1. Basal Joint Arthritis of the Thumb
Christian Veillette M.D., M.Sc., FRCSC
Assistant Professor, University of Toronto
Shoulder & Elbow Reconstructive Surgery
Toronto Western Hospital University Health Network

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] 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:
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  1o restraint to dorsoradial subluxation
Supported by clinical success of volar ligament reconstruction
Dorsoradial ligament
1o 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 1st MC base
Adducted posture of 1st MC
Distal aspect tethered to 2nd MC by adductor policis
Metacarpophalangeal joint hyperextension
Progressive functional deficit
Decreased grip
Narrowed palm, functional hand width

13. Diagnosis Typical patient Less commonly
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
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

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:

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;
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
20o of radial abduction
40o of palmar abduction

32. Anchovy Trapezium Excision Rolled Tendon Graft
FCR tendon interposition
Froimson. Clin. Orthop. (70):
30% Decrease pinch strength
50% Loss joint 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 A
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
30o 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) , 1986
Excision trapezium
Volar ligament reconstruction (FCR sling)
Interposition Arthroplasty (Anchovy) – FCR

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

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 Aug;6(4):
Randomized controlled trial of nettle sting for treatment of base-of-thumb pain. J R Soc Med 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 Feb;86-A(2):
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 Oct;83-A(10):
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 < )
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) Stage II-III Stage IV
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