Arthroscopy of the Small Joints of the Hand

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CHAPTER 27 Arthroscopy of the Small Joints of the Hand

Richard A. Berger

“Many of life’s failures are people who did not realize how close they were to success when they gave up.”

—Thomas Edison

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.1–3 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.

Indications

The principle indications for arthroscopy of the first CMC joint are, in general, the same as for other joints. These include the evaluation of a painful joint that is suspicious for arthrosis or ligament injury, the treatment of two–part fractures of the base of the first metacarpal, retrieval of floating loose bodies or foreign objects, and the irrigation of a septic joint. There has been a persistent interest in using the arthroscope as a means of performing a minimally invasive resection of arthritic joint surfaces and to facilitate the percutaneous interposition of tendon or other materials.2

Contraindications

The contraindications for arthroscopy of the first CMC joint are the same as for other joints, including poor soft–tissue coverage, active cellulites, and joint injury of such severity that it cannot be managed by percutaneous methods (such as a Rolando fracture).

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).

image

FIGURE 27.1 Drawing of the regional anatomy of the first carpometacarpal joint (mcI = first metacarpal, Tm = trapezium, Ra = radial artery, EPL = tendon of extensor pollicis longus, APL/EPB = tendons of abductor pollicis longus and extensor pollicis brevis, R and U = radial and ulnar arthroscopic portals, respectively).

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.

image

FIGURE 27.2 Drawing of the anterior surface of the first carpometacarpal joint capsule (I = first metacarpal, II = second metacarpal, Tm = trapezium, S = scaphoid, APL = tendon of abductor pollicis longus, FCR = tendon of flexor carpi radialis, FR = flexor retinaculum, AOL = anterior oblique ligament, UCL = ulnar collateral ligament, IML = intermetacarpal ligament).

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.

image

FIGURE 27.3 Drawing of the posterior surface of the first carpometacarpal joint capsule (I = first metacarpal, II = second metacarpal, III = third metacarpal, Tm = trapezium, Td = trapezoid, C = capitate, ECRL = tendon of extensor carpi radialis longus, APL = tendon of abductor pollicis longus, IML = intermetacarpal ligament, POL = posterior oblique ligament, DRL = dorsoradial ligament).

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.

Portals

There are two recognized portals for arthroscopy of the first carpometacarpal joint. The naming of portals is related to their relationship with the extensor pollicis brevis and abductor pollicis longus tendons. The 1–R portal is established at the joint line just radial to the abductor pollicis longus tendon (Figure 27.1). The 1–U portal is established at the joint line just ulnar to the extensor pollicis brevis tendon (Figure 27.1).

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).

image

FIGURE 27.4 (A) Drawing of the posterior joint capsule viewed from the 1-R portal (MI = first metacarpal, Tm = trapezium, DRL = dorsoradial ligament, POL = posterior oblique ligament). (B) Drawing of the ulnar joint capsule viewed from the 1-R portal (MI = first metacarpal, Tm = trapezium, POL = posterior oblique ligament, UCL = ulnar collateral ligament, AOLd = deep portion of the anterior oblique ligament). (C) Drawing of the anterior joint capsule viewed from the 1-U portal (MI = first metacarpal, Tm = trapezium, AOLd = deep portion of the anterior oblique ligament, AOLs = superficial portion of the anterior oblique ligament). (D) Drawing of the anterior joint capsule viewed from the 1-U portal (MI = first metacarpal, Tm = trapezium, AOLd = deep portion of the anterior oblique ligament, AOLs = superficial portion of the anterior oblique ligament).

Procedures

The following procedures have been proposed, although largely based on personal communications and anecdotal experiences. This is by no means meant to be an all–inclusive list.

Synovectomy

A partial or radical synovectomy can be carried out arthroscopically using a shaver less than 3 mm in diameter, and thermocouple probe system or a small suction punch device. Care should be exercised when using the shaver or a punch to avoid iatrogenic compromise of the capsular ligaments themselves. Because of the small diameter of the shaver, the suction sheath frequently becomes clogged with debrided tissue. This requires frequent cleaning, which some surgeons may become frustrated with.

Capsular Shrinkage

It may be advantageous in some circumstances to be able to shrink, and hence stiffen, the joint capsule—such as in a substantially lax individual with early arthrosis of the first CMC joint. Commercially available thermocouple probe systems, in a diameter suitable for this joint, are available—but little experience has been gained in this specific joint at this time. Because of the proximity of overlying tissues to the joint capsule and the very real chance of thermal injury to nerves, tendons, and even skin, the author has not personally advocated the use of thermocouple capsular shrinkage in the first CMC joint.

Staging Arthritis

The precise staging of arthritic involvement of the articular surfaces of the first CMC joint is easily accomplished with the arthroscope. This is important in those patients with painful instability of the first CMC joint in whom one is considering performing an extra–articular ligament reconstruction.6 If substantial arthrosis is present, but is not yet radiographically evident, a ligament reconstruction would be considered contraindicated. The most common locations for initial involvement of articular cartilage destruction in degenerative arthritis are the central aspect of the trapezial surface and the ulnar third of the metacarpal surface.

Resection of Joint Surface

There may be some indication for partially resecting either the base of the first metacarpal or the distal surface of the trapezium, although one would think that this would need to be accompanied by another procedure to either stabilize the joint or interpose some material (such as a section of tendon or fascia).2 This was advocated by Menon, where a strip of flexor carpi radialis was interposed arthroscopically after arthroscopic resection of the arthritic joint surfaces.

Septic Arthritis

Although rarely encountered, the irrigation and debridement of a septic first CMC joint is easily accomplished with the arthroscope and a shaver. A large volume of normal saline can be passed through the joint by simply running the shaver in the middle of the joint space while connecting the inflow to a wide–open source of fluid. Cultures can be obtained by sampling the initial aspirate.

Reduction of Intra–Articular Fracture

The arthroscope may be a valuable adjunct to the treatment of simple intra–articular fractures involving the base of the first metacarpal. A Bennett’s fracture consists of an intra–articular fracture through the ulnar condyle of the base of the first metacarpal. It may produce problems due to intra–articular step–off or to instability. The instability is generated by the uncompromised pull of the abductor pollicis longus on the thumb metacarpal, which results in a loss of contact with the ulnar collateral ligament. Because the first CMC joint is nearly circumferentially covered with stabilizing ligaments, any attempt to visualize the fracture line in a Bennett’s fracture will necessarily compromise these ligaments. Accurate visualization of the adequacy of reduction by closed means using radiographic imaging is difficult due to the highly curved nature of the articular surfaces of the joint.

When contemplating an arthroscopically assisted fixation of a Bennett’s fracture, it must first be determined that the fracture is mobile. It is important to remember that the arthroscope is not a reduction device per se. Rather, it is merely a means of visualizing the reduction carried out by other means. Regional or general anesthesia is required, and the patient should be prepared for the possibility that the procedure may be converted to an open reduction or aborted altogether if the arthroscopic procedure is not possible.

The easiest way to assess whether the fracture is mobile, and potentially amenable to closed reduction under arthroscopic assessment, is to distract the thumb on the operating table. Under fluoroscopy, the thumb metacarpal is manipulated while observing the fracture site. A typical manipulation maneuver is axial rotation, with the goal of reducing the thumb metacarpal (in the surgeon’s grasp) to the small fragment (the ulnar condyle of the first metacarpal base). If the fracture moves close to what is considered an adequate reduction, one may proceed with arthroscopy.

Next, a 0.045 K–wire is advanced into the base of the first metacarpal under fluoroscopic guidance in a line that will either skewer the small fragment upon reduction or will penetrate an adjacent bone to stabilize the reduction. The arthroscope is introduced in the standard fashion, as is a small shaver. The shaver is used to evacuate the intra–articular hematoma universally present. A careful assessment of the articular surfaces and the capsular ligaments is made. Once clear visualization is possible, the fracture is manipulated into an acceptable reduction under arthroscopic guidance. Once an acceptable reduction is achieved, the assistant advances the previously placed K–wire for secure fixation of the fracture. Final radiographs are obtained, and external dressings with reinforcement are applied (as in an open reduction procedure).

Because of the severe comminution and soft tissue disrupted in a Rolando fracture, this fracture pattern should be viewed as a relative contraindication for arthroscopic reduction. There is no advantage to using an arthroscope for an extra–articular fracture pattern. It should be possible to use the arthroscope for intra–articular fractures of the trapezium, but the author has had no experience with this approach.

Complications

Few complications are encountered with careful application of standard arthroscopic principles. The most serious complications are injury to cutaneous nerves or to the radial artery, both of which can be avoided with careful dissection techniques based on a sound understanding of the underlying anatomy. Iatrogenic injury to the articular surfaces is easily encountered unless a very gentle approach to the use of instruments is maintained. It is important to remember that the arthroscope typically moves only a few millimeters in a telescoping fashion to cover the entire joint. Do not force the arthroscope where it does not want to go. Infection remains a risk, regardless of surgical procedure. Many surgeons prefer to administer a prophylactic dose of parenteral antibiotics prior to initiating a joint–related procedure.

Metacarpophalangeal Joints

Arthroscopy of the metacarpophalangeal (MCP) joints of the hand is rarely performed, but may have limited applications.3 One must remember the advantages versus limitations of open versus arthroscopic procedures before deciding which technique to use. The advantages of open procedures typically hinge on the access to regions for procedural tasks, whereas the disadvantages include surgical scars, potential soft–tissue destabilization, and limitation of visualization in deep recesses. Arthroscopy offers the advantages of superior visualization of most regions of a joint that is otherwise difficult to access in an open procedure, through very small incisions with minimal impact on the status of contiguous tissues.

The major disadvantages of arthroscopic procedures lie in the limits of the procedural maneuvers possible through very small incisions. This dilemma is most evident in the MCP joint. Although a lengthy skin incision may be needed for an open exposure of the MCP joint, leaving largely a cosmetic effect, the disturbance of the soft tissues (extensor mechanism and joint capsule) probably has a minimal effect—especially with the proper postoperative rehabilitation protocol. However, there may be a case for which arthroscopy of the MCP joint may be an attractive option.

Indications

Indications for arthroscopy of the MCP joints are poorly worked out at this time, but may include assessment of arthritis, irrigation of a septic joint, retrieval of foreign bodies, and the identification and possible reapproximation of collateral ligaments avulsed from either the proximal phalanx or the metacarpal.7

Contraindications

The contraindications for arthroscopy of the MCP joints are the same as for other joints, including poor soft–tissue coverage, active cellulitis, and joint injuries not amenable to arthoscopic techniques. To this date, the techniques of arthroscopic reduction and fixation of intra–articular fractures of the metacarpal head or proximal phalanx base have not been worked out for general application.

Anatomy

Regional Anatomy

The skin over the dorsal surfaces of the MCP joints is typically loosely held to the subcutaneous tissue. Thus, care must be exercised when marking palpated landmarks such that stretching the skin location does not displace the marks prior to committing to an incision. Immediately deep to the skin are cutaneous sensory nerves (superficial radial and lateral antebrachial cutaneous nerves for the thumb, index, and long fingers; dorsal sensory branches of the ulnar nerve for the ring and small fingers). The major veins draining the fingers are typically found in the intermetacarpal valleys, well away from most arthroscopic approaches.

The tendons on the dorsal surfaces of the MCP joints share a common feature: the extensor hood (Figure 27.5). At the level of the joint, the extensor hood is composed of the extrinsic extensor tendon(s) and the sagittal fibers passing toward the volar plate. The extensor tendons for the thumb include the extensor pollicis brevis (radially) and longus (ulnarly). For the index through small fingers, the extensor digitorum communis tendon passes across the MCP joint as the radial–most tendon. Each finger also has an independent proprius tendon, although the extensor indicis proprius and extensor digiti minimi (quinti) tendons are the most widely recognized. These tendons do not insert directly into the proximal phalanx but are connected to the dorsal joint capsule and hence indirectly insert into the phalanx.

image

FIGURE 27.5 Drawings of the relevant anatomy for metacarpophalangeal (MP) joint arthroscopy. Top left: thumb MP joint showing the extensor hood formed in part by the adductor aponeurosis (aa) and the extrinsic extensor tendons (epb = extensor pollicis brevis). Top left: thumb MP anatomy after removal of the extensor hood, revealing the tendon of extensor pollicis longus (epl). Bottom: lateral view of the MP joint demonstrating the relationships among the metacarpal (MC), proximal phalanx (PP), tendon of extensor pollicis brevis (epb), and the collateral ligament system (cl). The black dots represent the location of recommended arthroscopic portals.

Intra–Articular Anatomy

The intra–articular anatomy of the first through fifth MCP joints is similar. The joint is described as a shallow glenoid–type joint. The articular surface of the second through fifth metacarpal heads is largely spherical, but widens palmarly in the transverse plane. The first metacarpal has little medial–lateral variance. The bases of the proximal phalanges have a shallow glenoid shape for articulation with the metacarpal head.

The lateral joint capsule is reinforced by the collateral ligament system. The true collateral ligaments span the distance from a depression on the lateral and medial surfaces of the head of the metacarpal to the palmar half of the proximal rim of the proximal phalanx. The accessory collateral ligaments are fan–shaped extensions of the true collateral ligaments, which attach to the lateral edges of the volar plate.

The volar plate forms the palmar surface of the MCP joint capsule. It has a poorly defined proximal attachment to the metacarpal, but has a definite attachment along the palmar rim of the base of the proximal phalanx. Often, there is a meniscal rim of the volar plate protruding into the joint space—biased toward the distal end of the volar plate. The dorsal joint capsule is thick and redundant, extending proximally to a line which is proximal to the level of collateral ligament attachment to the metacarpal head.

Portals

There are two recognized portals for arthroscopy of the MCP joints (Figure 27.5). The naming of the portals is related to the relationship with the extensor tendons. The radial portal is established at the joint line just radial to the extrinsic extensor tendons. The ulnar portal is established at the joint line just ulnar to the extrinsic extensor tendons.

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 or finger to be evaluated 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 palmarly. 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. I would advocate 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.

A comprehensive inspection of the articular surfaces is carried out. Next, an inspection of the intra–articular appearance of the collateral ligaments and volar plate may be completed. It is best to use the probe to validate the integrity of these structures, rather than simply relying on their visual appearance.

Procedures

The following procedures have been proposed, although largely based on personal communications and anecdotal experiences. This is by no means meant to be an all–inclusive list.

Septic Arthritis

Irrigation and debridement of a septic first CMC joint is easily accomplished with the arthroscope and a shaver. This may be considered particularly useful in the so–called “fight bites,” where an open intrusion of the patient’s MP joint has occurred during an altercation due to contact with an opponent’s teeth—which creates a septic hazard for the joint. A large volume of normal saline can be passed through the joint by simply running the shaver in the middle of the joint space while connecting the inflow to a wide–open source of fluid. Cultures can be obtained by sampling the initial aspirate.

Diagnosis of Collateral Ligament Injury

Most ligament injuries about the MCP joints are treated well with closed means. However, the Stener–type lesion creates a situation that is less likely to result in successful closed management. In the Stener lesion, the distally avulsed collateral ligament is displaced and trapped under the free proximal edge of the extensor hood.8 Although the ulnar collateral ligament of the thumb is the avulsion injury most commonly associated with a Stener lesion, it can occur in the fingers.8–10 This is particularly so with the ulnar collateral ligament of the index finger MCP joint and the radial collateral ligament of the small finger MCP joint. The arthroscope provides a minimally invasive means of readily identifying the presence of a Stener–type lesion in any of the digits.

In a subacute setting of instability following injury, it may prove to be a difficult task to know whether the injury is due to involvement of either the proximal or distal attachment of a finger MCP collateral ligament. Because scar tissue has likely developed, the surgeon will have a difficult time knowing where the injury occurred—leading to potential complications of elevating the wrong end of the ligament during open repair. Again, the arthroscope offers a ready means of identifying the level of the injury prior to conversion to an open procedure.

Reapproximation of Collateral Ligament Avulsion Injury

Ryu has advocated arthroscopic techniques as the definitive treatment for thumb Stener lesion injuries of the ulnar collateral ligament.7 After verifying the presence of the Stener lesion, the ligament is “hooked” by a probe and drawn back deep to the adductor apponeurosis—where it comes to rest adjacent to its normal attachment point on the ulnar rim of the base of the proximal phalanx. From here, it is treated as a nondisplaced collateral ligament injury. The author has no personal experience with this technique, but instead opts for an open procedure to stabilize all ulnar collateral ligament injuries with measurable instability.

Complications

Few complications are encountered with careful application of standard arthroscopic principles. The most serious complications are injury to cutaneous nerves, which can be avoided with careful dissection techniques based on a sound understanding of the underlying anatomy. Iatrogenic injury to the articular surfaces is easily encountered unless a very gentle approach to the use of instruments is maintained. It is important to remember that the arthroscope typically moves only a few millimeters in a telescoping fashion to cover the entire joint. Do not force the arthroscope where it does not want to go. Infection remains a risk, regardless of surgical procedure. Many surgeons prefer to administer a prophylactic dose of parenteral antibiotics prior to initiating a joint–related procedure.

Summary

Arthroscopy of the small joints of the hand has become a reliable clinical tool, although it is still somewhat limited to diagnostic applications. Therapeutic options are becoming increasingly available, but must be balanced against the efficacy of open procedures. Arthroscopy of these joints is safe, provided the surgeon thoroughly understands the relevant anatomy and is truly facile with the equipment and techniques. Again, the author would like to emphasize the need for restraint and honesty on the part of the surgeon to do what is truly best for the patient—not what is in vogue.

References

1 Berger RA. A technique for arthroscopic evaluation of the first carpometacarpal joint. J Hand Surg. 1997;22(A):1077-1080.

2 Menon J. Arthroscopic management of trapeziometacarpal arthritis of the thumb. Arthroscopy. 1996;12:581-587.

3 Ryu J, Fegan R. Arthroscopic treatment of acute complete thumb metacarpophalangeal ulnar collateral ligament tears. J Hand Surg. 1995;20(A):1037-1042.

4 Bettinger PC, Linscheid RL, Berger RA, Cooney WPIII, An K-N. An anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J Hand Surg. 1999;24(A):786-798.

5 Bettinger PC, Berger RA. Functional ligamentous anatomy of the trapezium and trapeziometacarpal joint. Hand Clin. 2001;17(2):151-168.

6 Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg. 1973;55A:1655-1666.

7 Ishizuki M. Injury to collateral ligament of the metacarpophalangeal ligament of a finger. J Hand Surg. 1988;13A:444-448.

8 Schubiner JM, Mass DP. Operation for collateral ligament ruptures of the metacarpophalangeal joints of the fingers. J Bone Joint Surg. 1989;71B:388-389.

9 Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg. 1962;44B:869-879.

10 Wolf BA, Cervino AL. Rupture of the radial collateral ligament of the fifth metacarpophalangeal joint. Annals of Plas Surg. 1988;21:382-387.

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