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Basal Joint Arthritis Of The Thumb

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Information about Basal Joint Arthritis Of The Thumb
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Published on July 3, 2008

Author: orthonet

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

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

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

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

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

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

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

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

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  1 o restraint to dorsoradial subluxation Supported by clinical success of volar ligament reconstruction Dorsoradial ligament 1 o restraint to dorsal translation Supported by cadaver studies simulating acute dorsal TM joint dislocations

Primary ligamentous stabilizers of TM joint

Anterior oblique or “volar beak” ligament

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

Supported by clinical success of volar ligament reconstruction

Dorsoradial ligament

1 o 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

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

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 1 st MC base Adducted posture of 1 st MC Distal aspect tethered to 2 nd MC by adductor policis Metacarpophalangeal joint hyperextension Progressive functional deficit Decreased grip Narrowed palm, functional hand width

Progression theory

Excessive laxity + repetitive loads

Synovitis

Osteophytes + joint space narrowing

Attenuation/insufficient volar beak ligament

Dorsal radial subluxation of 1 st MC base

Adducted posture of 1 st MC

Distal aspect tethered to 2 nd 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

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

“ 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

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

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

“ 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 I TM – Precedes cartilage degeneration TM - Contours normal TM - Joint space widening if effusion/synovitis TM stress subluxation ST joint normal Eaton, Lane, Littler. J. Hand Surg. 9A 1984

Stage I

TM – Precedes cartilage degeneration

TM - Contours normal

TM - Joint space widening if effusion/synovitis

TM stress subluxation

ST joint normal

Classification Stage II TM narrowing TM contours still normal TM joint osteophytes <2mm ST joint Normal

Stage II

TM narrowing

TM contours still normal

TM joint osteophytes <2mm

ST joint Normal

Classification Stage III TM joint destruction TM joint sclerosis, cystic changes TM joint osteophytes >2mm ST joint normal

Stage III

TM joint destruction

TM joint sclerosis, cystic changes

TM joint osteophytes >2mm

ST joint normal

Classification Stage IV Advanced disease TM and ST joints Exact risk and rate of progression cannot be precisely delineated. No longitudinal studies

Stage IV

Advanced disease TM and ST joints

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

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

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

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

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

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

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

Algorithm JAAOS. 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

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%

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 20 o of radial abduction 40 o of palmar abduction

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

20 o of radial abduction

40 o 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)

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

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

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 30 o dorsal closing wedge 12 yrs f/u no revisions all patients satisfied “ fully functional” Indications: High demand hand Young laborer

Base of thumb metacarpal, unload volar portion TM joint

Wilson JBJS 65B:179, 1983

Eaton Stage II

23 osteotomies

30 o 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

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) 1984 Eaton Stage I-II 50 reconstructions Avg age 45 yrs f/u – 7 years 95% good-excellent result

Eaton et. al. J. Hand Surg. 9A(5) 1984

Eaton Stage I-II

50 reconstructions

Avg age 45 yrs

f/u – 7 years

95% good-excellent result

Volar Ligament Reconstruction Long-term results: 15 years Freedman,Eaton,Glickel. J. Hand Surg. 25A(2) March 2000 23 patients Avg age 33 yrs female Eaton Stage I + Instability 15/23  90% satisfaction 8 % progressed on x-rays

Long-term results: 15 years

Freedman,Eaton,Glickel. J. Hand Surg. 25A(2) March 2000

23 patients

Avg age 33 yrs female

Eaton Stage I + Instability

15/23  90% satisfaction

8 % progressed on x-rays

Ligament Reconstruction with Tendon Interposition Arthroplasty (LRTI) Burton RI, Pellegrini VD. J. Hand Surg. 11A(3) 324-32, 1986 Excision trapezium Volar ligament reconstruction (FCR sling) Interposition Arthroplasty (Anchovy) – FCR

Burton RI, Pellegrini VD. J. Hand Surg. 11A(3) 324-32, 1986

Excision trapezium

Volar ligament reconstruction (FCR sling)

Interposition Arthroplasty (Anchovy) – FCR

 

LRTI - Results 8% 95% excellent 3 21 Horn resection Double LRTI Baron,Eaton J. Hand Surg 1998 13% 95% excellent 9 24 Excised LRTI Tomaino,Pellegrini,Burton J. Hand Surg. 77A,1995 11% 92% excellent 2 24 Excised LRTI Burton,Pellegrini J. Hand Surg 1986 n/a 92% excellent 3 25 Partial LRTI Eaton,Glickel,Littler J.Hand Surg. 10A(5)1985 Migration/ Loss Height Results F/U (yr) n Trapezium Proced. Author

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

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.

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

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

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)

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

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

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Thumb Basilar Joint Arthritis. by Arthur ... The CMC joint of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of ...
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Arthritis of the Base of the Thumb - American Society for ...

Arthritis of the Base of the Thumb ... Figure 1: Thumb Basal Joint metacarpal basal joint trapezium Figure 4: Treatment Diagram metacarpal basal joint
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Basal Joint Arthritis: How Therapy Can Help Thumb Pain - HSS

Many treatments for basal joint arthritis and thumb pain can be provided by therapists and physicians.
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Basal Joint Arthritis of the Thumb - LWW Journals

Anatomy and Biomechanics. The basal joint of the thumb consists of four trapezial articulations: the trapeziometacarpal (TM), trapeziotrapezoid ...
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