Abstract
Rheumatoid arthritis is characterized by hypertrophic synovitis destroying the involved joints. If medical treatment fails to control the synovitis, synovectomy is a worthwhile prophylactic procedure that might help to delay further distention of the joint capsule and ligament. Synovitis of the proximal interphalangeal joint is usually performed by an open approach. The major complication is scar development around the interphalangeal joint, leading to considerable joint contracture. Arthroscopy of the proximal interphalangeal joint is a minimally invasive technique that can eliminate the risk of joint contracture associated with open surgery. The purpose of this Technical Note is to report the technical details of arthroscopic complete synovectomy of the proximal interphalangeal joint of the finger. This procedure is indicated in patients with rheumatoid synovitis of the proximal interphalangeal joint of the finger recalcitrant to medical treatment. It is contraindicated in case of an established boutonniere or swan-neck deformity, the presence of large dorsal synovial cysts, advanced degeneration of the joint, the presence of joint instability, or a fresh skin lesion near portals.
Technique Video
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient i/s in the supine position with the operative hand on the side table. With the dorsal radial and dorsal ulnar portals used interchangeable as the viewing and working portals, synovectomy of the dorsal recess of the proximal interphalangeal joint is performed. With the scope in the dorsal ulnar portal, the inflamed synovium of the radial recess of the joint is resected with the shaver via the dorsal radial portal. Then, the scope is switched to the dorsal radial portal, and the inflamed synovium of the ulnar recess of the joint is resected with the shaver via the dorsal ulnar portal. Finally, the scope is switched back to the dorsal ulnar portal, and the inflamed synovium of the volar recess of the joint is resected with the shaver via the volar radial portal.
Rheumatoid arthritis is characterized by hypertrophic synovitis that eventually destroys the articular cartilage, erodes and ruptures tendons, compresses adjacent nerves, and dislocates and erodes the joint itself.1 If medical treatment fails to control the synovitis, synovectomy is a worthwhile prophylactic procedure that might help to delay further distention of the joint capsule and ligament.1,2 Although a real joint-preserving effect has not been clearly proved, pain reduction and improvement in joint function have made arthroscopic synovectomy a substantial treatment option in patients with rheumatoid arthritis.3 Arthroscopic synovectomy is regularly performed in the shoulder, elbow, wrist, and knee.3 On the other hand, synovectomy of the proximal interphalangeal joint is usually performed by an open approach.1,3 The major complication is scar development around the interphalangeal joint, leading to considerable joint contracture.1 Although arthroscopy of the proximal interphalangeal joint has not been widely accepted as a routine technique because of its technical limitations, it provides more precise information regarding the status of the intra-articular structures than alternative imaging modalities.4,5 It is a minimally invasive technique and can eliminate the risk of joint contracture associated with open surgery.
The purpose of this Technical Note is to present the technical details of arthroscopic complete synovectomy of the proximal interphalangeal joint of the finger. This procedure is indicated in patients with rheumatoid synovitis of the proximal interphalangeal joint of the finger recalcitrant to medical treatment. It is contraindicated in case of established boutonniere or swan-neck deformity, the presence of large dorsal synovial cysts, advanced degeneration of the joint, the presence of joint instability, or a fresh skin lesion near portals.6 Osteoarthritis is a relative contraindication because long-term clinical improvement is more distinct in joints with no or mild joint destruction (early synovectomy) compared with advanced joint damage (late synovectomy) (Table 1).3
Table 1.
Indications and Contraindications of Arthroscopic Complete Synovectomy of Proximal Interphalangeal Joint of Finger
| Indications |
| Rheumatoid synovitis of proximal interphalangeal joint of finger recalcitrant to medical treatment |
| Contraindications |
| Established boutonniere or swan-neck deformity |
| Presence of large dorsal synovial cysts |
| Advanced degeneration of joint |
| Presence of joint instability |
| Fresh skin lesion near portals |
Technique
Preoperative Assessment and Patient Positioning
Preoperative clinical assessment should include evaluation of the local condition of the interphalangeal joint, including local swelling or synovial thickening, local signs of inflammation, tender spots, range of motion, and joint stability. Radiographs are helpful for detection of osteoarthritic changes of the joint. Ultrasound study is a reliable and inexpensive investigation to confirm the diagnosis and study the extent of involvement of synovitis of the proximal interphalangeal joint.7, 8, 9
The patient is placed in the supine position with the operative hand on the side table. An arm tourniquet is applied to provide a bloodless operative field. A small towel roll is put into the palm and stabilizes the finger. No continuous traction is needed. A 1.9-mm 30° arthroscope (Henke Sass Wolf, Tuttlingen, Germany) is used for this procedure. Fluid inflow is driven by gravity, and no arthro-pump is used.
Portal Placement
The dorsal ulnar, dorsal radial, and volar radial portals at the proximal interphalangeal joint space level are used for this procedure. The dorsal ulnar and dorsal radial portals are located on the dorsal ulnar and dorsal radial sides of the proximal interphalangeal joint, respectively.10, 11, 12 The volar radial portal is located at the volar radial corner of the joint by use of a needle under arthroscopic guidance. Three-millimeter skin incisions are made at the portal sites. The subcutaneous tissue is bluntly dissected down to the joint capsule by a hemostat. This can avoid iatrogenic cartilage damage and possible digital neurovascular bundle injury.13 The capsule is perforated by the tip of the hemostat. The dorsal radial and dorsal ulnar portals are coaxial portals with the portal tract at the dorsal recess of the interphalangeal joint (Fig 1).12
Fig 1.
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. (A) The dorsal radial portal (DRP) and dorsal ulnar portal (DUP) are coaxial portals for arthroscopy of the dorsal recess of the proximal interphalangeal joint. (B) The volar radial portal (VRP) is located by a needle.
Arthroscopic Synovectomy of Dorsal Recess of Proximal Interphalangeal Joint
Proximal interphalangeal arthroscopy is started at the dorsal recess of the joint. The dorsal ulnar and dorsal radial portals are interchangeable as the viewing and working portals.
With the dorsal radial portal as the viewing portal and the dorsal ulnar portal as the working portal, the inflamed synovium of the ulnar half of the dorsal recess is resected with an arthroscopic shaver (Dyonics; Smith & Nephew, Andover, MA) (Fig 2). The arthroscope is then switched to the dorsal ulnar portal, and the inflamed synovium of the radial half of the dorsal recess is resected with the shaver via the dorsal radial portal (Fig 3).
Fig 2.
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. (A) The dorsal radial portal (DRP) is the viewing portal, and the dorsal ulnar portal (DUP) is the working portal. (B) The inflamed synovium (IS) of the ulnar half of the dorsal recess is resected with an arthroscopic shaver (AS). (MP, middle phalanx.)
Fig 3.
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. (A) The dorsal ulnar portal (DUP) is the viewing portal, and the dorsal radial portal (DRP) is the working portal. (B) The inflamed synovium (IS) of the radial half of the dorsal recess is resected with the arthroscopic shaver (AS). (MP, middle phalanx; PP, proximal phalanx.)
Arthroscopic Synovectomy of Radial Recess of Proximal Interphalangeal Joint
The dorsal ulnar portal is the viewing portal, and the dorsal radial portal is the working portal. The inflamed synovium of the radial recess of the proximal interphalangeal joint is resected with the shaver (Fig 4).
Fig 4.
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. The dorsal ulnar portal is the viewing portal, and the dorsal radial portal is the working portal. The inflamed synovium (IS) of the radial recess of the proximal interphalangeal joint is resected with the shaver. (MP, middle phalanx; PP, proximal phalanx.)
Arthroscopic Synovectomy of Ulnar Recess of Proximal Interphalangeal Joint
The dorsal radial portal is the viewing portal, and the dorsal ulnar portal is the working portal. The inflamed synovium of the ulnar recess of the proximal interphalangeal joint is resected with the shaver (Fig 5).
Fig 5.
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. The dorsal radial portal is the viewing portal, and the dorsal ulnar portal is the working portal. The inflamed synovium (IS) of the ulnar recess of the proximal interphalangeal joint is resected with the shaver. (MP, middle phalanx; PP, proximal phalanx.)
Arthroscopic Synovectomy of Volar Recess of Proximal Interphalangeal Joint
The dorsal ulnar portal is the viewing portal, and the volar radial portal is the working portal. The inflamed synovium of the volar recess of the proximal interphalangeal joint is resected with the shaver (Fig 6, Video 1, Table 2).
Fig 6.
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. (A) The dorsal ulnar portal (DUP) is the viewing portal, and the volar radial portal (VRP) is the working portal. (B) The inflamed synovium (IS) of the volar recess of the proximal interphalangeal joint is resected with the arthroscopic shaver (AS). (DRP, dorsal radial portal; MP, middle phalanx; PP, proximal phalanx.)
Table 2.
Pearls and Pitfalls of Arthroscopic Complete Synovectomy of Proximal Interphalangeal Joint of Finger
| Pearls |
| The dorsal ulnar and dorsal radial portals are coaxial portals for arthroscopy of the dorsal recess of the proximal interphalangeal joint. |
| Synovectomy of the dorsal recess of the proximal interphalangeal joint can improve arthroscopic visualization during synovectomy of the rest of the joint. |
| Synovectomy of the volar recess of the proximal interphalangeal joint via the volar portal can minimize the risk of chondral injury. |
| Manual traction of the finger applied by an assistant during volar synovectomy can improve arthroscopic visualization via the dorsal portal. |
| The arthroscope and instruments should be manipulated gently to avoid chondral injury and slippage out of the joint because the joint cavity is very small.21 |
| Pitfalls |
| Arthroscopic synovectomy of the volar recess of the proximal interphalangeal joint via the dorsal radial and dorsal ulnar portals will cause chondral injury even with the finger under traction. |
| If the shaver blade is not well seen during synovectomy, the articular cartilage, volar plate, extensor tendon, and collateral ligaments may be damaged. |
Postoperative Protocol
Postoperatively, the patient is prescribed nonsteroidal anti-inflammatory drugs and free mobilization of the fingers is allowed.
Discussion
The collateral ligaments and the lateral bands of the extensor mechanism are the critically important components of the function of the proximal interphalangeal joint.1 Injury to these components can lead to pain and contracture of the proximal interphalangeal joint, with overall diminished hand function.1
Arthroscopy of the finger joints was first described by Chen14 in 1979. The initially described portals are between the central extensor tendon and lateral bands, and the extensor mechanism between these structures may be injured.14 Later, Sekiya et al.10,11 described the portals at the intervals between the lateral bands and the collateral ligaments.1 These portals are considered safe to the extensor mechanism and the digital nerves.1,10,11 The more laterally placed dorsal portals increase the inter-portal distance and reduce the chance of slippage of the arthroscopic instruments out of the joint during the dorsal synovectomy.
Continuous traction is not used during the described technique because the working areas are the different recesses of the proximal interphalangeal joint and not the joint proper. Because the interval between the head of the proximal phalanx and the base of the middle phalanx is narrow and cannot be expanded, the volar joint space cannot be accessed, even with strong traction force.5 If volar synovectomy is performed via the dorsal portals, the articular cartilage will be damaged when the arthroscopic shaver passes through the joint proper to reach the volar recess. To eliminate this risk of chondral injury, volar synovectomy is performed via the volar portal. Creation of the volar portal bears a risk of injury to the digital neurovascular bundle. The use of the dorsal portal as the viewing portal can eliminate the need for creation of another volar portal and the risk of injury to the bilateral digital neurovascular bundles.
The reported technique has the advantages of better cosmetic results, less surgical trauma and less scar formation, feasibility of complete synovectomy, and allowance of early mobilization. The potential risks of this technique include injury to the digital neurovascular bundle; articular cartilage damage; and injury to the extensor tendon, collateral ligaments, and volar plate (Table 3).5 This technique is technically demanding and should be reserved for experienced hand arthroscopists.
Table 3.
Advantages and Risks of Arthroscopic Complete Synovectomy of Proximal Interphalangeal Joint of Finger
| Advantages |
| Better cosmetic results |
| Less surgical trauma and less scar formation |
| Feasibility of complete synovectomy |
| Allowance of early mobilization |
| Risks |
| Injury to digital neurovascular bundle |
| Articular cartilage damage |
| Injury to extensor tendon |
| Injury to collateral ligaments |
| Injury to volar plate |
Footnotes
The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. With the dorsal radial and dorsal ulnar portals used interchangeable as the viewing and working portals, synovectomy of the dorsal recess of the proximal interphalangeal joint is performed. With the scope in the dorsal ulnar portal, the inflamed synovium of the radial recess of the joint is resected with the shaver via the dorsal radial portal. Then, the scope is switched to the dorsal radial portal, and the inflamed synovium of the ulnar recess of the joint is resected with the shaver via the dorsal ulnar portal. Finally, the scope is switched back to the dorsal ulnar portal, and the inflamed synovium of the volar recess of the joint is resected with the shaver via the volar radial portal.
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Associated Data
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Supplementary Materials
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient i/s in the supine position with the operative hand on the side table. With the dorsal radial and dorsal ulnar portals used interchangeable as the viewing and working portals, synovectomy of the dorsal recess of the proximal interphalangeal joint is performed. With the scope in the dorsal ulnar portal, the inflamed synovium of the radial recess of the joint is resected with the shaver via the dorsal radial portal. Then, the scope is switched to the dorsal radial portal, and the inflamed synovium of the ulnar recess of the joint is resected with the shaver via the dorsal ulnar portal. Finally, the scope is switched back to the dorsal ulnar portal, and the inflamed synovium of the volar recess of the joint is resected with the shaver via the volar radial portal.
Arthroscopic complete synovectomy of proximal interphalangeal joint of right middle finger. The patient is in the supine position with the operative hand on the side table. With the dorsal radial and dorsal ulnar portals used interchangeable as the viewing and working portals, synovectomy of the dorsal recess of the proximal interphalangeal joint is performed. With the scope in the dorsal ulnar portal, the inflamed synovium of the radial recess of the joint is resected with the shaver via the dorsal radial portal. Then, the scope is switched to the dorsal radial portal, and the inflamed synovium of the ulnar recess of the joint is resected with the shaver via the dorsal ulnar portal. Finally, the scope is switched back to the dorsal ulnar portal, and the inflamed synovium of the volar recess of the joint is resected with the shaver via the volar radial portal.