Wrist surgery and osteoarthritis: the role of arthroscopy

What is osteoarthritis of the wrist?

The wrist is the mobile area between the forearm and the hand. The wrist is an articular chain, that is to say a set of joints: distal radio-ulnar joint, radiocarpal joint, pisotriquetral joint, mediocarpal joint, and carpometacarpal joints.

Fifteen bones are involved in the wrist’s joints and are held by dozens of ligaments; it is the most complex joint in the human body. Osteoarthritis of the wrist arthritis is worn cartilage in one of these joints or more.

Clinically, osteoarthritis of the wrist manifests itself as pain in the wrist, often associated with stiffness. The primary goal of wrist surgery will be to reduce pain whilst preserving maximum mobility.

Video of arthroscopic wrist surgery for osteoarthritis of the wrist:

Video of arthroscopic wrist surgery for lunatum osteoarthritis resulting from ulnar impaction syndrome (Wafer procedure) / Toulouse specialist 

 

Diagnosis of osteoarthritis of the wrist:

Osteoarthritis of the wrist manifests itself as pain, usually gradual. Wrist pain occurs as a long-term effect of an injury in posttraumatic arthritis or spontaneously when wrist arthritis is degenerative or rheumatoid.
The pain of osteoarthritis in the wrist is particularly incapacitating, making it difficult to grip and hold objects, but also to perform reflex movements. Wrist stiffness, that is to say reduced range in joints, is nearly always found. 

Ulnar impaction syndrome with lunate distribution (MRI)Lunatum arthritis in Ulnar impaction syndrome (CT arthrogram)

To determine which wrist surgery is the most suitable to the patient’s condition, a thorough clinical and x-ray examination will make it possible to qualify exactly the type and severity of osteoarthritis.

There are indeed several types of osteoarthritis of the wrist which can be classified based on their origin:

1- Post-traumatic wrist arthritis:

  • radiocarpal osteoarthritis resulting from articular distal radius fractures;

  • osteoarthritis following fracture of the scaphoid (nonunion), known as SNAC wrist;

  • osteoarthritis following severe scapholunate spain, known as SLAC (Scapholunate Advanced Collapse) wrist

Radioscaphoid osteoarthritis after scaphoid non-union (Scaphoid Non-union Advanced Collapse – SNAC– wrist)Mediocarpal and radioscaphoid osteoarthritis (Stage 3 SNAC wrist)

2- Degenerative wrist osteoarthritis:

  • lunatum osteoarthritis in ulnar impaction syndromes;

  • peritrapezial, scaphotrapezotrapezoidal (STT) and trapezometacarpal (rhizarthrosis) osteoarthritis;

  • pisotriquetral osteoarthritis which manifests itself as chronic wrist tendonitis

  • osteoarthritis due to Kienböck’s disease

STT osteoarthritis of the wristSTT osteoarthritis (CT arthrogram)

3 – Rheumatoid osteoarthritis, due to evolutive wrist arthritis:

  • microcrystalline arthritis (scaphoid chondrocalcinosis advanced collapse – SCAC wrist –, gout…)

  • auto-immune arthritis: rheumatoid arthritis, systemic lupus, psoriasis…

Osteoarthritis in microcrystalline arthrosis, wrist chondrocalcinosis SCAC wrist, osteoarthritis of the wrist after chondrocalcinosis

Avant la chirurgie, l'examen clinique de l’arthrose du poignet aura pour but :

The preoperative clinical examination will aim at:

  • looking for any pathologies associated with wrist arthritis, in particular a carpal tunnel syndrome;

  • assessing pre-operative mobility in the articular chain as a whole since osteoarthritis may affect the different joints in the wrist with varying degrees;

  • evaluating the wrist’s global grip strength (grasp, Jamar®).

The examination of wrist osteoarthritis is then completed by the x-ray analysis which in all cases will include CT (or MR) arthrography of the wrist so as to precisely determine the degree of wear of each joint and any possible associated ligament lesions.

After a clinical and radiographic examination of the wrist allowing the type of arthrosis to be specified, the most suitable wrist surgery for your condition can be determined.

Treatment of wrist osteoarthritis:

The primary objective of this treatment, whether it be medical to begin with or surgical, is to end the pain in the wrist.

In early forms of wrist osteoarthritis, the first line medical treatment is a combination of antalgic-based medication, slow-releas corticosteroid injections and a night rest orthosis.

This medical treatment of wrist osteoarthritis can be efficient to an extent, temporarily and only in early forms of wrist arthritis. Unfortunately the result of medical treatment is often disappointing in more severe forms of arthritis, which is when wrist surgery is justified.

There are different types of surgery for wrist osteoarthritis:

- wrist denervation in painful but mobile forms of osteoarthritis;

- partial fusion (scaphocapitate arthrodesis, 4-corner arthrodesis) in partial and already stiffened forms of arthritis;

- total joint fusion (complete arthrodesis) in complete forms of arthritis

- wrist protheses, total or partial (pyrocarbon, PLGA).

In forms of osteoarthritis where mobility is preserved, the total or partial wrist denervation surgery makes it possible to reduce pain and leave the joint intact.
In painful and stiffened post-traumatic forms of osteoarthritis, partial wrist arthrodesis or prosthetic (pyrocarbon or PLGA prostheses) surgical procedures aim at relieving the pain whilst preserving most of the wrist’s mobility.

In partial and moderate forms of wrist osteoarthritis, joint debridement (bone resection and synovectomy) procedures can be performed:

- styloidectomy in early radiocarpal osteoarthritis;

- Wafer procedure in some forms of osteoarthritis caused by ulnar impaction.

In the more severe forms of wrist osteoarthritis, the use of protheses (pyrocarbon or PLGA) can relieve pain whilst preserving most of the wrist’s mobility.

Most of these wrist surgery procedures can be performed arthroscopically which speeds up recovery, increases accuracy and reduces morbidity.

Arthroscopic wrist surgery in ulnocarpal arthritis:

The case for arthroscopic surgery is strong in most forms of wrist osteoarthritis.

However it is sophisticated hand surgery that should be performed by specialized surgeons only.

These arthroscopic wrist surgery procedures are performed on an outpatient basis, under regional anaesthesia, with the wrist and the hand comfortably numbed.
For ulnocarpal osteoarthritis, wrist surgery uses radiocarpal arthroscopy. Only a few 2-3 mm surgical incisions are needed.

The optical portal is a slightly ulnar 3-4 portal that makes it possible to see the osteoarthritis, which appears as a flap of cartilage detached from the ulnar aspect of the lunate, associated with a lesion of the lunotriquetral ligament.
The first stage consists in debriding the inflamed synovial membrane (joint synovectomy) through a 4-5 instrumental portal.
The flap of cartilage can be severed from the lunate which will alleviate the pain.

The procedure continues, focusing on the cause of osteoarthritis by shortening the lunate at its interface with the carpus; this is called the Wafer procedure.
To achieve this, the TFCC ligament is fenestrated on its radial aspect. A second radio-ulnar portal 8 mm distal to the 4-5 radiocarpal portal is then opened so that a bur can be introduced to debride to lower extremity of the ulna.
For this patient, there is also a superficial and foveal ulnar tear of the TFCC ligament, which can be arthroscopically repaired. Once wrist surgery is finished, the arthroscopic incisions are closed with Ster-istrip; suturing is not necessary in this wrist surgery.

R-ray after arthroscopic Wafer procedure

 

Recovery after wrist arthritis surgery:

A removeable split must be kept for 3 weeks, non-resistive wrist movements can resume after 3 weeks.
In recovery, the wrist can be used in daily activities after 2 to 3 months, and it will take from 6 to 9 months for it to regain its full strength.