Basal joint arthritis presentation


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Basal joint arthritis presentation

  1. 1. Basal Joint Arthritis
 of the Thumb
 (Trapeziometacarpal Arthritis)
 (Carpometacarpal Arthritis)
  2. 2. Ligamentous Anatomy 16 total ligaments Imaeda, et al, J Hand Surg, 1993 Five main stabilizing ligamentous structures Palmar Beak Ligament (Anterior Oblique Ligament) Dorsoradial Ligament Ulnar Collateral Ligament First Intermetacarpal Ligament Posterior Oblique Ligament
  3. 3. Ligamentous Anatomy Palmar Beak Ligament Dorsoradial Ligament
  4. 4. Epidemiology and Etiology
  5. 5. Epidemiology Most common site of osteoarthritis in the hand Most common site requiring surgery Most common in post-menopausal females 1:4 women will show radiographic degeneration Only ~ 20-30% symptomatic 8% with ST arthritis Only 1:12 men affected
  6. 6. Epidemiology Armstrong, et al, J Hand Surg (Br), 1994 evaluated 143 post-menopausal women 25% had isolated basal thumb osteoarthritis of those with isolated CMC osteoarthritis, 28% complained of thumb pain
  7. 7. Etiology No clear association with employment Repetitive motion suggests higher incidence Carpentry, manual labor Cow Milking (Seoane, 1997) Males with increased grip strength - increased radiographic changes (Chaisson, 2001)
  8. 8. Etiology 1) Trauma - dislocation, fracture 2) Inflammatory diseases - RA, gout 3) Idiopathic Osteoarthritis 4) Hypermobile States Moulton (2001) showed increased joint forces in TM joints with hyperextension laxity at the MCP joint
  9. 9. Etiology 5) TM Instability Acute: severe trauma (complete dislocation) Chronic: can be caused by recurrent stress or overuse more common often seen in young to middle-aged women
  10. 10. Etiology Pellegrini, Orth Clin N Amer, 1992 The palmar beak ligament was essential for translational stability of the MC on the trapezium There was a direct correlation between the status of the articular surfaces and the integrity of the beak ligament
  11. 11. Etiology Pelligrini’s Theory: 1) Attritional changes in palmar beak ligament 2) Detachment of the palmar beak ligament 3) Instability of TM joint 4) Increased dorsopalmar translation 5) Increased shear forces in the palmar contact areas 6) Hyaline cartilage wear and OA
  12. 12. Clinical Evaluation
  13. 13. Clinical Presentation Pain Aggravated by power pinch, grip movements, axial load or flexion/adduction maneuvers Turning jar lids, doorknobs, opening car doors Weakness with pinch Typically secondary to pain Dorsoradial subluxation of the metacarpal base in later stages
  14. 14. Physical Exam Well localized CMC joint tenderness Localized to radial margin of metacarpal base one finger-breadth distal to scaphoid tubercle
  15. 15. Physical Exam ! ! Grind Test Pain with axial compression with rotation
  16. 16. Physical Exam Laxity Test Dorsal-to-volar translation of the metacarpal base will reveal any dorsal subluxation Torque Test Pain with axial rotation and distraction of the thumb metacarpal
  17. 17. Coexisting Conditions DeQuervain’s tenosynovitis CMC arthritis may cause DeQuervain’s Good PE, x-rays, injections help differentiate Carpal Tunnel Syndrome Up to 43% coexists (Florak,1992) Dimensions of carpal tunnel affected by CMC arthritis ST arthritis FCR tendonitis MCP joint instability Requires intervention if severe enough
  18. 18. Radiographic Evaluation PA, lat and oblique views ! 30° oblique stress views Technique Thumbs w/ nail plates parallel to x-ray film Push thumb tips against each other Advantages Good visualization of pan-trapezial joints Helps assess TM joint laxity
  19. 19. Classification
  20. 20. Eaton Stage I Radiographs Pre-arthritic joint Normal articular contours Slight widening of joint space 2° effusion or ligament laxity Clinically Intermittent mild pain with heavy use Mild loss of strength + Grind test
  21. 21. Eaton Stage II Radiographs TM joint slightly narrowed Minimal sclerosis ± osteophytes (<2mm & ulnar) < 1/3 metacarpal base subluxation Clinically Frequent pain with normal activity + Grind test Metacarpal base subluxed radial and dorsal
  22. 22. Eaton Stage III Radiographs Marked narrowing TM joint Osteophytes > 2mm Increased sclerosis, cystic changes subluxation > 1/3 of metacarpal base Clinically Passive reduction of metacarpal base may be impossible Adduction of metacarpal and MCP joint hyperextension
  23. 23. Eaton Stage IV Radiographs Advanced degenerative changes & subluxation ST joint involvement Clinically Decreased mobility of TM joint Patients with relatively less pain
  24. 24. Treatment
  25. 25. Treatment Options Depends on stage of disease as well as degree of the patient’s discomfort ! Conservative: Rest, NSAID’s, steroid injections, splinting with thumb in abduction (Stage I) ! Surgical: Multiple surgical treatment methods (more advanced stages)
  26. 26. Conservative Treatment Swigart, et al, J of Hand Surg, 1999 Evaluated 130 thumbs treated with 6 weeks of splinting Stage I/II: 76% improvement Stage III/IV: 54% improvement Overall… splinting is well-tolerated effective protocol to diminish, but not eliminate the symptoms of basal joint OA
  27. 27. Operative Treatments Metacarpal Osteotomy Ligament reconstruction Arthroplasty Resection arthroplasty - trapeziectomy Prosthetic arthroplasty Ligament reconstruction with tendon interposition Arthrodesis
  28. 28. Prosthetic Arthroplasty Multiple Types: Silicone Metallic Ceramic Zirconia Silicone implant Orthosphere Swanson Implant
  29. 29. Prosthetic Arthroplasty Advantages (theoretical) Immediate stability and no need for long term immobilization Disadvantages Wear, loosening, osteolysis, infection, synovitis (silicone), periprosthetic fracture ! No report exists with results superior to biologic arthroplasty
  30. 30. Ligament Reconstruction and Tendon Interposition 1) Palmar beak ligament reconstruction 2) Tendon interposition arthroplasty using radial ½ of FCR tendon ! Often used for Stage II or Stage III disease
  31. 31. LRTI - Approach & Bone Resection Straight incision is made over dorsoradial aspect of TM joint avoid sensory branch of radial nerve and radial artery Partial or complete trapeziectomy Decision based on status of scaphotrapezial joint Base of metacarpal resected
  32. 32. LRTI -Tendon Harvest FCR tendon graft of 10 -12 cm in length Leading end passed into and through the base of the thumb MC Remaining tendon is folded to act as a spacer
  33. 33. LRTI MCP Joint Hyperextension Must be addressed if > than 30 degrees Volar capsulodesis EPB transfer from the base of the proximal phalanx to the metacarpal shaft Eliminates the EPB hyperextension force at the MCP joint
  34. 34. Postoperative Care Short-arm, thumb spica casting for 4 weeks Active ROM exercises Need for hand therapy depends on individual patient
  35. 35. LRTI Burton and Pellegrini, J Hand Surg, 1986 25 LRTI, average 2 yr f/u More consistent improvement in grip, pinch, thumb web space than silicone arthroplasty Excellent results in 23 of 25
  36. 36. Arthrodesis Often used in young laborers Post-traumatic Orient by “fist position”
  37. 37. Surgical Complications Approach related Injury to radial artery or dorsal sensory branch of the radial nerve Implant related Silicone synovitis, implant subluxation, carpal erosion Failure of ligament reconstruction Loss of pinch strength Proximal migration of the metacarpal
  38. 38. Cost Analysis Conservative Management Costs NSAID - Celebrex 200mg #60 = $250 Celestone Injection = $175 Custom OT splint = $200
  39. 39. Cost Analysis Surgical Costs Metacarpal Osteotomy = $2150 LRTI = $5665 Arthroplasty = $7260