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Basal Joint Arthritisof the Thumb
(Trapeziometacarpal Arthritis)(Carpometacarpal Arthritis)
Ligamentous Anatomy
16 total ligaments Imaeda, et al, J Hand Surg, 1993
Five main stabilizing ligamentous structures Palmar Beak Ligament (Anterior Oblique Ligament) Dorsoradial Ligament Ulnar Collateral Ligament First Intermetacarpal Ligament Posterior Oblique Ligament
Ligamentous Anatomy
Palmar Beak Ligament Dorsoradial Ligament
Mayoclinic.org
Epidemiology and Etiology
Epidemiology
Most common site of osteoarthritis in the hand
Most common site requiring surgery
Most common in post-menopausal females 1:4 women will show radiographic degeneration
Only ~ 20-30% symptomatic 8% with ST arthritis Only 1:12 men affected
Epidemiology
Armstrong, et al, J Hand Surg (Br), 1994 evaluated 143 post-menopausal women 25% had isolated basal thumb osteoarthritis of those with isolated CMC osteoarthritis, 28% complained of thumb pain
Etiology
No clear association with employment Repetitive motion suggests higher incidence
Carpentry, manual labor Cow Milking (Seoane, 1997)
Males with increased grip strength - increased radiographic changes (Chaisson, 2001)
Etiology
1) Trauma - dislocation, fracture
2) Inflammatory diseases - RA, gout
3) Idiopathic Osteoarthritis
4) Hypermobile States Moulton (2001) showed increased joint forces in TM joints with hyperextension laxity at the MCP joint
Etiology
5) TM Instability Acute: severe trauma (complete dislocation) Chronic: can be caused by recurrent stress or overuse
more common often seen in young to middle-aged women
Etiology
Pellegrini, Orth Clin N Amer, 1992 The palmar beak ligament was essential for translational stability of the MC on the trapezium There was a direct correlation between the status of the articular surfaces and the integrity of the beak ligament
EtiologyPelligrini’s Theory: 1) Attritional changes in palmar beak ligament 2) Detachment of the palmar beak ligament 3) Instability of TM joint 4) Increased dorsopalmar translation 5) Increased shear forces in the palmar contact areas 6) Hyaline cartilage wear and OA
Clinical Evaluation
Clinical Presentation
Pain Aggravated by power pinch, grip movements, axial load or flexion/adduction maneuvers
Turning jar lids, doorknobs, opening car doors
Weakness with pinch Typically secondary to pain
Dorsoradial subluxation of the metacarpal base in later stages
Physical Exam
Well localized CMC joint tenderness Localized to radial margin of metacarpal base one finger-breadth distal to scaphoid tubercle
Physical Exam
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Grind Test Pain with axial compression with rotation
Physical Exam
Laxity Test Dorsal-to-volar translation of the metacarpal base will reveal any dorsal subluxation
Torque Test Pain with axial rotation and distraction of the thumb metacarpal
Coexisting Conditions
DeQuervain’s tenosynovitis CMC arthritis may cause DeQuervain’s Good PE, x-rays, injections help differentiate
Carpal Tunnel Syndrome Up to 43% coexists (Florak,1992) Dimensions of carpal tunnel affected by CMC arthritis
ST arthritis FCR tendonitis MCP joint instability
Requires intervention if severe enough
Radiographic Evaluation
PA, lat and oblique views
!
30° oblique stress views Technique
Thumbs w/ nail plates parallel to x-ray film Push thumb tips against each other
Advantages Good visualization of pan-trapezial joints Helps assess TM joint laxity
Classification
Eaton Stage I
Radiographs Pre-arthritic joint Normal articular contours Slight widening of joint space
2° effusion or ligament laxity
Clinically Intermittent mild pain with heavy use Mild loss of strength + Grind test
Eaton Stage II
Radiographs TM joint slightly narrowed Minimal sclerosis ± osteophytes (<2mm & ulnar) < 1/3 metacarpal base subluxation
Clinically Frequent pain with normal activity + Grind test Metacarpal base subluxed radial and dorsal
Eaton Stage III
Radiographs Marked narrowing TM joint Osteophytes > 2mm Increased sclerosis, cystic changes subluxation > 1/3 of metacarpal base
Clinically Passive reduction of metacarpal base may be impossible Adduction of metacarpal and MCP joint hyperextension
Eaton Stage IV
Radiographs Advanced degenerative changes & subluxation ST joint involvement
Clinically Decreased mobility of TM joint Patients with relatively less pain
Treatment
Treatment Options
Depends on stage of disease as well as degree of the patient’s discomfort
!
Conservative: Rest, NSAID’s, steroid injections, splinting with thumb in abduction (Stage I)
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Surgical: Multiple surgical treatment methods (more advanced stages)
Conservative Treatment
Swigart, et al, J of Hand Surg, 1999 Evaluated 130 thumbs treated with 6 weeks of splinting
Stage I/II: 76% improvement Stage III/IV: 54% improvement
Overall… splinting is well-tolerated effective protocol to diminish, but not eliminate the symptoms of basal joint OA
Operative Treatments
Metacarpal Osteotomy Ligament reconstruction Arthroplasty
Resection arthroplasty - trapeziectomy Prosthetic arthroplasty Ligament reconstruction with tendon interposition
Arthrodesis
Prosthetic Arthroplasty
Multiple Types: Silicone Metallic Ceramic Zirconia
WMT.com
Silicone implant
Swanson Implant
Orthosphere
Prosthetic Arthroplasty
Advantages (theoretical) Immediate stability and no need for long term immobilization
Disadvantages Wear, loosening, osteolysis, infection, synovitis (silicone), periprosthetic fracture !
No report exists with results superior to biologic arthroplasty
Ligament Reconstruction and Tendon Interposition
1) Palmar beak ligament reconstruction 2) Tendon interposition arthroplasty using
radial ½ of FCR tendon !
Often used for Stage II or Stage III disease
LRTI - Approach & Bone Resection
Straight incision is made over dorsoradial aspect of TM joint
avoid sensory branch of radial nerve and radial artery
Partial or complete trapeziectomy Decision based on status of scaphotrapezial joint
Base of metacarpal resected
LRTI -Tendon Harvest
FCR tendon graft of 10 -12 cm in length Leading end passed into and through the base of the thumb MC Remaining tendon is folded to act as a spacer
LRTI
MCP Joint Hyperextension Must be addressed if > than 30 degrees
Volar capsulodesis EPB transfer from the base of the proximal phalanx to the metacarpal shaft
Eliminates the EPB hyperextension force at the MCP joint
Postoperative Care
Short-arm, thumb spica casting for 4 weeks
Active ROM exercises
Need for hand therapy depends on individual patient
LRTI
Burton and Pellegrini, J Hand Surg, 1986 25 LRTI, average 2 yr f/u More consistent improvement in grip, pinch, thumb web space than silicone arthroplasty Excellent results in 23 of 25
Arthrodesis
Often used in young laborers
Post-traumatic
Orient by “fist position”
Surgical Complications
Approach related Injury to radial artery or dorsal sensory branch of the radial nerve
Implant related Silicone synovitis, implant subluxation, carpal erosion
Failure of ligament reconstruction Loss of pinch strength Proximal migration of the metacarpal
Cost Analysis
Conservative Management Costs NSAID - Celebrex 200mg #60 = $250 Celestone Injection = $175 Custom OT splint = $200
Cost Analysis
Surgical Costs Metacarpal Osteotomy = $2150 LRTI = $5665 Arthroplasty = $7260