Trapeziometacarpal osteoarthritis

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Trapeziometacarpal osteoarthritis
Other namesCarpometacarpal (CMC) osteoarthritis (OA) of the thumb, osteoarthritis at the base of the thumb, basilar (or basal) joint arthritis, [1] rhizarthrosis [2]
Osteoarthritis of the CMC joint.png
Osteoarthritis of the trapeziometacarpal joint
Specialty Plastic surgery

Trapeziometacarpal osteoarthritis (TMC OA) is, also known as osteoarthritis at the base of the thumb, thumb carpometacarpal osteoarthritis, basilar (or basal) joint arthritis, or as rhizarthrosis. [3] [1] [2] This joint is formed by the trapezium bone of the wrist and the metacarpal bone of the thumb. This is one of the joints where most humans develop osteoarthritis with age. [4] Osteoarthritis is age-related loss of the smooth surface of the bone where it moves against another bone (cartilage of the joint). [3] [5] In reaction to the loss of cartilage, the bones thicken at the joint surface, resulting in subchondral sclerosis. Also, bony outgrowths, called osteophytes (also known as “bone spurs”), are formed at the joint margins. [6]

Contents

The main symptom is pain, particularly with gripping and pinching. [7] [8] This pain is often described as weakness, but true weakness is not a part of this disease. People may also note a change in shape of the thumb. [7] [8] Some people choose surgery, but most people find they can accommodate trapeziometacarpal arthritis. [9] [10] [11]

Signs and symptoms

The symptom that brings people with TMC OA to the doctor is pain. [8] Pain is typically experienced with gripping and pinching. People experiencing pain may describe it as weakness.

There may be enlargement at the TMC joint. [8] This area may be tender, meaning it is painful when pressed. There may also be hyperextension of the metacarpophalangeal joint. The thumb metacarpal deviates towards the middle of the hand (adduction). [12] Also a grinding sound, known as crepitus, can be heard when the TMC joint is moved, more so when axial pressure is applied. [13]

Etiology and Epidemiology

TMC OA is an expected part of aging in men and women equally. [4] A population-based study of radiographic signs of pathophysiology in 3595 people assessed in a research-related comprehensive health examination found no association with physical workload. [9] A study of people seeing a hand specialist for symptoms unrelated to TMC OA demonstrated no relationship of radiographic TMC OA to hand activity. [14]

Studies that compare people presenting with TMC symptoms to people without symptoms are sometimes interpreted as indicating that activities can contribute to the development of TMC OA. [15] A more accurate conclusion may be that hand use is associated with seeking care for symptoms related to TMC OA. Ligamentous laxity is often associated with TMC OA, but this is based on rationale rather than experimental evidence. [16] Obesity may be related to TMC OA. [9]

Anatomy

The TMC joint is a synovial joint between the trapezium bone of the wrist and the metacarpal bone at the base of the thumb. This joint is a so-called saddle joint (articulatio sellaris), unlike the CMC joints of the other four fingers which are ellipsoid joints. [17] This means that the surfaces of the TMC joint are both concave and convex.

This shape provides the TMC joint a wide range of motion. Movements include: [18]

The TMC joint is stabilized by 16 ligaments. [19] Of these ligaments, the deep anterior oblique ligament, also known as the palmar beak ligament, is considered to be the most important stabilizing ligament. [20]

Showing the bones of the hand Anatomy of the hand.png
Showing the bones of the hand

Diagnosis

TMC OA is diagnosed based on symptoms and signs. [8] Radiographs can confirm the diagnosis and the severity of TMC OA. Other diagnoses in this region include scaphotrapezial trapezoid arthritis and first dorsal compartment tendinopathy (De Quervain syndrome) although these are usually easy to distinguish.

Classification

TMC OA severity was classified by Eaton and Littler which can be simplified as follows: [21] [22]

Stage 1:

  • slight widening of the joint space
  • < 1/3 subluxation of the joint (in any projection)

Stage 2:

Stage 3:

Stage 4 trapeziometacarpal osteoarthritis, with major subluxation of the joint Trapeziometacarpal osteoarthritis with subluxation.jpg
Stage 4 trapeziometacarpal osteoarthritis, with major subluxation of the joint

Stage 4:

A simpler classification is no arthritis, some arthritis, and severe arthritis. [23] This simpler classification system omits the potentially contradictory details of the Eaton/Littler classification and keeps scaphotrapezial arthrosis separate.

Treatment

There are no treatments proved to slow or relieve TMC OA. In other words, there are no disease-modifying treatments. All treatments are symptom alleviating (palliative).  Most surgery is reconstructive—it removes the TMC joint. Metacarpal osteotomy was proposed as a potentially disease modifying surgery for more limited arthrosis, [24] but there is no experimental support for this theory. [25]  

There is limited and limited quality evidence regarding splints, corticosteroid injections, manual therapy and other palliative measures. Studies with adequate randomization, blinding, and independent assessment are lacking.

Arthrodesis fuses the TMC joint. It is uncommonly used. [26] Arthroplasty surgery for TMC OA removes part or all of the trapezium. [27] Surgery may also support the metacarpal by reconstructing a ligament using a tendon graft or weave.  Surgery may also place something in the space where the trapeziometacarpal joint was, either a tendon wrapped up into a ball or a prosthesis.

The best available evidence suggests no difference in symptom alleviation with these variations of TMC arthroplasty. [28]

Showing the forces after trapeziectomy Forces after trapeziectomy.jpg
Showing the forces after trapeziectomy

In one randomized trial comparing trapeziectomy alone with trapeziectomy with ligament reconstruction and trapeziectomy with ligament reconstruction and tendon interposition, patients evaluated 5 to 18 years after surgery had similar pain intensity, grip strength and key and tip pinch strengths after each procedure. [29] Trapeziectomy alone is associated with fewer complications than the other procedures.

Trapeziectomy

During trapeziectomy, [30] the trapezium bone is removed without any further surgical adjustments. The trapezium bone is removed through an approximately three centimeter long incision along the lateral side of the thumb. To preserve surrounding structures, the trapezium bone is removed "by splitting" it into pieces.

An empty gap is left by the trapeziectomy and the wound is closed with sutures. Despite this gap, no significant changes in function of the thumb are reported. [27] After the surgery, the thumb will be immobilized with a cast.

Trapeziectomy with tendon interposition

Some physicians still believe that it is better to fill the gap left by the trapeziectomy. They assume that filling the gap with a part of a tendon is preferable in terms of function, stability and position of the thumb. This is based on the assumption that interposition can help maintain the space between the metacarpal and the scaphoid, which will improve comfort and capability. Neither of these assumptions is supported by experimental evidence.

During trapeziectomy with TI, a longitudinal strip of the palmaris longus tendon is collected. [31] If this tendon is absent (which is the case in 13% of the population), half of the flexor carpi radialis tendon (FCR) can be used.

The tendon is then formed into a circular shape and placed in the gap, where it is stabilized by sutures. [12]

Trapeziectomy with ligament reconstruction

Another technique is used to reconstruct the volar beak ligament after trapeziectomy. The rationale is that ligament reconstruction(LR) helps maintain the gap between the metacarpal and the scaphoid, and that a larger gap is associated with greater comfort and capability. [32] Again these possibilities are not supported by experimental evidence.

During this procedure the anterior oblique ligament is reconstructed using the FCR tendon. There is a wide variety in techniques to perform this LR, but they all have a similar goal.

Arthrodesis of the thumb Arthrodesis of the thumb.jpg
Arthrodesis of the thumb

Trapeziectomy with LRTI

Some physicians believe that combining LR with TI will help maintain gap between the metacarpal and the scaphoid. [33] And that doing so will improve comfort and capability. Keep in mind that these aspects of the rationale are not supported by experimental evidence. The evidence suggests that all of these procedures have comparable long-term results.

Arthrodesis

Arthrodesis of the TMC joint is a surgical procedure in which the trapezium bone and the metacarpal bone of the thumb are secured together. They are held together by K-wires or a plate and screws until the bone will heal.

Disadvantages include inability to flatten the hand. [27] Additionally, the stress on the CMC joint is now spread over the adjacent joints, those joints are more likely to develop osteoarthritis. [34]

Nevertheless, this procedure can be used in patients with stage II and III CMC OA as well as in young people with posttraumatic osteoarthritis. [27]

Joint replacement

X-ray of trapeziometacarpal joint replacement. Left hand of a 58-year-old woman. X-ray of trapeziometacarpal joint replacement, F, cropped.jpg
X-ray of trapeziometacarpal joint replacement. Left hand of a 58-year-old woman.

The joint can be replaced with artificial material. An artificial joint is also referred to as a prosthesis. Prostheses are more problematic at the trapeziometacarpal joint compared joints like the knee or the hips.

[27] Prostheses come in many varieties, such as spacers or resurfacing prostheses.

It’s not clear within the current literature that a prosthesis has any advantage over trapeziectomy. [27]

Overall, joint replacements are related to long-term complications such as subluxation, fractures, synovitis (due to the material used) and nerve damaging. [35] In many cases revision surgery is needed to either remove or repair the prosthesis. Also note that usage of a joint replacement is heavy in costs.

The quality of the prostheses is improving and there is reason to believe this will have a positive effect on outcome in the years to follow. [27]

Osteotomy of the thumb Osteotomy of the thumb.jpg
Osteotomy of the thumb

Metacarpal osteotomy

The aim of metacarpal osteotomy is to change the pressure distribution on the TMC joint. The hope is that this will slow the pace of development of osteoarthritis. There is no evidence that this procedure can modify the natural course of TMC OA. Osteotomy may be considered for people with mild arthritis. [24]

During osteotomy, the metacarpal is cut and a wedge shape bone fragment is removed to move the bone away from the hand. [36] Postoperative, the thumb of the patient is immobilized using a thumb-cast.

Possible complications are non-union of the bone, persistent pain related to unrecognized CMC or pantrapezial disease and radial sensory nerve injury. [24]

Complications

The most common complication after surgery is pain persisting in the thumb. Over long term, there is pain relief, but on short term, patients experience pain from the surgery itself. The main complaint is a burning sensation or hypersensitivity over the incision. Some patients develop a complex regional pain syndrome. This is a syndrome of chronic pain with changes of temperature and colour of the skin.

Other general complications include superficial radial nerve damage and postoperative wound infection.

After arthrodesis, non-union, in which fusion of the trapezium bone with the metacarpal bone fails, occurs in 8% to 21% of the cases. [27]

Subluxation of a prosthesis is a complication where the prosthesis is mobile and is partially dislocated. When the prosthesis is fully dislocated it is called a luxation. Both are painful and need revision surgery so the prosthesis can be repaired or removed. [37] When using a prosthesis over a longer period of time, there is a chance of breaking the prosthesis itself. This is due to mechanical wear.

Prostheses might also cause a reaction of the body against the artificial material they are made of, resulting in local inflammation.

Epidemiology

CMC OA is the most common form of OA affecting the hand. [38] Dahaghin et al. showed that about 15% of women and 7% of men between 50 and 60 years of age develop CMC OA of the thumb. [39] However, in about 65% of people older than 55 years, radiologic evidence of OA was present without any symptoms. [39] Armstrong et al. reported a prevalence of 33% in postmenopausal women, of which one-third was symptomatic, compared to 11% in men older than 55 years. [38] This shows CMC OA of the thumb is significantly more prevalent in women, especially in postmenopausal women, compared to men.

Related Research Articles

<span class="mw-page-title-main">Polydactyly</span> Physical anomaly involving extra fingers or toes

Polydactyly or polydactylism, also known as hyperdactyly, is an anomaly in humans and animals resulting in supernumerary fingers and/or toes. Polydactyly is the opposite of oligodactyly.

<span class="mw-page-title-main">Wrist</span> Part of the arm between the lower arm and the hand

In human anatomy, the wrist is variously defined as (1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; (2) the wrist joint or radiocarpal joint, the joint between the radius and the carpus and; (3) the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, bracelet lines, the flexor retinaculum, and the extensor retinaculum.

<span class="mw-page-title-main">Trapezium (bone)</span> Bone of the wrist

The trapezium bone is a carpal bone in the hand. It forms the radial border of the carpal tunnel.

<span class="mw-page-title-main">De Quervain syndrome</span> Medical condition

De Quervain syndrome occurs when two tendons that control movement of the thumb become constricted by their tendon sheath in the wrist. This results in pain and tenderness on the thumb side of the wrist. Radial abduction of the thumb is painful. On some occasions, there is uneven movement or triggering of the thumb with radial abduction. Symptoms can come on gradually or be noted suddenly.

<span class="mw-page-title-main">Metacarpal bones</span> Bones of hand

In human anatomy, the metacarpal bones or metacarpus, also known as the "palm bones", are the appendicular bones that form the intermediate part of the hand between the phalanges (fingers) and the carpal bones, which articulate with the forearm. The metacarpal bones are homologous to the metatarsal bones in the foot.

<span class="mw-page-title-main">Hamate bone</span> Carpal bone in the wrist

The hamate bone, or unciform bone, Latin os hamatum and occasionally abbreviated as just hamatum, is a bone in the human wrist readily distinguishable by its wedge shape and a hook-like process ("hamulus") projecting from its palmar surface.

Arthroplasty is an orthopedic surgical procedure where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by osteotomy or some other procedure. It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis or some other type of trauma.

<span class="mw-page-title-main">Joint replacement</span> Orthopedic surgery to replace a joint

Joint replacement is a procedure of orthopedic surgery known also as arthroplasty, in which an arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. Joint replacement is considered as a treatment when severe joint pain or dysfunction is not alleviated by less-invasive therapies. Joint replacement surgery is often indicated from various joint diseases, including osteoarthritis and rheumatoid arthritis.

<span class="mw-page-title-main">Flexor pollicis brevis muscle</span> Muscle in the thenar compartment

The flexor pollicis brevis is a muscle in the hand that flexes the thumb. It is one of three thenar muscles. It has both a superficial part and a deep part.

In human anatomy, the abductor pollicis longus (APL) is one of the extrinsic muscles of the hand. Its major function is to abduct the thumb at the wrist. Its tendon forms the anterior border of the anatomical snuffbox.

<span class="mw-page-title-main">Carpometacarpal joint</span>

The carpometacarpal (CMC) joints are five joints in the wrist that articulate the distal row of carpal bones and the proximal bases of the five metacarpal bones.

<span class="mw-page-title-main">Madelung's deformity</span> Medical condition

Madelung's deformity is usually characterized by malformed wrists and wrist bones and is often associated with Léri-Weill dyschondrosteosis. It can be bilateral or just in the one wrist. It has only been recognized within the past hundred years. Named after Otto Wilhelm Madelung (1846–1926), a German surgeon, who described it in detail, it was noted by others. Guillaume Dupuytren mentioned it in 1834, Auguste Nélaton in 1847, and Joseph-François Malgaigne in 1855.

<span class="mw-page-title-main">Midcarpal joint</span>

The midcarpal joint is formed by the scaphoid, lunate, and triquetral bones in the proximal row, and the trapezium, trapezoid, capitate, and hamate bones in the distal row. The distal pole of the scaphoid articulates with two trapezial bones as a gliding type of joint. The proximal end of the scaphoid combines with the lunate and triquetrum to form a deep concavity that articulates with the convexity of the combined capitate and hamate in a form of diarthrodial, almost condyloid joint.

<span class="mw-page-title-main">Palmar carpometacarpal ligaments</span>

The Palmar carpometacarpal ligaments are a series of bands on the palmar surface of the carpometacarpal joints that connect the carpal bones to the second through fifth metacarpal bones. The second metacarpal is connected to the trapezium. The third metacarpal is connected to the trapezium, to the capitate, and to the hamate. The fourth and fifth metacarpals are connected to the hamate.

Protrusio acetabuli is an uncommon defect of the acetabulum, the socket that receives the femoral head to make the hip joint. The hip bone of the pelvic bone/girdle is composed of three bones, the ilium, the ischium and the pubis. In protrusio deformity, there is medial displacement of the femoral head in that the medial aspect of the femoral cortex is medial to the ilioischial line. The socket is too deep and may protrude into the pelvis.

<span class="mw-page-title-main">Bennett's fracture</span> Medical condition

Bennett fracture is a type of partial broken finger involving the base of the thumb, and extends into the carpometacarpal (CMC) joint.

<span class="mw-page-title-main">Unicompartmental knee arthroplasty</span>

Unicompartmental knee arthroplasty (UKA) is a surgical procedure used to relieve arthritis in one of the knee compartments in which the damaged parts of the knee are replaced. UKA surgery may reduce post-operative pain and have a shorter recovery period than a total knee replacement procedure, particularly in people over 75 years of age. Moreover, UKAs may require a smaller incision, less tissue damage, and faster recovery times.

<span class="mw-page-title-main">Radial dysplasia</span> Medical condition

Radial dysplasia, also known as radial club hand or radial longitudinal deficiency, is a congenital difference occurring in a longitudinal direction resulting in radial deviation of the wrist and shortening of the forearm. It can occur in different ways, from a minor anomaly to complete absence of the radius, radial side of the carpal bones and thumb. Hypoplasia of the distal humerus may be present as well and can lead to stiffness of the elbow. Radial deviation of the wrist is caused by lack of support to the carpus, radial deviation may be reinforced if forearm muscles are functioning poorly or have abnormal insertions. Although radial longitudinal deficiency is often bilateral, the extent of involvement is most often asymmetric.

<span class="mw-page-title-main">Wrist osteoarthritis</span> Medical condition

Wrist osteoarthritis is gradual loss of articular cartilage and hypertrophic bone changes (osteophytes). While in many joints this is part of normal aging (senescence), in the wrist osteoarthritis usually occurs over years to decades after scapholunate interosseous ligament rupture or an unhealed fracture of the scaphoid. Characteristic symptoms including pain, deformity and stiffness. Pain intensity and incapability are notably variable and do not correspond with arthritis severity on radiographs.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

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  33. ↑ Burton RI, Pellegrini VD (May 1986). "Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty". J Hand Surg Am. 11 (3): 324–32. doi:10.1016/s0363-5023(86)80137-x. PMID   3711604.
  34. ↑ Mureau MA, Rademaker RP, Verhaar JA, Hovius SE (September 2001). "Tendon interposition arthroplasty versus arthrodesis for the treatment of trapeziometacarpal arthritis: a retrospective comparative follow-up study". J Hand Surg Am. 26 (5): 869–76. doi:10.1053/jhsu.2001.26659. PMID   11561240.
  35. ↑ Wajon A, Vinycomb T, Carr E, Edmunds I, Ada L (February 2015). Wajon A (ed.). "Surgery for thumb (trapeziometacarpal joint) osteoarthritis". Cochrane Database Syst Rev. 2015 (2): CD004631. doi:10.1002/14651858.CD004631.pub4. PMC   6464627 . PMID   25702783. (Retracted, see doi:10.1002/14651858.cd004631.pub5 . If this is an intentional citation to a retracted paper, please replace {{ Retracted }} with {{ Retracted |intentional=yes}}.)
  36. ↑ Hobby JL, Lyall HA, Meggitt BF (May 1998). "First metacarpal osteotomy for trapeziometacarpal osteoarthritis". J Bone Joint Surg Br. 80 (3): 508–12. doi: 10.1302/0301-620x.80b3.8199 . PMID   9619947.
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  38. 1 2 Armstrong AL, Hunter JB, Davis TRC (1994). "The prevalence of reparative arthritis of the base of the thumb in post-menopausal women". J Hand Surg. 19B (3): 340–341. doi:10.1016/0266-7681(94)90085-X. PMID   8077824. S2CID   26424006.
  39. 1 2 Dahaghin S, Bierma-Zeinstra SM, Ginai AZ, Pols HA, Hazes JM, Koes BW (May 2005). "Prevalence and pattern of radiographic hand osteoarthritis and association with pain and disability (the Rotterdam study)". Ann. Rheum. Dis. 64 (5): 682–7. doi:10.1136/ard.2004.023564. PMC   1755481 . PMID   15374852.
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