19
Wrist Arthrolysis
Riccardo Luchetti, Andrea Atzei, and Tracy Fairplay
Wrist stiffness is a complication either from trauma (with or without extra- and/or intra- articular fractures) or surgery.1 Rehabilita- tion of the wrist is the treatment of choice when a pa- tient presents with wrist stiffness of over 3 to 6 months’ duration. Wrist manipulation under anesthe- sia may be used in cases in which a rehabilitation regime has failed to produce increased wrist range of motion. However, this procedure can also be danger- ous, provoking further damage such as ligament or bone lesions (ulnar head fracture). Surgical arthrolysis is an alternative option that can be performed via open surgery or arthroscopy. Surgical arthrolysis is rarely performed in cases of flexion-extension rigidity, but it is frequently used for distal radioulnar joint (DRUJ) wrist rigidity in which pronosupination range of mo- tion (ROM) is affected.2 This joint is easier to reach than the radiocarpal joint, and rehabilitation is initi- ated immediately after surgery.
Arthroscopic arthrolysis is a new procedure that allows the surgeon to treat all the wrist joints with- out running the risk of causing secondary damage to the articulations involved and, at the same time, per- mitting immediate postoperative mobilization.3–8The use of this technique to treat posttraumatic wrist stiff- ness began in the early 1990s.9,10An improvement of wrist ROM was seen after arthrography. This stimu- lated enthusiasm among surgical specialists to further research its surgical efficiency,10 which they hypoth- esized was due to the effect of the fluid that was in- jected into the joint, and thus causing joint distension.
In addition, other authors11–14 had already demon- strated that knee, elbow, and shoulder rigidity due to adhesive capsulitis or arthrofibrosis could be success- fully treated by arthroscopic arthrolysis.
INDICATIONS
Improvement of arthroscopic instruments, technique, and knowledge of arthroscopic wrist anatomy have led to the application of this technique in a much wider range of wrist pathologies. Indications for arthroscopic wrist arthrolysis include all cases in which rigidity has occurred following prolonged immobilization after trauma (fractures or dislocations) or surgery. Pain is
almost always present with articular rigidity. The causes of the rigidity could be intra- and/or extra- articular (Table 19.1). Localization of joint stiffness depends on the damaged site. Radiocarpal (RC), mid- carpal (MC), and DRUJ rigidity can be present indi- vidually or in association with each other.
The most frequent clinical pathological conditions are adhesive capsulitis and arthrofibrosis of the wrist.
Capsulitis is due to ligament and/or capsule contrac- tures, and wrist arthrofibrosis is usually due to osseous band fibrosis of the radius and/or first row carpal bone(s) from a radius articular fracture. These two con- ditions can be associated in the same case. Wrist rigid- ity can also be a consequence of injury to the wrist bones and/or ligaments, for example, a 4-corner in- tercarpal arthrodesis, a proximal row carpectomy, or reconstruction of the scapholunate interosseus liga- ment. Wrist rigidity can also be associated with other pathologies of the wrist, such as median nerve com- pression, stenosing tenovaginitis of the flexor tendons, or even an injury to the dorsal terminal root of the posterior interosseous nerve.
We must not forget that all hand articulations are susceptible to articular rigidity, as we frequently see in the first carpometacarpal (CMC) joint; even in this case, arthroscopic arthrolysis is a possible treatment of choice.
SURGICAL TECHNIQUE
RC, MC, and DRUJ portals are the arthroscopic sur- gical approaches of choice. Most recently two volar RC portals (radial and ulnar) have also been added.15 Wrist arthrolysis must be performed by using both tra- ditional and more elaborate instruments (Table 19.2).
Although arthroscopy starts at the level of the RC joint, the MC joint should always be thoroughly eval- uated. When there is a loss of pronosupination artic- ular range of motion, arthrolysis of the distal radioul- nar joint must also be performed.
In the most difficult cases, it is impossible to rec- ognize the normal arthroscopic anatomy of the wrist (Figures 19.1 and 19.2). Difficulties could be encoun- tered in performing triangulation with the instru- ments. Synovitis, fibrosis, and adhesions can obstruct
1 4 5
the visual field; therefore, they must be removed with caution, ensuring that no damage occurs to the sur- rounding structures. Obviously, the surgeon’s ability is of utmost importance.
Radiocarpal Joint
All the portals (1-2, 3-4, 4-5, 6-R, and 6-U) are used, including the volar, when needed. Fibrotic adhesions are initially removed with the appropriate instru- ments: motor engine, laser, and radiofrequency in- struments. This procedure is frequently sufficient to improve wrist ROM. When needed, the volar and/or dorsal radiocarpal ligaments must be resected from the border of the radius to improve wrist ROM (Figure 19.3). Miniblade, laser, or radiofrequency instruments are used to resect the ligament. Dorsal capsulotomy sometimes may require a volar approach. It is very im- portant to remember that the volar and dorsal ulnar ligaments must not be resected. Ulnar translation of the carpal bones has not been demonstrated after re- section of the radial ligaments.4
Limited articular steps of the radius (less than 1 mm) must be leveled, when possible (Figure 19.4). Tri- angular fibrocartilage complex (TFCC) central tears are also treated: the flap is removed and the borders are cleaned. When the patient presents with an ulnar plus wrist, it must be treated with wafer arthroscopic resection. The loose bodies must be removed if they are found inside the articulation. At the end of the surgery, wrist manipulation is performed to evaluate its range of motion and to determine if there has been an improvement in articular excursion.
Midcarpal Joint
The approach for this articulation is via the four por- tals (RMC, UMC, STT, and TH), thus making it pos- sible to verify if there is involvement of the MC joint that could be contributing to wrist stiffness. Arthro-
scopy of this joint is much easier to perform, and syn- ovitis is the most frequently found pathology in this zone. It is usually localized to the level of the STT and TH joints. Commonly, one sees an associated cap- itate and hamate chondritis. This also can cause the patient to have wrist pain. Debridement of the MC joint is performed in order to improve painless joint movement. MC joint arthroscopy does not require that ligament resection be performed.
Distal Radioulnar Joint
It is very unusual to have good visibility of this joint even in normal conditions. Stiffness of this joint is due to synovitis and fibrosis, which in turn increase the difficulty of performing the arthroscopy. In cases when this particular joint arthroscopy begins to take a pro- longed amount of time and becomes quite tedious, it is convenient to introduce a dissector into the proxi- mal portal and to detach the adhesions between the ulnar head and the sigmoid fossa, or resect the volar capsule from the bone. The dissector can also be in- troduced through the distal portal; then one should perform resection of the adhesions between the ulnar head and the ulnar surface of the TFCC. These ma- neuvers usually result in a good pronosupination wrist ROM improvement.
TABLE 19.2. Instruments for Arthroscopic Arthrolysis.
Motor powered Suction punch
Full radius blade Mini-scalpel (banana blade)
Cutter blade Laser
Razor cut blade Radiofrequency
Barrel abrader Dissector and scalpel
FIGURE 19.1. Arthroscopic normal appearance of volar ligaments (RSC and LRL ligaments). (Reprinted from Atlas Hand Clinics, 6(2):371–387, R. Luchetti, A. Atzei, and B. Mustapha, Arthroscopic wrist arthrolysis, pp. 371–387, © 2001 with permission from Else- vier Science.)
Technical Notes
Portals for introducing inflow and/or outflow, instru- ments, and the arthroscope must frequently be shifted.
It is advisable to set the water inflow pressure at 35/45 mmHg or more. Outflow is not necessary for all the joints.
Pre-, intra-, and postoperative fluoroscopic evalua- tion must be performed to verify the position and the anatomy of the wrist. Pre- and immediate postopera- tive wrist motion must be evaluated to determine if there has been an improvement.
POSTOPERATIVE REHABILITATION
Rehabilitation is started immediately after surgery.
Sometimes pain control may require an analgesic. The
physical therapist plays a vital role in evaluating the patient’s capacity to perform all the wrist range of mo- tion exercises and in instructing the patient in antiedema techniques that should be followed dili- gently at home for the first 7 days after surgery. In cases of severe edema, the therapist should begin a tenacious antiedema program consisting of the use of contrast baths to aid in stimulating the vasodilatation- vasoconstriction mechanism of the patient’s hand and forearm. The temperatures of the baths are 35 to 38 degrees C and 10 to 15 degrees C. The patient sub- merges the hand and forearm initially in the cool bath for 1 minute and then in the warm bath for 5 min- utes. This exercise is repeated continuously for 30 minutes. The patient should begin and end by sub- merging the hand in the cool bath. Once the contrast bath technique has finished, the therapist should im- mediately apply distal-proximal functional compres- sive bandaging to each finger, hand, wrist, and mid- forearm (Figure 19.5), to aid in lymph drainage and venous return. Lymph drainage massage should be done, following the bandaging, to the entire upper ex- tremity with the patient in a supine posture.
If the patient shows very limited wrist range of mo- tion and the initial onset of edema, it is appropriate to begin a home range of motion program using a con- tinual passive movement device (CPM) to help in maintaining the wrist ROM that was obtained during surgery and to increase blood circulation to the area, thus decreasing edema and the eventual onset of wrist stiffness (Figure 19.6). Pronation-supination and flex- ion-extension exercises are performed for almost 3 months, gradually increasing the number of repeti- tions and amount of resistance applied. Aquatic rehabilitation is the initial treatment of choice. The patient is instructed to perform nonresisted hand-
FIGURE 19.2. Common arthroscopic view of a wrist affected by post- traumatic stiffness (fibrotic bands between the radius and the carpal bones). (Reprinted from Atlas Hand Clinics, 6(2):371–387, R.
Luchetti, A. Atzei, and B. Mustapha, Arthroscopic wrist arthrolysis, pp. 371–387, © 2001 with permission from Elsevier Science.)
FIGURE 19.4. Evidence of an articular postfracture step-off after the joint debridment. (Reprinted from Atlas Hand Clinics, 6(2):371–387, R. Luchetti, A. Atzei, and B. Mustapha, Arthroscopic wrist arthrolysis, pp. 371–387, © 2001 with permission from Else- vier Science.)
FIGURE 19.3. Drawings showing the extent of the capsular and lig- ament release of the wrist. RSC (radioscaphocapitate), LRL (long ra- diolunate), SRL (short radiolunate), DRC (dorsal radiocarpal). The ul- nar ligaments, UL (ulnar lunate) and UT (ulnar triquetral) must not be sectioned. (Reprinted from Atlas Hand Clinics, 6(2):371–387, R.
Luchetti, A. Atzei, and B. Mustapha, Arthroscopic wrist arthrolysis, pp. 371–387, © 2001 with permission from Elsevier Science.)
grasping activities in tepid water, such as squeezing a sponge for 10 minutes four times a day. It is also im- portant that the hand and forearm are not submerged for a long period of time in water that is either too hot or too cold, since excessive vasodilation or constric- tion is counterproductive during the healing process.
The patient eventually progresses to performing all wrist exercises in all planes of motion, in the water, with associated hand exercises in which the fingers are in both the closed-fist or open-palm positions. The patient can gradually progress to exercising in anti- gravity postures out of water. The patient is instructed on how to perform passive, active, and active assisted exercises. It is advisable to begin the patient with no
ing isokinetic and isotonic rehabilitation equipment can be initiated 1 month after surgery under the strict supervision of a physical therapist (Figure 19.7A,B).
Patient protocols are individualized depending on the strength requirements they need to obtain in order to perform their jobs. It is advisable that the physical therapist do an on-site ergonomic evaluation of the patient being rehabilitated, and quantify the forces re- quired of the patient’s entire upper extremity in order to perform work duties.16
FIGURE 19.5. Functional compressive bandaging preventing the onset of stagnant distal edema of the hand.
FIGURE 19.6. The use of a continuous passive mobilizer helps to maintain the wrist range of motion that has been obtained during arthroscopic surgery.
FIGURE 19.7. A, B. Isokinetic rehabilitation can be started 1 month after surgery. A. Isokinetic exercise for improving both strength and endurance of wrist flexors and extensors. B. Isoki- netic work simulation is done to re-integrate the entire upper ex- tremity to assume the correct kinematic postures during specific work postures.
B A
PERSONAL CLINICAL EXPERIENCE
The authors’ clinical experience was initiated in 1988, and up until now we have operated on 43 cases. The first case operated on was to reduce first CMC joint rigidity due to prolonged immobilization after con- servative treatment of a Bennett fracture. Arthro- scopic arthrolysis of the patient’s first CMC joint al- lowed recovery of complete wrist range of motion without pain. All the other cases involved wrist rigid- ity secondary to immobilization after wrist fracture or surgery.
In our control series study, 18 patients (13 males and 5 females, with a mean age of 38 years) were in- cluded: one of our cases was operated on bilaterally and successively required an additional right wrist ar- throscopic arthrolysis in order to reach the same level of improvement as that of the contralateral side. Sev- enteen cases followed wrist fractures, and one fol- lowed open surgery for triangular fibrocartilage com- plex (TFCC) tear (type 1B).
Criteria for Inclusion
Criteria for inclusion in this study were:
• Wrist stiffness with or without pain.
• Decreased grip strength.
• Unsuccessful results from rehabilitation after 3 to 6 months.
Method of Evaluation and Results
Preoperative and postoperative evaluation of all the patients were done using the Mayo Wrist Score crite- ria.17,18The DASH questionnaire was included in the postoperative checkup (Table 19.3). All the cases were clinically reevaluated at a mean follow-up of 32
TABLE 19.3. Preoperative and Postoperative Evaluation Parameters.
Mayo Wrist Score (Preop) Pain (VAS)
Wrist ROM (degrees) Grip strength (Kg or %) Work status
DASH questionnaire (Postop)
TABLE 19.4. Results of Arthroscopic Wrist Arthrolysis for 18 Patients/19 Cases.
Preop Postop
(mean) (mean)
Pain (VAS) 7 1
Flexion/extension (degrees) 84 107
Rad/ulnar deviation (degrees) 48 49
Prono/supination (degrees) 132 156
Grip strength (Kgs) 27 36
FIGURE 19.8. A–D. Distal radius fracture treated with reduction and cast immobilization. Left wrist remained stiff in flexion and in semipronated position after 4 months of rehabilitation.
B A
C
D
ative) to 87 (postop), and the DASH questionnaire ob- tained an average of 21 points.
Clinical Cases
CASE19.1
A 26-year-old man with a distal radius fracture of the left wrist was treated with reduction and prolonged plaster cast immobilization in a Cotton-Loder posi- tion for 40 days. After 4 months of rehabilitation, the wrist remained completely stiff in flexion and in a semipronated position (Figure 19.8). X-rays taken af- ter 3 months showed osteoporosis and articular wrist space reduction (Figure 19.9). Arthroscopic wrist arthrolysis was performed after 4 months of rehabili- tation, obtaining improvement of flexion-extension and pronosupination wrist ROM (Figure 19.10).
CASE19.2
A 29-year-old woman had limitation in right wrist pronation ROM after a surgical repair of TFCC tear (Figure 19.11). Wrist ROM before surgery was 0 de- grees pronation (Figure 19.12). Flexion-extension and supination were normal. Arthroscopic arthrolysis al- lowed her to recover complete pronation of the wrist (Figure 19.13).
ing the improvement of wrist ROM after arthroscopic wrist arthrolysis is reported in Table 19.5.
In respect to Verhellen and Bain5and Osterman and Culp6our cases had a greater preoperative wrist ROM, but the final results of wrist motion were almost the same. Our indication for selecting surgical candidates is based on the subject’s level of wrist rigidity that is associated with pain. Wrist rigidity alone is not con- sidered to be important enough to require arthroscopic arthrolysis, but when rigidity is associated with pain, this surgical technique is strongly indicated.
An additional arthroscopic arthrolysis of the same wrist can also be performed again, if required (one case of this nature occurred in our study), based on the clin- ical results and degree of range of motion improve- ment. Reoperation is well accepted by patients since the surgery does not take a long time and it is not painful, but most of all because the patient is able to see immediate improvements in wrist motion.
Arthroscopy can reveal associated soft tissue tears that are considered to be the cause of the wrist pain.
In our cases, we frequently found loose bodies, arthrofibrosis, chondritis and osteochondritis, partial tears of the intercarpal ligaments (SL, LT, and TFCC) and/or a minimal articular step, which were not evi- dent in the X-ray and/or MRI (Figure 19.4). This con-
FIGURE 19.9. A, B. X-rays taken after 3 months of rehabilitation; osteoporosis and articular wrist space reduction are visible.
A B
firms the validity of arthroscopy in comparison to other methods.19,20Moreover, during the operation, it is possible to treat all these conditions, thus improv- ing both wrist pain and rigidity at the same time.
Conversion to open surgery is suggested only when it is necessary to surgically treat the DRUJ, when dif- ficulty is encountered during the arthroscopy. Other surgical approaches are adopted to treat associated soft tissue tears or pathologies, such as carpal tunnel syn- drome (CTS) and partial or total wrist denervation.
Arthroscopic arthrolysis of other joints, such as the first CMC joint, can also be contemporaneously performed.
Based on our experience, we suggest that ulnar avul- sion of the TFCC (type 1B) or a complete lesion of the SL ligament must not be treated simultaneously to this technique since they require prolonged immobilization that is contrary to the immediate rehabilitation that is initiated after arthroscopic arthrolysis. Therefore, it is important to discuss with the patient the surgical pro- cedure indicated. It is mandatory that the wrist be mo- bilized and that the patient initiate rehabilitation im- mediately after an arthroscopic arthrolysis procedure.
One must remember that if there is an underlying SL ligament tear in addition to the wrist rigidity, the surgeon will not be able to obtain good results from performing an arthroscopic arthrolysis. The injury to this ligament is predominantly hidden by wrist rigid- ity; only after the wrist has undergone an arthrolysis can the clinical manifestations of wrist instability due to ligament tear become apparent. The improvement
FIGURE 19.10. Both (A, B) flexion-extension and (C, D) pronation- supination are improved after arthroscopic arthrolysis.
FIGURE 19.11. A, B. TFCC tear of right wrist was surgically re- paired.
B A A
B
C
D
of wrist range of motion that is obtained during wrist arthrolysis can be inconsistent.
In a previous study (Figure 19.14), we found that intraoperative increase of wrist flexion-extension ROM was followed by a temporary decrease soon af- ter surgery but was restored by the final follow-up reevaluation.3 On the other hand, pronation-supina- tion improvement that has been obtained during sur- gery is almost always maintained postoperatively.
Rigidity of the wrist does not always involve the radiocarpal joint (flexion-extension) by itself. DRUJ (pronosupination) rigidity is more frequently encoun- tered, and it can be isolated (Case 19.2) or associated with the radiocarpal joint (Case 19.1). When the rigid- ity of the DRUJ is isolated, ROM recovery after sur- gery is easier to obtain than flexion-extension ROM, and this improvement has been maintained.
COMPLICATIONS
Unfortunately, it can happen that the surgeon is un- able to perform a wrist arthroscopic arthrolysis due to the presence of an osteofibrotic band that is too thick
to perform a surgical arthroscopic arthrolysis. Unfor- tunately, the underlying difficulties become quite ev- ident during the surgery, and if one is able to perform the wrist arthrolysis, the tenaciously adherent bands and the osteofibrotic bridges must be detached in or- der to improve visual field and, ultimately, articular range of motion. At the same time that this technique is being performed, it becomes quite evident that the radial surface is no longer completely covered by car- tilage and there is the presence of osteochondral le- sions of various severity.
Even if a proper physical therapy program is fol- lowed, it is quite common for fibrotic bridges to re- form in a few months and provoke partial or complete radiocarpal ankylosis. It is also possible to find extra- articular wrist rigidity that has been caused by reflex sympathetic dystrophy. In these cases, wrist arthrol- ysis must be associated with the release of extra- A
B
FIGURE 19.12. A, B. Wrist range of motion was 0 degrees pronation before arthroscopy; flexion-extension and supination were normal.
A
B
FIGURE 19.13. A, B. Arthroscopic arthrolysis restored complete pronation of the wrist.
articular soft tissue adhesions. Surgery in these cases must be approached with extreme caution since the root of the wrist rigidity is much more complex than just a localized articular dysfunction.
The surgeon can also run into unpleasant techni- cal situations during surgery such as the breakdown of instruments, including tweezers, scissors, mini- scalpel or motorized instruments.21
When the patient reports that wrist pain has reap- peared or has never completely disappeared after sur- gery, the surgeon should take note that there can still be an underlying articular pathology that has not been uncovered. Often, the pain can be due to intrinsic lig- ament tears (SL or LT) that had not been taken into consideration preoperatively. The use of articular in- struments and motorized instruments can cause un- wanted osteoarticular lesions (chondral scuffing, liga- ment injuries etc.) that can manifest themselves postoperatively in the form of pain or wrist instability.
CONCLUSION
Arthroscopic arthrolysis is a promising surgical option for the treatment of wrist rigidity after trauma or sur- gery. Reasons for performing arthroscopic wrist arthrolysis include the following:
• It is safe and requires a minimal amount of inva- sive surgery.
• It allows the surgeon to precisely identify the real causes of intra-articular rigidity and pain.
• It does not preclude the possibility of performing another surgical procedure in the future that re- quires prolonged immobilization.
• It does not preclude the possibility of converting an arthroscopic arthrolysis into an open surgery.
It must be remembered that arthroscopic arthroly- sis is a difficult procedure to perform and must be done by a skilled and well-trained arthroscopic surgeon.
References
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13. Warner JJ, Allen AA, Marks PH, et al. Arthroscopic release of post-operative capsular contracture of the shoulder. J Bone Joint Surg1996;79A:1151–1158.
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15. Doi K, Hattori Y, Otsuka K, et al. Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted reduc- TABLE 19.5. Comparison of Previous Studies in Literature.
Preop Postop
Follow-up Flex/Ext Flex/Ext
Publications No. cases months (mean degrees) (mean degrees)
Pederzini et al., 1991 5 10 44/40 54/60
Verhellen and Bain, 2000 5 6 17/10 47/50
Osterman and Culp, 2000 20 32 9/15 42/58
Luchetti, Atzei, Mustapha, 2001 19 32 46/38 54/53
FIGURE 19.14. Wrist range of motion in flexion, extension, prona- tion, and supination measured preoperatively, intraoperatively, and postoperatively. Data from Pederzini et al.3
18. Krimmer H. Gegenuberstellung der mediokarpalen Teil- arthrodese und der Totalarthrodese des Handgelenkes durch
Riv Chir Mano2001;38(2):180–187.
