Arthroscopic Capsular Shrinkage Is Safe and Effective in the Treatment of Midcarpal Instability in a Pediatric Population: A Single-Center Experience of 51 Cases

Abstract

Objective Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series.

Methods In a tertiary hand center for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analog scale (VAS) at rest and with load, and grip strength. Data were used to determine the safety and efficacy of this treatment in pediatric and adolescent patients.

Results Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone (p = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest (p = 0.02) and VAS with load (p = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion (p = 0.02), extension (p = 0.03), and radial deviation (p = 0.01).

Conclusion ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist center.

Level of Evidence This is a Level IV study.

Keywords

adolescence - arthroscopy - capsular shrinkage - juvenile idiopathic arthritis - midcarpal instability - synovectomy

Note

The cases described in this article were treated by thesenior author, Miss K. Oestreich, at Birmingham Women's and Children's Hospital.

Publikationsverlauf

Eingereicht: 03. Oktober 2021

Angenommen: 12. Mai 2022

Artikel online veröffentlicht:
28. Juni 2022

• References

• 1 Mouchet A, Belot J. Poignet à ressaut: subluxation mediocarpienne en avant. Bull Mem la Soc Natl Chir 1934; 60: 1243-1244
• 2 Lichtman D, Bruckner J, Culp R, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am 1981; 6 (06) 515-523
• 3 Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am 1993; 18 (02) 307-315
• 4 Ho P-C, Tse W-L, Wong CW. Palmer midcarpal instability: an algorithm of diagnosis and surgical management. J Wrist Surg 2017; 6 (04) 262-275
• 5 Jing SS, Smith G, Deshmukh S. Demystifying palmar midcarpal instability. J Wrist Surg 2021; 10 (02) 94-101
• 6 Higgin RPC, Hargreaves DG. Midcarpal instability: the role of wrist arthroscopy. Hand Clin 2017; 33 (04) 717-726
• 7 Hargreaves DG. Arthroscopic thermal capsular shrinkage for palmar midcarpal instability. J Wrist Surg 2014; 3 (03) 162-165
• 8 Garcia-Elias M. The non-dissociative clunking wrist: a personal view. J Hand Surg Eur Vol 2008; 33 (06) 698-711
• 9 Hagert E, Lluch A, Rein S. The role of proprioception and neuromuscular stability in carpal instabilities. J Hand Surg Eur Vol 2016; 41 (01) 94-101
• 10 Lindau TR. The role of arthroscopy in carpal instability. J Hand Surg Eur Vol 2016; 41 (01) 35-47
• 11 Toledo MM, Martini G, Gigante C, Da Dalt L, Tregnaghi A, Zulian F. Is there a role for arthroscopic synovectomy in oligoarticular juvenile idiopathic arthritis?. J Rheumatol 2006; 33 (09) 1868-1872
• 12 Evans DM, Ansell BM, Hall MA. The wrist in juvenile arthritis. J Hand Surg [Br] 1991; 16 (03) 293-304
• 13 Vermaak PV, Southwood TR, Lindau TR, Jester A, Oestreich K. Wrist arthroscopy in juvenile idiopathic arthritis: a review of current literature and future implications. J Wrist Surg 2018; 7 (03) 186-190
• 14 Farr S, Grill F, Girsch W. Wrist arthroscopy in children and adolescents: a single surgeon experience of thirty-four cases. Int Orthop 2012; 36 (06) 1215-1220
• 15 Lee HI, Lee KH, Koh KH, Park MJ. Long-term results of arthroscopic wrist synovectomy in rheumatoid arthritis. J Hand Surg Am 2014; 39 (07) 1295-1300
• 16 Ricks M, Belward P, Hargreaves D. Long-term results of arthroscopic capsular shrinkage for palmar midcarpal instability of the wrist. J Wrist Surg 2021; 10 (03) 224-228