The debate over the use of a small fiber optic instrument to see the deep recesses of a joint was waged more than 40 years ago when this concept was first addressed in the knee. It was argued that viewing "through a keyhole" could not be as good as simply "opening the door." We have now fully accepted this "instrument of the devil" as being indispensable in other joints including shoulder, hip, and elbow. Nevertheless, the broad indications of wrist arthroscopy are still being elucidated, and smaller joints, such as the trapeziometacarpal and metacarpophalangeal, are still considered somewhat taboo in arthroscopic, and even hand surgery, circles.
I would argue that in these smaller joints, the arthroscope is even more valuable. The "door" is smaller, more susceptible to scarring from open invasion, and a keyhole is actually necessary to truly see inside what we could not with the naked eye.
Advanced technology has now evened the playing field. The proximal interphalangeal joint, given the appropriate size arthroscope, now has the same field of view if one uses the same 21-inch flat screen monitor. The mechanical shavers, RF wands, and basket forceps all appear the same proportionally on screen given the change in size scale.
All that is left is for us to refine our indications and demonstrate the use of these techniques in small joints, from wrist down to distal interphalangeal joints.
The articles within this special technique issue demonstrate the range of procedures possible within these small joints suffering from ubiquitous pathologies. The authors hail from such far away lands as Australia, Asia, Europe, and America. Many have come to similar conclusions and methodologies despite their distance.
I trust the reader will feel inspired to attempt and refine the techniques within as these procedures soon become as commonplace as in the larger joints.
Alejandro Badia, MD, FACS
Miami Hand Center Miami, FL