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Basal joint arthritis: diagnosis and treatment.

Basal joint arthritis is a disabling condition that affects hand function. For the elderly, this arthritic condition may prevent or impair the performance of many activities of daily living. Basal joint arthritis is the most frequently surgically treated arthritic condition of the upper extremity. After the distal interphalangeal (IP) joints, the basal joint is the second most frequent location within the wrist and hand to be affected by osteoarthritis. The incidence of basal joint arthritis has varied in the literature, with one study reporting a prevalence of one in four females and one in twelve males. (1) In another study, baseline right wrist radiographs of 751 patients demonstrated the radiographic incidence of basal joint arthritis to be 42% in females and 26% in males. The average age of patients in the study was 55 years. (2)

Anatomy

The thumb is unique in that it is approximately 80[degrees] pronated relative to the plane of the hand. The trapeziometacarpal (TM) joint allows for arcs of motion in three anatomic planes: flexion-extension, abduction-adduction, and opposition. The trapezium, itself, has four articulations. The first two articulations, which are involved in longitudinal compression, consist of the TM and scaphotrapezial (ST) joints. The remaining two articulations are the trapezio-trapezoid (TT) and the trapezium-index metacarpal (radial facet) joint.

The TM joint is a biconcavoconvex articulation that has been likened to two "saddle-like" joints flipped 180[degrees] and rotated 90[degrees] upon each other. This unusual anatomy of the TM joint allows for its unique function. The TM joint has limited bony constraints and is, therefore, dependent on soft-tissue restraints for static stability. The trapezium also lacks a fixed axial base of support (the mobile scaphoid), which further contributes to its inherent instability. The articular surfaces have different radii of curvature, with the diameter at the base of the first metacarpal being 34% larger than the trapezium. (3) These unique features result in a relatively incongruous joint (except at the extremes of motion) with extraordinary mobility and very large contact stresses. (4)

During a lateral pinch, joint compressive forces can be up to 12-times those at the tip of the thumb. (5) In general, females appear to have smaller, less congruent TM joints, thus leading to higher contact stresses. (6) This may account for the increased incidence of basal joint arthritis in females.

Due to the large forces across the TM joint and the limited bony congruity, the basal joint relies on strong ligamentous support. Its primary stabilizer is the anterior oblique ligament (AOL), also termed the beak ligament, volar oblique ligament, volar carpometacarpal ligament, and the deep ulnar ligament. (7-12) The AOL is composed of a superficial (sAOL) and a deep (dAOL) portion. The dAOL is consistent with the beak ligament. There is an intra-articular origin at the beak of the first metacarpal that inserts on the trapezium, just ulnar to the trapezial ridge. It is shorter than its superficial portion and, therefore, becomes taut much sooner. The dAOL is also the pivot point for pronation and opposition. The sAOL is curtain-like and located just deep to the thenar muscles. The origin of the sAOL is the volar tubercle of the trapezium, with insertion to the metacarpal base, approximately 2 mm distal to the articular surface. The sAOL is a lax and redundant ligament that plays a role in limiting volar subluxation.

Secondary stabilizers of the TM joint include the first intermetacarpal (IM) ligament, the ulnar collateral ligament (UCL), the posterior oblique ligament (POL), and the dorsoradial ligament (DRL). Initially, it was felt that the DRL was not a significant stabilizer of the TM joint. (10) The DRL is the widest and thickest ligament to cross the TM joint. (13) It is also the shortest ligament spanning the joint and, therefore, limits dorsal subluxation in all thumb positions. In total, there are 16 ligaments that assist in stabilizing the trapezium and TM joint (Table 1).

Pathoanatomy

The unique anatomy of the basal joint results in a characteristic pattern of degenerative changes. The dorsoradial facet was thought to be the first area of the TM joint to undergo wear. (8) It was postulated that this area was under direct compressive forces when the thumb was in palmar abduction and extension, due to the close proximity of the abductor pollicis longus (APL) tendon's insertion on the base of the first metacarpal. More recent investigations have proven that it is the palmar area that is affected initially. Pellegrini simulated lateral pinch with a cadaveric model and confirmed the palmar joint surface was subject to increased contact pressures during this maneuver. (14) In several other studies, he and colleagues reconfirmed the palmar area to be the first involved. (15,16) Degeneration of the palmar lip cartilage was always associated with attritional detachment of the beak ligament.

Several steps appear to lead to the development of TM joint osteoarthritis. Repetitive loading of the thumb with or without excessive laxity leads to synovitis of the TM joint. Attritional detachment of the dAOL begins with excessive thumb use. The palmar contact area becomes subject to shear forces, and ultimately, degenerative changes occur. This leads to joint space narrowing and the formation of secondary osteophytes in response to altered stress patterns. Eventually, the metacarpal base begins to sublux in a dorsoradial direction due to the beak ligament detachment and the pull of the APL. Since the first metacarpal is dynamically tethered by the adductor pollicis, with continued dorsoradial subluxation of the TM joint, the thumb assumes an adducted posture. This eventually leads to difficulties with activities such as turning doorknobs and opening jars. In the elderly, it may lead to the inability to perform many activities of daily living. In response to the adducted posture, the thumb ray tries to compensate with metacarpophalangeal (MP) hyperextension. This is usually due to repetitive stretching of the volar plate, leading to attenuation. Additional damage to the UCL of the MP joint can be seen in the end stage of this disease. Ultimately, the patient is left with a narrowed functional hand width. (17)

Clinical Presentation

The typical clinical presentation with basal joint disease is a female between the years of 50 and 70 with complaints of pain on the radial side of the thumb or hand. Pain has an insidious atraumatic onset, often over a period of months to years. The patient may complain of pain during such activities as turning doorknobs, opening jars, and playing the piano. In the elderly, the pain may prevent patients from performing activities of daily living. The pain may be improved with rest, splinting, activity modification, or the use of nonsteroidal medication.

Alternatively, the patient may be a young woman in her twenties to thirties who is complaining of cramping in the first web space performing activities such as writing. These patients often have generalized ligamentous laxity upon presentation. In addition, these findings may present as late sequelae of a previous traumatic episode, such as a prior Bennett fracture or a simple dislocation.

Upon inspection, a dorsoradial prominence may be seen at the base of the thumb, known as the "shoulder sign." There may be an adduction contracture of the thumb and thenar atrophy. Palpation of each of the involved articulations is extremely important. The TM joint should be palpated just dorsal and volar to the first dorsal compartment, so as to rule out or discern a coexisting de Quervain's tenosynovitis. The ST joint can be palpated approximately 1 cm proximal to the TM joint. It is important to evaluate both the TM and ST joints for tenderness; degeneration of both these joints signifies stage IV disease. (18)

It is also essential to examine the MP joint. As discussed earlier, hyperextension deformity and UCL damage can be seen in the end stage of this disease. Failure to address the MP joint at the time of surgery may lead to poor results. Examination of the flexor carpi radialis (FCR) tendon should be performed in order to rule out tendonitis, partial tears, and full-thickness tears.

A goniometer should be used to measure both active and passive range of motion of the IP joint, the MP joint, and the basal joint. When present, crepitation should be noted. The TM joint is typically measured using the thumb-index web angle. This is usually done in maximal palmar and radial abduction. Subsequently, these angles are compared to the contralateral side.

Stability testing should be routinely performed when assessing the basal joint. It is important to note that there may be increased laxity in the basal joint due to dAOL attenuation. Conversely there may be what appears to be "increased" stability of this joint due to articular degeneration or the formation of secondary osteophytes. Strength testing should be done in the standard fashion, measuring both grip and pinch strength.

Finally, provocative maneuvers should be performed. The "grind test" is done by rotating the thumb while applying axial compression. (19) A positive result produces pain believed to be secondary to degenerative changes. The "crank test" is similar but combines axial compression with passive flexion and extension. (15) The "distraction test" is performed by rotating the thumb while applying axial traction. This test is more likely to be positive in the earlier stages of disease. The etiology of the source of the pain is thought to be due to inflammation of the joint capsule. (20)

Radiographs

Radiographic evaluation of the basal joint of the thumb should include posteroanterior (PA), lateral, and oblique views. Additional radiographic studies that are helpful include the TM stress view (7) and the Robert's view. (21) The TM stress view is a PA view of both thumbs as the patient forcefully presses the radial aspect of the distal thumb tip against the contralateral thumb tip. This maneuver may elicit subtle instability of the metacarpal. The Robert's view is performed with the hand hyperpronated and the X-ray beam directed from anterior to posterior. This view allows for excellent radiographic visualization of all four trapezial articulations.

Differential Diagnosis

Differential diagnosis of basal joint arthritis includes volar and dorsal ganglia. De Quervain's tenosynovitis must be carefully ruled out, but can exist concomitantly. Trigger digits and carpal tunnel syndrome can be seen concomitantly. One retrospective study examined 246 patients who underwent surgery for basal joint arthritis. (22) Forty-three percent of patients were found to have carpal tunnel syndrome requiring treatment. Wrist synovitis and tendonitis of the FCR can also present with radiovolar wrist pain. Fractures of the distal pole of the scaphoid are also able to cause tenderness near the TM joint. Isolated scaphotrapeziotrapezoid (STT) arthritis can also be confused with basal joint arthritis.

Classification

The most frequently used classification system of basal joint disease was originally described by Eaton and Littler (7) and later modified by various authors. (18,23) In this purely radiographic classification system, stage I disease has a normal articular surface without degenerative changes. The TM joint may be widened due to an effusion. TM joint subluxation must be equal to or less than one-third the width of the base of the first metacarpal. Stage II disease is hallmarked by early degenerative changes. There is mild joint space narrowing and sclerosis present. Osteophytes less than 2 mm may be observed. Subluxation may be greater than one-third the width of the metacarpal base; however, the ST joint is normal. Stage III disease has more advanced degenerative changes, to include significant joint space narrowing and sclerosis. Osteophytes are greater than 2 mm; however, the ST joint does not show radiographic changes. Stage IV disease is similar to stage III (significant joint space narrowing, osteophytes greater than 2 mm), with the addition of ST joint degenerative changes (Fig. 1).

[FIGURE 1 OMITTED]

Burton described a similar staging system with the addition of a stage to indicate involvement of the MP joint. (24) Dell and associates also described a staging system, in 1978, that incorporated both clinical and radiological findings. (25)

Nonoperative Treatment

Nonoperative measures are the primary treatment for basal joint arthritis and include rest, nonsteroidal antiinflammatory medication, steroid injections, and thenar extrinsic and intrinsic muscle strengthening. Rest is achieved by immobilization of the thumb basal joint and can be accomplished by two methods. The traditional splint is the long opponens splint that also immobilizes the wrist. An alternative is the hand-based thumb spica splint that partially immobilizes the wrist. One study examined the effect of splinting on basal joint disease; 76% of patients with Eaton stage I and II disease and 54% of patients with Eaton stage III and IV disease improved with splint immobilization over a six-month period. (26) Patients reported approximately 60% improvement in symptom severity. Typically, patients wear a thumb spica splint continuously for three weeks and then only in the evenings. Some patients may find it easier to alternate between the forearm and thumb-based splints.

Surgical Treatment

The indication for surgical treatment of basal joint disease is persistent pain and functional disability, despite adequate conservative treatment in a compliant patient. For Eaton stage I disease, the most common surgical treatment performed is the volar ligament reconstruction described by Eaton and Littler. (7) This surgical procedure traditionally uses half of the FCR tendon to reconstruct the AOL. The technique is also thought to augment the dorsal ligaments, now understood to be important secondary stabilizers--this is because, as part of the ligament reconstruction, the FCR tendon exits the dorsal aspect of the metacarpal base and is passed around the APL tendon, reinforcing the DRLs. To maximize the success of this procedure, it is important that the surgeon confirm the absence of degenerative changes of the TM joint by arthrotomy and have direct visualization at the time of surgery.

In 1987, Lane and Eaton described the outcome of volar reconstruction in a study that included surgery on 25 thumbs for stage I disease. (27) With an average of 5.2 years follow-up, all patients had a good or excellent result. Eighteen (72%) patients had no pain; seven (28%) patients experienced only rare discomfort with repeated or heavy use. Follow-up radiographs were taken, at minimum, one year postoperatively in 21 (84%) patients. All patients were free of radiographic degenerative changes.

In 2000, Freedman and coworkers reported the long-term result of volar ligament reconstruction. (28) This procedure prevented the development of osteoarthritis in 15 of 23 (65%) thumbs with stage I disease at an average follow-up of 15 years. Fifteen patients were, at minimum, 90% satisfied with their long-term results. Ten of the 15 patients classified as stage I disease at final follow-up were reported to have some pain but were able to return to their preoperative occupation. Pinch and grip strength were greater than on their contralateral side.

Another option for younger patients with stage I or early stage II disease is an extension osteotomy at the metacarpal base. The osteotomy is performed 1 cm distal to the TM joint. Pellegrini and colleagues performed a biomechanical analysis of a 30[degrees] extension osteotomy and found dorsal shift of the contact area, (29) which leads to a relative unloading of the palmar compartment. Recently, Tomiano reported the results of 12 patients who underwent an extension osteotomy for stage I disease, confirmed by arthrotomy. (30) At an average of 2.1 years follow-up, eight patients were very satisfied, three were satisfied, and one was not satisfied with the procedure. All patients were able to return to work. The average time to heal the osteotomy site was 7 weeks (range 6 to 10).

The hallmarks of stage II and III disease are the presence of degenerative changes in the TM joint with the preservation of the ST joint. In 1949, Gervis described simple trapezial excision for the treatment of osteoarthritis of the TM joint. (31) In 1970, Froimson reported the use of rolled-up tendon without ligament reconstruction to act as a spacer after trapezial excision. (32) Seventeen years later, he described a modified procedure to include a partial trapezial excision (stage II and III) in order to improve pinch strength and maintenance of thumb length. (33) However, the most common procedure is the ligament reconstruction and tendon interposition (LRTI) described by Burton and Pellegrini (34) for stage II and above. The principles are three-fold: First, trapeziectomy is performed to remove the painful arthritic surface; next, a ligament reconstruction is done to augment the weakened dAOL and, therefore, prevent axial shortening; and finally, tendon interposition is done to act synergistically with the ligament reconstruction to prevent proximal migration.

In Burton and Pellegrini's approach, the trapezium is excised through a dorsoradial distally-based T-shaped skin incision, and a longitudinal arthrotomy is performed. The degenerated articular surface at the base of the first metacarpal is excised. A bone tunnel is made from the base of the metacarpal through the dorsoradial cortex in the plane of the nail. The FCR tendon is harvested and split (alternatively, the entire tendon may be used) to its insertion on the base of the second metacarpal. A longitudinal K-wire is then placed, stabilizing the metacarpal base, while the thumb is placed in a position simulating a key pinch. Using a tendon passer, the FCR tendon is passed through the gouge hole and is sutured to the periosteum and to itself. This technique creates a sling that will suspend the metacarpal base at the level of the index carpometacarpal joint. The unused portion of the FCR tendon is then folded and sutured into the arthroplasty space. Additionally, the extensor pollicis brevis (EPB) is routinely transferred from the base of the proximal phalanx to the metacarpal base to reduce the hyperextension forces placed on the MP joint.

In 1995, Tomiano and associates reported on 24 thumbs that had undergone LRTI with an average follow-up of 9 years. (35) Ninety-five percent had excellent pain relief. Ninety-two percent were able to oppose to the base of the fifth proximal phalanx. Multiple other studies have also shown favorable results in terms of pain relief, function, and patient satisfaction. (36-38)

Multiple variations to the LRTI have been described. Thompson described the APL suspensionoplasty and was. (39) This procedure is similar to the LRTI, using the most dorsal slip of the APL tendon instead of the FCR tendon. The technique was originally portrayed as a salvage procedure. In addition to the previously described bone tunnel in the base of the first metacarpal, a tunnel is made in the proximal index metacarpal, beginning at the trapezial facet of the index metacarpal and exiting the metacarpal on its dorsal surface. The tendon is passed through both tunnels and then is woven through the substance of the extensor carpi radialis brevis (ECRB) tendon.

Most recently, Diao described his modification of Thompson's procedure. (40) His technique moves the entrance to the second bone tunnel more distally (metaphyseal-diaphyseal junction). This variation was thought to result in a stronger bone tunnel (cortical bone) and a more distally placed "suspension point."

A biomechanical study was done to determine thumb metacarpal base stability after basal joint reconstruction. (41) In this study, the relative migration of the base of the thumb metacarpal in proximal, dorsal, and radial directions was measured after standardized forces were applied through the digital flexor tendons. Three basal joint reconstructive procedures were tested: LRTI, Thomson suspensionoplasty, and Diao suspensionoplasty. The modified suspensionoplasty described by Diao was superior to the other two techniques in terms of stability and resistance to proximal migration. Additional techniques include Barron and Eaton's double interposition arthroplasty (42) as well as King and Eglseder's ECRB Tendinoplasty. (43)

Implants

Many types of implants have also been developed in an attempt to eliminate shortening and maintain the length of the first ray. Silicone implants have been used for many years. (44) Unfortunately, there were several reports of implant fracture, particulate synovitis, and late carpal bone erosions. (45,46) Typically, silicone implants are indicated for very low-demand elderly patients and patients with rheumatoid arthritis. Due to the early reports of complications with silicone implants, Swanson and coworkers developed the titanium convex condylar implant. (47) With this procedure, the authors recommended limiting the metacarpal base cut and careful shaping of the metacarpal canal. Several total joint arthroplasty systems, both cemented and uncemented, are under investigation and currently are considered experimental.

Joint Fusion

TM joint fusion is also a good option for the young patient with stage I, II, or III disease. Careful evaluation of the ST joint is necessary to minimize a poor clinical result. Since joint reactive forces are transmitted to neighboring joints, degenerative changes in the ST joint can be a continued source of pain. The optimal position of fusion is 20[degrees] of radial abduction and 40[degrees] of palmar abduction. Problems associated with successful TM fusions are related to the fixed first-second IM angle. Patients may have difficulty placing their hand through a narrow opening postoperatively.

Recently, arthroscopy has been used for the diagnosis and treatment of basal joint disease. As with the use of arthroscopic procedures in other orthopaedic conditions, its application in basal joint arthritis is thought to minimize morbidity and expedite recovery. For stage I and II disease, arthroscopic evaluation, debridement, and synovectomy can be performed. Hemi-trapeziectomy or complete trapeziectomy can be performed for stage III and IV disease. The technique involves making a 1R portal just radial to the APL tendon and a 1U portal just ulnar to the EPB tendon. Blunt dissection to the capsule is recommended to minimize iatrogenic injury to neighboring structures. A recent short-term study examined 24 thumbs after hemi-trapeziectomy or complete trapeziectomy (stage IV), combined with arthroscopic shrinkage of the beak ligament in more advanced cases. (48) Eighty-eight percent of patients had an excellent or good outcome with a follow-up of 1.2 to 4 years. Interestingly, eight patients preferred the arthroscopic procedure when compared to the traditional open procedure that was done on the contralateral side.

Metacarpophalangeal Joint

In advanced cases of basal joint disease, there is secondary deformity of the MP joint. Careful preoperative evaluation must be done in order to minimize a poor clinical outcome. If left untreated, this may prove to be a continued source of pain. (17,20) Treatment of this joint is based on the degree of hyperextension at presentation. When there is less than 30[degrees] of MP joint hyperextension without associated pain, observation alone may be sufficient. An alternate surgical approach is to place a transarticular K-wire with the joint held in flexion for 4 to 5 weeks. Also, the EPB insertion may be transferred to the metacarpal shaft in an attempt to correct a deforming force. When hyperextension is greater than 30[degrees], arthrodesis or volar capsulodesis may be performed. Eaton (20) reported the results of 13 patients who underwent volar capsulodesis for a hyperextension deformity that was greater than 30[degrees] at the time of basal joint surgery. At an average follow-up of 39 months, nine patients had an excellent result, three had a good result, and one had a poor result. When MP joint degenerative changes or UCL insufficiency is present, fusion of the joint is indicated.

Complications

Complications related to basal joint surgery can be minimized by performing a comprehensive physical examination and radiographic evaluation. Once the extent of local pathology is determined, an appropriate operative technique is selected that will minimize the risk of an unsatisfactory outcome. Complications related to surgery include infection (less than 1%), (33,35) scar hypersensitivity, reflex sympathetic dystrophy, and neuroma. Neuromas may occur from injury to the palmar cutaneous nerve, superficial radial nerve, or lateral antecubital cutaneous nerve branches. Despite attention to surgical detail, there are various reasons persistent pain may develop postoperatively, including an unrecognized coexisting carpal tunnel syndrome, trigger digits, or de Quervain's tenosynovitis. Chronic pain may also occur if a volar ligament reconstruction for more advanced disease or a hemi-trapeziectomy for stage IV disease is performed. However, this is secondary to joint loading through an osteoarthritic joint that has been left behind. Failure to address deformity at the MP joint may also lead to persistent pain and a poor outcome. Scaphometacarpal impingement can also occur due to severe postoperative instability of the thumb metacarpal joint. This is usually a result of iatrogenic release of the IM ligament or complete trapeziectomy without a ligament reconstruction. (39)

Implants have also been a source of complications. Instability, loosening, and fracture have been reported at various rates in the literature. (49-51) Silicone implants have the added complication of particulate synovitis and late carpal erosions.

Summary

Osteoarthritis of the TM joint is a common cause of pain and disability in several large populations each year, particularly females of either older or younger age groups. The staging of basal joint disease is most often based on plain radiographs; however, the severity of symptoms does not always correlate with radiographs. Nonoperative treatment is very effective in the management of basal joint disease. Operative intervention is indicated when conservative treatment fails to alleviate the symptoms in a compliant patient (Fig. 2).

[FIGURE 2 OMITTED]

The most common procedure for stage I disease is volar ligament reconstruction. For more advanced cases, ligament reconstruction with tendon interposition has proven to be very effective with regard to pain relief and a return to function. Alternatively, arthroplasty, osteotomy, or arthrodesis can be done. Careful evaluation of the MP joint is mandatory to minimize poor results. With the numerous surgical options available, good to excellent results in greater than 90% of patients can be achieved.

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(48.) Culp RW, Rekant MS. The role of arthroscopy in evaluating and treating trapeziometacarpal disease. Hand Clin. 2001 May;17(2):315-19.

(49.) Ruffin RA, Rayan GM. Treatment of trapeziometacarpal arthritis with silastic and metallic implant arthroplasty. Hand Clin 2001 May;17(2):245-53.

(50.) Hannula TT, Nahigian SH. A preliminary report. cementless trapeziometacarpal arthroplasty. J Hand Surg [Am]. 1999 Jan;24(1):92-101.

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Daniel B. Polatsch, M.D., was Administrative Chief Resident within the NYU Hospital for Joint Diseases Department of Orthopaedic Surgery, New York, New York. Nader Paksima, D.O., M.P.H., is Clinical Assistant Professor of Orthopaedic Surgery, NYU School of Medicine and Assistant Chief of the Hand Service, NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Nader Paksima, D.O., M.P.H., Suite 8U, 530 First Avenue, NYU Medical Center, New York, New York 10016.
Table 1 Ligaments Stabilizing the Trapezium and
Trapeziometacarpal Joint

1. dAOL (beak ligament)

2. sAOL

3. dorsal intermetacarpal ligament (DIM)

4. Dorsal trapezio-II metacarpal ligament (DT-II MC)

5. Dorsal trapeziotrapezoid ligament (DTT)

6. Dorsoradial ligament (DRL)

7. Intermetacarpal ligament (IM)

8. Posterior oblique ligament (POL)

9. Radial scaphotrapezial ligament (RST)

10. Transverse carpal ligament (TCL)

11. Trapeziocapitate ligament (T-C)

12. Trapezio-III metacarpal ligament (T-III MC)

13. Ulnar collateral ligament (UCL)

14. Volar scaphotrapezial ligament (VST)

15. Volar trapezio-II metacarpal ligament (VT-II MC)

16. Volar trapeziotrapeziod ligament (VTT)
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Author:Polatsch, Daniel B.; Paksima, Nader
Publication:Bulletin of the NYU Hospital for Joint Diseases
Date:Dec 22, 2006
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