Thumb Carpal Metacarpal Arthritis -...

Thumb CarpalMetacarpal Arthritis

AbstractThe thumb carpometacarpal (CMC) joint is the most common siteof surgical reconstruction for osteoarthritis in the upper extremity.In patients older than age 75 years, thumb CMC osteoarthritis hasa radiographic prevalence of 25% in men and 40% in women. Thethumb CMC joint obtains its stability primarily throughligamentous support. A diagnosis of thumb CMC arthritis is basedon symptoms of localized pain, tenderness and instability onphysical examination, and radiographic evaluation. A reproducibleradiographic classification for disease severity is based on the four-stage system described by Eaton. Nonsurgical treatment optionsinclude hand therapy, splinting, and injection. Surgical treatment istailored to the extent of arthritic involvement and may includeligament reconstruction, metacarpal extension osteotomy,arthroscopic partial trapeziectomy, implant arthroplasty, andtrapeziectomy with or without ligament reconstruction and tendoninterposition.

The thumb carpometacarpal(CMC) joint is the most com-

mon site of surgical reconstructionfor osteoarthritis (OA) in the upperextremity. In persons older than age75 years, the prevalence of radio-graphic CMC degeneration is 25%in men and 40% in women.1 A clearunderstanding of the anatomy andphysiology of the joint is necessaryto make well-informed decisions re-garding diagnosis and treatment ofthumb CMC arthritis.

Anatomy

Bony AnatomyThe thumb CMC joint is semi-

constrained and relatively incongru-ent. In 1854, Fick2 coined the term“saddle joint” to describe this com-plex association3 (Figure 1). TheCMC is made up of two saddles. Theaxes of the opposing saddles are per-

pendicular to each other, such thatthe distal saddle faces proximal andthe proximal saddle is rotated 90° inrelation to the distal upside-downsaddle. Biomechanically, the CMCis referred to as a universal joint.The anatomy of the joint allowsthumb motion in extension, flexion,adduction, and abduction (Figure 2).These motions can be combined toform the complex movements of op-position, retropulsion, palmar ab-duction, radial abduction, palmaradduction, and radial adduction.4

The thumb CMC joint is morecongruent along the radial-ulnaraxis than along the dorsal-volaraxis.5 This bony architecture allowsincreased range of motion for oppo-sition. The prevalence of ligamen-tous stability in the thumb CMCjoint allows greater mobility thanwere the joint stability provided bybone.

Ann E. Van Heest, MD

Patricia Kallemeier, MD

Dr. Van Heest is Associate Professor,Department of Orthopaedic Surgery,University of Minnesota, Minneapolis,MN. Dr. Kallemeier is OrthopaedicSurgeon, Des Moines OrthopaedicSurgeons, PC, Des Moines, IA.

None of the following authors or amember of their immediate families hasreceived anything of value from or ownsstock in a commercial company orinstitution related directly or indirectly tothe subject of this article: Dr. Van Heestand Dr. Kallemeier.

Reprint requests: Dr. Van Heest,Department of Orthopaedic Surgery,University of Minnesota, Suite 200,2450 Riverside Avenue, Minneapolis,MN 55454.

J Am Acad Orthop Surg 2008;16:140-151

Copyright 2008 by the AmericanAcademy of Orthopaedic Surgeons.

140 Journal of the American Academy of Orthopaedic Surgeons

Ligamentous StabilityThe ligamentous anatomy of the

thumb CMC joint is important forstability. Several ligaments play amajor role in the stabilization of thethumb CMC joint (Figure 3). Thepalmar ligament, also known as theoblique or beak ligament, acts as astatic restraint by virtue of its intra-capsular location. It originates fromthe palmar tubercle of the trapeziumand inserts on the articular marginof the ulnar side of the metacarpalbase.6 The palmar ligament resistsabduction, extension, and pronationforces. Doerschuk et al7 showed in acadaveric study that the degree ofpalmar (anterior oblique) ligamentdegeneration correlates with thestage of OA.

The dorsoradial ligament is theprimary stabilizer of dorsal and radialtranslation of the thumb metacarpalon the trapezium8 and is the primaryrestraint to dorsal dislocation.9 Thedorsoradial ligament also has beenshown to be the strongest and thick-est ligament of the CMC joint.6,10

The intermetacarpal ligament at-taches from the radial base of the2nd metacarpal to the ulnar aspect

of the base of the 1st metacarpal andconstrains radial translation of thebase of the 1st metacarpal. Thedorsoradial and posterior obliqueligaments provide secondary stabil-ity.

Muscular StabilityNine muscles provide dynamic

stabilization of the thumb CMCjoint. The volar muscles include thethree thenar muscles (abductor pol-licis brevis [APB], flexor pollicisbrevis, opponens pollicis), the flexorpollicis longus, and the adductor pol-licis. The dorsal muscles include thefirst compartment muscles (abductorpollicis longus [APL], extensor polli-cis brevis [EPB]), the extensor pollicislongus, and the first dorsal in-terosseous muscle. The coordinationof these muscles creates a balance ofstability, allowing positioning of thethumb to provide the platform forthumb pinch activities.

Pathophysiology ofDisease

The etiology of CMC joint arthritisis multifaceted and includes both

intrinsic and posttraumatic causes.Intrinsic causes may include liga-mentous hypermobility, ligamentlaxity related to hormonal influ-ences, sex differences, and biochem-ical differences. Jónsson et al11 pos-tulated that hypermobility is acause of CMC arthritis. In theirstudy of 50 patients, they correlatedthumb CMC joint arthritis withjoint hypermobility (passive exten-sion of the 5th finger of ≥90°).Patients with Ehler-Danlos syn-drome have been shown to have ahigher incidence of CMC joint sub-luxation and exhibit radiographicdegenerative changes at a mean ageof 15 years.12 Compared with men,women exhibit a higher amount of

Figure 1

The thumb carpometacarpal joint is known as the “saddle joint” because its shapeand configuration are similar to a saddle. (Adapted with permission from KuczynskiK: The thumb and the saddle. Hand 1975;7:120-122.)

Figure 2

The axes of the saddle configuration ofthe thumb carpometacarpal joint.Minimal bone congruity allows forthumb carpometacarpal motion, whichincludes extension, flexion, adduction,and abduction. These four movementscan be combined to form the complexmovements of opposition andretropulsion, palmar abduction, radialabduction, palmar adduction, and radialadduction. (Adapted with permissionfrom Ateshian GA, Rosenwasser MP,Mow VC: Curvature characteristics andcongruence of the thumbcarpometacarpal joint: Differencesbetween female and male joints. JBiomech 1992;25:591-607.)

Ann E. Van Heest, MD, and Patricia Kallemeier, MD

Volume 16, Number 3, March 2008 141

joint laxity (Figure 4) and a higher in-cidence of thumb CMC joint arthri-tis. This difference has been attrib-uted to the hormones prolactin,relaxin, and estrogen. The finding ofincreased joint laxity may be con-founded by the subtle sex differ-ences in trapezium geometry.

One group reported that CMCjoints are less congruent in femalesthan in males and that the trapezialsurface is smaller in women than inmen.5 In cadaveric studies, Northand Rutledge13 found that the trape-zial surface transformed from a sad-dle shape to a semicylindrical shapein patients with advanced arthritis.Furthermore, both female and malespecimens with early degenerativechanges exhibited a flatter trapezialsurface, which appears to be corre-lated with increased arthritic chang-es.

In their Finnish population study,Haara et al14 established a direct cor-relation between increased body

mass index (BMI) and increased prev-alence of CMC arthritis. The au-thors offered two proposed mecha-nisms for increased incidence ofCMC arthritis in obese patients.First, even though the thumb CMCis a non–weight bearing joint, pa-tients with a higher BMI may haveincreased mechanical loading acrossthe joint, causing increased wear.Second, patients with a higher BMImay have an altered biochemical en-vironment in the joint, such as achange in circulating lipid levels,insulin-like growth factor, and sexhormones. These hormonal differ-ences may provide local biochemicalchanges that promote joint degener-ation.

In addition to intrinsic causes ofCMC arthritis, a history of traumapredisposes to arthritic progression.A Bennett fracture resulting in jointincongruity can lead to arthritis. Ad-ditionally, injury to the anterior ob-lique ligament may cause altered

joint mechanics and may predisposea patient to thumb CMC arthritis. Inthe presence of an incompetent ante-rior oblique ligament, abnormaltranslation of the thumb metacarpalon the trapezium occurs (Figure 4).The shear forces wear on the volarcompartment of the CMC joint nearthe volar oblique ligament insertion.In late-stage arthrosis, articular wearbegins on the radial quadrant of themetacarpal and progresses to the vo-lar quadrants, while on the trapezi-um, wear starts on the dorsoradialsurface and progresses to the volarquadrants.15 The mechanism forwear occurs mainly in a shear mech-anism, secondary to ligament laxity.In anatomic studies, wear has beenshown to occur in a 3:1 ratio of tra-pezial to metacarpal degeneration.

Additional evidence points tometacarpophalangeal (MCP) jointsubluxation as a cause of CMC jointwear. In a cadaveric study, Moultonet al16 found that MCP joint flexioneffectively unloaded the most pal-mar surfaces of the CMC joint, andMCP joint hyperextension loadedthe most palmar surface of the CMCjoint. This is problematic becausethe volar compartment shows theearliest signs of arthritic changes.

Figure 4

Anteroposterior thumb radiographdemonstrating carpometacarpal jointsubluxation in a female athlete with jointlaxity and increased oblique orientationof the trapezium.

Figure 3

A, Dorsal view of the thumb right trapeziometacarpal joint illustrating the posterioroblique ligament (POL), dorsoradial ligament (DRL), abductor pollicis longus (APL),first intermetacarpal ligament (IML), and extensor carporadialis (ECRL) tendon.B, Palmar view of the thumb right trapeziometacarpal joint illustrating the anterioroblique ligament (AOL), ulnar collateral ligament (UCL), first IML, APL tendon,transverse carpal ligament (TCL), and flexor carpi radialis (FCR) tendon. MI = 1stmetacarpal, MII = 2nd metacarpal, MIII = 3rd metacarpal. (Reproduced withpermission from Imaeda T, An KN, Cooney WP III: Functional anatomy andbiomechanics of the thumb. Hand Clin 1992;8:9-15.)

Thumb Carpal Metacarpal Arthritis


This suggests that patients with hy-perextension of the MCP and symp-tomatic CMC joint arthritis mightbenefit from splinting or surgicalstabilization of the MCP joint in aflexed position. These treatmentswould effectively unload the volarcompartment of the CMC joint.16

Diagnosis

Symptoms of thumb CMC arthritisrange from insignificant, occasionalaching to severe pain with weaknessand disability. Patients often de-scribe the pain as a diffuse ache lo-calized to the thumb abductor andthenar musculature area. Physicalexamination tests for CMC arthritisinclude tenderness to palpation overthe dorsal or dorsoradial capsule ofthe CMC joint. Findings include lo-calized swelling and warmth at thebase of the thumb. The grind test in-cludes axial compression of thethumb CMC, which produces crep-itus and pain (Figure 5).

Secondary deformity related tothumb CMC arthritis occurs overtime. As the patient persistentlyavoids painful thumb abduction, ad-duction deformity occurs within thefirst web space contracture. As theCMC joint becomes stiff and adduct-ed, the thumb MCP joint may devel-op a hyperextension deformity tocompensate for the loss of motion.The compromised thumb metacar-pal cannot abduct adequately tograsp a sizable object, leading toMCP joint hyperextension with pro-gressive attenuation of the volarplate. Late-stage secondary deformi-ty includes a zigzag collapse pattern(Figure 6).

Other etiologies of pain at thebase of the thumb include de Quer-vain tenosynovitis of the first dorsalcompartment, flexor carpi radialis(FCR) tendinitis, and carpal tunnelsyndrome. The patient withscaphoid pathology (eg, fracture,nonunion, osteonecrosis) maypresent with pain at the base of thethumb. Additionally, arthritis of the

thumb MCP, radiocarpal joints, andscaphotrapeziotrapezoid (STT) jointmay cause pain along the thumb ray.Differential injections into thethumb STT, CMC, and MCP jointscan be helpful in determining theprecise etiology and location of thepain.

RadiographicClassification

The most widely used classificationsystem for thumb CMC arthritiswas described by Eaton in 1973.17

This classification was later modi-fied to include scaphotrapezial joint

Figure 5

The grind test for carpometacarpal arthritis. This test consists of axial compressionand rotation of the thumb carpometacarpal joint. (Adapted with permission fromAcquired deformities, in American Society for Surgery of the Hand: The Hand:Examination and Diagnosis, ed 3. New York, NY: Churchill-Livingstone, 1990, p85.)

Figure 6

As the carpometacarpal joint becomes stiff and adducted in the patient withosteoarthritis, the thumb metacarpophalangeal joint may develop a hyperextensiondeformity to compensate for the loss of motion, leading to a zigzag collapse pattern.



involvement.18 Radiographically, thepatient with Eaton stage I thumbCMC arthritis appears to have nor-mal articular cartilage. Often, thereis a widened joint space, which mayindicate joint effusion or synovitis(Figure 7). In Eaton stage II disease,slight narrowing can be seen at thethumb CMC joint space (<2 mm),along with maintained joint con-tours, minimal sclerosis, and jointdebris. Lateral dorsal subluxation ofthe thumb metacarpal on the trape-zium may be present. In Eaton stageIII disease, radiographic evaluationindicates significant narrowing ofthe thumb CMC joint and arthritiswith sclerosis, cyst formation, andosteophytes longer than 2 mm. Jointsubluxation is usually present. InEaton stage IV OA, the patient pre-sents with significant thumb CMCjoint space deterioration with con-comitant scaphotrapezial joint de-generation.

Several authors have studied thereliability of the Eaton classificationfor thumb CMC joint arthritis.Comparing observations by threehand surgeons and three orthopaedicresidents, Kubik and Lubahn19 re-ported intrarater reliability of 0.657and interrater reliability of 0.529.The hand surgeons had an interraterreliability of 0.601, and the chief res-idents had an interrater reliability of0.487. Most chief residents had high-er intrarater scores than did the jun-ior residents, suggesting that the useof the system may improve with ex-perience. Dela Rosa et al20 studiedthe use of a different radiographicview, called the Bett or Gedda view,which shows all four articulations ofthe trapezium without overlap fromsurrounding bones (ie, a view of thetrapezial–1st metacarpal, trapezial–2nd metacarpal, trapezial-trapezoid,scaphotrapezial joint spaces). Fortysets of radiographs were evaluatedby six hand surgeons in two sessionswith three subgroups. The postero-anterior, lateral, and Bett views pro-vided the best kappa intraobserverreliability (0.61). Use of these three

Figure 7

Bett views of the thumb carpometacarpal (CMC) joint that also provide a view ofthe scaphotrapezial joint. A, Eaton stage I thumb CMC arthritis, with normal articularcartilage and a widened joint space. B, Eaton stage II thumb CMC arthritis. Notethe slight narrowing at the thumb CMC joint space (<2 mm) along with maintainedjoint contours, minimal sclerosis, and joint debris. Lateral dorsal subluxation of thethumb metacarpal on the trapezium is seen on this radiograph, but is variablypresent in stage II disease. C, Eaton stage III thumb CMC arthritis showingsignificant narrowing of the thumb CMC joint arthritis with sclerosis, cyst formation,and the presence of osteophytes (>2 mm in length). Joint subluxation is usuallypresent and is evident on this radiograph. D, Eaton stage IV thumb CMCosteoarthritis showing significant thumb CMC joint space deterioration withconcomitant scaphotrapezial joint degeneration.



radiographic views has increased thereliability of the Eaton classification.Despite its prevalent use in the liter-ature, radiographic staging of CMCarthritis does not predict severity ofsymptoms in the clinical setting. Infact, the radiographic staging of thedisease has been shown to underes-timate the extent of degenerative pa-thology visualized at the time of sur-gery.21

Treatment

Treatment of thumb CMC arthritisshould be based on the severity ofthe clinical symptoms and not sim-ply on the radiographic stage. Treat-ment goals include improved painand disability as well as preventionof secondary deformity.

NonsurgicalNonsurgical treatment of CMC

arthritis includes hand therapy(stretching and strengthening exer-cises), splinting, and injection. Thegoals of hand therapy are to increaserange of motion of the thumb CMC,prevent secondary zigzag collapse de-formity, and strengthen the thumbmuscles to aid in providing joint sta-bility. Stretching of the first webspace helps prevent adduction con-tracture and subsequent MCP hyper-extension deformity. Strengtheningthe first dorsal interosseous ligamentcan help provide medial joint stabil-ity in the presence of an incompetentanterior oblique ligament.

Splinting with the thumb in ab-duction has been shown to decreasepain. Options range from a prefabri-cated hand-based thumb splint to acustom forearm-based splint. Splint-ing should reduce subluxation at theCMC joint, and it counters adduc-tion contracture. Some devices ac-commodate splinting of the MCPjoint in flexion to reduce the loadingacross the CMC joint. The use ofsplints has been shown to reducesymptoms by an average of 55% to60% within the first 6 months.22 Intheir 6-month retrospective study of

130 patients, Swigart et al22 reporteda decrease in pain of 76% in patientswith stage I and II disease followingapplication of a support splint. Theyconcluded that splinting was welltolerated and was an effective non-surgical treatment option.

Hand therapists typically can pro-vide assistive devices and modifyhousehold tools to help decrease theload across the thumb CMC joint.Berggren et al23 reported on 33 pa-tients who were treated nonsurgical-ly with adaptive devices, splints, andtherapy while awaiting CMC jointsurgery. After 7 months of nonsurgi-cal management, 70% of the pa-tients declined surgical treatment.During the subsequent 7 years, only2 of the 19 patients who were stillliving required surgical treatment.

Corticosteroids have been consid-ered the preferred injection therapy;however, evidence-based benefits ofthis treatment have been mixed. In adouble-blind, randomized controlledtrial, Meenagh et al24 treated 40 pa-tients with either triamcinolone orsaline intra-articular joint injection.At 24 weeks, the patients who re-ceived steroid injection showed noimprovement in hand function andno difference in the visual analogpain scales versus patients injectedwith saline. No clinical benefit ofcorticosteroid injection was found interms of joint stiffness or tender-ness.

Other studies have shown corti-costeroids to be effective when com-bined with splinting. Day et al25

found that steroids in conjunctionwith splinting was successful at anaverage follow-up of 18 months. Fiveof 6 patients with Eaton stage I dis-ease had an average of 23 months ofpain relief, and 6 of 17 patients withEaton stage II and III disease had re-lief of symptoms at 18 months.However, only one of seven patientswith Eaton stage IV disease had anypain relief. These studies suggestthat steroid injection plus splintingmay have a role in the treatment of

patients with earlier stages of CMCarthritis.

Studies evaluating the use of vis-cosupplementation for the manage-ment of thumb CMC arthritisindicate that a series of viscosupple-mentation injections may be moreeffective than one corticosteroid in-jection.26,27 Long-term results of vis-cosupplement injection with regardto preventing surgery have not beenreported, and viscosupplement injec-tions for thumb arthritis are notFDA approved, but are experimentalonly.

SurgicalSurgical treatment of CMC joint

arthritis is selected based on the ra-diographic stage of disease, patientsymptoms, patient age, and occupa-tion. Joint preservation proceduresare effective in the earlier stages ofdisease, whereas fusion or arthro-plasty is more effective in the laterstages of the disease process.

Volar LigamentReconstruction

Volar ligament reconstruction isindicated in the patient who pre-sents with prearthritic synovitiscaused by CMC joint laxity, includ-ing Ehlers-Danlos syndrome. Thissyndrome is characterized radio-graphically as Eaton stage I or II dis-ease and clinically with pain andweakness related to joint sublux-ation. The candidate for volar liga-ment reconstruction typically hashad no success with nonsurgicaltreatment, including splinting tech-niques aimed at stabilizing thethumb CMC joint. Preoperative as-sessment includes ruling out othercauses of pain. Ligament reconstruc-tion is most effective when preoper-ative stress radiographs show radialsubluxation of the thumb metacar-pal on the trapezium. This findingcorrelates with physical examina-tion findings of symptomatic jointsubluxation.

One of the many surgical ap-proaches for volar ligament recon-



struction involves using a tendonautograft to render the CMC jointstable through a full arc of motion.Brunelli et al28 described the use ofthe APL tendon to recreate stabilityof the anterior oblique ligament. Inthis technique, a hole is drilledthrough the metacarpal base in adorsal to volar direction, and thetendon (either the APL or one half ofthe FCR tendon) is passed from theulnar to radial direction. The Littler-Eaton procedure, which recon-structs the intermetacarpal, radial,and anterior oblique ligaments,makes use of the FCR tendon, whichis left attached to its insertion at thebase of the index metacarpal. TheFCR tendon is passed through thethumb metacarpal in a volar-ulnarto dorsal-radial direction and aroundthe APL to simulate the dorsoradialligament, then reattached back to it-self to reproduce the anterior ob-lique ligament (Figure 8). Alter-nately, the FCR tendon can belooped around the APL tendon andthen back beneath the intact FCRdistal attachment. Before suturing

the tendon graft in place, the thumbCMC joint is reduced in a position ofpalmar abduction and extension toallow a full arc of motion.

Eaton et al29 performed volar lig-ament reconstruction using theFCR. Patients at all stages of diseasewere treated surgically and followedfor an average of 7 years. Resultswere good and excellent in all pa-tients with stage I disease and in91% of patients with stage II disease.However, only 80% of patients withstage III disease and 66% of patientswith stage IV disease had good andexcellent results. Pain relief was cor-related with good and excellent re-sults. In 13 of 19 patients with stageI and II disease, pinch strength wasgreater than or equal to that on theopposite side. The authors empha-sized the importance of intraopera-tive assessment of the joint surfacesto determine whether more ad-vanced arthritis is present than wasassessed on preoperative radio-graphs.

In another study, Freedman etal30 limited their indications for vo-

lar ligament reconstruction to stageI and stage II disease. At an averagefollow-up of 5.2 years, all patientswith stage I disease had good or ex-cellent results, with complete painrelief. Patients with stage II diseasehad 82% good to excellent results,with 70% pain relief. Follow-up ra-diographs showed no further degen-eration at the CMC joint. At 15-yearfollow-up, all patients with stage Ithumb CMC arthritis who weretreated with volar oblique ligamentreconstruction had high satisfactionrates; 65% of patients showed nofurther progression of radiographicCMC arthritis.

Metacarpal ExtensionOsteotomy

Correcting the alignment of thethumb CMC joint also can be effec-tive in early CMC disease. Firstmetacarpal osteotomy is done to un-load the volar arthritic compartmentof the CMC joint by changing thejoint mechanics. Indications formetacarpal extension osteotomy in-clude CMC joint pain in patientswith Eaton stage I or II disease. Ex-clusion criteria include patientswith more advanced stages of dis-ease (assessed at the time of surgery).When cartilage wear extends beyondthe volar one third of the compart-ment, the extension osteotomy willtransfer little, if any, load to the dor-sal trapezium metacarpal articularsurface.31 Patients with hypermobil-ity or fixed subluxation of the CMCjoint are better treated with liga-ment reconstruction, soft-tissue ar-throplasty, or arthrodesis. Osteoto-my is also contraindicated in thepatient with MCP joint hyperexten-sion deformity >10°, as the volar as-pect of the joint would still be over-loaded.

First, a bone cut is made parallelto the metacarpal joint surface (Fig-ure 9). A second bone cut is made 5mm distal to the first cut at a 30° an-gle, allowing removal of a dorsalwedge of bone. The first metacarpalis then extended, and the bone gap is

Figure 8

Volar ligament reconstruction in a patient with thumb carpometacarpal joint arthritis.One half of the flexor carpi radialis (FCR) tendon is looped around the abductorpollicis longus tendon and then back beneath the intact FCR distal attachment.I = 1st metacarpal, II = 2nd metacarpal, III = 3rd metacarpal. (Adapted withpermission from Eaton RG, Littler JW: Ligament reconstruction for the painful thumbcarpometacarpal joint. J Bone Joint Surg Am 1973;55:1655-1666.)



closed and fixed using Kirschnerwires (K-wires), intraosseous wiring,or plate fixation. Hobby et al32 re-ported on 41 patients who weretreated with first metacarpal exten-sion osteotomy for Eaton stage I andII disease. All osteotomies healedwithin 7 weeks. At 6.8-year follow-up, 95% of patients had worthwhilepain relief. Grip and pinch strengthincreased to 90% of establishednorms. The authors concluded thatmetacarpal extension osteotomy is auseful treatment option for earlystages of CMC arthritis of thethumb. Further studies have shownthat in addition to unloading the vo-lar articulation of the CMC joint,osteotomy may reduce joint laxityand provide dynamic stabilization,which also may contribute to itssuccess.33,34

Carpometacarpal JointArthroscopy

Arthroscopy can be used to eval-uate the CMC joint and treat earlystages of arthritis with débridement,synovectomy, and/or electrothermalcapsular shrinkage.35 In the laterstages of disease (stages III and IV),arthroscopy can be combined withpartial or complete trapeziectomy,with or without interpositional ar-throplasty and percutaneous pin-ning. Arthroscopic surgery allowsassessment of posttraumatic arthri-tis, which is especially applicable inpatients with a previous Bennettfracture.

The portals used for CMC jointarthroscopy include a dorsal 1R por-tal (radial to the APL tendon) and adorsal 1U portal (ulnar to the EPBtendon between the EPL and EPBtendons) (Figure 10). The joint is in-sufflated with saline. An incision ismade with a no. 11 blade, followedby blunt dissection carried down tothe capsule to create the portals. A1.9-mm arthroscope is inserted intothe CMC joint, and a triangulationprobe is inserted. The articular sur-faces of the CMC joint are assesseddiagnostically. Therapeutic inter-

vention is determined based on thearthroscopic findings and stage ofdisease.

Culp and Rekant36 reported on 24thumbs following arthroscopy com-bined with various procedures, in-cluding hemitrapeziectomy, totaltrapeziectomy, and thermal capsularshrinkage. Good to excellent resultswere reported in 88% of patientsat 1.2- to 4-year follow-up. Pinchstrength improved by 22%.

Thumb CarpometacarpalArthrodesis

Fusion of the thumb CMC jointhas been shown to improve pain andincrease strength. This procedure is

indicated for the patient with pain-ful instability secondary to system-ic joint laxity, the patient youngerthan age 50 years in a high-demandoccupation, and the patient with iso-lated CMC arthritis with Eatonstage II/III disease. The STT jointshould be spared. The advantages offusion include a stable thumb, im-proved strength, pain relief, and jointstability. Disadvantages include therisk of the development of adjacentjoint degeneration (STT or MCPjoints), a fairly high nonunion rate,

Figure 9

Osteotomy of the thumb metacarpal tocorrect adduction contracture, restorethe first web space, and reduce thetendency of the action of the flexor andextensor pollicis longus to subluxatethe thumb carpometacarpal joint. A,The proximal cut is made parallel to themetacarpal joint surface. The distalcut is made at a 30° angle, allowingresection of a dorsal wedge of bone.B, The metacarpal is extended, and thebone gap is closed and held withinternal fixation. (Reproduced withpermission from Hobby JL, Lyall HA,Meggitt BF: First metacarpalosteotomy for trapeziometacarpalosteoarthritis. J Bone Joint Surg Br1998;80:508-512.)

Figure 10

Lateral (radial) view of the firstcarpometacarpal (CMC) joint region,illustrating the location of the 1R and1U arthroscopic portals utilized duringCMC joint arthroscopy. Note theproximity of the 1R portal to the radialartery (RA) and the relationship ofthe portals to the extrinsic tendons.APL = abductor pollicis longus tendon,EPB = extensor pollicis brevis tendon,EPL = extensor pollicis longus tendon,MI = 1st metacarpal, MII = 2ndmetacarpal, MIII = 3rd metacarpal,SRN = superficial radial nerve,Tm = trapezium. (Reproduced withpermission from the Mayo Foundation.)



and prolonged postoperative casting(up to 3 months). Additionally, thepatient loses full mobility of thethumb and may have difficulty get-ting her or his hand into a flat posi-tion or into pockets.

The preferred position for fusionis thumb key pinch, which involvespositioning the thumb in pronationso that the thumb pulp rests on theradial aspect of the index middlephalanx. This position generally isdescribed as 30° to 40° of palmar ab-duction and 10° to 20° of radial ab-duction and extension. CMC arthro-desis is performed through anS-shaped incision between the APLand APB tendons. The capsule is in-cised, and the scaphotrapezial jointis inspected for signs of arthritis. Fu-sion can be performed in the absenceof significant arthritis in this adja-cent joint. The cartilaginous surfac-es of the CMC joint are then re-moved down to a bleeding bone bed.The thumb is positioned in keypinch with the cut bone surfaces ap-proximated and correctly aligned.Various fixation methods can beused, including K-wires for a tension

band, plates and screws, condylarblade plates, and Herbert screws(Figure 11).

Fulton and Stern37 studied CMCarthrodesis in 49 patients (averagefollow-up, 7 years). The authors usedK-wire fixation and reported a 7%nonunion rate. Three of the fournonunions were asymptomatic; theone symptomatic patient was re-vised using blade-plate fixation. At7-year follow-up, the average visualanalog pain score was 1.5 (scale, 0 to10). Seven patients went on to devel-op adjacent joint arthritis—three atthe scaphotrapezial joint and four atthe trapezial-index metacarpal artic-ulation.

Implant ArthroplastyLong-term complications associ-

ated with silicone implants haveprecluded their use in the thumbCMC joint. Complications includeimplant wear and silicone synovitiscaused by wear-induced particles≤15 µm. Wear generally occurs at ap-proximately 2 years postoperativelyas a result of shear and compressionforces across the implant. Siliconesynovitis is treated with removalwith curettage and interpositionalarthroplasty with satisfactory re-sults.38

Athwal et al39 reported the resultsof the use of the Orthosphere(Wright Medical Technology, Arling-ton, TN), a zirconia implant, in sev-en patients. At a mean 33-monthfollow-up, six of the seven implantshad subsided into the trapezium,with the patients reporting pain andweakness. Five of the seven were re-vised to ligament reconstruction andtendon interposition (LRTI).

Swanson et al40 reported on theresults of 105 Swanson titaniumcondylar implants (Wright MedicalTechnology) at an average follow-upof 5 years. At 6 months postopera-tively, improvements were seen inmotion and strength, bone remodel-ing was seen radiographically, andthe implant was stable. No signs ofwear were noted at average 5-year

follow-up. These results have notbeen reproduced by other authors.Badia and Sambandam41 reported 24good and excellent results in 25elderly patients following fixed ball-socket CMC arthroplasty (averagefollow-up, 59 months).

Resection Arthroplasty With orWithout LRTI

Resection arthroplasty of theCMC joint is regarded as the goldstandard for surgical treatment ofthumb CMC arthritis. Indicationsinclude a symptomatic patient withEaton stage III/IV CMC arthritiswho has failed nonsurgical treat-ment.

Gervis42 first described simpletrapeziectomy in 1949 to treat symp-tomatic thumb CMC arthritis andwrote a descriptive report of 15 pa-tients who had undergone the proce-dure. Since then, trapeziectomy hasbecome one of the most popular sur-gical treatments for CMC arthritis,and many variations have been de-veloped. In 1970, Froimson43 de-scribed performing tendon interposi-tion in the space created by thetrapeziectomy in an effort to preventmetacarpal subsidence. He coinedthe term “anchovy operation” be-cause of the similarity of the appear-ance of the interposed tendon to ananchovy. In 1986, Burton and Pelle-grini44 described trapeziectomy com-bined with LRTI to augment stabil-ity after trapezial resection, therebypreventing painful impingement ofthe thumb metacarpal on thescaphoid. Trapezium excision can beperformed with or without ligamentreconstruction and with or withouttendon interposition. Tendons usedfor ligament reconstruction includethe APL, FCR, and palmaris longus.

Selection of the approach for re-section arthroplasty is based on sur-geon preference. Surgical approachesdescribed include volar, midradial,and dorsal incisions. A midaxial lat-eral incision takes advantage of theinternervous plane (radial and medi-an) and includes dissection between

Figure 11

Carpometacarpal arthrodesis usingmini-fragment blade plate fixation.



the APL (radial innervation) and APB(median innervation). If encoun-tered, branches of the superficial ra-dial sensory nerve should be protect-ed. Arthrotomy exposes the CMCjoint to allow for resection of the tra-pezium. After a simple trapeziecto-my is performed, the joint capsule,subcutaneous tissues, and the skinare closed; percutaneous pinning isoptional.

Once the decision has been madeto perform tendon interposition and/or ligament reconstruction,45 tendonharvest is the next step. Options fortendon used for ligament reconstruc-tion include slips of the APL,46,47 partor all of the FCR, and the palmarislongus. The palmaris longus can beused for tendon interposition with-out ligament reconstruction. Otherinterpositional materials have beendescribed in the literature, includinghematoma48 and gel foam.49 Whenligament reconstruction is per-formed, the FCR or APL tendon isplaced through drill hole tunnelsthat are made through the base ofthe first metacarpal in a volar-ulnarto dorsoradial direction (Figure 12).A more recently introduced alterna-tive to bone tunnels is the use ofbone anchor sutures. Most common-ly, the procedure is done as describedabove, after which the tendon ispassed back around the FCR tendoninsertion. Overtightening of the lig-ament reconstruction should beavoided. After the LRTI has beenperformed, the thumb is held in ab-duction and extension. Another op-tion is to use K-wire insertion fromthe 1st metacarpal to the 2nd meta-carpal after resection arthroplasty orLRTI procedure.

Gerwin et al50 reported on 20 pa-tients who were randomized to inter-positional arthroplasty or simple tra-peziectomy. At an average 23-monthfollow-up, the authors found no dif-ference between the groups in abilityto perform activities of daily living,pain relief, radiographic basilar jointheight, or patient satisfaction.

Kriegs-Au et al51 published a pro-

spective randomized study of 31 pa-tients in which they comparedtrapeziectomy plus ligament recon-struction without tendon interposi-tion with trapeziectomy plus LRTI(average follow-up, 48 months). Theauthors found no difference instrength or subjective scores for sat-isfaction and pain and found no dif-ference in proximal migration at restor on stress radiographs. No correla-tion was found between proximalmigration of the metacarpal andmaximal pinch strength.

Martou et al52 performed a meta-analysis of all techniques used forthe treatment of Eaton stage II, III,and IV arthritis. Of the available 254studies in the literature, only 2 wererandomized controlled trials. Theauthors found great variability in theindications for surgery and the out-come measurement tools used inthese studies. In their meta-analysis,the authors compared arthrodesis,trapeziectomy with or without in-terposition, trapeziectomy with orwithout LRTI, osteotomy, and jointarthroplasty. LRTI provided no addi-tional benefit compared with arthro-desis or trapeziectomy alone.Thumb CMC arthrodesis providedthe best strength and stability scorescompared with tendon interpositiontreatments. Patients with siliconearthroplasty had higher complica-tion rates, including joint sublux-ation implant fractures and siliconesynovitis. All procedures resulted inpain relief, but the objective mea-surements did not always correlatewith the patient satisfaction scores.Pain relief was the most consistentfinding across all studies. In a recentCochrane review, Wajon et al53 re-ported that the best and safest oper-ation was a simple trapeziectomy. Inthat review, trapeziectomy alonehad the lowest complication rateand provided the best pain relief.

Summary

The thumb CMC joint is very im-portant for pinch and grasp function.

Its bony incongruities and requiredligamentous and muscular attach-ments predispose it to arthritis.When managing CMC joint arthri-tis, it is important to exclude othercauses of symptoms and to obtainadequate radiographic assessment ofthe surrounding joints, including aBett view. The Eaton classification isused in conjunction with severity ofclinical symptoms to make treat-ment recommendations. For Eatonstages I and II thumb CMC arthritis,nonsurgical treatment should be thefirst line of treatment, includingmuscle strengthening/stabilizationexercises, splinting, and cortisoneinjection.

When nonsurgical measures fail,surgical treatments should be con-sidered based on patient symptomsand radiographic findings. An indi-vidualized approach is required. Vo-lar oblique ligament reconstructionmay be appropriate for Eaton stagesI and II disease when associated withjoint subluxation. Stable but symp-tomatic joints with Eaton stage I orII disease can be considered for meta-

Figure 12

Trapezium resection with flexor carpiradialis ligamentous interposition(ligament reconstruction and tendoninterposition) to treat carpometacarpalarthritis. (Reproduced with permissionfrom Burton R: Resection/suspensionarthroplasty of the basal joint of thethumb for osteoarthritis, in StricklandJW [ed]: The Hand. Philadelphia, PA:Lippincott-Raven, 1998, p 455.)



carpal extension osteotomy, provid-ed the disease is confined to the vo-lar one third of the joint. Trapezialresection arthroplasty with or with-out tendon interposition can be donewith or without ligamentous recon-struction, and with or without sup-plemental K-wire fixation. Each iseffective treatment for symptomaticEaton stage III and IV disease. Tra-peziectomy seems to be the com-mon denominator that is most im-portant for pain relief. No significantdifferences have been shown be-tween interpositional tendon tech-niques, ligament reconstruction, andpinning. Research is being done intonew synthetic implants, resurfacingarthroplasty, and spacer materials.The role of arthroscopic treatmenttechniques for the CMC joint and ofmetacarpal extension osteotomy forearlier stages of arthritis has recent-ly been defined.

References

Evidence-based Medicine: There areseveral level I (24-27, and 51) andlevel II (23, 48, and 52) studies. Theremaining references are case-control level III studies or expertopinion.

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