Advances in Hand and Upper Limb Arthroscopy

(Hand, wrist, elbow, shoulder)

Arthroscopy simply means observation of a joint utilizing an instrument. Watanabe first developed this in Japan nearly 50 years ago and it was soon obvious that the minimally invasive nature of this procedure lead to better visualization of a joint while simultaneously minimizing pain and joint morbidity.

As in many orthopedic procedures, the knee was for decades the sole benefactor of this new technology but soon other joints such as shoulder and elbow began to be explored. It is perhaps these joints, and others in the upper extremity, that best benefit from this technology since motion and dexterity are more important than in the weight-bearing lower extremity articulations.

A discussion regarding shoulder surgery is basically an arthroscopic review where perhaps only prosthetic implant surgeries are done open for the vast majority of pathology. Therefore, it is perhaps more interesting to discuss the nuances of arthroscopy of the fingers, thumb, and wrist in more detail manner with later mention of elbow and certainly the commonplace shoulder arthroscopy during this review.

Indications for small joint arthroscopy in the hand remain poorly understood

This is due to a paucity of papers discussing this technique in the literature, as well as inadequate hands on training in the pearls and pitfalls regarding this application within the commonly used “scope” of arthroscopy. Despite the fact that small joint arthroscopes have been available for over a decade, hand surgeons have been slow to adopt this technique within their treatment armamentarium for the treatment of both traumatic and degenerative conditions involving the thumb and the digital metacarpophalangeal joints.

Ten years ago, I proposed an arthroscopic classification for basal joint osteoarthritis which provides additional clinical information and can direct further treatment depending on the stage of disease. This technique can be incorporated into a treatment algorithm in managing this common affliction while usually avoiding open surgery at the base of the thumb, a typically painful procedure with prolonged recovery.

Metacarpophalangeal joint arthroscopy is even less commonly used, while traumatic and overuse injuries are frequently seen in the thumb, and present an ideal indication in certain scenarios. Painful conditions affecting the metacarpophalangeal joints of the fingers are less commonly seen, yet the small joint arthroscope presents a much clearer picture of the present pathology compared to other imaging techniques or even open, and potentially deleterious, surgery.

Wrist arthroscopy is better understood as this technique was developed in the late 80s

It is now a key part of most wrist specialists surgical armamentarium. While initially developed for diagnostic purposes, arthroscopy of the wrist is now vital for such common pathologies as triangular fibrocartilage tears (TFCC), carpal ligament injuries, ganglion cysts, articular injuries including distal radius fractures etc.

Alerting colleagues about the availability of wrist arthroscopy is now supplanted by actually ensuring that hand surgeons are facile in these techniques and cadaveric courses are crucial to this end. Wrist arthroscopy can eliminate the perpetual “wrist sprain” diagnosis and actually allows us to visualize and even treat the underlying problem. The use of wrist arthroscopy has been particularly helpful in athletic injuries, typically tennis and golf, with this technique being crucial to advances discussed by the International Society for Sport Traumatology of the Hand (ISSPORTH). This is a new society oriented towards educating athletes, trainers and sports medicine colleagues about the vital role hand surgery, including wrist arthroscopy, plays in the goal of functional recovery of upper limb injuries in sportsman.

Elbow Arthroscopy actually has much more limited role since the indications are scant

Perhaps the most common is for treatment of tennis, or golfers, elbow, although that is generally not the primary procedure chosen by orthopedists. Debridement of early arthritis and removal of loose bodies is an excellent indication and many baseball players careers have been saved by the elbow arthroscopist.

Shoulder arthroscopy remains the most commonly used arthroscopic procedure in the upper limb

It has become almost synonymous with shoulder surgery. The joint surfaces are rather simple , with extremely small cup (glenoid) and the large spherical head of the humerus, with the overhanging scapula acromion and its articulating clavicle. The challenge in the shoulder is managing the soft tissue injuries which are ubiquitous and perhaps part of the aging process. Cadaveric studies have shown that shoulders in the eighth decade have greater than 40% chance of a rotator cuff tear. Therefore much of the shoulder arthroscopic procedures are directed at degenerative problems which become increasingly important due to the very active elderly population in today’s society. Any golf or country club social event may involve standard discussions about how the latest shoulder procedure went on one of the members!

Shoulder arthroscopy also can be done on younger patients who sustained significant vehicular, sports related or even work injuries. The rehabilitation after shoulder arthroscopy remains critical in all groups. My recent use of Electro Neuro Muscular Therapy (ENMT) technology has minimize postoperative pain while limiting atrophy and accelerating the recovery process.

Any discussion of upper limb arthroscopy should include the decompression of the media and ulnar nerve which is actually done by an endoscopic not arthroscopic technique. The reason is simply that the nerve passes within a tunnel that is not formally a joint, therefore the term arthroscopy should not be used but this does warrant some comment due to its very commonplace nature within upper extremity pathology.

An example is Carpal Tunnel Syndrome whose treatment is often directed at decreasing the inflammation of the tendons. Injections of steroids such as cortisone can lead to a decrease in the swelling. This will allow the median nerve more room in the carpal tunnel and relieve the pain. The most common treatment without the use of drugs or injections is a night splint.

However, If the compression is severe enough and the patient does not respond to conservative treatment, the next step would be a minor procedure. Surgery for Carpal Tunnel Syndrome is also misunderstood by the public as well as many physicians. Rumors abound as to the final outcome after these procedures. People think they can lose function of their hand if they have surgery. The truth is that surgery is extremely successful.

This procedure actually entails a very simple concept. A division is made in the ligament which serves as the roof of the carpal tunnel. This increases the space in the carpal tunnel allowing the median nerve to function better.

The most recent breakthrough in treatment of Carpal Tunnel Syndrome is called endoscopic release

In this procedure, which I have been performing for over 15 years, an incision of less than one centimeter is made in the crease of the wrist and an endoscopic, a tiny camera, is inserted. This allows the surgeon to literally see the inside of the hand and make the division of the ligament without a large, open incision. Therefore this is not arthroscopy but rather an endoscopic procedure. Nevertheless , this allows for a rapid, minimally painful recovery, where nearly full use of the hand is regained immediately after this simple outpatient procedure.

Cubital tunnel syndrome is a similar entity, but is a compression neuropathy involving the ulnar nerve at the medial aspect of the elbow.

Traditional surgery entails open release of the nerve, frequently accompanied by anterior transposition, or physically moving the nerve to a position where there is minimal stress on the nerve to allow nerve function recovery and alleviate symptoms. Complications are fairly common as the nerve is very sensitive, and we are now doing the release endoscopically, a similar concept as mentioned for the median nerve at the wrist. Early results of a multi-center prospective clinical study that I am involved in, shows that the recovery is faster, less painful and with minimal complicaionsand high patient satisfaction. Surgeon use of the new technique does require certification via cadaveric exercises.

Common compression neuropathies of the upper limb can now be almost solely treated with endoscopic minimally invasive means and this advance needs to be conveyed to patient and referring physicians alike.

It is therefore apparent that arthroscopic or even endoscopic procedures will soon become the norm in treatment of a large percentage of upper limb pathologies. Furthermore , the application of this technology to the smaller joints will soon make the treating surgeon realize that a myriad of pathologies are readily visible and can augment treatment, as well as diagnosis. Similar to the wrist, small joint arthroscopy may one day supplant imaging techniques such as MRI or CT in establishing an accurate diagnosis. With the exception of shoulder, hand and upper limb arthroscopy is still not commonplace, but it is only a matter of time before the public will insist upon this based upon a greater awareness as now seen through the Internet or social media. Surgeons will need to perform more training and cadaveric courses in order to become facile with this technology.

By Alejandro Badia, M.D, F.A.C.S.

Orthopedic Hand Surgeon

Upper Extremity Specialist of Hand, Thumb, Wrist, Elbow & Shoulder
Badia Hand to Shoulder Center
Founder, OrthoNOW Immediate Orthopedic Care
Center
Doral, Florida