SURGICAL TECHNIQUE

Excisional Arthroplasty for Scaphotrapeziotrapezoidal

Osteoarthritis
Marc Garcia-Elias, MD

Symptomatic scaphotrapeziotrapezoidal (STT) joint osteoarthritis may occasionally require

surgery. In the absence of dorsal midcarpal instability, acceptable results may be obtained by
an excisional STT joint arthroplasty. After distal scaphoid resection, however, forces are no
longer transmitted along the radial column of the wrist. This often results in slight malro-
tation of the proximal row into extension. To mitigate this problem, different strategies have
been proposed (dorsal midcarpal capsulodesis, palmar radioscaphoid capsulodesis, tendon
interposition, or pyrocarbon implant interposition). As compared to STT fusion, excisional
arthroplasty is less technically demanding, requires less prolonged immobilization, and has
Surgical Technique

fewer complications. (J Hand Surg 2011;36A:516–520. Copyright © 2011 by the American

Society for Surgery of the Hand. All rights reserved.)
Key words Wrist, scaphotrapeziotrapezoidal joint, osteoarthritis, excisional arthroplasty,
midcarpal instability.

the scaphotrapezio- unstable MC joint. To rule out this problem, it is useful

P
AINFUL OSTEOARTHRITIS OF
trapezoidal (STT) joint tends to respond well to
conservative treatment. Splinting, anti-inflam-
matory drugs, intra-articular corticoid injections, and
physiotherapy are often successful in bringing these
wrists back to a painless situation.1–3 Surgery is indi-
cated only when conservative treatment fails to relieve
the patient’s symptoms.
Before deciding surgery, however, it is important to
ascertain whether the case is truly an idiopathic, isolated
STT osteoarthritis or a more extended problem result-
ing from chronic dorsal midcarpal (MC) instability.4 – 6
If the distal scaphoid is resected and the wrist has
insufficient dorsal MC capsuloligamentous constraints,
the carpus may collapse in a severe dorsal intercalated
segment instability (DISI) pattern of malalignment with
the capitate subluxing dorsally. Indeed, STT excisional
arthroplasty is not indicated in the context of a dorsally
From Institut Kaplan, Barcelona, Spain.
Received for publication August 12, 2010; accepted in revised form December 16, 2010.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Correspondingauthor:MarcGarcia-Elias,MD,InstitutKaplan,PasseigdelaBonanova,9,2o,2a,
Barcelona 08022, Spain; e-mail: garciaelias@institut-kaplan.com.
0363-5023/11/36A03-0027$36.00/0
doi:10.1016/j.jhsa.2010.12.016
to perform the so-called “posterior drawer’s test” under
fluoroscopy control.7 If the capitate can be dorsally
displaced beyond the posterior horn of the lunate, the
chances for a resection arthroplasty to further destabi-
lize the wrist are high.4 – 6 Even if the preoperative
carpal alignment is normal, a resection arthroplasty is
not recommended for the treatment of STT osteoarthri-
tis resulting from dorsal midcarpal instability. In such
circumstances an STT arthrodesis, as recommended by
Wollstein and Watson,8 is the treatment of choice. By
contrast, if the MC joint is stable, excisional arthro-
plasty is highly recommended because it provides reli-
able results, the technique is less technically demand-
ing, it requires less prolonged immobilization, and it has
fewer complications than a localized arthrodesis.
INDICATIONS
Resection arthroplasty of the STT joint is indicated for
the treatment of idiopathic, symptomatic, isolated STT
osteoarthritis, without MC instability, that failed to im-
prove with conservative treatment.
CONTRAINDICATIONS
Even if the preoperative carpal alignment is normal,
excisional arthroplasty of the STT joint is not indicated
if the midcarpal joint is easily subluxable owing to

516 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.

 EXCISIONAL ARTHROPLASTY FOR STT OSTEOARTHRITIS 517

FIGURE 1: Schematic representation of the author’s most commonly used STT excisional arthroplasty. To avoid excessive
scaphoid extension and carpal collapse, an anchovy of tendon is interposed in the empty joint space and a radioscaphoid
capsulodesis (arrow) has been used. The technique is not recommended when there is pre-existing dorsal midcarpal instability.

hyperlaxity or insufficiency of the dorsal MC capsulo-
ligamentous structures. The procedure is also contrain-
dicated if there is a more extended MC joint degener-
ation involving the lunocapitate joint, as in cases of
chronic scapholunate dissociation (scapholunate ad-
vanced collapsed wrist, stage 3).
SURGICAL ANATOMY
Under normal conditions, the proximal carpal row
maintains its balanced alignment as a consequence of
the scaphoid flexion tendency being counteracted by the
opposite extension moment generated at the triquetrum-
hamate articulation. If the scapholunate distal articular
concavity is shallow, the tendency for the capitate to
sublux dorsally is higher than if there is a deep
scapholunate socket. If aside from a shallow joint there
is an underdeveloped or hyperlax dorsal intercarpal
ligament, particularly the proximal fascicles that con-
nect the scaphoid to triquetrum, the wrist may experi-
ence dorsal MC instability.9 It is a relatively frequent
condition involving repeated dorsal capitate subluxation
during ulnar deviation. As the capitate subluxes dor-
sally, the STT joint undergoes increased shear stress
with the extended scaphoid eroding against the trape-
ziotrapezoidal articular surfaces. That is the most prob-
able mechanism for the association of STT osteoarthri-
tis and dorsal midcarpal instability. If under such
circumstances the distal scaphoid is excised, the trique-
tral extension moment is likely to predominate, induc-
ing severe DISI pattern of malalignment and carpal
collapse.
TECHNIQUE
Most often, the STT joint is approached through a
dorsolateral skin incision, taking care to identify and
Surgical Technique
protect both the sensory branches of the radial nerve
and the radial artery. The dorsal capsule of the STT
joint is transected along its oblique insertion onto the
dorsoradial ridge of the scaphoid. In cases where the
STT osteoarthritis is associated with flexor carpi radia-
lis (FCR) tendonitis, a palmar approach to the FCR
tendon is recommended. In this case, the inflamed te-
nosynovium is excised, the tendon is released from
adhesions, and a transverse capsulotomy distal to the
scaphoid tubercle is used to explore the STT joint and
complete the entire procedure.
The distal articular surface of the scaphoid is osteoto-
mized with an oscillating saw and removed from the
joint. It is important to preserve the proximal origins of
the dorsolateral STT and anteromedial scaphocapitate
ligaments, which originate at both medial and lateral
corners of the scaphoid tuberosity.
The direction of the scaphoid osteotomy is impor-
tant: With the wrist in neutral position and the scaphoid
at 45° relative to the radius, the plane of the osteotomy
is to be parallel to the plane of the trapezium-trapezoid
proximal surfaces. To facilitate direct vision of the
proximal surfaces of the trapezium and trapezoid, the
osteophytes at the periphery of the joint are removed.
Once the distal scaphoid has been excised, it is
imperative to double-check the amount of residual pas-
sive displaceability of the capitate relative to the lunate
under fluoroscopy. If there is substantial dorsal sublux-
ation of the lunocapitate joint, the case needs to be
reoriented toward a more stable construct, ideally an
STT arthrodesis.
If there is only minor lunocapitate instability, one op-
tion is to tighten the dorsal scaphotrapezial capsule.2 An-
other is to reattach the palmar radioscaphoid ligament to
the anterior edge of the osteotomized scaphoid, aiming

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 518 EXCISIONAL ARTHROPLASTY FOR STT OSTEOARTHRITIS

FIGURE 2: When the FCR has been damaged by extensive synovitis, the tendon may be used A, in the form of a tendon coil B,
Surgical Technique

and introduced as a fibrous spacer C, keeping its distal insertion intact.

FIGURE 3: To maintain the length of the scaphoid, a pyrocarbon spacer may be used. This allows compressive forces to be
dissipated across the implant into the scaphoid, thus preventing a DISI pattern of proximal row malrotation. A Preoperative x-ray
of STT osteoarthritis. B Same patient after 16 months after insertion of an STPI pyrocarbon spacer.

at preventing excessive scaphoid extension (Fig. 1).
Another option is to fill the empty joint space between
the scaphoid and trapezium with an anchovy of rolled
tendon (Fig. 2A–C). Finally, a fourth option is to inter-
pose a pyrocarbon spacer (STPI; Bioprofile-Tornier,
Grenoble, France) to preserve the length of the scaph-
oid, thus avoiding the triquetrum extension moment to
predominate (Fig. 3A, B).10 –12 In all circumstances, the
capsule needs to be carefully sutured and eventually
reinforced with local tissue, to prevent migration of the
interposed soft tissue or implant subluxation.
REHABILITATION AND POSTOPERATIVE CARE
Mobilization of the joint is not started until proper
capsular healing has occurred. Usually it takes 4 to 6
weeks of cast immobilization. In hypermobile joints,

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 EXCISIONAL ARTHROPLASTY FOR STT OSTEOARTHRITIS 519

Surgical Technique
FIGURE 4: A Posteroanterior radiograph shows STT joint narrowing (arrows) in an otherwise normal wrist. B Surgical exposure
of the FCR tendon after extensive synovectomy and excision of the scaphoid distal pole. C To induce a palmar radioscaphoid
capsulodesis, a strong transosseous suture is passed across the radiocarpal ligaments into the distal edge of the scaphoid. This aims
to prevent excessive extension of the bone. D Posteroanterior radiograph obtained 28 months after surgery. Minor intra-articular
calcification did not prevent the patient from having almost asymptomatic function. E Despite the radioscaphoid capsulodesis,
slight carpal misalignment is still present (arrow).

longer restriction of active/passive motion may be nec- CLINICAL CASE

essary. In selected cases, arthroscopic excision of the
distal scaphoid may be considered. In such cases, the
immobilization time may be substantially shortened.
In the early stages of hand therapy, the goal is to
regain motion, not grip strength. No isometric muscle-
strengthening exercises should be promoted during the
first weeks after surgery, and no gripping activities
should be carried out with the wrist flexed, but always
extended, as this would promote excessive compressive
load of the capitate against the dorsal horn of the lunate,
thus inducing further DISI malalignment and dorsal
midcarpal subluxation. For the first 6 months after sur-
gery, patients should avoid contact sports and wear a
removable, slightly extended splint for all activities
implying loading to the surgically treated wrist.
A 54-year-old woman sustained a minor injury to
her nondominant left wrist during a motor vehicle
accident. Radiographs were obtained and moderate
STT joint osteoarthritis was diagnosed; the condi-
tion had remained asymptomatic until the accident
(Fig. 4A). The wrist was immobilized with a
thumb spica cast for 3 weeks and an adequate
program physical rehabilitation was instituted.
Four months after the accident, the joint was still
painful with limited pinch strength. Marked swell-
ing along the distal 1 inch of the FCR tendon,
proximal to the palmar crease, disclosed the pres-
ence of an associated FCR tendonitis. Three sub-
sequent intraarticular corticoid injections plus a

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 520 EXCISIONAL ARTHROPLASTY FOR STT OSTEOARTHRITIS
removable splint did not overcome the symptoms.
The patient was finally eligible for an excisional
STT arthroplasty.
We used a zigzag anterolateral incision centered on
the scaphoid tuberosity to explore the FCR tendon,
excise its inflamed tenosynovium, and release its distal
portion from the entrapment within the FCR compart-
ment, medial to the trapezium (Fig. 4B). A distal-based
capsular flap was elevated to uncover the STT joint, and
the distal articular convexity of the scaphoid was re-
sected with an oscillating saw. Transosseous sutures
across the scaphoid were placed to create a radioscaph-
oid capsulodesis effect where the palmar radioscapho-
capitate ligament would prevent the scaphoid from ex-
cessive extension, thus limiting the chances of
developing a DISI malrotation (Fig. 4C). The wrist was
Surgical Technique
immobilized in a cast for 4 weeks, followed by phys-
iotherapy. At 28 months after surgery, there was only
minimal discomfort at the extremes of motion or when
performing strenuous work. Except for wrist extension,
which was reduced 35° compared with the contralateral
side, the overall range of motion was normal. Grip and
pinch strength were decreased 15% and 35%, respec-
tively. Despite the presence of slight DISI malrotation
(Fig. 4D, E), the patient is satisfied and returned to work
and leisure activities without restrictions.
COMPLICATIONS
The most serious complication of resecting the distal
scaphoid is the development of a dorsal midcarpal in-
stability, with the proximal row rotating into a DISI
malrotation, the capitate subluxing dorsally, and the
overall carpus collapsing.4 – 6 This is particularly fre-
quent among patients whose osteoarthritis has been
caused by a chronic inflammatory process such as
chondrocalcinosis or rheumatoid arthritis, or in those
whose carpus was already malaligned before surgery.
JHS 䉬 Vol A, March 
Again, this can be prevented by checking under fluo-
roscopy whether the capitate can be easily displaced
dorsally after distal scaphoid removal. Should this be
the case, a partial arthrodesis is to be preferred.
In cases where a pyrocarbon implant has been used
as spacer, dislocation of the implant is another possible
complication.10 –12 This usually results from either ex-
cessive resection leaving a much too unstable implant,
or suboptimal capsular closure with short postoperative
immobilization.
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