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Multiple procedures available to treat carpometacarpal joint osteoarthritis

In this virtual round table, participants discuss their surgical preferences, indications and results.

Issue: January 2005

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Osteoarthritis of the hand is a common disorder. Although the distal interphalangeal joint is most commonly involved, the basilar joint of the thumb — the carpometacarpal joint — is the most common joint in the hand to require surgery as a result of osteoarthritis.

Multiple operative procedures are available and surgeons continue to search for the best approach. For this discussion, I have asked several surgeons to express their preferences, indications and results. In this time of excellent results from minimally invasive surgery, I have also asked the participants to comment on whether there is a place for minimally invasive techniques for treatment of the arthritic CMC joint.

The thumb carpometacarpal joint has four articulations: the trapeziometacarpal joint, the trapezial 2nd metacarpal joint, the trapezio-trapezoid joint and the scaphotrapezial joint. One or all of these articulations can be affected by arthritis.

To date, surgeons have often not been selective about their surgical treatment; resection of the whole trapezium usually has been the operative choice. However, is there a benefit in just treating TM disease if the ST joint is spared?

The collapsed thumb or Z deformity (first metacarpal adduction and MCP hyperextension) is a problem never adequately addressed. I have asked the panelists to comment on their treatment of choice for this deformity.

Barry P. Simmons, MD
Moderator

Barry P. Simmons, MD: Dr. Meals, why do you prefer hematoma and distraction arthroplasty for treatment of osteoarthritis of the thumb CMC joint?

Roy A. Meals, MD: From a strictly mechanistic viewpoint, it is unsettling to remove the trapezium and not replace it with something or to leave the body to its own devices to reform a functional beak ligament.

We know, however, from many observations in all anatomical regions, that the body has remarkable capacities to heal itself, sometimes to a surgeon’s surprise, even without surgical intervention. Hence, my general philosophy is to nudge the body toward correction but also to let biology do the heavy lifting when possible.

Now a quarter century in practice, I have seen patients who have had every conceivable procedure performed for CMC osteoarthritis. On a gut level, I knew that the hematoma and distraction arthroplasty (HDA) gave at least comparable results to the more complicated procedures. Drs. Kuhns and Emerson challenged me to prove it, and, in fact, the results from HDA are better than for the more complicated procedures.

The HDA is simple — piecemeal removal of the entire trapezium, slight overdistraction of the thumb metacarpal in an abducted and pronated position, and pinning it there with a Kirschner wire. Surgical time averages 35 minutes. Then the hematoma and fibroplasia go to work.

After the cast comes off and the Kirschner wire comes out at five to six weeks, a majority of patients recover full opposition and full adduction into the plane of the palm in several weeks without formal hand therapy. Nearly all patients recover full opposition and adduction, and on average, the strengths at two years increase over preoperative measurements by 47% for grip, 33% for key pinch and 23% for tip pinch.

Although we reported results after two-year follow-up evaluation, I have been performing the procedure for 17 years in the same practice setting, and no patients have returned to complain of late onset symptoms or to request further treatment.

Hematoma and distraction arthroplasty is simple and quick. It does not scar the forearm. It leaves no synthetic implant to risk subluxation or foreign body reaction. The results are better than those published for the ligament replacement tendon interposition procedure. The correction is also durable.

Simmons: Do you alter your treatment if there is isolated trapeziometacarpal disease as opposed to pantrapezial disease?

Meals: No.

Simmons: Dr. Adams, why do you prefer implant arthroplasty for treatment of osteoarthritis of the thumb CMC joint?

Brian D. Adams, MD: First, in my opinion implant arthroplasty is indicated for only a select group of patients with osteoarthritis. It is an attractive and acceptable option because, in my experience and those of many others, an implant provides better initial pain relief and quicker rehabilitation than techniques involving excision with soft tissue interposition.

This seems to be true regardless of the material or the design of the implant, and it is why silicone implants remain popular with some surgeons throughout the world despite problems with silicone breakage and the potential for particulate synovitis. The combined effects of removing the arthritic surfaces and supporting the metacarpal by a biologically inert material is likely the reason for better early pain relief.

Also, by restoring or preventing collapse of the ray, implants give the thumb a more natural resting posture and greater potential for thumb motion. Finally, an implant seems to enhance thumb strength, at least for the first several months.

Unfortunately, CMC implants have been hampered by instability, breakage and subsidence. Most surgeons probably use an implant only for certain patients with rheumatoid arthritis, and in these cases it would likely be a traditional silicone design. I would also consider a nonsilicone implant in moderately active patients with osteoarthritis who have good bone stock and minimal deformity of the entire thumb ray including stable CMC and MP joints.

These patients are the ones with the greatest potential to benefit from an implant in terms of quicker recovery, strength, motion and cosmesis, and they have the least risk of instability and subsidence.

However, there is no question that proper counseling with an understanding of the risks associated with an implant is mandatory. Fortunately, nearly all implant designs allow for a straightforward conversion to a soft tissue interposition.

Simmons: Do you alter your treatment if there is isolated trapeziometacarpal disease as opposed to pantrapezial disease?

Adams: Most, if not all, nonsilicone implant designs are contraindicated if there is pantrapezial disease because the trapezium has to be retained to either support or fix the implant. Therefore there is fear that the remaining arthritis will be a source of persistent symptoms.

There are more choices for silicone implants, including total trapezium replacement. In fact, surgeons who use silicone implants usually prefer trapezium implants for all of their patients with CMC disease so they don’t have to worry about unrecognized arthritis or further progression of arthritis. In my practice, I would not use an implant for osteoarthritis if there was radiographic evidence of pantrapezial disease, but then again I do not use silicone implants for osteoarthritis.

Simmons: Dr. Stern, why do you prefer arthrodesis for treatment of osteoarthritis of the CMC joint?

Peter J. Stern, MD: Most of my colleagues agree that thumb trapeziometacarpal arthrodesis is the treatment of choice for symptomatic post-traumatic arthritis at the base of the thumb following an untreated Bennett or Rolando fracture, particularly in a young active individual. Controversy, however, exists when arthrodesis is used to treat symptomatic basal joint osteoarthritis in older patients. In this circumstance, most hand surgeons prefer trapezial excision with or without tendon interposition and ligament reconstruction.

A number of years ago, I decided to treat selected patients with an active lifestyle or laborers with symptomatic basal osteoarthritis by arthrodesis rather than arthroplasty. Patients with pantrapezial arthritis were not considered. My rationale was to preserve the height of the thumb osteoarticular column (prevent subsidence of the thumb metacarpal) and maintain basal joint stability.

Recently, we published our results of trapeziometacarpal arthrodesis compared to LRTI in patients younger than 60 with basal osteoarthritis. We found that the two procedures had similar results with regard to pain, function and satisfaction despite minimal differences in strength and motion. Although complications were more frequent following arthrodesis, most did not affect the overall outcome.

Simmons: Do you alter your treatment if there is isolated trapeziometacarpal disease as opposed to pantrapezial disease?

Stern: Yes. For patients with pantrapezial disease, I excise the trapezium and use the entire flexor carpi radialis for combined interposition and suspension.

Simmons: Dr. Blazar, why have you undertaken arthroscopic/minimally invasive surgery for osteoarthritis of the thumb? What are the results?

Philip E. Blazar, MD: Surgical treatment for arthritic thumb CMC joints is predictably successful. The vast majority of patients treated in multiple series in the literature with seemingly widely disparate techniques (hemitrapeziectomy, trapeziectomy, tendon interposition, ligament reconstruction, arthrodesis, hematoma/distraction arthroplasty) have very successful results.

However, the literature also supports that rehabilitation/recovery is lengthy for many procedures. Patients report improving strength and pain relief for greater than 12 months, and the time period of immobilization is not insignificant.

We have begun treating a select group of patients with basal joint arthritis with arthroscopic/mini open hemitrapeziectomy and tendon interposition in an effort to achieve surgical results comparable to other published techniques, reduce the time period of immobilization, and reduce the time period until patients report relief of their symptoms and return of function.

In addition, arthroscopy of the basal joint has been used to assess the status of the articular cartilage and capsular ligaments in patients with symptoms refractory to conservative measures but with radiographs that show very early or limited disease.

Our results are very preliminary, but with shorter periods of immobilization we have seen very good pain relief and rapid recovery of grip strength. No complications have been seen that are not reported with LRTI type procedures.

Simmons: Do you alter your treatment if there is isolated trapeziometacarpal disease as opposed to pantrapezial disease?

Blazar: Yes. I have considered pantrapezial disease a contraindication to arthroscopic or mini open management. In general, if these patients fail conservative treatment, they are treated with trapeziectomy. Our most commonly selected approach has been to perform an LRTI, with slight modifications in the ligament reconstruction from the original description by Dr. Burton. We also continue to use tendon interposition without ligament reconstruction in some patients. I continue to perform LRTI in younger, working, higher demand patients because of concerns about proximal migration and strength, although in my mind the literature is unclear if there is a significant difference in strength between these two techniques.

In addition, we routinely assess the scaphotrapezoid joint for degenerative changes and perform hemiresection of the trapezoid if the joint is very arthritic.

Simmons: Dr. Stern, what is your suggested solution for the Z thumb deformity?

Stern: Patients with a Z deformity have flexion-adduction posture of the thumb metacarpal and compensatory hyperextension of the metacarpophalangeal (MCP) joint. This is secondary to dorsal-radial subluxation of the base of the thumb metacarpal and is usually seen in advanced trapeziometacarpal arthrosis or in patients with ligamentous laxity (Ehlers Danlos syndrome).

Treatment depends on the severity of the MCP hyperextension and presence of arthrosis at that joint. I nearly always transfer the extensor pollicis brevis to the base of the thumb as it eliminates a deforming force on the MCP joint and augments thumb metacarpal radial abduction.

If there is symptomatic osteoarthritis at the MCP joint, I perform an arthrodesis. If there is less than 20° of hyperextension (no arthrosis), I temporarily pin the MCP joint in flexion for four weeks. If there is 20° to 40° of hyperextension (no arthrosis), I will do a MCP volar plate capsulodesis. If there is more than 40° hyperextension with or without arthrosis, I perform an arthrodesis of the MCP joint.

Simmons: Dr. Meals, what is your solution?

Meals: When the metacarpophalangeal joint hyperextends at least 30º, I will stabilize it with a volar plate arthroplasty, lifting the proximal edge of the volar plate from the metacarpal neck and advancing it proximally and securing it there.

For less extensive hyperextension, I will fix the metacarpophalangeal joint in mild flexion with a Kirschner wire for the five to six weeks that the metacarpal base is also pinned.

Simmons: Dr. Adams, what is your suggestion for the Z thumb deformity?

Adams: If an osteoarthritic thumb has a severe Z deformity, I believe an implant arthroplasty is nearly always contraindicated. The best chance to correct this deformity is to “decompress” the thumb ray. In other words, to improve the CMC flexion and adduction contractures and the MP hyperextension, the first ray must be shortened somewhere near its base.

I prefer a complete trapezium excision with soft tissue interposition and stabilization. This allows the metacarpal to migrate somewhat proximally, which reduces the forces contributing to the deformity. The preop MP joint hyperextension is usually relieved enough so the joint will rest in neutral.

Only in cases with combined severe MP hyperextension and lateral instability do I pin the joint temporarily. I almost never fuse the MP joint in osteoarthritis because I have found this substantially reduces thumb function. Patients with a Z deformity usually don’t regain good CMC motion, and they typically have some residual flexion contracture or extensor lag of the new CMC joint. The hypermobile MP joint increases the reach of the thumb tip, which I believe is more important than MP stability for overall function of the thumb and dexterity.

Simmons: Dr. Blazar, what do you recommend for the Z thumb deformity?

Blazar: I have based treatment of Z deformity on the degree of deformity (MCP hyperextension) and the underlying diagnosis. Patients with milder (<15º) hyperextension deformity, I have not addressed further than immobilizing the MCP in slight flexion at the time of CMC joint surgery. When the deformity is moderate (15º to 30º), our preference has been to address the deformity of the MCP at the same setting as the CMC disease.

I have used both closed pinning of the joint in slight flexion and volar plate advancement and have not been fully satisfied with either. Recurrence of MCP hyperextension has occurred in some patients, although typically it has not led to further surgical treatment. I have not routinely used EPB tenodesis or sesamoid arthrodesis but because of the tendency for capsular imbrication to “stretch out,” I am currently considering modifying our protocol to include these techniques.

I treat patients with MCP deformity that is severe (>40º) at the same setting, and our preferred treatment has been arthrodesis because of concerns with recurrent deformity early on after MCP capsulorraphy. In addition, I have tended to treat patients with arthritic changes on preop radiographs and/or disease processes where soft tissue procedures are less likely to be successful (eg, SLE) with arthrodesis of the MCP joint.

Simmons: I’d like to thank all of the panelists for contributions. I believe this covers the options available for treatment of carpometacarpal arthritis. As the reader can see, our panelists use a spectrum of surgical options that clearly yield good results. Hopefully, prospective well-designed studies will answer many of the questions that have been raised and allow a more uniform approach to this common, interesting disorder.

For more information:

• Hartigan BJ, Stern PJ, Kiefhaber TR. Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition. J Bone Joint Surg Am. 2001;83-A:1470-8.
• Kuhns C, Emerson E, Meals R. Hematoma and distraction arthroplasty for thumb basal joint arthritis: a prospective, single-surgeon study including outcomes measures. J Hand Surg. 2003;28A:381-389.
• Tomaino MM, Pellegrini VD Jr., Burton RI. Arthroplasty of the basal joint of the thumb: long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am. 1995;77:346-55.