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Updated: Jul 28 2023

Basilar Thumb Arthritis

4.1

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Images
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
  • Summary
    • Basilar Thumb Arthritis is a form of arthritis that causes pain at the base of the thumb and difficulty with pinching and grasping due to carpal-metacarpal (CMC) joint arthritis.
    • Diagnosis is made clinically with a painful CMC grind test and radiographs of the hand showing osteoarthritis of the 1st CMC joint.
    • Treatment can be conservative (bracing, injections) or operative depending on the severity of symptoms and the 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
  • Etiology
    • 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
      • MCP arthritis
      • concomitant carpal tunnel syndrome
        • occurs in up to 50%
  • 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 sclerosis, 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
    • 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
  • Prognosis
    • Osteoarthritis in 1 joint in a row (proximal row) predicts for osteoarthritis in other joints in same row
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