Updated: 4/8/2019

Basilar Thumb Arthritis

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Questions
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Evidence
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Videos
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Cases
2
https://upload.orthobullets.com/topic/6054/images/stage1.jpg
https://upload.orthobullets.com/topic/6054/images/CMC Arthritis_moved.png
https://upload.orthobullets.com/topic/6054/images/stage3.jpg
https://upload.orthobullets.com/topic/6054/images/stage4.jpg
https://upload.orthobullets.com/topic/6054/images/beam.jpg
Introduction
  • Description
    • basilar thumb arthritis, sometimes referred to as thumb arthritis, is a common form of arthritis that affects the carpal-metacarpal joint of the thumb.
      • treatment is nonoperative or operative depending on the severity of symptoms and Eaton and Littler stage of disease.
  • Arthritis of the carpal-metacarpal (CMC) joint
  • Epidemiology
    • race
      • thumb CMC arthritis is more common in Caucasians
      • hand OA is more common in native Americans than Caucasians/African Americans
    • common arthritis of the hand
      • 2nd only to DIP arthritis
      • DIP > thumb CMC > PIP > MCP
      • OA in 1 joint in a row (proximal row) predicts for OA in other joints in same row
  • 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
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 (zig-zag or "Z" deformity) 
      • occurs during pinch as a sequlae of CMC arthritis
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 
Differential Diagnosis
  • de Quervains tenosynovitis
  • STT arthritis
  • scaphoid nonunion/SNAC
  • radioscaphoid arthritis
Treatment
  • Nonoperative
    • NSAIDS, thumb spica bracing, symptomatic treatment, steroid injections
      • indications
        • indicated as first line of treatment for mild symptoms
    • hyaluronic acid injections
      • show no difference for the relief of pain and improvement in function when compared to placebo and corticosteroids
  • Operative
    • closing wedge dorsal extension osteotomy of 1st metacarpal  
      • indications
        • for early Stage I disease 
      • technique
        • redirects the force to the dorsal, more uninvolved portion of the first carpometacarpal joint
      • outcomes
        • gained in popularity 
        • 93% have symptom improvement at 7 years
    • ligament reconstruction with FCR
      • indications
        • Stage I disease when joint is hypermobile and unstable (pain with varus valgus stress)
    • trapeziectomy + 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 is most important, regardless of other specifics of CMC arthroplasty
          • FCR tendon most commonly used in reconstruction to suspend metacarpal
            • alternatively, ECRL or APL may be used for suspension 
            • or PL around FCR to correct subluxation
      • outcomes
        • can expect ~25% subsidence postoperatively
          postoperatively
          • with no change in outcomes
        • results in improved grip and pinch strengths
    • hematoma arthroplasty (trapezial resection alone without LRTI) 
      • indications
        • Stage II-IV disease 
      • technique 
        • trapezium resection and pinning of thumb metacarpal without LRTI
      • outcomes 
        • comparable outcomes to trapeziectomy + LRTI
    • excision of proximal third of trapezioid
      • indications
        • concomitant scaphotrapezioid arthritis (present in 62%), especially in Eaton-Littler stage IV
    • CMC arthroscopy and debridement
      • indications
        • early stages of disease
    • trapeziometacarpal (CMC) arthrodesis 
      • indications
        • Stage II-III disease in young male heavy laborers
          • preserves grip strength
      • contraindications
        • scaphotrapeiotrapezoidal (STT) arthritis
      • 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%
    • volar capsulodesis, EPB tendon transfer, sesamoid fusion, or MCP fusion  
      • indications
        • thumb MCP hyperextension instability (hyperextension > 30°) otherwise a Swan neck deformity will arise
        • see below (Complications) for algorithm
    • silicone replacements
      • indications
        • not recommended 
        • complications of prosthesis fracture, subluxation, or silicone synovitis
Complications
  • 1st metacarpal subsidence and narrowing of trapezial space height
    • after trapeziectomy ± tendon suspension
    • salvage 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
 

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Questions (7)

(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:
1

Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy

6%

(257/4349)

2

Trapeziectomy with interpositional palmaris longus arthroplasty

10%

(419/4349)

3

Trapeziectomy, interpositional arthroplasty, and palmar oblique ligament reconstruction using flexor carpi radialis autograft

27%

(1179/4349)

4

Partial trapeziectomy with capsular interpositional arthroplasty

37%

(1599/4349)

5

None of the above

20%

(855/4349)

ML 5

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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(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:
1

Type II hypoplastic thumb

1%

(55/4245)

2

Median nerve neuropathy

4%

(169/4245)

3

Lupus thumb deformity

5%

(202/4245)

4

Extensor tendon rupture

6%

(235/4245)

5

Osteoarthritis of the trapeziometacarpal joint

84%

(3559/4245)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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:
1

Saline

0%

(9/2224)

2

Steroid

41%

(922/2224)

3

Hylan

1%

(29/2224)

4

All of the above are equally effective

54%

(1203/2224)

5

All of the above are detrimental

2%

(49/2224)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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:
1

Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis

7%

(190/2800)

2

Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint volar capsulodesis

12%

(342/2800)

3

Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint fusion

69%

(1929/2800)

4

Carpometacarpal joint resection arthroplasty and temporary metacarpophalangeal joint percutaneous pin fixation

6%

(162/2800)

5

Carpometacarpal joint fusion and metacarpophalangeal joint fusion

5%

(153/2800)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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Topic COMMENTS (19)
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