Basilar Thumb Arthritis

Author: David Abbasi

Topic updated on 02/25/13 6:23pm

Introduction

Arthritis of the carpal-metacarpal (CMC) joint
Epidemiology
- common arthritis of the hand
  - 2nd only to DIP arthritis
Pathoanatomy
- theorized to be due to attenuation of anterior oblique ligament (Beak ligament)
  - leading to instability, subluxation, and arthritis of CMC joint

Anatomy

Trapezial metacarpal joint is a biconcave saddle joint
Trapezium has a palmar groove for flexor carpi radialis (FCR) tendon
Ligaments
- anterior oblique ligament (Beak ligament)
  - primary stabilizing restraint to subluxation of CMC joint
- intermetacarpal ligaments
- posterior oblique ligament
- dorsal-radial capsule (injured in dorsal CMC dislocation)
Biomechanics
- CMC joint reactive force is 13X applied pinch force

Classification

Eaton and Littler Classification of Basilar Thumb Arthritis
Stage I	slight joint space widening (pre-arthritis)
Stage II	slight narrowing of CMC joint with sclerosis, osteophytes <2mm
Stage III	marked narrowing of CMC joint with osteophytes, osteophytes >2mm
Stage IV	pantrapezial arthritis (STT involved)

Presentation

Symptoms
- pain at base of thumb
- difficulty pinching and grasping
- concomitant carpal tunnel syndrome
  - up to 50% incidence
Physical exam
- painful CMC grind test
  - combined axial compression and circumduction
- swelling and crepitus
- metacarpal adduction and web space contractures
  - are later findings
- may have adjacent MCP fixed hyperextension
  - during pinch

Imaging

Radiographs
- technique
  - X-ray beam is centered on trapezium and metacarpal with thumb flat on cassette and thumb hyperpronated
- findings
  - joint space narrowing
  - osteophytes
  - may show MCP hyperextension

Treatment

Nonoperative
- NSAIDS, bracing, symptomatic treatment
  - indications
    - indicated as first line of treatment for mild symptoms
  - technique
    - splints (thumb spica orthosis)
- hyalgan injections
  - show no difference for the relief of pain and improvement in function when compared to placebo and corticosteroids
Operative
- trapezial resection with LRTI (ligament reconstruction and tendon interposition)
  - indications
    - Stage II-IV disease
    - most common procedure and favored in most patients
  - technique
    - there are many different surgical options available
      - trapezial excision appears to be the most important step to this procedure, regardless of the other specifics of each individual style of CMC arthroplasty
      - FCR tendon most commonly used in reconstruction to suspend metacarpal
        
        alternatively, APL may be used
  - outcomes
    - can expect 25% subsidence postoperatively
      - with no change in outcomes
    - results in improved grip and pinch strengths
- ligament reconstruction with FCR
  - indications
    - Stage I disease when joint is hypermobile and unstable (pain with varus valgus stress)
- CMC arthroscopy and debridement
  - indications
    - early stages of disease
- extension osteotomy of the first metacarpal
  - indications
    - early Stage disease and minimal arthritic degeneration of CMC joint
  - technique
    - redirects the force to the dorsal, more uninvolved portion of the first carpometacarpal joint
  - outcomes
    - has gained in popularity and studies show that 93% are improved at seven years out
- trapeziometacarpal arthrodesis and fusion
  - indications
    - Stage II and Stage III disease in young male heavy laborers
  - technique
    - TM joint fused in
      - 35° radial abduction
      - 30° palmar abduction
      - 15° pronation
  - outcomes
    - good pain relief, stability, and length preservation
    - decreased ROM
    - nonunion rate of 12%
- volar capsulodesis, EPB tendon transfer, sesamoid fusion, or MCP fusion
  - indications
    - if thumb MCP hyperextension instability (joint can hyperextend > 30°)
      - otherwise a Swan neck deformity will arise
- silicone replacements
  - indications
    - not recommended due to complications of prosthesis fracture, subluxation, or silicone synovitis

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Qbank (3 Questions)

TAG

(OBQ11.246) A 68-year-old female office assistant reports left thumb pain that has progressively worsened over the past 2 years. She is left hand dominant and reports difficulty with opening jars and holding a coffee cup. On examination of the left hand she has a positive thumb carpometacarpal grind test and has a fixed deformity at the thumb metacarpalphalangeal joint. Figure A demonstrates the left hand grasping an object and Figure B shows a radiograph of the left thumb. What is the most appropriate next step in treatment? Topic

Review Topic

FIGURES: A

1. Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis
2. Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint volar capsulodesis
3. Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint fusion
4. Carpometacarpal joint resection arthroplasty and temporary metacarpophalangeal joint percutaneous pin fixation
5. Carpometacarpal joint fusion and metacarpophalangeal joint fusion

PREFERRED RESPONSE ▶

DISCUSSION: The patients history, examination, and images are consistent with thumb CMC (basilar) joint arthritis with associated MCP joint arthritis. At the MCP joint there is hyperextension of the thumb metacarpophalangeal (MCP) joint and adduction involving the first web space of the hand (Z deformity). Arthrodesis of the MCP joint is the treatment of choice when thumb MCP hyperextension exceeds 40°, the deformity is not passively correctable, or advanced degenerative changes are noted to affect the articulation.

The review article by Armbruster and Tan state that when MCP joint hyperextension is:
0° to 10°= Surgical intervention is not necessary when MCP hyperextension is less than 10°.
10° to 20°= Percutaneous pinning of the MCP joint in 25° to 35° of flexion for 3-4 weeks may be performed independently or as an adjunct to EPB transfer.
20° to 40°= Capsulodesis of the volar aspect of the MCP joint is recommened to provide a check rein for hyperextension and Sesamoidesis has also been investigated as an adjunctive procedure.

Cooney et al performed a Level 4 review of their CMC arthroplasty patients and found 15 patients with 17 revision arthroplasties in the treatment of mechanical pain related to instability or bone impingement. The revisions included soft-tissue interposition alone or soft-tissue interposition with ligament reconstruction and found that this provided satisfactory patient outcomes in more than 75% of the cases.

Illustration A depicts the forces accounting for the observed adduction and hyperextension deformities. The arrowhead indicates the direction of subluxation of the base of the thumb metacarpal (due to incompetent volar beak ligament). The arrow represents the force vector of the EPB potentiating the MCP hyperextension deformity

Illustrations: A

REFERENCES:

1. Armbruster EJ, Tan V. Carpometacarpal joint disease: addressing the metacarpophalangeal joint deformity. Hand Clin. 2008 Aug;24(3):295-9, vii. Review. PMID:18675721 (Link to Abstract)

2. Cooney WP 3rd, Leddy TP, Larson DR. Revision of thumb trapeziometacarpal arthroplasty. J Hand Surg Am. 2006 Feb;31(2):219-27. PMID:16473682 (Link to Abstract)

Question Authors:

Michael Hughes MD, Dave Marcu MD, John Badylak MD,

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TAG

(OBQ09.122) A 60-year-old man has chronic pain at the base of this thumb and weakness on attempted thumb pinch. A radiograph is shown in Figure A. Which injection would likely reduce his pain and increase his function? Topic

Review Topic

FIGURES: A

1. Saline
2. Steroid
3. Hylan
4. All of the above are equally effective
5. All of the above are detrimental

PREFERRED RESPONSE ▶

DISCUSSION: The patient has basal joint arthritis of the thumb and randomized controlled trials have failed to demonstrate an advantage of steroid or hylan over saline, so the answer is 4. A study by Heyworth demonstrated that all three injections were similarly effective for approximately 3 months at reducing pain and increasing thumb function over baseline levels. Stahl found that steroid and hylan were equally effective, but did not control with saline. Hylan derivatives have been extensively studied in the knee and Henderson found no advantage of hyaluronan over saline for knee arthritis during a 5 week treatment course.

REFERENCES:

1. Heyworth BE, Lee JH, Kim PD, et al. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: A prospective, randomized, double-blinded clinical trial. J Hand Surg Am 2008;33:40-48 PMID:18261664 (Link to Abstract)

2. Stahl S, Karsh-Zafrir I, Ratzon N, et al. Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints. J Clin Rheumatol 2005;11:299-302 PMID:16371798 (Link to Abstract)

3. Henderson EB, Smith EC, Pegley F, et al. Intra-articular injections of 750 kD hyaluronan in the treatment of osteoarthritis: A randomized single centre double-blinded placebocontrolled trial of 91 patients demonstrating lack of efficacy. Ann Rheum Dis 1994;53:529- 534 PMID:7944639 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD,

Please Rate Educational Value!

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TAG

(OBQ07.92) A 64-year-old female presents with pain in the base of her thumb and a positive grind test. A radiograph is shown in Figure A. Which of the following surgical steps is the most crucial in surgical treatment of this condition to achieve a successful clinical outcome? Topic

Review Topic

FIGURES: A

1. Suspension of the first metacarpal
2. Deep dissection of thenar/extensor compartments
3. Interposition material within CMC joint
4. Excision of the trapezium
5. Alignment of the skin incision

PREFERRED RESPONSE ▶

DISCUSSION: This patient is presenting with signs/symptoms consistent with 1st CMC arthritis. The most important step in a 1st CMC arthroplasty for basilar thumb arthritis is excision of trapezium.

The various surgical options that have been discussed in the literature include excision of the trapezium, excision of the trapezium with interposition arthroplasty and suspensory ligament reconstruction, and excision with interposition arthroplasty only.

Davis et al showed that the outcome of three common CMC arthroplasty procedures were similiar as long as trapeziectomy was included.

REFERENCES:

1. Davis TR, Brady O, Dias JJ. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition. J Hand Surg Am. 2004 Nov;29(6):1069-77. PMID:15576217 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Patrick McCulloch MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

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Cases

http://upload.orthobullets.com/cases/1185/oblique preop.jpg

http://upload.orthobullets.com/cases/1185/lateral preop.jpg

Basal joint arthritis (C1185)

Hand - - Basilar Thumb Arthritis

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Videos

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Posts

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Davis TR, Brady O, Dias JJ. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition. J Hand Surg Am. 2004 Nov;29(6):1069-77. PMID:15576217 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Armbruster EJ, Tan V. Carpometacarpal joint disease: addressing the metacarpophalangeal joint deformity. Hand Clin. 2008 Aug;24(3):295-9, vii. Review. PMID:18675721 (Link to Abstract)
Cooney WP 3rd, Leddy TP, Larson DR. Revision of thumb trapeziometacarpal arthroplasty. J Hand Surg Am. 2006 Feb;31(2):219-27. PMID:16473682 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Henderson EB, Smith EC, Pegley F, et al. Intra-articular injections of 750 kD hyaluronan in the treatment of osteoarthritis: A randomized single centre double-blinded placebocontrolled trial of 91 patients demonstrating lack of efficacy. Ann Rheum Dis 1994;53:529- 534 PMID:7944639 (Link to Abstract)
Heyworth BE, Lee JH, Kim PD, et al. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: A prospective, randomized, double-blinded clinical trial. J Hand Surg Am 2008;33:40-48 PMID:18261664 (Link to Abstract)
Stahl S, Karsh-Zafrir I, Ratzon N, et al. Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints. J Clin Rheumatol 2005;11:299-302 PMID:16371798 (Link to Abstract)

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Basilar Thumb Arthritis

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