arthroscopy of the trapeziometacarpal and...

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ArthroscopyoftheTrapeziometacarpalandMetacarpophalangealJoints

ArticleinTheJournalOfHandSurgery·May2007

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REVIEW ARTICLE

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Arthroscopy of the Trapeziometacarpaland Metacarpophalangeal Joints

Alejandro Badia, MD

From Miami Hand Center, Miami, FL; Baptist Hospital, Miami, FL; and the DaVinci Learning Center,Miami, FL.

Indications for small joint arthroscopy in the hand remain poorly understood. This is due toa paucity of articles discussing these techniques in the literature, as well as inadequatehands-on training in the pearls and pitfalls regarding this application within the routine“scope” of hand surgery. Despite the fact that small joint arthroscopes have been availablefor more than a decade, hand surgeons have been slow to adopt this technique for thetreatment of both traumatic and degenerative conditions involving the thumb and the digitalmetacarpophalangeal joints. An arthroscopic classification for basal joint osteoarthritis pro-vides additional clinical information and can direct further treatment depending on the stageof disease. This article will also review the brief history of trapeziometacarpal arthroscopyand provide insight as to how this technique can be incorporated into a treatment algorithmin managing this common affliction. Metacarpophalangeal joint arthroscopy is even lesscommonly utilized, while traumatic and overuse injuries are frequently seen in the thumband constitute ideal indications in certain scenarios. Painful conditions affecting the meta-carpophalangeal joints of the fingers are less commonly seen, yet the small joint arthroscopepresents a much clearer picture of the pathology compared with other imaging techniques oreven open, potentially deleterious surgery. The application of this technology to the smallerjoints will soon make the treating surgeon realize that a myriad of pathologies are readilyvisible and can augment treatment, as well as diagnosis. Similar to the wrist, small jointarthroscopy may one day supplant imaging techniques such as magnetic resonance imagingor computed tomography for establishing an accurate diagnosis. (J Hand Surg 2007;32A:707–724. Copyright © 2007 by the American Society for Surgery of the Hand.)Key words: Arthroscopy, metacarpophalangeal joint, trapeziometacarpal joint, treatmentoptions, technique.

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steoarthritis of the thumb trapeziometacarpaljoint is a common clinical problem as well asa perplexing challenge because of a myriad

f treatment options. That so many different surgicalptions exist for this condition attests to the fact thatone of them has an optimal success rate, or perhapst may be that the majority of treatment options worko the satisfaction of the surgeon; hence, the clinicianontinues to use his favorite technique despite theact that this may not be the most appropriate methodor a particular stage of disease. One thing is indis-utable: Basal joint osteoarthritis of the thumb hasany different clinical presentations, and one tech-

ique cannot be used for all of the different stagesnd a patient’s individual needs. When conservative
reatment has been exhausted, there is a wide range p
f surgical options that should be tailored to thendividual patient.

The early stages of basal joint osteoarthritis areost commonly seen in middle-aged women. This is

iscussed in the literature in many instances butarely is a solution given to the management of thesesually active patients. Anti-inflammatory drugs,plinting, and corticosteroid injections serve only asalliative measures with none of these altering jointechanics or affecting the articular surface itself in

ny manner. Moreover, use of injectable steroids canccelerate cartilage loss and worsen capsular attenu-tion. Only the mildest cases of transient synovitisill escape the inevitable progressive loss of carti-

age and, hence, the need for surgical treatment if the
atient indeed wants a definitive solution. After the
The Journal of Hand Surgery 707

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708 The Journal of Hand Surgery / Vol. 32A No. 5 May–June 2007

elatively unimportant distal interphalangeal joint,he thumb carpometacarpal joint remains the mostommon location for osteoarthritis in the hand. It islso the most critical for hand function. The argu-ent has been made that man’s evolution has been

argely due to the increased range of motion andunction as a consequence of the thumb basal jointnd has led to the progressive use of tools in hominidvolution. Treatment of this functionally importantoint remains a priority for the hand surgeon, and it ismportant to use the wide variety of surgical tech-iques to optimally manage this condition.Classically, the basal joint has been treated by

urgical means only when conservative options haveeen exhausted. The principal option has been, andemains, some type of open resectional arthroplasty.lthough good results are demonstrated in the liter-

ture in many different studies and using a variety ofechniques, it remains clear that this is a surgicallyggressive procedure because resection of an entirearpal bone is required to achieve pain relief. Thisertainly makes good sense in the most advancedases where the trapezium is typically flattened oras severe deformity including deforming marginalsteophytes, but earlier stages demand a more con-ervative option that allows for future interventions ifhe primary treatment is not successful. Other lessggressive options include a hemiresection with ten-on interposition arthroplasty or an Artelon spacer,hich can provide excellent pain relief but often lead

o some weakness of grip. Arthrodesis is often indi-ated in the younger manual laborer but has disad-antage of limitation of motion. Joint arthroplasty,ike in any other joint in the body, has the added riskf failure of the implant, whether this be silicone orf metallic and plastic components. This is certainlyot a good option for the younger, high-demandatients but is a suitable option for elderly, low-emand patients.

istoryhe advent of small joint arthroscopic technologyas allowed us to apply the concept of minimallynvasive surgery to smaller joints including the wrist,nkle, and now the smaller joints of the hand. Y-C.hen’s classic article in 1979 on arthroscopy of therist and finger joints discussed the feasibility oferforming small joint arthroscopic procedures usinghe Watanabe no. 24 arthroscope as early as 1970.1

owever, in Chen’s article there was surprisingly noention of arthroscopy of the thumb trapeziometa-

arpal joint, despite the fact that this may be the

reatest small joint application of arthroscopy. Inhen’s article, there was a detailed description ofrthroscopy of the wrist, metacarpophalangeal joints,nd even the small interphalangeal joints. Neverthe-ess, the common applicability of this technology touch a ubiquitous clinical scenario may prove to bets greatest contribution.

The first clinical article in the literature on basaloint arthroscopy was written by J. Menon in theournal of Arthroscopic and Related Surgery in996.2 This article, entitled “Arthroscopic Manage-ent of Trapeziometacarpal Joint Arthritis of thehumb,” described arthroscopic partial resection of

rapezium as well as an interpositional arthroplastysing autogenous tendon graft, Gore-Tex, or fasciaata allograft as interposing substances. In this article,t was obvious that the patients had a more advancedtage of arthritis, though Menon’s own clinical stagesresented the addition of metacarpal base subluxa-ion as criteria for the advanced stages, and he lim-ted the indications to less than stage 4 disease. In hislassification, this stage correlates with metacarpalase subluxation greater than one-third of its diam-ter and adduction contracture. No mention wasade whether very early stages of basal joint arthritisere treated with this innovative technique. In fact,y hope is to demonstrate that the utility of arthro-

copy may be greatest in the earlier stages. The goalf Dr. Menon’s procedure was to avoid destabilizinghe basal joint by avoiding an open arthrotomy anderforming the hemitrapeziectomy, which had al-eady been described as an open procedure, andnterposing the material with the assistance of anrthroscope. Three-quarters of the patients had com-lete pain relief in his series of 25 patients. Theesults were comparable with the open technique, bute described several advantages attributed to its min-mally invasive nature. For one, it is simply lessnvasive and, hence, has implicit advantages such as

lesser chance of injuring the radial sensory nervend that postoperative pain is much less. However,he less obvious advantage is that arthroscopy of therapeziometacarpal joint can detect any articularhanges long before they would be noted throughoutine radiographs. This enables us to treat basaloint osteoarthritis in much earlier stages, and thelinical indication for surgery could simply be pain,ot the stage of radiographic disease. This presents areat opportunity and allows us to use the arthro-cope as a tool for treating younger and more activeatients with the early stages of basal joint arthritis.
One year later, Richard Berger from the Mayo

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Badia / Trapeziometacarpal Arthroscopy 709

linic presented his experience of 1st carpometacar-al joint arthroscopy in a technique article in theournal of Hand Surgery in 1997.3 He believed thatmall joint arthroscopic technology presented severaldvantages over a standard open arthrotomy, whereoint visualization would be difficult because of theepth of the joint and that one could avoid disruptionf the critical ligamentous structures that he so aptlyescribed. After his clear description, he briefly men-ioned 12 arthroscopic procedures that he had per-ormed since 1994 with a variety of clinical scenariosncluding acute Bennett fractures of the thumb. Heoted that there was an excellent visualization and noomplications with this surgery. At that time, thendications for 1st carpometacarpal (CMC) joint ar-hroscopy were not clearly defined, but he noted thatt was obviously an excellent alternative to arthrot-my for visualizing the anatomy. This article fol-owed an instructional lecture and demonstration thate had performed at the Orthopaedic Learning Centeruring the wrist arthroscopy course, which I had theleasure of attending. Despite its infancy, it wasbvious to me at that time that basal joint arthroscopyould have a wide range of application and clinicaltility within this spectrum of pathology. Soon afterhis landmark article was published, Menon pre-ented a letter to the editor indicating the fact that head actually published the clinical use of arthroscopyn the basal joint in a previous article.4 In Dr. Berg-r’s reply, he diplomatically noted that his techniqueas developed independently as it was presented as

n instructional course in 1995, and the commonelays in publishing led to this overlap with Dr.enon’s publication.5 It is clear that both of these

uthors have made an invaluable contribution to ourreatment armamentarium for the basal joint. Further,linical utility was validated in the article by Oster-an et al presented in Arthroscopy in 1997 where

hey defined 2 groups of patients, traumatic and de-enerative, who would benefit from use of this im-ging technology.6 They, too, believed it had a prom-sing place in the treatment of both acute and chroniconditions of the thumb carpometacarpal joint. Theyere the first to mention that arthroscopy may allow

or appropriate staging of the degree of trapezialnvolvement and has particular application in theounger patient.Hence, it is obvious that arthroscopy of the thumb

arpometacarpal joint allows us to appropriatelytage the extent of cartilage degeneration and subse-uently determine therapeutic options. I maintain
hat the arthroscope can be used not only for treat- c
ent of earlier stages but also in advanced stages asenon so well described.The goal of this article, among many, is to describe

n arthroscopic classification of the thumb carpo-etacarpal joint and determine a treatment algorithm

ased on this staging system. Whether the clinicianecides to use arthroscopy definitively for treatmentemains an option. Before we expand on the diseasetaging that arthroscopy allows, we must better un-erstand the ligamentous anatomy and its functionalignificance as related to biomechanics. However,here can be no argument that the arthroscope givess the true extent of basal joint disease.

unctional Anatomyrthroscopy of the thumb carpometacarpal joint has

ittle relevance if the treating surgeon does not un-erstand the ligamentous anatomy. This has beenescribed extensively through cadaver dissections,nd over time we will be able to better correlate thesepen landmarks with the arthroscopic findings. Theioneering description of the trapeziometacarpal lig-ments dates way back to 1742 when Weitbrechtescribed these ligaments in a rudimentary fashion inis book Syndesmology.7 This book was reprinted in969. Since then, a variety of authors have furtherescribed the details of this anatomy with the mostetailed work coming from Bettinger and others athe Mayo Clinic in their article in 1999.8 They de-cribed a total of 16 ligaments, including ligamentsetween the metacarpal and trapezium as well as 2igaments attaching the trapezium to the secondetacarpal and separate stabilizers for the scaphotra-

ezial and trapezoidal joints. It was their conclusionhat this complex of ligaments functions as tensionands to prevent instability from cantilever bendingorces placed upon the trapezium by the act of pinch.his was a critical concept because extremely large

oads are transferred to the trapezium, and there is noxed base of support because the scaphoid is anxtremely mobile carpal bone. It is the attenuationnd pathologic function of these ligaments that mayndeed lead to the common scenario of basal jointrthritis. Based on improved ligamentous under-tanding, Van Brenk et al suggested that the dorso-adial collateral (RCL) ligament was, in fact, theost important ligament in the prevention of trape-

iometacarpal subluxation.9 This was determined bycadaveric study where serial sectioning of 4 sepa-

ate ligaments determined that RCL was the mostritical in preventing dorsoradial subluxation. Zan-
olli et al, in his landmark Atlas of Surgical Anatomy

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f the Hand, supports this concept but also adds theontroversial premise that aberrant slips of the ab-uctor pollicis longus may cause an excessive com-ressive force of the dorsoradial aspect of trapezi-metacarpal joint leading to arthrosis.10 He believedhe underlying ligamentous laxity may be due tonderlying variations in an individual person’s liga-entous laxity or a hormonal predisposition that may

xplain the increased incidence in the female gender.hese theories led to a greater understanding of theauses of basal joint arthritis, and arthroscopic visu-lization may in the future lend further credence tohese theories. Xu et al indicated that the trapezi-metacarpal joint is smaller and less congruous inomen and may also have a thinner layer of hyaline

artilage, suggesting this is a cause for the higherncidence of basal joint osteoarthritis in women.11

his, too, has been my experience and suggests thathe greatest applicability of arthroscopy may be inounger women, who present with this disease at auch earlier age and have, implicitly, less surgical

reatment options.Pellegrini in Hand Clinics 1979 continued to af-

rm that the volar beak ligament plays an importantole in preventing dorsal translation of the metacarpaluring common functional activities.12 This ligaments well as the dorsoradial ligament both are clearlyisualized via arthroscopy, and direct intervention isow feasible. His hypothesis is that there are attri-ional changes in the beak ligament at the metacarpalnsertion site, and this insertion zone may be partic-larly sensitive to estrogen-type compounds. Thisends further support to the genetic predisposition ofhis condition. Arthroscopically, I have confirmedhis, having noted particular cartilage loss at thensertion of the volar beak ligament on the deepetacarpal base in the early stages when the remain-

er of the hyaline cartilage appears normal. Many ofhese anatomic, clinical, as well as biomechanicaloncepts have been further defined by Bettinger anderger in their work on the functional ligamentousnatomy of this joint.13 They did note that the ar-hroscopic anatomy is much less complicated be-ause only a limited number of structures are able toe seen from the interior perspective. For the firstime, they outlined which of the 2 common portalsould lead to clear visualization of corresponding

igaments. Although they discussed optimal viewing,he reader should note that the small size of this jointllows one to visualize the majority of the surfaceimply by a change in the viewing direction and the
ngulation that the arthroscope is held in. Recently, s
ther authors have described new portals to helpurther define the topographic anatomy of this joint.rellana and Chow described a radial portal that they

ound was safer because of its distance from theadial artery and branch of the superficial radialerve, moreover, it allowed better triangulation.14

or this reason, Walsh et al also described anotherortal, the thenar portal, which was much more volar,ctually passing through the thenar muscles to allowor improved triangulation and visualization of theoint via a presumably safer location.15 A furtherdvantage of this portal is that it does not violate theeep, anterior oblique ligament, which, as alsoointed by Bettinger and Berger, serves as the majorestraining structure against dorsal subluxation.13

onzalez et al also described portals for better visu-lization.16 These newer portals suggest that thumbMC arthroscopic surgery is in a state of evolutionnd hopefully will allow us to better understandrthritis at this level. Again, careful documentation ofhese structures over time may allow arthroscopy tourther elucidate the cause of dorsal subluxation as aactor in basal joint arthritis.

Culp and Rekant were the first clinicians to sug-est that arthroscopic evaluation; debridement, andynovectomy “offer an exciting alternative for pa-ients with Eaton and Littler stages I and II arthri-is.”17 They described radiofrequency “painting” ofhe capsule of the trapeziometacarpal joint to stabi-ize the critical volar ligaments that may cause dorsalubluxation and, consequently, arthrosis of the basaloint. They also mention that if the majority of therapezial surface is abnormal, then at least one-half ofhe distal trapezium should be resected with an ar-hroscopic burr. This indicates that a more advancedtage of arthrosis is present and does not necessarilyupport its use in the early stages. In fact, theirhort-term results described in this paper followedrthroscopic hemi or complete trapeziectomy cou-led with electrothermal shrinkage. They had nearly0% excellent or good outcome in 22 patients with aoderate follow-up. They did make the critical point

hat “no bridges had been burned” because patientsho have the arthroscopic procedure can always

erve as suitable future candidates for more aggres-ive complete excisional trapezial arthroplasty bypen means. They concluded that debridement andhermal capsular shrinkage is a potentially goodreatment for early arthritis of the basal joint. It isow well apparent via these multiple articles describ-ng the arthroscopic findings that a more comprehen-
ive staging system is necessary to dictate treatment.

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ll of the clinical results in the studies to date haveocused on more advanced osteoarthritis and have alliscussed the results after an arthroscopic-assistedemitrapeziectomy. It is perhaps in the patient whoserapezium is largely spared that arthroscopy may findts greatest utility. A novel classification that I haveevised to dictate treatment for the respective stagerovides the basic framework for the arthroscopicvaluation and effective management of the differenttages of this disabling condition (Table 1).18

ndications for Basal Joint Arthroscopyn my practice over the past 11 years, the vast ma-ority of patients with the diagnosis of thumb basaloint arthritis who did not improve after conservativereatment had arthroscopy for further evaluation ofhe joint status and surgical treatment. The diseaseas staged radiographically according to Eaton’s cri-

eria.19 The notable exceptions were in patients withdvanced Eaton stage 4 arthritis who then had arapezial excisional suspensionplasty using a slip ofbductor pollicis longus. Stage 4 patients with onlyild scaphotrapezialtrapezoid (STT) changes were

till treated with arthroscopy. Another exception wasuch older, low-demand patients who did well usingcemented total joint arthroplasty as this required

lmost no immobilization and minimal therapy.any of these patients displayed an adduction con-

racture, and the open arthroplasty that permitted andductor release and a metacarpophalangeal (MCP)olar capsulodesis was often needed in cases withevere swan-neck deformity. The last exception was

Table 1. Badia Arthroscopic Classification ofBasal Joint Arthritis

Stage Arthroscopic Changes

1 ● Intact articular cartilage● Disruption of the dorsoradial ligament and

diffuse synovial hypertrophy● Inconsistent attenuation of the AOL

2 ● Frank eburnation of the articular cartilageon the ulnar third of the base of 1stmetacarpal and central third of the distalsurface of the trapezium

● Disruption of the dorsoradial ligamentplus more intense synovial hypertrophy

● Constant attenuation of the AOL3 ● Widespread, full-thickness cartilage loss

with or without a peripheral rim on botharticular surfaces

● Less severe synovitis● Frayed volar ligaments with laxity

he rare young, male laborer who had a trapeziometa- p

arpal joint arthrodesis. This indication has been wellubstantiated in the literature.20

urgical Techniquehe arthroscopic procedure is performed under wristlock regional anesthesia with tourniquet control. Aingle Chinese finger trap is used on the thumb with–8 lb of longitudinal traction. A shoulder holder,ather than traction tower, is used to easily facilitateuoroscopic intervention. The trapeziometacarpalTMC) joint is then detected by palpation. The inci-ion for the 1-R (radial) portal, which is used forroper assessment of the dorsoradial ligamentDRL), posterior oblique ligament (POL), and ulnarollateral ligament (UCL), is placed just volar to thebductor pollicis longus (APL) tendon. The incisionor the 1-U (ulnar) portal, which allows better eval-ation of the anterior oblique ligament (AOL) andCL, is made just ulnar to the extensor pollicisrevis (EPB) tendon. Joint distention is achieved bynjecting 2–3 mL of normal saline. A short-barrel,.9-mm, 30° inclination arthroscope is used for com-lete visualization of the TMC joint surfaces, cap-ule, and ligaments, and then appropriate manage-ent is performed as dictated by the pathology

ound. A full radius mechanical shaver with suctionas used in all cases, particularly for initial debride-ent and visualization. Many cases were augmentedith radiofrequency ablation in order to perform aore thorough synovectomy. Radiofrequency was

lso used to perform chondroplasty in cases withocal articular cartilage wear or fibrillation. Ligamen-ous laxity and capsular attenuation were treated withhermal capsulorraphy using a radiofrequencyhrinkage probe. We were careful to avoid thermalecrosis, and, therefore, a stripping technique wassed to tighten the capsule of lax joints. Although usef radiofrequency is relatively new, we can gainurther understanding by prior basic science studiesnd the clinical application in other joints. Prior tolaborating further on the details of TMC arthros-opy, it is important to understand the application ofadiofrequency technology to this small joint, as wells the later discussed MCP arthroscopy.

pplication of Radiofrequency in Smalloint Arthroscopyrthopedic surgeons have benefited from the use of

adiofrequency in a variety of procedures during theast decade. It is only now that we are realizing thatt may have some detrimental effects, and it is im-
ortant to look at this technology more critically.

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evertheless, as with any new technique, judiciousse of this technology may allow for stabilization ofhe joint capsule in a variety of clinical scenarios.houlder instability has been treated by a variety ofuthors using radiofrequency to stabilize the joint,articularly in those patients with global instabilityho classically have not been considered good op-

rative candidates. It has also been used in the kneextensively, but there has been minimal mention inhe literature of its application in the joints of theand. Obviously, this is coupled with the fact thatrthroscopy of the trapeziometacarpal joint and, fur-hermore, the metacarpophalangeal joint has beencant in the literature.

Radiofrequency has had many medical applica-ions since its initial use in the 1800s for creatingesions in brain tissue. It has also been used inardiology, oncology, and colorectal surgery. Lopeznd colleagues first demonstrated the effect of radio-requency energy on the ultrastructure of joint cap-ular collagen in a histologic study.21 They noted thatimilar applications had been used with a nonablativeaser energy in orthopedics but that radiofrequencyffered several advantages over the use of a laser.ot only is it less expensive and safer, but also thesenits are much smaller and easily maneuverable inpplication to arthroscopic techniques. Initial studiesn a sheep joint indicated that the thermal effect washaracterized by the fusion of collagen fibers withoutissue ablation, charring, or even crater formation.here was a linear relationship between the degree ofollagen fiber fusion and increasing treatment tem-erature. This indicates that the technology must bereated with respect to avoidance of aggressive use. Itas postulated that the coagulated tissue mediates aild inflammatory reaction that leads to the degra-

ation and replacement of the affected capsule with aenser tissue. This would obviously help to stabilizehe joint and thus have particular application in therapeziometacarpal joint based on previous discus-ions in this article. In a later study, Hecht andolleagues also looked specifically at effect of mo-opolar radiofrequency energy on the joint capsularroperties.22 They concluded that monopolar radio-requency caused increased capsular damage in themmediate area and depth that correlated with theattage used. The heat production increased linearlyith the duration of application. The arthroscopic

avage could protect the synovial layer from perma-ent damage as seen in sheep. These findings suggesthat radiofrequency probes must be used with ade-
uate fluid lavage as well as for short durations and f
ith the minimal wattage necessary to achieve theesired effect. I refer specifically to monopolar ra-iofrequency, as it is a common understandingmong orthopedic surgeons that monopolar radiofre-uency causes less heat production than bipolar mo-alities. This is particularly important to the handurgeon because there are close neurovascular struc-ures directly overlying the joint capsule in the smalloints compared with the knee or shoulder. Furthernderstanding may be gleaned in the future if a directlinical comparison can be made with monopolarersus bipolar radiofrequency treatments in the smalloints.

rthroscopic Stagingrthroscopic stage 1 patients (Table 1) are charac-

erized by diffuse synovitis but with minimal, if any,rticular cartilage loss. Ligamentous laxity, particu-arly the entire volar capsule, is a frequent finding.his presentation is relatively uncommon, as mostatients present late, having suffered with symptomsor a long period or referred at a delayed time, onceonservative means have been exhausted. These pa-ients have synovectomy, both mechanical and byadiofrequency, with occasional shrinkage capsulor-aphy performed depending on findings. The joint ishen protected in a thumb spica cast from 1 to 4eeks depending on the extent of capsular laxity.ore unstable joints require longer immobilization

n order to achieve joint stability and presumablylow the progression of articular cartilage degenera-ion.

Arthroscopic stage 2 patients are characterized by

igure 1. Arthroscopic view showing arthroscopic stage 2asal joint arthritis. Note the loss of cartilage deep on theetacarpal base and central part of the distal trapezium.

ocal wear of the articular surface on the central to

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orsal aspect of the trapezium (Fig. 1). In my opin-on, this represents an irreversible process and re-uires a joint modifying procedure in order to alterhe vector forces across the joint. After synovectomy,ebridement, and occasional loose body removal, theoint was reassessed to determine the extent of insta-ility and capsular attenuation. A shrinkage thermalapsulorraphy was performed in most of the cases,ith chondroplasty frequently performed to anneal

he cartilage borders. The arthroscope was then re-oved and the ulnar portal extended distally to ex-

ose the metacarpal base. A dorsoradial closingedge osteotomy, similar to Wilson’s original tech-ique,23 was then performed to place the thumb in aore extended and abducted position. This is toinimize the tendency for metacarpal subluxation

nd to change the contact points of worn articularartilage. The osteotomy is protected by a singleblique K-wire that is also placed across the 1stMC joint in a reduced position (Fig. 2).This not only allows for healing of the osteotomy

n the corrected position but also leads to a correctionf the metacarpal subluxation so often seen in thistage. A thumb spica cast protects this during heal-ng, and the wire is removed at 5 weeks after oper-tion. Only arthroscopy can determine the optimalndications for this osteotomy, which has demon-trated good results in the past and in a more recentrticle by Tomaino.24 Late follow-up on my patientsas demonstrated that the metacarpal remains “cen-ralized,” and it is unclear if the capsular shrinkagelayed a role versus the alteration of biomechanicsy use of osteotomy.Arthroscopic stage 3 is characterized by muchore diffuse trapezial articular cartilage loss (Fig. 3).he metacarpal base can also be devoid of cartilage

o varying degrees. Arthroscopic findings indicate

igure 2. Centralizing K-wire fixation of the metacarpal baseorsoradial osteotomy.

hat this is not a joint worth preserving, and a simple s

ebridement or even accompanying osteotomyould not give a good long-term result in this case.n arthroscopic hemitrapeziectomy is then per-

ormed by burring away the remaining articular car-ilage and also removing subchondral bone down to aleeding surface. This serves to not only increase theoint space but also to allow for bleeding that willorm an organized thrombus adhering to an inter-osed tendon graft or other interposed substance.his tendon graft, either palmaris longus or the volarlip of APL, is inserted via a portal similar to theechnique as proposed by Menon.2 A thumb spicaast in a palmar abducted position is then maintainedor 4 weeks followed by hand therapy to focus oninch strengthening. Artelon material for interposi-ion presents a good option to avoid the need forendon procurement (Figs. 4, 5). Minami et al in theirtudy using silicon rubber interposition arthroplastytrongly condemned the procedure and attributed

igure 3. Arthroscopic view showing arthroscopic stage 3asal joint arthritis. Note the diffuse loss of cartilage on theistal trapezium.

igure 4. Photograph showing the technique for arthro-
copic insertion of the Artelon spacer in the 1st CMC joint.

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ong-term failures to silicon synovitis and implantreakage.25 Nilsson et al in their prospective studyomparing tendon interposition arthroplasty and Ar-elon spacer have concluded that Artelon is a nonre-ctive material that markedly improved tripod andey pinch strengths compared with tendon interposi-ion arthroplasty.26

Stage 3 can also be treated by a traditional openxcisional arthroplasty,27–30 arthrodesis,20 or totaloint replacement,31,32 depending on the surgeon’sreference. The Artelon material can also be used inpen indications where the wings of the implant aresed to stabilize the joint, therefore being a goodption for advanced arthrosis where subluxation andoint stability is an issue. More aggressive options aretill feasible, as even open use of this implant doesot necessitate complete trapezial excision.

rthroscopic and Radiographic Correlationhe most consistent arthroscopic findings in theroup of patients who displayed radiographichanges compatible with stage 1 of the disease in-luded fibrillation of the articular cartilage on thelnar third of the base of the 1st metacarpal, disrup-ion of the dorsoradial ligament, and diffuse synovialypertrophy. A less reliable discovery was attenua-ion of the AOL.

Regular arthroscopic findings noted in patientslassified as having stage 2 arthritis were frank ebur-ation of the articular cartilage of the ulnar third ofhe metacarpal base and central third of the distalurface of the trapezium, disruption of the dorsora-

igure 5. Arthroscopic view showing Artelon spacer welllaced in the 1st CMC joint.

ial ligament, more noticeable attenuation of the i

OL, and more intense synovial hypertrophy (Fig.). Most of the patients with this arthroscopic stagelso presented as stage 2 radiographically, but onccasion patients deemed stage 1 may actually haveore advanced findings once the joint is truly as-

essed. Herein lies one of the great advantages ofberoptic technology as it allows true assessment of

he joint that no imaging procedure can challenge.nly the rare case demonstrated less cartilage wear

han supposed on the plain film. Consequently, ra-iographic stage 3 rarely is considered stage 2, buthat does greatly influence and expand the treatmentptions. Because this stage may have the most clin-cal impact on our method of treatment, due to lackf good options, it is important to review the patientutcomes for arthroscopic stage 2 disease.

rthroscopic Stage 2 Resultsretrospective assessment evaluated arthroscopic

tage 2 patients with adequate follow-up in a selected-year period. Forty-three patients (38 female and 5ale) were arthroscopically diagnosed as having

tage 2 basal joint osteoarthritis of the thumb be-ween 1998 and 2001. All the procedures were per-ormed by me with follow-up data generated byisiting fellows for objectivity. The average age was1 years (range, 31–69 years). The right thumb wasnvolved in 23 patients and the left in 20. There waso improvement after a minimum 6 weeks of con-ervative treatment under my direction. The surgicalrocedure consisted of arthroscopic synovectomy,ebridement, occasional thermal capsulorraphy fol-owed by an extension-abduction closing wedge os-eotomy in all cases. A 1.4 mm (0.045-in) K-wirerovided stability to the osteotomy site, and a shortrm thumb spica cast was used for 4–6 weeks untilin removal. The average follow-up was 43 monthsrange, 24–64 months).

Consistent arthroscopic findings in the selectedroup were frank eburnation of the articular cartilagef the ulnar third of the base of the 1st metacarpalnd central third of the distal surface of the trape-ium, disruption of the dorsoradial ligament, attenu-tion of the anterior oblique ligament, and synovialypertrophy. The osteotomy healed within 4–6eeks in all the cases. Radiographic studies at final

ollow-up depicted maintenance of centralization ofhe metacarpal base over the trapezium and no pro-ression of arthritic changes in 42 patients. Averageange of thumb MCP joint motion was 5°–50° andhumb opposition reached the base of the small finger
n all cases. The average pinch strength was 9.5 lb

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73% from nonaffected side). At final follow-up,atients were evaluated by Buck-Gramcko score,hich takes into account both the subjective as well

s objective outcomes.33 The mean total Buck-Gram-ko score in our series was 48.4 (“Good Outcome”).he constant pain in one of the patients was due torogressive osteoarthritis after the procedure. She didot respond to steroid injections and finally had toave arthroscopic-assisted hemitrapeziectomy due torogressive arthritis. A longer follow-up will be laterbtained to better assess the long-term utility of thisechnique and to publish these findings specifically intage 2 patients.

Arthroscopy in patients who had radiographic fea-ures of stage 3 and 4 generally display widespreadull-thickness cartilage loss with or without a peripheralim on both articular surfaces, less severe synovitis, andrayed volar ligaments with laxity (Fig. 3). This clearlyonstitutes arthroscopic stage 3, and the treatment op-ions here are quite varied. The arthroscope can beemoved and the most appropriate open procedure per-ormed. I prefer the arthroscopic interposition arthro-lasty in most of the cases. Based on the above findingsnd clinical experience, I have recently proposed therthroscopic classification and treatment algorithm de-ineated in Table 1 and Figure 6.

rapeziometacarpal Arthroscopy: Clinicalselinical assessment and radiographic studies used toe the only tools available for the selection of treat-ent modalities for thumb CMC arthritis.34,35 Eaton

nd Glickel proposed a staging system for this dis-ase that has been widely applied.19 Later, Bettingert al36 described the trapezial tilt as a parameter toredict further progression of the disease. Theyound that in advanced stages (Eaton 3 and 4), therapezial tilt was high (50° � 4; normal: 42° � 4).arron and Eaton concluded that there appears to beo indication for magnetic resonance imaging (MRI),omography, or ultrasonography in the routine eval-ation of basal joint disease.37

Although I believe that a radiographic classifica-ion is important for a stepwise interpretation of therogression of this entity, my experience has dem-nstrated instances when it is very difficult to maken accurate diagnosis of the extent of disease basedolely on radiographic features. Recent advances inrthroscopic technology have allowed complete ex-mination of smaller joints throughout the body withinimal morbidity.1 Moreover, arthroscopy has al-

eady proved to be reliable for direct evaluation of s

he 1st carpometacarpal joint as previously dis-ussed.3

In early stages of thumb basal joint arthritis; fornstance, in Eaton stage 1, it is very common to findssentially normal radiographic studies despite theresence of painful limitation of the thumb. In myxperience, I have found that this group of patientsisplays mild to moderate synovitis that could benefitrom a thorough joint debridement combined withhermal shrinkage of the ligaments to enhance thetability. This, of course, after assuming they haveot responded well to conservative treatment includ-ng splinting, nonsteroidal anti-inflammatory drugse, and corticosteroid injection. This stage is typi-ally seen in middle-aged women who are often notuitable candidates for more aggressive proce-ures.35 Arthroscopic treatment provides a particu-arly good option for this ubiquitous subset of pa-ients.

Tomaino concluded that 1st metacarpal extensionsteotomy is a good indication for Eaton stage 1.24

his invasive procedure may not be necessary in theccasional patient who has arthroscopy at an earlyime and demonstrates no focal cartilage loss. Futuretudies may indicate that synovectomy, and perhapshermal capsulorraphy, may avoid progression of dis-ase and the need for a mechanical intervention.owever, the arthroscopic findings that I previouslyescribed for arthroscopic stage 2 of the diseaseemand a joint modification such as osteotomy toinimize the chance of further articular degenera-

ion. My retrospective study indicates that this ap-roach is efficacious with only 1 out of 43 thumbseveloping progressive arthritis requiring further sur-ery.There remains little doubt that if complete articular

artilage loss is the arthroscopic scenario, the logicalext step is to perform some type of trapezium ex-ision with interposition arthroplasty. Menon de-cribed a technique demonstrating arthroscopic de-ridement of the trapezial articular surface andnterposition of autogenous tendon, fascia lata orore-Tex patch into the CMC joint in patients with

tage 2 and 3 with excellent results.2 I have demon-trated that this arthroscopic technique is even effec-ive in patients with underlying severe ligamentousaxity, as in Ehler-Danlos syndrome.38 Newer tech-iques may allow the arthroscopic insertion of Arte-on, which has proved successful with open tech-iques and confirmed histologically.25 In either case,omplete excision of the trapezium may not be de-
irable, particularly in younger patients. The stage 3


DORSAL SUBLUXATION

STABLE

ARTHROSCOPIC STAGE III • DIFFUSE ARTICULAR

WEAR

MIDDLE AGE, ELDERLY PT WITH AVERAGE ACTIVITY

YOUNG ACTIVE HEAVY WORKER

MILD SUBLUXATION

GROSSSUBLUXATION

ARTHRODESIS

THUMB BASAL JOINT PAIN

CMCARTHROSCOPY

ARTHROSCOPIC STAGE I • SYNOVITIS • INTACT ARTICULAR

CARTILAGE

ARTHROSCOPIC SYNOVECTOMY + ARTHROSCOPIC DEBRIDEMENT

ARTHROSCOPIC SYNOVECTOMY + ARTHROSCOPIC DEBRIDEMENT + THERMAL CAPSULORRAPHY

R

R

TRAPEZIOMETACARPAL OSTEOARTHRITIS CONFIRMED CLINICALLY AND RADIOGRAPHICALLY

ARTHROSCOPIC STAGE II • FOCAL ARTICULAR

WEAR

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R

ELDERLY LOW DEMAND PATIENT

ARTHROSCOPIC ARTELON ORARTHROSCOPIC TENDON INTERPOSITION

OPEN ARTELON

TOTAL JOINT ARTHROPLASTY

EXCISIONAL ARTHROPLASTY

R

R

R

RADIOGRAPHIC STAGE I, II AND III

RADIOGRAPHIC STAGE IV WITH SEVERE STT JOINT ARTHRITIS

R - RECURRENCE

TREATMENT ALGORITHM FLOW CHART

Figure 6. Treatment algorithm for thumb Basal joint arthritis.

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reatment needs to be further assessed by evaluatingong-term clinical results.

According to the arthroscopic classification pro-osed, I recommend arthroscopic synovectomy andebridement of the basal joint in patients with stagearthritis. In patients with stage 2 disease, synovec-

omy and debridement is combined with dorsoradialsteotomy of the 1st metacarpal. In both of thesetages, thermal shrinkage is used to manage ligamen-ous laxity. Finally, for stage 3 of the disease, arthro-copic interposition arthroplasty is my treatment ofhoice, although other factors must be considered inaking this determination.Arthroscopic assessment of the trapeziometacarpal

oint allows direct visualization of all components ofhe joint including synovium, articular surfaces, lig-ments, and the joint capsule. It also allows for thextent of joint pathology to be evaluated and stagedith intraoperative management decision-makingased on this information. I recommend this arthro-copic staging to ensure better judgment of this con-ition to provide the most adequate treatment optiono patients who have this disabling condition.

Future studies assessing the clinical long-term re-ults utilizing arthroscopy will likely ensure its placen the treatment armamentarium for trapeziometacar-al osteoarthritis.

etacarpophalangeal Arthroscopyespite the fact that arthroscopy of the metacarpo-halangeal joints of the hand was first describedearly 30 years ago, the clinical utility and indica-ions remain obscure. In fact, most orthopedic sur-eons are completely unaware of the possibility ofsing the ubiquitous arthroscope to explore this joint,hich can be afflicted with diverse pathology. Fur-

hermore, hand surgeons rarely use this technologyespite being faced daily with challenging clinicalroblems within this small but critical joint. One canpeculate as to reasons why this is the case, but Iuspect that minimal reporting in the literature asell as the lack of direct teaching of this techniqueas contributed to the poor utilization of what isotentially a very useful addition to our treatmentrmamentarium.

Dr. YC. Chen first described arthroscopy of theCP joints, among other small joints of the hand, in

is landmark article in Orthopedic Clinics of Northmerica in 1979.1 Despite a very simplistic review,

his article first described use of the Watanabe no. 24rthroscope within the wrist, metacarpophalangeal
oints, and even interphalangeal joints of the hand. g
lthough he described both proximal interphalangealPIP) and distal interphalangeal (DIP) joints beingcoped, there was strangely no mention of the trape-iometacarpal joint. Nevertheless, he first introducedhe concept of placing a small arthroscope into theetacarpophalangeal joint of several digits including

he thumb. He was the first to describe the anatomy,lbeit cursory, and he also presented several caseeports where he described the arthroscopic findingsnd clinical relevance. In total, he described 90 ar-hroscopies carried out in multiple joints encompass-ng 34 clinical cases as well as using 2 cadaver armsn the period November 1973 to August 1978. Sur-risingly, this novel concept was not expanded uponntil much later.Vaupel and Andrews, a well-known arthroscopic

urgeon, described the first case report involvingrthroscopic treatment of the metacarpophalangealoint 6 years after Chen’s report.39 In this particularase, they described a professional golfer who wasmpaired due to a 1-year history of chronic painfulynovitis within the thumb metacarpophalangealoint. They performed a synovectomy as well asrthroscopic burring of a small chondral defect thatad been identified. The patient did extremely wellnd was able to return to his sport within a 6-montheriod and was essentially pain free at his nearly-year follow-up examination. This was published inhe American Journal of Sports Medicine where handurgeons were unlikely to be exposed to this article.espite an excellent clinical outcome and a logical

pproach to care, neither general indications for uti-izing this small arthroscopic technique were out-ined, nor were further clinical recommendationsade. It was not until 2 years later, in 1987, whenilkes presented the first series of a pathology

reated with arthroscopic means in the metacarpopha-angeal joint.40 This consisted of arthroscopic rheu-atoid synovectomy on 13 joints within 5 patients,

ll having a chronic rheumatoid arthritis. These pa-ients lacked the usual joint subluxation or destruc-ion but did have notable synovitis that was foundithin the recesses of the collateral ligament origins.here was an adequate follow-up of 4 years, whichid demonstrate that there was recurrence of pain andhat the technique did not seem to alter the naturalistory of this disease at the MCP joint. Unfortu-ately, this critical series was published within theournal of the Medical Association of Georgia and,ence, did not have broad exposure to either handurgeons or arthroscopic surgeons within the field of
eneral orthopedics or sports medicine. For these

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easons, the subsequent paper in the literature utiliz-ng this technique was not seen until 1994 where itnally reached the Journal of Hand Surgery - Britisholume where a case report was presented.41 Theatient was a young male presenting with swellingnd recurrent locking of the metacarpophalangealoints of both the index and middle fingers bilater-lly. This is a typical presentation for hemochroma-osis. Up until that time, the treatment of arthropathyas osteotomy and arthroplasty or even a joint arth-

odesis for more advanced cases. This is a rarely seenematologic condition that is actually treated withhlebotomy, and the joint manifestations are poorlynderstood. However, at that time, it was clear tohese surgeons that arthroscopy presented an excel-ent alternative to open surgery with better visualiza-ion of the joint with subsequent treatment of theynovitis and a more rapid recovery due to its min-mally invasive nature. The emphasis of the caseeport was on the condition itself and did not giveny further recommendations other than stating thathis case suggested that arthroscopic surgery is “ofalue.” Likely due to the fact that the arthroscopicreatment was overshadowed by the unusual pathol-gy being treated, the common clinical application ofhis technology was still not heralded.

It was not until 1995 when Ryu and Fagan pre-ented their series on the treatment of the ulnarollateral ligament Stener lesion that we could see aommon clinical application for this new technol-gy.42 Their series described an arthroscopic reduc-ion of a Stener lesion on 8 thumbs with an averageollow-up period of just over 3 years. The techniqueimply involved reduction of the Stener lesion intohe joint so that the avulsed ligament would now beuxtaposed to its insertion site on the base of theroximal phalanx. Previously, the ligament had beenitting outside the adductor aponeurosis and couldot heal in appropriate position. Once the reductionas performed, the ligament ends were debrided and

he joint pinned for stability. Upon removing the cast,brief course of therapy was introduced, and at

ollow-up no patient reported any pain or functionalimitation. There was an excellent range of motionith strength parameters equal to or often greater

han the thumb on the unaffected side. The onlyomplication was a single pin tract infection. Theiresults indicated that an arthroscopic reduction of atener lesion obviated the need for open repair andll of its consequent complications such as prolongedecovery and stiffness. This clinical series repre-
ented the first clinical application to a common a
roblem that would then serve as a frequent reason toerhaps utilize arthroscopic treatment of pathology inhis joint. There was, however, no mention of bonyamekeeper’s lesions, nor was there a comparativenalysis with the open technique. Perhaps the great-st contribution of this paper was that it was pre-ented in a widely read journal. This most likelyntroduced the concept of arthroscopic surgery in thismall joint for the first time to the majority of theand surgery community. Nevertheless, despite theact that this paper was published more than 10 yearsgo, the technique remains minimally utilized andhere have been few clinical series since then.

In 1999, Rozmaryn and Wei presented the firsteneralized paper on the technical aspects of meta-arpophalangeal arthroscopy with further discussionn the possible indications and advantages of thisittle-used technique.43 They speculated that there

ay be a perception that the MCP joint is simply toomall to perform arthroscopic procedures in anyractical or relevant manner. While not discussingollow-up of a variety of indications, they did makehe first mention of the broad indications that mighte treated with this procedure. They specificallyentioned joint synovectomies and biopsies as pre-

iously mentioned and reiterated the possibility ofollateral ligament debridement, while adding theoncept of ligament repair as a possibility. They alsoentioned removal of loose bodies, treatment of

steochondral lesions, management of juxta-articularesions, and treatment of intra-articular fractures andther possible clinical applications. They too notedhat only a handful of case reports were present in theiterature, and they explained why this technique wasot expanded upon. It should be noted that this wasublished in the journal Arthroscopy: The Journal ofrthroscopic-Related Surgery in 1999, and this tooould have led to little exposure to dedicated hand

urgeons. Their report not only discussed some tech-ical aspects but also described the anatomic land-arks for the first time since Dr. Chen’s simplistic

escription with a much poorer arthroscope 20 yearsrior. They made a general observation that the ad-antages of arthroscopic as opposed to open tech-iques was similar to those experienced in largeroints and that perhaps with time, many more indi-ations would clearly emerge.

The same year of Rozmaryn and Wei’s technicalrticle, a broad review article was published by Sladend Gutow44 in Hand Clinics and titled “Arthroscopyf the Metacarpophalangeal Joint.” For the first time,
broad analysis of the technique was presented,

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ncluding detailed technical explanations, a descrip-ion of the broad clinical applications, as well asome illustrative cases. They also mentioned the rareomplications and how to avoid them. Interestingly,he concept of a triumph of technology over reasonas also mentioned, lending credence to the theory

hat arthroscopy of this small joint may not haveained widespread acceptance due to the fact that itay just not be practical. They emphasized that

mall joint arthroscopy in these joints requires notnly specialized instrumentation but also a thoroughnowledge of the anatomy within these joints. Theirroad review soon revealed that there were a wideariety of indications that could greatly benefit fromhis technology. Detailed treatment techniques wereescribed with several case examples, particularly inhe area of intra-articular fracture treatment. A novelechnique was also described where arthroscopyould be combined with small bone anchor applica-ion for reattachment of collateral ligament injuries.his obviously demonstrates a challenging technicalxercise, but the authors were quick to point out theelative advantages of this method. In their discus-ion with German colleagues, who had begun com-aring arthroscopic synovectomies in rheumatoid pa-ients with other joints treated in the same patientith open means, both surgeons and the patientsere impressed with the diminished postoperative

welling and the improvement in rehabilitation witharlier return to activity. This particular series has noteen published but represents a possible advantage ofhe arthroscopic technique as opposed to openeans. In fact, in that same year, there was an

bscure article in the rheumatology literature thatiscussed use of “mini-arthroscopy” of metacarpo-halangeal joints in staging a synovitis and using thiss an effective biopsy tool. The article was written byheumatologists in Germany and emphasized thecoring system of synovitis within rheumatoid pa-ients with little discussion of the operative tech-ique.45 They simply used this as a tool for assessinghe degree of disease involvement but again empha-ized its clinical utility. The authors believed thaticroarthroscopy provided an objective technique

or joint evaluation and microscopic assessment andllowed visual-guided synovial biopsy with in-reased accuracy and decreased the risk of any sam-ling errors. They performed this under local anes-hesia, indicating that general anesthesia was notecessary, and it could be easily done within anutpatient framework. Obviously, if the rheumatolo-
ists could see the great benefit of this technique,
and as well as arthroscopic surgeons could certainlyxpand upon its clinical utility. In the same year,ei, who had co-written the first technical descrip-

ion of metacarpophalangeal joint arthroscopy, pre-ented a series of arthroscopy synovectomy withinefractory rheumatoid arthritis.46 He described a se-ies of 21 patients treated with synovectomy withood short-term results. Although the article wasredominately meant to be a technique article, heelieved the short-term results were promising andhat the utility of this procedure in other types ofrthritis or other orthopedic conditions was war-anted. He raised the question of what is the long-erm effect of this procedure on joint preservation asell as what is the optimal timing for this surgery in

he rheumatoid patients. Although we certainly doot have the answers to these questions, it is hopedhat increased utilization of metacarpophalangealoint arthroscopy may answer this and many otheruestions.Sekiya and colleagues expanded on previous sur-

eons’ descriptions by evaluating 21 patients withheumatoid arthritis in 27 proximal interphalangealoints and 16 metacarpophalangeal joints. This waspparently the first clinical description of PIP jointrthroscopy and also added further information re-arding metacarpophalangeal joint arthroscopic sur-ery.47 They, too, found that arthroscopic assessmentf the articular surface and synovial membrane wasn excellent application of this tool and that moreccurate biopsies could be taken. They speculatedhat arthroscopy for the small joints in the handswill become a standard procedure in the near fu-ure.” However, their study did not assess other pa-hologies. Gaspar et al described a technique of sy-ovial biopsy of metacarpophalangeal joint using aeedle arthroscope, which can be of good use inheumatoid patients.48 It is apparent that there is aaucity of clinical articles in the literature and thaturther discussion regarding the indications and clin-cal application of this technique is necessary totimulate the hand surgeon to include this tool in hispectrum of treatment options. Whereas the arthro-copic surgeon, commonly identified as a sportsedicine specialist, may utilize this technique, it will

ikely remain for the hand surgeon to expand itslinical applications. This is simply because the va-iety of pathology seen in the metacarpophalangealoints is most commonly assessed by hand surgeons,nd it is up to this group of surgeons to expand thepplications of this still underutilized technique.

Pathology of the metacarpophalangeal joint is rel-

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tively common. Acute trauma can involve any onef these joints with the thumb being by far the mostommonly afflicted. The so-called gamekeeper’shumb is a frequent injury seen in any hand surgeon’sractice. My experience with the arthroscopic reduc-ion and internal fixation of the bony gamekeeper’shumb has been encouraging.49 Bony gamekeeper’shumb, which is a relatively common injury, providesore treatment options compared with the classictener lesion, which traditionally requires open re-air of the avulsed ligament. Hence the technique ofrthroscopic fixation of this avulsion fracture can besed effectively in routine practice. Acute trauma canlso involve the finger MCPs with both ligamentousnjuries and articular fractures being occasionallyeen. So-called overuse syndromes may reflect areviously unrecognized acute injury that was notddressed or may simply be a more chronic synovi-is. Arthroscopy of these small joints will not onlyssist in diagnosing the condition, but also, as will bellustrated, can serve to provide treatment.

echniquen arthroscope 1.9 mm in diameter will be necessary

o explore these small joints. Generally, the 30°cope commonly used by maxillofacial surgeons foremporomandibular pathology is used. Newer arthro-copes as small as 1 mm are now available and willake this technique even easier. A 2.0-mm shaver is

sually the main operative instrument although smalladiofrequency probes, both for ablation and shrink-ge, are frequently used.

In these smaller joints, it is much easier to proceedith local anesthesia and sedation. Several millilitersf lidocaine are introduced into the joint once theand is suspended using a single Chinese fingertrapn the affected digit. Adequate sedation is thenchieved to allow elevation of the tourniquet for theecessary time period.It is particularly important to introduce the tro-

ar into the joint in atraumatic fashion. These jointpaces are minimal, and it is feasible to causeonsiderable iatrogenic injury if care is not taken.he interval between metacarpal head and proxi-al phalanx base is quite narrow, and it is recom-ended to find the appropriate level and insertion

ngle by inserting a small curved clamp once theoint is sufficiently distended with lidocaine oraline solution. The arthroscope is then introducedt this same angle, and a thorough joint inspections performed (Fig. 7). The portals are quite simple
s they lie on either side of the visible extensor l
endon. Occasionally, a third portal might be usedor outflow and is placed by palpating the capsule,dentifying the interval as seen on the monitor, andhen passing an 18-gauge needle. A synovectomyust always be initially performed as only this will

llow thorough inspection of the joint. As this isone with a small full-radius shaver, the capsulend ligamentous structures become more apparent.

radiofrequency ablator probe can make this pro-ess more efficient and less tedious. It is importanto use this sparingly, as the joint capsule is rela-ively thin and subcutaneous, and thermal injuryan occur. Once synovectomy is performed, theurgeon can now sequentially identify any abnor-alities. This should be done in a routine system-

tic fashion to avoid missing any pathology. Myreference is to begin on one collateral ligament,hen assess the volar plate, then the contralateraligament followed by the dorsal capsule and ex-ensor mechanism. The articular surface of bothroximal phalanx and metacarpal head is then as-essed. Once the particular pathology is identifiednd appropriately addressed, the arthroscope isemoved and portals are closed with benzoin andteri-strips only. The thumb MCP is protected withshort arm thumb spica splint in extension. Ar-

hroscopy of any of the fingers will require a dorsaletacarpophalangeal block splint in flexion to al-

ow the collateral ligaments to heal in their mostaut position so that there is no resultant loss inotion. Time of immobilization is determined by

he type and extent of pathology found during therthroscopic intervention. Therapy after operationay play a role but is rarely needed for a pro-

igure 7. Photograph showing arthroscopy of the thumbCP joint with K-wire holding the reduction.

onged course.

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ndications of Metacarpophalangealrthroscopyurgical indications to perform MCP arthroscopyill usually involve chronic complaints as opposed

o acute injury. Most acute trauma about these jointsan be managed conservatively with a trial of immo-ilization. The thumb ulnar collateral ligament avul-ion is a notable exception where open repair of atener lesion is usually performed. Even here, how-ver, an arthroscopic repair has been described in theiterature.39 As the surgeon becomes more adept athis small joint arthroscopy, the more acute indica-ions may evolve as one can make a more accuratessessment of the extent of injury and often provideore precise treatment for this articular pathology.Acute indications generally involve an associated

igure 8. Intraoperative fluoroscopic view showing reducedony gamekeeper’s avulsion fracture of thumb MCP in aoung adolescent patient.

igure 9. Arthroscopic view showing the arthroscopic reduc-ion of the avulsed fragment with the K-wire, demonstrating
he necessary angle for fragment fixation. p
racture that will need articular reduction. This isecause the vast majority of ligamentous injuries willeal with conservative treatment or are so severe thathey will be treated open to correct the instability.erhaps, the best acute indication is reduction of anvulsion fracture with a rotated fragment from theollateral ligament insertion (Fig. 8).49 A hook probes used to derotate the bony fragment with arthro-copic visualization. K-wire fixation can then bedded with fluoroscopic confirmation. (Figs. 8, 9) Aess common lesion would be a die-punch articularracture, usually of the proximal phalanx base, wherehe scope can be used to achieve the best articulareduction possible. At that time, a synovectomy asell as removal of floating loose osteochondral frag-ents can be performed. This has an added benefit of

educing the inflammatory process besides reducinghe fracture. This arthroscopic technique has the ob-ious advantage of a more precise articular reductionFigs. 8, 9) with the added benefit of minimal cap-

igure 10. Radiograph of the same patient of Figure 9 show-ng consolidation of the fracture at 9 weeks after surgery, 1onth after pin removal.

igure 11. Range of motion at the 1st MCP joint in the same
atient of Figures 9 and 10 at 9 weeks follow-up.

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ular scarring and consequently faster recovery of aull range of motion (Figs. 10, 11).49 As in any otherrthroscopy, assessment of associated lesions such asigament or capsular injury can also be assessed andreated.

Chronic processes affecting the MCP joint tend toe the most common indications. This is perhapsecause there are few options in a persistently painfulnuckle joint. Acute injuries often improve with ap-ropriate rehabilitation and/or immobilization whileore severe trauma is managed with open repairs.herefore, persistent pain despite ample conservative

reatment in both thumb and finger MCP injury is theost common indication for MCP arthroscopy. It is

ot uncommon to encounter persistent symptoms af-er cast treatment for a skier’s thumb. This can be dueo a more severe ligamentous injury than originally

igure 12. Arthroscopic view showing radiofrequency ther-al capsulorraphy procedure after synovectomy in a patientith synovitis and articular changes in the 2nd MCP joint.

igure 13. (a) Frontal and (b) lateral photographs showing rafter arthroscopic synovectomy and debridement of both ind
ight pain in these chronically swollen joints.
urmised or a concomitant articular cartilage injuryith accompanying persistent synovitis. Sometimes

he contralateral ligament is injured as well and wasot completely addressed. An arthroscopic evalua-ion determines the location and extent of injury andives an opportunity to provide treatment, whethery simple debridement and/or thermal capsulorra-hy. This type of complaint is often managed by aourse of nonsteroidal anti-inflammatory drugs or aeries of cortisone injections. These treatments maynly provide temporary relief, if any, and cannot beontinued indefinitely. This is where the great valuef arthroscopy lies as it provides a viable option toake both a definitive diagnosis and institute a treat-ent based on these findings.Occult pain often associated with chronic swellingay be an indication to proceed with arthroscopic

valuation as well. This may have been from annrecognized injury, early presentation of osteoar-hritis, or an idiopathic synovitis. Steroid injectionsre often efficacious here but can lead to accelerationf cartilage and capsular degeneration. Arthroscopicebridement (Fig. 12) will avoid this complicationhile perhaps retarding the degenerative process. A

urther benefit is that complications are negligiblend the recovery is rapid (Fig. 13).

The earliest stages of osteoarthritis may not beeen on plain radiographs, and the diagnosis is oftenclinical one. After adequate conservative treatmentith nonsteroidal anti-inflammatory drugs and per-aps a course of therapy, the logical next level ofreatment remains an intra-articular corticosteroid in-ection. If symptoms recur despite several injections,rthroscopic debridement becomes the best option

overy of function in the same patient of Figure 12 at 4 daysd thumb MCP joints. Patient noted immediate resolution of

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hort of joint replacement. Open synovectomies areifficult because of poor visualization and limitedccess to all regions of the joint and can lead toonsiderable stiffness after operation. Although sili-one arthroplasty remains the gold standard treat-ent for advanced rheumatoid involvement of theCP joints, post-traumatic arthrosis and osteoarthri-

is are not good indications for replacement arthro-lasty. Arthroscopy provides a good treatment alter-ative before resorting to the newer nonconstrainedeplacement options now available.

Inflammatory arthritis, such as rheumatoid, is gen-rally managed with systemic pharmacotherapy andn late stages with replacement arthroplasty. Occa-ionally, a mono- or pauci-articular form is encoun-ered, and an arthroscopic biopsy may assist in mak-ng the diagnosis. Early involvement of these jointsay warrant an arthroscopic synovectomy and cap-

ular shrinkage. This is best suited for the 1–2 jointsost involved, where one can hope to retard the

estructive process. Long-term results of this proce-ure remain to be demonstrated.

ummaryrthroscopy has become a vital part of an orthopedic

urgeon’s armamentarium in treating large joint pa-hology. Advances in technology have now alloweds to apply this benefit to the smallest joints, such ashe metacarpophalangeal and trapeziometacarpaloints. Osteoarthritis will likely remain the mostommon indication for basal joint arthroscopy whilehronic pain and inflammation are useful indicationsor metacarpophalangeal arthroscopy. As in any newechnique, the appropriate and most suitable indica-ions will evolve over time. Further clinical studiesre necessary to validate the technique and to encour-ge further implementation as well as improvementsn the instrumentation.

eceived for publication December 29, 2006; accepted February 18,007.No benefits in any form have been received or will be received fromcommercial party related directly or indirectly to the subject of this

rticle.Corresponding author: Alejandro Badia, MD, FACS, Miami Hand

enter, 8905 SW 87th Ave., Miami, FL 33176; e-mail: [email protected]

Copyright © 2007 by the American Society for Surgery of the Hand0363-5023/07/32A05-0019$32.00/0doi:10.1016/j.jhsa.2007.02.020

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arthroscopy of the trapeziometacarpal and...

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