Thumb carpometacarpal arthrosis

THUMB CARPOMETACARPAL ARTHROSIS BY STEVEN D. YOUNG, MD, AND ELIZABETH A. MIKOLA, MD

Arthrosis of the thumb carpometacarpal joint is a very common, and often debilitating, affliction of postmenopausal women. Coexistent pathologic conditions are frequent. A thorough history and physical examination should lead the physician to an accurate diagnosis. Radiographs support the clinical suspicion and guide the treatment plan. Most patients, regardless of the severity of degeneration, will benefit from a conservative approach. However, when conservative management fails to relieve the patient’s symptoms adequately, surgical intervention is indicated. A plethora of surgical options are available, and controversy exists regarding the most effective surgical approach. Regardless of the technique used, one can usually expect pain relief, improved strength, and an overall increase in function. Therefore, satisfaction rates are high when surgery is performed on properly selected patients and associated conditions are addressed. Copyright © 2004 by the American Society for Surgery of the Hand he thumb is responsible for approximately 60% of the normal prehensile function of the hand.1 This can be attributed to its unique anatomic position and multiplanar motion at the carpometacarpal (CMC) joint. When its role has been diminished by pain and instability at the basal joint, simple activities such as turning keys, opening jars, and wringing out washcloths can be compromised severely. Unfortunately, this joint is a common site of degenerative arthrosis in the upper

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From Southern Orthopedic Associates, Herrin, IL; and the Department of Orthopaedic Surgery, University of New Mexico, Albuquerque, NM. Address reprint requests to Steven D. Young, MD, Southern Orthopedic Associates, 510 Lincoln Dr, Herrin, IL 62498. E-mail: [email protected] Copyright © 2004 by the American Society for Surgery of the Hand 1531-0914/04/0402-0005$30.00/0 doi:10.1016/j.jassh.2004.02.010

extremity, behind only the distal interphalangeal joints in frequency.2 The prevalence of thumb carpometacarpal arthrosis increases with age and is seen predominantly in postmenopausal women.3,4 Radiographic evidence of thumb carpometacarpal degeneration will be evident in one third of postmenopausal women, and one third of those individuals will be symptomatic.3 The female to male ratio is 6 to 1.2,5 Although previous trauma or rheumatoid arthritis can destroy the trapeziometacarpal (TMC) articulation, most cases are idiopathic in nature.6-8 Because the majority of arthritic basal joints are asymptomatic, the physician should not be misled by the radiographic presence of joint degeneration. The radiograph evaluation serves only as an adjunct to a careful history and physical examination. Associated skeletal or soft-tissue pathology is present in up to 75% of patients and must be treated accordingly.9 When this is performed, most patients will experience a satisfactory outcome.

JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND 䡠 VOL. 4, NO. 2, MAY 2004

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FIGURE 1. Deep volar ligaments of the thumb carpometacarpal joint. Abbreviations: APL, abductor pollicis longus; IML, intermetacarpal ligament; RST, radial scaphotrapezial ligament; SAOL, superficial anterior oblique ligament (beak ligament); VST, volar scaphotrapezial ligament; VT-II MC, volar trapezio–second metacarpal; VT-III MC, volar trapezio–third metacarpal; VTT, volar trapeziotrapezoidal ligament. Note that the superficial anterior oblique ligament and beak ligament are identified as synonymous structures in this figure. Also, notice that there is some variability between the identified structures and those mentioned in the text; such variability is not an uncommon occurrence when describing intercarpal ligament anatomy. (Reprinted with permission from Berger RA, Weiss APC, eds. Hand Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003:1280. © Lippincott Williams & Wilkins.)

ANATOMY he basal joint of the thumb consists of a unique anatomic configuration. The trapezium has 4 facets and articulates with the first metacarpal, distal scaphoid, second metacarpal, and trapezoid. Because the former 2 joints lie directly in the compression axis of the thumb, they frequently exhibit degenerative changes.10 North and Eaton11 found the trapeziometacarpal and scaphotrapezial joints to be degenerative in 60% and 34%, respectively, of the cadaver specimens that they visually inspected. In comparison, arthrosis affects the trapeziotrapezoid and trapezium–second metacarpal articulations only about 1% of the time.11 The presence of degeneration at 3 or 4 articulations is unlikely.11 Thus, the term pantrapezial arthritis is a frequently used misnomer.9,12 The trapeziometacarpal joint consists of 2 reciprocally oriented saddle articulations. The base of the first metacarpal is concave in the dorsal-volar plane and

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convex from radial to ulnar; conversely, the distal trapezium is convex from dorsal to volar and concave in the radial-ulnar plane.4 Two degrees of freedom and 2 axes of rotation exist.13 The abduction-adduction axis lies within the metacarpal base and the flexionextension axis lies within the trapezium.13 Because these axes are each offset from the anatomic planes, coupled rotation allows for motion in 3 planes.13 This arrangement is responsible for the tremendous thumb mobility required for strength and dexterity. As with other joints, such as the glenohumeral joint, motion occurs at the expense of stability. When a lack of bony constraint exists, strong ligamentous support is necessary to optimize joint stability. Multiple ligaments are present at the basal articulation (Fig 1). The extracapsular ligaments include: the anterior oblique, posterior oblique, dorsoradial, ulnar collateral, and intermetacarpal ligament.2 An intracapsular beak ligament has been described by Pellegrini14; it attaches to the volar-ulnar aspect of the

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trapezium and the volar beak of the metacarpal. It has been suggested that the anterior oblique ligament and the beak ligament are synonymous, but this is not a universal opinion.15,16 Controversy exists regarding which ligament is most important in stabilizing the trapeziometacarpal joint.6,14,16,17 Pellegrini14 and Doerschuk et al16 felt the beak ligament was the major static stabilizer of the joint during lateral pinch. It becomes taut with metacarpal pronation, an obligatory component of thumb opposition. If this ligament becomes incompetent, dorsal translation of the metacarpal base may occur and lead to subsequent arthrosis. This is the basis for reconstruction of the anterior oblique ligament as advocated by Eaton and Littler.6 Others have suggested that the dorsal oblique ligament is the strongest stabilizer of the trapeziometacarpal joint, and note that Eaton and Littler’s procedure not only reconstructs the anterior oblique ligament, but also reconstructs the dorsal oblique ligament.17 This observation may help to explain the efficacy of their procedure in the early arthritic process.

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combination of factors is responsible for basal joint degeneration. These include high local stresses, joint incongruity, and ligamentous laxity. With repetitive forceful pinching and gripping, the risk for arthritic changes at the basal joint increases. The trapeziometacarpal joint is subjected to high local stresses. Pellegrini et al18 have found the compressive force at the trapeziometacarpal joint to range from 8 to 16 times the thumb tip pressure. Cooney and Chao19 noted that a 1-kg force at the tip of the thumb is translated into 12 kg of force at the trapeziometacarpal joint. Rotational activities such as wringing out a washcloth may result in forces as high as 120 kg at this articulation.19 This alone is a significant factor in the development of joint wear. As the thumb flexes, pronation occurs. Baseline incongruity of the trapeziometacarpal joint is increased, and the resultant forces are concentrated at the dorsoradial and volar-ulnar regions of the joint.10 Additionally, the beak ligament is subjected to high tensile stresses. With time, attrition occurs at the ligament’s fibrocartilaginous insertion zone on the metacarpal base.16 A synovial recess forms between the proximal metacarpal and the ligament, progres-

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sively displacing the beak ligament attachment distally.16 Eventually, the entire ligament may detach from the metacarpal; the trapezial insertion site does not degenerate.16 Without the beak ligament serving as a volar tether, the metacarpal subluxes dorsally; the unopposed pull of the abductor pollicis longus contributes to this tendency. Joint incongruity is amplified, and significant shear stresses occur. The severity of arthrosis that develops is directly proportional to the area of ligament detachment.16 Arthritic changes are initiated at the volar-ulnar aspect of the metacarpal and the volar-central aspect of the trapezium.14,16,20 The area of eburnation on the trapezium will be larger than that on the metacarpal by as much as a 3:1 ratio.20 This signifies the metacarpal sliding on the trapezium caused by joint instability. As the disease process advances, degenerative changes will shift in a dorsoradial direction.16,18,20 Although the dorsoradial portion of the trapezium has been identified as a high load-bearing area, it does not degenerate in the early arthritic process.4,20 Chondromalacia is common on the dorsal down-sloping portion of the trapezium, but it infrequently progresses to eburnation.20 When eburnation is present dorsally, it likely is associated with complete beak ligament detachment from the metacarpal base.16 If the beak ligament is detached only partially, eburnation may be limited to the volar compartment.16 Advanced radiographic arthrosis may be present in either scenario.16 The surface of the trapezium becomes more concave in end-stage disease; the metacarpal, conversely, does not remodel to a significant extent.4 Although joint remodeling in the later stages of the arthritic process leads to an increase in joint congruity, this is at the expense of cartilage thinning.4 When the cartilage thins, forces are dissipated over a smaller area, thus, negating the expected benefit of the larger joint contact areas.4 Therefore, stresses are nearly the same in the early and late stages of the disease process.4 Clinically, remodeling manifests as stiffness in the late stages of the disease process as opposed to the laxity that is seen initially.10 Women have a significantly smaller trapezium in relation to the first metacarpal base and also exhibit a flatter trapezial articular surface compared with men.21 However, there is no gender-related difference in the shape of the first metacarpal articular surfaces.21

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FIGURE 2. The shoulder sign is evident as a prominence at the radial aspect of the thumb base. It is caused by metacarpal subluxation, osteophytes, and joint synovitis.

Thus, trapeziometacarpal joints in women are less congruent, have smaller contact areas, and are likely to experience higher contact stresses than joints in men for similar activities of daily living.4,21 In addition, carpometacarpal joints in women show, on average, as much as 20% thinner cartilage layers than joints in men.4 Finally, hormonal differences in women may be responsible for increased ligamentous laxity, contributing to their propensity for basal joint arthrosis.

EXAMINATION hen examining the patient complaining of pain at the base of the thumb, one must first observe the appearance of the thumb. Frequently there will be a prominence along the dorsoradial aspect of the carpometacarpal joint caused by joint subluxation, effusion, and osteophytes; this is known as the shoulder sign (Fig 2). First web space narrowing and meta-

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carpophalangeal hyperextension may be noticeable. The amount of hyperextension should be measured objectively because this might impact treatment. As is routine for any hand or wrist problem, range of motion, pinch strength, and grip strength should be documented. The patient likely will have discomfort with palpation directly over the carpometacarpal joint; this frequently is located at the volar radial aspect of the joint. The scaphotrapeziotrapezoidal (STT) joint is located one fingerbreadth proximal to this and must be palpated. Additional areas that deserve attention include the first dorsal compartment, flexor carpi radialis (FCR), radiocarpal joint, and the scaphoid. If trapeziometacarpal arthrosis is present, it usually can be identified with direct palpation. There are several provocative maneuvers that assist with making the correct diagnosis. In early disease, synovitis is prominent but degenerative changes are absent. The torque test, performed by applying traction and rotation to the thumb, produces pain when the inflamed capsule and synovium are stretched.6,10 The TMC stress test, also for early disease, is performed by trying to translate the metacarpal base dorsally while the metacarpal is adducted.22 A palpable and painful dorsal shift will be noted. Additional provocative maneuvers include the compression grind test, metacarpal compression test, and resisted opposition maneuver.23 The compression grind test is performed by applying an axial load combined with gentle rotation to the basal joint.23 Crepitance evident on examination implies that articular cartilage has been eroded completely in at least one area.10 The common scenario of crepitance without pain does not represent a positive finding; the patient’s symptoms must be replicated. The metacarpal compression test is considered positive when pain is produced by gently compressing the first and fifth metacarpals toward each other (Fig 3).23 Finally, the resisted opposition maneuver involves simply applying resistance to the patient’s active attempts at opposition (Fig 4).23 Finkelstein’s test also may be positive, but it is nonspecific. It usually is indicative of DeQuervain’s tenosynovitis, but also may elicit pain in the presence of intersection syndrome or radiocarpal arthrosis. Because of the proximity of the radial artery to the scaphotrapezial joint, one needs to be aware of the vascular supply to the hand by performing an Allen’s

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FIGURE 3. The metacarpal compression test places an adduction stress on the thumb carpometacarpal joint by compressing the first and fifth metacarpals toward each other.

test. If the hand lacks a complete vascular arch or adequate blood flow from the ulnar artery then the radial artery will have to be repaired if it is damaged intraoperatively. Even when a diagnosis of carpometacarpal arthrosis is obvious, other diagnoses must be entertained

because as additional pathology is common. In order of frequency, Melone et al9 have identified the following coexistent pathologic problems: scaphotrapezial arthrosis, carpal tunnel syndrome, metacarpophalangeal hyperextension, trigger digits, and tenosynovitis at the wrist. At least one concurrent

FIGURE 4. To perform the resisted opposition maneuver, the examiner resists the patient’s active attempts at opposition.

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surgical procedure was needed in 65% of their trapezium arthoplasties. They termed this increased propensity for concomitant pathologic problems the basal joint pain syndrome. Florack et al5 noted that 43% of their patients who underwent basal joint surgery had carpal tunnel syndrome. It is important to enquire about this problem because unrecognized carpal tunnel syndrome has been implicated as a source of postoperative pain and weakness that may precipitate a complex regional pain syndrome.24 It appears obvious that the patient’s symptoms will persist if the surgeon does not fully acknowledge the basal joint pain syndrome.

RADIOGRAPHIC EVALUATION he radiographic evaluation of the patient with suspected basal joint arthrosis should include a posteroanterior, oblique, true lateral, and a stress radiograph (Fig 5). A Robert’s hyperpronated anteroposterior view may be obtained instead of the posteroanterior view. The Robert’s view is performed by maximally pronating the hand and internally rotating the shoulder. This allows the dorsum of the thumb to rest on the radiograph cassette (Fig 6). All 4 facets of the trapezium are visualized readily with this view. An adequate true lateral radiograph is confirmed by superimposition of the 2 metacarpophalangeal sesamoids.10,12 Trapeziometacarpal congruity can be assessed on this projection. The oblique view is performed by placing the palm flat on the radiograph cassette. Trapeziometacarpal congruity cannot be determined with this radiographic view. Stress radiographs as originally described by Eaton and Littler6 are obtained with the plane of the thumbnails parallel to the radiograph cassette while the patient forcefully pushes the radial aspect of the thumb tips together. The degree of ligamentous laxity is proportional to the amount of radial subluxation at the carpometacarpal joint. A good contour of the second metacarpal, trapezoid, and scaphoid facets of the trapezium is obtained. Pellegrini25 has suggested that a stress view with both thumbs in a true lateral projection more accurately reflects the dorsal subluxation that occurs with lateral pinch. This variant, therefore, may have more clinical relevance than the Eaton and Littler stress radiographs.

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STAGING ultiple staging systems have been devised. The staging system of Eaton and Littler6,26 is used most commonly and is based solely on the appearance of the lateral radiograph.10,12 They originally described their classification in 1973; it was later modified to incorporate the scaphotrapezial joint.6,26 The modified system is discussed here. Stage I reveals normal articular contour (Fig 7). The joint space may be widened secondary to synovitis. Subluxation, if present, should be less than 30% of the metacarpal width. Stage II shows mild joint space narrowing with osteophytes and joint debris less than 2 mm in diameter (Fig 8). The osteophytes develop before joint narrowing.11 Stage III involvement has significant joint space narrowing and sclerosis; joint debris and peripheral osteophytes are greater than 2 mm in diameter (Fig 9). Stage IV disease is the same as stage III disease with the addition of scaphotrapezial arthrosis (Fig 10). In the original classification scheme, scaphotrapezial involvement was not considered, and stage IV disease signified advanced trapeziometacarpal degeneration.6 Because cartilage thinning occurs in the end stage of the arthritic process, radiographic joint space narrowing signifies late disease.4 Radiographs tend to lag behind anatomic involvement.4 In particular, a poor correlation exists between radiograph and anatomic findings at the scaphotrapezial joint.11 Hence, staging may not accurately reflect the degree of arthrosis. If surgical intervention is required, it is important that the surgeon visually inspect the joint surfaces to define the areas of wear.

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CONSERVATIVE MANAGEMENT conservative approach to treatment consists of thumb spica splinting, anti-inflammatory medications, steroid injections, and physical therapy— usually in the form of modalities and thenar strengthening. Although there is a paucity of literature devoted to this aspect of treatment, it frequently is recommended based on anecdotal experience. Swigart et al27 retrospectively reviewed 114 patients (130 thumbs) treated with a long opponens splint. The patients wore their splints continuously for 3 to 4 weeks, followed by a 3- to 4-week weaning

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FIGURE 5. Posteroanterior radiograph (A). Oblique radiograph (B). True lateral radiograph (C). Stress radiograph (D).

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FIGURE 6. The Robert’s view is performed with the dorsum of the thumb on the radiograph cassette.

period during which the splints were worn at night. Most patients were able to comply with the protocol. At a 4.5-year follow-up, 19% of the patients had undergone surgical intervention; of these patients, only 17% had any initial relief with splinting. Seventy-six percent of those with stages I and II disease and 54% with stages III and IV disease experienced relief from splinting (not statistically significant); improvement in symptom severity averaged 60%. Duration of preoperative symptoms, radiographic stage of arthrosis, and the institution of activity modification did not seem to have any effect on the response to splinting. Less than one third of the patients in the study modified their activities. A positive response to splinting could be expected even if symptoms had been present for several years. The investigators concluded that splinting is well tolerated and is equally efficacious for all stages of degeneration. It is expected to alleviate but not completely resolve the symptoms of basal joint arthrosis.27 Weiss et al1 conducted a prospective analysis of first carpometacarpal splinting using either a long or short opponens splint. Pain relief was the same for both splints. Only 7% of activities of daily living were harder to perform when the short opponens splint was used; 56% were harder when the long splint was worn. Overall, 73% of the patients preferred the short opponens splint. In patients with concomitant prob-

FIGURE 7. In stage I arthrosis, a normal articular contour is maintained. There is no joint space narrowing evident. In fact, the joint space may be widened secondary to synovitis.

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disease. There is no clear-cut consensus on the appropriate surgical procedure, and a unique situation exists in which the surgeon can develop a successful hybrid technique based on his own philosophy and experience.

THE PREARTHRITIC JOINT n occasional patient will exhibit pain localized to the trapeziometacarpal joint but will lack any radiographic evidence of degeneration. The cause is usually chronic beak ligament attrition with resultant carpometacarpal hypermobility and synovitis. A similar picture may occur from an acute hyperabduction or hyperextension injury that produces ligamentous damage. The torque test and trapeziometacarpal stress test may be positive. Crepitance will be absent with compression grind testing. An initial attempt at conservative management is warranted. In fact, with the prominent inflammatory

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FIGURE 8. In stage II arthrosis, joint space narrowing is mild and joint debris is less than 2 mm in diameter.

lems such as carpal tunnel syndrome or DeQuervain’s tenosynovitis, there was a tendency to prefer the long opponens splint.1 It appears that an initial attempt at thumb spica splinting is warranted regardless of the degree or duration of arthrosis. The majority of patients will experience a reduction of their symptoms. If basal joint arthrosis exists as an isolated condition, a short opponens splint is used; a long opponens splint should be used if comorbidities are present.

SURGICAL MANAGEMENT nce it has been determined that surgical intervention is needed, the surgeon must devise a comprehensive approach. All components of the basal joint pain syndrome must be identified by physical examination. The radiographic stage of arthrosis should be determined because the surgical options for mild arthrosis differ from those used in advanced

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FIGURE 9. Stage III arthrosis is characterized by severe joint space narrowing and osteophytes that are greater than 2 mm in diameter.

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FIGURE 10. Combined trapeziometacarpal and scaphotrapezial degeneration constitutes Eaton and Littler stage IV arthrosis.

component present in this stage of disease, patients may be more likely to respond to anti-inflammatory medications and steroid injections. Splinting remains the cornerstone of conservative care and should be used liberally because it can stabilize the basal joint and limit the amount of instability. Regardless, conservative management will not be successful in all patients, and surgical intervention will be indicated. In 1973, Eaton and Littler6 popularized ligament reconstruction for the painful hypermobile thumb carpometacarpal joint (Fig 11). They used a distally based strip of the FCR to reconstruct the anterior oblique ligament in 18 patients. As the disease process worsened, results declined. Of the 8 patients with stage III disease, 5 had an excellent result and 3 had a good result. Based on their initial grading system, which did not account for scaphotrapezial arthrosis, 5 of the patients had stage IV, or advanced trapeziometacarpal degenerative disease. All patients im-

proved from their preoperative status. Despite the encouraging results, even in advanced stages, this procedure only was recommended for stage I or II disease. The first 50 patients who underwent ligament reconstruction were reviewed at an average follow-up period of 7 years.26 The longest follow-up period was 13 years. Patients with stage I or II disease had 95% good or excellent results. Of those with stage III or IV disease, 74% had good or excellent results. There were no failures, and all patients experienced pain relief. Once again, however, the procedure only was recommended for stage I or II disease.26 The ligament reconstruction has since been combined with other procedures to remedy advanced arthrosis. An alternative procedure for early trapeziometacarpal disease is first metacarpal base osteotomy.18,22 A 30° closing wedge osteotomy is performed at the dorsal base of the thumb metacarpal. Biomechanically, this shifts the load from the more involved volar compartment to the dorsal compartment.18 Once volar eburnation occurs, the procedure becomes less efficient in transferring load. In end-stage disease, when pathologic congruity exists and the dorsal compartment may be eburnated, unloading of the volar compartment does not occur. The procedure is not, therefore, recommended for advanced disease.18 A prospective review of 12 patients followed-up for 2.1 years after metacarpal extension osteotomy revealed satisfaction in 11 patients.22 All osteotomies healed at an average of 7 weeks. All patients had a painful trapeziometacarpal stress test before surgery; none were painful or translated after surgery. Exclusion criteria included fixed metacarpal subluxation, global instability, joint space narrowing on radiographs, crepitance on compression grind testing, and metacarpophalangeal (MP) hyperextension greater than 10°.22 An arthrotomy was performed intraoperatively and confirmed that no patients had central or dorsal cartilage wear, which would be a contraindication to the procedure. For those patients with Eaton and Littler stage I or II disease who has been unresponsive to nonsurgical measures, beak ligament reconstruction is a wellaccepted surgical approach. Metacarpal extension osteotomy offers a reasonable alternative when lesser amounts of instability are present.

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FIGURE 11. Technique of volar thumb carpometacarpal ligament reconstruction. Half of the FCR tendon is passed through a drill hole in the base of the thumb metacarpal. After exiting the dorsal metacarpal, the tendon is passed dorsal to the abductor pollicis longus and through the remaining FCR before being sewn to the palmar carpometacarpal capsule and abductor pollicis longus tendon. (Reprinted with permission from Berger RA, Weiss APC, eds. Hand Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003:1283. © Lippincott Williams & Wilkins.)

TRAPEZIAL EXCISION n 1949, Gervis28 was the first to describe simple trapeziectomy for degeneration of the thumb basal joint. Murley29 later followed with a report on the same procedure. He identified residual weakness in a large percentage of his patients but he felt that this did not offset the excellent pain relief afforded by the procedure. Nevertheless, trapeziectomy has fallen out of favor with many surgeons owing to reports of postoperative weakness and instability. Dhar et al30 reported 6-year follow-up results on simple trapeziectomy with immediate postoperative mobilization. Postoperative pinch and grip strengths

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were less than on the nonoperated side (84% and 79%), but preoperative strengths were not reported. Only 3 of 34 patients complained of weakness of their grip. Thumb length on the operated side was 97% of the nonoperated side. All patients experienced dramatic relief of pain, and there were no poor results. On average, 9 months of postoperative rehabilitation was required for return of maximum function. Horlock and Belcher31 also reported encouraging results with simple trapeziectomy. At 6 months, grip and pinch strength was increased significantly from preoperative values despite significant shortening of the thumb. Results were similar whether the patients were mobilized at 1 week or 4 weeks. A small loss of

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motion was seen at the metacarpophalangeal joint in the late mobilization group. The investigators determined that prolonged postoperative splinting is not necessary and may be detrimental to the return of motion. They also recommended that this procedure be reserved for patients without significant thumb laxity. Vandenbroucke et al8 noted that 85% of his patients who underwent simple trapeziectomy had no or only mild pain. Subjectively, patients felt they had less power after 7 of the 22 procedures. Despite this, the investigators prefer simple trapeziectomy for treatment of thumb carpometacarpal arthrosis in the elderly population. A recent report by Kuhns et al32 described a technique known as hematoma and distraction arthroplasty. This is a simple trapeziectomy combined with 5 weeks of K-wire immobilization of the thumb in slight distraction and opposition. A 2-year follow-up of this procedure showed complete relief of pain in 92% of patients; this improved from 73% at 6 months. Increases in preoperative values of grip strength, key pinch strength, and tip pinch strength were 47%, 33%, and 23%, respectively. Radiographically, subsidence of the metacarpal was found to be 51% at rest, increasing to 61% with pinch; this compares with 21% at rest and 32% with pinch in Yang and Weiland’s33 study of the ligament reconstruction tendon interposition arthroplasty (LRTI). Tomaino et al34 also noted less subsidence (13%) in their study on the LRTI procedure. None of these investigators were able to show a correlation between loss of trapezial space height and results. Because the results of hematoma and distraction arthroplasty are similar to those of more involved procedures, and it is a technically easy surgery, Kuhns et al32 have questioned the need for ligament reconstruction and/or tendon interposition. In a prospective randomized study, Downing and Davis35 compared simple trapeziectomy, trapeziectomy with tendon interposition, and the LRTI procedure. A common feature of each of these procedures was 4 weeks of K-wire immobilization after surgery. There was no difference in the trapezial space ratio for any of the procedures. The trapezial space ratio was calculated by dividing the distance from the distal scaphoid to the base of the thumb metacarpal by the length of the thumb proximal phalanx. The space

decreased by about 50% in the postoperative period for each of the procedures. K-wire immobilization likely had more to do with maintaining the trapezial space than did ligament reconstruction or soft-tissue interposition. Grip and pinch strength improved for all procedures after surgery and were similar for the 3 groups. As with other studies, the investigators found no correlation between thumb length and strength. These investigators also questioned the need for ligament reconstruction or soft-tissue interposition.35

LRTI RTI arthroplasty is likely the most popular surgical remedy for thumb carpometacarpal arthrosis (Fig 12). The LRTI procedure as originally described by Burton36 in 1983 integrated techniques that had been published previously by other investigators. Gervis28 reported on trapezial excision in 1949. In 1970, Froimson37 added an FCR anchovy to the vacant trapezial space. Finally, in 1973, Eaton and Littler6 published their results on using the FCR to reconstruct the anterior oblique ligament for the unstable carpometacarpal joint. Thus, the 3 principles that this technique incorporates are the following: removal of the arthritic surfaces, soft-tissue interposition to reduce bony impingement, and reconstruction of the beak ligament to minimize metacarpal subsidence and subluxation. The technique presented by Burton and Pellegrini38 in 1986 has been modified in a number of ways.34,39 Complete trapezial excision now is performed routinely.7,34,39 This appears to be advantageous because any undiagnosed arthrosis at the scaphotrapezial joint is addressed. However, in one report in which hemitrapeziectomies were performed in the face of moderate scaphotrapezial arthrosis, the radiographic appearance of the ST joint and clinical results did not deteriorate over an 8-year period; 95% of the 18 patients were rated as good to excellent.40 This defies previous concerns that any unaddressed scaphotrapezial arthrosis may result in persistent postoperative pain.10,12 Those who support the use of a hemitrapeziectomy will cite less subsidence as an advantage over complete trapezial excision; this has not been borne out by clinical series.33,35 Additionally, there is no difference between complete trapezial excisions and hemitrapeziectomies with regard to first web space measurements.34 Thus, it would appear that either a

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FIGURE 12. A common method for performing the LTRI. After trapeziectomy, a drill hole is made from the proximal palmar to distal dorsal through the thumb metacarpal (A). The radial half of the FCR is harvested proximally and passed through the drill hole (B). The excess FCR is sutured to itself and folded into an anchovy. The anchovy is secured in the post-trapeziectomy space (C). (Reprinted with permission from Berger RA, Weiss APC, eds. Hand Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003:1284. © Lippincott Williams & Wilkins.)

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hemitrapeziectomy or a complete trapeziectomy is acceptable—the objective of either is to eliminate the arthritic surfaces. From a practical standpoint, complete trapeziectomy is simple to perform, provides optimal exposure of the FCR tendon, and simplifies the decision-making process. Another modification of the original technique is the routine use of the entire width of the FCR tendon.7,34,39 This allows the tendon to be harvested easily and provides a much bulkier interposition material. No subjective or objective differences have been noted between using half of the FCR or the entire FCR.34 The most obvious concern would be for a significant loss of wrist flexion strength. Without providing any objective data, Varitimidis et al7 noted that there was no morbidity associated with using the entire FCR. A prospective study by Tomaino and Coleman41 showed near-complete return of wrist flexion strength and endurance at 6-month follow-up with complete return at 1 year; there were no subjective patient complaints. He has recommended that the entire FCR be used with this technique.39 An additional area that was not addressed by the original technique is the scaphotrapezoidal joint. Although not in the direct axis of compression, it is not infrequently involved in the arthritic process.7,42 Tomaino et al42 showed a 62% prevalence of arthrosis; radiographic sensitivity was only 44%, but specificity was 86%. This articulation can be inspected easily after complete trapeziectomy; if degeneration exists, the proximal 2 mm of the trapezoid can be excised. Interposition material is placed into the space at the surgeon’s discretion. Excising the proximal trapezoid has no negative consequences on the amount of metacarpal subsidence.7,42 In a 9-year follow-up of the LRTI procedure, Tomaino et al34 showed a 95% patient satisfaction rate. In their series, half of the FCR tendon was used for the ligament reconstruction and tendon interposition. Both hemitrapeziectomies and total trapeziectomies were performed; subjective and objective results did not vary between the 2 procedures. Compared with preoperative values, strength of grip, tip pinch, and key pinch improved 93%, 65%, and 34%, respectively. Interestingly, these parameters continued to improve for 6 years before reaching a plateau. Mobility of the thumb also improved with time. At the 2-year follow-up period, 26% of patients could not

oppose the thumb to the base of the small finger; this number decreased to 8% at the 6-year follow-up.34 Lins et al43 published a retrospective review of 27 patients who underwent the LRTI procedure. Average follow-up time was 42 months. Twenty-four (89%) of the patients were satisfied with the relief of pain provided by the procedure. On average, postoperative pain was mild and occurred between a few times a week and a few times a month. Thirteen (48%) patients had no pain. Grip strength improved by 50% and pinch strength by 43%. They found no difference in pinch and grip strengths or metacarpal subsidence between patients who underwent LRTI using half of the FCR or those whose surgery involved the use of the entire tendon; complete trapeziectomy was performed in both groups. As has been seen in other studies, trapezial space did not diminish substantially with time.7,34,43 Varitimidis et al7 reported their results on 58 patients who underwent the LRTI at an average follow-up period of 3.5 years. Complete trapeziectomies were performed, and the entire FCR was used as interposition material. After surgery, 3 patients had mild pain and the remaining patients were completely pain free. A partial trapezoidectomy was performed in 32 of 62 joints because of scaphotrapezoidal arthrosis. All 3 patients with postoperative pain did not undergo a partial trapezoidectomy; their pain was improved later with a steroid injection into the joint. Additionally, the investigators did not feel that a lack of K-wire stabilization negatively influenced their results and in fact stated that this eliminated a potential source of complications.7 Thompson44 devised a suspensionplasty procedure to salvage failed silicone arthroplasties. Diao later modified the technique slightly and has used it as a primary procedure for Eaton and Littler stage II through IV disease.45 After excising the entire trapezium, he detaches the entire abductor pollicis longus at the musculotendinous junction, passes it through drill holes in the thumb and index metacarpals, and then secures it to the extensor carpi radialis brevis tendon with 3 tendon weaves. No interposition material is placed in the posttrapeziectomy space, and no transfixing K-wire is needed. He reported excellent recovery of motion and an 87% incidence of complete pain relief; subsidence averaged only 1 mm in loaded pinch. In a cadaver model, Diao’s suspensionplasty

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FIGURE 13. The incision for the LRTI procedure is made at the dorsal aspect of the thenar glabrous skin. The Kwire in the trapezium is used as a joystick to aid en bloc excision. Note the carpal tunnel incision, an oftenneeded procedure in patients undergoing basal joint surgery.

allowed less than half of the proximal migration that the LRTI procedure exhibited.

LRTI TECHNIQUE Wagner incision is made along the radial aspect of the metacarpal at the dorsal border of the glabrous skin. This extends proximally to the distal wrist crease and as far ulnar as the FCR tendon (Fig 13). The soft tissues are dissected bluntly. The superficial radial nerve and lateral antebrachial cutaneous nerve branches must be identified and protected. The former usually is located in the dorsal flap; it need not be skeletonized and forceful retraction should be avoided to minimize postoperative paresthesia or dysesthesia, a common complication. The thenar muscles are elevated in an extraperiosteal fashion. A volar longitudinal arthrotomy is then performed. The capsule should be dissected meticulously and tagged for later closure. A K-wire placed in the trapezium can be used as a joystick to aid capsular release. If difficulty is experienced in removing the trapezium en bloc, it can be removed in piecemeal fashion. The position of the FCR and the radial artery must be kept in mind so that they are not injured when excising the trapezium. By removing the entire trapezium any potential scaphotrapezial involvement is addressed. The

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scaphotrapezoid joint then should be inspected. If arthrosis is noted, the proximal aspect of the trapezoid is debrided to prevent scaphotrapezoidal impingement. Finally, osteophytes on the metacarpal should be removed. The entire FCR tendon then is harvested through 2 transverse incisions. The distal incision is made directly over the tendon near the distal wrist crease. The palmar cutaneous branch of the median nerve is located on the deep and ulnar aspect of the tendon and should not be damaged. By placing traction on the tendon with a hemostat, its proximal extent can be identified. The second incision is at the level of the musculotendinous junction where the tendon is divided. It is then pulled into the distal incision and, subsequently, into the posttrapeziectomy space (Fig 14). The tendon should be freed all the way to its second metacarpal insertion; this is necessary to provide the appropriate angle for ligament reconstruction. The ligament reconstruction or suspensionplasty is performed utilizing a suture anchor technique described by Strauch.46 First, the volar-ulnar and central aspects of the metacarpal base are debrided to allow for tendon-to-bone healing. Two suture anchors are then placed into these areas (Fig 15). Next, the thumb is distracted so its metacarpal base is level with the index metacarpal base. The FCR tendon then is pulled

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FIGURE 14. After the entire FCR is released at its musculotendinous junction, it is pulled into the posttrapeziectomy space.

taut and secured to the base of the thumb metacarpal. The sutures should not be cut at this point. A hemostat is used to grasp the end of the tendon perpendicular to its fibers. The tendon is rolled up on the hemostat, and, every 2 turns, a figure-of-8 suture is placed in each end of the anchovy with nonabsorbable

FIGURE 15. Two suture anchors placed into the base of the thumb metacarpal are used to secure the FCR tendon.

4-0 braided suture. The anchovy then is gently slid off of the hemostat. The sutures left attached to the anchors are passed through the anchovy and tied, stabilizing the interposition material in the posttrapeziectomy space (Fig 16). K-wire stabilization is not necessary.

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FIGURE 16. The FCR tendon is rolled into an anchovy and placed in the posttrapeziectomy space.

As a routine part of the procedure the extensor pollicis brevis can be released distally and tenodesed to the proximal metacarpal.38 This removes a hyperextension force from the MP joint. If there is MP hyperextension greater than 30°, an MP capsulodesis is performed and the joint is pinned in 40° flexion for 4 weeks. If the hyperextension is less than that, the joint simply is pinned in 30° to 40° of flexion for 4 weeks.47 The capsule is closed with 4-0 nonabsorbable braided suture in a figure-of-8 fashion. The thenar musculature should be reapproximated to the metacarpal with 4-0 absorbable suture in running fashion. The tourniquet then must be deflated to confirm radial artery patency. The subcutaneous tissue is closed with absorbable 4-0 sutures, and the skin is closed with 4-0 nylon horizontal mattress sutures. A short arm thumb spica splint with the interphalangeal joint free is applied. This is removed at approximately 10 days, at which time sutures are removed and a thumb spica cast is applied. The cast is removed at 4 weeks, and a hand-based orthoplast thumb spica splint is fabricated. Thumb range of motion exercises are begun, but adduction and flexion at the carpometacarpal joint should be avoided because this may stress the ligament reconstruction. Thenar strengthening is begun at 6 weeks. Pinch and grip strengthening starts at 8 weeks. Splinting is

continued for 12 weeks after surgery. The patient will notice improvement in strength and function for up to 1 year after surgery.

TRAPEZIOMETACARPAL ARTHRODESIS arpometacarpal fusion is useful in treating a variety of disorders affecting thumb function. Pain relief is the primary goal; maintaining motion, stability, and strength are secondary objectives. Fusion is indicated for isolated trapeziometacarpal arthrosis (stages II and III Eaton/Littler) in young active laborers. It is contraindicated in the presence of scaphotrapezial degeneration. Arthrodesis is a durable procedure that prevents thumb shortening and provides both good strength and pain relief. The biggest drawback is loss of motion and inability to flatten the palm. Klimo et al48 recommended fusing the trapeziometacarpal joint in 20° to 30° of radial abduction, 35° to 45° of palmar abduction, and pronation so that the thumb pulp rests on the radial aspect of the index middle phalanx with wrist extension. Increasing the rigidity of fixation decreases the nonunion rate and shortens the length of postoperative immobilization. Plating techniques result in the highest fusion rates.49 Surprisingly, Herbert screw fixation resulted in a 50% incidence of nonunion in one study.50 Hartigan et al49

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reported a 16% nonunion rate, but the outcome was not affected in the majority of cases. In the review by Caputo and Bennett,51 fusion resulted in an average extension loss of 10° and abduction loss of 9° compared with the contralateral side. Thirteen of 20 patients had full opposition, and 7 lacked only 1 cm of opposing the thumb tip to the fifth metacarpophalangeal joint. Most patients could not flatten the palm completely, yet this was a problem for only one patient. Chamay and PiagetMorerod52 reported that 44% of their patients could not flatten the palm. Bamberger et al53 showed a decreased range of motion of 61% in the coronal plane and 72% in the sagittal plane. Hartigan et al49 compared arthrodesis versus LRTI in 109 patients. A significantly stronger lateral and chuck pinch was seen in those patients who underwent fusion. Mureau et al54 reviewed 43 cases of arthrodesis or tendon interposition; a higher percentage of the arthrodesis group resumed their jobs or activities. In both of these studies, motion was better in the LRTI group.52,54 Despite the negative aspects of trapeziometacarpal arthrodesis, pain relief, strength, and patient satisfaction generally are good. It should be reserved for the young manual laborer with isolated trapeziometacarpal arthrosis.

SILICONE IMPLANT ARTHROPLASTY ilicone replacement of the trapezium was developed by Swanson55 in 1965, and it was formerly a popular method of treating advanced basal joint degeneration. The technique was very effective in relieving pain and restoring range of motion, but was hampered by implant instability, fracture, particulate synovitis, and late bone erosions.56 In an attempt to curtail these problems, numerous modifications to the sizes, shapes, and composites of silicone material were made. However, these complications could not be reduced to an acceptable level. With the advent of the LRTI procedure and its various modifications, silicone implant arthroplasty largely has been reduced to a technique of historic significance. The Swanson et al57 silicone implant replaces the entire trapezium. A triangular intramedullary stem fits into the first metacarpal base. The original convex implant was changed to a concave surface to allow a more stable fit on the distal pole of the scaphoid.

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Despite the rapid development of a fibrous capsule around the implant, instability was problematic. A distally based slip of FCR tendon thus was used to reinforce the volar capsule. Eaton’s58 prosthesis had a perforation in it that allowed passage of the FCR through the implant; the tendon then was fixed to the trapezoid. Another modification was a conical stem, which allowed axial rotation. Poppen and Niebauer’s59 Dacron-reinforced silicone tie-in trapezium implant (Sutter Biomedical Inc., San Diego, CA) allowed tissue in-growth into the first metacarpal. Swanson et al57 reviewed 150 thumbs in 121 patients treated with their implant. At an average follow-up evaluation of 42 months, excellent functional results were seen in 147 of 150 patients. All patients had improved pinch and grip strengths; these increased 250% and 267%, respectively. The ability to perform activities of daily living was improved in 78% of patients. Radial abduction and opposition increased 38% from the preoperative status. Subluxation, defined as translation of one third or more of the implant, occurred in 14.5% of the patients. Six percent of the prostheses dislocated. Bone resorption was seen in 2 patients. The reoperation rate was 3.3%. Eaton reviewed 50 prostheses in 46 patients. Follow-up evaluation ranged from 14 to 40 months. All patients experienced pain relief, and 88% were completely pain free. All but one patient was improved functionally. Strength reached a maximum at 6 to 12 months. Near-normal carpometacarpal motion occurred in 82% of patients. Four of the 50 prostheses subluxated and 6 dislocated.58 Pellegrini and Burton60 reviewed 32 silicone arthroplasties with an average of 3.9 years of follow-up evaluation. The subluxation rate was 35%. Ligament reconstruction did reduce implant instability, yet it increased silicone wear and cold flow. Sotereanous et al61 showed an 83% subluxation rate in his series on the Niebauer prosthesis. Subluxated prostheses were not painful, but the dislocated ones were. The incidence of subluxation was shown to increase over time. Silicone synovitis is an intense inflammatory response that occurs secondary to microparticles (ⱕ15 ␮m) from silicone elastomer prostheses. The proliferative synovitis invades and destroys bone and cartilage and is seen as osteolysis and erosions adjacent to the implant. This typically presents more than 2 years after surgery and is characterized by pain, swelling,

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and lytic lesions on radiographs.56 The patients’ subjective symptoms do not correlate with the degree of scaphoid or metacarpal changes on radiographs.62 Rest, splinting, and steroid injection offer transient relief. Salvage requires implant removal and curettage of cysts. Synovitis is the complication that is responsible for the reduction in enthusiasm over silicone arthroplasty.

THE METACARPOPHALANGEAL JOINT s the thumb MP joint degenerates and the metacarpal base subluxes dorsally, the thumb metacarpal assumes an adducted position and the first web space narrows. Because the first web does not expand adequately to allow grasping of large objects, a compensatory metacarpophalangeal hyperextension must occur. With time, the volar plate and capsule will become attenuated, and the laxity will persist even if the carpometacarpal pathology is treated. With persistent MP hyperextension, the metacarpal head will continue to experience an adduction moment. This produces a dorsal subluxation force on the metacarpal base. When silicone implants were performed frequently, there was concern that this force would result in shearing of the implant and possible dislocation. This force also may result in attenuation of a ligament reconstruction procedure. Because it is not universally accepted that a ligament reconstruction is necessary, and because silicone implants have fallen out of favor, these arguments may not be adequate to recommend a simultaneous procedure on the MP joint. More importantly, it is felt that pinch and grip strength will be affected adversely if the hyperextension deformity is not corrected. Force will be dissipated at the metacarpal head instead of being transferred to the thumb tip. The flexor pollicis longus will produce exaggerated interphalangeal joint flexion as it attempts to limit metacarpophalangeal hyperextension.47 If the MP joint is stabilized, force of pinch and grip will be transmitted more efficiently to the thumb tip, and strength will be optimized. This can be accomplished by pinning the MP joint in flexion, transferring the extensor pollicis brevis to the base of the metacarpal, advancing the abductor pollicis distally on the metacarpal, volar plate capsulodesis, thumb MP sesamoidesis, or thumb MP arthrodesis. Metacarpophalangeal capsulodesis is recommended for hyperextension deformity greater than 30°.47 An

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incision is made over the radial aspect of the metacarpophalangeal joint. The abductor aponeurosis is incised and retracted dorsally. The interval between the radial collateral ligament and the volar plate is split. The distal metacarpal cortex is debrided to bleeding bone. A nonabsorbable 3-0 braided suture is placed in grasping fashion into the proximal volar plate. The free ends are passed dorsally through the metacarpal. Traction is then applied to the sutures and they are tied dorsally with the MP joint in flexion. The joint then is pinned in 30° to 40° of flexion and maintained for 4 weeks with the addition of a thumb spica splint. Eaton reported on 13 patients who underwent MP capsulodesis at the time of basal joint surgery.47 The follow-up period averaged 39 months. The average preoperative hyperextension was 46°. All but 3 patients had full correction of their preoperative hyperextension. One patient exhibited 20° postoperative hyperextension, and 2 patients had 10° hyperextension. The mean postoperative flexion arc was 38°, representative of a 38% loss of preoperative motion. One patient in the series had 80° of preoperative hyperextension, and this was corrected completely. Eaton, thus, felt that this procedure could be used effectively with severe deformity. For hyperextension deformities less than 30°, he simply recommended pinning the joint in 30° flexion for 4 weeks.45 Arthrodesis is an alternative procedure for MP hyperextension greater than 30°. Tomaino et al34 recommended fusing the MP joint in 10° of flexion. Eaton and Floyd,47 however, suggested that compensatory flexion occurs at the basal joint and may destabilize the ligament reconstruction.

CONCLUSION humb carpometacarpal arthrosis is a common debilitating condition seen mostly in postmenopausal women. It often coexists with other pathologic conditions such as scaphotrapezial arthrosis, carpal tunnel syndrome, or DeQuervain’s tenosynovitis. It will be evident radiographically, in one third of postmenopausal women, but two thirds of these patients will be asymptomatic. Thumb spica splinting is the cornerstone of conservative management. Regardless of the length of symptoms or the arthritic stage, the majority of discomfort will be relieved in the majority of patients. Most patients prefer a short opponens splint because

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of its less restrictive nature. If associated pathology is present, a longer splint may be more beneficial. A variety of surgical options are available for the patients who have failed conservative measures. For early disease, beak ligament reconstruction is the time-honored procedure. Metacarpal base osteotomy is a reasonable alternative in select patients. For the obviously arthritic joint, more surgical decision making is required. Although there are theoretical advantages to reconstructing the palmar beak ligament or adding in-

terposition material in the form of an anchovy, various series have shown excellent results when either one or both of these options are not performed. It appears that the most important aspect of surgical intervention is the removal of the arthritic surfaces. Addressing additional pathology and stabilizing the MP joint when it is lax will optimize results. Fortunately, for those who are symptomatic from basal joint disease, both conservative and surgical interventions yield high success rates.

REFERENCES 1. Weiss S, LaStayo P, Mills A, Bramlet D. Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment. J Hand Ther 2000; 13:218-226. 2. Strauch RJ, Rosenwasser MP. Thumb carpometacarpal joint. In: Weiss APC, Hastings H, eds. Surgery of the arthritic hand and wrist. Philadelphia, PA: Lippincott Williams & Wilkins, 2002:106-110. 3. Armstrong AL, Hunter JB, Davis TRC. The prevalence of degenerative arthritis of the base of the thumb in postmenopausal women. J Hand Surg 1994;19B:340-341. 4. Xu L, Strauch RJ, Ateshian GA, Pawluk RJ, Mow VC, Rosenwasser MP. Topography of the osteoarthritic thumb carpometacarpal joint and its variations with regard to gender, age, and osteoarthritic stage. J Hand Surg 1998;23A: 454-464. 5. Florack TM, Miller RJ, Pellegrini VD, Burton RI, Dunn MG. The prevalence of carpal tunnel syndrome in patients with basal joint arthritis of the thumb. J Hand Surg 1992; 17A:624-630. 6. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg 1973; 55A:1655-1666. 7. Varitimidis SE, Fox RJ, King JA, Taras J, Sotereanos DG. Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon. Clin Orthop 2000;370:164-170. 8. Vandenbroucke J, De Schriver F, DeSmet L, Fabry G. Simple trapezectomy for treatment of trapeziometacarpal osteoarthritis of the thumb. Clin Rheum 1997;16:239-242. 9. Melone CP, Beavers B, Isani A. The basal joint pain syndrome. Clin Orthop 1987;220:58-67. 10. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rationale for treatment. Hand Clin 1987;3:455469. 11. North ER, Eaton RG. Degenerative arthritis of the trapezium: a comparative roentgenologic and anatomic study. J Hand Surg 1983;8:160-166. 12. Cooke KS, Singson RD, Glickel SZ, Eaton RG. Degenerative changes of the trapeziometacarpal joint: radiologic assessment. Skeletal Radiol 1995;24:523-527. 13. Hollister AM, Giurintano D. How joints move. In: Brand PA, Hollister AM, eds. Clinical mechanics of the hand. 3rd ed. St. Louis, MO: Mosby, 1999:34-60. 14. Pellegrini VD. Osteoarthritis of the trapeziometacarpal joint: the pathophysiology of articular cartilage degeneration. I.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24. 25.

26.

27.

28.

Anatomy and pathology of the aging joint. J Hand Surg 1991;16A:967-974. Imaeda T, An K, Cooney WP, Linscheid RL. Anatomy of the trapeziometacarpal ligaments. J Hand Surg 1993;18A:226231. Doerschuk SH, Hicks DG, Chinchilli VM, Pellegrini VD. Histopathology of the palmar beak ligament in trapeziometacarpal osteoarthritis. J Hand Surg 1999;24A:496-504. Bettinger PC, Smutz P, Linscheid RL, Cooney WP, An K. Material properties of the trapezial and trapeziometacarpal ligaments. J Hand Surg 2000;25A:1085-1095. Pellegrini VD, Parentis M, Judkins A, Olmstead J, Olcott C. Extension metacarpal osteotomy in the treatment of trapeziometacarpal osteoarthritis: a biomechanical study. J Hand Surg 1996;21A:16-23. Cooney WP, Chao EYS. Biomechanical analysis of static forces in the thumb during hand function. J Bone Joint Surg 1977;59A:27-36. Pellegrini VD. Osteoarthritis of the trapeziometacarpal joint: the pathophysiology of articular cartilage degeneration. II. Articular wear patterns in the osteoarthritic joint. J Hand Surg 1991;16A:975-982. Athesian GA, Rosenwasser MP, Mow VC. Curvature characteristics and congruence of the thumb carpometacarpal joint: differences between female and male joints. J Biomechanics 1992;25:591-607. Tomaino M. Treatment of Eaton stage I trapeziometacarpal disease with thumb metacarpal extension osteotomy. J Hand Surg 2000;25A:1100-1106. Weinzweig J, Watson HK. Examination of the wrist. In: Watson HK, Weinzweig J, eds. The Wrist. Philadelphia, PA: Lippincott Williams and Wilkins, 2001:47-59. Burton RI. Complications following surgery on the basal joint of the thumb. Hand Clin 1986;2:265-269. Pellegrini VD. The basal articulations of the thumb: pain, instability, and osteoarthritis, In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGrawHill, 1996:1019-1042. Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometacarpal joint: a long term assessment. J Hand Surg 1984;9A:692-699. Swigart CR, Eaton RG, Glickel SZ, Johnson C. Splinting in the treatment of arthritis of the first carpometacarpal joint. J Hand Surg 1999;24A:86-91. Gervis WH. Excision of the trapezium for osteoarthritis of

THUMB CARPOMETACARPAL ARTHROSIS 䡠 YOUNG & MIKOLA

29. 30. 31. 32.

33.

34.

35. 36. 37. 38.

39. 40. 41.

42.

43.

44.

the trapezio-metacarpal joint. J Bone Joint Surg 1949;31B: 537-539. Murley AHG. Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint. J Bone Joint Surg 1960;42B: 502-507. Dhar S, Gray ICM, Jones WA, Beddow FH. Simple excision of the trapezium for osteoarthritis of the carpometacarpal joint of the thumb. J Hand Surg 1994;19B:485-488. Horlock N, Belcher HJCR. Early versus late mobilization after simple excision of the trapezium. J Bone Joint Surg 2002;84B:1111-1115. Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective, single-surgeon study including outcome measures. J Hand Surg 2003;28A:381-389. Yang SS, Weiland AJ. First metacarpal subsidence during pinch after ligament reconstruction and tendon interposition basal joint arthroplasty of the thumb. J Hand Surg 1998; 23A:879-883. Tomaino MM, Pellegrini VD, Burton RI. Arthroplasty of the basal joint of the thumb: long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg 1995;77A:346-355. Downing ND, Davis TRC. Trapezial space height after trapeziectomy: mechanism of formation and benefits. J Hand Surg 2001;26A:862-868. Burton RI. The arthritic hand. In: Evarts CM, ed. Surgery of the muscoskeletal system. New York, NY: Churchill Livingstone, 1983;670-681. Froimsom A. Tendon arthroplasty of the trapeziometacarpal joint. Clin Orthop 1970;70:191-199. Burton RI, Pellegrini VD. Surgical management of basal joint arthritis of the thumb. Part II: Ligament reconstruction with tendon interposition arthroplasty. J Hand Surg 1986; 11A:324-332. Tomaino MM. Ligament reconstruction tendon interposition arthroplasty for basal joint arthritis: rationale, current technique, and clinical outcome. Hand Clin 2001;17:207-221. Glickel SZ, Kornstein AN, Eaton RG. Long-term follow-up of trapeziometacarpal arthroplasty with coexisting scaphotrapezial disease. J Hand Surg 1992;17A:612-620. Tomaino MM, Coleman K. Use of the entire width of the flexor carpi radialis tendon for the ligament reconstruction tendon interposition arthroplasty does not impair wrist function. Am J Orthop 2000;29:283-284. Tomaino M, Vogt M, Weiser R. Scaphotrapezoid arthritis: prevalence in thumbs undergoing trapezium excision arthroplasty and efficacy of proximal trapezoid excision. J Hand Surg 1999;24A:1220-1224. Lins RE, Gelberman RH, McKeown L, Katz JN, Kadiyala RK. Basal joint arthritis: trapeziectomy with ligament reconstruction and tendon interposition arthroplasty. J Hand Surg 1996;21A:202-209. Thompson JS. Complications and salvage of trapeziometacarpal arthroplasties. In Programs and Abstracts of the American

45. 46. 47.

48. 49.

50. 51. 52. 53. 54.

55. 56. 57. 58. 59. 60.

61. 62.

93

Association of Orthopaedic Surgery. Instr Course Lect 1989; 38:3-13. Diao E. Trapeziometacarpal arthritis; trapezium excision and ligament reconstruction not including the LRTI arthroplasty. Hand Clin 2001;17:223-236. Strauch RJ. Trapezial resection with suspension arthroplasty. Presented at: The American Society for Surgery of the Hand 57th Annual Meeting; October 3, 2002; Phoenix, AZ. Eaton RG, Floyd WE. Thumb metacarpophalangeal capsulodesis: an adjunct procedure to basal joint arthroplasty for collapse deformity of the first ray. J Hand Surg 1988;13A: 461-465. Klimo GF, Verma RB, Baratz ME. The treatment of trapeziometacarpal arthritis with arthrodesis. Hand Clin 2001;17: 261-270. Hartigan BJ, Stern PJ, Kiefhaber TR. Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition. J Bone Joint Surg 2001; 83A:1470-1478. Clough DA, Crouch CC, Bennett JB. Failure of trapeziometacarpal arthrodesis with use of the Herbert screw and limited immobilization. J Hand Surg 1990;15A:706-711. Caputo RJ, Bennett JB. Power staple fixation in trapeziometacarpal arthrodesis. J Hand Surg 1993;18A:926-929. Chamay A, Piaget-Morerod F. Arthrodesis of the trapeziometacarpal joint. J Hand Surg 1994;19B:489-497. Bamberger HB, Stern PJ, Kiefhaber TR, McDonough JJ, Cantor RM. Trapeziometacarpal joint arthrodesis: a functional evaluation. J Hand Surg 1992;17A:605-611. Mureau MAM, Raemaker RPC, Verhaar JAN, Hovius SER. Tendon interposition arthroplasty versus arthrodesis for the treatment of trapeziometacarpal arthritis: a retrospective comparative follow-up study. J Hand Surg 2001;26A:869876. Swanson AB. Disabling arthritis of the base of the thumb: treatment by resection of the trapezium and flexible (silicone) implant arthroplasty. J Bone Joint Surg 1972;54A:456-471. Peimer CA. Long-term complications of trapeziometacarpal silicone arthroplasty. Clin Orthop 1987;220:86-98. Swanson AB, Swanson GD, Watermeier JJ. Trapezium implant arthroplasty. J Hand Surg 1981;6:125-141. Eaton RG. Replacement of the trapezium for arthritis of the basal articulations. J Bone Joint Surg 1979;61A:76-82. Poppen NK, Niebauer JJ. “Tie-in” trapezium prosthesis: long-term results. J Hand Surg 1978;3:445-450. Pellegrini VD, Burton RI. Surgical management of basal joint arthritis of the thumb. Part I. Long-term results of silicone implant arthroplasty. J Hand Surg 1986;11A:309324. Sotereanous DG, Taras J, Urbaniak JR. Niebauer trapeziometacarpal arthroplasty; a long-term follow-up. J Hand Surg 1993;18A:560-564. Creighton JJ, Steichen JB, Satrickland JW. Long-term evaluation of silastic trapezial arthroplasty in patients with osteoarthritis. J Hand Surg 1991;16A:510-519.