SURGICAL MANAGEMENT OF THE BASAL ARTHRITIS OF THE THUMB

Roland LILLE MDCLINIQUE CHARCOT

Sainte Foy lès Lyon (France)

• The most frequent of hand arthritis and one of the most frequent arthritis of the human body

• Women prevalence ( beginning at the 5th and 6th decade of life)

• Primary arthritis• Secondary arthritis (post traumatic)• Some works encourage this pathology

Thumb trapeziometacarpal joint

BICONCONCAVE‐CONVEXE JOINT

16 STABILISATING LIGAMENTOUS STRUCTURES

1 LUXATING MUSCLE (APL)

3 PLANES MOVEMENTS:abduction‐adductionflexion‐extensionaxial rotation

Pathomecanics

‐ The thumb CMC joint isINSTABLE,‐ works in COMPRESSION,‐ is stabilisated by LIGAMENTOUS STRUCTURES (DRL,POL,IML),‐ that preventSUBLUXATION fromforces (APL) during PINCH

Clinical aspects

• Pain at the thumb base, exacerbated by grip and pinch

• Physical exam• Tenderness overlying the cmc joint• Grind test, crepitation• Pain with thumb retropulsion• Research tenderness on the STT• Subluxation of thumb base• In more advanced cases: adduction of the 1° metacarpal, MCP1 hyperextended

Radiologic aspects

• Kapandji Incidences • Stages of the disease

• TMC OA• TMC OA + scapho trapezium OA + trapezium trapezoid OA + trapezium‐M2 OA

• Classification system (usefull for surgical indication)• DELL• EATON• COMTET

• Consider status of MCP and STT joints

Radiologic aspects

• Stage 1• Slight joint space widening• No subluxation

Radiologic aspects

• Stage 2• Slight joint spacenarrowing

• Subluxation M1 < 1/3 surface trapezium

• Trapezium osteophytespresent < 2mm

Radiologic aspects

• Stage 3• Joint narrowing• Trapezium osteophytes > 2mm• M1 subluxation > 1/3

Radiologic aspects

• Stage 4• Advanced degenerative changes• Marqued joint narrowing• Cystic and sclerotic bone changes• Major subluxation of M1• Erosion of the dorso radial trapezial facet

Radiologic aspects

• Peritrapezium OA• When concerningTMC+ST+T Trapezoïd+TM2

MCP and STT

• It is important to evaluate•

• The aspect of the MCP joint– Mobility, degree of hyperextension,alterations of cartilage

• Also the aspect of the STT joint – Osteoarthritis ?

Medical treatment

• Non steroid anti inflammatory drugs• Physiotherapy• Activity modification• Custom made opponent splints ++++• Joint injection in association with the splint ++

– Corticosteroid– Hyaluronic acid

Surgical treatment

Depends on

• the radiologic stage• the age and the sex of the patient• the occupation• the status of the MCP joint,of the STT joint• the response to medical treatment

Surgical treatment

• Stage 1

• Arthroscopic debridement• M1 osteotomy• Ligamentoplasty

Arthroscopic treatment

• Early stages (I or II) • Is availlable for diagnostic and treatment• Badia arthroscopic classification• Technique 

– Debridement of synovium anddiseased cartilage– Capsular shrinkage– Hemitrapezial excision if necessary

• 2 weeks splint post operative• Self rehabilitation• Good results on pain and pinch strength

LigamentoplastyStage 1Failure of the anterioroblique « beak » ligamentLigamentoplasty with a strip of FCR6 weeks of immobilisationLong time of rehabilitation (3 months)

Osteotomy

• Early stages (I or II)• cartilage wear = volar

surface of the joint• Technique

– Basal abduction osteotomycorrecting the metacarpaladduction (improve thumbgrasp)

• 6 weeks of immobilisation• Results

– 80% painfree and normal pinch at 7 years of follow up

Surgical treatment in more avancedcases

• Stage 2 and Stage 3

• Arthroscopic debridement (stage2)• Interposition arthroplasty with pyrocarbon• Hemitrapezectomy + ligamentoplasty + tendon interposition (young people)

• Prosthetic arthroplasty (after 60)• Trapezometacarpal arthrodesis

Interposition Arthroplasty

• pyrocardan

Hemitrapezectomy+ligamentoplasty+tendinous interposition

• Resection of the distal part of the trapezium

• Ligamentoplasty with a strip of FCR tendon

• Tendon interposition between trapeze and M1

• 6 weeks of immobilisation

• Long rehabilitation• Young people

TMC fusion• Heavy worker• Young man • STT free of arthritis

• Painfree• Restore a good pinch

force

• Abduction‐antepulsionposition of the thumb

• Time of immobilisation very long ( 3months)

TMC prosthetic arthroplasty

• Non cimented trapezialcup + polyethylen insert

• Non cimented fillmetacarpal implant

• Angulated modularneck

• Needs 8 mm of trapezial high

• Restore the thumbcolumn high

Tmc prosthesis

TMC prosthesis complications

• Luxation• Not frequent,  improved by

– Retentive polyethylen insert– DOUBLE MOBILITY OF THE TRAPEZIAL CUP =    =

• Trapezial cup loosening• unfrequent

• Polyethylen wear• Unfrequent change the insert

• Ni or Cr allergy

TMC prosthesis results

• Restore a painfree, mobile, strong thumb

• 3 weeks of immobilisation

• Self rehabilitation• Quick recovery to full activity

• Long time follow up

Surgical treatment

• Stage 4

• Trapezectomy• Trapezectomy + ligamentoplasty + tendinous interposition• Trapezectomy + prosthetic implant interposition + stabilisation

– MCP• Anterior capsulorraphy• MCP arthrodesis

– STT• Implant arthroplasty + TMC arthroplasty• Resection of the distal pole of the scaphoïde + TMC arthroplasty• Scaphotrapezoïd arthrodesis

Trapezectomy + ligamentoplasty+ tendon interposition

• Remove the trapezium• Ligamentoplasty with

the strip of FCR fixed atthe radial side of M1

• Interposition in the trapezial area of the remaining strip

• 6 weeks of immobilisation

• Long time to recovery• Pain free

Trapezectomy + ligamentoplasty‐suspension

mcp‐capsulorraphy

Trapezectomy and prosthetic implant interposition

• Remove the trapezium• Pyrocarbon implant 

interposition• Stabilisation:

• Capsulorraphy• Ligamentoplasty with a strip of FCR

• 6 weeks of immobilisation• 3 to 6 months before

recovery full activity

Trapeziectomy + trapezium implant

• Pyrocarbon implant

• Pyrocarbon implant + MCP joint anteriorcapsulorraphy

Surgical treatment

• Stage 4 with STT arthritis

• Several options– Arthroplasty TMC + 

arthroplasty STT– Trapezectomy + 

ligamentoplasty + tendon interposition +scapho‐trapezoïdarthrodesis

– Trapezectomy + implant interposition + scapho‐trapezoïd arthrodesis

Results

Evaluation of• Pain• Mobility• Strength• Stability• Satisfaction• Time to return to work or full activity• Follow up

Results

• On pain always good or excellent• On mobility TMC prosthesis gives the best, TMC arthrodesis let the thumb in abduction –antepulsion

• On strength TMC prosthesis and TMC arthrodesisgive the best, trapezectomy alone the poor, better with ligamentoplasty and tendon interposition or implant

• On stability TMC prosthesis and TMC are the best, trapezectomy the worth

Results

• On satisfaction PATIENTS ARE MOST OF THE TIME SATISFIED because of the relief of pain

Results

• Time to return to full activity

– Prosthesis allow full activity in 6 weeks– Trapezectomy with implant or tendon interposition, hemitrapezectomy withligamentoplasty and tendon interposition require3 to 6 months to full activity

– TMC arthrodesis 6 months

Discussion

• The differents surgical procedures give good results especially in term of pain.

• At each stage correspond an appropriateprocedure.

• It is illogical to purpose a TMC prosthesis for a peritrapezium osteoarthritis, as it is non logical to purpose a trapezectomy for a strictlytrapezometacarpal osteoarthritis

Conclusion

• When medical treatment is inefficient, the surgery give good to excellent results

• Surgery permits to restore a painfree,mobilethumb, with a good strength and a good fonctionality.

• The TMC prosthesis seems to be the gold standard in the TMC osteoarthritis because of the quality of the results on the long term and the quickness of the fonctionnal recovery