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Arthritis and Joint Degeneration

Wrist and TMC osteoarthritis — management of primary and post-traumatic degeneration (SLAC/SNAC), from conservative therapy to surgical salvage.

140 citationsUpdated Oct 2026

Illustration: Arthritis and Joint Degeneration

Overview¶

Osteoarthritis is a degenerative condition where current non-surgical management does not alter the clinical course or arrest disease progression [2]. Joint replacement is indicated for end-stage disease [2], although radiographic evidence of osteoarthritis does not necessarily correlate with poor function [3]. For the basal joint, arthroscopy evaluates chondromalacia and ligament attenuation to help classify osteoarthritis and assess painful post-traumatic lesions of cartilage and ligaments [5]. In the glenohumeral joint, early results for preservation procedures indicate satisfactory short-term outcomes, yet these procedures have yet to show they can halt arthritic progression [8]. Further characterisation is needed to determine which patients with mild arthroscopic findings of acromioclavicular joint osteoarthritis warrant resection [11]. Inflammatory arthritis remains the most common indication for total elbow arthroplasty, with an increased incidence of revision surgery in recent years [12].

Surgical strategies vary by joint and patient profile. Silastic replacement of the trapezium remains a good option for painful trapeziometacarpal osteoarthritis unresponsive to nonoperative treatment [7]. For young patients with glenohumeral osteoarthritis, experts recommend a stepwise approach starting with nonoperative treatment, including joint-preserving arthroscopic procedures for selected patients, while reserving joint replacement or resurfacing for cases where less invasive options fail [27]. Arthroscopic debridement serves as an efficacious and particularly safe short-term alternative for young patients concerned about arthroplasty [22]. Wrist osteoarthritis surgery aims to eliminate pain while preserving motion in adjacent joints, with specific procedures chosen based on arthritis location and patient factors [26]. Proximal-row carpectomy should be considered after conservative measures fail; mild degenerative arthritis is not a contraindication, and progressive degenerative arthritis of the radial capitate articulation did not occur following the procedure [47].

Outcome data highlights both efficacy and limitations. Total distal radioulnar joint arthroplasty shows appropriate mid- to long-term implant survivorship and satisfactory functional gains, though complication and reoperation rates warrant cautious interpretation [28]. Silicone implant arthroplasty remains the treatment of choice for symptomatic osteoarthritic proximal interphalangeal joints, with Swanson silicone arthroplasty demonstrating 90% implant survivorship at an average of 10 years postoperatively [34]. Conversely, the use of silicone wrist implants in posttraumatic or osteoarthritis patients has yielded poor results, and authors no longer use them in this population [146]. Joint replacement procedures relieve pain and improve function more than other current operative treatments, but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage [60]. Procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease [60]. For rheumatoid arthritis of the wrist, arthroplasty is preferred over arthrodesis based on higher expected gain in quality-adjusted life years, although the minimal increase in utility suggests surgeons do not view arthroplasty as superior [150].

Anatomy & Pathophysiology¶

Osteoarthritis Pathophysiology¶

Osteoarthritis is a chronic synovial joint arthrosis affecting all synovial joint structures, including the synovium, joint capsule, cartilage, and bone [15]. It is a disease of the whole joint, affecting the functional unit of articular cartilage, subchondral bone, and synovium [152]. The condition consists of a generally progressive loss of articular cartilage accompanied by attempted repair, remodeling and sclerosis of subchondral bone, and the formation of subchondral bone cysts and marginal osteophytes [14]. A diagnosis requires the presence of symptoms and signs that may include joint pain, restriction of motion, crepitus with motion, joint effusions, and deformity [14]. Osteoarthritis occurs most frequently in the foot, knee, hip, spine, and hand joints [14].

Osteoarthritis is typically induced by acute or chronic mechanical injury to hyaline cartilage as a consequence of trauma, joint instability, ligamentous deficiency, skeletal malalignment, obesity, or anatomic deformity [15]. Mechanical overloading results in glycosaminoglycans loss, collagen disorganization, fibrillation, tissue swelling, surface wear, and incites an inflammatory response mediated by a cascade of cytokines [15]. Elevated cytokines in osteoarthritis synovial fluid, such as interleukin 1α and tumor necrosis factor-α, induce enzyme-mediated cartilage degeneration via metalloproteinases and ADAMTS [15]. In osteoarthritis, the synovial fluid's capacity for both fluid and boundary lubrication decreases due to a reduction in hyaluronic acid molecular weight and lubricin degradation [15]. In advanced osteoarthritis, synovial fluid contains minimal hyaluronic acid and lubricin, contributing to poor lubricity and a higher coefficient of friction similar to saline [15].

Histopathologically, osteoarthritis is characterized by the simultaneous presence of cartilage matrix degradation and repair including chondrocyte death, replication, and regeneration [15]. The earliest macroscopic sign of articular cartilage degeneration is fibrillation of its superficial layers [61]. As osteoarthritis progresses, superficial surface irregularities form clefts, the articular surface roughens, and fibrillations extend deeper into the cartilage until fissures invade the subchondral bone [61]. Articular cartilage degeneration in osteoarthritis can be broken down into three stages: cartilage matrix damage, chondrocyte response to tissue damage, and decline of chondrocyte synthetic response and progressive loss of chondral tissue [61]. In the first stage of osteoarthritis, the matrix molecular framework is altered and water content increases [61]. On a microscopic level, articular cartilage loses proteoglycan aggregation and experiences swelling, which leads to hypertrophy [61]. Chondrocytes increase synthesis of types II, IX, and XI collagen, aggrecan, and type IV collagen in an attempt to regenerate the extracellular matrix [61].

In most patients, damage to normal articular cartilage occurs by physical forces due to a single event of macrotrauma or repeated microtraumas [61]. In a smaller percentage of patients with altered joint biomechanics, past inflammatory joint diseases, congenital abnormalities, or metabolic syndromes, genetically defective cartilage fails under normal joint loading [61]. Subchondral bone remodelling is an integral part of osteoarthritis and involves the development of subchondral sclerosis seen on plain imaging, along with osteophyte formation [170]. The development of subchondral changes in osteoarthritis is due to persistent abnormal mechanical stresses which create a cellular and biomolecular response to microfractures in the subchondral bone and osteochondral junction [170]. An early sign of subchondral bone remodelling in osteoarthritis is bone marrow lesions seen on MRI scanning [170]. Microfractures of the osteochondral junction, coupled with articular cartilage fissuring and loss, allow synovial fluid to penetrate the subchondral bone along with cytokines and other molecules reacting with the bone cells [170]. Basic calcium phosphate crystals that contain hydroxyapatite have been detected in 70% of osteoarthritis cases, which correlate with the extent of cartilage degradation and lesion severity [92]. Basic calcium phosphate crystals activate joint cells including fibroblasts, macrophages, chondrocytes, and osteoclasts, which produce cartilage-degrading matrix proteinases and pro-inflammatory cytokines [92].

Posttraumatic osteoarthritis occurs after traumatic injury to the joint and is most common following injuries that disrupt the articular surface or lead to joint instability [133]. The reported risk of posttraumatic osteoarthritis following significant joint trauma is as high as 75% [133]. Articular fractures can increase the risk of posttraumatic osteoarthritis more than 20-fold [133]. The pathogenesis of posttraumatic osteoarthritis after intra-articular fracture is likely multifactorial and may be associated with acute cartilage injury as well as chronic joint overload secondary to instability, incongruity, and malalignment [133]. Approximately 12% of the overall symptomatic osteoarthritis burden can be attributed to posttraumatic osteoarthritis of the hip, knee, or ankle [133]. The annual healthcare costs associated with posttraumatic osteoarthritis in the United States are approximately $3 billion [133]. Post-traumatic osteoarthritis has an incidence of over 50% at 20 years after ACL tear and reconstruction [152]. The initial inflammatory response after joint injury may be harmful to the long-term health of articular cartilage and subchondral bone [152]. Aberrant overproduction of reactive oxygen species is a potential component of the biochemical inflammatory response to joint injury that may sensitize the joint to the development of post-traumatic osteoarthritis [152].

Wrist Anatomy¶

The wrist is the anatomic region between the forearm and the hand, including the distal radioulnar, radiocarpal, and ulnocarpal joints and the eight carpal bones and their proximal and distal articulations and attached ligaments [72]. The eight carpal bones include the scaphoid, lunate, triquetrum, and pisiform in the proximal row and the trapezium, trapezoid, capitate, and hamate in the distal row [72]. The carpal bones vary in size from the smallest, the pisiform and trapezoid, to the largest, the capitate [72]. The amount of articular cartilage allowing for articulation varies from one bone by the pisiform (the triquetrum) to seven bones by the capitate [72]. The radiocarpal joints are formed by the articulation of the distal radius with the scaphoid and lunate through their respective concave facets on the distal radius and the triquetrum on the triangular fibrocartilage [72]. The distal concave articular surfaces of the proximal carpal row form the midcarpal articulations with the distal row [72]. The distal row articulates with the metacarpals, allowing mobility in the thumb, stability in the index and long finger metacarpals, and increased mobility in the ring and little finger metacarpals [72].

The distal ulnar convexity articulates at the lesser sigmoid notch of the distal radius [72]. The sigmoid notch articular surface accommodates the ulnar head through two thirds of its arc [72]. There is about a 20-degree inclination of the distal ulna at its articulation with the radius [72]. The ulnar styloid lies dorsal to the ulnar head and extends distally [72]. The triangular fibrocartilage attaches to the base of the ulnar styloid and separates the hyaline cartilage–covered ulnar head from the styloid [72]. The chondroligamentous supports attaching the distal radius and ulnar side of the carpus to the distal ulna are designated as the triangular fibrocartilage complex [72]. The triangular fibrocartilage complex includes the ulnar collateral ligament, the dorsal and volar radioulnar ligaments, the articular disc, the meniscal homologue, the extensor carpi ulnaris sheath, and the ulnolunate and ulnotriquetral ligament [72].

Interosseous ligaments include the scapholunate and lunotriquetral interosseous ligaments connecting the proximal carpal row and the ligaments connecting the trapezium to the trapezoid, the trapezoid to the capitate, and the capitate to the hamate in the distal carpal row [72]. Extrinsic or crossing ligaments include the radial collateral ligament from the radial styloid to the scaphoid waist, the ulnar collateral ligament from the base of the ulnar styloid attaching to the pisiform, and the transverse carpal ligament [72]. The volar extrinsic or crossing ligaments include the radioscapocapitate ligament, the radiolunotriquetral ligament, and the radioscapolunate ligament on the radial side and the ulnolunate and ulnotriquetral components of the triangular fibrocartilage complex on the ulnar side [72]. On the palmar side of the carpus, between the radiolunotriquetral ligament and the radioscapocapitate ligament, is a relatively thin area, the space of Poirier, overlying the palmar surface of the lunate [72]. Dorsally, the identifiable extrinsic ligaments include the dorsal radiocarpal and the dorsal intercarpal ligaments [72]. The trapezoidal dorsal radiocarpal ligament attaches along the dorsal radial articular margin of the lunate fossa, from the Lister tubercle to the lesser sigmoid notch [72]. The dorsal radiocarpal ligament spans the lunotriquetral joint and inserts on the dorsal surface of the triquetrum [72]. The dorsal intercarpal ligament is attached to the distal, dorsal surface of the triquetrum and passes across the midcarpal joint to attach to the dorsal surfaces of the scaphoid waist and the trapezoid [72].

The distal radius has three articular components: distally the scaphoid and lunate fossae, and the sigmoid notch which allows articulation with the ulna medially [76]. Between the scaphoid and the lunate fossa is a ridge that corresponds with the scapholunate interval [76]. The entire articular surface of the distal radius is covered with articular cartilage [76]. The radial styloid allows attachment of the brachioradialis tendon and is the origin of several important wrist ligaments, including the radial scapholunate and radial lunocapitate ligaments [76]. The sigmoid notch is a convex structure that allows the radius to rotate around the distal ulna [76]. The distal ulna has an ulnar styloid which contains attachments to the triangular fibrocartilage complex, including the meniscus homolog, the volar and dorsal ulnar carpal ligaments, and the ulnar collateral ligament at the wrist [76]. The concave elliptical distal radius is oriented in the sagittal plane with an average of 11 degrees of volar tilt [76]. In the frontal plane, the average radial inclination of the distal radius is 23 degrees [76]. Radial length is measured from the tip of the radial styloid to the ulnar articular surface and averages 13 mm [76].

On the dorsal surface of the wrist, six dorsal compartments contain wrist and digital extensor tendons [76]. On the volar surface reside the contents of the carpal tunnel, with nine flexor tendons and the median nerve [76]. On the ulnar surface, the flexor carpi ulnaris tendon can be palpated near its insertion on the pisiform [76]. The boundaries of the ulnar tunnel, or Guyon’s canal, are the volar carpal ligament and transverse carpal ligament, the hook of the hamate radially, and the pisiform ulnarly [76]. Guyon’s canal contains the ulnar artery and nerve [76]. The ulnar shaft remains fixed in its rotation at the ulnohumeral joint, and the radius rotates around the ulna in pronation and supination [76]. The radius has a lateral bow that is crucial to the maintenance of full pronation and supination [76]. The interosseous membrane in the interosseous space connects the shafts of the radius and ulna [76]. The central portion of the interosseous membrane is thickened and has been shown to be important in force transmission between the radius and ulna [76].

The distal radius articular surface has two concave facets, the scaphoid and lunate facets, separated by the scapholunate, or anterior-posterior, ridge [79]. The sigmoid notch along the ulnar border of the distal radius is a shallow concavity for the articulating ulnar head at the distal radioulnar joint [79]. The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces [79]. The ulnar styloid projects distally; at its base, the fovea is the insertion for the triangular fibrocartilaginous complex [79]. The scaphoid's primary vascular supply is a branch of the radial artery at the dorsal ridge [79]. A group of smaller vessels enters the palmar tubercle of the scaphoid and supplies the distal 30% [79]. The transverse carpal ligament attaches to the palmar tubercle of the scaphoid [79]. A dorsal and a palmar vascular supply are found in 80% of wrists for the lunate; in 20% of wrists, only a palmar supply is found [79]. The lunate is broader palmarly than dorsally [79].

The triquetrum articulates with the hamate distally, the lunate radially, and the pisiform volarly [79]. The triquetrum is stabilized to the fovea of the ulna through the ulnotriquetral ligament [79]. The hamate consists of the body and the hook (hamulus) of the hamate, which serves as an attachment for the transverse carpal ligament and for the origins of the flexor digiti minimi and opponens digiti minimi [79]. The head of the capitate often relies on a retrograde vascular supply [79]. Two ridges separate the distal articular surface of the capitate into three facets for articulation with the metacarpals of the index, long, and ring fingers [79]. The trapezoid has two distal facets, which articulate with the metacarpal of the index finger [79]. The trapezium has a saddle-shaped articulation with the base of the thumb metacarpal [79]. The trapezium has a palmar groove for the flexor carpi radialis, bordered laterally by a palmar tuberosity and the attachment for the transverse carpal ligament [79]. The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon [79]. The pisiform is the origin for the abductor digiti minimi [79].

The extrinsic wrist ligaments include the dorsal intercarpal ligament and the dorsal radiocarpal ligament [79]. The intrinsic wrist ligaments include the scapholunate interosseous ligament and the lunotriquetral interosseous ligament [79]. The scapholunate interosseous ligament is C-shaped in the sagittal plane [79]. The dorsal third of the scapholunate interosseous ligament is the thickest, strongest portion of the ligament [79]. The volar portion of the lunotriquetral ligament is the thickest [79]. The triangular fibrocartilage complex is formed by the central meniscus homolog, the dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris tendon sheath, and the volar ulnocarpal ligaments [79]. The triangular fibrocartilage complex arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna through the ligamentum subcruentum [79]. The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [79]. Only the peripheral 10% to 40% of the volar, ulnar, and dorsal triangular fibrocartilage complex has a vascular supply [79]. The terminal branches of the radial, ulnar, and anterior interosseous arteries provide extraosseous blood supply to the carpus through three dorsal and three palmar transverse arterial arches with longitudinal connections [82]. The dorsal radiocarpal arch is located at the radiocarpal joint and supplies the lunate and

Classification¶

General Osteoarthritis Pathology and Definition¶

Osteoarthritis is a chronic, synovial joint arthrosis afflicting 140 million people worldwide [15]. It consists of a generally progressive loss of articular cartilage accompanied by attempted repair of the cartilage, remodeling and sclerosis of subchondral bone, and, in many instances, the formation of subchondral bone cysts and marginal osteophytes [14]. The disease affects all synovial joint structures, including the synovium, joint capsule, cartilage, and bone [15]. While the etiology is multi-factorial, osteoarthritis is typically induced by acute or chronic mechanical injury to hyaline cartilage as a consequence of trauma, joint instability, ligamentous deficiency, skeletal malalignment, obesity, or anatomic deformity [15]. Mechanical overloading results in glycosaminoglycans (GAG) loss, collagen disorganization, fibrillation, tissue swelling, surface wear, and incites an inflammatory response mediated by a cascade of cytokines [15]. Elevated cytokines in OA synovial fluid (eg, interleukin 1α [IL‐1α], tumor nucrosis factor‐α) induce enzymemediated (eg, metalloproteinases and ADAMTS) cartilage degeneration [15]. In advanced OA, synovial fluid contains minimal hyaluronic acid and lubricin, further contributing to poor lubricity and higher coefficient of friction (similar to saline) [15]. Histopathologically, OA is characterized by the simultaneous presence of cartilage matrix degradation and repair including chondrocyte death, replication, and regeneration [15]. Degenerative joint disease is a focal process, probably related to mechanical stresses, and not to a generalized matrix deficiency [21]. Joint cartilage shows a remarkable degree of plasticity, the various structural zones play different roles in the response to stress, and changes in mechanical behavior with age are related to changes in fibrillar texture and cellular grouping [140].

Wrist and Hand Osteoarthritis Patterns¶

Wrist osteoarthritis comprises primary or secondary degenerative joint diseases and is associated with chronic pain, loss of strength, and functional impairment [145]. In Germany, the number of affected individuals with wrist osteoarthritis increased from 472,492 in 2018 to 580,526 in 2024 [145]. This rise corresponds to an increase in standardized prevalence from 6.5 to 7.8 per 1,000 individuals [145]. Age- and sex-specific analyses demonstrate a pronounced increase in disease burden with advancing age as well as a higher incidence among women [145]. Wrist osteoarthritis is particularly marked in individuals aged 60 years and older [145]. Wrist osteoarthritis frequently develops secondarily following traumatic ligamentous, cartilaginous, osseous lesions, infections, or osteonecrosis [145]. Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought, with isolated osteoarthritis of the scaphotrapeziotrapezoidal joint being the most prevalent pattern [18]. Contrary to previous reports, the SLAC pattern of arthritis does not represent the majority of the patterns of degeneration encountered [19].

Thumb Carpometacarpal (CMC) Joint Classification¶

Burton: The Burton classification system for trapeziometacarpal arthritis utilizes clinical signs, patient symptoms, and radiographs [177]. Stage I involves early degeneration of the trapeziometacarpal joint characterized by patient reported pain, a positive grind test, and ligamentous laxity demonstrated by subluxation in a dorsoradial direction [177]. Stage II demonstrates increased instability, chronic subluxation, and degenerative changes evidenced by radiograph [177]. Stage III is a further progression of the degeneration to involve the scaphotrapezial joint [177]. Stage IV is either stage II or III with metacarpophalangeal joint changes [177]. The Burton classification depends on subjective symptoms and objective signs rather than pure radiographic changes and makes large transitions from stage to stage in terms of degenerative changes on radiograph without subclassifying finer differences [177].

Eaton: The Eaton classification relies on radiographic changes only, removing the patient's symptoms and signs from the staging process [177]. Radiographic staging of TMC arthrosis has moderate interobserver and intra-observer reliability [62]. There is only fair inter-observer agreement in treatment recommended based on radiographic staging (kappa 0.33) [62].

Roentgenographic Evaluation: Roentgenographic evaluation of basal joint arthritis has been highly inaccurate, often tending to overdiagnose the extent of basal joint disease [185]. Elongation of the common osteophyte on the palmar (deep) horn of the thumb metacarpal facet of the trapezium frequently projects across the index metacarpal facet, which gives it the roentgenographic appearance of also being diseased [185]. In a cadaver study correlating roentgenographic with anatomic findings, the index and trapezoid facets are rarely involved (1%), whereas in specimens in which the CMC facet of thumb was arthritic, the scaphotrapezial facets were also involved in 46% of cases [185]. With a true lateral view (metacarpophalangeal [MP] sesamoids superimposed), degeneration of the facets of the trapezium, the basal joints, can be divided into four stages [185]. Stage I of basal joint degeneration precedes any cartilage degeneration, articular contours are normal, and the joint space may be widened if an effusion is present [185]. Stage II of basal joint degeneration presents slight narrowing of the trapeziometacarpal joint of the thumb, but articular contours are maintained, and joint debris, when present, is <2 mm in size [185].

Shoulder and Elbow Arthritis Classification¶

Walch: The Walch classification provides a useful frame of reference when assessing subluxation and glenoid morphology in primary glenohumeral osteoarthritis, but it does not allow perfect agreement among observers [125]. Using the "area index" and consistent radiological views makes future comparisons more reliable than the Samilson-Prieto classification alone [168].

Elbow: Inflammatory arthritis remains the most common indication for total elbow arthroplasty in recent years, accompanied by an increase in the incidence of revision surgery [12]. The incidence of Outerbridge grade II-IV lesions in the glenohumeral joint is estimated at 5% during arthroscopic evaluation [63]. These glenohumeral cartilage lesions may be related to a wide spectrum of pathology, including idiopathic focal defects, chondrolysis, posttraumatic defects, OCL, avascular necrosis, postsurgical cartilage abnormalities, and osteoarthritis [63].

Rheumatoid Arthritis Classification¶

The 1958 revised criteria for rheumatoid arthritis are hoped to aid in obtaining more uniformity in the classification of patients with rheumatoid arthritis and should be reviewed in two or three years [41]. The differential expression of genes in RA compared with OA indicates potential targets for molecular diagnosis and treatment [167].

Diagnostic Imaging and Grading Limitations¶

A universal and definitive grading system for lesions is necessary, and measurement devices are needed for objective cartilage grading in questionable cases [99]. Marked radiographic differences in modified Eaton score distinguish progressing from stable OA, indicating that structural progression is a key marker of disease advancement [4]. Each of the three osteoarthritic rat models showed a specific pattern of osteoarthritis progression [135]. The severity of the osteoarthritis of the distal radioulnar joints can be evaluated according to the scoring system of Kellgren and Lawrence (1957), which depends on radiological features including osteophyte formation, the presence of periarticular ossicles, narrowing of the joint cartilage and sclerosis of the subchondral bone to grade disease as none (0), doubtful (1), minimal (2), moderate (3) or severe (4) [192].

Clinical Presentation¶

Osteoarthritis affects any synovial joint [14], with structural and functional changes appearing relatively late in the disease process but driving long-term morbidity and disability [15]. The pathophysiology involves elevated cytokines in synovial fluid, specifically interleukin 1α (IL-1α) and tumor necrosis factor-α, which induce enzyme-mediated cartilage degeneration [15]. In advanced disease, synovial fluid contains minimal hyaluronic acid and lubricin, resulting in poor lubricity and a higher coefficient of friction [15]. While joint replacement is indicated for end-stage osteoarthritis [2], understanding this physiopathology clarifies mechanisms by which minimally invasive interventions might halt or reverse early-stage disease [13]. Although many biomarkers are available, none currently serve as surrogate markers for clinical or imaging features for diagnosis or prognosis [42].

Imaging and Diagnostic Modalities¶

Magnetic resonance imaging (MRI) is evolving as a complete solution for cartilage imaging, addressing lesion description, treatment planning, and outcome measurement [44]. As a noninvasive tool, MRI overcomes radiographic shortcomings by detecting preclinical disease and subtle early abnormalities [44]. In rheumatoid arthritis, the application value of MRI for diagnosing subclinical inflammation in patients in remission is established [1], supporting the importance of early diagnosis and treatment to prevent joint destruction [1]. However, MRI reliability varies by joint; scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis [24]. Some studies report over 80% changes in MRI and plain radiographs even in asymptomatic joints, raising concerns about MRI’s usefulness in guiding treatment for acromioclavicular arthritis [24]. Stein et al. found bone marrow oedema in 80% of patients with symptomatic acromioclavicular arthritis, concluding its presence may assist treatment decision-making [24]. Conversely, Choo et al. did not find marrow oedema reliable and suggested capsular distension on MR arthrography is a more predictive finding for symptomatic acromioclavicular arthritis [24].

Specific exfoliative cytological patterns in aspirated joint fluids can be readily recognized in various arthritides, supporting the technique as a valuable diagnostic aid [102]. In patients with suspected inflammatory arthritis, routine ultrasound use in newly referred patients is associated with significantly earlier diagnosis and DMARD initiation [94].

Specific Joint Presentations¶

Acromioclavicular Joint¶

Acromioclavicular joint arthritis is a common cause of shoulder pain [24]. The joint is incongruous and often begins degenerating as early as the second decade of life [24]. Although degenerative changes start early, most joints become symptomatic in the fifth decade [24]. Asymptomatic acromioclavicular osteoarthritis remained asymptomatic in 90% of cases over 7 years [16]. In glenohumeral arthritis, there were no differences in the need for secondary intervention based on the severity of radiographic osteoarthritis or baseline shoulder dysfunction [17].

Wrist and Hand¶

Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought [18]. Isolated osteoarthritis of the scaphotrapeziotrapezoidal joint is the most prevalent pattern of wrist osteoarthritis [18]. Contrary to previous reports, the SLAC pattern does not represent the majority of degeneration patterns in radiocarpal and midcarpal arthritis [19]. The prevalence of midcarpal arthritis in patients with basal joint arthritis is 24% [105]. When treating osteoarthritis at the base of the thumb, the presence of pre-arthritic lesions or established wrist arthritis, even if treated, must be taken into consideration [25]. Surgical treatment of wrist osteoarthritis aims to eliminate pain while preserving motion in adjacent joints, with the specific procedure chosen based on the location of arthritis and patient factors [26].

In early carpometacarpal osteoarthritis, marked radiographic differences in the modified Eaton score distinguish progressing from stable disease [4]. Structural progression is a key marker of disease advancement in early carpometacarpal osteoarthritis [4]. Diagnostic indications for basal joint arthroscopy include the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis [5]. The size of the opponens pollicis muscle may have a weak association with the diagnosis of early thumb carpometacarpal osteoarthritis [54]. Thumb adduction and extension provocative tests were more specific for basal joint arthrosis than the elicitation of point tenderness at the joint [49].

Arthritis of the distal radioulnar joint can be primary or secondary to inflammatory, congenital, or post-traumatic conditions [53]. In a cross-sectional study from Japan, 12% of patients had primary osteoarthritis of the distal radioulnar joint [53]. The prevalence of primary osteoarthritis of the distal radioulnar joint was 13% in a European study with patients over 50 years old [53]. Radiographic abnormalities in the distal radioulnar joint developed in 78% of patients with rheumatoid arthritis [53]. An important complication of osteoarthritis of the distal radioulnar joint is extensor tendon rupture [53]. Patients with distal radioulnar joint osteoarthritis may complain of ulnar wrist pain, loss of grip strength, and stiffness [53]. Symptoms may be worse when there is instability of the distal ulna or other conditions causing ulnar wrist pain, such as ulnocarpal impaction, tendonitis, and lesions of the triangular fibrocartilaginous complex or lunotriquetral ligament [53]. Arthritis of the distal radioulnar joint could also be a radiological finding without much clinical importance, with the majority of patients remaining asymptomatic [53]. Initial management of symptomatic distal radioulnar joint arthritis is nonsurgical, with surgery reserved for patients with refractory pain [48]. Excision of pisotriquetral loose bodies appears to provide satisfactory relief of symptoms in patients without evidence of joint degeneration [107].

Shoulder¶

The most common symptoms of sternoclavicular joint osteoarthritis are pain, tenderness, and swelling of the joint [45]. Diagnostic imaging for sternoclavicular joint osteoarthritis was computed tomography in 58.3% of cases or magnetic resonance imaging in 41.7% of cases [45]. Arthroscopic debridement with capsular release may provide a window of improved symptoms and function before joint deterioration leads to a more significant operation, especially in younger patients with mild or moderate osteoarthritic changes [108]. A review describes the challenges associated with the diagnosis and management of glenohumeral arthritis and provides a treatment framework for use in these challenging patients [46].

Other Joints and Conditions¶

Deceptive clinical manifestations of tuberculous carpal osteoarthritis, often presenting as chronic monoarthritis, lead to diagnostic and therapeutic delays responsible for irreversible functional lesions [9]. The final diagnosis of palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time [10]. While joint involvement in familial Mediterranean fever is typically transient, permanent joint damage can occur, particularly in older children at onset [50]. The diagnosis of the articular manifestations of periodic disease (familial Mediterranean fever) is clinical, based on the association of monoarticular arthritis with recurrent fever and abdominal pain, as there are no specific laboratory aids [95]. Patients with underlying wrist arthritis may be at risk for delay in diagnosis of Group B β-hemolytic streptococcal arthritis and osteomyelitis of the wrist [97]. Physicians should be aware of Charcot joint disease presentation in patients with insensate joints to avoid overtreatment [104]. The revised criteria for rheumatoid arthritis are hoped to aid in obtaining more uniformity in the classification of patients with rheumatoid arthritis and should be reviewed in two or three years [41].

Investigations¶

General Principles: Associated treatments for osteoarthritis cost $125 billion annually [15]. Changes in joint structure and function appear relatively late in the osteoarthritis disease process but account for long-term morbidity and disability [15]. Mechanical overloading in osteoarthritis results in glycosaminoglycan loss, collagen disorganization, fibrillation, tissue swelling, surface wear, and an inflammatory response mediated by a cascade of cytokines [15]. Elevated cytokines in osteoarthritis synovial fluid induce enzyme-mediated cartilage degeneration [15]. Degenerative joint disease is a focal process probably related to mechanical stresses, not a generalized matrix deficiency [21]. Early diagnosis and treatment are important for preventing joint destruction in rheumatoid arthritis [1]. Although many osteoarthritis-related biomarkers are currently available, none can be considered a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease at this time [42].

MRI: The primary advantages of MRI compared with CT and radiography are improved tissue characterization, especially of soft tissues such as ligamentous structures in the wrist and synovium in the hand, and the lack of ionizing radiation [78]. MRI is the modality of choice for imaging radiographically occult fractures of the hand and wrist [78]. Modern MRI is generally at 1.5T or 3T, with 3T much preferred for hand and wrist imaging, especially for imaging small fields of view [78]. 7T MRI has recently become approved for clinical use and has the potential to become a powerful tool for hand and wrist imaging as applications are developed [78]. MRI with contrast enhancement is most commonly used to determine whether soft-tissue lesions are solid or cystic or, in the case of rheumatologic imaging, to better visualize erosions and synovial burden [78]. Dynamic contrast enhancement has been used with inconsistent results to assess for the presence of avascular necrosis in the lunate or scaphoid after injury [78]. MR angiography of the hand and wrist can be helpful in situations such as diagnosis of the hypothenar hammer syndrome [78]. MR arthrography can be performed for evaluation of the triangular fibrocartilage and intercarpal ligament tears, but this is generally unnecessary with the increasing availability of high field MRI [78].

A properly performed, high-resolution MRI aids in the evaluation of ligament injuries of the wrist [85]. A static magnetic field strength of at least 1.5 T using a dedicated wrist coil is recommended for analyzing the interosseous, intrinsic, and extrinsic ligament insertions [85]. The volar extrinsic, scapholunate interosseous, dorsal intercarpal, and lunotriquetral ligaments are best visualized using 1 mm slices with no interslice gap in the coronal plane [85]. The dorsal radiocarpal and intercarpal ligaments are best viewed on both the coronal and sagittal images [85]. Oblique axial views along the longitudinal axes of ligaments allow further analysis, especially when an injury is suspected [85]. Concomitant cartilage-sensitive imaging is integrative to influence the assessment and surgical management, as cartilage integrity will influence clinical and surgical management, especially in the setting of scapholunate advanced collapse wrist [85]. Real-time MRI has been used to investigate dynamic instabilities, although its routine use in clinical practice is yet to be further determined [85]. T2-weighted images in the coronal plane proved to be of the greatest diagnostic value for the triangular fibrocartilage complex because the synovial fluid of the joint spaces serves as an excellent endogenous contrast agent [189].

MRI has an expanding role in the evaluation of inflammatory arthritis, providing earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs [87]. MRI is more reproducible in the assessment of glenoid version in osteoarthritis and provides excellent intraobserver and interobserver reliability [182]. The application value of MRI in the diagnosis of subclinical inflammation in patients with rheumatoid arthritis in remission has been evaluated [1]. Asymptomatic acromioclavicular osteoarthritis diagnosed by MRI remained asymptomatic in 90% of cases over 7 years [16]. Patients with edema on MRI were more likely to present pain than patients without edema in acromioclavicular joint osteoarthritis [156]. Subchondral bone edema on histologic examination was more frequent in patients with pain in acromioclavicular joint osteoarthritis [156]. MRI can provide an evaluation of the morphologic and compositional quality of cartilage repair [63].

Radiography and CT: Marked radiographic differences in modified Eaton score distinguish progressing from stable osteoarthritis, indicating that structural progression is a key marker of disease advancement [4]. Contrary to previous reports, the scapholunate advanced collapse pattern of arthritis does not represent the majority of the patterns of degeneration encountered [19]. Glenoid retroversion is increased in patients with severe arthritis compared to normal subjects [197]. Computerized tomographic scans accurately reveal the extent and pattern of bone erosion in severe arthritis [197]. CT scanning enables the 3D analysis of carpal dysfunction [85]. By adding motion in real time (4D CT), this may hold promise in the future to potentially quantify the location and degree of injury noninvasively and help surgeons plan their surgical treatment [85]. Joint space width evaluation has a potential diagnostic value in the work-up of patients with suspected pisotriquetral osteoarthritis [195]. Clinical-radiologic correlation revealed many asymptomatic patients with calcification and arthropathy and many symptomatic patients with normal radiographs in calcium pyrophosphate dihydrate crystal deposition disease [183]. Radiographic acromioclavicular joint osteoarthritis is common in patients undergoing reverse shoulder arthroplasty [143].

Arthroscopy and Other Diagnostic Modalities: Diagnostic indications for basal joint arthroscopy include the assessment of painful post-traumatic basal joint lesions of cartilage and ligaments, and the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis [5]. Arthroscopy is considered by many to be the diagnostic intervention of choice for determining the degree of injury to the wrist and can assess the condition of the cartilage, ability to reduce the carpus, and any other associated injuries [85]. The degree of intrinsic and extrinsic ligament injury can be identified from the arthroscopic evaluation [85]. Geissler grade II scapholunate interosseous ligament injuries tend to be isolated, whereas grade IV injuries often involve complete dorsal extrinsic ligament disruption [85]. Dynamic fluoroscopy shows abnormal motion between the scaphoid and lunate and changes in the kinematics of the midcarpal joint [85]. Live imaging shows whether the dorsal intercalated segment instability is reducible, giving the physician valuable information as the treatment is planned [85]. The thumb adduction and extension provocative tests were more specific for basal joint arthrosis than was the elicitation of point tenderness at the joint [49]. There were no differences in the need for secondary intervention based on the severity of radiographic osteoarthritis or baseline shoulder dysfunction after a single, image-guided corticosteroid injection for glenohumeral arthritis [17].

Treatment¶

General Principles and Disease Course¶

There is currently no curative treatment for osteoarthritis [139]. While existing literature demonstrates the anti-inflammatory properties of orthobiologics, no treatment has clearly demonstrated significant joint preservation properties, including the ability to reverse the progression of osteoarthritis [112]. Current clinical treatments for articular cartilage defects have a limited ability to repair tissue and often result in mechanically inferior cartilage [116]. Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage [60]. The understanding of osteoarthritis physiopathology clarifies the core mechanisms by which minimally invasive interventions might be able to halt and reverse the course of early-stage OA [13]. None of the current experimental methods for facilitating cartilage repair have been shown to stimulate the formation of tissue that duplicates the structure, composition, mechanical properties, and durability of articular cartilage or to improve function and relieve symptoms predictably in osteoarthritic joints [129]. Improvements in controlling synovitis in rheumatoid arthritis have not resulted in comparable reductions in disability measured by HAQ [110].

Non-Operative¶

An initial trial of nonsurgical management is usually warranted for articular cartilage injuries, taking the form of rest, activity modification, anti-inflammatory medications, physical therapy, bracing treatment, or injections [90]. For joints that show degenerative changes or where symptomatic osteoarthritis is present, non-operative treatments are used clinically but largely only manage the symptoms until progressive joint degeneration becomes so severe that a total joint replacement must be performed [139]. Nonoperative treatment is almost always initiated for primary and posttraumatic arthritis of the elbow, although surgical treatment may be indicated in cases refractory to conservative management [175]. Nonoperative modalities should be utilized before surgical options for shoulder osteoarthritis, particularly for patients with moderate-to-mild disease [153]. Treatment of Kienböck’s disease is stage-dependent, ranging from nonoperative management in early stages to revascularization, unloading procedures, or arthrodesis in advanced stages [157]. There is no evidence to guide clinicians about the individual or combined effectiveness of nonpharmacological interventions for individuals with persistent acromioclavicular joint osteoarthritis [120], though conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management [148]. Further research is needed to determine the efficacy of physical therapy for patients with moderate glenohumeral arthritis as well as the utility of preoperative physical therapy for improving postoperative outcomes [128]. Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care [159]. Healthcare professionals should support patients with thumb base osteoarthritis in a self-management programme to optimise outcome [111]. Self-management for thumb base osteoarthritis should be individualised to patients to ensure the relevance of the information and treatment, for example, exercises tailored to address specific deficiencies and task modification tailored to the aggravating activities [111]. The results show a non-pharmacological treatment gap in osteoarthritis care, with most patients reporting no pain or mild pain and having not received non-pharmacological treatment prior to surgical consultation [164]. Most videos regarding conservative management of carpometacarpal osteoarthritis have limited evidence to support their content, and expert clinicians are rarely represented in these resources [171]. Long-term administration of glucosamine and chondroitin sulfate reduced cartilage degeneration at 8 months of age in a model of spontaneous osteoarthritis in Hartley guinea pigs [33]. There is considerable variation in the practice of both non-surgical and surgical management of base of thumb osteoarthritis [190].

Operative¶

Indications: Surgical treatment for wrist osteoarthritis aims to eliminate pain while preserving motion in adjacent joints, with the specific procedure chosen based on the location of arthritis and patient factors [26]. Arthroplasty is indicated for fibrous or bony ankylosis of the elbow, partial ankylosis with insufficient motion, or pain as a disabling factor in patients aged 20 to 50 [113]. Indications for surgery for first carpometacarpal joint arthritis are disabling pain not relieved by conservative measures and X-ray changes confirming the presence of 1st CM arthritis [136]. If a neuropathic joint becomes grossly unstable, total joint arthroplasties are contraindicated, but careful joint debridement, osteotomies, or arthrodesis may improve function and stability [56]. Arthroplasty should be used as an alternative to arthrodesis in the treatment of posttraumatic wrist arthritis, given the proper patient selection and indications [119].

Surgical Approach / Technique: Surgical management of articular cartilage injuries should focus on removing inflammatory mediators and restoring the osteochondral unit [90]. Surgical options for articular cartilage injuries include arthroscopic débridement, bone marrow stimulation, osteochondral autograft transfer, osteochondral allograft transplantation, autologous chondrocyte implantation, and various newer, emerging techniques [90]. Proper indication for autologous osteochondral grafting relies on identifying and simultaneously correcting malalignment and/or traumatic changes in affected joints [51]. Both arthroscopic and open approaches can result in excellent clinical outcomes for patients with symptomatic sternoclavicular joint arthritis [59]. Diagnostic imaging for sternoclavicular joint osteoarthritis was computed tomography in 58.3% of patients or a magnetic resonance imaging scan in 41.7% [45]. Early results indicate satisfactory short-term outcomes for joint preservation procedures in young, active patients with glenohumeral osteoarthritis, though these procedures have yet to show they can halt arthritic progression [8]. Clinical studies report that an arthroscopic approach to glenohumeral arthritis using various joint-preserving procedures reduces pain, improves function, and improves clinical outcome scores in the short- to mid-term follow-up period [37]. Surgical treatments like arthroplasty are considered effective for severe cases of shoulder osteoarthritis [153]. Dorsoradial capsulodesis for Stage I trapeziometacarpal joint arthrosis showed no midterm progression to advanced arthritis in the studied cohort [6]. A systematic review provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis, with some interventions showing moderate-to-large superior effects compared with others [121]. Although indications for first carpometacarpal joint suspension arthroplasty with palmaris longus tendon graft are limited, it adds an additional option for complicated cases of thumb base arthritis [117]. Proximal-row carpectomy should be considered after conservative measures fail for diseases of the proximal row, as mild degenerative arthritis is not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur [47]. Treatment of the symptomatic degenerative triscaphe joint by triscaphe arthrodesis was found to be successful in relieving pain, preserving a useful arc of motion greater than 100 degrees and preventing further degenerative changes at an average of 5 years after operation [124].

Other Considerations: Radiographic staging of trapeziometacarpal arthrosis has moderate interobserver and intra-observer reliability [62]. There is only fair inter-observer agreement in treatment recommended based on radiographic staging of trapeziometacarpal arthrosis (kappa 0.33) [62]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [38]. Despite advancements in management, in most scenarios there is no single preferred option for wrist osteoarthritis [179]. Osteoarthritis and traumatic arthritis management can be a challenge to the surgeon, the therapist, and especially the patient, with both nonsurgical and surgical care requiring careful planning to achieve pain control and restoration of optimal function [115]. The International Consensus Meeting recommended that disease-modifying antirheumatic drugs should be halted prior to elective total joint arthroplasty based on their half-life, with cessation performed under the direction of the treating physician [29]. Intra-articular TNFi therapy appears to have equal efficacy to intra-articular steroids for rheumatoid arthritis, though the optimal dose and frequency of injections is yet unknown [127]. Mesenchymal stromal cells are being tested in patient studies for a wide range of conditions such as osteoarthritis, rheumatoid arthritis, fracture repair, regeneration of articular cartilage, tendon repair and for treatment of degenerative disc disease [57]. The effectiveness of mesenchymal stromal cells as a treatment modality for these conditions is still uncertain and market authorisations have been limited [57]. Critical and clear phenotypic parameters for defining mesenchymal stromal cells are uncertain and a coherent biological framework surrounding the therapeutic mechanism of action is not yet available [57]. Cell manufacturing protocols for mesenchymal stromal cells are complex and costly and present substantial challenges in terms of regulatory oversight and standardisation [57].

Complications¶

The evidence base for this section does not support the standard arthroplasty complication categories (e.g., infection, aseptic loosening, periprosthetic fracture). Instead, the available data addresses diagnostic pitfalls, disease progression, and specific surgical outcomes across various joint arthropathies.

Diagnostic and Prognostic Complications: Asymptomatic acromioclavicular osteoarthritis diagnosed by MRI remained asymptomatic in 90% of cases over a seven-year period [16]. In the hand, marked radiographic differences in the modified Eaton score distinguish progressing from stable early carpometacarpal osteoarthritis, indicating that structural progression is a key marker of disease advancement [4]. The SLAC pattern of arthritis does not represent the majority of the patterns of degeneration encountered in radiocarpal and midcarpal arthritis [19]. In the cervical spine, the progressive nature of cervical rheumatoid disease resulted in the recurrence of long-tract symptoms in three patients due to further subaxial subluxation distal to the original fusion site [67].

Surgical Complications and Outcomes: Total wrist arthroplasty in rheumatoid arthritis patients showed a complication rate of 75% and mobility was lost in 33% of the surviving implants [35]. Total distal radioulnar joint arthroplasty shows appropriate mid- to long-term implant survivorship and satisfactory functional gains, though complication and reoperation rates warrant cautious interpretation [28]. In a series of nearly 700 consecutive cases of thumb basal joint arthroplasty, an unexpected early reoperation rate of 1.5% was identified, with only a 0.6% reoperation rate specifically for painful subsidence requiring a revision arthroplasty [70]. Revision surgery for failed trapeziometacarpal joint arthritis can result in satisfactory long-term outcomes particularly when metacarpophalangeal joint pathology is addressed and complications are avoided [173]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for radial head arthroplasty [176]. Early synovial chondromatosis can progress to extensive chondromatosis, with subsequent subluxation of the hip and marked degenerative osteoarthritis that led to total hip replacement [191]. The danger of abnormal growth from rheumatoid inflammation is an indication for synovectomy, especially in children with unilateral knee involvement [165].

Disease Progression and Structural Changes: The stiffening of 38 percent from a normal to an early arthritic condition was accompanied by a trabecular contiguity change from 0.7 to 0.8 in human subchondral cancellous bone [71]. Early results of glenohumeral joint preservation procedures indicate satisfactory short-term outcomes, though these procedures have yet to show they can halt arthritic progression [8]. Bone-preserving arthroplasty with abductor pollicis longus tenodesis showed satisfying results in patients presenting with early-stage trapeziometacarpal osteoarthritis, although a larger study population and a longer follow-up period are needed to draw conclusions [69]. Suture button suspensionplasty for carpometacarpal arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates [158]. With an implant survivorship of 90% at an average of 10 years postoperatively, silicone implant arthroplasty remains the treatment of choice for the symptomatic osteoarthritic proximal interphalangeal joint [34]. Combined with synovectomy and ulnar head resection, radiolunate arthrodesis confers on the wrist mobility, stability, and physiologic ulnar orientation of the hand, which prevents or partially corrects ulnar deviation of the fingers [36]. There has been no long term deterioration of wrist function following costo-osteochondral grafts in the wrist [30]. At the last follow-up, arthritis had not developed in any patient treated with minimally invasive surgery for perilunate dislocations and fracture dislocations [32]. Clinical experience and literature analysis do not support the commonly held assumption that untreated distal radial fractures lead to symptomatic osteoarthritis [68]. Early diagnosis and treatment are important for preventing joint destruction in patients with rheumatoid arthritis in remission [1].

Other Considerations: Further research is required in anatomic and biomechanic studies, experience in inflammatory arthropathy, and long-term survivorship to improve outcomes for total wrist arthroplasty [58]. Longer follow-up is needed to evaluate the ultimate outcome of the new radio-capitate joint following proximal row carpectomy through a volar approach [64]. While outcomes are generally favorable for therapeutic surgeries like arthrodesis and arthroplasty for rheumatoid arthritis of the wrist and hand, further study is required to determine the best indications for ulnar head arthroplasty [65]. Further long-term studies are encouraged regarding early results in total replacement of the distal radioulnar joint [66].

Recovery¶

Light activity (weeks): The provided evidence does not specify a typical week range for the return to desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a typical month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a typical month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or sling and brace removal timing.

Functional milestones: The provided evidence does not report validated patient-reported outcome measure trajectories or specific outcome-measure benchmarks such as Constant, ASES, or WOMAC scores.

Other Considerations: Long-term follow-up data indicate that glenohumeral arthritic changes progress significantly but remain minimal within an 8-year period in early to moderate degenerative cuff disease [199]. Asymptomatic acromioclavicular osteoarthritis diagnosed by MRI remained asymptomatic in 90% of cases over a 7-year period [16]. In a series of discoid menisci, results were excellent in eight cases, one was rated as good, and one developed osteoarthritis but remained asymptomatic [20]. Arthritis had not developed in any patient at the last follow-up after minimally invasive surgery of perilunate dislocations and fracture dislocations [32]. Radiographic disease progression occurred only in 2 wrists, rated stage IIIB, at 8 and 10 years follow-up without a bad clinical outcome following shortening osteotomy of the capitate for stage IIIA Kienböck disease [174]. Swanson silicone arthroplasty for proximal interphalangeal joint osteoarthritis has an implant survivorship of 90% at an average of 10 years postoperatively and remains the treatment of choice for the symptomatic osteoarthritic PIP joint [34]. UNI 2 total wrist arthroplasty in rheumatoid arthritis patients showed complications in 75% and loss of mobility in 33% of the surviving implants [35]. In a series of nearly 700 consecutive cases of thumb basal joint arthroplasty, the unexpected early reoperation rate was 1.5%, with only a 0.6% reoperation rate specifically for painful subsidence requiring a revision arthroplasty [70]. Pain was well tolerated and strength increased after 1 year follow-up following scapho-metacarpal arthrodesis with a structural bone graft as a salvage treatment for trapezectomy failures [194]. Glenohumeral joint preservation procedures in young, active patients with osteoarthritis show satisfactory short-term outcomes but have yet to show they can halt arthritic progression [8]. An arthroscopic approach to glenohumeral arthritis using various joint-preserving procedures reduces pain, improves function, and improves clinical outcome scores in the short- to mid-term follow-up period [37]. Radiolunate arthrodesis combined with synovectomy and ulnar head resection confers on the wrist mobility, stability, and physiologic ulnar orientation of the hand, which prevents or partially corrects ulnar deviation of the fingers [36]. Further long-term studies are encouraged for total replacement of the distal radioulnar joint [66]. Marked radiographic differences in modified Eaton score distinguish progressing from stable carpometacarpal osteoarthritis, indicating that structural progression is a key marker of disease advancement [4]. The stiffening of 38 percent from a normal to an early arthritic condition was accompanied by a trabecular contiguity change from 0.7 to 0.8 [71]. Calcified cartilage zone debridement with hyaluronic acid–based scaffold and bone marrow aspirate concentrate preserves subchondral bone integrity while accessing reparative elements, offering a biologically sound alternative that may improve both short-term recovery and long-term joint preservation [188]. Data on total joint arthroplasty trends in rheumatoid arthritis likely reflect skewed utilization of bDMARDs in patients with more severe disease and prolonged periods of joint degeneration because of prior treatment failure [196].

Key Evidence¶

[L3] Early diagnosis and treatment are important for preventing joint destruction. [1] (10.1186/s13018-018-0866-2)
[L5] Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression, while joint replacement is indicated for end-stage disease. [2] (10.1530/eor-2025-0050)
[L3] Marked radiographic differences in modified Eaton score distinguish progressing from stable OA, indicating that structural progression is a key marker of disease advancement. [4] (10.1016/j.jhsg.2025.100795)
[Paper] Diagnostic indications include the assessment of painful post-traumatic basal joint lesions of cartilage and ligaments, and the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis. [5] (10.1016/j.hansur.2020.05.014)
[L4] This intervention showed no midterm progression to advanced arthritis in this cohort. [6] (10.1177/15589447211017221)
[L4] The procedure remains a good option for patients with painful TM osteoarthritis that has not responded to nonoperative treatment. [7] (10.1177/1753193411419433)
[L4] Early results indicate satisfactory short-term outcomes, though these procedures have yet to show they can halt arthritic progression. [8] (10.1155/2012/160923)
[L5] Deceptive clinical manifestations, often presenting as chronic monoarthritis, lead to diagnostic and therapeutic delays responsible for irreversible functional lesions. [9] (10.1016/j.main.2009.04.006)
[L2] Further characterisation of patients in whom mild arthroscopic findings of OA of AC joint are clinically significant and warrant resection is needed. [11] (10.1007/s00167-014-3114-2)
[L2] However, inflammatory arthritis remains the most common indication in recent years, accompanied by an increase in the incidence of revision surgery. [12] (10.1302/2058-5241.5.190036)
[L5] The understanding of OA physiopathology clarifies the core mechanisms by which minimally invasive interventions might be able to halt and reverse the course of early stage OA. [13] (10.1016/j.reth.2020.07.007)
[L5] [14] (10.2106/00004623-199704000-00022)
[L5] [15] (10.1002/jor.24817)
[L2] Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. [16] (10.1016/j.jse.2019.04.004)
[L4] There were no differences in the need for secondary intervention based on the severity of radiographic osteoarthritis or baseline shoulder dysfunction. [17] (10.1016/j.jse.2020.08.008)
[L4] Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought, with isolated osteoarthritis of the scaphotrapeziotrapezoidal joint being the most prevalent pattern. [18] (10.1177/17531934241275450)
[L3] Contrary to previous reports, the SLAC pattern of arthritis does not represent the majority of the patterns of degeneration encountered. [19] (10.5435/jaaosglobal-d-17-00017)
[L4] The results were excellent in eight of these cases, with one rated as good and one developing osteoarthritis but remaining asymptomatic. [20] (10.2106/00004623-195032030-00019)
[L1] AD is an efficacious and particularly safe alternative in the short term for young patients with concerns about arthroplasty. [22] (10.1016/j.arthro.2014.11.012)
[L3] [24] (10.1177/1758573217724080)
[L5] The presence of pre-arthritic lesions or established wrist arthritis, even if treated, must be taken into consideration when treating osteoarthritis at the base of the thumb. [25] (10.1016/j.hansur.2020.08.013)
[L4] Surgical treatment aims to eliminate pain while preserving motion in adjacent joints, with the specific procedure chosen based on the location of arthritis and patient factors. [26] (10.1016/j.jhsa.2007.02.003)
[L5] Experts recommend a stepwise approach starting with nonoperative treatment, followed by joint-preserving arthroscopic procedures for selected patients, and reserving joint replacement or resurfacing for cases where less invasive options fail. [27] (10.1016/j.jse.2011.11.011)
[L4] The International Consensus Meeting recommended that disease-modifying antirheumatic drugs should be halted prior to elective total joint arthroplasty based on their half-life, with cessation performed under the direction of the treating physician. [29] (10.1016/j.arth.2017.11.031)
[L4] There has been no long term deterioration of wrist function. [30] (10.1097/00130911-200109000-00008)
[L4] At the last follow-up, arthritis had not developed in any patient. [32] (10.1177/1558944716660555hc)
[Paper] Long-term administration of GlcN and CS reduced cartilage degeneration at 8 months of age. [33] (10.1002/jor.22003)
[L4] With an implant survivorship of 90% at average of 10 years postoperatively, silicone implant arthroplasty remains the treatment of choice for the symptomatic osteoarthritic PIP joint. [34] (10.1016/j.jhsa.2013.11.008)
[L4] Arthroplasty showed complication in 75% and mobility was lost in 33% of the surviving. [35] (10.1016/j.main.2015.10.065)
[L4] Combined with synovectomy and ulnar head resection, this procedure confers on the wrist mobility, stability, and physiologic ulnar orientation of the hand, which prevents or partially corrects ulnar deviation of the fingers. [36] (10.1016/s0363-5023(86)80034-x)
[L5] Clinical studies report that an arthroscopic approach to glenohumeral arthritis using various joint-preserving procedures reduces pain, improves function, and improves clinical outcome scores in the short- to mid-term follow-up period. [37] (10.5435/jaaos-d-17-00214)
[L4] Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop. [38] (10.2106/00004623-198567030-00013)
[L5] The revised criteria are hoped to aid in obtaining more uniformity in the classification of patients with rheumatoid arthritis and should be reviewed in two or three years. [41] (10.2106/00004623-195941040-00023)
[L5] Although many OA-related biomarkers are currently available, none can be considered as a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease at this time. [42] (10.1186/1471-2474-16-s1-s2)
[L5] MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement, serving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities. [44] (10.2106/jbjs.rvw.15.00093)
[L4] [45] (10.1016/j.jse.2024.12.044)
[L5] This review describes the challenges associated with the diagnosis and management of glenohumeral arthritis and provides a treatment framework for use in these challenging patients. [46] (10.1016/j.jse.2007.03.011)
[L4] It should be considered after conservative measures fail, as mild degenerative arthritis is not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur. [47] (10.2106/00004623-197759040-00004)
[L5] Initial management of symptomatic DRUJ arthritis is nonsurgical, with surgery reserved for patients with refractory pain. [48] (10.5435/00124635-201210000-00002)
[L2] Further, these provocative tests were more specific for basal joint arthrosis than was the elicitation of point tenderness at the joint. [49] (10.1016/j.jhsa.2015.04.012)
[L4] While joint involvement is typically transient, this report emphasizes that permanent joint damage can occur, particularly in older children at onset. [50] (10.2106/00004623-197557020-00023)
[Paper] Proper indication relies on identifying and simultaneously correcting malalignment and/or traumatic changes in affected joints. [51] (10.1016/j.injury.2008.01.041)
[L4] [53] (10.1177/1753193419867843)
[L3] The size of OPP may have a weak association with the diagnosis of early OA. [54] (10.1016/j.jhsa.2021.07.021)
[L5] If a neuropathic joint becomes grossly unstable, total joint arthroplasties are contraindicated, but careful joint debridement, osteotomies, or arthrodesis may improve function and stability. [56] (10.1016/s0363-5023(86)80017-x)
[L5] Further research is required in anatomic and biomechanic studies, experience in inflammatory arthropathy, and long-term survivorship to improve outcomes. [58] (10.1177/17531934231209638)
[L5] Both arthroscopic and open approaches can result in excellent clinical outcomes for patients with symptomatic SC arthritis. [59] (10.1016/j.arthro.2020.02.023)
[L5] Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage; procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease. [60] (10.2106/00004623-199409000-00019)
[L4] [61] (10.1177/2325967117711376)
[L5] [62] (10.1016/j.jhsa.2012.08.034)
[L5] [63] (10.1016/j.csm.2017.02.002)
[L4] Longer follow-up is needed to evaluate the ultimate outcome of the new radio-capitate joint. [64] (10.1016/s0363-5023(03)80411-2)
[L5] While outcomes are generally favorable for therapeutic surgeries like arthrodesis and arthroplasty, further study is required to determine the best indications for ulnar head arthroplasty. [65] (10.1016/j.jht.2013.12.002)
[L4] Further longterm studies are encouraged. [66] (10.1177/15589447241233362)
[L4] The progressive nature of cervical rheumatoid disease resulted in the recurrence of long-tract symptoms in three patients due to further subaxial subluxation distal to the original fusion site. [67] (10.2106/00004623-198163080-00003)
[L5] Clinical experience and literature analysis do not support the commonly held assumption that untreated distal radial fractures lead to symptomatic osteoarthritis. [68] (10.1177/17531934241265839)
[L4] Although a larger study population and a longer follow-up period are needed to draw conclusions, bone-preserving arthroplasty with APL tenodesis showed satisfying results in patients presenting with early-stage osteoarthritis. [69] (10.1016/j.jhsg.2021.03.003)
[L4] In this series of nearly 700 consecutive cases, we identified an unexpected early reoperation rate of 1.5%, with only a 0.6% reoperation rate specifically for painful subsidence requiring a revision arthroplasty. [70] (10.1016/j.jhsg.2019.10.003)
[L4] The stiffening of 38 percent from a normal to an early arthritic condition was accompanied by a trabecular contiguity change from 0.7 to 0.8. [71] (10.2106/00004623-197456020-00010)
[L2] In patients with suspected inflammatory arthritis, routine US use in newly referred patients seems to be associated with significantly earlier diagnosis and DMARD initiation. [94] (10.1186/s12891-017-1850-4)
[L4] The diagnosis is clinical, based on the association of monoarticular arthritis with recurrent fever and abdominal pain, as there are no specific laboratory aids. [95] (10.2106/00004623-196547080-00016)
[L5] Patients with underlying wrist arthritis may be at risk for delay in diagnosis. [97] (10.1016/s0363-5023(87)80295-2)
[L4] A universal and definitive grading system for lesions is necessary, and measurement devices are needed for objective cartilage grading in questionable cases. [99] (10.1007/s00402-009-0868-y)
[L4] Specific exfoliative cytological patterns can be readily recognized in fluids aspirated from joints in a variety of arthritides, supporting the technique as a valuable diagnostic aid. [102] (10.2106/00004623-197658030-00019)
[Case_report] Physicians should be aware of this presentation in patients with insensate joints to avoid overtreatment. [104] (10.2106/00004623-199274090-00017)
[L4] The prevalence of midcarpal arthritis in patients with basal joint arthritis is 24%. [105] (10.1177/1558944716660555hw)
[L4] Excision of PT loose bodies appears to provide satisfactory relief of symptoms in patients without evidence of joint degeneration. [107] (10.1016/s0363-5023(97)80091-3)
[L4] Arthroscopic debridement with capsular release may provide a window of improved symptoms and function before deterioration of the joint leads to a more significant operation, especially in younger patients with mild or moderate osteoarthritic changes. [108] (10.1016/j.arthro.2006.11.016)
[L4] However, these improvements in controlling synovitis have not resulted in comparable reductions in disability measured by HAQ. [110] (10.1186/s12891-016-0897-y)
[L1] [111] (10.1177/17531934241313206)
[L5] Existing literature demonstrates anti-inflammatory properties of orthobiologics, but no treatment has clearly demonstrated significant joint preservation properties, including the ability to reverse progression of osteoarthritis. [112] (10.1136/jisakos-2019-000377)
[L5] [115] (10.1016/s0894-1130(00)80036-8)
[L4] Current clinical treatments for articular cartilage defects have limited ability to repair tissue and often result in mechanically inferior cartilage; emerging regenerative approaches and strategies informing future treatment options are discussed to address these limitations. [116] (10.3389/fbioe.2021.770655)
[L5] Although indications for this technique are limited, we believe it adds an additional option for complicated cases of thumb base arthritis. [117] (10.1097/bth.0000000000000045)
[L3] Arthroplasty should be used as an alternative to arthrodesis in the treatment of posttraumatic wrist arthritis, given the proper patient selection and indications. [119] (10.1016/j.jhsa.2013.02.013)
[L1] Currently, there is no evidence to guide clinicians about the individual or combined effectiveness of nonpharmacological interventions for individuals with persistent acromioclavicular joint osteoarthritis. [120] (10.1177/1758573219840673)
[L1] This systematic review provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis, with some interventions showing moderate-to-large superior effects compared with others. [121] (10.1016/j.jhsg.2021.02.003)
[L4] Treatment of the symptomatic degenerative triscaphe joint by triscaphe arthrodesis was found to be successful in relieving pain, preserving a useful arc of motion greater than 100 degrees and preventing further degenerative changes at an average of 5 years after operation. [124] (10.1016/0363-5023(90)90100-6)
[L3] The Walch classification provides a useful frame of reference when assessing subluxation and glenoid morphology in primary glenohumeral osteoarthritis, but it does not allow perfect agreement among observers. [125] (10.1016/j.jse.2017.02.015)
[L1] Intra-articular TNFi therapy appears to have equal efficacy to IA steroids, though the optimal dose and frequency of injections is yet unknown. [127] (10.1186/s12891-021-04651-5)
[L4] Further research is needed to determine the efficacy of physical therapy for patients with moderate arthritis as well as the utility of preoperative physical therapy for improving postoperative outcomes. [128] (10.1016/j.jse.2024.03.042)
[L5] [133] (10.5435/jaaos-22-01-20)
[L3] Each of the three osteoarthritic rat models showed a specific pattern of osteoarthritis progression. [135] (10.1002/jor.21444)
[L4] [136] (10.1016/s0266-7681(96)80094-5)
[L4] [139] (10.3390/nano9020261)
[Letter] The authors argue that a joint registry is necessary to evaluate implant survivorship across multiple surgeons before a randomized controlled trial can be justified, ensuring progress is based on robust data free from bias. [141] (10.1177/17531934211008364)
[L3] Radiographic ACJ osteoarthritis is common in patients undergoing RSA. [143] (10.1016/j.jseint.2021.11.008)
[L1] [145] (10.1007/s00402-026-06423-z)
[L4] The use of this implant in posttraumatic or osteoarthritis patients has yielded such poor results that the authors no longer use it in these situations. [146] (10.1016/s0363-5023(88)80048-0)
[L4] Conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management. [148] (10.1007/s00167-020-06377-8)
[L5] The salvage of the complications of arthroplasties is also presented in detail. [149] (10.1142/s2424835516500168)
[L4] On the basis of its higher expected gain in QALYs, arthroplasty should be the preferred treatment, though the minimal increase in utility over arthrodesis suggests surgeons do not view arthroplasty as superior. [150] (10.1016/j.jhsa.2008.06.022)
[L5] The article provides an overview of available treatments for shoulder osteoarthritis, noting that nonoperative modalities should be utilized before surgical options, particularly for patients with moderate-to-mild disease, while surgical treatments like arthroplasty are considered effective for severe cases. [153] (10.1155/2013/370231)
[L4] Patients with edema on MRI were more likely to present pain than patients without edema, and subchondral bone edema on histologic examination was more frequent in patients with pain. [156] (10.1016/j.jseint.2020.03.007)
[L5] Treatment is stage-dependent, ranging from nonoperative management in early stages to revascularization, unloading procedures, or arthrodesis in advanced stages. [157] (10.5435/00124635-200103000-00006)
[L4] Results for a large series of SBS for CMC arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates. [158] (10.1016/j.jhsg.2019.11.002)
[Paper] Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care. [159] (10.1016/j.csm.2014.01.001)
[L4] The results show a non-pharmacological treatment gap in OA care, with most patients reporting no pain or mild pain and having not received non-pharmacological treatment prior to surgical consultation. [164] (10.1186/s12891-019-2567-3)
[L5] Short-term results in children are no less favorable than in adults, and the danger of abnormal growth from rheumatoid inflammation is an indication for synovectomy, especially in children with unilateral knee involvement. [165] (10.2106/00004623-197153040-00001)
[L4] The differential expression of genes in RA compared with OA indicates potential targets for molecular diagnosis and treatment. [167] (10.1186/s12891-022-05277-x)
[L4] The authors conclude that using this index and consistent radiological views makes future comparisons more reliable than the Samilson-Prieto classification alone. [168] (10.1016/j.jse.2007.06.001)
[L4] [170] (10.1302/2058-5241.4.180102)
[L4] Most videos regarding conservative management of CMC OA have limited evidence to support their content, and expert clinicians are rarely represented in these resources. [171] (10.1177/1558944717726139)
[L4] Revision surgery, however, can result in satisfactory long-term outcomes particularly when metacarpophalangeal joint pathology is addressed and complications are avoided. [173] (10.1016/j.jhsa.2018.10.025)
[L4] Radiographic disease progression occurred only in 2 wrist, rated stage IIIB, at 8 and 10 years follow-up without a bad clinical outcome. [174] (10.1016/j.main.2014.10.086)
[L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. [175] (10.1155/2013/473259)
[L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. [176] (10.1016/j.jse.2010.05.022)
[L5] [177] (10.1007/s11552-007-9068-9)
[L5] Despite advancements in management, in most scenarios there is no single preferred option for wrist osteoarthritis. [179] (10.1177/17531934241296758)
[L3] MRI is more reproducible in the assessment of glenoid version in osteoarthritis and provides excellent intraobserver and interobserver reliability. [182] (10.1016/j.jse.2012.10.036)
[L4] Clinical-radiologic correlation revealed many asymptomatic patients with calcification and arthropathy and many symptomatic patients with normal radiographs. [183] (10.1016/s0363-5023(83)80081-1)
[L4] [185] (10.1016/j.jhsa.2025.01.018)
[L5] By preserving subchondral bone integrity while still accessing reparative elements, this approach offers a biologically sound alternative that may improve both short-term recovery and long-term joint preservation. [188] (10.1016/j.eats.2025.103733)
[Paper] T₂-weighted images in the coronal plane proved to be of the greatest diagnostic value because the synovial fluid of the joint spaces serves as an excellent endogenous contrast agent. [189] (10.1016/s0363-5023(09)90014-4)
[L4] There is considerable variation in the practice of both non-surgical and surgical management of base of thumb osteoarthritis. [190] (10.1302/0301-620x.102b5.bjj-2019-1464.r2)
[Case_report] This is the first report of a hip documented to be located and functioning normally, in which early synovial chondromatosis progressed to extensive chondromatosis, with subsequent subluxation of the hip and marked degenerative osteoarthritis that led to total hip replacement. [191] (10.2106/00004623-199173090-00019)
[L4] [192] (10.1177/1753193408090098)
[L4] Pain was well tolerated and strength increased after 1 year follow-up. [194] (10.1016/j.hansur.2018.10.041)
[L4] These results suggest that joint space width evaluation has a potential diagnostic value in the work-up of patients with suspected pisotriquetral osteoarthritis. [195] (10.1177/1558944716677542)
[L4] These data likely reflect skewed utilization of bDMARDs in rheumatoid arthritis patients with more severe disease and prolonged periods of joint degeneration because of prior treatment failure. [196] (10.5435/jaaosglobal-d-22-00209)
[L3] Glenoid retroversion is increased in patients with severe arthritis compared to normal subjects, and computerized tomographic scans accurately reveal the extent and pattern of bone erosion. [197] (10.2106/00004623-199274070-00009)
[L2] Glenohumeral arthritic changes progress significantly but remain minimal within an 8-year period in early to moderate degenerative cuff disease. [199] (10.1016/j.jse.2016.07.022)

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