This retrospective case–control study compares arthroscopic surgery (AS) with open reduction and internal fixation (ORIF) in early and late follow-up outcomes for perilunate injuries. Of 74 patients treated between 2012 and 2023, 28 were matched into two groups: 14 AS and 14 ORIF. Baseline characteristics were similar. Arthroscopic surgery had a significantly shorter operative time (mean difference (MD) 71 min, 95% confidence interval (CI) 10 to 132 min, p = 0.021). At early follow-up (mean 4.1, SD 1.3 months), AS patients had significantly higher Mayo Wrist Scores (MWS) with better pain relief, return to work and grip strength (MWS MD 24 points, 95% CI 12.4, 35.6 points, p < 0.001). The subscales levelled off at late follow-up (mean 14.7, SD 4.8 months). There were no significant differences in complications, revision incidence or intercarpal angles at final follow-up. When feasible, AS is a promising, time-efficient alternative to dorsopalmar double approach ORIF for the treatment of perilunate injuries, particularly in terms of early postoperative clinical outcomes.
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