Basal Joint Arthritis: A Review of Pathology, History, and Treatment.
The term "basal joint" is commonly used to refer to the carpometacarpal (CMC) joint of the thumb. However, the basal joint is actually composed of five joints. In addition to the CMC, there are the scaphotrapezial, scaphotrapezoidal, trapezium-index metacarpal, and trapezium-trapezoid joints. The scaphoid-trapezium-trapezoid complex is often referred to collectively as the STT joint and can be considered separately from the basal joint. (4)
The bony anatomy of the CMC joint is a biconcave, reciprocating saddle joint that allows for multiple axes of motion including flexion-extension, abduction-adduction, and rotation. These motions combine to allow the thumb to perform complex actions including opposition and circumduction. These combined movements of the thumb are what allow the hand to perform more advanced prehension, or grasping. There are five main types of grasp that the thumb performs: cylindrical grasp, tip pinch, palmar grasp, spherical grasp, and lateral pinch. (4)
Evolutionarily, the development of the mobile thumb is believed to have given humans an extraordinary evolutionary advantage over other similar species. The anatomy of the CMC joint of hominid ancestors demonstrated a single axis hinge joint that allowed only flexion and extension of the thumb. These hinge joints had more bony stability, and anatomic studies of the specimens revealed no evidence of degenerative arthritic changes within the basal joint. Modern humans evolved greater mobility of the CMC in order to develop greater degrees of prehension and grasping, however this mobility came at the sacrifice to the bony stability of the joint. The bony volar beak of the metacarpal became recontoured into the smooth saddle joint, and the surrounding ligaments became the dominant stabilizing force of the joint during pinching activities. The metacarpal and trapezium articulations developed asymmetric, or mismatched, radii of curvature to allow more mobility and translation at the joint surface. The radius of the metacarpal became smaller than the trapezium, resulting in a 34% smaller articular surface for contact. This smaller point of contact resulted in larger concentration of contact stresses of up to 12 to 20 times increased pinch forces across the joint. Other evolutionary changes occurred to accommodate this new mobility of the thumb, including development of thenar muscles for opposition and the extensor pollicis brevis tendon for extension. (4,5)
Due to the inherent instability of the CMC joint, the ligaments serve as the major stabilizers during grasp. There are 16 ligaments that stabilize the first CMC joint. The anterior oblique ligament (AOL) is the primary stabilizer. It arises from volar tubercle of the trapezium and inserts on volar ulnar aspect of first metacarpal. It has superficial and deep components, and the deep component is commonly referred to as the "beak" ligament, a reference to the evolutionary bony beak of the metacarpal for which the ligament functions in place of. (2,4) The AOL prevents ulnar and dorsal translation of the first metacarpal base during grasp and pinch. Biomechanical and anatomic studies have demonstrated that injury of this ligament--which is largely responsible for the remaining stability of the thumb--results in the pattern of osteoarthritis seen at the base of the thumb and contributes to the characteristic "shoulder deformity." A secondary stabilizer of the CMC joint is the dorsal intermetacarpal ligament (IML), which prevents proximal migration of thumb metacarpal following trapeziectomy. (4,5) The AOL and the IML are the main two ligaments that are considered for reconstruction following trapeziectomy to stabilize the thumb metacarpal base.
During pinch and grip, the CMC joint demonstrates a cantilever "see-saw" type bending effect across the joint surface. (6) Pressure map studies have demonstrated that the primary contact area is the palmar half of the joint, while the dorsal half of the joint exhibits almost no contact at all. This location of maximal contact coincided with the location of the beak ligament. Loss or attenuation of the AOL ligament resulted in dorsal migration of the metacarpal with cartilage wear and eburnation of volar bone, preferentially from the larger trapezial surface at a 3:1 ratio. Furthermore, in pathologic specimens studied, all cases of severe arthritis with eburnation of the joint demonstrated complete rupture of the AOL ligament. (4-6)
Basal joint arthritis had been described in medical literature as early as the 1920s. (3) In 1949, several seminal papers emerged describing the etiology and treatments for basal joint arthritis. French surgeon Lasserre (3) described the trapeziometacarpal joint as the most important site for hypertrophic osteoarthritis in the hand. He went on to describe methods of immobilization for symptomatic basal joints. That same year, English surgeon Muller (7) described arthrodesis for treatment of symptomatic CMC arthritis in eight patients using bone graft. He reported good fusion results in six of those patients. And finally, that year Gervis, (8) another English surgeon, published a study of 15 patients with basal joint arthritis and described a new technique involving removal of the trapezium. He reported high satisfaction rates, improved function, and pain relief for 13 of his 15 patients. He noted, however, that outcomes were better in patients with isolated trapeziometacarpal arthritis rather than extensive arthritis and that younger patients had a quicker recovery. What Gervis had essentially pioneered was the hematoma and distraction arthroplasty. While studies since then have demonstrated mixed results, trapeziectomy and hematoma arthroplasty is still performed to this day almost 70 years later. (8-9)
Robert E. Carroll is credited with laying much of the foundation for using tendon graft in the basal joint which he described in personal communications, (10) however it was Froimson in 1970 who first published a technique of tendon interposition following trapezial resection. (11) He reported on 12 thumbs and described careful dissection and excision of the trapezium, followed by taking a split portion of the flexor carpi radialis (FCR) tendon and using it as a graft by rolling it into a ball, or "anchovy," and placing it into the void created by trapezial excision. Thus was coined the term "tendon interposition arthroplasty." A bulky soft dressing held the thumb "in functional position" for 3 weeks. Patients were instructed to use their hands immediately without a therapy protocol. All patients achieved pain relief and stability, with minimal shortening of the thumb. He reported that removal of the trapezium allowed for release of adduction contracture, facilitating an abducted position to maximize function. (11) In spite of the good results reported, weakness and instability were concerns and this led other investigators to still search for a better alternative.
In 1973, Eaton and Littler (12) published a seminal paper that established the now accepted notion that hypermobility of the thumb CMC joint was due to degeneration and laxity of the anterior oblique, or volar beak, ligament and was responsible for the development of basal joint arthritis. They developed the Eaton classification method involving four radiographic stages of progressive subluxation, osteophyte formation, and joint space narrowing. Outcomes were reported on 18 patients who underwent a technique to reconstruct the beak ligament. A half strip of the FCR tendon was passed through a hole created in the base of the metacarpal to stabilize the joint and was pinned with K wires. The trapezium was not removed. Thus was coined the term "ligament reconstruction arthroplasty." Pins were removed at 4 weeks. Outcomes measured at 2.5 years postoperatively demonstrated that all patients had improvements in pain and weakness compared to preoperatively, with the best outcomes predominantly in patients with early stage disease. They also noted more radiographic progression of arthrosis in patients with more advanced disease. The authors concluded that while patients with severe articular involvement appeared to have some success with this procedure, ligament reconstruction in isolation was recommended only for patients with early stage arthritis. (12)
Eaton et al. (13,14) published two short-term and long-term follow-up studies of his procedure. They reported on 50 patients treated with the FCR ligament reconstruction procedure at an average 7 years postoperatively. Ninety-five percent of patients with early arthritis had good or excellent results, with excellent defined as absence of pain, pinch strength greater than 90% of the contralateral thumb, and minimum laxity of the CMC joint. Only 74% of patients with advanced arthritis achieved good or excellent results. (13) The authors further reinforced their previous findings that the outcomes of FCR reconstruction were directly related to the extent of articular damage and that better outcomes were achieved when surgery was performed before the onset of more severe articular damage. (13,14)
Seeking further refinement of techniques for advanced basal joint arthritis, Burton and Pellegrini (15) developed the more comprehensive "ligament reconstruction and tendon interposition" (LRTI) arthroplasty. They described partial or complete excision of the trapezium in conjunction with harvesting a half slip of FCR tendon for graft. The FCR graft was used to both reconstruct the AOL and IML (similar to the technique performed by Eaton and Littler) and create an "anchovy" (similar to the technique of Froimson). The first metacarpal was pinned with a K wire. Over time, the procedure was revised to excise the entire trapezium for better exposure of the FCR tendon and the scaphotrapezial (ST) joint as well as the harvest of the entire FCR tendon rather than a half-slip for a stronger ligament reconstruction. In their initial report of 25 patients with a 2-year follow-up, they demonstrated 92% excellent results, including strength and functional improvements for up to 12 months after surgery. (15,16)
In 1995, Tomaino et al. (17) published a long-term follow-up study of Burton's LRTIs on 24 thumbs in 22 patients over an average of 9 years. They demonstrated good results that did not deteriorate over time, including excellent relief of pain and a significant improvement in strength and function. They did note an 11% radiographic subsidence, but it did not correlate with symptoms. They reported an overall consistent integrity of the reconstruction technique at long-term follow-up and emphasized the importance of using LRTI to duplicate normal anatomy to provide a stable, functional, and durable reconstruction of the thumb. (17)
In 1981, Thomson (18) began performing a novel technique of LRTI using the abductor pollicis longus (APL) tendon rather than the FCR tendon. It was originally described as a salvage technique for prior failed implant arthroplasty, but by 1982 he began using it in primary cases of basal joint arthritis. A trapeziectomy was first performed, and then a distally-based slip of the APL was harvested and used to suspend the base of the first metacarpal to the second metacarpal using bone tunnels. In describing his technique, Thomson coined the term "suspensionplasty." In 1995, Thompson reported his own long-term follow-up on 50 cases over an 8-year period and described excellent outcomes with pain reduction and improved mobility and strength. (18)
In the 1960s, the silastic implant for basal joint arthritis was introduced. This marked a period of rapid growth and development of implant arthroplasties in the treatment of advanced CMC arthritis. Various classes of CMC implants were developed including metal-polyethylene, pyrocarbons, silicone, and polyurethane. (19)
Among the metal-on-polyethylene implants, the de la Caffiniere total joint prosthesis was one of the earliest developed. (20,21) It consisted of a semiconstrained ball and socket design with both components cemented. The metacarpal component was made of cobalt chromium, and the trapezium component was a polyethylene cup. Multiple studies demonstrated radiographic loosening of components and high revision rates. (20-22) The Steffee was a similar ball-and-socket cemental total joint replacement with cobalt-chrome alloy metacarpal stem and ultra-high molecular weight polyethylene cup. Follow-up studies demonstrated development of radiolucent lines and other signs of radiographic loosening, often resulting in the need for revision. The Guepar prosthesis was a cemented design with a cobalt chrome metacarpal component that snap-fit into a polyethylene trapezium to function in a constrained fashion. Several studies demonstrated similar development of radiolucent lines and pain at long-term follow-up. The Braun prosthesis was a similarly cemented total joint replacement that consisted of a titanium collarless stem and a polyethylene socket designed for use in later stage arthritis. This implant showed reasonable results in elderly, low-demand patients with advanced CMC arthritis. The Elektra prosthesis was a modular design in which a cobalt chrome socket threaded into the trapezium. This design also showed component loosening. The Avanta and Cooney designs were cemented implants with matching sloped saddle shaped components approximating the natural contour of metacarpal and trapezium. The trapezium component was made of cobalt chrome, and these were the first metacarpal components made of polyethylene. Long-term studies showed multiple complications including heterotopic bone formation, ankylosing, loosening, and a high revision rate. The Ledoux prosthesis was an uncemented ball-andsocket design that required the trapezial component to be secured with screws until bony ingrowth. Studies showed a high failure rate from improper cup alignment, loosening, subsidence, dislocations, implant size mismatch, and high revision rates from metallosis wear. Swanson also made a titanium hemiarthroplasty implant pressfit into the metacarpal without a trapezial component. These designs demonstrated various complications including loosening, trapezial wear, pistoning behavior, implant settling, and titanium modulus of elasticity mismatch. (19-21)
The next group of implants were made of pyrolytic carbons. These were thought to more closely mimic the modulus of cortical bone and surface lubrication compared to metal implants. (23) The Integra PyroHemiSphere[R] and NuGrip[R] PyroCarbon CMC Implant (Integra LifeSciences, Plainsboro, New Jersey) were pyrolytic carbon hemiarthroplasty resurfacing implants in which the stem was implanted into the metacarpal and the trapezium was reamed to accept the spherical surface. Complications including subluxation, dislocation, and pain lead to high reoperation rates. (19,20) The Pi2[R] implant was a pyrocarbon interpositional disc that was implanted and encapsulated into the trapezium fossa after resection. (23) The implant was prone to subluxation and demonstrated high removal rates. Various interpositional disc designs including the Integra PyroDisk[R] and the Pyrocardan [R] were developed to correct for implant subluxation and allow minimal bone resection. (19,20)
Among the silicone implants, the Swanson implants were the most widely used and studied. These silicone implants were often modified to be incorporated into fixation with ligamentous reconstructions. (19-21) The Niebauer was silicone implant with large dacron ties attached to the prosthesis designed to be tied into the FCR or index metacarpal. Longer-term analysis of silicone implants identified various problems included breakage, subluxation or dislocation, bone erosion, and silicone synovitis. (19-21,24)
The Artelon[R] was a T-shaped biodegradable implant that functioned as both an interpositional spacer within the CMC joint and also a ligament stabilizer by fixing the wings of the implant to the metacarpal and trapezium with screws. Several follow-up studies demonstrated high rates of pain, extrusion, histologic foreign body reactions, and high rates of implant removal. The Orthosphere[R] (Wright Medical Technologies, Memphis, Tennessee) was a zirconia ceramic implant similar to the Pi2[R] but was used as a spacer between the metacarpal and trapezium. Similarly though, it has been shown to have high complication rates including dislocation, subsidence, erosion, and trapezial fracture. GraftjacketTM (Wright Medical Group, Memphis, Tennessee) was considered as an interpositional arthroplasty for midstage CMC arthritis, however studies demonstrated high subsidence rates and the cost of the implant as a deterrent to use. (19-21) More recently, the TightRope[R] (Arthrex, Inc., Naples, Florida, USA) implant has been introduced to avoid harvest of autogenous tissue. The implant consists of a FiberWire[R] suture suspended by endobuttons between the thumb and index metacarpals. The main complication is fracture of the index metacarpal. (25-27)
While many iterations of implants were created along the way, the majority of long-term follow-up studies showed that many of these implants developed high complication and reoperation rates, causing the pendulum to eventually swing back toward the LRTI procedures and the continued search for better treatment options. (28)
In the 1990's, arthroscopy emerged as a promising new technique for early forms of arthritis. (29) The first clinical article in the literature on basal joint arthroscopy was reported by Menon (29); he described arthroscopic partial resection of trapezium in combination with various interpositional arthroplasties. Advocates of this technique have proposed multiple advantages, including the minimally invasive approach that can limit further destabilizing the basal joint, decreased risk of injury to the radial sensory nerve, and decreased postoperative pain when compared to open techniques. In 2006, Badia (30) described a staging classification, based on arthroscopic findings. He reported on a cohort of 43 patients with arthroscopic midstage CMC arthritis who were treated with synovectomy, debridment, thermal capsulorraphy, and metacarpal extension osteotomy. Long-term follow-up showed good range of motion, opposition, pinch strength, and pain relief. (30-31)
The main classification of basal joint arthritis was described by Eaton and Littler in 1973. The four stages are based on a true lateral radiograph of the trapeziometacarpal joint in which the sesamoid bones are superimposed on one another. In Stage I, there is normal joint space or in some cases even widening of the joint space due to early synovitis. In Stage II, there is mild joint space narrowing with osteophyte formation of 2 mm or less. In Stage III, there is marked joint space narrowing with osteophyte formation greater than 2 mm. And, finally, in Stage IV, there are all of the changes of Stage III disease with progression to scaphotrapezialtrapezoidal (STT) osteoarthritis. (12)
While this is the most widespread classification system used, recent literature has shown only moderate reliability of this classification system and relatively poor utility in guiding treatment. (32-38) In their original paper, Eaton and Littler12 recommended that ligament reconstruction be used for patients with stage I or II changes, while more comprehensive arthroplasty or arthrodesis be used in more advanced stages III or IV.
Spaans et al. (34) independently presented 40 cases of CMC arthritis to five muscuoloskeletal radiologists and eight hand surgeons to evaluate interobserver reliability of classification and treatment. They demonstrated that despite the relatively simple appearing classification system, there was only moderate interobserver reliability. Furthermore, the surgeons agreed on the same treatment option in only 10% of the cases, illustrating that, as in real life, a patient's treatment often depends on which surgeon he decides to visit. (34) Berger et al. (35) conducted a systematic review of four studies (including Spaans' study) on the reliability of the classification system and found only poor to fair interobserver reliability and fair to moderate intraobserver reliability. Becker et al. (36) surveyed 92 hand surgeons and found that shortening the Eaton-Littler classification to three stages by eliminating STT arthritis improved the interobserver reliability. They further found that interobserver reliability could be improved by taking into account clinical information in addition to radiographic criteria. (36)
In a cleverly titled study "Death, Taxes, and Trapeziometacarpal Arthrosis," Becker et al. (37) reviewed the imaging of 2,321 patients and demonstrated that radiographic signs often did not occur sequentially in a stepwise progression through the classification system, noting cases in which STT arthritis could precede CMC arthritis. Additionally, Hoffler et al. (38) demonstrated that the Eaton radiographic staging failed to correlate with symptom severity in 62 prospectively reviewed patients with unliateral CMC arthritis.
Ligament Reconstruction and Tendon Interposition (LRTI)
The ligament reconstruction tendon interposition (LRTI) is the workhorse surgical procedure for CMC arthritis. There are two main goals of the LRTI. The first is to create a disease free basal joint. Given the multiple articulations of the trapezium, this generally requires complete resection of the bone. The second goal is to support the metacarpal from subsiding after trapeziectomy. This requires either ligament reconstruction, interposition, or both. In ligament reconstruction, the AOL and IML ligaments are reconstructed such that the thumb becomes suspended by the base of the index metacarpal (IML) and stabilized from subluxing at its base (AOL). The two most commonly used tendon grafts are FCR and the APL. These provide reciprocal anatomic reconstructive advantages: the APL inserts onto the base of the thumb metacarpal and can be reconstructed to the second metacarpal, and the FCR inserts onto the base of the second metacarpal and can be reconstructed to the thumb metacarpal. (39-44)
The classic Burton LRTI and modified Eaton LRTI utilized a strip of FCR. (12-15) Exposure is performed through the APL and EPB interval to expose the CMC joint. The trapeziectomy is performed and a bone tunnel is created at the base of the metacarpal exiting at the approximate footprint of the AOL ligament. A distally-based strip of FCR tendon is harvested approximately 10 to 12 cm in length and delivered into the trapeziectomy fossa, remaining in continuity with its insertion on the metacarpal. The graft is delivered through the osseous tunnel, recreating the beak ligament, while its insertion on the second metacarpal base serves as the intermetacarpal ligament. The metacarpal is pinned in place with a K wire. In the modified Eaton LRTI, the tendon is then passed beneath the APL tendon, around the remaining slip of FCR, and sutured to itself. (12-14) In the Burton LRTI, the tendon is sutured to itself to create the suspension and then anchovied into the trapezium fossa to create the interposition. (15,45) Other modifications include the Weilby LRTI in which the FCR slip is repeatedly wound around the APL and the remaining FCR slip and then sutured to itself. (46) Barron and Eaton (47) further described a double interpositional arthroplasty for stage IV arthritis in an attempt to save the trapezium in which the FCR slip was interposed into both the CMC joint and the ST joint.
In the Thomson procedure, a distally attached slip of the APL tendon is passed through the osseous tunnel at the base of the thumb metacarpal, through a second bone tunnel in the base of the index metacarpal, and then Pulvertaft weaved into the ECRL and sutured. (18,48) Modifications have been described, including a more distally based index metacarpal drill hole to enhance the suspensory effect. (28) In the Kochevar procedure, the APL tendon graft is similarly passed through the thumb and index osseous tunnels and then passed around the ECRL, beneath the dorsal radial artery, and sutured to the FCR or periosteum within the trapezium fossa. (49) Kleinman and Eckenrode (50) described an LRTI utilizing both the FCR and APL. The distal slip of FCR was repeatedly woven around APL creating the suspension sling, and then the APL was advanced distally onto the thumb metacarpal base to create an abduction moment arm and eliminate webspace contracture. (50)
Several comparison studies have failed to show superiority of any one technique. (51-55) Gangopadhyay et al. (52) performed a prospective randomized trial on 174 thumbs divided into three groups: simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with LRTI using a strip of FCR graft. Patients were followed at a minimum of 5 years up to 18 years. The authors found no difference in any procedure with regard to pain, strength, or functional status. They concluded that there appeared to be no benefit to tendon interposition or ligament reconstruction in the long term. (52)
Vermeulen et al. (53) performed a systematic review of 35 articles on eight commonly performed basal joint procedures. They found no evidence that trapeziectomy, trapeziectomy with tendon interposition, trapeziectomy with ligament reconstruction, or trapeziectomy with LRTI were superior to any of the other techniques. They did note that follow-up in the studies with a higher level of evidence was relatively short and therefore long-term benefits could not be assessed. In addition, trapeziectomy with LRTI appeared to be associated with a higher complication rate. (53)
A Cochrane database review (54) evaluated 11 randomized-controlled trials (RCT) with 670 patients covering seven basal joint procedures. This review was unable to demonstrate that any technique conferred a benefit over others in terms of pain and functional outcome. However, this review noted that many of the studies were not of high enough quality to definitely prove that the techniques were equivalent. (54) In a database study by Yuan et al., (55) the national trends of the surgical treatment of thumb CMC arthritis were studied to evaluate surgeon preferences over time. Their findings demonstrated an increasing trend in the utilization of LRTI from 84% in 2001 to 90% in 2010. Additionally, 95% of surgeons performed only one type of surgical procedure, and among those, 93% of surgeons performed only LRTI. They concluded that despite trials supporting trapeziectomy-only procedures, most US surgeons favored the LRTI. (55)
None of the authors have a financial or proprietary interest in the subject matter or materials discussed in the manuscript, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.
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Ayesha M. Rahman, MD, MSE, and Steven M. Green, MD
Ayesha M. Rahman, MD, MSE, New York-Presbyterian Queens Hospital, Queens, New York, USA. Steven M. Green, MD, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA.
Ayesha M. Rahman, MD, MSE, New York-Presbyterian Queens Hospital, 72-06 Northern Boulevard, Queens, New York 11372, USA; firstname.lastname@example.org.
Please Note: Illustration(s) are not available due to copyright restrictions.
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|Author:||Rahman, Ayesha M.; Green, Steven M.|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Article Type:||Disease/Disorder overview|
|Date:||Jan 1, 2019|
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