Basal Joint Arthritis of the Thumb

Christian Veillette, MD, MSc, BSc(Hon)Orthopaedic Resident PGY-4Upper Extremity Rounds 2004St. Michael’s Hospital

Objectives

Epidemiology Etiology Anatomy and Biomechanics Pathoanatomy Diagnosis Imaging Classification Treatment Options Literature Review Complications

Epidemiology

Trapeziometacarpal joint OA - common 1 in 4 women 1 in 12 men

The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. Armstrong et al. J Hand Surg [Br]. 1994 Jun;19(3):340-1 143 post-menopausal women radiological prevalence

isolated carpometacarpal OA – 25% Isolated scapho-trapezial OA – 2% combined carpometacarpal and scapho-trapezial OA - 8%

Symptomatic – basal thumb pain 28% with isolated carpometacarpal OA 55% with combined carpometacarpal/scapho-trapezial OA

“The most frequent site in the upper extremity in need of surgery for disabling osteoarthritic disease” Pellegrini Clin. Orthop 23(1) 1992

Etiology Osteoarthritis Inflammatory arthritis Hypermobile laxity

young females Connective tissue disorders Failed reconstructive procedures Trauma

Bennett’s/Rolando Fractures Dislocations Ligamentous injuries

No longitudinal natural history study has established clear etiology for basal joint disease

Strong association between excessive basal joint laxity development of premature degenerative changes

Anatomy and Biomechanics

Shallow saddle-joint architecture little intrinsic osseous stability must rely on static ligamentous constraints

Four trapezial articulations Trapeziometacarpal (TM) Scaphotrapezial (ST) Trapeziotrapezoid Trapezium-Index metacarpal

Only the TM and ST joints lie along the longitudinal compression axis of the thumb

Radiographic disease most commonly affects TM and ST joints

Term pantrapezial arthritis is somewhat misleading

Anatomy and Biomechanics Grasping and pinching

functions of the thumb involve three arcs of motion: Flexion-extension Abduction-adduction Opposition

TM joint compression =12 x thumb-index pinch Cooney 1977 JBJS

Differential radius of curvature Maximal congruence at

extremes Ab/Adduction

Anatomy and Biomechanics

Opposition Axial rotation at TM joint Shear forces Flexion-adduction Volar articular surface

concentration Minimal dorsal contact Palmar pattern joint surface wear

Role of palmar beak ligament

Pellegrini et. al Contact patterns in the trapeziometacarpal joint: The role of the palmar beak ligament. J Hand Surg [Am] 1993;18:238-244 23 cadaver forearm specimens Loaded to simulate lateral pinch, and pressure-sensitive film

used to record joint contact patterns in functional positions palmar compartment of TM joint was primary contact area during

flexion adduction Simulation of dynamic pinch and release produced dorsal

enlargement of contact pattern physiologic translation of the metacarpal on the trapezium

Detachment of palmar beak ligament resulted in dorsal translation of the contact area producing a pattern similar to that of cartilage degeneration seen in the osteoarthritic joint

End-stage osteoarthritic specimens had a nonfunctional beak ligament and demonstrated a pathologic total contact pattern of joint congruity

Anatomy and Biomechanics

Primary ligamentous stabilizers of TM joint Anterior oblique or “volar beak” ligament

Tethers base of thumb metacarpal to trapezium 1o restraint to dorsoradial subluxation

Supported by clinical success of volar ligament reconstruction

Dorsoradial ligament 1o restraint to dorsal translation Supported by cadaver studies simulating acute dorsal

TM joint dislocations

Anatomy Adductor pollicis longus spans

the .V. between the thumb and index metacarpals

Abductor pollicis longus inserts at the base of the thumb metacarpal and causes dorsal subluxation in absence of sufficient ligamentous stability

Intermetacarpal ligament is an extracapsular tether between the two metacarpals

Palmar (anterior) oblique ligament is eccentrically positioned and tightens with thumb metacarpal pronation

Flexor carpi radialis tendon

Pathoanatomy

Unique architecture of basal joint allows its varied functions but predisposes it to unusual wear patterns when joint is unstable

Rate of degeneration influenced by the forces subjected to over the course of time

Repetitive thumb pinch are at greater risk for developing symptomatic basal joint disease than the average person

No consistent relationship between symptoms and degree of radiographic evidence basal joint degeneration

Series of steps in joint degeneration

Pathoanatomy Progression theory

Excessive laxity + repetitive loads Synovitis Osteophytes + joint space narrowing Attenuation/insufficient volar beak ligament Dorsal radial subluxation of 1st MC base Adducted posture of 1st MC

Distal aspect tethered to 2nd MC by adductor policis Metacarpophalangeal joint hyperextension

Progressive functional deficit Decreased grip Narrowed palm, functional hand width

Diagnosis Typical patient

50-70 year-old woman, radial-side hand or thumb pain Insidious onset, duration from several months to several years Exacerbated by common activities (handwriting, holding heavier books,

turning doorknobs or keys in locks, doing needlepoint, using scissors) Pain relieved by rest, NSAIDS, splint Functional limitations vary depending on patient’s vocation and hand

dominance Older individuals complain of progressive inability to perform ADLs

(opening jar tops by hand, opening cans with can opener) Less commonly

women in 20s or 30s pain in the thenar eminence due to TM joint synovitis associated excessive joint laxity pain may radiate up radial aspect of the forearm with certain

activities, especially extensive writing may complain of muscle cramping in the first web space and thenar

eminence

Clinical Exam

“Shoulder sign” = dorsoradial prominence Subluxation Inflammation Osteophytes

Adduction contracture MP hyperextension

collapse

Clinical Exam

Focal tenderness dorsal + volar to APL/EPB MP: volar plate + UCL ST joint – 1 cm proximal to TM joint

ROM Radial + palmar abduction Active + passive pinch (MP hyperextension collapse)

Laxity Dorsovolar: Beak ligament attenuated Radioulnar Generalized laxity testing

Neurovascular

Clinical Exam

Special tests “Grind Test”: axial load + MC rotation “Crank Test” : axial load + flexion/extension Pinch Test – MP hyperextension collapse Distraction Test – relief of pain

Imaging

“Poor correlation between X-rays + symptomatic disease” Swanson JBJS-A (54) 1972

X-rays- 3 views Pronated AP Lateral Oblique

Special X-rays Stress view – basal joint subluxation Pinch lateral - assess basal joint height, follow up

measurements

Classification - Eaton

Stage ITM – Precedes cartilage

degenerationTM - Contours normalTM - Joint space widening if

effusion/synovitisTM stress subluxationST joint normal

Eaton, Lane, Littler. J. Hand Surg. 9A 1984

Classification

Stage IITM narrowingTM contours still normalTM joint osteophytes

<2mmST joint Normal

Classification

Stage IIITM joint destructionTM joint sclerosis, cystic

changesTM joint osteophytes

>2mmST joint normal

Classification

Stage IVAdvanced disease TM and

ST joints

Exact risk and rate of progression cannot be precisely delineated.No longitudinal studies

Differential Diagnosis

OA/RA Hypermobile Laxity Trauma Inflammation

Dequervain’s Stenosing flexor synovitis

Carpal Tunnel Trigger Thumb

Wrist ganglia Carpal instability Metabolic Tumour Infection Referred pain

Non-operative Treatment

Education Activity modification

less forceful pinching, alternating hand use, switching to larger diameter writing instruments and golf grips, using reading stand to hold books

NSAIDS Intra-articular steroid injections Physiotherapy

thenar/adductor stretching & strengthening Splinting

Splinting Long Opponens/Thumb spica

Full time 3-4 weeks Part time 3-4 weeks + night use Prefabricated versions appear to be

less effective and less comfortable than a well-fitted custom splint

Swigart et al. J. Hand Surg. 24A(1)1999 Stage I-II – 76 % StageIII-IV – 54 % sufficient symptomatic relief to allow

continued activities with intermittent time-limited splint use

19% progress to surgery

Operative Indications

Persistent pain Functional disability Failure conservative treatment Compliant patient

Principles of Surgery Pain relief Maintain function/strength

Grip Pinch

Ligamentous stability Carpal height Hyperextension collapse at MCP joint

Cause of failed surgical treatment Intraoperative Staging

Assess cartilage erosion: T-M, S-T joints

Procedures

Trapezium Excision Excision + Rolled Tendon

Graft (ANCHOVY) Silicone Arthroplasty Arthrodesis Osteotomy 1st MC Volar Ligament Reconstruction

(EATON Procedure) Ligament Reconstruction +

Tendon Interposition Arthroplasty (LRTI)(BURTON)

Double Interposition Arthroplasty

Interposition Costochondral Allograft

Cemented Arthroplasty Cementless Arthroplasty Ceramic Arthroplasty

AlgorithmJAAOS. 2000;8:314-323

Trapezium Excision Gervis WH JBJS Br 1949;31:537-539.

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint

Burton RI. Orthop. Clin North Am. 1986;17;493-503 Loss of pinch strength Instability CMC joint Proximal MC migration MCP hyperextension instability

Trapezium excision should be limited to the painfully arthritic TM joint in the low-demand elderly patient without evidence of significant subluxation

Arthrodesis – TM Joint Younger patients (<50 yrs) + High demand Advantages

Reliable pain reduction Maintain ADL’s Improved grip

Disadvantages Adjacent joint arthrosis ROM (key pinch) Hand flattening MCP hyperextension Nonunion 13%-29%

Arthrodesis – TM Joint Cavallazzi RM J. Hand Surg. 1986;11B

Trapeziometacarpal arthrodesis today: why? 10 year f/u, 42 patients Relief of pain, maintenance of stability Good function Patients pleased

Primary indications Salvage of failed reconstruction Treatment of manual laborer

Optimal position of fusion for thumb CMC joint 20o of radial abduction 40o of palmar abduction

Anchovy

Trapezium Excision Rolled Tendon Graft FCR tendon interposition Froimson. Clin. Orthop. (70): 191-199 1970

30% Decrease pinch strength 50% Loss joint space @ 6 yrs

APL tendon interposition Robinson J. Hand Surg. 16A:504-9, 1991

39 patients 50% excellent (no pain, full ROM, normal grip) 35% good (75% ROM)

Silicone Arthroplasty

Lower demand + Rheumatoid Concerns:

Weakness Dislocation Fracture Deformation Osteolysis Synovitis Immunologic alterations

Silicone Arthroplasty

Sollerman J. Hand Surg. 13B 1988 12 year f/u 51-84 % carpal erosion

Pellegrini, Burton J. Hand Surg. 1996 20A 4 year f/u 25% clinical failure 35% subluxation 50% loss of height

Osteotomy

Base of thumb metacarpal, unload volar portion TM joint Wilson JBJS 65B:179, 1983

Eaton Stage II 23 osteotomies 30o dorsal closing wedge 12 yrs f/u no revisions all patients satisfied “fully functional”

Indications: High demand hand Young laborer

Volar Ligament Reconstruction

Radial ½ FCR distal, ulnar ½ proximal

Hole in thumb MC base – dorsal to volar

Deep to APL Deep to intact FCR Final anchor point APL

Volar Ligament Reconstruction

Eaton et. al. J. Hand Surg. 9A(5) 1984Eaton Stage I-II50 reconstructionsAvg age 45 yrs f/u – 7 years95% good-excellent result

Volar Ligament Reconstruction

Long-term results: 15 years Freedman,Eaton,Glickel. J. Hand Surg.

25A(2) March 200023 patientsAvg age 33 yrs femaleEaton Stage I + Instability15/23 90% satisfaction8 % progressed on x-rays

Ligament Reconstruction with Tendon Interposition Arthroplasty (LRTI)

Burton RI, Pellegrini VD. J. Hand Surg. 11A(3) 324-32, 1986Excision trapeziumVolar ligament reconstruction (FCR sling) Interposition Arthroplasty (Anchovy) – FCR

LRTI - ResultsAuthor Proced. Trapezium n F/U (yr) Results Migration/

Loss Height

Eaton,Glickel,Littler

J.Hand Surg. 10A(5)1985

LRTI Partial 25 3 92% excellent n/a

Burton,Pellegrini

J. Hand Surg 1986

LRTI Excised 24 2 92% excellent 11%

Tomaino,Pellegrini,Burton

J. Hand Surg. 77A,1995

LRTI Excised 24 9 95% excellent 13%

Baron,Eaton

J. Hand Surg 1998

Double LRTI

Horn resection

21 3 95% excellent 8%

Double Interposition Arthroplasty

Eaton Stage IV Maintains height ratio

PPx/MC-T Barron,Eaton. J.Hand Surg.

23A(2) 1998 95% good excellent

functional outcome 3 yr f/u

PubMed

Search for “thumb arthritis randomized trial” 2 results: Randomized, prospective, placebo-controlled double-

blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy.J Altern Complement Med. 2000 Aug;6(4):311-20.

Randomized controlled trial of nettle sting for treatment of base-of-thumb pain.J R Soc Med. 2000 Jun;93(6):305-9.

Ligament reconstruction with or without tendon interposition to treat primary thumb carpometacarpal osteoarthritis. A prospective randomized study. Kriegs-Au G, Petje G, Fojtl E, Ganger R, Zachs I. J Bone Joint Surg

Am. 2004 Feb;86-A(2):209-18. 43 patients (52 thumbs) randomized

trapezial excision with ligament reconstruction (n=15) trapezial excision with ligament reconstruction combined with tendon

interposition (n=16) mean follow-up period of 48.2 months Group I had significantly better mean scores for palmar and radial

abduction, cosmetic appearance, willingness to undergo surgery again under similar circumstances (p < 0.05)

mean scores for tip-pinch strength and mean subjective scores for pain, strength, daily function, dexterity, and overall satisfaction did not differ significantly between the groups

Both groups had satisfactory results with regard to performance of ADLs and ability to return to work

amount of proximal metacarpal migration, at rest and under stress, did not differ significantly between groups

Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition. Hartigan BJ, Stern PJ, Kiefhaber TR. J Bone Joint Surg Am.

2001 Oct;83-A(10):1470-8. 109 patients (141 thumbs), < 60 yo retrospective review subjective evaluation of pain, function, and satisfaction

demonstrated no significant difference between the two groups >90% of patients satisfied following either procedure Grip strength did not differ between the groups, the arthrodesis

group had significantly stronger lateral pinch (p < 0.001) and chuck pinch (p < 0.01)

Group treated with ligament reconstruction and tendon interposition had better ROM with regard to opposition (p < 0.05) and the ability to flatten the hand (p < 0.0001)

Higher complication rate in the arthrodesis group, with nonunion of the fusion site accounting for the majority of the complications

All of the patients with nonunion had improvement in their pain status compared with preoperatively, and all were very satisfied with the outcome

Recommendations

Stage I (Laxity + Instability) Eaton Procedure (Volar Ligament Reconstruction)

Stage II-III Low demand

LRTI Trapezium excision/interposition anchovy

High demand Arthrodesis MC osteotomy

Stage IV Double Interposition LR LRTI + excision trapezium Trapezium excision (low demand)

Complications Neurologic

Radial Nerve : Dorsal sensory branch Median Nerve : Palmar cutaneous branch Neuroma RSD

Vascular Superficial branch radial artery – volar to S-T Joint

Infection <1% (LRTI)

Carpal Tunnel Postoperative decompression

Silicone Fracture, synovitis, erosion, subluxation

Fusion Nonunion

Arthroplasty Loosening, fracture, dislocation, osteolysis, difficult revision