-mm, 1.9-mm, 2.0-mm, and 2.3-mmdevices are used.7,12,14,18 The authors’ preferenceis a 1.9-mm, 30� arthroscope.Various commercial traction tower devices are

available. An overhead T-bar device (Fig. 5), isdescribed in the technique section.Normal saline or lactated Ringer solution can be

used, at the surgeon’s preference. An arthro-scopic fluid pump can facilitate fluid management,provided that a low-pressure setting is used.

Technique

The patient is placed in the supine position andgeneral or regional anesthesia is established. Apneumatic tourniquet is placed around thebrachium of the operative extremity and an armholder is applied. The arm holder attaches to theoperating room bed and provides countertraction.An overhead T-bar is applied to the bed, directly

opposite the operative extremity. The hand andarm are prepared and draped in routine sterilefashion. A sterile finger trap is applied to the oper-ative digit or thumb, and then attached to a hookon the T-bar. Sterile finger-trap application canbe aided by the application of tincture of benzoinor Mastisol to the involved digit. Alternatively,a K-wire may be inserted through the digit andfinger trap to prevent slippage of the trap.18

Weights are suspended from the opposite end ofthe pulley system in the T-bar. Traction of 4.5 kg(10 pounds) is applied through an overheadadjustable T-bar (see Fig. 5).Radial and ulnar MCP portals are localized with

the aid of 2 18-gauge needles (Figs. 6 and 7).Fluoroscopic guidance may be used to assist in

adequate identification of the joint space. Theportals are established after distending the jointwith 0.5% Marcaine or 0.9% normal saline solu-tion. The radial and ulnar portals are each locatedoff the midline, in the region of the sagittal hoodfibers, in the interval between the collateral liga-ments and the extensor tendon. In the digits thetubercles at the base of the proximal phalangescan be palpated and these represent the insertionpoints of the collateral ligaments. The extensortendon is not violated. The skin is lanced and bluntdissection is performed until the joint capsule isencountered. A blunt arthroscopic trochar andcannula are inserted into the joint. The trochar isremoved and the 1.9-mm, 30� arthroscope isplaced in the MCP joint. Fluid inflow is throughthe arthroscope. An intravenous pressure bag is

Fig. 6. MCP: portal localization.

New Frontiers in Hand Arthroscopy 387

applied to a 1-L bag of sterile 0.9% normal salinesolution at 100 mm Hg. The pressure bag servesas a pump. Viewing and instrumentation portalsare alternated. Small joint biopsy punches andgraspers may be used. Debridement and synovec-tomy are performed with a 2.0-mm full-radius re-sector blade. Osteocartilagenous loose bodiesare removed when encountered. A radiofrequencyprobe may be helpful to perform synovectomy anddebridement, but care should be taken to provideadequate flow so as to avoid generating hightemperatures in this low-volume joint. A monopo-lar probe may be preferable in this regard. Micro-currettes, elevators, and osteotomes may beuseful for clearing debris, and performing manipu-lation of fragments during treatment of fractures.K-wires can be used as joysticks to assist in frac-ture reduction and may be used for provisionalor definitive fracture fixation. Headless screwscan be useful for treating large articular fracturefragments. These screws can be inserted percuta-neously with arthroscopic and fluoroscopic guid-ance. Minisuture or microsuture anchors may berequired for ligament repair.

Fig. 7. MCP: portal localization.

Procedures and Illustrative Cases

Inflammatory arthropathyArthroscopy can be useful for staging and treat-ment of inflammatory arthropathy.11–16,19,20 Syno-vectomy can be performed with a motorizedshaver or a radiofrequency device. Maintenanceof constant, but low-level inflow pressure providesadequate distention, because hypertrophic syno-vium may obscure visualization. Adequate inflowdecreases the possibility of thermal damage tocartilage and soft tissue structureswhen using a ra-diofrequency device. Compared with alternativeimaging modalities, arthroscopy provides moreprecise information regarding the status of thearticular cartilage, and this may aid in planningfuture procedures.20 Reports of synovectomyhave shown good short-term results, although theliterature does not report maintenance of theshort-term benefits over the long-term.14,20 There-fore, it seems that the usefulness of MCP arthros-copy for inflammatory arthropathy is to aid indiagnosis through synovial biopsy, as well as forstaging of articular cartilage involvement. A short-term palliative benefit has also been shown withsynovectomy (Figs. 8 and 9).

Degenerative arthritis/cartilage lesionsIsolated cartilage lesions and early degenerativearthritis can be assessed, staged, and treated ar-throscopically. Debridement of loose cartilageand chondroplasty has been reported in the lit-erature. Good intermediate-term results havebeen noted with chondroplasty for isolated full-thickness cartilage lesions (Figs. 10 and 11).10

However, there are no established guidelinesoutlining a treatment algorithm for degenerativearthritis.

Removal of loose bodiesSimilar to larger joints, loose body removal can beperformed on the MCP joints of the digits and thethumb (Figs. 12 and 13). The unicompartmentalnature of the joint facilitates localization andremoval of loose bodies. The minimally invasiveapproach is preferable, because it permits rapidreturn to activity by obviating incision in the ex-tensor expansion and capsulotomy.

Intra-articular fracturesFractures involving the articular surfaces and sup-porting subchondral bone of the MCP joint can beassessed, and treated with an arthroscopically as-sisted approach (Figs. 14–16). K-wires may beused as joysticks to assist reduction, and canalso be used for definitive fixation. Alternatively,small conventional screws or headless screws

Fig. 8. MCP: inflammatory arthropathypreoperatively.Fig. 10. MCP: after traumatic cartilage lesion.

Cobb et al388

can be used based on surgeon preference andfracture pattern.

Collateral ligament repairLigament injuries in the digits and thumb can betreated with arthroscopically assisted repair. Inthe thumb, reduction of Stener lesions and jointstabilization has been reported for the treatmentof acute unstable UCL injuries (Figs. 17 and 18).17

The thumb MCP joint is ideally suited for arthro-scopically assisted arthrodesis. For individualswith widespread cartilage loss, or with gross insta-bility, fusion may be indicated. Arthroscopic prep-aration of the joint surfaces and percutaneouscannulated screw fixation are a minimally invasivealternative to open arthrodesis.The MCP joint of the thumb is ideally suited

for arthroscopically assisted fusion. However,

Fig. 9. MCP: inflammatoryarthropathypostoperatively.

maintenance of mobility is of paramount impor-tance for the MCP joints of the digits. Arthro-scopically assisted joint resurfacing may be ofbenefit for the digits. Arthroscopic evaluationand assistance in preparation of the joint surfacefor osteocartilagenous transplant can be per-formed and may play an expanded role in thetreatment of isolated articular cartilage defects.In vitro analysis of arthroscopically assisted jointsurface preparation for insertion of synthetic ordenatured allograft material is under way; thistechnique may hold great promise for the futureand further study, including in vivo analysis, iswarranted.

Fig. 11. MCP: after traumatic cartilage lesion afterchondroplasty.

Fig. 14. MCP: articular fracture.

Fig. 12. MCP: loose body.

New Frontiers in Hand Arthroscopy 389

Summary of MCP Joint Arthroscopy

The MCP joint is ideally suited for arthroscopicevaluation and treatment. Nonetheless, thepaucity of information in the literature suggeststhat operative arthroscopy of the MCP jointsremains less commonly performed when com-pared with other joints in the upper extremitysuch as the wrist, elbow, and shoulder. Furtherawareness and study will likely expand the appli-cation of arthroscopy to surgery to the MCP joints.

PT ARTHROSCOPY

Pisotriquetral arthroscopy is a novel, yet seldomindicated procedure that makes the gee-whiz list.It is indicated for persistent, painful PT jointarthrosis unresponsive to conservative care. PT

Fig. 13. MCP: after removal of loose body.

arthroscopy is also useful for synovectomy, irriga-tion debridement of septic joints, arthrodesis, orloose body removal.23

The hand is suspended by finger-trap tractionfor convenience of positioning. Two portals arelocalized with 18-gauge needles under fluoros-copy (Fig. 19). Both are placed ulnar to the PTjoint, one proximal and one distal. Access to thePT joint can be obtained via the 6R wrist portal insome patients.24 From the 6R portal, the arthro-scope is directed ulnarly, volarly, and distally.Access depends on the presence or absence ofa membrane separating the PT joint from the wristjoint. Membrane, if present, can be debrided forentry into the PT joint. However, we prefer directentry from the ulnar portals.

Incisions are made through the skin. A small,blunt hemostat is used to gain entrance into thePT joint. A 1.9-mm, 30� arthroscope and a 2-mm

Fig. 15. MCP: arthroscopic reduction.

Fig. 18. MCP:UCLafter debridement andmobilization.

Fig. 16. MCP: arthroscopically assisted percutaneousreduction.

Cobb et al390

shaver are used to perform synovectomy and clearthe joint of debris. A 2-mm bur is used to remove2 mm of bone from the pisiform and triquetrum(Fig. 20). The portals are closed with Steri-Stripsafter the procedure. A short-arm splint is usedfor 1 week.

Illustrative Case

A 57-year-old woman presented with a several-year history of ulnar-sided wrist/hand pain. Shehad pain with palpation over the PT joint. PTarthritis was noted on the plane film, and a bonescan showed uptake at the PT joint. She hadimmediate relief of pain with an injection of localanesthetic into the PT joint under fluoroscopiccontrol. A cortisone injection of the PT joint gaveonly temporary relief of pain.A diagnostic injection test has to be interpreted

with some caution and in context with other

Fig. 17. MCP: chronic UCL tear.

findings of the workup because many patients donot have a membrane separating the PT jointfrom the radiocarpal joint.24 Therefore, a localanesthetic injection into the PT joint may anesthe-tize and therefore eliminate pain from adjacentareas of the wrist.Full-thickness, widespread cartilage loss was

noted at the time of arthroscopy (Fig. 21). Arthro-scopic resection arthroplasty of PT joint was per-formed. Two years after arthroscopic resectionarthroplasty, she remained essentially pain free.

PIP ARTHROSCOPY

Arthroscopy of the PIP joint has limited usefulness.The indication for arthroscopy of the PIP joint

Fig. 19. PT: portal fluoroscopy.

Fig. 20. PT: bur removal of 2 mm of pisiform andtriquetrum.

New Frontiers in Hand Arthroscopy 391

includes synovectomy, irrigation debridement ofa septic joint, loose body removal, or diagnostic/staging purposes.25

Contraindications include an active cellulitis orsevere scarring or contracture of the dorsal tissuesecondary to injury or burn.

The authors prefer the use of portals betweenthe lateral bands and collateral ligaments. Portalsbetween the central slip and the lateral bandshave also been described.26

The digit can be positioned vertically with finger-trap traction or horizontally with manual traction.Because the PIP is a tight bicondylar joint, accessto the volar aspect of the joint is limited. Therefore,horizontal positioning allows for joint flexion

Fig. 21. PT: cartilage loss noted during arthroscopy.

and improved access. General or regional anes-thesia may be used with either brachial or digitaltourniquet.

The joint is distended with saline, and a 3-mm to4-mm incision is made over the desired portals.Portals can be localized with an 18-gauge needleand fluoroscopy. Blunt spreading with smallhemostat allows access into the joint. A taperedblunt trocar is used, and flow is provided throughthe cannula. The authors use a 1.9-mm, 30�

arthroscope (Fig. 22). Synovectomy is performedwith a 2-mm shaver (Fig. 23). Portals are closedwith Steri-Strips after the procedure. Early motionis encouraged after synovectomy.

FOURTH AND FIFTH CMC ARTHROSCOPY

The fourth and fifth CMC joints are amenable toarthroscopic evaluation. Usefulness and indica-tions have not been established.

The hand is suspended by finger traps on thefourth and fifth digits with 4.5 kg (10 pounds) oftraction. An ulnar portal is localized with an18-gauge needle and fluoroscopy. The fifth CMCjoint is easily viewed arthroscopically througha direct ulnar portal. A dorsal portal is localizedwith an 18-gauge needle under fluoroscopy(Fig. 24). This portal is used for a working portal.A 2-mm shaver is used for synovectomy.

The author uses a 1.9-mm, 30� arthroscope.With the arthroscope in the ulnar portal, the arthro-scope can then be transitioned to view across thefifth CMC and into the fourth CMC.

DIP

Arthrodesis of the DIP joint of the fingers or inter-phalangeal joint of the thumb is an effectivesurgical treatment of painful arthrosis. The head-less screw has been shown to be a safe and effec-tive alternative for fixation with open arthrodesis

Fig. 22. PIP: 1.9-mm, 30� arthroscope.

Fig. 25. DIP: digit suspended in finger-trap traction.

Fig. 23. PIP: synovectomyperformedwith 2-mm shaver.

Cobb et al392

techniques.27–29 Arthroscopic arthrodesis of theDIP joint of the fingers or interphalangeal joint ofthe thumb is indicated for pain, deformity, or insta-bility. Common causes include degenerative orposttraumatic arthritis, chronic mallet finger, andchronic flexor digitorum profundus injury. This isa technically challenging procedure and shouldbe reserved for only very experienced arthroscop-ists. The learning curve is steep and the risk ofscope damage is high. Contraindications includeactive infection, bony geometry too small to allowfor safe placement of headless screws, and lack

Fig. 24. 5th CMC Arthroscopic portals localized underfluroscopy.

of equipment or experience to safely performprocedure.

Surgical Technique

The digit is suspended with finger-trap traction(Fig. 25). This traction is accomplished by turninga standard disposable finger trap inside out todouble the wall. It is then placed over the distalphalanx and secured with a transverse 0.35 K-wire through the distal phalanx. The procedurecan be performed with a digital or brachial tourni-quet. General or regional anesthesia can be used.Traction of 2.3 to 4.5 kg (5–10 pounds) is applied.Eighteen-gauge needles are used to localize the

medial and lateral joint lines under fluoroscopy.Longitudinal incisions are placed over the medialand lateral sides of the joint, 5 to 6 mm long.

Fig. 26. DIP: collateral ligaments released with number69 Beaver blade.

Fig. 27. DIP: joint is opened with Freer elevator.

New Frontiers in Hand Arthroscopy 393

The collateral ligaments are released witha number 69 Beaver blade. The joint is openedenough to create a working space with a Freerelevator (Fig. 26). A 1.9-mm arthroscope is in-serted in 1 side of the joint, and a 2.5-mm shaveris inserted in the opposite side of the joint(Fig. 27). The joint is cleared of debris. The scopeand shaver are then switched, and the oppositeside of the joint is cleared of debris, allowing forvisualization of both sides of the joint.

Next a 2-mm hooded bur is brought into the jointand 1 to 2 mm of bone is removed from the prox-imal and distal sides of the joint (Fig. 28). Only one-half of the medial and lateral dimensions of thejoints are burred to minimize arthroscope damage.The scope and the bur are then switched, and theother side of the joint is burred down to bleeding

Fig. 28. DIP: 1.9-mm arthroscope inserted in 1 side ofjoint, 2.5-mm shaver on another.

subchondral bone. Care must be taken not todamage the scope because the working space islimited. Dorsal osteophytes can be removed bypalpating the osteophyte under the dorsal capsuleand carefully working the bur along the dorsalmargin of the joint. The amount of bone resectionis assessed visually through the scope and alsowith the aid of fluoroscopy. If dorsal osteophytesare large, a small flat rasp can be placed dorsallyunder the extensor tendon for removal.

After resection of the joint the finger trap andtransverse fixation wire are removed. A longitu-dinal guide wire is then placed in the central axisunder fluoroscopic control. A cannulated drill isused to drill across the DIP joint followed by place-ment of the screw (Fig. 29).

The authors prefer the mini Acutrak screwbecause it is small enough to minimize the chanceof nail beddamage. Theguidewire is then removed.Portals are closed with Steri-Strips. A bulkydressing is applied with a splint for 7 to 10 days. Aremovable splint is then used for protection asneeded, based on patient comfort, for 4 weeks.MCP andPIP joints aremobilized immediately aftersurgery. Clinical healing occurs at about 6 weeks,with radiographic healing at approximately 8weeks.30

Complications

Complications include nonunion, nail bed injury,and infection.28 One case was complicated bypartial thickness skin loss secondary to fluid

Fig. 29. DIP: 2-mm hooded bur removes bone fromjoint.

Cobb et al394

infiltration.30 This complication resolved by thesecond week postoperatively without additionaltreatment. Medial and lateral approaches placethe digital nerves at risk. Care should be taken toavoid injury to these structures.

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