Author: Alejandro Badia, M.D, F.A.C.S.
Section Heading SUB HEADING a report by
Alejandro Badia, MD, FACS
Hand & Upper Extremity Surgeon
Incidence
Osteoarthritis of the basal joint of the thumb is the second most common location for arthritis in the hand. However, it is by far the most functionally disabling. While distal interphalangeal joint arthritis is much more common, it is often minimally symptomatic, and the only good treatment option is fusion of this joint.This method of treatment is simple, and the results are reproducible with excellent return of function. Conversely, due to the many degrees of freedom involved in basal joint motion, the treatment is much more complex and the results less predictable. Not only is motion at this joint so functionally critical, but incredible stresses are transmitted across the basal joint even with simple, everyday activities. The forces seen at the tip during pinch, for example, are transmitted tenfold to the base of the thumb.1 It has been theorized that the basal joint of the thumb is what most separates us from other simians, and that its role in tool-making separates us from the remainder of the animal kingdom.
Conservative Management
The treatment of symptomatic basal joint arthritis is most often initially palliative. Anti-inflammatories, splinting, or even corticosteroid injections simply give pain relief—they do not alter the often inevitable course of progressive pain, and even deformity. Therapy plays little role in conservative treatment and may actually aggravate symptoms. For this reason, surgery has been generally the mainstay of treatment in symptomatic cases.The problem lies in the fact that so many different procedures are available, which either indicates that all of the procedures are effective or that perhaps no one procedure has really resolved the issue to a satisfactory degree. Regarding conservative treatment, it is often not effective because nothing is being done to change the joint itself. Since pinching activity is so ubiquitous in everyday life, the joint continues to experience stresses that propagate the symptomatic arthritis.A wide variety of splints are available that allow the joint to rest and may minimize the pain, but the fact that motion of this joint is important for hand function underscores the need for something other than splinting. Non-steroidal antiinflammatories have only a transient effect and are used simply for marginal symptomatic relief. Corticosteroid injections have a more sustained effect, but can have long-term detrimental effects on the articular cartilage or joint capsule. Persistent pain demands that something more definitive be instituted for treatment.
Surgical Options
One of the earliest surgical treatments described was complete excision of the trapezium. This was a simple operation, first described by Gervis in 1949.2 It is ironic that we have come full circle regarding surgical treatment, since Meals recently described a similar procedure in the literature nearly 50 years later.3 A more complex modification of this procedure has been described as the LRTI (ligament reconstruction tendon interposition). This has been, and remains, the most commonly used surgical procedure for treatment of painful basal joint osteoarthritis.4 This relatively complex operation combines several previously described procedures, encompassing the complete excision of the trapezium bone and stabilization of the metacarpal base, using a strip of the flexor carpi radialis wrist tendon in order to stabilize the newly formed joint. While reports in the literature are generally favorable in terms of the outcome, there are several problems that remain with this operation. One of them is that the recovery process is relatively long and can be painful. However, the main problem lies in the fact that there are few salvage options if painful symptoms persist. The reason lies in the simple fact that the trapezium has been completely excised. Once this bone, the pillar base of the thumb, is removed, there are few remedies available to reconstruct the thumb. Similar problems are faced after fusion, since the adjacent joints—which are frequently arthritic as well—can become more symptomatic. Reversing a fusion is a formidable task, and joint replacement may be the only option.
Total Joint Arthroplasty
For all of these reasons, a variety of different surgical approaches have been suggested to manage this common problem. As in so many other joints of the body, joint replacements are available. Unfortunately, some of the early designs were quite poor, and in cases of better implants, the selection criteria for patients were haphazard. The earliest implants were resurfacing implants that provided either little stability or tended to loosen. Silicone replacement became quite popular at the same time that Al Swanson was introducing a variety of other silicone joint implants in other joints of the hand.5 Frequent problems with instability, however, soon led to almost complete abandonment of this procedure, and the complications of silicone synovitis helped fuel this decline. In the hands of certain surgeons, the technique has been successful largely due to precise surgical technique that has often been difficult to reproduce.
In the past decade, total joint arthroplasty was revisited by using a semi-constrained, cemented implant that would allow freedom of motion in all axes while providing good stability at the interface.7 This option has not been popular amongst American surgeons, since early studies in the European literature show a relatively high complication rate, including loosening or dislocation.8 Careful scrutiny of these studies indicates that the implant surgery was applied to a wide range of patient ages and activity levels. Analysis of the literature does reveal that older patients had quite good outcomes with rapid recovery. There is little mention, however, of one of the main advantages of total joint arthroplasty—the fact that ‘no bridges have been burned.’ If the implant either fails or the patient is persistently symptomatic, the implant can be easily removed and the trapezium excised, allowing use of the standard LRTI procedure. Hence, total joint replacement remains a viable alternative in older patients where functional recovery is rapid, and there is a good salvage potential if necessary. While longterm studies are scarce, it is implicit that loosening of the implants can occur in scenarios where a great deal of stress is placed on the joint. For this reason, alternatives have been sought and a new concept has recently been developed.
Artelon® is a polyurethane urea material that allows for an interposition arthroplasty that would serve as a cushion for the joint to provide pain relief and also provide stability to the joint via its fixation method.A Swedish study documenting the early follow-up results indicates excellent pain relief with minimal complications.9 Again, one of the most compelling reasons to use it is simply that there are salvage options. If failure should occur, the implant can be excised and the remainder of the trapezium removed. As the procedure requires only several millimeters of trapezial excision, the underlying biomechanics of the thumb are maintained. Long-term studies are necessary, but this newer implant may solve the dilemma of allowing for a minimally invasive procedure with minimal bone resection, and provide adequate stability while allowing for biologic ingrowth at the new joint location. In certain scenarios, the implant may even be inserted arthroscopically and provide for a more minimally invasive procedure that accomplishes the same goals.
Role of Arthroscopy
The concept of arthroscopy may be most beneficial in the early stages of basal joint arthritis. The earliest presentation of this painful condition has few surgical options once conservative treatment has been exhausted. It is obvious that a 35-year-old active woman may not agree to a complete open excision of the trapezium, even when her symptoms are persistent. The other surgical options discussed are also relatively aggressive for the younger, active patient. Hence, failed conservative treatment of basal joint osteoarthritis in the younger, active patients remains a dilemma. However, there is now a viable alternative in arthroscopy.The patient who continues to have pain, despite several cortisone injections and prolonged splinting, may agree to an arthroscopic procedure. This is because a minimally invasive procedure at this small joint presents the same advantages that it does in larger, but more accepted, procedures, such as knee arthroscopy. An arthroscopic evaluation of this joint gives us the true stage of arthritis and minimizes the importance of radiographic staging. In fact, an arthroscopic classification has been suggested, and may well lead to the treatment options.10 For example, an arthroscopic stage one would comprise a joint with significant synovitis but no articular cartilage loss.This patient may gain considerable symptomatic relief by a simple synovectomy and, perhaps, radiofrequency shrinkage capsulorrhaphy. This roll of radiofrequency in small joints is only now being explored, but may present the same advantages that it has in larger joints.11 However, it can also lead to the same pitfalls as have been seen treating shoulder instability.12 Judicious use of this new technology is important, and further studies are necessary regarding its role in the treatment of small joint arthritis.
More advanced arthroscopic stages dictate more aggressive treatment. Stage two arthrosis, which indicates a focal articular cartilage loss, is a good indication to perform an osteotomy that alters the joint biomechanics. This is a previously described procedure that has only been recently revisited.13,14 Arthroscopic stage three implies nearly complete cartilage loss, and this would be an indication to either perform one of the open procedures, as previously described, or perhaps an arthroscopic interposition arthroplasty.This can be done with a free tendon graft as is done in the open LRTI procedure, or the Artelon® material can be used as mentioned. Therefore, arthroscopy allows us to treat much earlier stages of this condition in a minimally invasive manner, while giving us a true clinical picture of what is occurring.The same advantages that we have seen in other large joints are present in this joint, as well as others, such as the metacarpophalangeal joints. Further studies will determine the role of arthroscopy in the clinician’s treatment armamentarium.
Summary
As the population ages and continues to be more active, it will be necessary to provide different options for the painful osteoarthritic basal joint of the hand. Newer technologies, such as small joint arthroscopy, or advances in biomaterials will lead to greater treatment options at this small but critical joint. Resection arthroplasty, or fusion, will likely continue to have a role in treatment, but I suspect that over time it will not be the primary option as is currently the gold standard.
References:
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2. Gervis H W,“Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint”, J Bone Joint Surg Br (1949);31:pp. 537–539.
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