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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