Introduction Overview basilar thumb arthritis is a common form of arthritis that affects the carpal-metacarpal (CMC) joint of the thumb treatment is nonoperative or operative depending on the severity of symptoms and Eaton and Littler stage of disease Epidemiology incidence common arthritis of the hand 2nd only to DIP arthritis DIP > thumb CMC > PIP > MCP seen in 25% of men and 40% of women aged > 75 years old demographics more common in women thumb CMC arthritis is more common in Caucasians hand OA is more common in native Americans than Caucasians/African Americans risk factors female gender Ehler-Danlos syndrome increased BMI Pathoanatomy theorized to be due to attenuation of anterior oblique ligament (Beak ligament) leading to instability, subluxation, and arthritis of CMC joint Associated conditions MCP hyperextension deformity concomitant carpal tunnel syndrome occurs in up to 50% Prognosis OA in 1 joint in a row (proximal row) predicts for OA in other joints in same row Anatomy Osteology thumb carpal-metacarpal joint is a biconcave saddle joint consists of 4 articulations trapeziometacarpal (TM) trapeziotrapezoid scaphotrapezial (ST) trapezium-index metacarpal trapezium has a palmar groove for the flexor carpi radialis (FCR) tendon Ligaments anterior oblique (volar beak) ligament primary stabilizing static restraint to subluxation of CMC joint originates from the palmar tubercle of the trapezium and inserts on the articular margin of the ulnar metacarpal base intermetacarpal ligament attaches from the radial base of the 2nd metacarpal to the ulnar base of the 1st metacarpal primary restraint to radial translation of the base of the 1st metacarpal assisted by the dorsoradial and posterior oblique ligaments posterior oblique ligament dorsoradial ligament primary restraint to dorsal dislocation injured in dorsal CMC dislocation strongest and thickest ligament 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 pain at base of thumb symptoms of concomitant carpal tunnel syndrome function difficulty pinching and grasping Physical exam inspection swelling and crepitus metacarpal adduction and web space contractures later findings may have adjacent MCP fixed hyperextension (zig-zag or "Z" deformity) occurs during pinch as a sequlae of CMC arthritis provocative tests painful CMC grind test combined axial compression and circumduction Imaging Radiographs recommended views AP lateral Roberts view 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 Differential Diagnosis de Quervains tenosynovitis STT arthritis scaphoid nonunion/SNAC radioscaphoid arthritis Treatment Nonoperative NSAIDS, thumb spica bracing indications first line of treatment for mild symptoms injections indications second line of treatment for mild to moderate disease types steroid injections good evidence to support hyaluronic acid injections not indicated - studies show no difference for the relief of pain and improvement in function when compared to placebo and corticosteroids Operative CMC arthroscopic debridement indications early stages of disease 1st metacarpal osteotomy indications early Stage I-II disease contraindications hypermobility or fixed subluxation of the CMC joint MCP hyperextension > 10° technique performed with closing wedge dorsal extension trapeziectomy +/- ligament reconstruction indications Stage I-IV disease multiple techniques with none showing clear benefit trapeziectomy + LRTI (ligament reconstruction and tendon interposition) most common procedure and favored in most patients hematoma arthroplasty (trapeziectomy without LRTI) trapeziectomy + suture suspension (suture suspension with APL to FCR) newer technique growing in popularity volar ligament reconstruction with FCR useful for Stage I disease when joint is hypermobile and unstable (pain with varus valgus stress) excision of proximal third of trapezioid ideal for patients with concomitant scaphotrapezioid arthritis (present in 62%), especially in Stage IV disease CMC arthrodesis indications Stage II-III disease in young male heavy laborers preserves grip strength contraindications scaphotrapeiotrapezoidal (STT) arthritis CMC prosthetic arthroplasty indications not recommended Techniques CMC Arthroscopic Debridement technique portals dorsal 1R radial to the APL tendon dorsal 1U ulnar to the EPB tendon between the EPL and EPB tendons 1st Metacarpal Osteotomy technique redirects the force to the dorsal, more uninvolved portion of the 1st CMC joint perform closing dorsal wedge extension osteotomy fixation using K wires, intraosseous wiring, or plates outcomes gained in popularity 93% have symptom improvement at 7 years Trapeziectomy +/- Ligament Reconstruction technique many different surgical options are available trapezial excision is most important, regardless of other specifics of CMC arthroplasty FCR tendon most commonly used in LRTI to suspend metacarpal can also use ECRL or APL for suspension can use PL around FCR to correct subluxation outcomes can expect ~25% subsidence postoperatively with no change in outcomes results in improved grip and pinch strengths CMC Arthrodesis technique CMC joint fused in 35° radial abduction 30° palmar abduction 15° pronation outcomes good pain relief, stability, and length preservation decreased ROM, inability to put hand down flat nonunion rate of 12% CMC Prosthetic Arthroplasty technique several implant types exist most experience has been using silicone implants complications specific to this treatment implant fracture or loosening subluxation silicone synovitis Complications 1st metacarpal subsidence and narrowing of trapezial space height occurs after trapeziectomy ± tendon suspension treatment LRTI with ECRL tendon or APL tendon if FCR is already used/ruptured MCP hyperextension deformity treatment depends on degree of hyperextension <10° - no surgical intervention 10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer 20-40° - volar capsulodesis or sesamoidesis >40° - MCP fusion
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ13.95) A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity? Review Topic QID: 4730 FIGURES: A B Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Type II hypoplastic thumb 1% (55/4354) 2 Median nerve neuropathy 4% (175/4354) 3 Lupus thumb deformity 5% (207/4354) 4 Extensor tendon rupture 6% (240/4354) 5 Osteoarthritis of the trapeziometacarpal joint 84% (3650/4354) L 1 Select Answer to see Preferred Response SUBMIT RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (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? Review Topic QID: 3669 FIGURES: A B Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis 7% (217/2971) 2 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint volar capsulodesis 12% (356/2971) 3 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint fusion 69% (2037/2971) 4 Carpometacarpal joint resection arthroplasty and temporary metacarpophalangeal joint percutaneous pin fixation 6% (170/2971) 5 Carpometacarpal joint fusion and metacarpophalangeal joint fusion 6% (166/2971) L 3 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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? Review Topic QID: 2935 FIGURES: A Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Saline 0% (9/2264) 2 Steroid 41% (937/2264) 3 Hylan 1% (30/2264) 4 All of the above are equally effective 54% (1224/2264) 5 All of the above are detrimental 2% (51/2264) L 4 Select Answer to see Preferred Response SUBMIT RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ07.92) A 56-year-old right hand dominant male presents to your office complaining of right thumb pain worsened with pincer grip and using his mobile phone. He is a writer, and is having difficulty holding his pen. Radiographs from this visit are shown in Figure A. Compared with trapeziectomy alone, which of the following treatment options is likely to result in superior pain relief and improvement of key-pinch strength? Review Topic QID: 753 FIGURES: A Type & Select Correct Answer Type in at least one full word to see suggestions list 1 Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy 6% (261/4587) 2 Trapeziectomy with interpositional palmaris longus arthroplasty 10% (456/4587) 3 Trapeziectomy, interpositional arthroplasty, and palmar oblique ligament reconstruction using flexor carpi radialis autograft 27% (1251/4587) 4 Partial trapeziectomy with capsular interpositional arthroplasty 35% (1608/4587) 5 None of the above 21% (972/4587) L 5 Select Answer to see Preferred Response SUBMIT RESPONSE 5
2018 Orthopaedic Summit Evolving Techniques Trapeziectomy - Brian D. Adams, MD (OSET 2018) Brian Adams Hand - Basilar Thumb Arthritis 4 weeks ago 305 views 2018 Orthopaedic Summit Evolving Techniques LRTI Is The Only Way, It Has Survived The Test of Time - Don't Be Stupid - Fraser J. Leversedge, MD (OSET 2018) Hand - Basilar Thumb Arthritis 4 weeks ago 360 views 2019 California Orthopaedic Association Annual Meeting Postoperative Protocols After LRTI for CMC Surgery - Steven S. Shin, MD, MMSc Steven Shin Hand - Basilar Thumb Arthritis 7/11/2019 253 views See More See Less
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