MANAGEMENT OF OSTEOARTHRITIS

ROLE OF ARTHROSCOPY AND

INDICATIONS FOR OTHER SURGICAL
TECHNIQUES

Christian Dumontier, MD, PhD

Guadeloupe, FWI, France

Presentation can be downloaded at www.diuchirurgiemain.org

HAND AND WRIST DEGENERATIVE OSTEOARTHRITIS

• DRUJ

• Wrist OA: SLAC, SNAC, SCAC

• STT, TH, Piso-triquetral OA

• 1st CMC OA

• MP, PIP, DIP OA

 HAND AND WRIST DEGENERATIVE
OSTEOARTHRITIS & ARTHROSCOPY

ulno-carpal abutment

• DRUJ Styloid resection, PRC

• Wrist OA: SLAC, SNAC,

STT &
ar throp TH
lasty
• STT, TH, Piso-triquetral OA
Synov
Par tia ectomy,
l ar thr
• 1sr CMC OA oplast
y

No
• MP, PIP, DIP OA ind
icat
ion
s
DRUJ OSTEOARTHRITIS

DRUJ osteoarthritis Ulno-carpal abutment syndrome

ULNO-CARPAL ABUTMENT SYNDROME

• Excessive impact stress between

ulna and carpal bones (primarily
lunate)
• Associated with positive ulnar
variance
• In a neutral wrist ≈ 20% ulna,
80% radius
• +2 mm ulnar variance ≈ 40%
of the load to the ulna, 60% to
the radius
From Radsource.org
ULNO-CARPAL ABUTMENT SYNDROME
• Progressive deterioration with

• Central degenerative tearing of the

TFCC,

• Chondromalacia of the proximal

lunate, radial triquetrum, and distal
ulnar head

• Instability and/or ligamentous tearing

at the LT articulation.

• Ulnocarpal osteoarthritis.
 PALMER CLASSIFICATION, TYPE II
DEGENERATIVE TFCC LESIONS
• II,A: TFCC wear

• II,B – TFCC wear + lunate, triquetrum

osseous abnormalities, +/- ulnar
chondromalacia

• II, C – TFCC perforation + lunate, triquetrum,

+/- ulnar chondromalacia

• II,D – TFCC perforation + lunate, triquetrum,

+/- ulnar chondromalacia & LT ligament tear

• II, E – TFCC perforation + lunate, triquetrum,

+/- ulnar chondromalacia, LT perforation &
ulnocarpal arthritis
 INDICATIONS
• Load pressure on the ulna decrease
from 20% to 4% by shortening the ulna
by 2,5 mm ☞ Ulnar head resection
through the scope ?

• Less than 4 mm of positive ulnar

variance,

• Palmer classification 2C or 2D lesion

of the TFCC,

• Stable (DRUJ) and/or lunotriquetral

joint,

• No evidence of osteoarthritis of the

DRUJ or ulnocarpal joint

Werner FW, Glisson RR, Murphy DJ, Palmer AK. Force transmission through the distal radioulnar carpal
joint: effect of ulnar lengthening and shortening. Handchir Mikrochir Plast Chir 1986;18(5):304–308.
 ARTHROSCOPIC TREATMENT OF ULNO-ULNA-
CARPAL ABUTMENT SYNDROME

• In stage II, C & D

• TFCC débridement +
synovectomy + bone
resection
 TFCC DEBRIDEMENT

• Scope 3/4 Portal

• Instruments: 4/5 or 6R portal

• Mechanical (or VAPR)

debridement
TFCC DEBRIDEMENT-TECHNICAL DIFFICULTIES

• The anatomical limits

between the vascularized/
non vascularized part of
TFCC (to avoid creating
DRUJ instability)

• The posterior part of the

TFCC (too close to the
instrument)
 BONE RESECTION

• Distal ulna (wafer

procedure)

• Cartilage debridement
(lunate/triquetrum)
BONE RESECTION - TECHNICAL DIFFICULTIES

• Do not resect too close

to the radial side of the
joint

• Try to be flat with the

burr using pronation/
supination
BONE RESECTION - TECHNICAL DIFFICULTIES

• Use fluoroscopy if
needed
 CARPAL MIRROR LESIONS

• Slight debridement of
unstable cartilage fragments
 ALTERNATIVE

• Ulna shortening

• Open Wafer

• Ulnar head osteotomy

 A°SCOPIC WAFER VS ULNAR SHORTENING
OSTEOTOMY

• No difference between groups (23 vs 12) but faster

recovery in the arthroscopic group (De Smet)

• Better outcomes at 3 months for the A°scopic groupe (n

=19) versus USO (n = 23) but no difference at 2 years
(Oh). Complication rates were 34.8% for USO and
10.5% for the AWP

De Smet L, Vandenberghe, L, Degreef I. Ulnar Impaction Syndrome: Ulnar Shortening vs. Arthroscopic
Wafer Procedure. J Wrist Surg 2014;3:98–100.
Oh WT et al. Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy as a Surgical Treatment
for Idiopathic Ulnar Impaction Syndrome. Arthroscopy. 2018;34(2):421-430.
WRIST OSTEOARTHRITIS
 WRIST OA
• SLAC
Early stages only
• SNAC

• SCAC No indication

• Midcarpal OA No indication
• TH OA hamate tip resection
• Piso-triquetral OA No indication

• STT OA distal pole resection

SNAC & SLAC
A°SCOPIC TREATMENT OF SLAC/SNAC

• Radial styloidectomy

• Proximal pole resection w/

wo spacer (SNAC)
A°SCOPIC STYLOID RESECTION
• Scope in the 4/5 portal

• Start with synovectomy

• Burr in the 1/2

 A°SCOPIC STYLOID RESECTION
• Less than 4 mm (Don’t release
the RSC ligament)

• Start by a medial trench using the

burr diameter to locate it

• And finish laterally

 RESULTS ?

• Only one series published (12 cases- 4 SLAC, 5

SNAC and 3 sequelae of distal radius fracture)

• No complication at 21 months FU

• Diminution of pain, no change in the mobility

Levadoux M, Cognet JM. Styloïdectomie sous arthroscopie [Arthroscopic styloidectomy]. Chir Main 2006 ;
25S1 : S197–201
 A°SCOPIC PROXIMAL POLE
RESECTION +/- SPACER
• In SNAC Stage 1

• Scope in the 4/5 or 6R portal

• Instruments in the RMC or 3/4

portals
 A°SCOPIC PROXIMAL POLE
RESECTION +/- SPACER
• 1st: sectioning of SL ligament

• Remove the proximal pole

piecemeal (loss of pressure)

• Use fluoroscopy to be complete

A°SCOPIC PROXIMAL POLE
RESECTION +/- SPACER
 ARTHROSCOPIC ARTHROPLASTY ID
ADVANCED STAGES ?

• 17 patients, 14 reviewed at 2 years

• A°scopic resection of arthritic surfaces 14 mm (9-20mm)

• Pain improved from 6,6/10 to 1,3

• DASH improved from 66 to 28,

• Motion improved from 124° to 140°

• Strength improved from 16 to 18 kg (66 % of controlateral wrist).

Cobb TK, Walden AL, Wilt JM. Arthroscopic resection arthroplasty of

the radial column for SLAC wrist. J Wrist Surg 2014 ; 3(2) : 114–22.
TRIQUETRO-HAMATE
OSTEOARTHRITIS
 TRIQUETRO-HAMATE OA
• Over 400 wrists evaluated, 58%
has evidence of arthrosis

• Proximal pole of the hamate was Handsurgery source

the most common site (28%).

• Typical patient is a late middle

aged right handed male manual
laborer who presents with right
ulnar wrist pain.

• TH OA is associated with type II

lunate (69% vs 13%, p<0.01)
Harley BJ, Werner FW, Boles SD, Palmer AK.Arthroscopic resection of arthrosis of the proximal hamate: a
clinical and biomechanical study. J Hand Surg Am2004;29(4):661-7.
 TWO TYPES OF LUNATE

• Type 1: No articulation with the hamate, smooth

configuration, 34% of patients
Burgess RC. Anatomic variations of the midcarpal joint.J Hand Surg Am 1990;15(1):129-31.
TWO TYPES OF LUNATE

• Type I1: the lunate has a medial

facet which articulates with the
hamate in addition to the facet
articulating with the capitate
(66% of patients).

• There is a ridge, between the

capitolunate and
triquetrohamate joint

Burgess RC. Anatomic variations of the midcarpal joint.J Hand Surg Am 1990;15(1):129-31.
Viegas SF, Patterson RM, Hokanson JA, Davis J: Wrist anatomy: incidence, distribution, and correlation of
anatomic variations, tears, and arthrosis. J Hand Surg [Am] 1993;18:463–475
 A°SCOPIC TREATMENT OF TH OA

• Tip of hamate resection

C
• No mechanical
consequences H

L
• Good results if no
associated lesions (HALT,
TFCC,…)

Pirolo JM, Yao J. Minimally invasive approaches to ulnar-sided wrist disorders. Hand Clin 2014;30(1):77-89.
STT OSTEOARTHRITIS
 STT OSTEOARTHRITIS
• Quite frequent (16% of
wrist OA)

• Mainly women > 50 years

of age

• Association with type II

lunate
Pegoli L, Pozzi A. Arthroscopic Management of Scaphoid-Trapezium-Trapezoid Joint Arthritis. Hand Clin 33
(2017) 813–817.
Kapoutsis DV, Dardas A, Day CS. Carpometacarpal and Scaphotrapeziotrapezoid Arthritis: Arthroscopy,
Arthroplasty, and Arthrodesis. J Hand Surg 2011;36A:354–366.
McLean JM, Turner PC, Bain GI, Rezaian N, Field J, Fogg Q. An association between lunate morphology and
scaphoid-trapezium- trapezoid arthritis. J Hand Surg 2009;34B:778 –782.
 STT OSTEOARTHRITIS
• Associated frequently with
chondrocalcinosis (pseudogout)

• Is there a FCR tendinitis ?

• Is there a TM joint OA ?

• Is there a DISI deformity ? Perform

a drawer test: If the capitate can
be dorsally displaced beyond the
posterior horn of the lunate, the
chances for a resection
arthroplasty to further destabilize
the wrist are high.
Garcia-Elias M. Excisional Arthroplasty for Scaphotrapeziotrapezoidal Osteoarthritis. J Hand Surg 2011;36A:
516–520
 STT PORTALS

• RMC portal

• STT-U portal (ulnar to 3rd

compartment tendons)

• STT-R (radial to 1st

compartment tendons)

Carro LP et al. The radial portal for scaphotrapeziotrapezoid arthroscopy. Arthroscopy 2003;19(5):547–53.
• STT-U portal located in line with the midshaft axis of the index
metacarpal, just ulnar to the EPL

• STT-R Portal radial to the APL tendon at the level of the STT
joint. radial artery by a mean of 8.8 mm (range 6 to 10 mm).
branches of the superficial radial nerve virtually surround the
arthroscopic field;

• STT-P Portal midway between the radial styloid and the base of
the first metacarpal, 3 mm ulnar to the APL tendon and 6 mm
radial to the scaphoid tubercle. This portal lay 7.6 mm (range 5
to 11 mm) from the radial artery, 6.5 mm (range 4 to 11 mm)
from the superficial branch of the radial artery, and 11.6 mm (3
to 20 mm) from the closest radial sensory nerve branch.
 STT & ARTHROSCOPY

• Limited vision (synovitis)

 STT & ARTHROSCOPY

• Distal pole resection 3-4 mm

 STT & ARTHROSCOPY

• Difficulties to make a flat surface (use fluoroscopy)

 ALTERNATIVE

• Open distal pole resection

• STT fusion: Pain relief in 58-70% of cases, non

union 4-21 %, stiffness.
TRAPEZIOMETACARPAL
OSTEOARTHRITIS
 TM OA
• Frequent

• Conservative treatment is
largely indicated

• Surgical treatment in case of

failure (5 %?)

• Trapezium resection +/- LRTI

is the gold standard (except
France and Belgium with TM
prosthesis)
 TM OA CLASSIFICATION
• Stage I: synovitis phase. Radiograph may show mild widening of the joint space
- Articular surfaces are congruent and no more than one- third subluxation of
the joint is present in any view.

• Stage II has significant capsular laxity present with subluxation being at least
one-third of the joint. In addition, osteophytes less than 2 mm in diameter are
present.

• Stage III there is significant joint space narrowing, subchondral sclerosis, and
peripheral osteophytes greater than 2 mm in diameter, but a normal STT joint.

• Stage IV is pantrapezial osteoarthritis

Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg
Am 1973;55:1655–66.
TRAPEZIOMETACARPAL ARTHROSCOPY
• A°scopic classification:

• Stage 1 intact CMC cartilage,

• Stage 2 partial loss of cartilage,

• Stage 3 widespread loss of

cartilage.

• Stage 4, widespread loss of

articular cartilage of both the
CMC and the STT joints
(Cobb).

Badia A. Arthroscopy of the trapeziometacarpal and metacarpophalangeal joints. J Hand Surg Am.
2007;32(5):707-724.
TRAPEZIOMETACARPAL ARTHROSCOPIC PORTALS

• 1-R (radial) portal

• 1-U Portal

• Thenar Portal

• Dorso-ulnar

• Modified radial portal (RP)

located just distal to the
oblique ridge of the trapezium
following a line along the
radial border of the FCR
(flexor carpi radialis) tendon.
 1-R PORTAL

• Radial to APL

• Assessment of the DRL,

POL, UCL

• Passes through the

nonligamentous capsule just
lateral to the AOL.
 1-U PORTAL

• Ulnar to EPB

• Assessment of AOL & UCL

 THENAR PORTAL

• From inside-outside: transillumination through the 1-U

portal, and then inserting an 18-gauge needle through the
bulk of the thenar muscles at the level of the TMJ (approx.
90° from the 1-U portal).
Walsh EF, Akelman E, Fleming BC, et al. Thumb carpometacarpal arthroscopy: a topographic, anatomic study
of the thenar portal. J Hand Surg [Am] 2005;30:373–9
 ANATOMY
• Radial artery: within 2.7 mm (range
2 to 3.5 mm) of the 1-U portal

• Radial superficial sensory nerves

located at a mean of 6.3 mm (range
4 to 8 mm) from the 1-U portal, 1,2
mm from the 1-R, 7.8 mm from
the RP and 33,7 mm from the
thénar portal.

• Tendons

Abzug JM, Osterman AL. Arthroscopic Hemiresection

for Stage II-III Trapeziometacarpal Osteoarthritis. Hand
Clin 27 (2011) 347–354.
• SRN has 2 volar branches: SR1parallels the first extensor compartment; SR2
crosses the first web space.

• Logli (2018) reported 5 out of 30 patients with transient superficial radial nerve
neuritis that resolved over 3 months - Desmoineaux reported 10% of his cases
 A°SCOPIC TREATMENT OF STAGE I TM
OSTEOARTHRITIS

• Synovectomy

• Shrinkage (for denervation

and treatment of acquired
laxity)

• Fat interposition

• 4 Weeks immobilisation
postop
Kemper R, Wirth J, Baur EM. Arthroscopic Synovectomy From Badia: synovitis w/o
Combined with Autologous Fat Grafting in Early Stages of CMC
Osteoarthritis of the Thumb. J Wrist Surg. 2018;7(2):165-171 articular damage
 A°SCOPIC TREATMENT OF STAGE I: DO WE DO
BETTER THAN CONSERVATIVE TREATMENT ?

Conservative
A° (n =23)
(n= 21)

VAS 65% ➡ 3 % ➡

• Eaton-Littler stage I
or II DASH 55% ➡ 2% ➡

• 1 year FU Pinch strength 50 % 7 %

Exc. + Good
82 % 0 %
results

Furia JP. Arthroscopic debridement and synovectomy for treating basal joint arthritis. Arthroscopy
2010;26:34 – 40.
 STAGE II
small area of cartilage loss on the
metacarpal and trapezium

• Synovectomy

• Thermal shrinkage (for

denervation and treatment
of acquired laxity)

Badia A. Trapeziometacarpal Arthroscopy: A Classification and Treatment Algorithm. Hand Clin 22 (2006) 153–163.
 STAGE II

• Wilson osteotomy

• 4-5 weeks post

immobilization

Wilson J. Basal osteotomy of the first metacarpal in the treatment of arthritis of the carpometacarpal joint of the
thumb. Br J Surg 1973;60:854 – 858.
 STAGE III
• Synovectomy

• Bone debridement until

bleeding (3-4 mm)- Divide
trapezium in quadrant.

Badia A. Trapeziometacarpal Arthroscopy: A Classification and Treatment Algorithm. Hand Clin 22 (2006) 153–163.
 STAGE III

• Tendon interposition

• 4-5 weeks post

immobilization

Badia A. Trapeziometacarpal Arthroscopy: A Classification and Treatment Algorithm. Hand Clin 22 (2006) 153–163.
• 6 months: 30/30 had pain
improvement (from 8,2 to
1,3) - Quick DASH was 17,5

• 5 years: Pain (0,8),

QuickDASH was 8,9

• Pinch, grip strength were

unchanged

• Small reduction of joint space

at 5 years

Logli AL et al. Arthroscopic Partial Trapeziectomy With Soft Tissue Interposition for Symptomatic
Trapeziometacarpal Arthritis: 6-Month and 5-Year Minimum Follow-Up. J Hand Surg Am. 2018;43(4):
384.e1-e7
Pre-op Per-op 6 months 5 years
 CLINICAL RESULTS ARE FAVORABLE
• Pain relief is obtained within 6 months and last for 4-6 years

• Mobility is unchanged and maintained with time

• Grip/pinch strength improve

• Interposition offers no advantage (Artelon®,

OrthADAPT® has been withdrawn from market)
Cobb TK et al. Long-Term Outcome of Arthroscopic Resection Arthroplasty With or Without Interposition
for Thumb Basal Joint Arthritis. J Hand Surg Am. 2015;40(9):1844-1851
Edwards SG, Ramsey PN. Prospective Outcomes of Stage III Thumb Carpometacarpal Arthritis Treated
With Arthroscopic Hemitrapeziectomy and Thermal Capsular Modification Without Interposition. J Hand
Surg 2010;35A:566–571
Desmoineaux P, Delaroche C, Beaufils P. Partial arthroscopic trapeziectomy with ligament reconstruction
to treat primary thumb basal joint osteoarthritis. Orthop Traumatol Surg Res. 2012;98(7):834-9.
Cobb’s series of 144 TM arthroscopic resection
 ALTERNATIVE
• Arthrodesis

• Trapezium resection w/wo interposition, w/wo Ligament

reconstruction

• Prosthesis or implant

• Denervation

• Partial resection with interposition

MCP, PIP, DIP OSTEOARTHRITIS
ARE NOT AMENABLE TO
ARTHROSCOPIC TREATMENT
Thumb MP and DIP arthrodesis has been performed
Badia A. Arthroscopy of the trapeziometacarpal and metacarpophalangeal joints. J Hand Surg Am.
2007;32(5):707-724.
 CONCLUSION

• Arthroscopy is a tool, not a goal

• Indications for arthroscopic treatment of wrist/

hand OA are limited to localized, degenerative OA
THANK YOU FOR YOUR
INVITATION