Wrist and hand arthroscopic surgery–current status and future horizons in hand surgery: a narrative review

1. Background

Wrist arthroscopy was first utilized in 1979 to diagnose wrist pathologies and, during its early development in the mid-1980s through the early 1990s, was primarily employed for diagnostic evaluation of various wrist joint disorders, tissue biopsy, simple synovectomy, and partial resection of the triangular fibrocartilage complex (TFCC). In South Korea, wrist arthroscopy, which uses small-diameter arthroscopes of approximately 2.4 mm, was adopted following the introduction of arthroscopic procedures for larger joints such as the knee, hip, and shoulder. The evolution of wrist arthroscopy has paralleled advances seen in arthroscopy for other joints.

Over the subsequent 3 decades, enhanced anatomical understanding of the hand and wrist, together with refinement of surgical techniques, has significantly expanded the scope of wrist arthroscopy. This evolution has been further accelerated by the miniaturization of arthroscopic instruments specifically designed for finger and wrist joint surgery, along with the development of specialized devices such as punches, shavers, and radiofrequency ablators that improve surgical efficacy. Additionally, advancements in high-resolution monitors have enabled more precise and complex procedures, thereby broadening the range of indications for arthroscopic intervention.

2. Objectives

This review presents the fundamental instruments and surgical techniques used in hand and wrist arthroscopy, introduces contemporary arthroscopic surgical approaches for the wrist and hand joints, and explores future directions in this rapidly evolving field.

1. Equipment and anesthesia

Wrist arthroscopy requires a standard set of equipment, including a surgical arm board, an arthroscopic system with monitor and camera, a fiberoptic light source, an electric shaver, a radiofrequency ablator, a C-arm fluoroscopy unit, and a traction tower system. Regional nerve blocks, such as axillary block, or general anesthesia are typically used. To achieve a bloodless surgical field, a tourniquet is usually applied to the upper arm.

2. Patient positioning and traction

The patient is placed supine, with the arm abducted to 90° and the elbow flexed at 90°. The wrist is maintained in a neutral position with respect to pronation and supination. Joint space distraction is accomplished using a traction tower, with finger traps applied to the index and middle fingers, or occasionally the ring finger, and a traction force of 3.5 to 7 kg.

3. Portal placement

Prior to incision, arthroscopic and instrument portal sites are marked using anatomical landmarks. Proper joint entry is confirmed with a needle before insertion of instruments. The initial portal is typically the 3 to 4 portal, situated between the third and fourth extensor compartments—that is, between the extensor pollicis longus and the extensor digitorum communis compartments. Other commonly used portals, selected according to anatomical site and surgical objectives, include the 4–5, 6R (radial to extensor carpi ulnaris [ECU]), 6U (ulnar to ECU), 1–2, and scaphoid-trapezium-trapezoid (STT) portals.

4. Special arthroscopic portals

Midcarpal arthroscopy is performed using the midcarpal radial (MCR) and midcarpal ulnar (MCU) portals to visualize the intra-articular space. This approach is valuable for assessing injuries to the intercarpal rows and intercarpal ligaments between the proximal and distal carpal bones.

Distal radioulnar joint (DRUJ) arthroscopy is conducted through dorsal and volar DRUJ portals. This technique permits evaluation of deep (proximal) TFCC tears, the foveal attachment of the TFCC to the ulna, the articular cartilage of the sigmoid notch of the radius, and the integrity of the joint capsule (Figure 1).

Figure 1.

Portals for wrist arthroscopic surgery. STT, scaphoid-trapezium-trapezoid; TH, triquetrum-hamate. Illustrated by the author.

1. Arthroscopic repair of TFCC tears

Treatment strategies for TFCC tears depend on both the lesion's location and chronicity. Central or radial TFCC tears are often managed by simple debridement to relieve pain, whereas proximal peripheral tears—particularly those involving the deep (foveal) insertion at the ulnar fovea—are closely linked to DRUJ instability. If untreated, such tears may result in persistent ulnar-sided wrist pain, ongoing instability, and ultimately, degenerative arthritis.

2) Classification of TFCC tears

In 1989, Palmer classified TFCC lesions into 2 principal categories: class I for traumatic injuries and class II for degenerative changes. Class I lesions (Figure 2) are traumatic tears further subdivided into 4 types based on the location of lesion (Table 1).

Figure 2.

Palmer type 1 triangular fibrocartilage complex tears. Illustrated by the author.

Table 1.

Palmer classification: class I (traumatic TFCC injury)

Type IA lesions are tears in the avascular central portion of the TFCC disc and are typically managed with arthroscopic debridement rather than repair.

Type IB lesions (ulnar peripheral tears) occur at the ulnar attachment of the TFCC and are a major cause of ulnar-sided wrist pain and DRUJ instability. Cadaveric studies have shown that the ulnar 15% to 20% of the TFCC receives the majority of its blood supply [8,9], suggesting that ulnar-sided TFCC tears may heal if anatomic structure is surgically restored. Due to their clinical significance, more detailed classification systems, such as the Atzei & European Wrist Arthroscopy Society (EWAS) classification, have been developed specifically for type IB tears to support precise diagnosis and treatment strategies.

Type IC lesions involve tears of the palmar aspect of the TFCC in the region of the ulnocarpal ligaments.

Type ID lesions are characterized by avulsion of the radial attachment of the TFCC from the radius and, like type IA tears, are generally treated with debridement.

Class II lesions represent degenerative TFCC tears, which most often appear as perforations in the central articular disc from chronic impingement between the ulnar head and carpal bones, particularly in cases of UIS where the ulna is longer than the radius (positive ulnar variance). These are subdivided into Stages A through E according to severity, including the presence of TFCC perforation, chondromalacia of the ulnar head and lunate, lunotriquetral interosseous ligament tears, and degenerative DRUJ arthritis. Surgical management focuses on reducing ulnar-sided load, with common interventions including arthroscopic debridement and ulnar shortening osteotomy (Table 2).

Table 2.

Palmer classification: class II (degenerative TFCC pathology)

4) Arthroscopic surgical techniques

Arthroscopic management of peripheral TFCC tears employs various techniques depending on the location of the tear, the degree of DRUJ instability, and patient functional demands. Standard approaches include the inside-out, outside-in, all-inside, and bone tunnel techniques.

The inside-out technique provides the advantage of tying sutures externally through small incisions, minimizing the need for internal knotting. In this method, a suture is passed through the periphery of the TFCC using a Tuohy needle, then re-passed in the opposite direction to create a horizontal mattress suture. This approach offers excellent visualization and is suitable for distal TFCC tears, but is less ideal for proximal fiber tears that are essential for DRUJ stability.

For cases requiring proximal, deep repair, a bone anchor can be inserted into the ulnar fovea to directly secure the TFCC to bone. This method is appropriate for Palmer type IB proximal tears. Although it requires a direct foveal portal approach involving a small open incision, the procedure can be relatively complex.

The knotless all-inside arthroscopic technique is performed through the 3 to 4 portal, 6R portal, and an accessory 6R portal. This approach utilizes a suture lasso that simultaneously passes through both the distal and proximal portions of the TFCC, securing the suture to the ulnar fovea using a pushLock® anchor without the need for tying knots. This technique offers shorter operative times and less patient discomfort, as there are no suture knots. It is also suitable for patients with significant DRUJ instability. However, challenges include difficulty in debriding the ligament attachment site and the potential for unintended or incomplete anchor placement, as well as soft tissue impingement.

Transosseous repair enables anatomical reattachment of both the proximal and distal TFCC to the ulnar fovea. Transosseous repair techniques are generally classified into the Nakamura method—which utilizes 2 K-wires to create bone tunnels for suture passage—and the single large bone tunnel technique (approximately 3–4 mm). The author has developed and implemented a transosseous repair method that uses a single, large bone tunnel through which all torn portions can be repaired (Figure 3). The 2 K-wire transosseous repair technique allows only a single suture and creates a limited contact area between the ligament and bony attachment, potentially resulting in ineffective fixation if the bone tunnel is not precisely located at the TFCC’s foveal attachment. In contrast, a large bone tunnel allows for repair of complex TFCC tears. Considering the elliptical footprint of the TFCC's bony attachment (approximately 6×9 mm), a 3 to 4 mm bone tunnel provides a sufficient contact surface between the torn ligament and bone. It also supports ligament regeneration by inducing fresh bleeding and providing adequate tissue regenerative factors through the bone tunnel [5,10].

Figure 3.

Arthroscopic transosseous triangular fibrocartilage complex (TFCC) repair (J.W.P.). (A) C-guide positioning on the TFCC for guide pin insertion at the foveal insertion site of the deep fiber of TFCC. (B) Drilling for bone tunnel. (C) First suture insertion through the bone tunnel using a 22-G needle. (D) Suture positioning on TFCC. (E) Suture is retrieved through the loop wire using a sharp mosquito forceps. (F) One more suture with the same technique. (G) Sutures through the bone tunnel were fixed with a push-lock anchor. (H) Final configuration of 2 sutures on the TFCC. Illustrated by the author.

2. Scapholunate interosseus ligament (SLIL) instability: arthroscopically assisted ligament repair

The scapholunate interosseous ligament (SLIL) is a key intrinsic ligament connecting the scaphoid and lunate bones in the wrist. It is essential for maintaining intercarpal stability and normal wrist joint movement. A tear of the SLIL disrupts wrist biomechanics and, if instability persists, can progress to scapholunate advanced collapse (SLAC wrist), resulting in irreversible pain and severe arthritis. SLIL injuries may occur due to trauma, repetitive overuse, or degenerative changes, underscoring the importance of early diagnosis and appropriate treatment for optimal prognosis.

Traditional imaging modalities, such as X-rays and MRI, often struggle to clearly identify SLIL lesions. However, the introduction of 3.0 T MRI and the widespread adoption of wrist arthroscopy have markedly improved diagnostic accuracy and broadened therapeutic possibilities. Arthroscopic classification systems, such as the Geissler classification and the more recent EWAS classification, provide detailed assessments of the anatomical and functional status of SLIL tears and help guide treatment strategies at each stage.

The Geissler classification remains the most widely used arthroscopic standard for evaluating SLIL lesions. This system categorizes lesions into grades I to IV based on arthroscopic findings regarding the gap, changes in the scapholunate interval, and the presence of intercarpal instability. It is used to select surgical approaches and predict prognosis according to the degree of ligamentous instability.

1) EWAS classification

The EWAS classification is an up-to-date arthroscopic grading system that comprehensively incorporates the anatomical location, extent, and functional stability of SLIL injuries. For example, EWAS 3-C designates a complete tear of the dorsal, palmar, and membranous portions, usually accompanied by instability and often requiring surgical repair or reconstruction. The EWAS system allows for more detailed sub-classification of lesion severity compared to the Geissler classification, thereby facilitating better treatment decisions, and its clinical application is growing (Table 3) [4].

Table 3.

Arthroscopic EWAS classification for scapholunate ligament injury

3. Arthroscopic-assisted reduction and internal fixation of intra-articular distal radius fractures

Distal radius fractures account for approximately 15% to 20% of all fractures and are among the most common fractures in the elderly. In cases of intra-articular fractures, precise anatomical reduction of the articular surface is essential. Step-offs or gaps of 2 mm or more can result in chronic complications, such as post-traumatic arthritis, impaired wrist function, and persistent pain. Although conventional management has relied on closed reduction and internal fixation or open reduction and internal fixation (ORIF) under fluoroscopic guidance (C-arm), recent advances have established arthroscopy as an important adjunct, particularly for severely comminuted intra-articular fractures or situations where satisfactory reduction is not achieved. Arthroscopic assistance enables direct visualization of the articular surface, which allows for more accurate fragment reduction. It also provides the substantial advantage of permitting direct assessment and management of associated soft tissue injuries, which frequently accompany distal radius fractures, including intercarpal ligament injuries, TFCC tears, and damage to the carpal cartilage.

Indications for arthroscopic-assisted fragment reduction and internal fixation include AO type B3 and C1–C3 fractures with articular incongruity; articular impaction of 1 to 2 mm or greater; concomitant soft tissue injuries (such as TFCC tears or SLIL injuries); and cases involving young patients, athletes, or musicians who require precise reduction.

The surgical procedure involves maintaining wrist traction with a traction tower, followed by insertion of the arthroscope through the 3 to 4 and 6R portals to facilitate reduction of intra-articular fragments. Subchondral impacted fragments are elevated and reduced using an elevator, then fixed with cannulated screws or K-wires. While the primary fixation for metaphyseal comminution or the main radial fracture is usually performed with a volar plate and screws, arthroscopic reduction of articular fragments is performed as an adjunctive step (Figure 4).

Figure 4.

Arthroscopic-assisted distal radius fracture reduction and plate fixation. Illustrated by the author.

Compared with conventional ORIF performed under fluoroscopic guidance, arthroscopic-assisted reduction of distal radius fractures has demonstrated superior accuracy in articular surface reduction and functional recovery, with 93% of reductions achieving less than 1 mm of residual articular incongruity. All patients reportedly returned to work and daily activities within 6 weeks. Additionally, arthroscopy revealed further articular incongruities not detected by fluoroscopy in 5 cases (33%), and enabled the simultaneous diagnosis and treatment of associated TFCC injuries (21%) and SLIL injuries (14%) [3,15,16].

Although arthroscopic-assisted reduction of distal radius fractures offers several distinct advantages over traditional methods—including improved accuracy of anatomical reduction, comprehensive evaluation of soft tissue lesions, and the opportunity for simultaneous treatment—it requires specialized instrumentation and a high level of surgical proficiency. Disadvantages include increased operative time and higher associated costs. The consensus is that, when used selectively with appropriate indications, arthroscopic-assisted surgery can achieve superior functional, anatomical, and rehabilitative outcomes compared to conventional ORIF. Nevertheless, as most distal radius fractures are still managed with conventional ORIF under fluoroscopic guidance—with generally good results—it remains difficult to definitively claim that arthroscopic reduction, with its additional operative time, cost, and technical complexity, consistently guarantees better outcomes. Therefore, further long-term clinical outcome evaluations and comparative studies are warranted.

4. Arthroscopic-assisted reduction and bone grafting for scaphoid nonunion

The scaphoid is one of the most critical of the 8 carpal bones, playing a central role in the biomechanics and stability of the wrist joint. However, due to its limited intraosseous blood supply, scaphoid fractures carry a high risk of progressing to nonunion or avascular necrosis (AVN). Even in undisplaced scaphoid fractures, approximately 10% can progress to nonunion with non-surgical treatment. Persistent nonunion may ultimately lead to arthritis in adjacent joints and carpal collapse, known as SNAC (scaphoid nonunion advanced collapse). Although scaphoid nonunion has traditionally been managed with open reduction, autogenous bone grafting, and rigid internal fixation, arthroscopic-assisted bone grafting and internal fixation can minimize soft tissue damage while performing bone grafting, resulting in excellent outcomes when used appropriately.

Indications for arthroscopic-assisted bone grafting for scaphoid nonunion include scaphoid waist or proximal pole nonunion persisting for over 6 months, mild humpback deformity (angular deformity), mild dorsal inter­calated segmental instability (DISI) deformity, and SNAC stage 1 or less without severe degenerative changes of the articular surface. However, this technique is challenging in cases showing signs of AVN of the proximal pole of the scaphoid, SNAC stage 2 or greater arthritis, extensive bone defects or cysts, or revision surgery after previous surgical failure.

The arthroscopic bone grafting procedure for scaphoid nonunion involves applying joint traction with a traction tower and performing radiocarpal arthroscopy to evaluate primary intra-articular pathologies. The arthroscope is then transitioned to the MCU portal, and typically, the MCR portal or additional portals around the nonunion site are created to debride fibrous tissue and freshen the fracture surfaces. Fibrous tissue and bone fragments at the nonunion site are removed using a curette and motorized shaver. Sclerotic bone from both fracture ends is removed with a burr, and active bleeding from the fracture surfaces is confirmed. Cancellous bone for grafting is usually harvested from the iliac crest (autogenous iliac crest bone graft) or the distal radius. The harvested bone graft is crushed into small pieces and packed firmly into the scaphoid fracture site using a cannula or sheath. After graft insertion, the fracture is stably fixed with K-wires or a headless compression screw. Guide wires for K-wire or screw fixation may be pre-positioned in the distal fragment before bone grafting, then advanced into the proximal fragment after reduction and bone grafting. To prevent graft displacement, fibrin glue may be applied over the graft, or K-wires spanning the SL joint may be used temporarily to enhance stability (Figure 5).

Figure 5.

Arthroscopic bone graft and internal fixation for scaphoid fracture nonunion. Illustrated by the author.

Compared to open surgery, arthroscopic bone grafting offers a minimally invasive approach that minimizes soft tissue damage and preserves blood supply. It also allows for simultaneous diagnosis and treatment of associated intra-articular pathologies (such as TFCC and SLIL injuries), minimizes post-surgical stiffness due to adhesions, and enables faster recovery and earlier rehabilitation. However, disadvantages include a steep learning curve, the need for specialized equipment, longer operative times, limited ability to correct angular deformities (such as humpback or DISI), restricted applicability in cases of bone necrosis, extensive defects, or SNAC stage 2 or higher, and potentially inferior radiological correction accuracy or fixation strength compared to open procedures.

Therefore, arthroscopic bone grafting and internal fixation represent an effective minimally invasive treatment for scaphoid nonunion. When performed with precise indications, high union rates and excellent functional recovery can be expected. Recent systematic reviews indicate similar union rates for both arthroscopic and open procedures, with arthroscopic techniques offering the advantages of reduced soft tissue damage and shorter recovery periods. Nevertheless, the most critical factor remains the choice of surgical method, which must be determined through comprehensive consideration of patient selection, surgeon experience, and the specific characteristics of the lesion [7,17–20].

5. Arthroscopic debridement for wrist arthritis and synovitis

Inflammatory arthritis of the wrist, including rheumatoid arthritis, septic arthritis, and crystalline arthritis, often results in synovial proliferation and persistent inflammation, leading to chronic pain and disability. In particular, chronic synovitis unresponsive to pharmacotherapy can progress to functional impairment due to destruction of the surrounding carpal bones and DRUJs, necessitating surgical intervention. Additionally, in some cases, precise diagnosis and treatment require synovial biopsy and extensive synovectomy. However, traditional open synovectomy, which involves a large incision, often leads to significant soft tissue damage, delayed postoperative recovery, and a risk of joint stiffness. By contrast, arthroscopic synovectomy offers a minimally invasive approach, enabling accurate tissue biopsy, lavage, debridement, and lesion removal with more rapid recovery. As a result, it has recently become the preferred minimally invasive surgical option for inflammatory wrist conditions [21–23].

Arthroscopic synovectomy is indicated in various inflammatory conditions. Primary indications include chronic synovitis in rheumatoid arthritis patients who are unresponsive to medical therapy, and wrist pain due to synovial proliferation in patients with psoriatic arthritis or reactive arthritis. For crystalline arthritis, arthroscopic debridement of synovitis caused by intra-articular uric acid or calcium crystals is an effective treatment. Moreover, for non-specific synovitis or cases with unclear diagnoses, arthroscopic tissue biopsy serves as a highly valuable diagnostic tool.

During arthroscopic synovectomy, it is often necessary to remove synovial tissue from all compartments of the wrist joint. Therefore, in addition to the standard portals used in most arthroscopic procedures, additional portals such as the MCR, MCU, 1-2, STT, and DRUJ portals may be utilized. A shaver and radiofrequency ablator are used to resect hypertrophied synovial tissue, while continuous irrigation of the joint capsule is maintained to ensure a clear surgical field. Postoperatively, early joint mobilization is encouraged and combined with pharmacotherapy to control inflammation [23–25].

6. Arthroscopy of finger and small joints

Finger joints and other small joints, defined by their compact size and narrow joint spaces, have historically required open surgical approaches. However, recent advancements in small joint arthroscope technology have revolutionized their diagnosis and treatment. In the hand, in particular, arthroscopy has become a minimally invasive option for biopsy and treatment of various pathologies affecting the metacarpophalangeal joints and the first CMC joint.

A critical aspect of small joint arthroscopy is establishing and maintaining a clear view within the confined joint space, which is accomplished through the use of traction devices and specialized portals. Typically, the 1R and 1U portals—located radially and ulnarly to the digital extensor tendons, respectively—are used for inserting the arthroscope and instruments. These portals enable procedures such as synovectomy, cartilage debridement, loose body removal, and radiofrequency ablation. Thermal shrinkage, which applies thermal energy to the joint capsule and ligaments to promote tissue contraction, is particularly useful for treating joint instability and enhancing stability (Figure 6).

Figure 6.

Thumb carpometacarpal joint arthroscopic synovectomy. Illustrated by the author.

Thumb CMC joint osteoarthritis is a common degenerative condition in older women. When conservative treatment is ineffective or the disease is advanced, open excisional arthroplasty, arthrodesis, or prosthetic arthroplasty may be considered. Recently, the use of small arthroscopes has enabled early diagnosis and surgical treatment of these lesions, allowing for simultaneous identification and management of cartilage damage, synovitis, and articular surface abnormalities. Common arthroscopic procedures include synovectomy, thermal shrinkage, debridement, and removal of intra-articular loose bodies. For advanced osteoarthritis, partial or complete trapeziectomy (removal of the trapezium, one of the carpal bones) followed by suspension arthroplasty using a suture-button technique can be performed. Arthroscopic trapeziectomy, compared to open bone resection, is minimally invasive and promotes faster postoperative recovery while achieving both intra-articular stability and preserved range of motion [26,27]. Recent research by Maeda et al. [28] has shown that arthroscopic partial trapeziectomy provides rapid recovery and excellent functional outcomes.

7. Arthroscopic carpal tunnel syndrome surgery

Carpal tunnel syndrome is a common condition caused by compression of the median nerve within the carpal tunnel, resulting in numbness, pain, thenar muscle atrophy, and weakened grip strength. Treatment options include both non-surgical interventions and surgical decompression. Surgical approaches are classified as traditional open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR), the latter employing an endoscope. Recently, ECTR has been widely adopted in hand surgery due to its minimally invasive nature and more rapid recovery.

ECTR, similar to OCTR, involves incising the transverse carpal ligament (TCL) to decompress the carpal tunnel. However, ECTR offers the advantage of reducing postoperative pillar pain and infection risk, as it avoids incisions through the skin and subcutaneous fat overlying the TCL. Indications for ECTR include patients with typical carpal tunnel syndrome who have failed non-surgical treatment, persistent nocturnal pain, positive findings on physical examination, and confirmation by electrodiagnostic studies. Relative contraindications include anatomical variations, a history of previous surgery, active infection, or tumors.

During the procedure, under regional or general anesthesia, a 1-cm transverse incision is made at the volar wrist crease, ulnar to the palmaris longus tendon. The palmar fascia between the palmaris longus and flexor carpi ulnaris tendons is incised, and the endoscopic instrument is inserted. The TCL is then incised with a specialized knife under arthroscopic visualization. Postoperative pain is typically mild, allowing for immediate finger exercises and resumption of daily activities, with most patients experiencing a rapid recovery. Thus, ECTR offers advantages over conventional OCTR, including faster pain relief, fewer complications, and earlier return to daily life. Nevertheless, precise anatomical knowledge and surgical skill are essential for successful outcomes, making it advisable that the procedure be performed by an experienced hand surgeon (Figure 7) [29,30].

Figure 7.

Endoscopic carpal tunnel release. Illustrated by the author.