Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

439.e1
References
References
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human cartilage. Evidence for both matrix metalloproteinase and
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joints. J Clin Invest. 1997;100:93–106.
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Comparison of treatment strategies in early rheumatoid arthritis: a
randomized trial. Ann Intern Med. 2007;146:406–415.
18. Bathon JM, Martin RW, Fleischmann RM, et al. A comparison of
etanercept and methotrexate in patients with early rheumatoid
arthritis. N Engl J Med. 2000;343:1586–1593.
19. Lipsky PE, van der Heijde DM, St Clair EW, et al. Infliximab and
methotrexate in the treatment of rheumatoid arthritis. Anti-Tumor
Necrosis Factor Trial in Rheumatoid Arthritis with Concomitant
Therapy Study Group. N Engl J Med. 2000;343:1594–1602.
20. Bongartz T, Sutton AJ, Sweeting MJ, et al. Anti-TNF antibody
therapy in rheumatoid arthritis and the risk of serious infections
and malignancies: systematic review and meta-analysis of rare
harmful effects in randomized controlled trials. JAMA.
2006;295:2275–2285.
21. Grennan DM, Gray J, Loudon J, et al. Methotrexate and early
postoperative complications in patients with rheumatoid arthritis
undergoing elective orthopaedic surgery. Ann Rheum Dis.
2001;60:214–217.
22. Jain A, Maini R, Nanchahal J. Disease modifying treatment and
elective surgery in rheumatoid arthritis: the need for more data.
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23. Jain A, Witbreuk M, Ball C, et al. Influence of steroids and
methotrexate on wound complications after elective rheumatoid
hand and wrist surgery. J Hand Surg Am. 2002;27:449–455.
24. Bongartz T. Elective orthopedic surgery and perioperative DMARD
management: many questions, fewer answers, and some opinions. J
Rheumatol. 2007;34:653–655. An excellent review of the current state of
the evidence regarding perioperative DMARD management. An
evidence-based, practical and conservative approach is recommended by
the authors.
25. Union A, Meheus L, Humbel RL, et al. Identification of citrullinated
rheumatoid arthritis-specific epitopes in natural filaggrin relevant
for antifilaggrin autoantibody detection by line immunoassay.
Arthritis Rheum. 2002;46:1185–1195.
26. Nielen MM, van Schaardenburg D, Reesink HW, et al. Specific
autoantibodies precede the symptoms of rheumatoid arthritis: a
study of serial measurements in blood donors. Arthritis Rheum.
2004;50:380–386.
27. Fleming A, Crown JM, Corbett M. Early rheumatoid disease. I.
Onset. Ann Rheum Dis. 1976;35:357–360.
28. Guerne PA, Weisman MH. Palindromic rheumatism: part of or
apart from the spectrum of rheumatoid arthritis. Am J Med.
1992;93:451–460.
29. Moffat DA, Ramsden RT, Rosenberg JN, et al. Otoadmittance
measurements in patients with rheumatoid arthritis. J Laryngol Otol.
1977;91:917–927.
30. Fleming A, Benn RT, Corbett M, et al. Early rheumatoid disease. II.
Patterns of joint involvement. Ann Rheum Dis. 1976;35:361–364.
31. Mens JM. Correlation of joint involvement in rheumatoid arthritis
and in ankylosing spondylitis with the synovial: cartilaginous
surface ratio of various joints. Arthritis Rheum. 1987;30:359–360.
32. Jackson CG, Chess RL, Ward JR. A case of rheumatoid nodule
formation within the central nervous system and review of the
literature. J Rheumatol. 1984;11:237–240.
33. Mannerfelt L. Surgical treatment of the rheumatoid wrist and
aspects of the natural course when untreated. Clin Rheum Dis.
1984;10:549–570.
34. Brook A, Corbett M. Radiographic changes in early rheumatoid
disease. Ann Rheum Dis. 1977;36:71–73.
35. Ruby LK, Cassidy D. Evaluation and treatment of the rheumatoid
wrist. In: Watson HK, Weinzweig J, eds. The Wrist. Philadelphia:
Lippincott Williams & Wilkins; 2001:645–657.
36. Hindley CJ, Stanley JK. The rheumatoid wrist: patterns of disease
progression. A review of 50 wrists. J Hand Surg [Br].
1991;16:275–279.
37. Muramatsu K, Ihara K, Tanaka H, et al. Carpal instability in
rheumatoid wrists. Rheumatol Int. 2004;24:34–36.
38. Pirela-Cruz MA, Firoozbakhsh K, Moneim MS. Ulnar translation of
the carpus in rheumatoid arthritis: an analysis of five determination
methods. J Hand Surg Am. 1993;18:299–306.
39. Linscheid RL, Dobyns JH. Rheumatoid arthritis of the wrist. Orthop
Clin North Am. 1971;2:649–665.
40. Spinner M, Kaplan EB. Extensor carpi ulnaris. Its relationship to the
stability of the distal radio-ulnar joint. Clin Orthop Relat Res.
1970;68:124–129.
41. Flury MP, Herren DB, Simmen BR. Rheumatoid arthritis of the
wrist. Classification related to the natural course. Clin Orthop
Relat Res. 1999;366:72–77. The authors present a classification system for
the rheumatoid wrist that is now commonly used and frequently
referenced. This classification system uses radiologic indicators to divide
wrists into those that are stable (types I and II) and those that are unstable
(type III).
42. Vaughan-Jackson OJ. Attrition ruptures of the tendons in the
rheumatoid hand. J Bone Joint Surg. 1958;40A:1431. The brief paper by

439.e2
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Vaughan-Jackson is a classic original description of extensor tendon
attrition ruptures.
43. Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in
rheumatoid arthritis caused by bony spurs in the carpal tunnel. A
clinical and radiological study. J Bone Joint Surg Br. 1969;51:270–277.
44. Flatt AE. Some pathomechanics of ulnar drift. Plast Reconstr Surg.
1966;37:295–303.
45. McMaster M. The natural history of the rheumatoid metacarpo-
phalangeal joint. J Bone Joint Surg Br. 1972;54:687–697.
46. Littler JW. The finger extensor mechanism. Surg Clin North Am.
1967;47:415–432.
47. Watson HK, Weinzweig J. Principles of rheumatoid arthritis. In:
Watson HK, Weinzweig J, eds. The Wrist. Philadelphia: Lippincott
Williams & Wilkins; 2001:639–644.
48. Shapiro JS. The wrist in rheumatoid arthritis. Hand Clin.
1996;12:477–498.
49. Flatt AE. The Care of the Rheumatoid Hand. St. Louis: Mosby; 1974 An
excellent historical overview of surgical treatments for the rheumatoid
hand, as well as descriptions of the mechanics of the disease process.
50. Shapiro JS, Heijna W, Nasatir S, et al. The relationship of wrist
motion to ulnar phalangeal drift in the rheumatoid patient. Hand.
1971;3:68–75.
51. Nalebuff EA. Surgical treatment of tendon rupture in the
rheumatoid hand. Surg Clin North Am. 1969;49:811–822. A detailed
description of the surgical management of tendon ruptures by a hand
surgeon with extensive experience in treating patients with rheumatoid
arthritis.
52. Howard LD Jr. Surgical treatment of rheumatic tenosynovitis. Am J
Surg. 1955;89:1163–1168.
53. Stellbrink G. Trigger finger syndrome in rheumatoid arthritis not
caused by flexor tendon nodules. Hand. 1971;3:76–79.
54. Vetter TR. Acute airway obstruction due to arytenoiditis in a child
with juvenile rheumatoid arthritis. Anesth Analg. 1994;79:1198–1200.
55. Urban MK. Anaesthesia for orthopedic surgery. In: Miller RD,
Eriksson LI, Fleisher LA, et al., eds. Miller’s Anesthesia. Philadelphia:
Churchill Livingstone; 2009.
56. Allieu Y, Lussiez B, Asencio G. Long-term results of surgical
synovectomies of the rheumatoid wrist. Apropos of 60 cases. Rev
Chir Orthop Reparatrice Appar Mot. 1989;75:172–178.
57. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with
synovectomy of the extensor tendons and the wrist joint combined
with a Darrach procedure. J Hand Surg Am. 1992;17:1109–1117.
58. Clayton ML. Surgical treatment at the wrist in rheumatoid arthritis:
a review of thirty-seven patients. J Bone Joint Surg Am. 1965;47:
741–750.
59. Mannerfelt L, Malmsten M. Arthrodesis of the wrist in rheumatoid
arthritis. A technique without external fixation. Scand J Plast
Reconstr Surg. 1971;5:124–130.
60. Dolphin JA. Extensor tenotomy for chronic boutonniere deformity
of the finger; report of two cases. J Bone Joint Surg Am.
1965;47:161–164.
61. Krueger G, Ellis CN. Psoriasis – recent advances in understanding
its pathogenesis and treatment. J Am Acad Dermatol.
2005;53:S94–S100.
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pseudogout: insights for the clinician. Ther Adv Musculoskelet Dis.
2012;4:121–131.
64. Hu HJ, Liao MY, Xu LY. Clinical utility of dual-energy CT for gout
diagnosis. Clin Imaging. 2015;39:880–885.

SECTION III • Acquired Non-traumatic Disorders
20 
Osteoarthritis in the hand and wrist
Paige M. Fox, Brian T. Carlsen, and Steven L. Moran
SYNOPSIS
■ Osteoarthritis is characterized by a loss of articular cartilage.
■ The development of osteoarthritis is a dynamic process that represents
an imbalance between destruction and repair of the articular cartilage.
It can result from trauma, such as an intra-articular fracture or a
ligamentous injury that results in abnormal load-bearing
characteristics, or it can be idiopathic without an identifiable cause.
■ Osteoarthritis can affect the entire joint, including the articular
cartilage, subchondral bone, ligaments, joint capsule, synovial
membrane, and periarticular muscles and tendons.
■ Patients with osteoarthritis seek treatment because of pain, loss of
function, or both. However, there is often a poor correlation between
the patient’s symptoms and radiographic findings.
■ Osteoarthritis is more common in women. In the hand, the distal
interphalangeal (DIP) joints of the fingers and the carpometacarpal
(CMC) joint of the thumb are most commonly affected, followed in
order by the finger proximal interphalangeal (PIP) and
metacarpophalangeal (MP) joints.
■ Radiocarpal arthritis is most commonly a result of traumatic injury and
follows a regular progression over time as seen in scapholunate
advanced collapse (SLAC) and scaphoid nonunion advanced collapse
(SNAC) wrist arthritis patterns.
■ Treatment of arthritis is directed toward alleviating pain and improving
function.
■ Treatment strategies include operative and non-operative treatments.
Non-operative treatments include lifestyle modification, hot and cold
therapy, splinting, oral or topical non-steroidal anti-inflammatory drugs
(NSAIDs), and alternative therapies (diet modification, ultrasound,
transcutaneous electrical nerve stimulation (TENS), and acupuncture).
■ Surgical management of osteoarthritis includes load-altering
procedures, joint debridement and/or synovectomy, arthrodesis, and
arthroplasty procedures.
■ The appropriate type of operation varies depending on multiple factors
including patient age, demands placed on the joint, the requirement for
motion to perform one’s activities of daily living or job requirements,
patient desires, and the likelihood of success of restoring function and
alleviating pain.
Access the Historical perspective section online at

Introduction/epidemiology
■ Osteoarthritis (OA) is a heterogeneous disease that
includes conditions with different etiology, distribution,
heredity, clinical presentation, and progression.
■ It is characterized by mechanical and biological events
that alter the homeostatic relationship of degradation and
repair of the surrounding articular tissues.
■ Although all joint tissues are involved, including the
subchondral bone, damage to the articular cartilage is the
hallmark of the disease.
■ Osteoarthritis is the most common rheumatologic
disorder in the world. It affects all races, sexes, and age
groups.
■ It is a major cause of adult morbidity. It is the cause of
disability in 10% of the population over age 60.3
■ The age-standardized prevalence of hand osteoarthritis
was 44.2% in women and 37.7% in men in the
Framingham OA Study.4 DIP, PIP and thumb base
arthritis were more prevalent in women while
metacarpophalangeal (MCP) and wrist OA were more
frequent in men.
■ It is estimated that 21% of the population or 46.4 million
Americans in 2005 were affected by osteoarthritis.5
■ Symptoms of OA may include joint pain, swelling,
tenderness, stiffness, and crepitus. OA is typically
considered a non-inflammatory condition to differentiate
it from the inflammatory arthropathies such as
rheumatoid and psoriatic arthritis.
■ There is no cure for osteoarthritis and no effective
method of altering the progression of the disease process.
  Access video content for this chapter online at expertconsult.com

440.e1
Historical perspective
Historical perspective
Osteoarthritis is evident across species, with evidence in other
mammals, amphibians, certain species of birds, and even
ancient dinosaurs. The disease is likely as old as man, with
evidence of its existence in prehistoric man from 2 million
years ago.1,2 The disease is considered synonymous with
aging.

441
Basic science/disease process
vertically with intervening radial collagen fibers. Zone 4 is the
deepest layer or calcified layer. It lies adjacent to the subchon­
dral bone and resists shear stress between cartilage and bone.9
Between zone 3 and zone 4 is the tidemark (Fig. 20.1). With
age, articular cartilage becomes thin and there is relative
advancement of the tidemark zone that occurs together with
replacement of calcified cartilage with bone.11 The result of
this anatomic design is a shiny and slippery surface with a
friction coefficient lower than any prosthetic replacement.
This remarkable construct is able to withstand millions of
loading cycles each year with forces that may reach up to
18 MPa.12
In the healthy, homeostatic state, the chondrocyte responds
to the mechanical and biochemical environment by altering
the synthesis and degradation its macromolecules. Two
groups of enzymes function to degrade the extracellular
matrix: matrix metalloproteinases (MMPs) and a disintegrin
and metalloproteinase with thrombospondin-like motifs
(ADAMTS). MMPs break down collagen13 and ADAMTS
functions to break down aggrecan. The main MMP in cartilage
is MMP-13 that breaks down type II collagen and the main
ADAMTS in cartilage are ADAMTS-4 and ADAMTS-5.14,15
This chapter will review the presentation, evaluation, and
treatments of osteoarthritis as it presents in the various joints
of the hand and wrist. Both non-operative and operative
approaches will be discussed, with particular attention to the
indications and contraindications of specific treatments.
Basic science/disease process
OA is characterized by a loss of articular cartilage. It can be
either primary or secondary in nature. Primary OA (idiopathic
OA) occurs in the absence of antecedent trauma. The patho­
genesis is likely heterogeneous; genetics, joint shape and
underlying endocrine abnormalities can contribute. Secondary
OA is the result of direct trauma to the joint and can occur as
a result of fracture, dislocation, or infection.
In order to understand the pathophysiology of osteoarthri­
tis, one must first consider the normal anatomy and biochem­
istry of the synovial joint. Normal articular cartilage consists
of an extensive extracellular matrix composed primarily of
proteoglycans, collagens (predominantly type II), and water.
While chondrocytes compose only 1% of the volume of the
cartilage extracellular matrix, they are responsible for main­
taining its architecture and composition. The matrix is com­
posed primarily of collagen, proteoglycans, proteins, and
glycoproteins. Cartilage proteoglycans belong to two major
classes: large aggregating molecules (aggrecans), and smaller
non-aggregating molecules. The aggrecan molecule consists
of a central protein core with about 100 glycosaminoglycan
(GAG) side branches composed of repeating, negatively
charged disaccharides. Aggrecan molecules form proteogly­
can aggregates by linking with a long central hyaluronan
molecule. The result is a very large molecule with 105 nega­
tively charged groups. These groups fill voids in the cartilage
framework and create a high osmotic pressure in the frame­
work, providing a stiff construct resistant to compression.
Non-aggregating proteoglycans and other matrix proteins
serve a variety of functions in the matrix including framework
stabilization, regulation of fibrillogenesis, and matrix metabo­
lism through chondrocyte interactions.6 Such molecules
include biglycan, decorin, fibromodulin, chondroadherin,
cartilage oligomatrix protein, and fibronectin. The interstitial
fluid provides an important function in terms of altering the
cartilage friction coefficient with changes in pressure (load).7
Microscopically, articular cartilage can be divided into four
zones based on the cartilage matrix composition and architec­
ture.8 Zone 1 is the most superficial zone and is called the
superficial or tangential zone. Here, the chondrocytes are flat
and oriented parallel to the articular surface. The collagen is
condensed and proteoglycans are sparse. The thin collagen
fibers are arranged parallel to the articular surface. This con­
struct resists shear force and has been compared to a “tough
skin” that protects the underlying intermediate and deep
zones.9 In zone 2, the intermediate zone, the chondrocytes are
isolated or in isogenous groups and are surrounded by oblique
collagen fibers. This zone is the thickest and is rich in proteo­
glycans. Proteoglycans are complex macromolecules com­
posed of a protein core with attached glycosaminoglycan
chains (chondroitin sulfate and keratan sulfate). The negative
charge of the glycosaminoglycans accounts for the hydration
and large swelling pressure of cartilage.10 Zone 3 is the radiate
layer and includes large, round chondrocytes oriented
A
Fig. 20.1  Histological section of (A) normal and (B) abnormal cartilage.
(A) Normal joint articular cartilage is connected to the bone through a layer of
calcified cartilage. The basophilic line, or blue line, histologically separates the
articular cartilage from calcified cartilage. The calcified cartilage receives nutrients
through the epiphyseal vessel; the articular cartilage receives nutrients primarily
through diffusion from the overlying joint fluid. (B) In joints affected by
osteoarthritis, there is fraying in the superficial cartilage and decrease in articular
cartilage thickness.
B

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SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
Osteoarthritis may also be present in the absence of pain. In
a classic study looking at arthritis among miners in their 40s,
Kellgren and Lawrence found that only 24% of miners with
radiographic OA had pain and 8% of radiographically normal
knees had pain.
Radiographs are the most helpful test in making the diag­
nosis. In primary and secondary OA, joint spaces are nar­
rowed radiographically due to a loss of radiolucent articular
cartilage. Subchondral bone remodeling can manifest as
increased density within the subchondral bone or sclerosis.
Osteophytes and loose bodies may also be present (Fig. 20.2).
In 1957, Kellgren and Lawrence described a grading system
for the radiographic appearance of OA.23 Findings considered
included: (1) the presence of peripheral osteophytes; (2)
periarticular ossicles (commonly found in association with
DIP and PIP joints); (3) narrowing of joint cartilage and sub­
chondral sclerosis; (4) small pseudocystic areas with sclerotic
walls, typically in the subchondral bone; and (5) altered shape
of the bone ends. The authors then classified the arthritis into
five grades23:
1. Normal joint
2. Doubtful
3. Minimal (but definitely present)
4. Moderate
5. Severe.
This system has been broadly applied for grading osteoarthri­
tis in various joints; unfortunately the grading system can be
ambiguous as there are no specific cut-off criteria between the
grades. In a recent analysis by Schiphof and colleagues, the
The regulation of matrix degradation and synthesis is poorly
understood, but cytokines play an important role in both
anabolic and catabolic pathways.8,16,17 The interplay between
these cytokines is complex. Anabolic activity seems to be a
response of the structural needs of the matrix, as may occur
in response to mechanical loading. Cytokines involved in the
anabolic pathway include transforming growth factor-beta
(TGF-β) and insulin-dependent growth factor I.8 Catabolism
within the matrix involves a complex cascade that includes
interleukin-1, stromelysin, aggrecanase, and plasmin, in
response to stimulation or inhibition by TGF-β, tumor necrosis
factor, tissue inhibitors of metalloproteinases, tissue plasmino­
gen activator, plasminogen activator inhibitor, and other
molecules.8
Pathophysiology
Osteoarthritis involves all of the tissues around the synovial
joint, including the articular cartilage, joint capsule, ligaments,
subchondral bone, metaphyseal bone, and the muscles acting
across the joint. However, the principle pathological change
is that of loss of articular cartilage. Other changes are noted
such as subchondral sclerosis, subchondral cyst formation,
and marginal osteophytes.8,18,19
The earliest microscopic findings of OA are that of fibrilla­
tion and fraying of the superficial zone cartilage along with
decreased staining for proteoglycans in the superficial and
transitional zones and in-growth of blood vessels into the
tidemark from subchondral bone (Fig. 20.1B).8 Progression of
the disease leads to clefts in the articular surface, fracture of
the superficial cartilage, and decrease in cartilage thickness.
Enzyme activation leads to further destruction of the cartilage
leading to complete loss of articular cartilage exposing dense
and eburnated bone.8
Associated with these changes of the cartilage are altera­
tions in the subchondral bone, specifically an increased
density. This increased density can be seen as a sclerotic line
on radiograph. These changes may be more pronounced at
the joint periphery where the new bone formation may be so
exuberant as to produce osteophytes. The exact pathophysiol­
ogy of osteophyte formation is not known; however, it may
be related to the release of anabolic cytokines from the matrix
that stimulate the abnormal bone and cartilage growth.20,21
The changes involving the joint also affect the periarticular
tissues. The synovial membrane becomes inflamed as frag­
ments of cartilage become embedded within them.22 As the
joint loses motion due to mechanical factors and pain, the
capsule and surrounding ligaments become stiff due to myo­
tendinous contraction and ongoing edema. The lack of motion
and use can lead to muscle atrophy.8
Diagnosis
The most common symptoms of OA are pain, swelling, and
stiffness of the affected joint. Pain is the primary feature of the
condition and is the focus of treatment. Examination confirms
swelling, tenderness, and limited range of motion. In the case
of post-traumatic arthritis, there may be joint instability
associated with previous ligamentous injury.
Symptoms can dissipate with time and are not always
correlated with the radiographic severity of disease.
Fig. 20.2  Posteroanterior radiograph of the hand of a 69-year-old male showing
typical bony changes seen in advanced osteoarthritis. Osteophyte formation is seen
at the distal interphalangeal and proximal interphalangeal joints and
trapeziometacarpal joint of the thumb. Joint narrowing is seen within the fingers as
well as evidence of subchondral sclerosis.

443
Distal interphalangeal joint (DIP) arthritis
cyst. A mucous cyst is a dorsal synovial cyst, often limited
to a single digit. They are often associated with lateral
deviation of the distal phalanx, and a limited range of motion
(Fig. 20.3).
Radiographically, joint space narrowing and osteophyte
formation are common findings. However, the radiographic
appearance of the DIP is not consistently associated with the
patient’s symptoms. Frequently, the only significant concern
for the patient is the aesthetic appearance. Even patients with
severe DIP deformity may have little pain or functional
impairment and the presence of Heberden’s nodes alone is
not generally considered an indication for surgery.
Indications for surgery
The treatment of DIP OA is dictated by the severity of pain
and functional limitation. Splinting allows the joint to be
rested and protected from minor trauma. Splinting used in
conjunction with oral or topical anti-inflammatory medication
and lifestyle modification are the mainstays of non-operative
treatment. This approach is usually sufficient to treat acute
exacerbations of pain and swelling. Steroid injections can be
attempted for temporary pain relief but are difficult to admin­
ister in such a small joint, and multiple repeated injections are
not a convenient as a long-term treatment plan. When intrac­
table pain, deformity, and misalignment are severe enough to
interfere with precision pinch, oppositional pinch, and global
hand function, surgery is indicated.
The surgical option for treatment of severe DIP arthritis is
essentially limited to arthrodesis, which is well tolerated in
the DIP position. Although implant arthroplasty is technically
feasible, it is not commonly performed because of concerns of
long-term joint instability.26–30
authors note inconsistency in the application of the grading
system within multiple cohort studies and have recommended
the development of a single validated classification system.24
Management of OA of the fingers
Hand and finger arthritis is one of the most common presenta­
tions of primary OA. Its onset is insidious with progressive
aesthetic deformity followed by pain and functional limita­
tion. Epidemiological studies of the joint-specific prevalence
of hand arthritis consistently show the distal interphalangeal
joint to be the site most frequently affected by OA, followed
by the thumb CMC joint, and the PIP joint.25 These studies
typically defined OA based on the radiographic features
described by Kellgren and Lawrence, which include the pres­
ence of osteophytes, joint space narrowing, subchondral
sclerosis, and subchondral cysts.23
Distal interphalangeal joint
(DIP) arthritis
Diagnosis
Osteoarthritis of the DIP joint is common and affects females
more frequently than males. Clinically, patients present with
enlarged joints and hard, knobby protuberances overlying
the DIP joints of multiple fingers. These, so called Heberden’s
nodes, are pathognomonic for the condition and are attrib­
uted to osteophyte formation with overlying soft-tissue
thickening. These should be differentiated from a mucous
Fig. 20.3  Typical appearance of a mucous cyst in this 67-year-old female with distal interphalangeal joint osteoarthritis. (A) A mass is palpable over the joint. (B) The cyst
is clearly seen at the time of surgical exploration. (C) Mucous cysts may also present with nail grooving, which results from pressure on the germinal and sterile matrix of
the nail.
A
B
C

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SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
conjunction with K-wires for greater stability. Zavitsanos et al.
described a technique which allows the K-wires to be com­
pletely buried, minimizing the risk of infection.34
K-wire fixation
After the joint is prepared, two crossed 0.045-inch Kirschner
wires are passed across the joint. Alternatively, an axial K-wire
and a single oblique wire can be used. A minimum of two
wires needs to be used to prevent rotation. The wires are
typically cut beneath the skin at the fingertip. This enables the
patient to continue to use the finger in activities of daily
living. The DIP joint is immobilized in a splint to protect the
fusion. Once union is documented radiographically, the wires
can be removed. Wire removal can be done in the office under
digital block anesthesia.
Tension band wiring
With the joint surfaces prepared, two 0.045-inch K-wires are
placed parallel across the joint. Distally, the pins are buried in
the distal volar cortex of the distal phalanx while proximally
the pins exit on the dorsal cortex of the middle phalanx. A
transverse canal is made dorsal to the wires in the proximal
distal phalanx. A 28-gauge dental wire is passed through this
canal and secured proximally around the K-wires exiting on
the dorsal proximal phalanx in a figure-of-eight fashion. The
dental wire is twisted and secured and the K-wires are bent
to assure the construct is as low profile as possible. The tension
band construct is remarkably stable and early motion may be
permitted in selected patients. If the hardware is bothersome,
it can be removed after bony union.
Biomechanical effects of DIP fusion
The normal range of motion at the DIP joint is 0–60°; however,
only 15% of digital flexion occurs at the DIP and the joint only
contributes 3% of the overall flexion arc of the whole finger.31
Thus, of all finger joint fusions, DIP arthrodesis confers the
least detrimental impact to hand motion, and is the well toler­
ated. One study of splint-simulated DIP fusion found a 20%
reduction in grip strength, which was attributed to the quad­
riga effect, as a result of the limited excursion of the flexor
digitorum profundus (FDP) tendon in the fused digit.32 Sig­
nificant loss of grip strength has not been shown in clinical
studies.
DIP arthrodesis
Indications
The single most common indication for arthrodesis is intrac­
table pain at the DIP joint that has failed all conservative
treatments. Other less common indications include chronic
mallet deformity, missed flexor tendon avulsions, or distal
phalanx nonunions.
Techniques
A multitude of fixation techniques have been described,33
including interosseous wiring,34 percutaneous pinning,
tension band wiring,35,36 bio-resorbable pinning,37 plating,38
oblique lag screw fixation,39 and axial compression screw fixa­
tion.33,40 Regardless of the technique chosen, the joint is pre­
pared in a similar manner and the requirements for a successful
outcome are: (1) full apposition of the cancellous bone sur­
faces; (2) preservation of distal phalanx bone stock to allow
for hardware purchase; (3) fusion in approximately 5–10° of
flexion if possible; and (4) stable fixation.
Most techniques utilize a transverse skin incision overlying
the joint. Oblique or axial extensions are made proximally and
distally and skin flaps are raised to complete an H-shaped
exposure centered over the joint. Alternatively, a midlateral or
a Y-shaped dorsal incision can be used. Specific care should
be taken to avoid injury to the germinal nail matrix located
just distal to the extensor insertion. The extensor tendon and
joint capsule are sharply divided in a transverse orientation,
the collateral ligaments are divided, and the joint is maximally
flexed to allow access to the articular surfaces.
With the base of the distal phalanx and the condyles of the
middle phalanx exposed, a rongeur is used to remove dorsal
and lateral osteophytes. The articular surfaces are decorticated
until cancellous bone is visualized. Alternatively, osteotomies
can be created with a small oscillating saw to achieve precise
apposition of the cancellous bone. If power saws or burrs
are to be utilized, copious irrigation should be maintained
throughout the cutting process to avoid the risk of thermally
induced osteonecrosis, which can elevate the risk of nonunion
postoperatively.41
Interosseous wiring
Interosseous wiring involves securing the distal and middle
phalanx together by means of one or two dental wires passed
through bone tunnels. Interosseous wiring can be used to
achieve some compression of the joint and is usually used in
Clinical tips
Tension band wiring
• Take down the collateral ligaments for clear visualization of
the entire joint.
• A rongeur or small saw can be used to prepare the joint for
fusion.
• K-wires can be placed retrograde from the joint into the
middle phalanx to assure an appropriate trajectory that will
capture a sufficient portion of the distal phalanx.
• After confirming the correct length of the parallel K-wires,
back them out of the bone slightly, bend, and cut to length
prior to gently tapping back into place. This will allow for
better coaptation to the bone and make hardware irritation
less likely.
Axial compression screw
A single axial compression screw (Fig. 20.4) can be used to
reliably achieve DIP joint fusion. A traditional lag screw
technique can be used but will result in prominent hardware
at the fingertip and is discouraged. Buried headless compres­
sion screws are preferred. The technique for the use of a
threaded headless compression screw initially involves prepa­
ration of the joint surfaces followed by the placement of an
antegrade axial K-wire through the distal phalanx exiting at
the hyponychium. The bone surfaces are then coapted in the
position of fusion and the same wire is drilled retrograde
back into the middle phalanx. The position of the wire and

445
Distal interphalangeal joint (DIP) arthritis
thumb), and the chances of a stable construct are reduced.
Additionally, specific attention should be paid to the antero­
posterior (narrowest) diameter of the distal phalanx to ensure
that the screw thread diameter is not greater than this mea­
surement, otherwise dorsal fracturing and nail bed deformity
can occur.42
The major advantages of this technique over other methods
of DIP fusion are buried hardware and stable fixation. Immo­
bilization time with the use of compression screws has been
shown to be significantly shorter when compared to other
arthrodesis are checked fluoroscopically, and a cannulated
drill is used prepare the channel for screw placement. The
appropriate screw size is determined through fluoroscopic
measurement, and a cannulated, fully threaded, self-tapping
screw is inserted in a retrograde fashion to complete the
fusion (see Fig. 20.4).
The screw should be long enough to engage the cortical
isthmus of the middle phalanx. Occasionally, the intramedul­
lary canal of the middle phalanx is too wide for the thread
to engage the endosteal cortex even at the isthmus (e.g.,
Fig. 20.4  (A) Technique for fusion of distal interphalangeal (DIP) joint using axial
compression screw. In preparation for fusion, all articular cartilage needs to be
removed from the joint surface. A K-wire is then driven retrograde out of the distal
phalanx. The joint is then reduced in preparation for fusion and the wire is then
driven across the DIP joint. A cannulated drill is used to prepare the bones for
screw placement. The screw may then be placed over the wire to complete the
fusion. (B) Final position of screw within joint. (C) DIP fusion may also be
accomplished with the use of K-wires alone or tension band technique.
A
B
C

446
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
damaging the germinal matrix, resulting in nail deformity
and nail grooving. Progressive thinning of the overlying skin
and recurrent inflammation are also common. Infection can
be troublesome, as communication with the joint risks the
development of septic arthritis and recurrently symptomatic
cysts should be removed surgically.
Needle aspiration of the mucous cyst with subsequent
corticosteroid injection of the DIP joint is appealing because
it can be performed in the office setting with minimal
morbidity.50–52 Typically, the cyst is too small for effective
needle aspiration and instead, multiple punctures are made
with a 25-gauge needle and manual expression of the cyst
fluid is performed. The joint may then be injected with a
lidocaine and corticosteroid solution and wrapped snugly for
several days. This technique has been associated with a 60%
resolution of the cyst.50 However, one must observe careful
sterile technique to minimize chance of infection into the joint
space.
If the cyst recurs surgical excision can be performed. Our
preferred surgical technique consists of marking the margins
of the cyst under loupe magnification followed by excision of
the cyst and overlying attenuated skin. The underlying
inflamed synovium should be debrided and associated dorsal
and marginal osteophytes removed. Specific attention should
be paid to preservation of the extensor insertion, which can
be challenging as it may be significantly attenuated. Skin
closure may require the use of local skin flaps in rare
circumstances.50,53–55
Fritz et al. reported the results of surgical excision of 86
mucous cysts. Nail deformities were present in 29% of patients
preoperatively.56 Postoperative loss of extension of 5–20° at
the interphalangeal (IP) or DIP joints was seen in 17% of
patients. One patient developed a superficial infection and
two developed a DIP pyarthrosis, eventually requiring DIP
arthrodesis. A total of 7% of patients without preoperative nail
deformity developed one postoperatively; however, 60% of
preoperative nail deformities were improved by the proce­
dure. Recurrence was seen in 3% of cases and other complica­
tions included persistent swelling, pain, numbness, stiffness,
and radial or ulnar deviation at the DIP joint.
Proximal interphalangeal (PIP)
joint arthritis
Within the hand, the PIP joint is the third most frequently
affected by OA. The joint is more commonly affected in
females.25 The PIP joint has been described as the “functional
locus of the finger” as it produces 85% of intrinsic digital
flexion and contributes 20% to the overall arc of finger
motion.57 Despite this, a full range of motion is not absolutely
necessary for good hand function, and a 45–90° flexion arc
allows for most activities.
As in DIP arthritis, PIP joints affected by OA are often
enlarged and painful. Patients will complain of their inability
to wear or remove rings from the affected fingers. Bouchard’s
nodes are pathognomonic for PIP OA and are bony protuber­
ances at the joint, analogous to Heberden’s nodes at the DIP
joint. Range of motion at the PIP joint tends to be preserved
until late in the disease process. Radiographic findings include
joint space narrowing, subchondral sclerosis, and osteophytes
(see Fig. 20.2).
techniques for DIP fusion. Patients may often be splinted for
only 1–3 weeks, allowing patients to return to work earlier.43
One disadvantage of this technique is the difficulty in achiev­
ing the optimal prehensile position at the DIP as the joint is
typically fused straight due to the conical shape of the screw.
Other reported complications have included a single case of
skin necrosis of the fingertip requiring secondary amputa­
tion44; this was likely due to unrecognized prominent
hardware.
Complications of DIP fusion
Infection
Traditional fixation techniques for small joint arthrodesis
include interosseous wiring, crossed K-wires, or a combina­
tion of these techniques. The rate of deep infection and
osteomyelitis with these techniques remains up to 20% in
some studies.45 Surgeons who prefer this technique should
consider burying the K-wires during the consolidation phase,
as infection and nonunion rates are much lower with buried
techniques are utilized.46
Nonunion
Reported nonunion rates for DIP arthrodesis range from
0–20%. Several studies have reported low rates of nonunion
with screw techniques44,45,47–49 as well as traditional tech­
niques46; however, a clear relationship between fixation tech­
nique and the rate of nonunion has not been shown for DIP
arthrodesis.45
Kirschner wire and interosseous wire techniques produce
significantly less compression across the fusion site than
compression screw techniques and compression itself has
been shown to achieve more rapid fusion. In a biomechanical
cadaver study comparing fixation techniques, the use of a
single buried axial compression screw (Herbert screw) was
shown to be superior in terms of fixation strength when
compared to a combined K-wire/tension band technique.42
Despite this biomechanical study, retrospective clinical studies
have noted similar nonunion rates when comparing compres­
sion screws, interosseous wiring, and crossed K-wires tech­
niques; it is thought that nonunion rates most closely correlate
with the amount cortical bone and condition of the bone stock
at the time of operative procedure.45
DIP arthroplasty
Distal interphalangeal joint arthroplasty is an uncommon
procedure with few indications. The obvious advantage is
maintained range of motion of the DIP, which may be benefi­
cial in selected cases, e.g., in professional musicians.30 There
are few published series and these all report on the use of sili­
cone interposition implants.27–29 The largest series reported 38
DIP arthroplasties of which 10% were removed by 10 years.
The average range of DIP motion was 33° with an average
extension lag of 12°.28
Mucous cyst
Dorsal synovial cysts are commonly associated with DIP
arthritis and develop in response to irritation of the joint by
marginal osteophytes (see Fig. 20.3). Cysts slowly expand,

447
Proximal interphalangeal (PIP) joint arthritis
configuration on the opposing bone surfaces. The digit is
necessarily shortened by preparation of the bone surfaces.
Prolapse of the volar plate in between the bone ends may
result in non union; the volar plate should be resected if this
occurs. Fixation can be achieved by one of the following
techniques:
Crossed K-wire technique
After preparation of the joint, two crossed 0.045-inch or larger
Kirschner wires are passed obliquely across the joint in a
coronal plane. Alternatively, an axial K-wire and a single
oblique wire can be used. Similar to DIP fusion, the wires can
be buried beneath the skin and removed once there is radio­
graphic union. During this time, the joint is protected in an
immobilizing splint.
Tension band wire technique
Tension band wiring uses a combination of K-wires and
interosseous wire to achieve moderate stability and compres­
sion. After preparation of the joint, a transverse hole is drilled
through the middle phalanx approximately 5 mm distal to the
osteotomy and a 0.6-mm stainless steel wire is passed through
the hole. Two parallel 1-mm K-wires are inserted across the
joint, and left protruding through the dorsal cortex of the
proximal phalanx. The steel wire is passed around the K-wires
Management
Patients with occasional or minor symptoms are medicated
with oral or topical non-steroidal anti-inflammatory drugs.
Resting the joint by splinting in extension can be used to
decrease pain in acute exacerbations. Intra-articular steroid
injections can also be used to decrease pain but repeated injec­
tions are impractical for the long-term management of severely
symptomatic patients. When non-operative management
strategies are insufficient to control the patient’s symptoms,
PIP joint OA is usually treated surgically, with either arthro­
desis or implant arthroplasty. Vascularized joint transfer is
technically feasible but uncommonly practiced due to signifi­
cant donor site morbidity and inferior outcomes when com­
pared with implant arthroplasty.58–61
The decision for PIP arthrodesis or arthroplasty is dictated
by the patient’s functional needs, desires to preserve PIP
motion, and the requirements for lateral stability at the joint.
The ulnar three digits are important for generating grip
strength. Maximal grip strength requires almost full PIP
flexion to avoid the quadriga effect. The index finger’s rela­
tively independent FDP function does not impose a significant
quadriga effect on the remaining digits during grasp. In
comparison, the index finger is used to generate oppositional
and adduction pinch strength, which requires PIP lateral
stability but little PIP motion if metacarpophalangeal joint
motion is preserved. Therefore, the decision for arthrodesis
versus arthroplasty may be different for each digit involved.
For example, arthrodesis of the index finger PIP joint provides
finger stability for pinch and is well tolerated; however, for
the ring and small finger PIP joints, implant arthroplasty may
be preferred, as PIP joint motion in these digits is important
for grip function and strength. If fusion is to be performed on
the PIP joints of the ulnar three digits, care must be taken in
placing the joints in enough flexion to preserve grip strength.
A significant decrease in grip strength occurs when the PIP
joint of the small finger is fused in less than 45° of flexion, and
when the PIP joint of the middle and ring fingers are fused in
less than 60° of flexion.62
PIP arthrodesis
PIP arthrodesis can be accomplished using the same tech­
niques as described for DIP arthrodesis. The optimal position
of PIP fusion varies according to the digit, with some authors
recommending 40° of flexion for index, 45° for the long, 50°
for the ring and 55° for the small finger (Fig. 20.5)63; however,
this can be tailored according to the patient’s occupation and
recreational activities. Preoperative splints simulating fusion
at various angles can be used to allow the patient to make a
more informed decision.
Techniques
The PIP is approached dorsally through a longitudinal inci­
sion centered over the joint. The extensor tendon and joint
capsule are split longitudinally and dissected radially and
ulnarly. The central slip should be elevated subperiosteally off
the base of the middle phalanx. The proximal origins of the
collateral ligaments are divided and the joint is flexed to
expose the joint surfaces. The bone ends are prepared using
angled saw cuts on both phalanges. Alternatively, rongeurs or
a burr can be used to create a concave–convex (cup and cone)
Fig. 20.5  Illustration of recommended fusion angles for distal interphalangeal
(DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP) joints. DIP
fusion angles are often performed with 0–15° of flexion. PIP fusion angles increase
as one moves from the index to the small finger, to correspond with the natural
cascade of the hand. Recommended fusion angles for the PIP joint have been 40°
of flexion for the index, 45° for the long, 50° of flexion for the ring, and 55° of
flexion for the small. MCP fusion angles have been recommended to progress from
25° of flexion at the index to 40° of flexion at the small finger.
25º
30º
35º
40º
40º
45º
50º
55º
0–5º
5º
5º
5º

448
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
in a figure-of-eight fashion and tightened to produce com­
pression of the construct. The wire ends and K-wires should
be cut short and manipulated to lie flat on the dorsal cortex
and prevent extensor tendon attrition. (Fig. 20.6). The dorsal
soft tissues are closed and a splint is applied. A splint is worn
for protection until radiographic union.
Compression screw
Arthrodesis of the PIP joint can be accomplished by antegrade
insertion of a headless compression screw across the prepared
joint (Fig. 20.7A). A K-wire is used to start a hole in the dorsal
cortex of the proximal phalanx and oriented obliquely in a
sagittal plane. The angle of insertion should correspond to the
desired angle of fusion and the wire is inserted antegrade
across the joint, into the middle phalanx. The position of the
entry hole in the proximal phalanx should be at least 6 or
7 mm proximal to the joint to prevent fragmentation of the
dorsal cortex, which can be a complication of this technique.
The K-wire is used as a guide wire for the cannulated drill
sequence required for the particular screw being used (as
described above for DIP arthrodesis). Fluoroscopy is used to
check alignment, and to choose an appropriately sized screw
that is then inserted in an antegrade fashion, with the assistant
holding manual compression of the bone surfaces. The thread
should reach the cortical isthmus of the middle phalanx to
achieve endosteal purchase. The dorsal soft tissues are closed
and a bulky splint is applied. A thermoplastic splint can
replace this after 7 days, which should be worn for approxi­
mately 3 weeks. The major advantage of this method of fixa­
tion is the substantial stability of the construct, which allows
early mobilization, and less likelihood of hand stiffness.
Plating
For severely osteoporotic bone, or for salvage of failed
fusion attempts using other methods, PIP arthrodesis may
be obtained using mini-plates (1.7 mm up to 2.7 mm). Newer
plate designs allow for compression or locking screw
Fig. 20.6  Lateral (A) and anteroposterior (B) radiographs of a long finger following
proximal interphalangeal joint fusion using a tension band technique.
A
B
Fig. 20.7  Example of a proximal interphalangeal joint fusion with (A) headless
compression screw and (B) dorsal plating technique.
A
B

449
Proximal interphalangeal (PIP) joint arthritis
placement, which can significantly improve fixation in
severely osteoporotic bone. Plates are applied using standard
AO technique. Pre-contouring of the plates is required to
achieve the appropriate angle (Fig. 20.7B).
PIP arthroplasty
Arthroplasty will allow for some preservation of joint motion.
Arthroplasty techniques consist of soft-tissue interposition,
silicone spacers, and a variety of constrained and uncon­
strained implants. Soft-tissue arthroplasties are mentioned
for historical purposes but have been largely replaced by
implants, silicone or other. Techniques for soft-tissue arthro­
plasty have included resection of the head of the proximal
phalanx,64 volar plate interposition,65 and perichondrial trans­
plant arthroplasty.66–68
Currently, there are two popular approaches to implant
arthroplasty – interposition silicone spacers including the
Swanson implant (Wright Medical Technologies, Arlington,
TN) and NeuFlex implant (DePuy, Warsaw, IN); and surface
replacement or total joint replacement implants such as the
SR-PIP implant (Small Bone Innovations, Morrisville, PA) and
the PyroCarbon PIP (Integra, Plainsboro, NJ). The success of
PIP implant arthroplasty is largely dependent on the condi­
tion of the surrounding soft tissues including the collateral
ligaments, tendons, and volar plate. When these structures are
preserved, implant arthroplasty has a higher success rate.
Silicone interposition arthroplasty
Silicone interposition implants consist of one-piece flexible,
stemmed, hinged elastomer spacers that can be used in all
digits after resection arthroplasty of the PIP joint. Swanson
and Niebauer first devised these implants in the 1960s. The
implant consists of a single silicone unit with a tapered proxi­
mal and distal stem with a central interposed flexion region,
which is dorsally offset. The implant does not function as a
true joint but rather a spacer that is stabilized by the fibrous
capsule, which develops around the implant. The implant
glides or “pistons” within the medullary canals during move­
ment and this was originally believed to disperse forces over
a broader surface area potentiating the life of the implant.
Newer implant designs have maintained the same general
concept but have incorporated a 30° pre-flexed hinge between
the proximal and distal stems to facilitate finger flexion.
Technique
The PIP joint can be exposed by one of three surgical
approaches – dorsally, laterally, or from the volar surface. We
prefer a longitudinal dorsal approach in most cases, as it
affords superior exposure to the joint and allows easier inser­
tion of the implants. A 2–3 cm straight or curved dorsal inci­
sion is made over the PIP joint and continued through the
center of the extensor tendon from mid-proximal phalanx
until just distal to the insertion of the central slip on the
middle phalanx. The two parallel halves of the central slip are
then mobilized off the underlying middle phalanx. This pro­
duces radial and ulnar tendinous bands, each containing half
of the central slip and a lateral band, which are allowed to
sublux laterally when the middle phalanx is flexed, exposing
the PIP joint. The joint is flexed to 90°, and osteophytes are
removed as necessary. An alternative exposure of the PIP joint
involves the use of Chamay technique, where a distally based
flap of the extensor mechanism is elevated from proximal to
distal (Fig. 20.8). The flap is then repaired at the completion
of the surgical procedure.69
A micro-oscillating saw is used to make a transverse oste­
otomy at the distal-most portion of the flare of the proximal
phalanx, just proximal to the condylar insertion of the col­
lateral ligaments. In general, no resection of the base of the
middle phalanx is necessary. Specially designed awls and
broaches (specific to implant system used) are used both
proximally and distally to open the intramedullary canal to
allow the largest size implant. After a trial implant is inserted,
the joint is taken through a range of motion to assess stability
and fit and the definitive implant is placed. The soft tissues
are closed and the hand and wrist are immobilized in the
intrinsic plus position. Within a week, the patient is provided
a dynamic splint and motion is initiated in a supervised
rehabilitation program.
Surface replacement arthroplasty with non-
constrained implants
The first PIP joint replacement prosthesis was described in
1959 by Brannon and Klein.70 Numerous implant designs have
since been produced and many have been abandoned due to
implant failure, instability or high complication rates.71–74 At
present, the two designs available in the United States are
made of metal or PyroCarbon.
Clinical tips
PIP silicone arthroplasty
• A central dorsal approach provides easy access and clear
visualization of the PIP joint.
• We prefer a central incision through the extensor tendon
and central slip to the Chamay approach.
• Only the cartilaginous surface of the middle phalanx needs
to be removed. No formal cut is made in the middle
phalanx.
• If the insertion of the central slip is disrupted during implant
placement, a non-absorbable suture should be used to
repair the tendon to the bone through small holes placed in
the dorsal cortex of the middle phalanx prior to final implant
placement.
• A minimal or no-touch technique helps decrease the risk of
infection when placing the final implant. Clean smooth
forceps are ideal for placing the implant.
Linscheid and Dobyns introduced the first non-constrained
PIP prosthesis in 1979 and this design is still available as the
SR-PIP implant.75 The proximal component is made of a
chromium–cobalt alloy with a polished articular surface, and
the distal component has an ultra-high molecular weight
polyethylene (UHMWPe) articular surface fixed to a titanium
base and stem. The articulating surfaces are a tongue-in-
groove configuration, similar to the PIP joint anatomic design.
For this reason, the manufacturer has described the system as
“semiconstrained.” This congruency adds to the lateral stabil­
ity of the joint. The titanium stems are textured and are

450
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
Administration (FDA) as Humanitarian Use Devices (HUD).
Such devices are authorized for use in PIP joint arthroplasty
when the patient:
… has soft tissue and bone that can provide adequate
stabilization and fixation under high-demand loading conditions
after reconstruction; and needs a revision of a failed PIP
prosthesis, or has pain, limited motion, or joint subluxation/
dislocation secondary to damage or destruction of the articular
cartilage.
Because these devices are used for HUD purposes, their use
requires Institutional Review Board (IRB) approval. However,
once approved, the IRB does not have to review and approve
each individual case.
Patient selection
A trial of non-operative management is recommended in all
patients with PIP OA prior to discussing operative interven­
tion. Unconstrained surface-replacement implants rely on the
preservation of the collateral ligaments for stability. Patients
with gross ligamentous instability or who have damaged their
collateral ligaments may not be appropriate candidates for
arthroplasty and would be better served with fusion. Evidence
designed to “press-fit.” However, non-cemented implants
have been shown to have a higher incidence of subsidence
and loosening.76
Pyrolytic carbon implants have been developed for use in
the PIP joint. Pyrolytic carbon is a substance similar to graph­
ite, which is formed by the high-temperature pyrolysis
(thermal decomposition) of hydrocarbons, and their subse­
quent recrystallization as a surface coating. Pyrolytic carbon
is used in joint arthroplasty as a 0.5–1.0 mm coating on a
graphite substrate and 1% tungsten is added to produce
radio-opacity. The elastic modulus of PyroCarbon (23 GPa) is
a much closer match to that of cortical bone (29 GPa), than
other implant systems (titanium, 105 GPa; CoCr, 230 GPa),
thus it is presumed that there should be less subsidence. The
pyrolytic carbon proximal interphalangeal – PyroCarbon PIP
– is a non-cemented, minimally constrained, two-component,
non-linked total joint replacement implant. Joint stability is
achieved as a function of the complementary shape of the
component surfaces, but ultimately depends on surgical
preservation of the collateral ligaments and soft tissues. Like
the SR-PIP arthroplasty, the device can be cemented at the
surgeon’s discretion.
Both the PIP pyrolytic carbon implant system and SR-PIP
arthroplasty are approved for use by the US Food and Drug
Fig. 20.8  The dorsal approach to the proximal interphalangeal joint involves either a
longitudinal split of the extensor mechanism or the use of the Chamay approach.
(A) The Chamay approach involves the creation of a distally based rectangular flap of
extensor tendon. (B) The flap is mobilized distally and preserves the attachment of
the central slip at the level of the middle phalanx. (C) This flap may then be repaired
to the surrounding extensor mechanism at the end of the procedure.
A
B
C

451
Proximal interphalangeal (PIP) joint arthritis
to the insertion of the central slip on the middle phalanx.
The two parallel halves of the central slip are then mobilized
off the underlying middle phalanx. This produces radial and
ulnar tendinous bands, each containing half of the central
slip and a lateral band, which are allowed to sublux laterally
when the middle phalanx is flexed, exposing the PIP joint.
The joint is flexed to 90°, and osteophytes are removed as
necessary.
A 0.035-inch K-wire is inserted into the dorsal third of the
proximal phalanx head, and fluoroscopy is used to confirm a
central position in the medullary canal. A starter awl is then
used to enlarge the intramedullary canal. A cutting guide is
then used to create a vertical osteotomy approximately
0.5–1 mm distal to the insertion of the collateral ligaments on
the head of the proximal phalanx removing the articular
cartilage. Next, the proximal phalanx is broached, until the
medullary canal is filled with the largest broach possible. The
lateral fluoroscopic view will be the first to show the size
limitations of the intramedullary canal. Once the canal has
been enlarged, a matched oblique cutting guide is used to
create a back cut in the proximal phalanx, congruent with
the sized implant shape. A proximal trial implant can then
be inserted and checked radiographically for size and
alignment.
of insufficient bone stock, inadequate intramedullary space,
marked soft-tissue compromise, or ongoing active or chronic
infection, are all contraindications to implant arthroplasty,
and an alternative surgical option should be pursued. Patients
should be informed that average joint motion following
arthroplasty is only 40–60°, and joint motion may deteriorate
over time. Preoperatively, true anteroposterior (AP) and
lateral radiographs are obtained of each PIP joint so that joints
may be templated for implant sizes. The index finger PIP joint
is subject to significant lateral force during pinch maneuvers.
Therefore the surgeon and the patient must discuss the
increased potential for complications after index finger PIP
arthroplasty.
Technique for non-constrained or semiconstrained
PIP arthroplasty
Surface replacement arthroplasty of the PIP joint can be per­
formed through either a dorsal, lateral, or volar approach. Our
preference is for the dorsal approach as it provides excellent
exposure of the joint and facilitates implant placement (Fig.
20.9). A 2–3 cm straight or curved dorsal incision is made
over the PIP joint and continued through the center of the
extensor tendon from mid-proximal phalanx until just distal
A
B
C
D
Fig. 20.9  (A) The posteroanterior (PA) radiograph of a 73-year-old woman with advanced osteoarthritis of the proximal interphalangeal (PIP) joints of the index through
ring fingers, who has elected to undergo PyroCarbon arthroplasty of the index and long finger PIP joints. The arthroplasties are performed through a dorsal approach.
(B) The proximal phalanx is prepared initially with the aid of a cutting guide to remove the articular surface. (C) A broach is used to prepare the canal of the proximal
phalanx so that it will accept the implant. (D) A back cut is then created in the proximal phalanx so the implant can be properly seated.

452
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
E
F
G
H
(E) The proximal component is then trialed to assess the fit and position. (F) A similar procedure is then performed on the middle phalanx. (G) PA
radiographs showing results at 1 year and functional result. The ring finger PIP was not treated because it was not producing pain and still had reasonable motion (H).
Fig. 20.9, cont’d
Hyperflexion of the joint then exposes the middle phalanx
joint surface. Preparation of the middle phalanx proceeds
similarly to the proximal phalanx with the goal of inserting
the largest implant possible. Due to the increased amount of
cortical bone in the middle phalanx a side-cutting burr is used
to facilitate implant placement. Ideally the distal implant
should be the same size as the proximal implant, but implants
can be mismatched one size smaller or larger if necessary. The
distal trial implant is then inserted and a good press-fit is
checked. Apposition of both the dorsal and volar collar of the
prosthesis against the osteotomy is required for a good
outcome.
Prior to final implant insertion, holes are drilled with a fine
K-wire into the dorsal bony ridge on the middle phalanx and
non-absorbable sutures are placed to attach the central slip
back to the bone. The distal implant is inserted and impacted,
followed by the proximal implant, and the central slip is
reconstructed using the previously placed sutures. If the col­
lateral ligaments have been compromised during the implant
placement, collateral ligament-stabilizing sutures should be
placed to prevent ulnar or radial laxity or hyperextension. The
remainder of the tenotomy is closed longitudinally and the
skin is closed with non-absorbable sutures. A padded dorsal,
blocking splint is applied in a neutral position.
Postoperative therapy for PIP arthroplasty
Patients must adhere to strict hand therapy follow-up for
approximately 10 weeks following surgery and this should be
discussed preoperatively, as poor therapy compliance will
lead to poor outcome (Fig. 20.10).77 Hyperextension of the PIP
joint must be avoided at all costs, and we therefore do not
pursue complete joint extension, preferring to accept a 5–10°
flexion deformity, as hyperextension will lead to joint
dislocation.
During the first 2 weeks postoperatively, the patient is
splinted or casted in full extension and minimal motion is
allowed at the PIP joint. Strict elevation is encouraged to
manage swelling. The plaster splint is removed after 10–14
days and sutures are removed and the patient is allowed to
start a short arc motion protocol allowing for 30° of flexion at
the PIP joints. Flexion is gradually increased each week to

453
Proximal interphalangeal (PIP) joint arthritis
extension from 32° to 18°, but no change in total active motion
of the PIP joint.85 Complications included fractures in 15%
of the implants, and nine joints required revision. Patients
rated their outcome as good in 25 joints, fair in 27, and poor
in 18.
Lin et al. reviewed their experience of 69 PIP silicone
arthroplasties done through a volar approach.81 There was an
improvement in the extension deficit from 17° to 8° but no
improvement in overall arc of motion. Complete resolution of
preoperative pain was noted in 67 of 69 joints and complica­
tions were observed in 12 joints, including five implant frac­
tures and three cases of implant malrotation. More recent
studies by Namdari and Weiss reported 4-year outcomes of
16 joint replacements using the pre-flexed NeuFlex silicone
implant.86 After an average 4-year follow-up, the mean range
of motion was 61°, with 0° of extension lag. Pain relief was
excellent or good in 84% and overall patient satisfaction was
rated at 90%. Pettersson et al. compared this new implant with
a traditional silicone implant design, and found better patient
satisfaction but otherwise similar results.87 Silicone interposi­
tion PIP arthroplasty remains popular and is often used as
a benchmark comparison for newer surface-replacement
implants such as metal or PyroCarbon systems.
The outcomes of metal surface-replacement arthroplasty
was reported by Linscheid et al., where they described
the outcomes of 66 cemented CoCr–UHMWPE surface-
replacement prostheses with an average 4.5-year follow-up.71
In this study, the average arc of motion improved from 35 to
47°, and total pain relief was achieved in 85%. There were a
significant number of complications, including five swan-
neck deformities; five unstable joints; coronal deviation in
four joints, and 12 joints required re-operation.
Jennings and Livingstone reviewed 43 metal surface-
replacement PIP arthroplasties with an average follow-up of
37 months, and found no change in arc of motion and a 25%
revision rate.88 Revision arthroplasties were generally per­
formed for loosening of the components. They found a sig­
nificantly higher loosening rate for uncemented components
(39%) when compared with cemented components (4%).
Johnstone et al. reported similar findings in their study.76
Johnstone and colleagues noted a higher incidence of subsid­
ence and component loosening in newer generation implants
which were not cemented.76 Luther et al. recently reported an
average 27-month follow-up on 24 SR-PIP arthroplasty.89 They
found that 14 joints required re-operation (58%), including
four that required removal. Despite this, 70% were satisfied
with their final functional results.89
The results of pyrolytic carbon arthroplasty for proximal
interphalangeal joint replacement have been the subject of
several recent studies.90–94 Bravo et al. published the largest
and most comprehensive study to date.91 A total of 50 PIP
PyroCarbon joint replacements were performed in 35 patients.
The minimum follow-up was 27 months. The average age at
the time of surgery was 53 years. Joints replaced included the
index,15 middle,18 ring,10 and small.7 The mean preoperative
range of motion was 40°, mean pinch and grip measurements
were 3 and 19 kg, respectively, and the mean preoperative
pain score was 6 by visual analog scale (0–10). Postopera­
tively, mean range of motion improved to 47°, mean pinch
and grip measurements were 4 and 24 kg, respectively.
Despite these modest improvements, the mean postoperative
pain score was 1 and overall patient satisfaction was high
achieve a goal of 70–90° of flexion by 6 weeks. Resting splints
are discontinued after 6 weeks if there is no extension lag and
active flexion is encouraged with no limits. Isolated pinching,
deviation, and rotation should be avoided during the rehabili­
tation phase. Buddy tapping may be used to increase motion
of stiff joints.
Outcomes and complications of PIP arthroplasty
Successful implant arthroplasty of the PIP joint affords obvious
benefits over arthrodesis; however, despite multiple advance­
ments in implant design, uniformly predictable results have
been difficult to achieve.78 The major complications from PIP
arthroplasty continue to be implant failure, instability, and
loss of motion. Pellegrini and Burton compared arthrodesis
and silicone and metal arthroplasty in 43 patients, and noted
better pinch strength in the arthrodesis group, especially in
the index finger. Few revisions were necessary in the silicone
arthroplasty group; however, seven patients underwent revi­
sion of the metal prosthesis in order to improve lateral stabil­
ity. All of these failed and required revision, and the authors
concluded that arthrodesis remains the treatment of choice
for the index finger, and silicone arthroplasty for the ulnar
digits.79
Silicone implants have been used for PIP replacement
for over 40 years with several large series reported in the
literature. Pain relief tends to be good and the degree of func­
tional improvement and patient satisfaction is high; however,
very few series report improvement in range of motion.
The reported incidence of implant fracture with silicone
arthroplasty is variable, ranging from 5–44%, and rotational
malalignment and lateral deviation may occur with longer
follow-up.80–82 The first large series of silicone interposition
arthroplasty was reported by Swanson in 1972.83 He reviewed
148 implants and there were no major complications. The
series was later expanded to report 424 PIP joint arthroplas­
ties. In this series, complete pain relief was achieved in 98%
of patients, with an average increase in the arc of PIP motion
of 10°.84 Complications included bone resorption in 1.2% of
cases and implant fracture in 5%. More recently, Takigawa
et al. reviewed 70 implants with an average follow-up of
6.5 years and reported pain relief in 70%, improvement in
Fig. 20.10  The typical splints used when rehabilitating the proximal
interphalangeal (PIP) joints following surface-replacement arthroplasty. The PIP
joints are allowed protected flexion with passive extension for the first several weeks
following surgery.

454
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
OA of the metacarpophalangeal
(MCP) joint
Anatomy and biomechanics
The MCP joint is a multiaxial condyloid joint that allows for
flexion, extension, abduction, adduction, and a limited degree
of circumduction. Circumduction or rotation is not a motion
under active control, but is allowed for passively by the
intrinsic joint mechanics. The joint contributes to 77% of the
total arc of finger flexion.98 The metacarpal head has been
described as having a unique “cam” shape. However, this
description is not true to its mechanical reality. A cam is
mechanical link that translates rotational motion into linear
motion or vice versa, typically with a rotating eccentric wheel.
However, the head of the metacarpal is round and, therefore,
the analogy is not valid. The circular metacarpal head is offset
volar to the axis of the metacarpal shaft, which does result in
differential tension of the collateral ligaments in flexion and
extension. The unique three-dimensional shape of the head,
being wider on its volar aspect, adds to the collateral ligament
tension in joint flexion and limited lateral motion in this posi­
tion. On the other hand, when the MCP joint is extended the
collateral ligaments are lax and there is maximal abduction
and rotation of the joint in this position.
The MCP joint capsule is composed of areolar tissue dor­
sally that is loosely reinforced by the extensor tendon and the
sagittal band.99,100 Laterally, the collateral ligaments support
the joint, while the volar plate provides volar support. The
intrinsic muscles provide only modest, secondary capsular
support. The ulnar and radial proper collateral ligaments
are fan-shaped, thick, and wide, arising from the dorsal
aspect of the metacarpal head and inserting into the volar
aspect of the proximal phalanx. The accessory collateral
ligaments are located volar to the origin of the proper col­
lateral ligaments on the metacarpal head and interdigitate
with the proper collateral ligaments distally. The collateral
ligaments play a major role in stabilizing the MCP joint in
all directions of joint displacement. The accessory collateral
ligaments contribute primarily to abduction–adduction and
rotational stability, while the volar plate prevents dorsal dis­
location of the joint when fully extended. The dorsal capsule
provides a very modest contribution to stability when the
joint is in distraction and at the extremes of supination and
pronation.99,100
OA affects the MCP joint less commonly than other hand
joints and is usually secondary to injury or trauma, e.g., intra-
articular fracture, septic arthritis, chronic repetitive trauma in
setting of heavy labor occupations, and occasionally in meta­
bolic disorders such as hematochromatosis.101–103 MCP OA
usually affects the index and middle fingers.101,102 Conserva­
tive treatment with splinting, hand therapy, non-steroidal
anti-inflammatory drugs, and steroid injections is the first-line
treatment of MCP OA. Surgery is indicated for stiffness and/
or pain that are refractory to non-operative treatments.
Resection and resurfacing arthroplasty
Resurfacing arthroplasty involves the resection of diseased
metacarpal cartilage and bone, followed by the placement of
(80%). Fourteen joints required additional procedures and the
revision arthroplasty rate was 8%. There were no cases of
implant infection. Notably, radiographic evidence of subsid­
ence was noted in 20 joints although there was no apparent
loosening.
Tuttle et al. also reported a retrospective series of 18 joint
replacements in eight patients.93 The average active range of
motion was unchanged, however there were no cases of
lateral instability. Complete resolution of preoperative pain
was apparent in only eight cases. Complications included two
dislocations evident at the first office visit; five contractures
(with a motion arc of <35°), and eight squeaky joints. Wijk
et al. reported 2-year follow-up on 53 PIP PyroCarbon arthro­
plasty procedures.94 Range of motion and grip strength were
unchanged postoperatively; however, pain relief and occupa­
tional performance were improved and patient satisfaction
was high. Revision surgery was required in seven patients,
including two who required subsequent arthrodesis.
Chung et al. evaluated 14 patients (21 joints) prospec­
tively. The mean arc of motion at 12 months was 38°, grip
and pinch strength both improved postoperatively. Patient-
rated outcomes were studied by questionnaire, showing a
significant improvement in pain, satisfaction, and aesthetic
outcome.58
Herren et al. performed 17 PyroCarbon PIP joint arthro­
plasty procedures for osteoarthritis, which were followed
prospectively for a mean of 20.5 months.95 All patients noted
significant pain relief with a reduction in mean preoperative
pain score of 7.6 on a 10-point visual analog scale, to 1.3 at
final follow-up. One patient required a revision procedure
because of implant migration. Nunley et al. performed five
PyroCarbon PIP arthroplasties on younger patients with post-
traumatic arthritis.92 These were followed prospectively for 1
year and were found to have no statistically significant
improvement in pain or motion arc, however grip strength
increased significantly postoperatively.
Watts et al. reviewed outcomes and complications of 97
joints after pyrocarbon PIP arthroplasty with a minimum
2-year follow-up.96 Thirteen percent of digits required a revi­
sion at an average of 15 months postoperative. There were no
significant differences in preoperative and postoperative
range of motion. Overall joint survivorship was 85%.
Branam et al. have published a study comparing the out­
comes of pyrolytic carbon implants with silicone implants for
PIP arthroplasty.90 This retrospective study compared out­
comes of 19 PyroCarbon implants with 23 silicone implants.
Although differences in final motion arc and pain relief were
statistically insignificant, coronal plane deformity was more
prevalent, and more pronounced in patients who had silicone
arthroplasty. Overall it is apparent that both joints provide
benefits with regard to pain relief and preservation of some
motion. The superiority of one type of implant over another
has yet to be determined.
More recently the idea of hemiarthroplasty for manage­
ment of PIP joint arthritis has become a reality. Pettersson et al.
reviewed their experience with 42 fingers in 38 patients
undergoing PIP joint hemiarthroplasty.97 While there was
significant improvement in the Disabilities of the Arm, Shoul­
der and Hand (DASH) and visual analog pain scales, there
was no significant change in grip, pinch, or range of motion.
Only four joints required revision for failure. Average
follow-up at 4.6 years was overall promising.

455
OA of the metacarpophalangeal (MCP) joint
soft tissue into the joint space to prevent direct bone contact.
This procedure was used historically to treat MCP OA but
now is reserved as a salvage procedure for cases of failed
implant arthroplasty. Tupper104 described the use of the volar
plate for interposition arthroplasty. The volar plate is detached
proximally from the metacarpal head before the diseased
cartilage and bone of the metacarpal head is resected. This
distally based volar plate is then attached to the dorsal edge
of the osteotomy by means of sutures preplaced through drill
holes in the metacarpal. Before the joint capsule is closed, the
collateral ligaments are reattached using horizontal mattress
sutures preplaced through drill holes on the sides of the distal
metacarpal.105,106 Other resection/interposition arthroplasty
techniques using tendon and interosseous muscles have been
described by Vainio107 and Riordan and Fowler,108 although
not specifically for OA.
Costal perichondrium may also be used for joint resurfac­
ing. After harvesting the perichondrium and cutting it to the
size and shape of the joint surface, the perichondrial graft
is secured by means of a horizontal mattress suture. There
are limited and variable reports on the outcomes of using
rib perichondrium for resurfacing arthroplasty.67,109 A study
by Seradge67 noted poor outcomes in patients over 40 years
of age and uniform failure in cases of reconstruction after
septic arthritis. He concluded that such patients constitute
a contraindication for the procedure. If perichondrium
is to be used it should be oriented with the deep surface
facing the joint as this is the chondrogenic surface. Similarly
if the retinaculum or volar plate are used for resurfacing,
the synovial (deep) surface should be oriented facing
the joint.109
MCP Implant arthroplasty
MCP implant arthroplasty is most commonly used in patients
with rheumatoid arthritis. These patients tend to have a lower
demand on the hands and therefore make implant arthro­
plasty more appealing (Fig. 20.11). In distinction to patients
with rheumatoid arthritis, patients with OA of the MCP joint
tend to have preservation of the collateral ligaments and
fewer issues with soft-tissue imbalance and thus can be excel­
lent candidates for implant arthroplasty of the MCP joint.
Contraindications for MCP arthroplasty are similar to PIP
arthroplasty. The index finger MCP joint can be considered for
arthroplasty, even in a manual laborer. MCP joint prostheses
can be grouped into one of four basic groups: hinged designs,
flexible (silicone) prostheses, surface-replacement prostheses,
and PyroCarbon implants.
Hinged prostheses
Metal-hinged prostheses are rarely used today. The 1953,
Brannon and Klein prosthesis was the first prosthesis to be
used for MCP arthroplasty.70 This simple, uniaxial metal
prosthesis resulted in bone resorption with subsequent finger
shortening and loss of range of motion. In the 1970s and
1980s, the hinge implants evolved into multiaxial designs
made of metal, polymers, or ceramics. The two-component
ball-and-socket Griffith-Nicolle prosthesis110 and ceramic
prostheses111,112 were strong enough to prevent fracture, but
postoperative range of motion was too limited for adequate
joint function.110
Fig. 20.11  (A) Anteroposterior (AP) radiograph of a 62-year-old woman with
longstanding history of rheumatoid arthritis. She complains of metacarpal
phalangeal (MP) joint pain at all fingers and the thumb. She has previously
undergone a Darrach procedure to control distal radioulnar joint arthritis.
Radiographs show evidence of advanced arthritis at the MP joint of the thumb,
index, long, ring, and small fingers. In addition, there is evidence of ulnar deviation
of the long, ring, and small fingers. While there is radiocarpal arthritis, the patient
has no pain at the wrist and the wrist shows no evidence of radiographic instability
or radial deviation on the AP radiograph. (B) AP radiograph 6 months after surgery
to address MP arthritis. Patient has undergone a thumb MP joint fusion using a
compression screw, PyroCarbon joint replacement at the long and index finger MP
joints, and silicone joint arthroplasty at the ring and small MP joints. Silicone
arthroplasty was chosen for the ring and small finger because of poor soft tissue at
the collateral ligaments. The silicone implant, unlike the PyroCarbon implant, does
not rely on the collateral ligaments for radial and ulnar stability due to its
constrained design.
A
B

456
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
but it is also relatively cheap and easy to place and remove
(Fig. 20.12).124–126
Surface-replacement prostheses
Silicone implants are inadequate in patients who place a
higher demand on the MCP joint due to employment or life­
style. Surface-replacement prostheses are more appropriate in
such patients unless the soft tissue around the MCP joint is
inadequate to offer implant stability.127–130 Surface-replacement
prosthetics attempt to recreate normal joint anatomy. They
vary in their design: a single-component silicone implant
with a Dacron-coated stem127; a non-joined, two-component
Pyrolite carbon implant128; a four-component polyethylene-
titanium implant129; or a three-component titanium plate-
silastic hinge implant.130 Studies on surface-replacement
prostheses are small, consisting mainly of RA patients,
with short postoperative follow-up. With the exception of
a 20% fracture rate with the Hagert prosthesis, the surface-
replacement prostheses are associated with a high patient sat­
isfaction, resolution of pain, improved cosmetic appearance,
average range of motion of 47–60°, and a low fracture rate.127–130
The main problem with these implants is instability and
dislocation.128
Kung et al. developed a stable surface-replacement arthro­
plasty implant based on cadaveric evaluation of normal MCP
joint articular geometry.131 The implant is a non-constrained,
two-component implant with a hemispherical cobalt–chrome
alloy metacarpal component with and an ultra-high molecular
weight polyethylene phalangeal component. The head has
lateral volar contours that increase lateral stability during
Silicone constrained prostheses
The Swanson prosthesis was the first silicone MCP joint
prosthesis and has been in use since the 1960s.113 This pros­
thesis has been widely used and studied, although primarily
for rheumatoid arthritis (RA). The silicone elastomer is cross-
linked, which creates a rubber-like form to the implant. The
implant acts as a dynamic spacer and not a true joint. The
prosthesis is held in position by a process of fibrous encapsu­
lation, instead of osteointegration.113 The prosthesis does not
flex at the central hinge section until the joint has been flexed
beyond 45°. Instead, in early flexion, the implant bends at the
interface between the stem and the hinge.114 This results in a
high incidence of stem fracture. Beckenbaugh reported a
fracture rate of 26% at 2.5 years when using the original
Swanson MCP prosthesis. After this study, the silicone elasto­
mer used in the prosthesis was modified to increase its tear
propagation strength and its fatigue-crack growth resistance,
and a newer, “high performance implant” was released.115
Kirschenbaum et al.116 reported a 10% fracture rate within 8.5
years of insertion of the modified Swanson implant. Fracture
rates of around 5–7% have been reported at 2–5-year
follow-up.117,118 Interestingly, many of these fractures do not
require treatment as they go unnoticed by the patients.116
Other complications with the implant have included implant
deformation and silicone synovitis.116,119,120
The clinical experience with the Swanson implant in
patients with RA constitutes the main body of the literature
on this implant. However, Rettig et al.121 reported their experi­
ence with silicone MCP arthroplasty in the setting of OA.
While the experience in RA can shed some light on the man­
agement of patients with OA, the outcome of silicone arthro­
plasty in this population is likely to be different than patients
with OA. They reported 100% patient-reported overall
improvement with a mean MCP flexion of 59°. This small
study consisted of 12 patients and 14 MCP joints. In contrast
to the literature on Swanson implant failures in the setting of
MCP RA, this study, albeit small, demonstrated no Swanson
implant fractures in patients with OA.
The limitations of the Swanson implant in patients with RA
have motivated the development of new silicone implant
designs like MCP Soft Skeletal Implant (Small Bone Innova­
tions, Morisville, PA) and the NeuFlex implant (DePuy,
Warsaw, IN). Studies are promising for the NeuFlex implant,
an anatomically neutral silicone implant with a block-hinge
design and a preformed 30° resting angle that approximates
the relaxed MCP position. The logic for this design is that with
the finger in repose, there is no stress on the implant, contrary
to the Swanson design. In vitro studies also suggest that the
NeuFlex implant has greater longevity than the Swanson
implant before fracture.122 Weiss et al.123 compared MCP joint
mechanism after NeuFlex, Swanson and Sutter (previously
made by Avanta) arthroplasty and found that the mechanics
of the NeuFlex implant most closely matched that of an intact
MCP joint. Only one study86 specifically examines the in vivo
use of NeuFlex implants in OA of the MCP joint. At 4-year
follow-up, NeuFlex implants were associated with a mean
flexion arc of 65°, a mean extension lag of 3°, no implant
fractures, and high patient satisfaction.86 Despite the limita­
tions of the Swanson MCP prosthesis, it remains the current
“gold standard” to which other implants are compared. Not
only is it effective in relieving pain and improving motion arc,
Fig. 20.12  Example of silicone metacarpophalangeal arthroplasties of the index
and long finger in a 63-year-old woman who was suffering from post-traumatic
arthritis.

457
OA of the metacarpophalangeal (MCP) joint
flexion. Also, its arc of rotation is greater than that of an
anatomical joint to decrease the risk of palmar subluxation.
The stem of each component may be “press-fit” or secured
into the intermedullary canal with bone cement. When
mechanically tested at different angles, axial loads, and direc­
tions of motion, this semiconstrained MCP joint implant
demonstrates more intrinsic stability than cadaveric MCP
joints.131
PyroCarbon arthroplasty
Pyrolytic carbon, formed by the pyrolysis of a hydrocarbon
gas, has an elastic modulus similar to cortical bone.132 This
makes the material ideal for implant–bone stress transfer,
potentially reducing implant wear and subsidence.132 The
implant is stabilized by appositional bone growth and does
not require cement fixation.133 PyroCarbon implants require
minimal bone resection and preserve the collateral ligaments
allowing for greater distribution of compressive forces.
However, such nonconstraint prostheses are more likely to
sublux or dislocate, especially in the setting of suboptimal
soft-tissue support. It is for this reason that these implants
are less stable in patients with RA. Cook et al. reported
a 70% 16-year implant survival for the early PyroCarbon
implant design. The patients in that study, the majority of
whom had RA, had good outcomes.134 A short-term study
by Nunez and Citron135 specifically focuses on the use of
the implant in patients with OA; after a mean follow-up
of 2.2 years, 10° of motion was gained, pain significantly
improved, and there were no cases of implant failure. In 2007,
a study by Parker and colleagues reported similar range of
motion as previous reports.134,136 A systemic review of the
literature, however, suggests that PyroCarbon prostheses
may provide no significant advantage over the Swanson
implant with regard to postoperative motion and that
complication rates of both implant designs may be similar.58
Overall, PyroCarbon arthroplasty has been shown to decrease
pain, improve extension lag, and improve grip and pinch
strength.134,136
Technique for MCP joint arthroplasty with
PyroCarbon implant
Prior to surgery AP and lateral radiographs are used to
template the size of the implants needed for the surgical
procedure, keeping in mind that most routine radiographs
are magnified by 3%. The MCP joint is exposed through a
longitudinal incision; alternatively, if several joints are to be
replaced, a transverse incision can be made, as in the case
of RA. The extensor mechanism is split centrally; alterna­
tively, it can be mobilized from the radial or ulnar aspect
of the sagittal bands (Fig. 20.13). If the extensor mechanism
is divided from the sagittal bands for joint exposure, these
structures will need to be reconstructed and the exten­
sor mechanism must be centralized at the completion of
the case.
Once the joint is exposed, a starter awl is used to identify
the intramedullary canal of the metacarpal. An alignment
guide is placed within the intramedullary canal and the
cutting guide is attached to the alignment guide. Using the
cutting guide, a 27.5° back cut is created into the metacarpal
head. The guide is then removed and the remaining osteotomy
is completed by hand. The cutting plane of the guide is
positioned 1.0–2.0 mm distal to the dorsal attachments of the
collateral ligaments. Upon completing the metacarpal oste­
otomy, the proximal phalangeal base is prepared in a similar
manner; however, the cutting plane is positioned 0.5–1.0 mm
distal to the dorsal edge of the proximal phalanx and is tilted
5° distally from vertical. It is strongly recommended that a
conservative osteotomy (limited to the joint’s articular sur­
faces) be performed initially to avoid damage to the collateral
ligaments. Additional metacarpal and proximal phalanx can
always be removed later if the joint space is too small to
accommodate the implants.
Following completion of the osteotomies, the proximal
phalanx is broached to accommodate the largest implant. The
metacarpal is then broached to match the proximal phalanx.
Trial components are then inserted and checked using fluo­
roscopy. Motion should allow for approximately 10–15° of
hyperextension and full flexion. Impaction grafting with
autograft or allograft can be used if there is any concern about
implant seating against the intramedullary bone. When satis­
fied with the preliminary appearance of the trial implants and
the MCP joint motion, the trials are removed, and permanent
implants are press-fit into the intramedullary canals. Unlike
the PIP PyroCarbon joints, the MCP implants should not be
mismatched for size, as this may produce edge wear on the
implant. Care must be taken to assure the correct axial rota­
tion of the component by verifying that the dorsal surface of
the component is parallel to the dorsal surface of the proximal
phalanx. To prevent volar subluxation or dislocation of the
implant, a capsular repair is performed and the extensor
tendon is centralized.
Postoperatively, the hand is placed in a volar splint with
the wrist at 10–15° of dorsiflexion and slight ulnar deviation;
the MCP joints are placed in full extension, and the PIPs may
be left in slight flexion (5–10°). Short arc (30°) MCP joint
flexion is started on day 5–10. Flexion is increased weekly by
20° until full flexion is obtained. Nighttime and resting splints
are worn for 6 weeks keeping the joint in full extension
when not exercising to minimize and resultant extension lag
(Fig. 20.14).
MCP arthrodesis
Current implant arthroplasty techniques have made MCP
arthrodesis a final resort in the treatment of MCP OA. MCP
arthrodesis can be very debilitating, particularly if the other
joints of the fingers have limited motion due to OA. Arthro­
desis can be considered whenever arthroplasty is not possible
due to inadequate soft-tissue support or significant damage
to the metacarpal or proximal phalanx bone stock. In general,
the MCP joints should be fused in increasing flexion starting
with 25° of flexion for the index finger and adding an addi­
tional 5° of flexion for each finger as one advances in an ulnar
direction (Fig. 20.15). In preparation for arthrodesis, good
cancellous-to-cancellous bone contact is essential and this
may be achieved in a “ball-in-socket” or a flat surface configu­
ration. There are many techniques for arthrodesis of the MCP
joints. Intramedullary olecranon bone137 and prosthetic pegs138
have been described. Some 97–99% fusion rates have been
reported with crossed Kirschner pin stabilization.139,140 In
contrast, intraosseous wiring is associated with a 9% nonunion
rate141 and an 8% nonunion was reported with AO screw
arthrodesis.142 Arthrodesis with miniplates has been reported

458
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
Fig. 20.13  Technique for use of PyroCarbon
metacarpophalangeal (MCP) joint arthroplasty.
(A) posteroanterior (PA) radiographs of a 63-year-old male
with osteoarthritis of the MCP joint, as demonstrated
radiographically by joint narrowing of the index and long
finger MCP joints. (B) The surgical exposure is obtained
through a longitudinal incision over the MCP joint. (C) The
joint surfaces are prepared with a cutting guide similar to
proximal interphalangeal joint arthroplasty. After the
articular cartilage has been removed, the proximal phalanx
is broached in preparation for implant placement. Broach
position is verified with intraoperative fluoroscopy. (D) A
similar procedure is performed on the metacarpal. (E) The
final implants are placed and the extensor mechanism is
reconstructed with braided suture with the finger held in
extension. (F, G) Final position of the implants on PA and
lateral radiographs 6 months following the surgery.
A
B
C
D
E
F
G

459
OA of the metacarpophalangeal (MCP) joint
to achieve 96% fusion rates (Fig. 20.16).143 Alternatively,
tension band arthrodesis allows for another means of
fixation with acceptable fusion rates.144,145 Tension bands can
transform distracting flexor tendon forces across an arthro­
desis site to compressive forces dorsally, that stabilize the
arthrodesis.
Fig. 20.14  Splint design for rehabilitation of surface-replacement arthroplasty at
the metacarpophalangeal joint.
Fig. 20.15  Metacarpophalangeal (MCP) joint fusion can be achieved with various
techniques. Angled cuts in the proximal phalanx base and MCP head allow one to
maximize surface contact and create appropriate fusion angles. MCP fusion angles
increase as one moves from the index finger to the small finger. Recommended
fusion angles for the MCP joints have been 25° of flexion for the index, 30° for the
long, 35° of flexion for the ring and 40° of flexion for the small.
A
B
C
25º – Index finger
30º – Long finger
35º – Ring finger
40º – Small finger
Fig. 20.16  Oblique radiograph of the index finger demonstrating an
metacarpophalangeal joint fusion obtained with a dorsally applied mini-plate.
Clinical tips
MCP PyroCarbon arthroplasty
• Splitting the extensor tendon longitudinally down the middle
provides good visualization of the entire joint throughout
the procedure without the need to reposition the tendon.
• Be sure that the hole created in the metacarpal head for
placement of the cutting guide is centrally located with an
appropriate trajectory down the middle of the metacarpal
medullary canal.
• Protect the collateral ligaments during the proximal and
distal cuts. These structures are critical to avoid joint
instability.
• Use imaging to confirm the correct trajectory when
broaching.
• Impaction grafting is valuable to create a tight fit between
the prosthesis and bone.
Vascularized joint transfer/
costochondral replacement
Although not commonly performed, the MCP joint can be
replaced with a free vascularized or pedicled transfer of
another joint. When compared to implant arthroplasty, vascu­
larized toe transfer is less effective in improving postoperative
arc of motion.58 Thus, in cases of OA of the MCP joint, vascu­
larized joint transfers are only indicated in patients where
implant arthroplasty is contraindicated or has already failed,
in young manual workers where implants have a high failure
rate, and/or in cases where there is inadequate bone stock for

460
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
thumb weakness, and instability, severely limiting hand func­
tion. Many treatment options exist, including NSAIDS, splint­
ing, and corticosteroid injections.151–154 When conservative
options fail, surgical treatment should be considered.
The effect of basal thumb OA on disability and mortality is
modest, and as such, it is likely underdiagnosed in clinical
practice.150 Basal thumb arthritis usually involves the carpo­
metacarpal joint, but the scaphotrapeziotrapezoid (STT) joint
can also become involved. Combined CMC/STT disease is
twice as likely to be symptomatic than isolated CMC arthri­
tis.155 Males with thumb arthritis are more likely to be symp­
tomatic than females.156
Epidemiological studies suggest that basal thumb arthritis
is most common in postmenopausal women. While the preva­
lence of radiographic thumb carpometacarpal OA among men
is 7%, it is more than double that (15%) in women150 and
quadruple that in the postmenopausal population.155 The
discrepancy is not as wide when considering only symptom­
atic disease; 5% of men and 7% of women over the age of 70
years suffer from symptomatic basal thumb OA.156 Among
postmenopausal women with radiographic evidence of basal
thumb arthritis, the majority have isolated CMC disease; 6%
have isolated STT disease; and 23 % have combined CMC/
STT.155 The gender differential seen in this disease may be
explained by anatomic differences in the joint. Female CMC
joints have greater reciprocal articular surface curvatures and
lower degree of surface congruity, resulting in smaller contact
areas with greater stresses.157 Hormonal factors may also
contribute to the development of basal thumb OA in females.
Spector et al.158 found an increased risk for the disease in
women who had a hysterectomy. Interestingly, the relation­
ship is not demonstrable with other hand joints, putting the
validity of this relationship into question.159
Other risk factors for thumb CMC OA have been extensively
studied. Obesity is a strong determinant of thumb CMC OA
in both sexes.150,160,161 Obesity causes OA by increasing the load
on weight-bearing joints; however, the first CMC is not a
weight-bearing joint. Obesity may predispose to CMC osteo­
arthritis via non-mechanical, biological mechanisms related to
elevated serum lipids.162 Unlike weight-bearing joints,163,164
there is no independent association between thumb CMC OA
and diabetes or hypertension.159 Furthermore, while an asso­
ciation between thumb CMC OA and OA in weight-bearing
joints has been reported by some investigators,165–167 others
have dismissed this relationship.150 While thumb CMC OA is
not specifically associated with heavy physical activity,159 it
is clearly associated with occupations requiring repetitive
thumb use (especially in the absence of enough rest breaks)
and occupations that expose the thumb to greater than normal
forces.
Family history is another strong predictor in the develop­
ment of thumb CMC OA. In a classic twin study, Spector168
provided clear evidence of a genetic link for the development
of TM OA in females. Jonsson and colleagues169 went on to
suggest that the genetic influence increased with the severity
of the disease.
Anatomy and biomechanics
The TM joint comprises the articulation between the trape­
zium and the base of the thumb metacarpal. The trapezium
and first metacarpal base have reciprocal concavoconvex
implant arthroplasty.146 Vascularized joint transfers are also
recommended in children, as it is the only procedure that
preserves the epiphyseal growth plate and allows for some
longitudinal growth.58 Better functional results in MCP joint
reconstruction can be seen with the use of the second meta­
tarsophalangeal joint.147 After harvesting the flap, the whole
second ray should be amputated for rapid recovery of normal
gait. A small dorsalis pedis flap can be raised for any associ­
ated hand skin defects.
OA of the thumb
The thumb accounts for 50% of overall hand function and, as
such, it is the most important digit in the hand.31 Arthritis of
the thumb can occur at the IP, MP, or trapeziometacarpal (TM)
joints. Arthritis of the interphalangeal joint is managed in a
manner similar to that of the finger DIP joints as described
above. One needs to decide the degree of flexion in which to
fuse the joint and the method of fixation (K wires, 90–90
interosseous wiring, or headless compression screw fixation).
The technique of joint debridement and fixation is essentially
the same as with the finger DIP joints. Similarly, mucous cyst
formation can be a complication of IP joint arthritis of the
thumb. This is managed similar to a manner identical to that
described for DIP arthritis above.
MCP joint arthritis of the thumb
Osteoarthritis of the thumb MCP joint is relatively uncommon
and frequently the result of injury, particularly chronic radial
or ulnar collateral ligament injury.148 While arthroplasty may
be an appropriate option for the thumb MCP joint in rheuma­
toid arthritis, MCP arthrodesis has been the standard of care
for OA of the thumb MCP joint for more than 50 years.149 MCP
thumb joint fusion is well tolerated due to the large degree of
motion at the thumb CMC joint. As with the IP joint of the
thumb, MCP joint fusion can be accomplished by a variety of
techniques that have been outlined above, such as tension
band wiring, crossed K-wires, or plate fixation. The primary
decision is what position the joint should be fused. The posi­
tion must be functional, that is, it should facilitate opposition
to the fingers and not hinder the ability to oppose to the tip
of the ring finger or small finger. This typically means fusing
the joint in slight (15°) of flexion.149 However, fusing the joint
in slightly more flexion (20–40°) takes some work out of
opposition for the CMC joint and may decrease the load
across this joint and therefore be protective against the
development of OA at this location or at least slow its
progression.149
Trapeziometacarpal arthritis
Etiology and epidemiology
Osteoarthritis of the TM joint of the thumb is very common,
with a reported age adjusted prevalence of 7% in men and
15% in women.150 In a retrospective study of patients present­
ing with distal radius fracture, the prevalence of TM arthritis
rose steadily after age 40, with 91% of patients over 80 dem­
onstrating arthritic changes (85% of men and 94% of women
over age 80). While many patients remain relatively asymp­
tomatic, a subset of patients will develop debilitating pain,

461
OA of the thumb
Basal joint arthritis typically presents in females 50–70
years old who complain of worsening thumb pain interfering
with activities of daily living. Patients often complain that
activities requiring opposition or pinch grip, such as opening
jars or carrying heavy objects between the thumb and fingers,
produce pain at the base of the thumb. Complaints of stiffness
or pain at rest are usually indicators of late stage disease.
On physical examination, patients may show the following
signs175,176:
1. Shoulder sign: classically reveals squaring or prominence
at the base of the thumb (dorsoradial subluxation
secondary to ligamentous laxity and the pull of
abductor pollicis longus (APL) on the base of the
metacarpal).
2. Point tenderness at the CMC joint.
3. Grind test: pain on axial compression with rotation of
the metacarpal on the trapezium is pathognomonic of
CMC arthritis.
4. Distraction test: pain on thumb metacarpal base rotation
and axial traction may be present in early stage disease
due to joint capsule inflammation.
5. Adduction deformity: in later stages of the disease, the
metacarpal adopts an adducted posture and the patient
may develop a subsequent contracture of the first
webspace.
6. Hyperextension deformity: as a result of the adduction
deformity or severe joint stiffness, there may be a
surface, which resembles a biconcave saddle joint.170 The tra­
pezial surface is concave in an ulnar–radial direction and
convex in a dorsopalmar direction. Reciprocally, the base of
the first metacarpal is convex in an ulnar–radial direction and
concave in a dorsopalmar direction. The radius of curvature
of the metacarpal base is 34% greater than that of the trape­
zium and is thought to predispose to joint incongruity and
instability.171 The trapezial surface flattens and transforms
from a saddle type to a semicylindrical type joint with advanc­
ing arthritis.172 The scaphotrapezial (ST), trapeziotrapezoid
and trapezium-index metacarpal joints are also considered as
part of the basal joint of the thumb and can become involved
in late stage OA.
Due to the bony incongruity and large cantilever forces,
the CMC joint relies heavily on static ligamentous restraints
for stability. Up to 16 ligaments have been identified171,173;
however, the there are five major internal ligamentous stabi­
lizers of the trapeziometacarpal (TMC) joint; these ligaments
are the dorsal radial ligament, posterior oblique ligament,
first intermetacarpal ligament, ulnar collateral ligament, and
the anterior oblique ligament. The dorsal radial ligament
prevents lateral subluxation. The posterior oblique ligament
provides stability in flexion, opposition, and pronation. The
first intermetacarpal ligament (IML) is taut in abduction,
opposition, and supination; it holds the first metacarpal
tightly against the second metacarpal. The IML is joined by
the ulnar collateral ligament, which prevents lateral sublux­
ation of the first metacarpal on the trapezium and controls
for rotational stress. The fifth and most important ligament
is the volar anterior oblique ligament (AOL) with its deep
(dAOL) and superficial (sAOL) components. The ligament
arises form the volar tubercle of the trapezium and inserts on
the volar aspect of the thumb. The AOL is taut in extension,
abduction, and pronation; it controls pronation stress and
prevents radial translation. The dAOL serves as a pivot point
for the TMC joint and guides the metacarpal into pronation
while the thenar muscles work in concert to produce abduc­
tion and flexion. These fibers limit ulnar translocation of the
metacarpal during palmer abduction while working with
the sAOL to constrain volar subluxation of the metacarpal
(Fig. 20.17).170,171,173
The TM joint surface allows for biaxial movements –
flexion/extension of the CMC and palmar abduction/
adduction.170 Capsular laxity allows for rotation of the
metacarpal on the trapezium. Combined flexion, palmar
abduction and rotation allow for opposition.170 Cooney et al.
radiologically demonstrated that the average total motions
of the TM joint (defined as motions of the first metacarpal
with reference to the third metacarpal) is 53° of flexion–
extension, 42° of abduction–adduction, and 17° of axial rotation
(pronation–supination).174
Diagnosis and classification
The diagnosis of TM OA is usually made from the history and
physical examination. Radiographs are used to stage the
disease. When evaluating a patient with thumb base pain, the
differential diagnosis is broad and includes: flexor carpi radia­
lis (FCR) tendonitis, de Quervain’s tenosynovitis, inflamma­
tory arthritides, rheumatoid arthritis, gout, pseudogout,
gamekeeper’s thumb, radial sensory neuritis, and radiocarpal
or STT arthritis.
Fig. 20.17  Diagram of the trapeziometacarpal joint looking from dorsal to palmar.
A portion of the dorsal radial ligament (DRL) and posterior oblique ligament (POL)
have been removed to show the palmar ligaments. The most important ligaments
for thumb stability are the DRL, POL, ulnar collateral ligament (not depicted), first
intermetacarpal ligament (IML), and the anterior oblique ligament, deep and
superficial heads (DAOL, SAOL). DIML, dorsal intermetacarpal ligament.
Intermetacarpal
ligament
DIML
Dorsal radial
ligament
Abductor pollicis
longus
Dorsal radial
ligament
Posterior oblique
ligament
Superficial anterior
oblique ligament
Posterior oblique
ligament
Deep anterior
oblique ligament
Dorsal trapezium
2nd metacarpal
ligament
Dorsal trapezium
trapezoid ligament

462
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
compensatory hyperextension deformity of the thumb
MCP joint.
7. Thumb weakness: pinch strength is almost always
diminished and functional hand width is often
narrowed.
8. Carpal tunnel syndrome: up to 43% of patients with TM
OA may have evidence of median nerve compression on
nerve-conduction studies.177 The prevalence is even
higher in women, worker’s compensation patients, and
those with diabetes mellitus. Given this high
association, one should take great care to diagnose
coexistent carpal tunnel syndrome in patients scheduled
for basal joint surgery. If present, carpal tunnel
syndrome can be treated at the same time of TM OA
surgery.177
AP, lateral, and oblique radiographs of the TM joint can be
used to confirm the diagnosis and stage the disease. TM stress
views (30° posteroanterior (PA) view with the patient force­
fully pushing the radial aspects of their thumb tips against
each other) can help assess the degree of joint subluxation and
joint space loss.178 Stress views also demonstrate the ST joint
and the index finger TM joint very well. The Robert’s view
(AP view with the hand hyperpronated) also provides a clear
image of all four trapezial articulations.175 Only 28% of women
who have radiographic signs of isolated TM arthritis and 55%
of women with pantrapezial arthritis admit to symptoms of
thumb arthritis, thus radiographic changes must always be
correlated with physical signs prior to developing any treat­
ment plan.155
There are two frequently used classification systems for
CMC arthritis. The Eaton classification (Table 20.1)178 is most
commonly used and is based on radiographic features alone.
Individual symptoms may not correlate with the Eaton stage.
In comparison, Burton classification (Table 20.2) is based on
clinical and radiographic findings.179,180
The Eaton classification of TM OA follows the progressive
changes that occur with progression of disease. In stage I, the
Table 20.1  Eaton classification
Stage
Radiographic characteristics
Stage I
Normal or slightly widened trapeziometacarpal joint
Trapeziometacarpal subluxation up to one-third of
articular surface
Normal articular contours
Stage II
Decreased trapeziometacarpal joint space
Trapeziometacarpal subluxation up to one-third of
articular surface
Osteophytes or loose bodies <2 mm
Stage III
Decreased trapeziometacarpal joint space
Trapeziometacarpal subluxation > one-third of articular
surface
Osteophytes or loose bodies ≥2 mm
Subchondral cysts or sclerosis
Stage IV
Involvement of the scaphotrapezial joint or less
commonly the trapeziotrapezoid or
trapeziometacarpal joint of the index
(Data from Eaton RG, Littler JW. Ligament reconstruction for the painful thumb
carpometacarpal joint. J Bone Joint Surg Am. 1973;55:1655–1666.)
Table 20.2  Burton classification
Stage
Findings
Stage I
Pain
Positive grind test
Ligamentous laxity
Dorsoradial subluxation of CMC joint
Stage II
Instability
Chronic subluxation
Radiographic degenerative changes
Stage III
Involvement of the scaphotrapezial joint or less
commonly the trapeziotrapezoid or
trapeziometacarpal joint of the index
Stage IV
Stage II or III with degenerative changes of the MCP
CMC, Carpometacarpal; MCP, metacarpophalangeal.
(Reproduced from Braun RM, Feldman CW. Total joint replacement at the base
of the thumb. Semin Arthroplasty. 1991;2:120–129; and Brunelli G, Monini L,
Brunelli F. Stabilisation of the trapezio-metacarpal joint. J Hand Surg Br.
1989;14:209–212.)
joint appears normal or slightly widened, associated with
effusion or ligamentous laxity. In stage II there is slight nar­
rowing of the joint associated with cartilage loss. Joint debris
such as loose bodies and osteophytes may be seen, but
measure less than 2 mm in size and sclerotic changes are
minimal. In stage III, the joint space is markedly narrowed or
obliterated, subchondral sclerosis and cystic changes are
apparent, dorsal subluxation is variably seen, and osteophytes
and debris exceed 2 mm in size. The STT joint is spared
(normal) in stage III. However, in stage IV, there is pantrape­
zial arthritis with STT joint involvement in addition to those
changes seen in stage III (Fig. 20.18).178
Non-operative treatment
Splinting alone may be effective in early stage disease. Recon­
structive procedures aimed at providing pain relief, as well as
restoring thumb motion and strength, are usually necessary
in the later stages. Regardless of stage at presentation, all
patients should undergo a trial of conservative management
prior to operative intervention. This includes activity modifi­
cation, splinting, NSAIDs, and steroid injections.
Teaching patients to avoid aggravating activities of the
thumb improves their pain control and overall function.181
Patients should be advised to avoid twisting, lifting, gripping,
and pinching movements. Joint protection by dividing stress
among multiple hand joint and using assistive devices pre­
serves the integrity of the joint structure and improves joint
function, both in the short and the long term.182,183 Patients
may be taught home hand exercises that aim to strengthen the
thenar muscles, the abductor pollicis longus, and the extensor
pollicis longus (EPL). These exercises counter the flexion–
adduction force of the adductor pollicis muscle, prevent
adduction contracture of the first webspace, and improve grip
strength and global hand function.182,184,185 The use of a joint
protection arthritis education program with educational–
behavioral teaching methods has proven beneficial in adher­
ence, pain, disease status, and functional ability in arthritis
patients.183 Such strengthening exercises, however, should
only be recommended to patients with early stage OA without
significant pain.

463
OA of the thumb
greater pain relief and are generally preferred by patients over
the more rigid splints.189 Patients are instructed to wear the
splints whenever they feel basal thumb pain, whether it is day
or night.189 After 3–4 weeks, patients may notice a decreasing
need for splinting. Recently, however, a randomized European
trial suggested that patients with thumb CMC OA may need
to be splinted longer (several months) before one can actually
see significant improvement in their overall pain and
disability.191
Medical therapy for basal thumb OA includes NSAIDs and
intra-articular steroids. Systemic and topical NSAIDs help
reduce synovitis, but they do not halt or reverse disease
progression. There is no difference in the effectiveness of cur­
rently available NSAIDs.192 Intra-articular steroid injections
can be used to resolve synovitis refractory to activity modifi­
cation, splinting, and NSAID therapy. When followed by 3
weeks of splinting, a 40% success rate for subjective symptom
Splinting rests the joint and holds it in a position of
maximum surface contact, thus increasing joint stability and
diminishing mechanical stress.186,187 This often decreases the
associated acute inflammation and pain enough that an ade­
quate level of function returns. A long opponens splint holds
the thumb in palmar abduction with the MP joint in 30° of
flexion and pronation and the wrist in 15° of extension. This
shifts the center of pressure dorsally and away from the
palmar side of the CMC joint that is susceptible to OA.187 A
short opponens splint by definition does not immobilize the
wrist. A modified short splint that only immobilizes the CMC
is also commercially available.186 Although the long and short
splints are equally effective, patients tend to prefer the less
bulky design of the short splints.188 Splints may be prefabri­
cated neoprene or custom-fitted thermoplast.189,190 While some
authorities prefer the individualization and rigidity offered by
the custom-fitted thermoplast splints,190 neoprene splints offer
Fig. 20.18  Radiographs of Eaton stage I–IV trapeziometacarpal (TMC) osteoarthritis. (A) An example of stage I
arthritis displaying a slightly widened TMC joint space due to ongoing synovitis. (B) An example of stage II
arthritis with joint space narrowing and small osteophyte formation. (C) An example of stage III showing
significant joint destruction and osteophyte formation but preservation of the scaphotrapeziotrapezoid (STT)
joint. (D) An example of stage IV arthritis with narrowing and arthrosis at both the TMC and STT joints.
A
B
C
D

464
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
Thumb CMC arthroscopy
Not only is arthroscopy diagnostic in cases of basal thumb
arthritis, but also it can serve as primary therapy in early
disease or as adjunctive therapy in advanced stages.203,204
Thumb CMC arthroscopy is viewed as a less invasive thera­
peutic intervention. Synovectomy, debridement, and thermal
shrinkage capsulorrhaphy of the beak ligament may all be
performed arthroscopically. Synovectomy and debridement
are appropriate for early stage disease that failed conservative
therapy.203,204 Arthroscopic intervention is not recommended
for more advanced disease with significant cartilage loss.
Menon205 described arthroscopic interposition arthroplasty
(using tendon, fascia lata, or Gore-Tex patch) with excellent
results. Badia, however, cautions against arthroscopic interpo­
sition arthroplasty for stage III disease in young, active
patients (who may benefit more from arthrodesis) and in low-
demand patients (who may benefit more from trapeziectomy
with or without ligament reconstruction).203,204
Thumb CMC arthroscopy is usually performed under
regional anesthesia with tourniquet control. A total of 5–8 lb
of longitudinal traction is applied on the thumb using a single
finger trap. Joint distension is achieved by injecting 5 mL of
normal saline into the joint under direct palpation. A radial
portal (1-R) and an ulnar portal (1-U) are usually needed. The
radial portal is placed just radial to the APL tendon, and the
ulnar one is placed ulnar to EPL tendon. The dorsal radial
ligament, posterior oblique ligament, and the ulnar collateral
ligament are best evaluated using the radial portal. The ulnar
portal allows for better assessment of the beak ligament.
A short barrel, 1.9-mm 30° arthroscope and a full-radius
shaver with suction are utilized.203,204 A radiofrequency probe
may be used to perform the synovectomy, the chondroplasty
(in cases with focal cartilage wear), or the thermal capsulor­
rhaphy (in patients with ligamentous laxity). Performing
an arthroscopic trapeziectomy in stage III disease requires
burring away the articular cartilage and removing subchon­
dral bone down to a bleeding surface. This increases joint
space and allows for hematoma formation, optimizing tendon
graft placement and adherence. A volar slip of APL or pal­
maris longus may be used as a tendon graft and is inserted
into the joint space via a portal. The joint is protected in a
thumb spica splint for 1–5 weeks depending on the pathology
and the intervention.
Dorsal wedge extension osteotomy
The volar compartment of the CMC joint is where compres­
sive forces localize when the thumb is in its functional position
of flexion and adduction.201 One way to unload this compart­
ment in early disease is to perform a dorsal, closing wedge
osteotomy of the thumb metacarpal that extends and abducts
the metacarpal away from the trapezial joint surface. Pel­
legrini and his colleagues206 were the first to evaluate the
biomechanical efficacy of a 30° dorsal wedge osteotomy. Their
data suggested that the procedure is successful at offsetting
the subluxing forces acting on the base of the metacarpal. This
procedure was found to not only shift the joint load dorsally206
but also tighten the dorsoradial ligament and reduce overall
joint laxity.207 In a cadaveric model of extension osteotomy,
Shrivastava et al. demonstrated that the procedure reduced
laxity in all directions (40% reduction in the dorsal–volar
improvement has been reported.193 While steroid injections
seem to offer short-term pain relief in early basal thumb OA,194
their long-term effectiveness is uncertain.195 Steroid injections
should not be more often than two to three times a year and
should be used cautiously in very early stage disease as they
can potentially accelerate arthritic degeneration. As demon­
strated in a small 2004 randomized controlled trial, patients
with stage IV disease are unlikely to benefit from steroid
injections.152 With increasing evidence that hyaluronic acid
contributes to joint hemostasis196 and reduces pain in patients
with knee OA,197 investigators have studies injections of
hyaluronic acid into the thumb CMC joint. While studies
suggest that hyaluronic acid may result in some basal thumb
pain relief, there is no evidence that its effectiveness is supe­
rior to that of steroids.198 Interestingly, a recent prospective,
randomized, double-blinded trial199 studying hyaluronic acid
and steroid injections found no improvement in pain, strength,
range of motion, or disability with either when compared
with placebo. However, this study did not exclude patients
with advanced stage disease, and follow-up was limited to 26
weeks.
The technique for CMC injection is straight-forward;
however, advanced disease associated with large osteophytes
and distorted anatomy may present a challenge. The landmark
for thumb CMC joint injections is the dorsoradial aspect of the
proximal end of the first metacarpal.190 The thumb is opposed
against the little finger so that the proximal end of the first
metacarpal is palpable. Traction is applied to the thumb in
order to widen the CMC joint space. The CMC joint is then
injected using a 25-gauge needle. The needle is inserted at a
point proximal to the prominence at the base of the first meta­
carpal on the palmar side of the extensor pollicis brevis and the
abductor pollicis longus tendons. The needle is advanced
distally until it penetrates the joint capsule.190 Fluoroscopy can
be used if the joint anatomy is distorted. The anatomical snuff­
box should be avoided because it contains the radial artery
and superficial radial nerve. Several corticosteroid prepara­
tions are commercially available. Betamethasone is water
soluble and does not leave intra-articular precipitates behind.
About 1.5 mL of a 50/50 mix of betamethasone and 1% lido­
caine without epinephrine may be used.190
Surgical procedures for stage I disease
Surgery for TM arthritis is indicated in patients with per­
sistent pain, instability, and decreased function refractory to
conservative therapy. The type of procedure used is dictated
by disease severity, depending primarily on whether the
cartilage of the CMC joint is unaffected (stage I) or shows
signs of degeneration (stages II–IV). Attritional changes
in the beak ligament cause hypermobility and synovitis
that precede any cartilaginous degeneration.200 The palmar
articular cartilage neighboring the beak ligament is subject
to compressive forces in early disease. Attrition of the beak
ligament results in dorsal translation of the contact area with
subsequent cartilage degeneration.201 The goal of surgery
in early stage of disease is to stabilize the joint, preventing
further subluxation, and to offload the palmar cartilage,
preventing further degeneration.202 Surgical procedures that
are appropriate for such early stage CMC arthritis include
arthroscopy, metacarpal abduction–extension osteotomy, and
volar ligament reconstruction.

465
OA of the thumb
direction, 23% reduction in the radial–ulnar direction, 15%
reduction when distracted, and 15% reduction in pronation–
supination).207 Because of the changes it creates in the articular
forces, the procedure is contraindicated in cases of global joint
instability and cases of non-reducible subluxation.
The technique for a dorsal wedge extension osteotomy is
described by Tomaino.208,209 After establishing regional anes­
thesia and Esmarch bandage exsanguination, tourniquet
control is applied, and a 3 cm dorsal incision is made from
the base of the thumb metacarpal distally. The dorsal sensory
branch of the radial nerve and lateral antebrachial cutaneous
nerve as well as the extensor pollicis longus tendon are identi­
fied and protected. The CMC joint is identified using a
25-gauge needle. A transverse arthrotomy may be performed
to document normal joint surfaces if the radiographs are
questionable or if there is crepitance on examination.208,209 One
centimeter distal to the joint, subperiosteal, circumferential
dissection of the metacarpal is obtained. Using a microsagittal
saw, a partial transverse osteotomy is performed in this loca­
tion down to the volar cortex. A new saw blade is used to
make a 30° osteotomy 5 mm distal to the first one. The two
osteotomies are connected at the volar cortex completing a
dorsally based 30° wedge of bone that is removed. The distal
metacarpal is extended and compressed against the base. The
reduction is secured in place with K-wires208 or two 11 × 8
staples.209 Plates or tension band technique can be used for
fixation as well. The periosteum and skin is then closed, and
a thumb spica splint is placed for 10 days. A thumb spica cast
(with the interphalangeal joint left free) is then placed for an
additional 4 weeks. At around 6 weeks postoperatively, the
cast is replaced with a forearm-based thumb spica Orthoplast
splint, and the patient is instructed to start gentle TM motion.
Osteotomies heal at an average of 7 weeks. Unless union
is delayed, grip and pinch exercises are started 8 weeks
postoperatively.208,209
Pain relief and improved hand function following exten­
sion osteotomy are likely related to both load transfer and
increased joint stability. Some 80% of patients have good–
excellent long-term pain relief.202 At 2.1-year follow-up, grip
and pinch strengths increase by an average of 8.5 and 3.0 kg,
respectively.208 At 6.8-year follow-up, 82% of patients have
normal grip and pinch strengths.202 This procedure also has
the added benefit of correcting any adduction contracture that
may be present. Overall long-term patient satisfaction with
this procedure is reported at 91–93%.202,208
Volar ligament reconstruction
Since volar ligamentous laxity contributes to CMC joint
instability and degenerative disease progression, early basal
thumb OA can be addressed surgically by reconstructing the
volar ligaments. Eaton and Littler described a technique for
reconstructing the volar ligaments by passing the radial half
of the FCR tendon through the base of the thumb metacarpal
and then suturing it to the APL tendon. The procedure was
initially described for the treatment of late disease178; however,
subsequent reports have confirmed the efficacy of the proce­
dure in early disease.210,211 This procedure is viewed by many
as the first of choice for early disease when there is only early
chondromalacia.211 The presence of STT OA precludes use of
this procedure. This technique has been reported to slow the
radiographic progression of the disease in up to 94% of female
patients at 15-year follow-up.211 This compares favorably with
the 17% reported radiographic prevalence of stage III–IV
disease in postmenopausal women in the general popula­
tion.155 While it eliminates long-term pain in only 29% of
patients, patients with persistent pain tend to have only mild
pain and are generally satisfied with the procedure. The
technique appears to be less effective in men and patients
involved in worker compensation claims.211
Technique for Eaton–Littler procedure
Adequate thumb CMC joint exposure for volar ligament
reconstruction usually necessitates a modified Wagner inci­
sion, which is a longitudinal incision that is located parallel
to the long axis of the thumb metacarpal at the interval
between the glabrous palmar and non-glabrous dorsal skin
(Fig. 20.19). The dorsal sensory branch of the radial nerve and
branches of the lateral antebrachial cutaneous nerve crossing
the operative field must be identified and protected. The radial
edge of thenar muscles is elevated extraperiosteally off the
metacarpal, exposing the trapezium, the metacarpal base and
the CMC joint. The interval between EPL and extensor pollicis
brevis is developed to expose the dorsal cortex of the meta­
carpal base. Using handheld awls or a cannulated drill over
a K-wire, a tunnel is made in the metacarpal base in a dorsal
to volar direction (perpendicular to the axis of the thumbnail,
1 cm distal to the dorsal surface of the joint aiming volarly
just distal to the insertion of the beak ligament, and parallel
to the articular surface). A 28-gauge stainless steel wire, or
Hewson suture passer, is passed through the tunnel from volar
to dorsal and is used to pass the tendon through the bone.212
After incising the FCR tendon sheath longitudinally,
the ulnar half of the FCR tendon is split longitudinally with
a heavy suture.212 The tendon slip is harvested using multiple
transverse incisions on the volar forearm from the level of the
wrist to the level of the musculotendinous junction. The
tendon is divided proximally and delivered through the
subfascial plane into the distal incision. The split is completed
distally to the level of the trapezium. The FCR tendon slip is
then delivered through the metacarpal base in a volar to
dorsal direction using the previously placed wire or tendon
passer. After the tension is set, the tendon is secured to the
periosteum of the dorsal cortex using 3-0 braided synthetic
suture. The tendon is then secured beneath the APL tendon.
The remaining tendon is directed volarly, looped around the
FCR tendon, sutured to the FCR tendon, and finally redirected
dorsally where it is sutured beneath the APL tendon. Although
not absolutely necessary, the CMC joint may be further
secured with K-wires. Finally, the thenar muscles are reap­
proximated, and the skin is closed.
Postoperatively, the thumb is immobilized in a short arm
thumb spica cast for 4 weeks. After that, the thumb is
protected in a thermoplast long opponens splint which is
removed for hand therapy. Active and active-assisted range
of motion of wrist, thumb CMC, MP, and interphalangeal
joints are performed in hand therapy. Palmar abduction is
started before radial abduction. During the first 2 weeks out
of cast, opposition and flexion to the index and long fingers
are encouraged. Strengthening is begun after 4 weeks of cast
removal. This is started with minimal resistance putty and
then gradually increased to unrestricted activity by 3 months
postoperatively.212

466
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
Fig. 20.19  Stress views of a 28-year-old female with right thumb pain and grade I radiographic changes (A), showing
evidence of joint instability of the right trapeziometacarpal (TMC) joint. (B) The patient elected to undergo an Eaton–Littler
procedure for stabilization of the TMC joint. The procedure is performed through a modified Wagner incision, which is a
longitudinal incision parallel to the long axis of the thumb, in the interval between the glabrous and non-glabrous skin.
(C) Vessel loop is around the radial artery. The TMC joint is easily exposed through the incision. (D) A strip of the flexor carpi
radialis is then passed through a bone tunnel parallel to the base of the thumb metacarpal. (E) An anteroposterior radiograph of
the thumb showing restoration of TMC joint congruity.
A
B
C
Abductor pollicis longus
Flexor carpi radialis
Portion of flexor carpi radialis
D
E

467
OA of the thumb
hematoma arthroplasty, as blood is thought to fill the space left
by the removed trapezium, eventually forming scar.220,226 A
standard trapeziectomy is performed followed by temporary
K-wire fixation of the thumb in a position of distraction,
palmar abduction, and opposition for about 4 weeks. A single
1.6-mm (0.062-inch) K-wire is inserted percutaneously through
the thumb and index metacarpal bases. The fixation is intended
to promote dense hematoma formation and scarring in the
area of the excised trapezium, hence reducing thumb subsid­
ence. Transverse wire placement is preferred over a longitu­
dinal as the latter may allow the thumb metacarpal to slide
proximally along the wire into the trapeziectomy space.220,226
Unfortunately, as reported by Gray and Meals in 2007,217 such
fixation does not seem to prevent thumb subsidence. However,
the procedure is associated with an 82% rate of pain resolution
with an average of 11% and 21% increase in pinch and grip
strengths, respectively. These results are equivalent to that of
the more complex tendon interposition techniques. Despite its
effectiveness, unless the patient is a low-demand elderly
patient who does not have metacarpal subluxation,227 some
authorities do not recommend hematoma arthroplasty as a
primary treatment and suggest that it be avoided in young
patients who require strong grasp and pinch strengths for
work.216,228 However, recent comparative studies and a
Cochrane review recommend trapeziectomy alone for the
treatment of CMC arthritis since outcomes are similar among
the different techniques but complications and costs are lower
with trapeziectomy alone.224,225,229
Trapeziectomy with ligament reconstruction and/or
tendon interposition
Several procedures for tendon interposition arthroplasty are
available (Video 20.1
). These procedures consist of a com­
plete or partial trapeziectomy and interposition of tendinous
tissue in the trapeziectomy void. The different operations
described for biological arthroplasty are distinguished by: (1)
the choice of tendon used to fill the trapeziectomy void and
prevent thumb subsidence, and (2) the choice of method used
to stabilize the thumb following trapeziectomy. An attempt to
reconstruct the intermetacarpal ligament anchoring the thumb
metacarpal to the index metacarpal is known as suspension
arthroplasty.
Froimson’s fascial arthroplasty is one of the first described
interposition arthroplasties that did not include any element
of ligament reconstruction. After a standard trapeziectomy,
half of the FCR tendon is harvested, rolled up in an “anchovy”
fashion, and used to fill the trapeziectomy space. Froimson230
reported a 90% rate of pain relief at 88-month mean follow-up,
but pinch power was reduced by 30%. Radiographically, the
procedure resulted in a 50% decrease in the interval between
the first metacarpal base and the scaphoid, but clinically the
thumb shortening was minimal.
Burton and Pelligrini228 described a thumb ligament recon­
struction performed with the radial half of the FCR tendon
routed through the base of the thumb metacarpal, and the
remaining length of the tendon was placed in the trapeziec­
tomy void. This procedure has become known as the ligament
reconstruction and tendon interposition procedure, or LRTI, and
is one of the most common trapeziectomy soft-tissue recon­
structive procedures performed (Fig. 20.20). At a mean 2-year
follow-up, grip and pinch strengths increased 19% compared
Procedures for stage II–IV disease
In stage II–IV disease, there is loss of articular cartilage. In
such cases, joint salvage will not provide adequate pain relief.
Surgical procedures to manage more advance disease can be
grouped into four major categories, which include: (1) trape­
ziectomy; (2) trapeziectomy with soft-tissue arthroplasty; (3)
arthrodesis; and (4) replacement of the TM joint (prosthetic
arthroplasty). The goal of surgery is to reduce pain while
maintaining thumb strength and motion.
Trapeziectomy alone
Complete excision of the trapezium is the earliest described
surgical procedure for CMC arthritis. It was first described by
Gervis in 1947 at the Royal Society of Medicine.213 His work
was published the next year in the Postgraduate Medical
Journal.214 The procedure has been shown to be effective at
resolving joint pain.215–217 The improvement in thumb pain
allows for improvement in hand function despite some loss
in grip and pinch strengths. Historical concerns with this
procedure include the possibility of proximal migration of the
thumb metacarpal producing painful metacarpo-scaphoid
impingement218–221 and thumb instability.216,222,223 This has led
to the development of stabilization and suspensionplasty
procedures in an attempt to return more thumb stability and
prevent metacarpal subsidence.221 Loss of trapezial space
height has not been directly correlated with loss of grip or
pinch strength.218,219 In addition, prospective studies have
failed to show any difference in function or metacarpal sub­
sidence when comparing simple trapeziectomy to soft-tissue
procedures224,225 while partial trapeziectomy can be done,
excising the whole bone is important in cases of STT disease.
Surgical technique for simple trapeziectomy
A dorsal approach to the thumb is usually employed.220,226
Blunt dissection is undertaken down to the first dorsal com­
partment and then continued dorsoulnarly to the radial artery.
The artery and radial sensory nerves are dissected off the
underlying CMC joint. The joint space can be identified by
palpation and opened with a longitudinal capsulotomy that
is ulnar to the first dorsal compartment, starting 5 mm on the
metacarpal base and extending proximally until the scapho­
trapezial joint is encountered. Longitudinal traction on the
thumb may help visualization in cases of severe subluxation.
The trapezium is identified by visualization of the saddle joint
and the metacarpal base. Confirmation may be obtained with
fluoroscopy. The trapezium is removed piecemeal from within
the surrounding capsule using a rongeur, a knife, an elevator,
or an osteotome. Attention to the FCR tendon at the base of
the wound is paramount to avoid inadvertent injury. The
wound is irrigated, and all small bone fragments are removed
before closing the capsule and skin.218,224
Postoperatively, the thumb is immobilized for 6 weeks,
after which the patients are instructed to start range of motion
exercises as they wean from using an elastic bandage splint
over the course of 4 days. Activity is advanced as tolerated
over another 10 days. Patients who, at that point, cannot touch
the small finger metacarpal head with the tip of their thumb
are referred to hand therapy.226
A variation of the simple trapeziectomy approach is trape­
ziectomy and distraction arthroplasty, also referred to as

468
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
with preoperative values.228 At 9-year follow-up, thumb func­
tion improved further (grip strength 93%, tip-pinch strength
65%, and key-pinch strength 34%), suggesting that the proce­
dure is not only durable but also improves thumb function
for several years postoperatively.231 Loss of trapezial space
averaged 11% at 2 years228 and 13% at 9 years postoperatively,231
despite the interposition of a portion of the FCR tendon.
Another variation on LRTI is the Brunelli procedure.180
Described in 1989, Brunelli utilized one of the slips of the APL
tendons for the ligament reconstruction. The tendon is divided
proximally, leaving its insertion intact. It is then passed
through a tunnel created in the base of the thumb and index
metacarpals and sutured to the second and third carpometa­
carpal ligaments. Tendon interposition may be achieved using
a palmaris longus graft. Like ligament reconstruction with
FCR, this form of ligament reconstruction has also been
advocated for use in early (stage I) disease without perform­
ing a trapeziectomy.180
Other modifications to the trapeziectomy procedure have
included the use of tendon slings or suspensionplasties. Sus­
pensionplasties are thought to resist the sagittal plane collapse
that occurs when the weakened arthritic thumb is loaded
during pinch.221 Weilby described a suspensionplasty that
avoids the use of bony tunnels by simply weaving a slip of
FCR around the APL and remaining FCR in a figure-of-eight
fashion (Fig. 20.21).232 The procedure has been reported to
relieve pain in 92% patients.233 It affects thumb mobility in
12% patients, and while it improves grip and pinch strengths,
recovery usually takes 3–6 months.
Exposure for the Weilby suspensionplasty is accomplished
using the modified Wagner incision previously described. The
radial artery and sensory nerve are identified and protected.
A radial slip of FCR is released at the level of its myotendinous
junction and freed all the way distally to base of the metacar­
pal. A capsulotomy of the CMC joint is performed and fol­
lowed by a trapeziectomy. If the scaphotrapezoidal joint
appears arthritic on traction of the index and long fingers, a
proximal trapezoidectomy is performed.221 The thumb is then
held in distraction and radial abduction, making sure the base
of the first metacarpal is in line with the base of the second
metacarpal. The slip of the FCR is then passed through a slit
in the APL tendon. The tendon is then secured at its insertion
through the APL. The remaining tendon is then passed in a
figure-of-eight fashion around the APL and remaining FCR to
form a firm sling at the base of the metacarpal. The tendon
construct is secured with sutures and then the capsule and
skin are closed.232 This procedure may be performed alterna­
tively with a slip of the APL passed through a slit in the FCR
(see Fig. 20.21).234
At around 10 days postoperatively, a cast replaces the
thumb spica splint for another 3 weeks. The patient is placed
in a custom-made thumb spica splint when range of motion
exercises are started at around 4 weeks postoperatively.
Fig. 20.20  The Burton and Pelligrini procedure begins with the removal of the
trapezium, followed by the harvest of a portion of the flexor carpi radialis tendon (or
whole tendon, as illustrated). (A) The tendon is passed through a drill hole created
in the base of the metacarpal in a volar to dorsal direction. (B) The tendon is then
sewn to itself to stabilize the metacarpal base of the thumb. (C) The remaining
tendon is then placed into the space left by the resected trapezium to function as
an interpositional spacer.
0.54 K-wires
K-wires not shown
FCR
FCR bolus
Pre-placed
anchoring suture
(A and B strands
are threaded onto
Keith needles
The 0.54 K-wire......?
Four corner sutures (to be tied individually,
one in each corner of bolus)
The second (B’)
0.54 K-wire is
optional
Layered capsular
closure
B’
B
a
A
b
B
C
A

469
OA of the thumb
OA. The review concluded that, “while no procedure appears
to be superior over another in terms of pain, physical func­
tion, patient satisfaction, or range of motion, there is insuffi­
cient evidence at this time to be certain.” The review, however,
did demonstrate that LRTI, when compared to simple trape­
ziectomy, is associated with 12% more adverse effects (includ­
ing scar tenderness, tendon adhesion or rupture, sensory
change, or complex regional pain syndrome type 1). The small
number of studies included in this review and each study’s
unclear risk of bias have raised some doubts with regard to
these results.
Prosthetic arthroplasty
Silicone arthroplasty for the TM OA was introduced inde­
pendently in the late 1960s by Swanson237 and Niebauer.238
The procedure had the theoretical advantage of minimizing
proximal migration of the thumb metacarpal after trape­
ziectomy. Early reports showed good results in the short
Strengthening and opposition across the palm are delayed
until around 8 weeks postoperatively. The splint is then
weaned by 10 weeks.221
Despite variation in surgical technique, there seems to be
minimal outcome differences between simple trapeziectomy,
trapeziectomy with ligament reconstruction, and LRTI. When
compared in a 2004 prospective randomized trial,235 no differ­
ence in grip strength, pinch strength, or thumb subsidence
was noted at 8.2-month follow-up between patients who
underwent trapeziectomy and ligament reconstruction alone
and patients who underwent ligament interposition as well.
A randomized control trial published in 2014 compared the
LRTI technique of Burton and Pellegrini to the Weilby in 79
patients. While the LRTI group had less pain and better
Patient-Related Wrist and Hand Evaluation (PRWHE) at 3
months, these differences did not persist to 12 months, at
which point both groups had similar results.236
A 2009 Cochrane review229 included nine studies involving
477 patients undergoing various procedures for basal thumb
Fig. 20.21  The Weilby suspensionplasty uses a portion of the flexor carpi radialis (FCR) to create a sling
below the metacarpal base to prevent proximal migration of the thumb. The slip of the FCR is wrapped
between the abductor pollicis longus (APL) and the remaining slip of the FCR (A, B). (C) An intraoperative
photograph of the weave being started by wrapping the slip of the FCR around the APL tendon.
Abductor pollicis longus
Flexor carpi radialis
Portion of flexor carpi radialis
A
Abductor pollicis longus
Flexor carpi radialis
B
C

470
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
high-demand patients who wish to maintain grip strength or
as a salvage procedure for failed reconstructions. Although a
previous report has suggested that mild pantrapezial arthritis
is not an absolute contraindication for TM arthrodesis,255 most
authorities feel that the procedure should not be performed
in the setting of STT arthritis.256–258 The optimal position to
fuse the joint is 35° of radial and palmar abduction with 15°
pronation and 10° of extension.259 This position replicates the
position of the thumb in a fully clenched fist with the distal
phalanx of the thumb resting on the middle phalanx of the
index finger. Methods for CMC arthrodesis include slotted
bone grafts, cerclage wiring, tension band wiring, staples,
K-wire fixation, and screw fixation.259 Screw and plate fixation
has a higher rate of complications requiring hardware
removal.260
Technique for arthrodesis
The surgical exposure for CMC arthrodesis (Fig. 20.23) is
similar to that of a trapeziectomy. The base of the thumb
metacarpal is delivered into the incision by flexing and
adducting the shaft.259 The eburnated articular cartilage and
term237,239; however longer follow-up noted a high incidence
of dorsoradial subluxation.240 Subluxation continued to be a
problem even after modifications in technique and implant
design.237,239,240 Reports of implant wear, silicone synovitis,
and bone erosion also started emerging in the late 1980s.241
With implant wear, investigators noted a 50% loss of implant
height (especially on the ulnar border of the implant) at 4-year
follow-up.242 A 16% revision rate for silicone synovitis was also
noted. Because of these complications, silicone implant CMC
arthroplasty fell out of favor with most surgeons. Recently,
however, Bezwada and colleagues243 showed that osteolysis,
implant wear, and subluxation did not directly correlate with
clinical or subjective outcomes. In their study, they reported
an 84% rate of patient satisfaction with and no radiographic
evidence of synovitis.
Comparative studies are few, but in 2005, Taylor et al.215
performed a retrospective comparison between patients
undergoing silicone arthroplasty, resection arthroplasty (with
and without ligament reconstruction), and arthrodesis for the
treatment of TM OA. Taylor found no significant differences
in the clinical outcomes between silicone arthroplasty and
resection arthroplasty over 5-year period. In this study, the
arthrodesis group was found to have a higher re-operation
rate.215 While the follow-up may not be long enough to docu­
ment clinical deterioration of silicone implants,244 this study
suggests that silicone arthroplasty may be a reliable option for
disabling, refractory basal thumb OA, especially in the low-
demand patient. A newly developed one-piece silicone
implant that has been shown to be biomechanically superior
to LRTI may expand the current indications for silicone
arthroplasty in CMC OA.245
Other types of TM arthroplasty have included metallic
prostheses mainly of a ball-and-socket design.246 Constrained
TM joint prostheses are more prone to loosening, while non-
constrained prostheses dislocate more easily.246 The de la Caf­
finiere implant (ball-and-socket, cemented, semi-constrained
prosthesis) is probably the most widely used and most
studied.247 The implant has a cobalt–chromium ball inserted
into the shaft of the metacarpal and a polyethylene cup placed
in the trapezium. Outcome studies have shown that patients
with preoperative complaints of pain or instability do better
than those with preoperative stiffness as their major com­
plaint.247 The implants have a 72–89% 16-year implant survival
rate, with higher prevalence of loosening of the trapezial
component and a greater need for revision surgery in working-
age men.248,249 In lieu of a silicone prosthesis, this implant may
be considered in women over the age of 60 years for whom
joint stiffness is not a main complaint.246,250
Other TM joint prostheses have produced high failure rates
over time and have fallen from favor due to loosening, het­
erotopic bone formation and subsidence.251–253 More recent
implant designs have focused on metacarpal resurfacing in
hopes of producing a hemiarthroplasty. The PyroCarbon meta­
carpal replacement hemiarthroplasty (Integra, Plainsboro, NJ)
has shown promise in grade II and III disease. Subluxation of
the implant, however, is a likely complication if the trapezial
cup is made too shallow (Fig. 20.22).254
Trapeziometacarpal arthrodesis
With the success of the above reconstructive techniques,
arthrodesis is now usually reserved for young (<50 years)
Fig. 20.22  Example of a PyroCarbon arthroplasty of the thumb trapeziometacarpal
joint.

471
OA of the wrist
trapeziectomy, or LRTI.259 In the literature, radiographic
nonunion rates range from 6–12.5%,255,258,261–264 with one study
reporting a nonunion rate as high as 50%.265 There appears to
be no correlation between nonunion rates and the use of bone
grafts.266 Rizzo and colleagues recently reported on the out­
comes of 126 patients following TM arthrodesis. Over the
average follow-up period of 11.2 years, the incidence of
radiographic STT arthritis was noted to be 31% and MP
arthritis was identified in 12.7% of patients.266 Despite these
high values, none of the patients with radiographic MP arthri­
tis were symptomatic and only 6% of patients with STT
arthritis were symptomatic.266
Despite its disadvantages and complications, patient satis­
faction with TM arthrodesis is usually high, with adequate
recovery of pinch and grip strength postoperatively. While
some have reported satisfaction rates as low as 60–78%,261,264
most studies report a satisfaction rate >90%.257,265,267 Although
arthrodesis is generally recommended for younger patients,
the procedure actually has favorable outcomes in patients
over 50 years as well.268
OA of the wrist
Etiology
Osteoarthritis of the wrist may be primary (idiopathic) or
secondary. Causes of primary OA include avascular necrosis
of the lunate or scaphoid (Kienbock’s or Preiser’s disease,
respectively), which can lead to degenerative changes
throughout the wrist in later stages.269,270 Congenital deformi­
ties, such as Madelung’s deformity, can alter articular load
patterns at the ulnocarpal, radiocarpal, and distal radial ulnar
joints leading to the development of wrist OA. Perhaps the
most common idiopathic OA of the wrist is that involving the
STT joint. Epidemiologic studies note a very high incidence
of STT arthritis in the general population. A radiographic and
anatomic study by North and Eaton demonstrated an inci­
dence of STT arthritis in 34% of wrists.271 Another cadaver
study reported the incidence of STT arthritis in 83% of cadaver
wrists.272
Secondary causes of osteoarthritis of the wrist usually are
related to trauma, with scapholunate ligamentous injury,
distal radius fractures, and scaphoid fractures contributing
most frequently to the development of secondary radiocar­
pal OA. Scapholunate interosseus ligament injury can lead
to a progressive form of carpal instability, which may lead
to the development of scapholunate advanced collapse (SLAC)
arthritis.273,274 In 1984, Watson and Ballet published a review
of 121 wrist radiographs with degenerative arthritis due to
scapholunate advanced collapse.273 This pattern accounted for
55% of all wrists with degenerative changes and was the most
common pattern of wrist arthritis. They found that arthritis
initially involved the radial styloid (stage 1) and scaphoid
waist, then progressed to involve the proximal scaphoid
and scaphoid fossa of the radius (stage 2), with arthritis
finally being identified in the midcarpal joint at the luno­
capitate articulation (stage 3).273 Other authors have added
a fourth stage, which describes pan-carpal arthritis with
diffuse involvement of the radiocarpal and midcarpal joints,
with or without involvement of the distal radioulnar joint
(Fig. 20.24).275–277
bone of the trapezium and metacarpal base are removed,
exposing the cancellous bone. Surfaces are molded to allow
for maximum bone contact between the two ends. If K-wires
are being used, three 0.045 wires are usually needed, with one
wire placed parallel to the long axis of the bones and the other
two crossing at 15° to the axis. The K-wires should not extend
proximal to the trapezium unless the trapezium is too
osteopenic to hold stable fixation. K-wires are usually removed
6–8 weeks postoperatively. Postoperatively, patients are
immobilized in a thumb spica until fusion is confirmed
radiographically.259
Successful fusion will result in diminished thumb opposi­
tion and an inability to lay the hand flat.259 Normal MP and
ST joints, however, can compensate well for this limitation to
allow for a functional thumb range of motion post-fusion.
Post-fusion, MP joint and ST joint motions can increase by
75% and 25%, respectively.256
Common complications of CMC arthrodesis include non­
union, progression to peritrapezial arthritis, and symptomatic
hardware requiring removal.259 Radial sensory neuritis may
also occur. Many nonunions are asymptomatic. Symptomatic
nonunions may be treated with repeat arthrodesis, simple
Fig. 20.23  Example of a trapeziometacarpal joint fusion.

472
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
SNAC arthritis that have been adapted from the description
by Ruby et al.: stage I involves arthritis at the radial styloid
and scaphoid articulation279,287,288; stage II involves progressive
degeneration of the radioscaphoid articulation and scapho­
capitate joint; stage III includes the pathology found in stages
I and II but with progression to include the lunocapitate
articulation (Fig. 20.25).279,288
Patient evaluation
Evaluation of the patient with suspected wrist arthritis begins
with a careful history and physical examination. Important
aspects of the history include the mechanism of original
injury, quality and location of the pain, and exacerbating and
alleviating factors. It is important to note what measures the
patient has already tried to treat the pain, such as splinting,
steroid injection or NSAIDs. It is important to determine the
degree to which the pain is affecting the patient’s lifestyle
and work, as this will dictate the decision to treat with non-
operative methods or proceed to wrist salvage. This is an
important consideration as surgery may require a significant
investment by the patient in terms of time off work due to
immobilization and a potential loss of wrist motion. For
these reasons, it is often advisable to see the patient on more
than one occasion and sometimes follow them for years
before embarking on a reconstruction. In the meantime,
pain is managed with non-operative means such as splint­
ing, NSAIDs (oral and/or topical), and periodic steroid
injections.
A critical evaluation of PA and lateral wrist radiographs is
essential. In doing so, one should get a sense of the etiology
of the OA, whether secondary or primary. One must note
which articulations are involved and which are spared as this
will dictate what surgical options are available, i.e., involve­
ment of the lunocapitate articulation in the SLAC wrist.
The important point to note about SLAC arthritis is that the
radiolunate joint is typically spared.274–279 However, a recent
publication by Lane et al. suggests that in a minority of cases
(5–6% of SLAC wrists), the lunate fossa may be arthritic as
well.280 For this reason, it is important to assess the lunate
fossa before committing to a particular reconstruction.
Wrist or forearm fracture can also lead to osteoarthritis of
the wrist. The cause can be related directly to damage to the
articular surface of the joint with an intra-articular fracture,
with or without malunion. Alternatively, extra-articular distal
radius fractures can result in malunion leading to abnormal
joint wear.281,282 Extra-articular distal radius fracture malunion
can result in radial shortening, loss of radial inclination, loss
of volar tilt, supination of the distal fragment, or radial or
ulnar translation of the distal fragment. Each of these mal­
union patterns can result in abnormal load patterns across the
wrist or adaptive malalignment deformities that can resemble
instability patterns.281,283 The end result of the abnormal load
and wear may be osteoarthritis. In a classic report of intra-
articular distal radius fractures, Knirk and Jupiter report 91%
incidence of arthritis on late follow-up if there was any degree
of articular step-off after fracture reduction and 100% inci­
dence of arthritis (8/8) if there was >2 mm step-off of the
articular surface.284 Only 11% of those wrists with a congruent
articular reduction developed arthritis at late follow-up. The
presence of wrist arthritis within this study adversely affected
the clinical outcome.
The final major cause of wrist OA is the sequela of untreated
or mal-united scaphoid fractures. It is estimated that between
5% and 10% of all scaphoid fractures will fail to heal.285 Scaph­
oid nonunion can lead to a pattern of carpal instability similar
to that seen with scapholunate ligament injury.286 Like the
SLAC wrist, scaphoid nonunion can lead to wrist arthritis in
a predictable pattern and is termed scaphoid nonunion advanced
collapse (SNAC) arthritis.279,285,287 There are three stages of
Fig. 20.24  Examples of scapholunate advanced collapse (SLAC) arthritis. (A) An example of stage II SLAC changes. There is evidence of advanced arthritis at the radial
styloid and radioscaphoid fossa, but the midcarpal joint is still relatively free of arthritic changes. (B) A posteroanterior radiograph of a wrist with stage III SLAC changes. In
addition to arthritis at the scaphoid fossa, there is narrowing of the capitolunate articulation, and midcarpal arthritis. (C) A lateral wrist radiograph in the same patient
showing significant midcarpal instability with a dorsal intercalated segment instability (DISI) pattern.
A
B
C

473
OA of the wrist
Involvement of the lunocapitate articulation should give one
pause before proceeding with a proximal row carpectomy
reconstruction as this will leave an arthritic capitate head
behind to articulate with the lunate fossa. In this situation, a
midcarpal fusion, such as a scaphoidectomy and four-corner
fusion may be more appropriate. Further imaging such as a
computed tomography scan, magnetic resonance imaging, or
bone scan is not part of the routine evaluation, but may be
indicated in select situations to evaluate for early signs of
midcarpal arthritis. Another helpful diagnostic adjunct is a
selective injection of lidocaine, with or without steroid, into
the joint in question. This test can be potentially useful for
diagnosis as well as treatment. A study by Bell et al. looked at
the diagnostic utility of midcarpal lidocaine (with or without
corticosteroid) injection in patients with chronic wrist pain.289
They noted that patients with chronic wrist pain had an
improvement in grip strength with the injection, whereas
normal volunteers had a reduction in grip strength. In addi­
tion, those patients with an improvement of >6 kg or >28%
improvement over baseline had a 73% sensitivity and 70%
specificity of having intracarpal pathology at arthroscopy.
Surgical treatment
Surgery is directed at elimination of pain at the arthritic joint
through debridement (radial styloidectomy), denervation
(neurectomy), arthroplasty, or partial or total wrist arthro­
desis. The specific treatment is carefully selected based on the
patient’s symptoms, expectations, pattern of arthritis, and
functional demands. Biomechanical data is available to help
predict the range of motion that may be expected with proxi­
mal row carpectomy, midcarpal joint fusion, and radiocarpal
joint fusion.290,291 Based on these studies, midcarpal fusion can
result in a wrist with 50–67% of the motion of the normal side,
radiocarpal fusion will provide only 33–40% of contralateral
motion. If the distal pole of the scaphoid is removed following
a radioscapholunate fusion, an additional 15–20% of motion
is possible. Proximal row carpectomy can preserve 50–75% of
contralateral wrist motion.276
Fig. 20.25  A posteroanterior wrist radiograph of a patient with stage II
scapholunate advanced collapse (SLAC) arthritis.
Technique for dorsal approach to the wrist
The surgical approach to the wrist should account for the
likelihood of future additional procedures should the selected
initial treatment option fail. A total wrist fusion represents the
ultimate salvage for wrist arthritis. Since this is typically
performed through a longitudinal dorsal wrist incision in line
with the third metacarpal, this approach is recommended for
limited salvage procedures, such as partial wrist arthrodesis.
Following the skin incision, full-thickness flaps are raised in
an ulnar and radial direction. The extensor retinaculum is
opened over the third extensor compartment and the extensor
pollicis longus tendon is transposed. The retinaculum is raised
in a radial and ulnar direction. The second and fourth com­
partment tendons are retracted and the dorsal wrist capsule
is exposed. A ligament sparing incision is made in the capsule
(Fig. 20.26).292,293 The incisions create a radially based flap in
line with the dorsal radiotriquetral ligament and dorsal inter­
carpal ligament. This approach gives excellent exposure of the
midcarpal joint as well as the scaphoid.
Radial styloidectomy
For patients with early SLAC arthritis where arthritis is con­
fined to the radial styloid, radial styloidectomy may be per­
formed as a conservative palliative procedure, either in
isolation or in combination with other another procedure.
Radial styloidectomy is usually performed subperiosteally
through the anatomic snuffbox. It is important to preserve the
volar attachment of the radioscaphocapitate ligament during
the procedure, which inserts into the radial styloid. If more
than a 6–10 mm of styloid is removed, the radioscaphocapitate
ligament origin will be significantly compromised, possibly
resulting in ulnar translation of the carpus.294–296 The radial
styloid fragment may be used as a bone graft for concomitant
fusion procedures.
Neurectomy
Total denervation of the wrist is associated with improved
pain without loss of motion and with minimal morbidity and
convalescence.297–299 Partial denervation of the anterior inter­
osseous nerve (AIN) and posterior interosseous nerve (PIN)
is possible through a single dorsal incision.300 This procedure
has been shown to provide partial relief of wrist pain in cases
of radiocarpal arthritis at an average of 31 months after
surgery.301 In a study of 20 patients, performed by Weinstein
and Berger, only three patients required additional procedures
for pain relief following AIN/ PIN neurectomy. Most patients
in this study continued to have some wrist pain, but the
majority (90%) were significantly improved. Prior to proceed­
ing with neurectomy, patients should undergo a selective
AIN/PIN block with long-acting anesthetic to verify that pain
relief will be adequate. This allows the patient to assess the
level of relief that may be expected from the denervation
procedure.301
Proximal row carpectomy
Proximal row carpectomy (PRC) is an option when the
proximal capitate articular surface and the lunate fossa of
the radius are preserved (Fig. 20.27). In other words, there is
no arthritis at the midcarpal joint or radiolunate joint. PRC

474
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
Fig. 20.26  Dorsal exposure to the wrist bones is accomplished through the use of
a ligament-sparing capsulotomy. (A) A triangular shaped flap is designed over the
dorsum of the wrist capsule extending from the Lister’s tubercle to the triquetrum
and back to the upper third of the scaphoid. (B) The capsulotomy runs in line with
the fibers of the dorsal radioscaphocapitate ligament and the dorsal intercarpal
ligament. S, scaphoid. L, lunate. C, capitate. T, triquetrum. H, hamate.
Dorsal radiocarpal
ligament
T
H
C
L
S
Dorsal intercarpal
ligament
Radius
Lister’s tubercle
B
A
entails removal of the entire proximal carpal row (scaphoid,
lunate, and triquetrum) and results in the wrist functioning as
a simple hinge joint. The capitate articulates with the lunate
facet of the radius. The radius of curvature of the lunate
fossa is larger than that of the capitate head and there is
resultant incongruity at the new articulation. This incongru­
ity may lead to articular wear between the capitate head
and radius.
Proximal row carpectomy has some advantages over inter­
carpal fusions. It does not require a lengthy period of immo­
bilization for an arthrodesis to heal. Krakauer et al. have
compared proximal row carpectomy with intercarpal fusion.302
They found that carpectomy preserved better motion, an
average arc of 71° versus 54° for limited arthrodesis. Both
types of procedure preserved reasonable strength and reduced
pain.
There is limited data on long-term outcomes after PRC.
Jebson and colleagues reported on 20 patients, 11 of who
underwent PRC for osteoarthritis. Two patients in this series
required wrist arthrodesis for persistent pain. The remaining
18 patients were evaluated at an average of 13 years following
surgery. The average wrist range of motion and the average
maximal grip strength was 63% and 83%, respectively, of the
opposite extremity. Sixteen of the 18 patients had returned to
their previous employment. Flattening of the capitate was
present in 33% of patients and 22% of patients had some
evidence of moderate to severe radiocapitate arthrosis.
However, this finding did not correlate with patient satisfac­
tion, wrist pain, or function.303 DiDonna and colleagues have
also published similar findings in a long-term outcome study
of PRC with a minimum of 10-year follow-up. There were
four failures (18%) requiring fusion at an average of 7 years
following initial surgery. The average flexion extension
Fig. 20.27  A posteroanterior wrist radiograph of a proximal row carpectomy (PRC).
A PRC involves the removal of the scaphoid, lunate and triquetrum. The lunate
fossa of the radius and the articular surface of the capitate should be free of arthritic
changes to maximize the outcome of this procedure.

475
OA of the wrist
averaged 53% of the contralateral side and final grip strength
averaged 80% of the contralateral side. Nonunion occurred in
only 3% of patients; 51% of patients had total resolution of
wrist pain, while 15% continued to have pain with daily
activities or at rest.305 More recently, Neubrech et al. reported
on over 500 four-corner fusions with greater than 10-year
follow-up. Forty (6.7%) fusions required conversion to com­
plete wrist arthrodesis while 11% of patients required revision
surgery. Fifty-six patients returned for follow-up exam an
average of 14 years after initial surgery. They had an average
flexion–extension arc of 62.5% and an average grip strength
of 84.9% compared to the unaffected wrist.309
Techniques ensuring successful outcome have focused on
adequate decortication of the four bony surfaces and correc­
tion of the dorsiflexed lunate to re-establish a collinear rela­
tionship between the lunate and capitate. Failure to correct
lunate position can lead to limited wrist extension, hardware
abutment, and pain.305,306 The use of bone graft has not been
shown to clearly correlate with fusion rates, nor has hardware
choice; however, hardware complications have been noted
with pins, staples, and circular plates.302,307,310 In Vance et al.’s
study, nonunion and impingement occurred in 48% of cases
treated with circular plate fixation in comparison to a 6% rate
with traditional fixation (K-wires, staples, or compression
screws). Plate fixation was also associated with a higher rate
of patient dissatisfaction.310
A variation of four-corner fusion can involve capitolunate
arthrodesis alone. Early attempts using this limited arthro­
desis were associated with high rates of nonunion, most likely
due to a smaller bony contact areas for successful bony
fusion.311–313 These results were significantly improved by
Calandruccio and colleagues, who combined capitolunate
fusion with scaphoid and triquetral excision.314 This procedure
may provide for more wrist motion than four-corner fusion
but long-term data is still pending.
Total wrist arthrodesis and total wrist arthroplasty
In advanced arthritis where longstanding changes have
resulted in injury to the midcarpal joint and the lunate fossa,
wrist arthrodesis and wrist arthroplasty may be the only
options for wrist salvage. Arthroplasty may be an enticing
option because of the potential for motion preservation;
however, the normal wrist functions through complicated
interactions at multiple articulations across the wrist joints. It
is impossible for a prosthesis to duplicate this complexity of
motion and strength.315 Therefore, there is a compromise that
occurs for motion at the expense of strength. For these reasons,
wrist arthroplasty is carefully selected only for those patients
with low-demand wrists or who have a fusion of the contra­
lateral wrist.316 Patients with rheumatoid arthritis as opposed
to osteoarthritis of the wrist tend to match the patient profile
more appropriately for total wrist arthroplasty. The choice of
wrist arthroplasty is dependent on the patient’s age, activity
level, and status of the contralateral wrist.
Total wrist arthrodesis represents the ultimate salvage
procedure for all types of wrist arthritis. It involves fusion of
the radiocarpal, midcarpal and third carpometacarpal joint.
Total wrist arthrodesis is an established method of achieving
pain relief and maintaining strength in patients without
alternative options such as those with pan-carpal arthritis.
This procedure is typically performed with the use of a dorsal
arc was 72° with and average grip strength of 91% of the
contralateral side. Of the 18 wrists that did not fail, all patients
were either satisfied or very satisfied with the procedure, with
an overall DASH score of 9. Degenerative changes were seen
in 14 of 17 wrists at the radiocapitate articulation at follow-up.
However, like the findings by Jebson, this did not correlate
with symptoms.304
Four-corner fusion
Scaphoidectomy and four-corner fusion represents another
method for treating midcarpal and radial-sided wrist arthritis
(Fig. 20.28). This procedure entails excision of the scaphoid
and fusion of the midcarpal joint (lunate, capitate, triquetrum,
and hamate). This procedure does not require preserva­
tion of the lunocapitate articulation and therefore may be
appropriate in more advanced stages of the SLAC/SNAC
wrist; however, it does require preservation of the radiolu­
nate articulation.280 In 1984, Watson presented outcomes of
his “SLAC procedure” for the SLAC wrist.273 Although this
SLAC wrist procedure was initially proposed to be used
with a silicone scaphoid implant, scaphoid excision without
an implant works equally well and avoids the long-term
risk of silicone synovitis. Potential advantages of four-
corner fusion over PRC include: the retention of the native
radiolunate interface; and preservation of the lunate and
capitate preserves carpal height, which arguably maintains
the resting muscle tension across the wrist, preserving grip
strength.273,274
Several studies have examined the functional outcome
following four-corner fusion.302,305–309 Ashmead et al. reported
on 100 cases, of which final wrist flexion–extension arc
Fig. 20.28  A posteroanterior radiograph showing an example of a scaphoidectomy
and four-corner fusion. This wrist salvage option is indicated if there is evidence of
arthritis at the midcarpal joint and the scaphoid fossa.

476
SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
Future directions
The likely future direction of osteoarthritis treatment is carti­
lage replacement or regeneration. Articular cartilage has a
limited capacity for regeneration and repair when damaged,
due to its primarily avascular nature. Blood or bone marrow,
which would usually enter an injured site and provide support
for healing, do not arrive to the site of cartilage damage.
Microfracture and drilling techniques are based on improving
the blood flow to an area of injured cartilage to increase
healing factors that may allow for cartilage regeneration.
Tissue engineering, which involves the use of scaffolds,
cells, and stimulating factors (alone and in combination), is a
potential avenue for treating cartilage damage.317 Multiple
clinical trials have shown early promising results for cartilage
repair. Collagen-based, hyaluronic acid-based, and fibrin-
based matrices have all been examined.318–320 However, each
material has its limitations and drawbacks. For example, cell
migration is limited in fibrin-based matrices while collagen-
based gels require placement under a periosteal cover to
avoid displacement. More recently, interest has shifted toward
three-dimensional tissue-engineered constructs.321 In this
emerging technology, cells can be laid down layer by layer
into the preformed shape necessary to replace the area of
damage. The layered cell organization more closely mimics
native cartilage structure. Despite the significant advances in
tissue engineering, this technology remains limited in clinical
application today but provides hope for the future of osteo­
arthritis treatment.
wrist fusion plate, but alternative methods have also been
described using pins alone. Because the distal radioulnar joint
(DRUJ) is not involved in a standard wrist fusion, forearm
rotation is still possible. The ideal position for wrist fusion is
in mild extension with mild ulnar deviation. This position
maximizes grip strength (Fig. 20.29).
Wrist fusion is usually performed through a dorsal incision
centered over the fourth extensor compartment. Decortication
of the radiocarpal joint, midcarpal, and third finger CMC joint
have been recommended to obtain solid fusion throughout
the carpus. Alternatively, a proximal row carpectomy can
be performed and the capitate can be fused to the lunate
fossa of the radius. This technique can be beneficial for
cases of profound wrist contractures, where decreasing the
carpal height may allow for improvement in wrist position;
however, it dramatically decreases the area of bony contact
through which the fusion may occur. Bone graft is not neces­
sary if good opposition between the bone ends is achieved,
but in difficult cases bone graft may be acquired from the
iliac crest, radial styloid, or any bones that are removed from
the carpus at the time of fusion. During plate fixation, screws
are ideally placed within the shaft of the third metacarpal
and shaft of the radius. It is often possible to place additional
screws into the capitate for additional fixation. Pin fixation,
which lacks the rigidity of plate fixation, is usually achieved
by placing long Steinmann or Rush pins through the inter­
metacarpal space of the index/long and long/ring fingers.
Following fusion, the wrist is placed into plaster immobiliza­
tion for 6–8 weeks, or until bony consolidation is seen on plain
radiographs.
A
Fig. 20.29  (A) A complete wrist fusion
may be accomplished with either the use of
a dorsal plate or (B) the use of large
intramedullary pins.
B

477
Future directions
173. Bettinger PC, Linscheid RL, Berger RA, et al. An anatomic study of
the stabilizing ligaments of the trapezium and trapeziometacarpal
joint. J Hand Surg Am. 1999;24:786–798. This article provides a
comprehensive and well-illustrated description of the ligaments
stabilizing the trapezium and TMC joint. An anatomic study of 37
cadaver hands was performed identifying 16 ligaments with attachments
at this important joint. Insertions, fiber orientations, and positions
producing ligament tension are described for each ligament. A discussion
of the biomechanical role and clinical relevance of the most important
ligaments is presented.
211. Freedman DM, Eaton RG, Glickel SZ. Long-term results of volar
ligament reconstruction for symptomatic basal joint laxity. J Hand
Surg Am. 2000;25:297–304.
223. Burton R. Basal joint arthritis. Fusion, implant, or soft tissue
reconstruction? Orthop Clin North Am. 1986;17:493–503.
225. Davis TR, Pace A. Trapeziectomy for trapeziometacarpal joint
osteoarthritis: is ligament reconstruction and temporary
stabilisation of the pseudarthrosis with a Kirschner wire
important? J Hand Surg Eur Vol. 2009;34:312–321. This is a
randomized prospective study comparing two surgical treatment options
for basal thumb arthritis. A total of 61 thumbs underwent trapeziectomy,
LRTI, K-wire immobilization and 6 weeks of splinting and 67 thumbs
underwent trapeziectomy alone and 3 weeks of immobilization with a soft
bandage. Outcome measures included pain, DASH scores, and thumb
and grip strengths, which were all assessed at 3 and 12 months. Detailed
results are presented and no significant difference between the procedures
was detected in any of the outcomes measures.
227. Barron OA, Glickel SZ, Eaton RG. Basal joint arthritis of the
thumb. J Am Acad Orthop Surg. 2000;8:314–323.
266. Rizzo M, Moran SL, Shin AY. Long-term outcomes of
trapeziometacarpal arthrodesis in the management of
trapeziometacarpal arthritis. J Hand Surg Am. 2009;34:20–26. The
authors performed a 33-year retrospective study of trapeziometacarpal
(TMC) arthrodeses performed at Mayo Clinic. Amongst 241 procedures
reviewed, they included 126 thumbs with adequate pre- and postoperative
clinical and radiographic data at an average 11-year follow-up. They
report improvement of preoperative pain scores, oppositional and
appositional pinch strength, and grip strength (p < 0.01). There was no
significant change of any thumb motion arc. Nonunion rate was 13%
and was unrelated to the use of bone grafting. Radiographic progression
of STT arthritis was seen in 39 thumbs, only eight of which were
symptomatic. This study presents detailed long-term outcomes of TMC
arthrodesis, providing level IV evidence for the management of TMC
arthritis.
283. Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic instability
of the wrist. Diagnosis, classification, and pathomechanics. J Bone
Joint Surg Am. 1972;54:1612–1632. This is a seminal article from 1972
that presents the foundation for study of carpal instability. The authors
describe wrist instability that develops as a result of scapholunate and
other carpal ligament injuries in addition to instability from fracture
dislocations, scaphoid fractures, and fractures of the distal radius and
ulna. They provide the earliest comprehensive dialogue of the diagnosis of
carpal instability. The article includes clinical and radiographic data, a
detailed discussion of the biomechanics of carpal instability, and proposal
of the now accepted classification of dorsal and palmar intercalated
segment instability. The radiographic parameters and nomenclature
presented in this article remain in use today. The article has been
recognized as a “classic orthopedic reference” and a summary was
republished in the Journal of Bone and Joint Surgery in 2002.
304. DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy:
study with a minimum of ten years of follow-up. J Bone Joint Surg
Am. 2004;86:2359–2365. The authors retrospectively evaluate the
long-term results of 22 proximal row carpectomy procedures performed
for the treatment of scapholunate advanced collapse, scaphoid nonunion
with advanced collapse or Kienbock’s disease. Outcomes were assessed
by means of follow-up radiographs, objective measurement of motion
and grip strength, and the DASH questionnaire. Their surgical technique
is reviewed and results at a minimum 10-year follow-up (average
14 years) are presented. There were four failures (18%) at an average
of 7 years, all of which occurred in patients younger than 35 years.
The authors report a wrist motion arc of 72° and grip strength of
91% of that of the contralateral side in the 18 (82%) successes. They
conclude that proximal row carpectomy is a viable motion-preserving
procedure for advanced carpal arthritis that provides satisfactory
long-term results in most patients, and advise against it in patients
younger than 35 years.
305. Ashmead D, Watson HK, Damon C, et al. Scapholunate advanced
collapse wrist salvage. J Hand Surg Am. 1994;19:741–750.
307. Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures
in the treatment of scapholunate advanced collapse wrist:
proximal row carpectomy versus four-corner arthrodesis. J Hand
Surg Am. 1995;20:965–970.
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significant change of any thumb motion arc. Nonunion rate was 13%
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304. DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy:
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Am. 2004;86:2359–2365. The authors retrospectively evaluate the
long-term results of 22 proximal row carpectomy procedures performed
for the treatment of scapholunate advanced collapse, scaphoid nonunion
with advanced collapse or Kienbock’s disease. Outcomes were assessed by
means of follow-up radiographs, objective measurement of motion and
grip strength, and the DASH questionnaire. Their surgical technique is
reviewed and results at a minimum 10-year follow-up (average 14 years)
are presented. There were four failures (18%) at an average of 7 years, all
of which occurred in patients younger than 35 years. The authors report
a wrist motion arc of 72° and grip strength of 91% of that of the
contralateral side in the 18 (82%) successes. They conclude that proximal
row carpectomy is a viable motion-preserving procedure for advanced
carpal arthritis that provides satisfactory long-term results in most
patients, and advise against it in patients younger than 35 years.
305. Ashmead D, Watson HK, Damon C, et al. Scapholunate advanced
collapse wrist salvage. J Hand Surg Am. 1994;19:741–750. The
authors present a substantial series of 100 scaphoid excisions and
four-corner fusions with an average 4-year follow-up. Long-term
subjective, clinical, and radiographic data is presented. At the time of
follow-up, 91% of cases had significant improvement in pain levels, and
no patient described their pain as worse. Flexion/extension averaged 72°
and grip strength was 80% that of the contralateral side. Nonunion
occurred in only three cases and only two instances of radiolunate
destruction were noted, both in conjunction with ulnar translation of the
carpus. Outcomes with and without the use of silicone scaphoid spacers
were found to be similar.
306. Tomaino MM, Miller RJ, Cole I, et al. Scapholunate advanced
collapse wrist: proximal row carpectomy or limited wrist
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307. Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures
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comparing proximal row carpectomy (PRC) with four-corner fusion for
scapholunate advanced collapse. Two cohorts of 19 patients each (from
separate institutions performing exclusively either PRC or four-corner
arthrodesis) were compared. The cohorts were well matched and the
authors found significant improvement in function and pain with both
procedures. Postoperative motion and functional outcomes were similar
in both procedures. The authors discuss the surgical techniques,
outcomes, and controversies related to the two procedures.
308. Cohen MS, Kozin SH. Degenerative arthritis of the wrist: proximal
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arthrodesis. J Hand Surg Am. 2001;26:94–104.
309. Neubrech F, Muhldorfer-Fodor M, Pillukat T, et al. Long-term
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310. Vance MC, Hernandez JD, Didonna ML, et al. Complications and
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traditional techniques. J Hand Surg Am. 2005;30:1122–1127.
311. Viegas SF, Patterson RM, Peterson PD, et al. Ulnar-sided perilunate
instability: an anatomic and biomechanic study. J Hand Surg Am.
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312. Kirschenbaum D, Schneider LH, Kirkpatrick WH, et al. Scaphoid
excision and capitolunate arthrodesis for radioscaphoid arthritis.
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313. Kadji O, Duteille F, Dautel G, et al. [Four bone versus capito-
lunate limited carpal fusion. Report of 40 cases]. Chir Main.
2002;21:5–12.
314. Calandruccio JH, Gelberman RH, Duncan SF, et al. Capitolunate
arthrodesis with scaphoid and triquetrum excision. J Hand Surg
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315. Adams BD. Complications of wrist arthroplasty. Hand Clin.
2010;26:213–220.
316. Murphy DM, Khoury JG, Imbriglia JE, et al. Comparison of
arthroplasty and arthrodesis for the rheumatoid wrist. J Hand Surg
Am. 2003;28:570–576.

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SECTION III
CHAPTER 20 • Osteoarthritis in the hand and wrist
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