Thumb Carpometacarpal Joint Arthritis

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Thumb Carpometacarpal Joint Arthritis

• Dr. James Mahoney
• St. Michaels Hospital

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Thumb Carpometacarpal (CMC)Arthritis
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Thumb Carpometacarpal Joint Arthritis

• Most commonly surgically reconstructed area
  with OA in arm
• Surgical indications
• - Refractory to non-operative treatment

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CMC Osteoarthritis

• Affects 16-25 of postmenopausal women
• Causes pain swelling, instability, deformity
  loss of motion
• Radiographic evidence of basal joint arthritis
• 1 in 4 women
• 1 in 12 men

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CMC Basic Science

• Four Articulations
• Trapeziometacarpal TM
• Trapeziotrapezoid
• Scaphotrapezial ST
• Trapezium-Index Metacarpal
• CMC joint enables opposition allows arcs of
  movement in 3 planes
• Flexion-extension
• Abduction-adduction
• opposition

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Saddle Joint

• Minimal osseous stability
• Rely on static ligamentous constraints to limit
  MC base translation
• 5 stabilizing ligaments
• Anterior oblique
• Posterior oblique
• Anterior intermetacarpal
• Posterior intermetacarpal
• Dorsal radiocarpal

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Etiology

• Secondary to excessive basal joint laxity
• Only the TM ST joint lie along the longitudinal
  compression axis of the the thumb
• Radiographic disease most commonly affects these
  2 joints

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Etiology

• During opposition axial rotation results in
  increased contact forces between opposing joint
  surfaces subjecting the cartilage to shear

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Pathophysiologic Stages

• Cartilage is sheared worn
• Osteophytes in response to inflammation
• Dorsoradial subluxation of the 1st MC base
• Excessive laxity repetitive loading
• MC adopts an adducted posture leading to
  functional deficits as the ability to spread the
  hand palm compromised
• Opening jars
• Octave on a piano
• Hyperextension at MCP joint as a result of this
  adduction deformity
• Focal pain, diminished pinch strength,
  narrowing of the functional hand width

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Thumb Carpometacarpal Joint Arthritis
Eaton classification of Radiographic stages of
Thumb CMC OA 1 - Normal appearance 2 - Joint
space narrowing osteophytes lt 2mm 3 - Sclerosis,
Subchondral cysts osteophytes gt 2mm 4 -
Pantrapezial arthritis
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Demographics

• Incidence
• Prevalence in postmenopausal women
• Isolated carpometacarpal 25
• Scaphotrapezial 2
• Combined - 8
• Symptomatic Arthritis
• 28 isolated and 55 combined
• Classification
• Interrater and intrarater variationof the Eaton
  Classification
• .6

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Clinical Findings

• Dorsoradial prominence of the thumb MC base
  secondary to subluxation, inflammation,
  osteophytes
• Adduction deformity later in disease
• Point tenderness at CMC joint
• MCP joint hyperextension tenderness
• Decreased ROM
• Pinch strength decreased
• TM Grind test (axial loading with MC rotation)

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Thumb Carpometacarpal Joint Arthritis

• Differential diagnosis
• De Quervains (1st compartment) tenosynovitis
• Radial sensory neuritis
• 2nd compartment dorsal tenosynovitis
• Arthritis
• Metacarpophalangeal
• Scaphtrapeziotrapezoid
• Radiocarpal

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Investigation

• Standard radiographic views of thumb (AP,
  lateral, oblique)
• Provocatory views (lateral pinch)
• Bone scan
• Rule out other diagnosis
• Carpal tunnel
• DeQuervains Tenosynovitis
• Trigger Thumb

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Treatment Options Non-Operative

• Activity modification
• Anti-Inflammatory medications
• Splinting (Thumb spica)
• Study 114 thumbs
• Long thumb spica for 3-4 weeks continuously, then
  less
• Stage 1 2 67 improved
• Stage 3 4 54 improved
• At 6 months 55 improvement in symptom severity

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Various Splints
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Intra-Articular steroid injections

• 25 gauge from dorsoradial direction while
  traction on thumb (0.5 ml of steroid /- local
  anaesthetic)
• Ultrasound guided

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Intra-articular injection

• Study
• Double blind randomized controlled trial of 5 mg
  triamcinolone vs saline
• 40 patients with OA
• Assessments _at_ 4, 12, 24 weeks for joint
  tenderness, physician, patient global assessments
• Results
• No clinical benefit in moderate to severe
  arthritis
• Research should focus on the outcome of the first
  presentation of pain

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Treatment OptionsSurgical

• Indicated if pain persists is severe enough to
  limit patients function ADLsnever for
  deformity alone
• Generally
• Osteotomy of thumb metacarpal
• Resection arthroplasty with or without
  interposition of autologous material
• Arthrodesis

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Osteotomy of the Metacarpal

• Designed to offset the subluxing forces on the
  base of the MC
• Usually closing wedge

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Thumb Carpometacarpal Joint Arthritis
Appearance of excised trapezium
Courtesy of Donald H. Lee, MD
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Volar Ligament Reconstruction

• Stage I addresses laxity of the volar oblique
  ligament
• Radial ½ of FCR is passed through hole made in MC
  base
• Anchored with appropriate tension

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Ligament Reconstruction Tendon Interposition
(LRTI)

• Stage II / III / IV disease
• Removal of the involved joint
• partial trapeziectomy Stage II / III
• Total trapeziectomy Stage IV
• Slip of FCR to stabilize lax volar oblique
  ligament.
• End of FCR then coiled and inserted into defect
  to maintain length and provide painless mobility.

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Thumb Carpometacarpal Joint Arthritis
Excisional arthroplasty of trapezium with rolled
tendon graft
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Tendon Interposition Arthroplasty

• Studies
• 45 patients, follow-up 8 years pain reduction in
  93, Function 90 of opposite hand, function
  improved in 90 . Damen et al, 1996
• 28 patients, followup 3 years pain reduction
  very good in gt 90, 87 satisfaction, improved
  functional mobility but decreased key pinch.
  Rayan et al, 1997

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Partial Trapeziectomy with ligament
reconstruction and interposition costochondral
graft

• Study
• 41 patients, hemiresection arthroplasty, FCR,
  allograft costochondral reconstruction
• Result
• Absorption
• 90 improved

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Surgical Effects

• Thumb shortening
• In arthritis
• More after surgery

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Arthrodesis

• Indications
• when major correction of the position of the MC
  required a procedure to correct MP Joint
  hyperextension
• Young heavy labourers
• Cartilage surfaces debrided, bone graft inserted,
  then K-Wire pinning, screw (cancellous lag)
• 400 abduction 450 extension
• Immobilize thumb spica

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Trapeziometacarpal Arthrodesis

• Study 49 patients, 7 year followup, fixation
  with K wires, use of a bone graft in most
• Results nonunion 7, pain better, 20-25
  developed peritrapezial arthrits
• Recommended in isolated arthritis, care with
  thumb positioning, increased laxity of
  peritrapezial joints may cause laxity pain and
  arthritis

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Carpometacarpal Joint Replacement

• De La Caffiniere
• Study 93thumbs in 71 patients
• Results survival 89 _at_ 16 years, avoid in men lt
  65
• Silicone
• 84 satisfaction in pain _at_ 16 years, strength
  improved
• 6 implant fractures, no frank silicone synovitis

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Arthroplasty

• Swanson Silicone Implant
• Titanium Implants

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Additional Surgical Options

• Replacement materials
• ePTFE (Goretex) , PTFE ( Marlex)
• Tendons FCR, Abd pollicis longus
• Ceramic
• Joint

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Comparison Studies
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Additional Surgical Considerations

• Scaphotrapezial arthriritis
• Scaphotrapezoid arthritis
• Hyperextension of the MCP joint
• Subluxation of the thumb
• Adduction contracture

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Secondary MCPJ DeformityHyperextension

• Less than 300
• Transarticular K-Wire with joint in flexion for
  4-5 weeks
• Moving the extensor pollicis brevis from base of
  proximal phalanx to metacarpal shaft
• Greater than 300
• Arthrodesis (unstable joint)
• Volar capsulodesis

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End