Minimally Invasive Hand and Wrist Surgery

What is Minimally Invasive Hand and Wrist Surgery?

Minimally invasive hand and wrist surgery refers to surgeries performed using smaller incisions or portals, rather than a larger incision as in traditional open surgery, along with thin surgical tools and cameras to treat bone and soft tissue injuries of the hand and wrist. Minimally invasive surgery focuses on minimal muscle trauma to the body so that the postoperative recovery period is shorter and there is less pain and scarring and a decreased chance of infection as a result. With the advancement in arthroscopic instrumentations and surgical techniques, minimally invasive hand and wrist surgery has become the most popular treatment options for common hand and wrist conditions.

What are the Types of Hand and Wrist Conditions Treated Using Minimally Invasive Surgery?

Some of the common hand and wrist conditions treated using minimally invasive surgery include:

• Arthritis: Chronic pain, stiffness, and swelling in your joints generally indicate that you have arthritis. This condition can be specifically bothersome when it affects your fingers, wrist, or hand, as it can restrict your ability to perform your activities of daily living.
• Torn ligaments and tendons: Ligaments and tendons are fibrous tissue made of collagen that attach bones to other bones and muscles. Ligament and tendon tears may cause pain and swelling and limit movement of the hands and wrist joints. Surgery may be needed to treat the problem so the ligament or tendon can heal and restore full function.
• Fractures: A fracture is a break in the bone and occurs when more force than the bearable limit is applied against a bone. Crushing injuries to the hand or wrist occurring due to a high degree of force or pressure may also cause fractures. A fracture may cause severe pain, swelling, bruising or bleeding, discoloration of the skin, and limit the mobility of the hand and wrist. 
• Repetitive Trauma Syndrome: Repetitive stress injury occurs as a result of repeated similar movements for long periods of time. This often causes pressure on the joints resulting in inflammation, pain, and decreased function in the extremity. The condition is more likely to develop with repetitive, rapid, forceful, and prolonged movements of the hand and wrist, or vibration or frequent pushing, pulling, or carrying heavy objects.  Carpal tunnel syndrome is the most common of these syndromes.
• Carpal Tunnel Syndrome: Carpal tunnel syndrome is a condition characterized by numbness or pain in the thumb and first two fingers and occurs when the median nerve is compressed at the wrist. Carpal tunnel syndrome is often a common complaint in individuals who use their hands for a prolonged period of time in a particular occupation.
• Dupuytren’s Contracture: Dupuytren’s contracture is a hand condition where the thickening of the underlying fibrous tissues of the palm causes the fingers to bend inward. This makes it difficult to fully straighten the affected fingers. It commonly occurs on the ring finger and little finger. Occasionally, the middle finger is affected, but the thumb and index finger are rarely affected.
• Trigger Finger: Inflammation in the tenosynovium leads to a condition called trigger finger, also known as stenosing tenosynovitis or flexor tendonitis, where one of the fingers or thumb of the hand is caught in a bent position. The affected digit may straighten with a quick snap, like pulling and releasing the trigger on a gun, hence the name trigger finger.
• Mallet Finger: A mallet finger is a condition where the end of the finger is bent and does not straighten. This condition occurs when the extensor tendon at the back of the finger is damaged. Mallet finger commonly occurs due to sports activities (such as baseball) or other activities that cause a direct and forceful impact on the fingers that jam the finger.

Preparation for Minimally Invasive Hand and Wrist Surgery

In general, preparation for minimally invasive hand and wrist surgery will involve the following steps:

• A review of your medical history and a physical examination to check for any medical issues that need to be addressed prior to surgery.
• Diagnostic tests such as blood work and imaging such as X-ray and MRI may also be performed to determine the extent and type of injury and plan the procedure accordingly.
• Disclosing information about any allergies to medications, anesthesia, or latex.
• You should inform your doctor of any medications or supplements you are taking or any conditions you have such as heart or lung disease.
• You may be asked to stop taking medications such as blood thinners and anti-inflammatories, or other supplements for a week or two.
• You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
• You should not consume any solids or liquids at least 8 hours prior to surgery.
• You should arrange for someone to drive you home after surgery.
• A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.

Procedure for Minimally Invasive Hand and Wrist Surgery

Minimally invasive hand and wrist surgery involve various minimally invasive surgical techniques such as arthroscopic surgery that involves small incisions and passing tiny cameras and thin surgical instruments into the joints of the hand and wrist to correct joint abnormalities; endoscopic surgery, which is similar to arthroscopic surgery except that tiny cameras and instruments are inserted into the soft tissues of the hand and wrist to correct soft tissue abnormalities, and percutaneous soft tissue surgery that involves using a special needle.

Arthroscopic Surgery: Minimally invasive arthroscopic surgery is most commonly used to treat arthritic joint conditions, as well as torn ligaments and tendons.

In general, minimally invasive arthroscopic surgery of the hand and wrist involves the following steps:

• The procedure is performed under general and/or regional anesthesia with your arm held in a position that provides the best operative angle for your surgeon.
• A few small keyhole incisions or arthroscopic portals (openings) are made on specific locations of the hand and wrist, depending on the areas that need to be treated.
• An arthroscope is inserted into the treatment area through one of the portals. The arthroscope is a thin tube with a camera, lens, and light source. Your surgeon will be guided by the images relayed from the arthroscope onto a video monitor throughout the procedure. 
• Special surgical instruments are inserted through other incisions to carry out the required repair such as suturing of the torn ends of the soft tissues, fracture reduction and fixation, removal of loose bodies and osteophytes, or joint fusion. 
• Once the procedure is complete, the instruments are withdrawn, and the incisions are closed with a bandage. 

Endoscopic Surgery: Endoscopic surgery is similar to arthroscopic surgery and is commonly used to release stiffened ligaments or structures affecting hand and wrist motion. One of the most common surgeries performed using a minimally invasive endoscopic technique is endoscopic carpal tunnel surgery. This surgery is performed under general or local anesthesia and may involve the following steps:

• A single incision is made in the wrist. Sometimes, your surgeon may make two incisions – one on the wrist and the other on the palm.
• A tube with a slot on the side called a cannula is inserted through the incision and placed next to the median nerve, just under the offending transverse ligament.
• An endoscope, a thin, flexible tube with a camera attached is passed through the cannula to look at the carpal ligament from below. The images from the endoscope are visible to the surgeon on the video monitor in the operating room. Your surgeon ensures that the nerves and arteries are not in the way while cutting the ligament.
• A special cutting tool with a hook is inserted into the cannula.
• As the tool is pulled back out of the cannula, it cuts the carpal ligament and releases pressure over the median nerve.
• The cut ends of the ligament eventually fill in with scar tissue.
• The skin incision is closed with dissolvable stitches and a dressing is placed.

Percutaneous Soft Tissue Surgery: Percutaneous procedures for soft tissue injuries include treatment for conditions such as trigger finger, in which a tendon becomes entrapped within a tight sheath in the palm, and painfully snaps during routine use of the hand. The release is provided by dividing the stenotic sheath. In traditional surgery, this required an open incision in the palm of the hand. The percutaneous technique enables your surgeon to achieve the same surgical outcome without an incision, utilizing a special needle.

Postoperative Care and Recovery

In general, postoperative care and recovery after minimally  invasive hand and wrist surgery will involve the following steps:

• You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
• You may notice some pain, swelling, and discomfort in the hand area. Pain and anti-inflammatory medications are provided as needed to address these.
• Antibiotics are also prescribed to address the risk of surgery-related infection.
• Your hand may be immobilized for up to 6 weeks to protect the repair and promote healing.
• You will need to keep your hand elevated at all times during the first month. Your physician may recommend a foam wrist-elevation pillow or other devices.
• You may start rehabilitation or a physical therapy regimen as recommended by your surgeon after a specified period of time to improve range of motion and strengthen hand muscles.
• Keep the surgical site clean and dry. Instructions on surgical site care, splint/cast management, and bathing will be provided.
• You will be weaned off the splint/cast and can gradually return to normal daily activities in a couple of months. However, it may take at least 6 months for your hand to regain its full strength.
• A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Minimally invasive hand and wrist surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:

• Infection
• Bleeding
• Scarring
• Swelling
• Postoperative pain
• Damage to soft tissue structures such as nerves and vessels