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 the stage of disease multiple operative procedures are performed with none showing clear benefit over the other. 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 C6 Radiculopathy 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 over the others 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 denervation indications Stage I-IV disease 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 Denervation technique can be performed using 2 incisions dorsal apex of the first interosseous space volar distal wrist flexion crease, extending from the ulnar side of the FCR tendon to the 1st extensor compartment resect 4 nerves thenar cutaneous branch of the median nerve palmar cutaneous branch of the median nerve superficial branch of the radial nerve, via the dorsal articular nerve of the 1st interosseous space of the hand lateral antebrachial cutaneous nerve of the forearm, via the branch of Cruveilhier complications specific to this treatment injury to the sensory brach of the radial nerve outcomes improved hand function, grip strength, and pain comparable results to trapeziectomy and CMC arthrodesis in terms of pain improved ROM compared to CMC arthrodesis 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 9 1 2 3 4 5 6 7 8 9 Previous Next (OBQ17.93) A 57-year-old woman presents to clinic with left thumb pain. She reports difficulty with pinching and grasping. Physical examination is remarkable for a painful CMC grind test. A radiograph of her left hand is shown in Figure A. All of the following are possible sequelae of her disease EXCEPT: Tested Concept QID: 210180 FIGURES: A Type & Select Correct Answer 1 Thumb metacarpal adduction deformity 4% (70/1620) 2 Thumb interphalangeal (IP) joint flexion deformity 28% (458/1620) 3 Thumb carpometacarpal (CMC) joint extension deformity 39% (636/1620) 4 Thumb metacarpophalangeal (MCP) joint hyperextension deformity 8% (127/1620) 5 Thumb metacarpal palmar flexion deformity 19% (309/1620) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 4730 FIGURES: A B Type & Select Correct Answer 1 Type II hypoplastic thumb 1% (62/5132) 2 Median nerve neuropathy 4% (216/5132) 3 Lupus thumb deformity 5% (254/5132) 4 Extensor tendon rupture 5% (281/5132) 5 Osteoarthritis of the trapeziometacarpal joint 84% (4288/5132) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 3669 FIGURES: A B Type & Select Correct Answer 1 Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis 7% (259/3507) 2 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint volar capsulodesis 12% (408/3507) 3 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint fusion 68% (2393/3507) 4 Carpometacarpal joint resection arthroplasty and temporary metacarpophalangeal joint percutaneous pin fixation 6% (203/3507) 5 Carpometacarpal joint fusion and metacarpophalangeal joint fusion 6% (213/3507) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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 most offer the greatest degree of symptomatic improvement? Tested Concept QID: 2935 FIGURES: A Type & Select Correct Answer 1 Saline 0% (11/2578) 2 Steroid 43% (1101/2578) 3 Hylan 1% (32/2578) 4 All of the above are equally effective 53% (1357/2578) 5 All of the above are detrimental 2% (60/2578) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 753 FIGURES: A Type & Select Correct Answer 1 Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy 5% (275/5665) 2 Trapeziectomy with interpositional palmaris longus arthroplasty 10% (574/5665) 3 Trapeziectomy, interpositional arthroplasty, and palmar oblique ligament reconstruction using flexor carpi radialis autograft 28% (1587/5665) 4 Partial trapeziectomy with capsular interpositional arthroplasty 29% (1632/5665) 5 None of the above 27% (1553/5665) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept
All Videos (5) Podcasts (1) 2018 Orthopaedic Summit Evolving Techniques Trapeziectomy - Brian D. Adams, MD (OSET 2018) Brian D. Adams Hand - Basilar Thumb Arthritis A 8/21/2019 1877 views 4.5 (6) 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 A 8/21/2019 1933 views 4.0 (2) 2019 California Orthopaedic Association Annual Meeting Postoperative Protocols After LRTI for CMC Surgery - Steven S. Shin, MD, MMSc Steven Shin Hand - Basilar Thumb Arthritis C 7/11/2019 964 views 3.0 (1) HandāBasilar Thumb Arthritis Team Orthobullets 4 Hand - Basilar Thumb Arthritis Listen Now 12:44 min 10/21/2019 353 plays 5.0 (2) See More See Less
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