5. Epidemiology
Most common site of osteoarthritis in the
hand
Most common site requiring surgery
Most common in post-menopausal females
1:4 women will show radiographic
degeneration
Only ~ 20-30% symptomatic
8% with ST arthritis
Only 1:12 men affected
6. Epidemiology
Armstrong, et al, J Hand Surg (Br), 1994
evaluated 143 post-menopausal women
25% had isolated basal thumb
osteoarthritis
of those with isolated CMC osteoarthritis,
28% complained of thumb pain
7. Etiology
No clear association with employment
Repetitive motion suggests higher incidence
Carpentry, manual labor
Cow Milking (Seoane, 1997)
Males with increased grip strength - increased
radiographic changes (Chaisson, 2001)
8. Etiology
1) Trauma - dislocation, fracture
2) Inflammatory diseases - RA, gout
3) Idiopathic Osteoarthritis
4) Hypermobile States
Moulton (2001) showed increased joint forces in
TM joints with hyperextension laxity at the MCP
joint
9. Etiology
5) TM Instability
Acute: severe trauma (complete
dislocation)
Chronic: can be caused by recurrent
stress or overuse
more common
often seen in young to middle-aged women
10. Etiology
Pellegrini, Orth Clin N Amer, 1992
The palmar beak ligament was essential
for translational stability of the MC on
the trapezium
There was a direct correlation between
the status of the articular surfaces and the
integrity of the beak ligament
11. Etiology
Pelligrini’s Theory:
1) Attritional changes in palmar beak ligament
2) Detachment of the palmar beak ligament
3) Instability of TM joint
4) Increased dorsopalmar translation
5) Increased shear forces in the palmar contact areas
6) Hyaline cartilage wear and OA
13. Clinical Presentation
Pain
Aggravated by power pinch, grip movements,
axial load or flexion/adduction maneuvers
Turning jar lids, doorknobs, opening car doors
Weakness with pinch
Typically secondary to pain
Dorsoradial subluxation of the metacarpal
base in later stages
14. Physical Exam
Well localized CMC joint tenderness
Localized to radial margin of metacarpal
base one finger-breadth distal to
scaphoid tubercle
16. Physical Exam
Laxity Test
Dorsal-to-volar translation of the metacarpal
base will reveal any dorsal subluxation
Torque Test
Pain with axial rotation and distraction of
the thumb metacarpal
17. Coexisting Conditions
DeQuervain’s tenosynovitis
CMC arthritis may cause DeQuervain’s
Good PE, x-rays, injections help differentiate
Carpal Tunnel Syndrome
Up to 43% coexists (Florak,1992)
Dimensions of carpal tunnel affected by CMC arthritis
ST arthritis
FCR tendonitis
MCP joint instability
Requires intervention if severe enough
18. Radiographic Evaluation
PA, lat and oblique views
!
30° oblique stress views
Technique
Thumbs w/ nail plates parallel to x-ray film
Push thumb tips against each other
Advantages
Good visualization of pan-trapezial joints
Helps assess TM joint laxity
20. Eaton Stage I
Radiographs
Pre-arthritic joint
Normal articular contours
Slight widening of joint space
2° effusion or ligament laxity
Clinically
Intermittent mild pain with heavy use
Mild loss of strength
+ Grind test
21. Eaton Stage II
Radiographs
TM joint slightly narrowed
Minimal sclerosis
± osteophytes (<2mm & ulnar)
< 1/3 metacarpal base subluxation
Clinically
Frequent pain with normal activity
+ Grind test
Metacarpal base subluxed radial and dorsal
22. Eaton Stage III
Radiographs
Marked narrowing TM joint
Osteophytes > 2mm
Increased sclerosis, cystic changes
subluxation > 1/3 of metacarpal base
Clinically
Passive reduction of metacarpal base may be
impossible
Adduction of metacarpal and MCP joint
hyperextension
23. Eaton Stage IV
Radiographs
Advanced degenerative changes &
subluxation
ST joint involvement
Clinically
Decreased mobility of TM joint
Patients with relatively less pain
25. Treatment Options
Depends on stage of disease as well as degree
of the patient’s discomfort
!
Conservative: Rest, NSAID’s, steroid injections,
splinting with thumb in abduction (Stage I)
!
Surgical: Multiple surgical treatment methods
(more advanced stages)
26. Conservative Treatment
Swigart, et al, J of Hand Surg, 1999
Evaluated 130 thumbs treated with 6 weeks of
splinting
Stage I/II: 76% improvement
Stage III/IV: 54% improvement
Overall…
splinting is well-tolerated
effective protocol to diminish, but not eliminate the
symptoms of basal joint OA
29. Prosthetic Arthroplasty
Advantages (theoretical)
Immediate stability and no need for long term
immobilization
Disadvantages
Wear, loosening, osteolysis, infection,
synovitis (silicone), periprosthetic fracture
!
No report exists with results superior to
biologic arthroplasty
30. Ligament Reconstruction
and Tendon Interposition
1) Palmar beak ligament reconstruction
2) Tendon interposition arthroplasty using
radial ½ of FCR tendon
!
Often used for Stage II or Stage III disease
31. LRTI - Approach & Bone Resection
Straight incision is made over dorsoradial aspect
of TM joint
avoid sensory branch of radial nerve and radial artery
Partial or complete trapeziectomy
Decision based on status of scaphotrapezial joint
Base of metacarpal resected
32. LRTI -Tendon Harvest
FCR tendon graft of 10 -12 cm in length
Leading end passed into and through the
base of the thumb MC
Remaining tendon is folded to act as a
spacer
33. LRTI
MCP Joint Hyperextension
Must be addressed if > than 30 degrees
Volar capsulodesis
EPB transfer from the base of the proximal
phalanx to the metacarpal shaft
Eliminates the EPB hyperextension force at the
MCP joint
35. LRTI
Burton and Pellegrini, J Hand Surg, 1986
25 LRTI, average 2 yr f/u
More consistent improvement in grip,
pinch, thumb web space than silicone
arthroplasty
Excellent results in 23 of 25
37. Surgical Complications
Approach related
Injury to radial artery or dorsal sensory branch of the
radial nerve
Implant related
Silicone synovitis, implant subluxation, carpal
erosion
Failure of ligament reconstruction
Loss of pinch strength
Proximal migration of the metacarpal
