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A artrite na base do polegar já pode ser comigída com una ténicca minimamente invasiva. S artroscopia para correção do desgaste da articulação do dedão foi uma das técnicas apresentadas no Congresso da Sociedade Brasileira de Ortopedia e Traumatologia, que terminou ontem, no Rio. A cirurgia já era usada para corrigir artrite nos joelhos e ombros. .No caso do polegar, por ser uma área menor, e, portanto, mais delicada, foi necessário criar equipamentos especiais. O Dr. Alejandro Badía, do Centro da Mão de Miami, desenvolveu a técnica há quatro anos e vem obendo excelentes resultados. Nos casos mais brandos, é feito um pequeno corte num dos ossos, modificando o ângulo de contato. Um pino é introduzido na região para fixar a nova posição e retirado seis semanas depois. 

Arthroscopy Basal Joint or Carpometacarpal Joint – CMC

Turning a key, twisting the lid off a jar and grasping a door handle appear to be such simple tasks. In each movement, the thumb plays an integral part. Without cooperation from this key digit, squeezing and gripping motions would be virtually impossible.

Over time, though, even the thumb can reach its limits. The basal joint or carpometacarpal joint (CMC)–located at the base of the thumb–allows these crucial swiveling and pivoting motions. But because sophisticated movements depend on this joint, it’s susceptible to wear-and-tear from normal use. And when the CMC joint wears down, arthritis can develop and hinder even the easiest functions.

For patients, a well-structured program of hand therapy may restore previous levels of function. But if that doesn’t work or the CMC joint disorder is too severe, surgery may be the only option. One such procedure–arthroscopy–can help identify the stage of the problem and give patients a minimally invasive solution to a common problem.

Arthritis at the CMC joint is a common, painful condition that occurs more frequently in middle-aged women. It also occurs with men, although it tends to begin at a later age and causes less disability. The condition progresses gradually and, eventually, the joint is destroyed, which causes pain, disability and pinch weakness.

Early symptoms of CMC joint disorder are often ignored, as patients heed the advice of physicians who often provide a myriad of diagnoses to explain subtle pain at the base of the thumb or along the radial side of the wrist. Swelling and tenderness are noted at the base of the thumb with a painful grinding that can be illicited with passive compression and motion of the CMC joint by the examiner. Pain often radiates up the arm and can lead to carpal tunnel syndrome, which is often the first sign of a problem.

When a patient begins to complain of even subtle pain at the base of the thumb, obtain an X-ray to determine the radiographic stage of potential arthritis. Although X-rays are frequently normal in this early stage, it’s the best time to initiate treatment because patients will respond well to simple conservative measures. Those measures include splinting to immobilize the thumb by using a hand-based or wrist-extended spica splint. In addition, nonsteroidal anti-inflammatory drugs can help alleviate symptoms. Clinicians should also begin hand therapy to strengthen surrounding muscles, reduce inflammation, and promote good motion flexibility and pinch strength.

However, because most osteoarthritic conditions tend to be progressive, the pain never really resolves and patients start looking for other options beyond therapy. Corticosteroid injections offer relief from painful joint arthritis, but that respite is only temporary. In fact, it can lead to progressive cartilage wear. Multiple catabolic steroid injections in the hand joint can lead to weakening of the joint capsule and surrounding ligaments, and even cause further breakdown to articular cartilage.

In severe cases of dysfunction, surgery may be the only choice, even though reconstruction can alter normal anatomy; a prolonged, painful postoperative recovery process ensues.

The classic surgical procedure for more advanced basal joint arthritis consists of a complete excision of the arthritic trapezium bone, with a ligament reconstruction using either the flexor carpi radialis or the long thumb abductor in the first compartment. The remainder of the tendon is then stuffed into the space between the metacarpal base and trapezium to serve as an “anchovy spacer.” The anchovy represents a rolled up tendon graft that then acts as a biological cushion to avoid contact between the two arthritic surfaces and minimizes collapse.

When X-rays show obvious signs of advanced degenerative changes, patients are usually offered the classical open reconstruction. Although this procedure remains the gold standard in basal joint reconstruction, recovery time is often lengthy. This reconstruction carries another risk: A patient has few salvage alternatives if it doesn’t provide expected relief. For instance, the basal joint exerts a great deal of force, and the ligament reconstruction often has complications, such as loosening.

Total joint arthroplasty offers a better solution, especially in the late stages of basal joint arthritis. This procedure provides an excellent alternative with extremely rapid recovery of function and complete pain relief. It’s used predominantly in much older, low-demand patients. This is because a total joint replacement with metal and plastic components can wear out or loosen as in any other joint arthroplasty. This risk is minimized when patients place less strenuous demands on the joint and have a shorter life span remaining.

An arthroscopic procedure allows for synovectomy and debridement, which provides pain relief. With an arthroscope, a hand surgeon can also inspect the articular cartilage for early degeneration. If the cartilage is still intact, then the patient may undergo a capsular shrinkage procedure to minimize the laxity that often accompanies these joints during arthritic stages. This step may halt the progress of arthritis and provide pain relief without the obvious drawbacks of corticosteroids.

X-rays will show subtle changes, but an arthroscopy determines the true level of arthritis based on cartilage loss. This allows clinicians to either choose osteotomy in the early stages, or an arthroscopic interposition arthroplasty for advanced stages. If cartilage damage is focal, patients can benefit from arthroscopic debridement and a shrinkage procedure to stabilize the joint.

A hand surgeon can then perform a limited incision metacarpal osteotomy to alter joint biomechanics. The metacarpal can be centralized on the trapezium, avoiding subluxation and, perhaps, terminating the vicious cycle of osteoarthritis in the unstable joint.

If the cartilage damage seems to be advanced, then the surgeon conducts a burring of the trapezium’s articular surface to increase joint space. This minimizes direct contact between the metacarpal base and trapezium. It also causes bleeding of the subchondral bone, producing clotting that adheres to the tendon graft. This tendon graft, such as the palmaris longus tendon, is inserted through one of the arthroscopic portals,. When this graft is introduced into the joint through one of the portals, the blood clot from trapezial debridement acts as a cushion between the opposing bony surfaces. This leads to good pain relief across the joint with minimal contact. This is minimally invasive and hence is less painful postoperatively.

Following arthroscopy, patients are treated for a three- or four-week period of thumb spica cast immobilization so the capsule can heal, and the new joint is stabilized. With postop therapy, patients can regain good opposition and supple range of motion, while regaining pinch strength that was lost from thenar muscle atrophy.

Dequervain’s tendinitis also called DeQuervain’s tendinosis or occurs when the tendons around the base of the thumb are irritated or constricted. The word “tendinitis” refers to a swelling of the tendons. Thickening of the tendons can cause pain and tenderness along the thumb side of the wrist. This is particularly noticeable when forming a fist, grasping or gripping things, or when turning the wrist.

Anatomy 
Two of the main tendons to the thumb pass through a tunnel (or series of pulleys) located on the thumb side of the wrist. Tendons are rope-like structures that attach muscle to bone. Tendons are covered by a slippery thin soft-tissue layer, called synovium. This layer allows the tendons to slide easily through the tunnel. Any thickening of the tendons restrains gliding of the tendons through the sheath. Movement of the thumb may cause pain at the thumb side of the wrist.

Causes 
DeQuervain’s tendinitis is caused when tendons on the thumb side of the wrist are swollen or irritated. The irritation causes the lining (synovium) around the tendon to swell, which changes the shape of the compartment. This makes it difficult for the tendons to move as they should. DeQuervain’s tendinitis is most common in middle-aged women. It can be seen in association with pregnancy. It may be found in inflammatory arthritis, such as rheumatoid arthritis. Tendinitis may be aggravated by overuse.

Symptoms

• Pain may be felt over the thumb side of the wrist. This is the main symptoms. The pain may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm or down the thumb. The pain is usually worse when the hand and thumb are in use. This is especially true when forcefully grasping objects or twisting the wrist.
• Swelling may be seen over the thumb side of the wrist. This swelling may occur together with a fluid-filled cyst in this region.
• A “catching” or “snapping” sensation may be felt when moving the thumb.
• Pain and swelling may make it difficult to move the thumb and wrist.

MIAMI–(BUSINESS WIRE)–A group of leading European hand surgeons will tomorrow view ‘live’ an arthroscopic surgical procedure to implant a biodegradable thumb joint resurfacing material called a ‘spacer’.

The procedure will be performed by Alejandro Badia, MD, Chief of Hand Surgery at Baptist Hospital, Miami, and owner of the Badia Hand-to-Shoulder Center in Doral. His patient is a woman in her late sixties with a five year history of arthritis pain in the base of her thumb. This is a common complaint generally treated using invasive surgery involving tissue removal and replacement using tendon ‘harvested’ from a patient’s forearm.

The audience of surgeons gathering in Strasbourg, France for the satellite viewing of the surgery are members of the European Wrist Arthroscopy Society (EWAS). The society’s formation was inspired by Dr. Badia’s work in applying arthroscopic surgery techniques, long used in knee and shoulder repair, to the intricate bones and joints of the hand and wrist.

“Arthritis in the base of the thumb affects millions of people, especially women, and can eventually be debilitating when one loses the pinch strength needed to do many everyday chores as basic as opening a door,” Dr. Badia said.

“When treatment with splinting and medication eventually fail, surgery is the only way of regaining that strength. This relatively new procedure is vastly less invasive and tissue sparing – especially when using arthroscopy,” he added.

According to Dr. Badia, the advantage of arthroscopy over more traditional surgery is that the joint does not have to be opened up fully. Instead, only two small incisions are made – one for the arthroscope and one for the surgical implant. This reduces recovery time and healing process due to less damage to the connective tissue around the thumb.

The implant or ‘spacer’ used by Dr. Badia is called the Artelon® CMC Spacer Arthro from Small Bone Innovations, Inc., Morristown, PA. It was cleared by the US FDA last year for marketing in the U.S. Since then Dr. Badia has become something of a pioneer in the procedure, treating several hundred patients in the US and Latin America.

Anthony G. Viscogliosi, Chairman & CEO of Small Bone Innovations, added: “By working closely with surgeons like Dr. Badia, we are committed to producing more advanced, keyhole-type surgical solutions, such as the Artelon® CMC Spacer Arthro, that are tissue-sparing, function-restoring and motion-preserving, to allow faster and more normal restoration of patients’ quality-of-life.”

About Dr. Badia

Alejandro Badia, MD studied at Cornell University in Physiology and obtained his medical degree at New York University followed by an Internship in General Surgery and Residency in Orthopedic Surgery.

He went on to a Hand and Upper Extremity Fellowship at Allegheny General Hospital in Pittsburgh Pennsylvania.

This was followed by a Hand Fellowship in Europe through the prestigious AO Trauma Association. He is the founder of the Badia Hand-to-Surgery Center, a full service center for the upper limb including extremity MRI imaging, digital radiography, therapy, and surgical facilities located under one roof in Doral, Florida.

Dr. Badia also runs a prestigious hand surgery fellowship that has trained surgeons from five continents and he conducts a small joint arthroscopy course at a laboratory within the center.

He also organizes the annual Miami Hand Reconstruction Course (http://cts.businesswire.com/ct/CT?id=smartlink&url=http%3A%2F%2Fwww.miamihandcourse.com&esheet=5837599&lan=en_US&anchor=www.miamihandcourse.com&index=1) that brings together both surgeons and therapists to discuss hand/wrist/elbow joint replacement and arthroscopic procedures.

Dr. Badia is a member of the American Society for Surgery of the Hand, American Academy of Orthopedic Surgeons, American Association for Hand Surgery and numerous other national and local medical/surgical societies. He is also honorary member of multiple foreign hand surgery, orthopedic and arthroscopic surgery societies including those from Italy, Peru, Venezuela, Argentina, Bolivia and Colombia.

Treatment of Early Basal Joint Arthritis Using a Combined Arthroscopic Debridement and Metacarpal Osteotomy

ABSTRACT
Osteoarthritis of the thumb basal joint is a common and disabling condition, and early stages of which are often seen in middle-aged women. Arthroscopic assessment of the first carpometacarpal joint allows easy identification and classification of joint pathology with minimal morbidity. This allows the condition to be managed either arthroscopically or converted to an open procedure as indicated. Different procedures have been described to treat different stages of this disease. The senior author has recently described an arthroscopic staging system to determine treatment for basal joint osteoarthritis. We now present our surgical technique and early clinical experience with arthroscopic synovectomy, debridement, and corrective osteotomy for arthroscopic stage II of thumb basal joint arthritis. Forty-three patients (38 women and 5 men) were arthroscopically diagnosed as having stage II basal joint osteoarthritis of the thumb between 1998 and 2001, and they were the focus of the present study. In all the patients, there was no improvement after a period of 6 to 12 weeks of conservative treatment. All the procedures were performed by the senior author. The surgical procedure included arthroscopic synovectomy, debridement, and occasional thermal capsulorraphy, followed by an extension-abduction closing wedge osteotomy in all the cases. A 0.045-in Kirschner wire provided stability to the osteotomy. By performing an osteotomy that redirects the axial loads in this joint, we have obtained satisfactory results in terms of pain relief, stability, and pinch strength. Arthroscopy allows us to not only determine the optimum indication for this osteotomy, but also to debride the joint and minimize the inflammatory response. Hence, we recommend arthroscopic synovectomy, debridement with or without a thermal capsulorraphy, and a dorsoradial closing wedge osteotomy for the treatment of arthroscopic stage II of thumb carpometacarpal joint osteoarthritis. Keywords: thumb, carpometacarpal, osteoarthritis, arthroscopy, osteotomy.

HISTORICAL PERSPECTIVE
The trapeziometacarpal (TMC) joint displays an exclu- sive anatomic design that allows arc of motion in three different planes to place the thumb for axial loads. For this reason, it is not uncommon for this joint to develop osteoarthritis even when other small joints in the vicinity stay unchanged.1 It has been demonstrated that there is a strong correlation between extreme basal joint laxity, specifically volar ligament instability, and evolvement of the early degenerative changes.1Y8 These alterations are common causes of pain, weakness, and adduction deformity.9 Different procedures have been proposed for the treatment of first carpometacarpal (CMC) joint arthritis.1,3Y5,9Y32 Clinical and radiographic assessments have constituted the basic tools for evalu- ation of the first CMC joint during the last several decades.1,5,29Y31 Eaton and Glickel5 proposed a staging system for thumb CMC arthritis, which has been extensively used not just to categorize the disease, but also to provide a treatment rationale. Bettinger et al30 introduced the trapezial tilt as a parameter to predict further progression of the disease. They found that in advanced stages (Eaton III and IV), the trapezial tilt was high (50- T 4-; normal, 42- T 4-). Barron et al1 concluded that there appeared to be no indication for magnetic resonance imaging (MRI), tomography, or ultrasonography in the routine evaluation of basal joint disease. Despite the importance of a radiographic classification to understand the progression of the disease, our experience has showed us that there are instances when it is very difficult to make an accurate diagnosis of the disease stage, based solely on radio- graphic studies. Clinical symptoms are often much more pronounced than plain radiographs would suggest.

Recent advances in arthroscopic technology have allowed complete examination of smaller joints throughout the body with minimal morbidity.33 More- over, arthroscopy has already been proved to be reliable for direct evaluation of the first CMC joint.32 This technique is often used initially for diagnostic purposes and, once established, can be incorporated into our treatment plan. Arthroscopy of the thumb basal joint allows us to look within a joint that is commonly affected by both traumatic and chronic conditions, providing clear visualization of the articular surfaces and assessment of ligamentous integrity, and hence permitting confirmation of the preoperative radiograph- ic staging in all the cases. The senior author recently described an arthroscopic classification for thumb CMC osteoarthritis29 (Table 1).

The benefits of basal joint arthroscopy are evident in early stages of the disease. For instance, in arthroscopic stage I, it is very common to have normal radiographic studies in the presence of painful limitation of the thumb. In our experience, we have found that this group of patients displayed mild to moderate synovitis that could benefit from a thorough joint debridement/ synovectomy, combined with thermal shrinkage of the ligaments to enhance the stability if necessary. Tom- aino24,25 concluded that Eaton stage I disease is a good indication for thumb metacarpal extension osteotomy. A more reliable indication might be when there is only focal articular cartilage loss and the joint is, therefore, worth preserving. First metacarpal osteotomy has been advocated to modify the mechanical stress areas of the joint.9,23Y29 Based on the arthroscopic changes found in stage II, we support the fact that it may be feasible to modify the joint by an osteotomy and preserve the trapezium. Moreover, the metaphyseal osteotomy leads to decompression and reactive hyperemia that may help in arresting the progression of the arthritis.34,35 Menon described a technique demonstrating arthroscopic de- bridement of the trapezial articular surface and interposition of autogenous tendon, fascia lata, or Gore-Tex patch into the CMC joint in patients with stage II and III.31 The main goal of the present study is to present the surgical technique and results of our arthroscopic stage II patients treated with an arthroscopic basal joint debridement with capsulorraphy and a closing wedge extension-abduction metacarpal osteotomy.

INDICATIONS AND CONTRAINDICATIONS
Stage II arthroscopic CMC joint arthritis is our indication for the extension abduction metacarpal osteotomy coupled with a thorough arthroscopic syno- vectomy and capsulorraphy. The joint findings that we have previously described for arthroscopic stage II of the disease warrants a modification of the joint by changing the load vector on both the articular surfaces through an osteotomy. Arthroscopy not only allows staging of the arthritis but the joint can also be effectively debrided, and capsulorraphy can be done. However, this procedure should be avoided in advanced basal joint arthritis or when scaphotrapezial-trapezoid joint is arthritic, wherein a more aggressive procedure is warranted. Eaton stage I might be amenable to a simple synovectomy/debridement, reserving the osteotomy for more advanced arthroscopic findings. On the other hand, if the arthroscopic evaluation depicts complete articular cartilage loss, the next logical step is to perform partial trapezium excision with tendon interpo- sition arthroplasty.

| ARTHROSCOPIC AND RADIOGRAPHIC CORRELATION
Arthroscopic stage I universally correlate well with that of radiographic stage I. Arthroscopic stage II usually corresponds to radiographic stage II changes, but some radiographic stage I patients may display focal loss of articular cartilage consistent with arthroscopic stage II. Herein lays one of the great advantages of this technology. Only the rare case demonstrates less cartilage wear than expected on the plain radiograph. Consequently, radiographic stage III rarely is considered arthroscopic stage II, but that does greatly influence and diversify the treatment options. More advanced radio- graph findings will usually reveal widespread cartilage loss when arthroscopy is performed. Hence, later stages are not necessarily a panacea as related to the use of arthroscopy.

Surgical Technique
The procedure was performed under wrist block regional anesthesia with tourniquet control. A single Chinese finger trap was used on the thumb with 5 to 8 lb of ongitudinal traction. The arm was held down with wide tape around the tourniquet securing it to the hand table to serve as countertraction. A shoulder holder, rather than a traction tower, was used to facilitate fluoroscopic intervention more easily. The Trapeziometacarpal joint was detected by palpation. Joint distension was achieved by injecting 1 to 3 mL of normal saline (Fig. 1). It is important to distally direct the needle approximately 20 degrees to clear the dorsal flare of the metacarpal base and enter the joint capsule. This course should be reproduced upon entering with arthroscopic sleeve/ trocar assembly to minimize iatrogenic cartilage injury. Fluid distention is important to facilitate this. The incision for the 1-R (radial) portal, used for proper assessment of the dorsoradial ligament, posterior oblique ligament, and ulnar collateral ligament, was placed just volar to the abductor pollicis longus tendon. The incision for the 1-U (ulnar) portal, for better evaluation of the anterior oblique ligament and ulnar collateral ligament, was made just ulnar to the extensor pollicis brevis tendon. A short-barrel, 1.9-mm, 30- degree inclination arthroscope was used for complete visualization of the CMC joint surfaces, capsule, and ligaments, and then appropriate management was done, as dictated by the stage of the arthritis detected (Fig. 2A). A full-radius mechanical shaver with suction was used in all the cases, particularly for initial debridement and visualization. Most of the cases were augmented with radiofrequency ablation to perform a thorough synovectomy and radiofrequency was also used to perform chondroplasty in the cases with focal articular cartilage wear or fibrillation. Chondroplasty refers to thedebridement of the fibrillated cartilage to improve vascularity of the cartilage and enhance the growth of fibrocartilage. Ligamentous laxity and capsular attenu- ation were treated with thermal capsulorraphy using a radiofrequency shrinkage probe. We were careful to avoid thermal necrosis; hence, a striping technique was used to tighten the capsule of the lax joints. The striping technique refers to thermal shrinkage performed in longitudinal stripes on the lax capsule, so as to leave vascular zones between the stripes; hence, thermal necrosis is prevented. Arthroscopic stage I disease was characterized by synovitis without any cartilage wear, wherein a synovectomy coupled with thermal capsulor- raphy as described was performed.

Arthroscopic stage II patients were characterized by focal wear of the articular surface (Fig. 2B) that required a joint modifying procedure, to alter the vector forces across the joint. After synovectomy, debridement, and occasional loose body removal, the joint was reassessed to determine the extent of instability and capsular attenuation. A shrinkage capsulorraphy was performed in many of the cases, with chondroplasty done to anneal the cartilage borders. The arthroscope was then removed, and the ulnar portal extended distally to expose the metacarpal base. Mini Hohmann retractors were placed around the base allowing good access for the oscillating saw (Fig. 3A). A dorsoradial closing wedge osteotomy was then performed to place the thumb in a more extended and abducted position (Fig. 3B and C), which minimized the tendency of subluxation and changed the contact points of worn articular cartilage. This wedge of bone is usually 3 mm wide dorsally and should also be wider on the radial side. This places the thumb in the requisite dorsal and radially abducted position. The osteotomy was fixed by a single oblique 0.045-inch Kirschner wire placed across the first CMC joint in a reduced position (Fig. 4A and B). This not only allowed for healing of the osteotomy in the desired position but also corrected the metacarpal subluxation, so often seen in this stage (Fig. 5A and B). As the metaphysis heals, the volar capsule also tightens minimizing the chance of recurrent subluxation. A thumb spica cast was given for protection, and the wire was removed at approximately 4 to 5 postoperative weeks. After the wire removal, the patient is subjected to an intense rehabilitation protocol for about 4 to 6 weeks to gain maximum motion and strength.

COMPLICATIONS
In the present series, one of the patients developed constant pain later owing to the progression of osteoar- thritis after the procedure. She did not respond to steroid injections and physical therapy. Eventually, she had to undergo an arthroscopic assisted hemitrapezectomy, with a good result. The second complication encoun- tered in our series was complex regional pain syndrome (type I) in one patient, who developed it after the pin removal. This patient was managed with continuous physical therapy, stellate brachial plexus blockades, and neurontin.

SUMMARY
As arthroscopy becomes validated as a technique, we might see a day where less intra-articular injections are given and more joint preservation, rather than palliation, is sought. Arthroscopic assessment of the CMC joint allows direct visualization of all components of the joint including synovium, articular surfaces, ligaments, and the joint capsule. Hence, it allows the evaluation and staging of the joint pathology. Furthermore, the most suitable intraoperative management decision can be made based on this information. We recommend closing wedge extension-abduction osteotomy of the first metacarpal combined with synovectomy and capsulor- raphy for the arthroscopic stage II patients. By preserv- ing the joint, we have ”burned no bridges,^ and a more aggressive procedure, either arthroscopic or open, can be done in the future if symptoms warrant. Hence, arthroscopic visualization allows for the least aggressive procedure to be performed as dictated by the intra- operative findings. According to the arthroscopic clas- sification proposed, we recommend arthroscopic synovectomy and thermal capsulorraphy in patients with stage I, whereas in patients with stage II disease, we combine the synovectomy and capsulorraphy with dorsoradial osteotomy of the first metacarpal.

Download stageII CMC1 »

Small Bone Innovations, Inc. (SBi), a single-source provider of products, technology and education for the small bone and joint sector of the orthopedic industry, announced that its Artelon(R) CMC Spacer Arthro has been cleared by the FDA for marketing in the U.S. This product is an extension of SBi’s line of carpal metacarpal (CMC) spacers to treat osteo-arthritis (OA) in the base of the thumb. The Artelon(R) CMC Spacer Arthro was designed with the guidance and assistance of surgeons to allow minimally invasive, arthroscopic implantation in the joint between the first metacarpal and the trapezium. By avoiding violation of the joint capsule, the procedure may offer significant advantages to surgeons and their patients such as maintenance of joint stability, faster recovery and less pain. Dr. Alejandro Badia, of the Miami Hand Center, said “The most convincing argument for using the Artelon spacer in a more minimally invasive, arthroscopic approach may be the rapid recovery and return to normal activities. This could have a profound economic impact as patients may quickly return to near normal function.” Dr. Randall W. Culp, Associate Professor of Orthopedic, Hand and Microsurgery, Thomas Jefferson University, Philadelphia, said: “Arthroscopic implantation of an Artelon spacer is a good option for younger, more active, people who may be reluctant to undergo invasive surgery for a condition that is increasingly common among this group.” SBi’s Chairman and CEO, Anthony G. Viscogliosi, said: “This technology offers a superior solution to a widespread problem. This adaptation for minimally invasive, arthroscopic implantation reflects our philosophy of first serving patient needs while advancing surgeon education and training in the continuum of care for OA at the base of the thumb. “By working closely with surgeons, we are committed to produce more advanced, keyhole-type surgical solutions, such as the Artelon(R) CMC Spacer Arthro, that are tissue-sparing, function-restoring and motion-preserving, to allow faster and more normal restoration of patients’ quality-of-life,” he added. Since the introduction of the Artelon(R) Spacer CMC-I, in 2005, and the addition last year of the Artelon (R) CMC Spacer LG, this degradable technology has offered a conservative surgical option for patients suffering from early to mid-stage OA in the base of the thumb. According to Mr. Viscogliosi, these spacers have previously been implanted, using an open, surgical incision, in more than 3,000 patients in the U.S. and Europe. “Each of the three Artelon spacers: CMC-I, CMC LG (a larger version of CMC-I) and CMC Arthro permit therapy earlier in disease progression, and eliminate or minimize the sacrifice of healthy tissue in other CMC-I joint OA procedures that commonly include removal of the trapezium and harvesting tendon from the forearm,” Mr. Viscogliosi noted.   Small Bone Innovations, Inc. (SBi) was founded in 2004 by Viscogliosi Bros., LLC, (VB), the New York-based merchant banking firm that specializes in the musculoskeletal/orthopedic sector. VB created SBi as the first company to focus purely on small bone & joint science. By integrating established companies and professionals in the field, SBi can offer a broad, clinically proven portfolio of products and technologies to treat trauma and diseases in small bones & joints. Today, SBi has more than 140 employees at facilities in New York, NY, Morrisville, PA and Minneapolis, MN. SBi closed on the sale of $42.2 million of its securities in December 2005. At the time, based on data provided by Venture Source, this was the largest venture capital investment ever recorded in the field of orthopedic devices. SBi was a 2006 recipient of Red Herring magazine’s annual “Red Herring 100 North America” award, recognizing SBi as one of the nation’s leading technology companies and the only orthopedic device company selected among an initial entry of more than one thousand firms. Additionally, SBi’s Artelon(R) CMC-I Spacer, developed for patients with osteoarthritis at the base of the thumb, was featured on the cover and highlighted within Medical Design Technology magazine’s “Year of Innovation” issue as one of the most fascinating technologies influencing the medical device industry. Medical Device & Diagnostic Industry magazine named SBi to its list of “50 Companies to Watch” in 2006, noting, “Small Bone Innovations is going against the grain in its determination to become a market leader in the small bone & joint device sector.” For more information on SBi, please visit: http://www.totalsmallbone.com About Viscogliosi Bros., LLC Established by Marc R. Viscogliosi, John J. Viscogliosi and Anthony G. Viscogliosi in New York City in 1999, Viscogliosi Bros., LLC (VB) was the first venture capital/private equity and merchant banking firm dedicated to the musculoskeletal/orthopedics sector of the health care industry. Today, VB is a leading independent firm with a mission to create, build and finance companies founded on innovations developed by surgeons and uniquely focused on “life changing” musculoskeletal/ orthopedic technologies. VB has worldwide surgeon, industry and trade relationships and significant financial expertise in the musculoskeletal/ orthopedic sector. As principals of VB, the Viscogliosi brothers have a combined total of nearly half a century of experience analyzing and investing in the musculoskeletal/orthopedics sector, directing literally billions of dollars through the orthopedics industry. They have pioneered innovative financial, strategic and management initiatives for nearly 150 companies in the sector, from start-up, seed and development stage all the way to exit, while helping people lead better lives through the orthopedic and spinal products marketed and sold by the companies they have assisted in developing and financing.   About Artimplant AB Artimplant is a biomaterials company, based in Vastra Frolunda, Sweden, and focused on solutions to problems in orthopedic, odontological and reconstructive surgery. The Company is engaged in the development, production and marketing of degradable implants designed to restore active lifestyles and improve quality of life. The proprietary Artelon(R) technology, a long-term degradable biomaterial, offers new solutions to unmet clinical needs and opens new markets. Artimplant’s business model is that of licensing its products and technology to global partners. The Company currently has six licensing agreements and one distribution agreement with three global partners. Artimplant is a public company, listed on the Stockholm Stock Exchange, O-list. For additional information, please visit: http://www.artimplant.com Forward-looking statements This press release contains forward-looking statements as defined in the U.S. Private Securities Litigation Reform Act of 1995. Readers are cautioned not to place undue reliance on these forwardlooking statements. Actual results may differ materially from those indicated by these forward-looking statements as a result of risks and uncertainties impacting SBi’s business including increased competition; the ability of SBi to expand its operations and to attract and retain qualified professionals; technological obsolescence; general economic conditions; and other risks. Small Bone Innovations, Inc.

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