Arthroscopic Release of Wrist Contractures

Wrist contracture can be debilitating not only for loss of wrist motion but for its effect on hand function and grip strength.(1,2) This paper looks at the long term outcome of arthroscopic release of wrist and distal radius ulnar joint contractures. Entry Criteria were: I. Significant ROM Loss : Total Flex/Ext Arc < 30° Total Rotation Arc < 90° II. Radiographically Preserved Joint Space III. Full Digital Motion IV. Pain Score Less than 5 on Visual Analog Scale V. Functional Impairment VI. Failure of Nonoperative Therapy . Between 1995 and 2004 74 patients met this criteria: 43 wrist ; 23 DRUJ ; 8 Combined . 21 patients subsequently excluded because of concomitant open surgery such as CTR, plate removal , or tenolysis. The 54 remaining patients had only arthroscopic release of the wrist, DRUJ, or both. 33 F / 20M ; 42 yrs (14-64); 74% Dominant Hand ; Duration Contracture 9 Mos (5-21). Evaluations included ROM, grip strength, Mayo wrist score, Dash (24/53), and Xray. Preop mean flex/extension for the wrist group was: 12°F/ 18° . For the DRUJ group , preop mean pron/sup was 42°P / 31°S. Grip Strength 52% Pain Score Analog 2.4 (out of 10) Mayo Clinic Wrist Score 50.3 Dash 36.4+/-15.2 . All patients had intrinsic adhesions but only 35% of the wrist contracture group had a single scapholunate spot weld as described by Hattori (3). 64% had capsular contracture requiring release, with the dorsal capsule more involved. Despite normal articular xrays, 58% had definable chondral lesions. Ligament and TFC defects were seen in 22%; Loose bodies in 17%. For the Wrist Contracture Group FU was 62 mos. One Lost to Follow up @ 9 months. No Surgical or Post Operative Complications. 31/33 (94%) Extremely Satisfied/Would Repeat Surgery . 2 Failed – No motion gained. One of those with extensive Grade IV Chondral Changes underwent successful Fusion 2.5 Yrs postop . Mean post op flex/extension for the wrist group was: 47°F/ 59°. This represents a gain of 35° flexion and 41° extension. For the DRUJ FU was 50 mos. None lost to FU. One pt had a nondisplaced distal ulna fracture that required casting for 3 weeks but did not appear to compromise the end result. 18/19 (95%) Extremely Satisfied/Would Repeat. One failed and had a subsequent open release to gain more supination without further improvement and a final arc of 35°sup/ 65°pron . In both groups 30% of intraoperative motion on average was lost. Comparing ROM at 1 year to final FU, 53% improved another 5-10° . Combining both groups, the pain analog score decreased from 2.5 to 1.2 ; Grip improved from 40% to 76%. The mean Mayo wrist score improved from 47 to 69 postoperatively and the mean score on the Disabilities of the Arm, Shoulder and Hand questionnaire from 36 to 20. All of the outcome measures yielded statistically significant results (P < .0001) . Final xrays were normal in 47 and arthritic in 6 - all of whom had intraop chondral changes. There was no evidence of carpal instability .

In summary, Arthroscopic Release of Wrist and DRUJ Contractures is feasible, safe, and worthwhile with Restoration of a Functional Motion Arc , High Patient Satisfaction , and a maintenance of results over time. Despite normal xrays over 50% of significant wrist contractures have intra-articular abnormalities that do not compromise the release result in most patients.

1.Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion: A biomechanical study. J Hand Surg Am 1985;10:39-46. 2.Hanson EC, Wood VE, Thiel AE, Maloney MD, Sauser DD. Adhesive capsulitis of the wrist. Clin Orthop 1988;234:51-55. 3. Hattori T, Tsunoda K, Watanabe K, Nakao E, Hirata H, Nakamura R.Arthroscopic Mobilization for Contracture of the Wrist. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 8 (August), 2006: pp 850-854.