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. 2025 Jan 4;62:102877. doi: 10.1016/j.jcot.2024.102877

Managing the arthritic wrist: Complication prevention and management

Camelia Qian Ying Tang a, Margaret Woon Man Fok b,⁎, Sze-Ryn Chung a, Muntasir Mannan Choudhury c, Andrew Yuan Hui Chin a
PMCID: PMC11764480  PMID: 39872121

Abstract

Wrist arthroscopy presents a significant learning curve, necessitating various precautions to avoid complications like tendon laceration or nerve injury. Arthroscopic procedures become even more challenging in arthritic wrists due to altered anatomy and reduced joint space, which in turn increase the risk of complications. In this review article, we offer tips and tricks to minimize these risks. Despite the challenges, wrist arthroscopy remains a valuable diagnostic and therapeutic tool when performed by an experienced surgeon with thorough preoperative planning and careful patient selection.

Keywords: Arthritic wrist, Wrist arthroscopy, Complication, Preventing complications

1. Introduction

Wrist arthritis, while conceptually simple, presents practical challenges in management. Patients often experience dissatisfaction due to persistent loss of function or ongoing pain, frequently necessitating salvage procedures that trade off motion for pain relief. Managing wrist arthritis is further complicated by the wrist's intricate structure, which includes the radiocarpal, ulnocarpal, distal radioulnar joints (DRUJ), and synchronous carpal articulations. Wrist arthroscopy has become a valuable tool in managing wrist arthritis, providing minimally invasive options for salvage procedures such as synovectomy, arthrolysis, radial styloidectomy, proximal row carpectomy, and various limited carpal fusions1,2.

Various pathologies can result in arthritic changes in the wrist, including degenerative conditions at the scaphotrapeziotrapezoidal [STT] or pisotriquetral articulations, avascular necrosis (Kienböck, Preiser), post-traumatic conditions (scaphoid lunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), radius malunion) or inflammatory causes (rheumatoid arthritis, gout, pseudogout) 3. The management strategies for arthritic changes vary based on the underlying pathology and the pattern of these changes. In this review article, we aim to explore realistic difficulties involved in managing the arthritic wrist, with a focus on non-inflammatory causes of arthritis, while not delving deeply into specific pathological patterns.

2. Defining the arthritic wrist

A mechanically driven and biologically mediated process, osteoarthritis results in degeneration and articular cartilage loss, with reduced joint space, synovial proliferation and subchondral bone remodelling. Wrist arthritis is diagnosed clinically and accompanied by corresponding radiographic evidence4 There remains no conclusive standard for diagnosis and treatment of the arthritic wrist3 Patients present with chronic mechanical pain and stiffness, together with a reduced range of motion and grip strength. This diagnosis is further supported by radiographic findings, such as joint space narrowing, osteophyte formation, subchondral sclerosis, and subchondral cysts (Fig. 1). The Kellgren and Lawrence system5 that is widely used to classify osteoarthritis in general can be applied to the wrist, where radiographic findings are used to grade severity of osteoarthritis. However, there remains no strong correlation between radiographic and clinical severity6 where there is a variable association between radiographic findings to patients’ pain perception, activity levels and disabilities.

Fig. 1.

Fig. 1

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Example of significant degenerative osteoarthritis secondary to scapholunate (SL) dissociation, with loss of joint space and subchondral sclerosis seen involving the radiocarpal.

Arthritic changes can be described using Bain and Begg's arthroscopic description7 It perceives an articular surface with extensive fibrillation, fissuring, localized or widespread loss, a floating articular surface, or fractures as an indication of osteoarthritis. Loose bodies, either cartilage or bone fragments, in addition to frank loss of cartilage, are also frequently observed (Fig. 2, Fig. 3). Similarly, just as there is no standardized radiographic classification for wrist osteoarthritis, there is also no universally accepted arthroscopic classification for wrist arthritis. In an attempt to more accurately describe wrist cartilage injuries, Culp et al.8 Introduced a modified Outerbridge classification. Grades I to III indicate partial thickness injuries that, according to his perspective, can be managed with debridement. Grade IV, the most severe, features full-thickness cartilage defects extending down to the bone. Culp's description forms the basis of our proposed algorithm for different stages of arthritic changes in the wrist (Fig. 4).

Fig. 2.

Fig. 2

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Arthroscopic picture from the 3–4 view showing full thickness chondral loss (yellow arrows) from the proximal scaphoid surface at the radioscaphoid joint. Black asterisk represent the radial styloid.

Fig. 3.

Fig. 3

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Arthroscopic midcarpal ulnar (MCU) view showing loose bodies (yellow arrow) and full thickness chondral loss at the head of the capitate surface.

Fig. 4.

Fig. 4

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Flowchart of arthroscopy algorithm for the arthritic wrist based on severity of cartilage defect, including suggested size of cartilage defect of 5 mm2 11.

3. Managing the arthritic wrist

As radiological severity does not correlate with clinical severity, we recommend trial of nonoperative measures prior to surgical treatment, with a focus on managing symptoms while preserving function9 It is crucial to work closely with hand therapists to maximise activity modification, wrist proprioceptive exercises and physical therapies. Appropriate splinting to support and reduce strain on the wrist may also be beneficial. Pharmacological treatments for acute osteoarthritis flare, such as non-steroidal anti-inflammatory drugs or intra-articular corticosteroid injections, are useful. As the severity of symptoms vary, it is imperative to tailor treatment strategies in an individualised fashion10

In cases refractory to nonoperative treatment, surgical intervention may be offered to relief pain and restore function. Depending on the severity of the arthritic changes, the treatment will be either restorative or salvage procedures e.g. arthrodesis and arthroplasty (resection, interposition and constraint) (Fig. 4). Localized partial thickness defects (modified Outerbridge classification8 grades I to III) can be treated with arthroscopic debridement and management of the primary pathology11 For localized full thickness defects, the treatment approach include bone marrow stimulation and osteochondral graft harvesting12 for slightly larger defects larger than 5 mm2 11. For diffuse arthritic wrist, interpositional procedures with tendon13 or acellular dermal matrix allograft14 or arthrodesis (partial and total) should be considered. Yet, key considerations on optimal treatment must include anatomical site of osteoarthritis, underlying pathology, patient's age, morbidity and functional demands. Inappropriate choice of treatment may result in patients suffering from persisted symptoms, prolonged rehabilitation as well as progression of arthritis. In a patient with localized full thickness cartilage loss in distal lunate bone, bone marrow stimulation may be the treatment of choice. However, in a heavy manual laborer, he may choose a limited carpal fusion for a more guaranteed outcome. Conversely in a diffuse arthritic wrist, synovectomy alone can lead to have persisted symptoms and progression of arthritic changes. Wrist denervation15 may be a standalone or adjuvant treatment option. It can be a buy-time procedure for pain relief leading to fast recovery time (but with progression of arthritic changes) or it can an adjuvant treatment with other salvage procedures for better pain control.

4. Complications in wrist arthroscopy

Wrist arthroscopy is generally regarded as a safe procedure; complications reported in literature remain rare (1.2–7.9 %) and are mostly minor16, 17, 18, 19 A complication is defined as an unfavorable event directly or indirectly linked to the technique of wrist arthroscopy, excluding secondary failures linked to the technique, or to the initial pathology18 This is summarised in Table 1. They can be categorized as serious or benign complications according to Beredjiklian et al.16 and Luchetti et al.20 classification.

Table 1.

Summarising the complications of wrist arthroscopy in arthritic wrist, with tips and tricks to prevent these complications.

S/N Types of Complications Description Tips to Prevent Complication
1 Neurovascular Injury When using the 1–2 portal, the superficial radial nerve and radial artery are at risk of injury. The 6-U portal puts the dorsal sensory branch of the ulnar nerve at risk. Ensure accurate portal placement using anatomic landmarks. Use blunt dissection with an artery forceps, particularly when approaching the superficial radial nerve (SRN) (1–2 portal) and the dorsal sensory branch of the ulnar nerve (DSBUN) (6-U portal).
2 Tendon Injury Extensor tendon rupture or injury can occur during portal insertion or instrument manipulation. Use a blunt trocar during portal insertion. Gently spread extensor tendons with artery forceps to avoid injury during instrumentation.
3 Chondral Damage Cartilage lesions or loose bodies may occur due to instrument manipulation or tight joint spaces. Use a 1.9 mm arthroscope in tight joints to avoid cartilage injury. Use a burr with a protective hood during procedures.
4 Fluid Extravasation and Compartment Syndrome Extravasation or compartment syndrome can result from improper fluid management during the procedure from wet arthroscopy. Monitor fluid pressures carefully. Limit high-pressure irrigation duration. Use dry arthroscopy where possible.20 Intermittent irrigation may be used to wash-out unwanted debris.
5 Portal-related Complications Ganglia, adhesion, or pain can develop from improper portal placement or redundant portals. Minimize the number and size of portals. Avoid redundant portals near sensitive structures.
6 Complex Regional Pain Syndrome Early recognition and initiation of analgesia, physical therapy, and psychotherapy is crucial.
7 Wrist Stiffness Postoperative wrist stiffness, particularly in arthritic wrists, may limit range of motion and causes pain. Early mobilization where appropriate is recommended. Dry arthroscopy omits intraoperative and postoperative oedema, potentially reducing the risk of stiffness.
8 Failure to Achieve Intended Procedure Difficulty in achieving the intended outcome due to joint pathology or surgical complications. Thorough preoperative planning and patient counselling. Consider alternative surgical options such as open procedure if arthroscopy is not feasible.
9 Infection Superficial infection or septic arthritis can develop post-operatively. Apply strict aseptic techniques. Administer prophylactic antibiotics, particularly for high-risk patients.
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Most complications associated with wrist arthroscopy are minor16, 17, 18, 19 and tend to resolve on their own, particularly when the procedure is performed by experienced surgeons. However, the steep learning curve of wrist arthroscopy necessitates certain precautions to minimize complications. Preoperatively, it is essential to conduct a thorough clinical examination and obtain necessary imaging, such as MRI or CT scans, especially in cases where pathology has altered the anatomy. Adequate anaesthesia, whether general or regional, is crucial, while performing wrist arthroscopy under portal site local anaesthesia can be more challenging. A thorough understanding of surface anatomy, as illustrated in Fig. 5, is important to avoid erroneous portal creation21

Fig. 5.

Fig. 5

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Illustrating the proximity of portal placement to tendons, highlighting the need to exercise caution in order to avoid tendon or nerve injury when creating wrist arthroscopy portals (midcarpal radial = MCR; midcarpal ulnar = MCU).

Applying adequate traction facilitates the insertion of the arthroscope and instruments. Careful planning and placement of portals are necessary to avoid damaging nerves and tendons (Table 2). Instead of making blind stab incisions, skin alone should be opened by surgical blade. Haemostat is recommended to be used to create the portals, while retracting nerves and tendons from its path22 If in doubt, a larger incision can be used to prevent inadvertent lacerations (Fig. 6). Similarly, care should be taken when debriding with a shaver, to prevent accidental tendon laceration. While saline infusion helps to distend the joint and improve visualization, it also carries a risk of extravasation, which must be managed with early recognition or alternating dry with wet scope (Fig. 7). Until one becomes an experienced arthroscopist, it is advisable to take the time to visualize structures and handle instruments and the arthroscope with care, gradually overcoming the learning curve. Post-operatively, patient should be followed-up closely, especially if patient complains of pain. With incidence ranging from 0.49 %18 to 3.7 %23 CRPS is a difficult complication to treat, requiring multimodal modalities and close cooperation with patients.

Table 2.

Summarising some wrist portals and their difficulty that could be faced with each of these portals for a beginner.

Wrist portals Access benefits when managing the arthritic wrist Structures at risk How to prevent
1,2 Scaphoid and lunate fossa, dorsal rim of radius, oblique views of volar wrist ligaments SRN and radial artery Blunt dissection with tenotomy scissors or blunt forceps to spread the soft tissue
3,4 Access to scaphoid and lunate, with good visualization of the wrist from volar rim of radius to TFCC radial insertion and central disc Extensor pollicis longuns (EPL) & extensor digitorum communis (EDC) tendons, small branches or SRN or superficial cutaneous veins Careful palpation of the concavity overlying the lunate between EPL and EDC. In an arthritic wrist, the joint space is limited, so it is crucial to angle portal to consider the volar inclination of radius.
4,5 Access to central carpal region, including triquetrum and pisiform Superficially, extensor tendons EDC and extensor digitorum minimis (EDM). Deep to soft tissue: lunate cartilage When inserting, care not to injure the lunate. Cautious use of instruments such as shavers to prevent damaging extensor tendons
6R Access to the DRUJ and ulnar wrist DCBUN nerve branch, exensor carpi ulnaris (ECU) tendon, with the triangular carpi ulnaris (TFCC) immediately below the entry site, triquetrum bone Blunt dissection with tenotomy scissors or blunt forceps to preserve neurovascular structures, with entry angling 10° proximally just distal to ulnar head to avoid hitting triquetrum and TFCC.
6U Dorsal rim of TFCC or for instrumentation DCBUN nerve branch, ECU tendon superficially. Deep to capsule is triquetrum bone Ulnar to ECU tendon which should be retracted, with need to angle the needle distally and deviating the wrist radially to avoid running into the triquetrum
MCR MCU Access to midcarpal joints, such as in SLAC or SNAC wrists 1 cm distal to 3,4 portal and 4,5 portal respectively, with extensor tendons and superficial veins nearby Careful palpation of bony landmarks to identify soft spot between articulating carpal bones. Joint space may be narrowed in arthritic wrist, increasing complexity of accurate port placement.
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Fig. 6.

Fig. 6

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Depicting the close proximity of the dorsal cutaneous branch of ulnar nerve (black arrow) to the 6U portal. It is important to ensure tendons and nerves are safely retracted away during portal placement and incision.

Fig. 7.

Fig. 7

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Extravasation complication with use of wet scope, as indicated with black arrows.

5. Arthroscopy for the arthritic wrist

Arthroscopy in an arthritic wrist requires a higher level of technical expertise and familiarity with the altered anatomy to avoid complications and achieve optimal outcomes. Joint space narrowing makes it difficult to manoeuvre the arthroscope and instruments, which is further compounded by osteophytes and joint deformities that obstruct the view and access to the wrist joint. Extensive cartilage damage, irregular joint surfaces and loose bodies may hinder the smooth movement of arthroscope and instruments, further increasing the risks of iatrogenic injury.

Arthroscopic management of the arthritic wrist minimizes soft tissue damage and preserves ligament integrity with use of small skin incisions. In addition to allowing for direct visualization of the joint and detailed cartilage assessment, arthroscopy also facilitates therapeutic interventions like synovitis debridement, and removal of loose bodies and osteophytes. In wrist arthritis, where stiffness is a major issue, a key advantage of arthroscopic arthrolysis is that it leads to less stiffness and scarring compared to the traditional open approach24. Whether used solely for diagnosis or combined with therapeutic procedures such as ligament repair or fracture fixation, it is a versatile tool for managing wrist osteoarthritis.

6. Preventing complications in an arthritic wrist

Considering the challenges and benefits of wrist arthroscopy, we approach the arthritic wrist with careful pre-operative planning. During surgery, sustained traction using a traction tower is crucial to widen the narrowed joint space. Although dry arthroscopy has its advantages and reduces risk of extravasation injury, a wet scope maybe more approachable for arthritic wrists. The fluid pump maintains joint distension, enhancing visualization and facilitating easier instrument manipulation. Given the limited joint space for manoeuvring instruments and the scope, using a smaller diameter arthroscope, like the 1.9 mm Arthrex Nano Needle Scope with its 2.2 mm outer sheath, may offer a significant advantage25 (Fig. 8).

Fig. 8.

Fig. 8

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A typical set up of wrist arthroscopy with traction (asterixis), with use of wet scope (black arrow) to maximise joint distension and nanoscope with its smaller diameter.

For wrists with significant carpal collapse and carpal bossing, precise portal placement is essential for comprehensive access, relying heavily on surface anatomy and landmarks. Care must be taken when creating the portal site due to the risk of lacerating tendons or nerves22. Using small arthroscopic blades and graspers strategically is effective for managing loose chondral bodies. Concomitant intra-articular steroid injections26 can provide short-term relief from symptoms, but there remains limited evidence for intra-articular hyaluronic acid injection to the wrist27. Good clinical outcomes have been reported post arthrolysis for traumatic wrist injuries, with similar and satisfactory results reported in both arthroscopic and open procedures28

Post-operatively, unless a salvage fusion procedure is performed, we recommend early mobilization to reduce stiffness and improve range of motion. In cases where wrist denervation was performed with additional neurectomies of anterior and posterior interosseous nerve29, multimodal pain management may be required for patient with persistent symptoms.

7. Preventing complications during arthroscopy in management of radiocarpal arthritis

SLAC or SNAC wrists commonly give rise to radiocarpal and midcarpal arthritis. Apart from arthroscopic debridement in early stages, various techniques of arthroscopic resection arthroplasty have been described. This includes resection of the radial column performed entirely arthroscopically30 which entails careful burring up to healthy-appearing cartilage, or with interposition tendon arthroplasty31 For more advantaged stage of arthritis, arthroscopic limited carpal fusion to stabilise the wrist while preserving some motion can be performed. Good outcomes32 were reported for arthroscopic four-corner fusion (Fig. 9) or capitulonate fusion.

Fig. 9.

Fig. 9

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Illustrating scaphoidectomy and four corner fusion performed entirely arthroscopically. (A) Pre-operative MRI scan revealed SLAC wrist with arthritis. Patient elected for arthroscopic management, where (B) a hooded burr was used to prepare the capitate surface (asterisk) for fusion. (C) Post-operative radiographs at three months show fusion, and patient was satisfied with good functional outcomes and pain relief. He had comparable range of motion and grip strength to contralateral uninjured wrist at six months.

Patience is crucial during arthroscopic partial wrist fusion: it is of utmost importance to ensure meticulous bone preparation to promote successful bony union and fusion. The optimal surgical technique and implant remains a topic of discussion, but several experts have shared tips for achieving precise fixation. We recommend Ho's method, which involves expertly inserting and impacting cancellous bone graft at the fusion site through a cannula under direct arthroscopic visualization33. A small foley catheter may be inserted at the radiocarpal joint to prevent leakage of bone graft into the joint space. Excessive bone graft may also been present outside the capsule if insertion and impaction are not done meticulously (Fig. 10).

Fig. 10.

Fig. 10

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Plain radiographs PA and lateral view of the wrist showing excessive bone graft present outside the capsule, posing risk of developing wrist stiffness.

8. Arthroscopic treatment for ulnocarpal arthritis

Ulnocarpal abutment syndrome can lead to significant ulnocarpal arthritis, and it is also imperative to address underlying TFCC degenerative changes. The primary surgical options for addressing ulnocarpal abutment before considering salvage procedures for the DRUJ are the arthroscopic wafer procedure and ulnar shortening osteotomy.34 A recent systematic review and meta-analysis concluded that arthroscopic wafer procedure may present a superior alternative for ulnar impaction syndrome.35 Although the arthroscopic wafer procedure offers a quicker recovery and is less invasive compared to open techniques, it demands precise execution to prevent damage to surrounding structures while determining the amount of resection required to adequately reduce the load on the ulnocarpal joint.

9. Conclusion

While wrist arthroscopy offers numerous benefits from its minimally invasive nature, it is not without complications. These risks are even more pronounced when managing an arthritic wrist arthroscopically. For patients with arthritic wrists who do not respond to nonoperative treatments, wrist arthroscopy remains a valuable option. However, it is crucial to emphasize the importance of surgical experience. The altered anatomy and reduced joint space in arthritic wrists significantly increase the complexity of the procedure. Therefore, we strongly advise that only experienced surgeons undertake these cases to minimize risks and ensure optimal outcomes.

Informed consent and patient details

All personal details of patients are removed and not included in any part of the article and in any illustrations.

Ethical statement

Ethics approval and consent was not required as this paper does not involve the use of any animal or human data or tissue.

Authorship contribution

All named authors contributed equally in conceptulisation and writing of paper.

Generative AI

Generative AI was not used in any form during preparation or writing of the manuscript.

Funding statement

This research received no specific grant from any funding agency in the public, commercial, or not-for profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgment

None.

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