Basal Joint Arthritis Of The Thumb

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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Clinical Exam
“Shoulder sign” =
dorsoradial prominence
Subluxation
Inflammation
Osteophytes
Adduction contracture
MP hyperextension
collapse

15. 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

16. 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

17. 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

18. 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

19. Classification
Stage II
TM narrowing
TM contours still normal
TM joint osteophytes
<2mm
ST joint Normal

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

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

22. 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

23. 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

24. 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

25. Operative Indications
Persistent pain
Functional disability
Failure conservative treatment
Compliant patient

26. 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

27. 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

28. Algorithm
JAAOS. 2000;8:314-323

29. 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

30. 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%

31. 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

32. 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)

33. Silicone Arthroplasty
Lower demand + Rheumatoid
Concerns:
Weakness
Dislocation
Fracture
Deformation
Osteolysis
Synovitis
Immunologic alterations

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

41. LRTI - Results
8%95% excellent321Horn
resection
Double
LRTI
Baron,Eaton
J. Hand Surg 1998
13%95% excellent924ExcisedLRTITomaino,Pellegrini,Burton
J. Hand Surg. 77A,1995
11%92% excellent224ExcisedLRTIBurton,Pellegrini
J. Hand Surg 1986
n/a92% excellent325PartialLRTIEaton,Glickel,Littler
J.Hand Surg. 10A(5)1985
Migration/
Loss Height
ResultsF/U (yr)nTrapeziumProced.Author

42. 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

43. 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.

44. 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

45. 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

46. 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)

47. 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