The role of arthroscopy in trapeziometacarpal arthritis

Abstract

Background: Trapeziometacarpal (TM) arthroscopy should be viewed as a useful minimally invasive adjunctive technique rather than the operation itself since it allows one to visualize the joint surface under high-power magnification with minimal disruption of the important ligamentous complex. Relatively few articles describe the arthroscopic treatment of TM osteoarthritis (OA) and the arthroscopic anatomy of the TM joint. There is lingering confusion as to whether soft tissue interposition and K-wire fixation of the joint are needed and whether the outcomes of arthroscopic procedures compare to the more standard open techniques for TM arthroplasty.

Questions/purposes: This paper describes (1) the arthroscopic ligamentous anatomy of the TM joint, (2) the portal anatomy and methodology behind TM arthroscopy, and (3) the arthroscopic treatment for TM OA, including the current clinical indications for TM arthroscopy and the expected outcomes from the literature.

Methods: A MEDLINE(®) search was used to retrieve papers using the search terms trapeziometacarpal, carpometacarpal, portal anatomy, arthroscopy portals, arthroscopy, arthroscopic, resection arthroplasty, and arthroscopic resection arthroplasty. Eighteen citations satisfied the search terms and were summarized.

Results: Careful wound spread technique is needed to prevent iatrogenic injury to the surrounding superficial radial nerve branches. Traction is essential to prevent chondral injury. Fluoroscopy should be used to help locate portals as necessary. Cadaver training is desirable before embarking on a clinical case. Questions regarding the use of temporary K-wire fixation or thermal shrinkage or the need for a natural or synthetic interposition substance cannot be answered at this time.

Conclusions: Longitudinal prospective studies are needed to answer these lingering questions. An intimate knowledge of the portal and arthroscopic anatomy is needed to perform TM arthroscopy. Minimally invasive techniques for resection arthroplasty in TM OA with and without soft tissue interposition can yield good outcomes in the treatment of TM OA.

Fig. 1

A view of the right thumb from the 1-U portal looking volarly and radially is shown. The sAOL and dAOL are seen. MTC = metacarpal base. Reprinted with permission of David J. Slutsky.

Fig. 2

A view of the right thumb from the 1-U portal looking volarly and radially is shown. A tear of the sAOL demonstrates the FCR. MTC = metacarpal base. Reprinted with permission of David J. Slutsky.

Fig. 3

A view of the oblique fibers of the UCL (**) in a right thumb from the modified thenar portal looking ulnarly is shown. MTC = metacarpal base; Tm = trapezium. Reprinted with permission of David J. Slutsky.

Fig. 4

A view of the right thumb from the modified radial portal looking ulnarly is shown. The dorsal capsule is to the right. The POL (**) is being tensioned with a probe in the 1-U portal. MTC = metacarpal base; Tm = trapezium. Reprinted with permission of David J. Slutsky.

Fig. 5A–B

Views of the dorsal capsule in a right thumb from the modified radial portal looking ulnarly and dorsally are shown. (A) The fibers of the DRL (**) are being placed on traction by a probe placed in the 1-R portal. (B) A close-up view of the DRL fibers (**) is shown. MTC = metacarpal base; Tm = trapezium. Reprinted with permission of David J. Slutsky.

Fig. 6A–C

(A) An AP view of a right TM dislocation is shown. The arrow is pointing to an avulsion fracture of the insertion of the AOL. (B) An arthroscopic view of the AOL through the 1-R portal demonstrates the attached avulsion fracture (***). (C) A view of the avulsed POL (***) as seen from the modified radial portal is shown. The probe is in the 1-U portal. MTC = metacarpal base. Reprinted with permission of David J. Slutsky.

Fig. 7A–B

(A) The D-2 portal is located 1 cm distal to the juncture of the thumb and index metacarpals. (B) Deep dissection of the D-2 portal is shown. Note how the needle in the D-2 portal points down toward the trapezium as compared to the needle in the 1-R portal, which crosses the trapezium horizontally. RA = radial artery. Reprinted with permission of David J. Slutsky.

Fig. 8A–B

(A) An outside view shows a cannula in the modified radial portal. The arthroscopic probe is in the 1-U portal. (B) An arthroscopic view of the right thumb looking volar and ulnarly from the 1-U portal shows a 22-gauge needle inserted through the modified radial portal. MTC = metacarpal base; Tm = trapezium. Reprinted with permission of David J. Slutsky.

Fig. 9

A line drawing of the standard portal placement illustrates the location of the 1-R, l-U, and D-2 portals. RA = radial artery. Reprinted and modified with permission by Elsevier from Berger RA. A technique for arthroscopic evaluation of the first carpometacarpal joint. J Hand Surg Am. 1997;22:1077–1080.

Fig. 10A–C

(A) Surface landmarks for the D-2 portal are shown. (B) A probe in the D-2 portal is used to localize the medial osteophyte. (C) An arthroscopic burr inserted through the 1-R portal is used to resect the medial osteophyte. Reprinted with permission of David J. Slutsky.

Fig. 11A–D

(A) An AP view shows advanced TM OA. (B) An arthroscopic view of the right thumb from the 1-U portal is shown with the resector (**) in the 1-R portal. Note how the trapezium is devoid of all cartilage. (C) Partial resection of the trapezium and (D) the completed hemitrapeziectomy are shown. MTC = metacarpal base; Tm = trapezium. Reprinted with permission of David J. Slutsky.