FIRST CMC JOINT ARTHRITIS

CHRISTIAN DUMONTIER, MD, PHD

CENTRE DE LA MAIN, GUADELOUPE

IT IS SO
FREQUENT, IS
THERE
SOMETHING I
SHOULD KNOW
THAT I AM NOT
AWARE OF ?
Remember: the thumb represents 40% of hand function and about
25% of bodily function

RHIZARTHROSIS
- 1ST CMC JOINT OA

Forestier (1937)

2nd OA in frequency (< IPD)

Age-adjusted prevalence: 15% ;

7%
- rare before 50 yrs (8% of
women)

57% of CMC-1 OA after 60

71-100 yrs : symptomatic 26%

females, 14% males (Zhang 2002)]

48 ans

Age-specific prevalence rates

(Haara 2004)
Kellgren grade 2, 3, 4
Kellgren grade 3, 4

EPIDEMIOLOGY

Trapezio-metacarpal arthrosis is a normal part of

human aging ? - 2321 patients 31 years or older

Prevalence increased to 85% between the ages of

71 and 80 years and reached 100% in women aged
91 years or older and 93% in men of 81 years or
older.

More severe arthrosis at earlier ages among women

Only 3 patients had surgery prior to the study

Becker SJ, Briet JP, Hageman MG, Ring D. Death, taxes, and trapeziometacarpal
arthrosis. Clin Orthop Relat Res. 2013 Dec;471(12):3738-44.

EPIDEMIOLOGY

The female predilection is attributable to:

Anatomic (a smaller less congruous

shallow saddle joint, flat trapezial facet),

Hereditary (dysplastic joint surfaces)

Hormonal factors (increased ligament

laxity)

Resulting in greater joint contact pressure.

No correlation with work (strong association

between excessive joint laxity and premature
joint degenerative changes)

ETIOLOGY
Preventive treatment ?

Ligamentous laxity

Hormonal

Articular hypermobility (Jnsson 1995, 2008)

Idiopathic

Marfan, Ehler Danlos

Functional overload (males, XVIth century)

Trauma : Articular fracture, luxation

Hypoplasia of trapezium

BIOMECHANICS

The 1st CMC joint is a complex one

Compared to a saddle on a scoliotic horse

BIOMECHANICS

The joint is inherently unstable

Obliquity of the joint line

Importance of the

Orientation of TM ligaments

Traction pulling of the APL

ligaments to stabilize
the1st CMC

Mechanical loads during pinch

TM JOINT INSTABILITY

Favored by dysplasia of the trapeze and the pull of

tendons (APL +++)

Normal angulation around

130, abnormal if > 135

BIOMECHANICS

Highly constrained joint: Over 12,8

times the pressure of the tip is
exerted on the TM joint

chondral constraints, dorsoradial subluxation, 1st web

shortening, MP joint mechanical
consequences

IT IS A REGIONAL DISEASE

Isolated TM joint involvement

is rare

TM + STT(30-60%), TzTzode (35%), Tz-2nd

metacarpal (86%)

If STT is involved TM (90%)

IT IS A REGIONAL DISEASE

Regional joint instability:

MP +++: Frontal or sagittal instability cause of failure of surgical treatment [De Smet, 2006] -

Stabilisation if MP extension > 30

1st web space : Closure - cause of failure of

surgical treatment [Michon, 1985. De Smet, 2006]

IT IS A REGIONAL DISEASE

Soft-tissue regional disease: Carpal tunnel: 4-46%

of cases; Tendinitis: FCR, De Quervains, trigger
finger

CLINICAL
EXAMINATION

Signs of OA:

Mechanical pain (during pinch wearing tights, turning a key)

Pain at palpation, stress tests +,

Synovitis, deformity,...

Loss of strength

Thenar atrophy

Do not forget to examine the MP joint

STRESS TESTS

Palpation of TM joint

Grind test

Distraction test

Traction-shift

Torque test

Extension test (Se 94, Sp 95)

Adduction test (Se 94, Sp

93)

RADIOLOGY

Special X-rays incidences

(Kapandji, Robert)

Robert P. Bulletins et mmoires de la Socit

de Radiologie Mdicale de France.
1936;24:687-690.

Signs of OA: condensation, sclerosis, joint

narrowing, osteophytes (1st web), subluxation,

THREE IMPORTANT
THINGS TO ANALYSE
ON X-RAYS

TM joint narrowing

TM joint subluxation

STT joint involvement

(around 10%)

Special imaging techniques are useless

NO PARALLELISM BETWEEN CLINICAL

SYMPTOMS AND SEVERITY ON X-RAYS

Eaton (1973, 1984)

Dell (1978, 1990)

Comtet (2001)

Instabilit. Interligne
normal ou largi.
Subluxation rductible

Stade 0

Stade 1

Contours articulaires
normaux

Stade 2

Minime pincement ou
lgre ostocondensation
sous-chondrale.
Ostophytes ou corps
trangers < 2mm

Interligne normal ou
minime pincement ou
lgre ostocondensation
sous-chondrale. Pas de
subluxation, ou
dostophyte
Pincement,
ostocondensation souschondrale. Ostophytes.
Subluxation < 1/3 surface
articulaire mtacarpienne

Minime pincement.
Osteophytes. Subluxation
non rductible

Dtrioration TM,
hyperextension MP
rductible

Stade 3

Pincement marqu, godes

et ostocondensation souschondrales. Subluxation
variable. Fragments
articulaires > 2mm

Pincement marqu, godes

et ostocondensation souschondrales. Osteophytes.
Subluxation > 1/3 surface
articulaire mtacarpienne.
Atrations STT.

Dtrioration TM et MP,
hyperextension MP non
rductible

Stade 4

Arthrose TM + STT

Arthrose TM et STT.

Arthrose TM et STT

Radiological classification does not describe all stages of carpometacarpal joint osteoarthritis
accurately enough to permit reliable and consistent communication between clinicians (Choa et al.
JHSAm 2014)

TREATMENT MODALITIES

Modalities conditionally recommended for the

management of hand OA include instruction in joint
protection techniques, provision of assistive devices,
use of thermal modalities and trapeziometacarpal joint
splints, and use of oral and topical nonsteroidal
antiinflammatory drugs (NSAIDs), tramadol, and topical
capsaicin

These recommendations are based on the consensus judgment of clinical

experts from a wide range of disciplines, informed by available evidence,
balancing the benefits and harms of both nonpharmacologic and
pharmacologic modalities, and incorporating their preferences and values.
Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G,
Tugwell P; American College of Rheumatology. American College of Rheumatology 2012
recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of
the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012 Apr;64(4):465-74.

MEDICAL TREATMENT

Pharmacological TTT (Pain-killers, NSAID, slowaction anti-arthritis medication like sodium

chondroietin sulfate), orthosis +++, Physical TTT
(paraffin, heat,)

Steroid injections, Hyaluronic acid injections

Is said to be efficient in 90% of cases - pain relief in

8-11 years (Amor)

HAND THERAPY

Many publications, few are randomized

Hand therapy seems to provide some pain

reduction in patients with symptomatic TMC OA.

However, level of evidence is low

Spaans AJ, van Minnen LP, Kon M, Schuurman AH, Schreuders AR, Vermeulen GM. Conservative
treatment of thumb base osteoarthritis: a systematic review. J Hand Surg Am. 2015 Jan;40(1):16-21

ASSISTIVE DEVICES

ORTHOSES

76% of patients with moderate involvement and 54% with

severe disease have a 60% improvement with an orthosis
(Swigart, 1999)

Benefice is immediate (or never)

The type of orthesis +/- physiotherapy has no influence on

the evolution at 6 weeks (Wajon, Aust J Physiother 2005) - Patients prefer

to immobilize MP & TM joint over only the TM (Weiss, J Hand Ther 2004)

No difference between short (wrist is free) or long orthoses, but

patients preferred short orthoses (Weiss, J Hand Ther 2000)

No difference between rigid or supple orthosis, but patients

preferred the more supple one (Buurke, Clin Rehab 1999)

WHAT ABOUT INJECTIONS ?

Intra-articular steroid injections under fluoroscopic

control do not increase pain relief (24 weeks), joint
sensibility, stiffness or subjective evaluation by the
patient (Meenagh, Ann Rheum Dis 2004).

Prospective analysis -single intraarticular steroid

injection + 3 weeks of splinting:

80% pain relief at 18 months in Eaton stage I

35% of patients with Eaton Stage II and III

25% of stage IV patients

Day CS, Gelberman R, Patel AA, Vogt MT, Ditsios K, Boyer MI. Basal joint osteoarthritis of the thumb:
a prospective trial of steroid injection and splinting. J Hand Surg 2004;29:24751.

WHAT ABOUT INJECTIONS ?

3 injections of HA are less efficient initially than

steroids but more helpful at 26 weeks (Fuchs,
Osteoarthritis Cartilage, 2006).
No complications reported (very few)
There is some evidence for pain relief by both
steroid and hyaluronate intra- articular injections in
patients with TMC OA.Most authors found
injection of hyaluronate more effective with a
superior long-lasting effect.

Most rheumatologists consider it as a very efficient treatment: in patients with inflammatory signs ?

PHARMACOLOGY

Topical NSAID

Oral NSAID

No real studies

1/1200 chance of death from complications of NSAID after two

months of treatment

Incidence of GE complications is 120/100 000 inhabitants/year.

Incidence of GE complications due to NSAID is 480/100 000/year.

Death due to NSAID is 36% of which 12% (1/3) due to low-dose
aspirin. Global mortality is 6%

Preventive treatment of NSAID double the price of the treatment

SURGICAL TREATMENT

EULAR Recommandations (Zhang ARD 2007):

Surgery is an efficient treatment for CMC joint
arthroses and can be done in patients who are
painful or with a important functional deficit after
failure of more conservative treatments (FDR =
68).

SURGERY

Many techniques

Symptomatic treatment

Arthrodesis (Muller, 1949)

Osteotomy (Wilson, 1973)

Articular resection (i.e. trapezectomy w/wo stabilisation,

interposition,) [Gervis, 1949; Froimson, 1970; Eaton 1973]

Prostheses - implants [Swanson, 1972] or prosthesis [De la Caffinire,

1974]

Preventive Treatment ?

Arthrodesis 13 yrs FU

TM ARTHRODESIS

Usually proposed in young people (to maintain

their strength) with some loss of mobility

No difference in results in the (rare, retrospective)

comparative studies

84% satisfactory results (25 years FU)

40% re-intervention [Chamay] (Hardware removal,

Nonunion 4%, De-arthrodesis 6%)

Cultural indications that diminish

TRAPEZIECTOMY

Partial or complete

With / wo interposition

W/wo stabilisation

Trapeziectomy always lead to a

diminution of key-pinch strength
[Vandenbroucke, 1997].

All patients will complain of a loss of

strength after trapeziectomy +++

www.maitrise-orthop.com

POTENTIAL PROBLEMS
B

Thumb column will

collapse into the
dead space with time
(0,5 mm / year)
Abutment with
trapezoid and/or
scaphoid

Trapzial Space Ratio = A/B

Kadiyala & Downing, JHS, 1996.

EBM: TRAPEZIECTOMY +/- INTERPOSITION

+/- STABILISATION (DAVIS - PROSPECTIVE
STUDIES)

183 patients, with 3 & 12M & > 5yrs FU

82% good results, 68% sufficient strength

Long recovery (6 months). Normal

Mobility

No difference between groups

No correlation between the metacarpal

shortening and key-pinch strength

Gangopadhyay S, McKenna H, Burke FD, Davis TR. Five- to 18- year follow-up for treatment of
trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and
liga- ment reconstruction and tendon interposition. J Hand Surg Am. 2012;37(3):411-417

COCHRANE DATABASE
SYST REV 2009

9 studies (477 participants)

7 techniques: Trapeziectomy with ligament reconstruction and tendon

interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction,

trapeziectomy with interpositional arthroplasty, Artelon joint resurfacing,
arthrodesis and joint replacement.

Stage II-IV osteoarthritis

No procedure demonstrated any superiority over

another in terms of pain, physical function, patient
global assessment or range of motion

LRTI = 22% adverse effects (including scar tenderness, tendon

adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type

vs 10% for trapeziectomy. RR = 2.21, 95% CI 1.18 to

4.15.
1))

RECENT REVIEW

There were no statistically significant differences in

postoperative grip strength (p = 0.77); tip pinch
strength (p = 0.72); key pinch strength (p = 0.90);
pain visual analogue scale score (p = 0.34);
Disabilities of the Arm, Shoulder and Hand score
(p = 0.75); and number of adverse events (p =
0.13).

Li YK, White C, Ignacy TA, Thoma A. Comparison of trapeziectomy and trapeziectomy with ligament
reconstruction and tendon interposition: a systematic literature review. Plast Reconstr Surg. 2011 Jul;
128(1):199-207.

RECENT REVIEW (CONT)

35 papers analyzed

(1) there is no evidence that trapeziectomy or

trapeziectomy with tendon interposition is superior to any
of the other techniques.

(2) Trapeziectomy with ligament reconstruction or

trapeziectomy with ligament reconstruction and tendon
interposition (LRTI) is not superior to any of the other
techniques (in the short-term). In addition, trapeziectomy
with LRTI seems associated with a higher complication rate.

Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of primary
thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am. 2011 Jan;36(1):157-69.

(3) we are not able to conclude whether CMC

arthrodesis is superior to any other technique. Nonunion
rates average 8% to 21% and, complications and repeat
surgeries are more frequent following CMC arthrodesis.

(4) total joint prosthesis might have better short-term

results compared to trapeziectomy with LRTI.

We conclude that, at this time, no surgical procedure is

proven to be superior to another.

Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of primary
thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am. 2011 Jan;36(1):157-69.

TM PROSTHESES

Many designs

Mostly French

1st case, De La Caffinire,

1974

ADVANTAGES OF TM
PROSTHESES

7 ans

Early recovery (2-3 months) - No rehabilitation

No thumb shortening (Can be used even if MP

hyperextension) - esthetic

100 pts, 83% good results (4 years FU [Regnard 2006])

COMPLICATIONS

About 15%, that increase with time

Loosening (+/- 15%), dislocation (+/- 7%), trapezial

fracture,

C/I: Trapezial dysplasia, short or thin trapezium,

MP arthrodesis, MCL insuffisiency (MP), STT
arthroses (young patient)

SURVIVAL OF TM PROSTHESES

Survival rate between : 68 to 89% (de

la Caffinire, 2001; Nicholas et Calderwod, 1992; Van
Capelle et al., 1999; Chakrabati et al., 1997; Apard et
Saint-Cast, 2007; Skyta et al., 2005; Wachtl et al., 1997;
Comtet, 2000; Brutus et Kinnen, 2004; Jacoulet, 2005;
Schuhl, 2001; Ledoux, 1997; Badia et Sambandam,
2006)

16% re-operation at 41 months FU

(Apard et Saint-Cast, 2007)

Most re-operation are done within

the first year (Apard et Saint cast, 2007, Comtet,
2000)

were treated with the Artelon spacer, and 37

patients were treated with trapeziectomy and
LRTI (using either APL, extensor carpi radialis longus, or the Burton procedure). Pain and postoperative swelling were more common in patients
treated with Artelon than those treated with LRTI.
Additionally, 8% of patients treated with Artelon
had subsequent removal of their implants. In
contrast to the initial results, there was no increase
in key pinch or tripod pinch strength. Although
both groups experienced significant improvement
in DASH scores and pain relief, those treated with
LRTI had significantly better pain relief than those
treated with Artelon arthroplasty.
Several case reports have emerged from the
literature describing foreign body reactions with
use of Artelon in the TM joint, and this reaction
may be more common than reported in initial
studies. Choung and Tan41 described a patient
with swelling, pain and radiographic osteolysis
10 weeks after an Artelon arthroplasty mimicking
infection, with the end result implant removal and
multiple surgical synovectomies and a biopsy
revealing acute and chronic inflammatory synovitis
with multinucleated giant cells. Giuffrida and
colleagues42 similarly reported a patient with
painful synovitis and trapezial erosion after
implantation of the Artelon spacer into the
scaphotrapezial-trapezoidal joint, requiring removal of the implant and revision to LRTI. Biopsy
of the soft tissue and synovium revealed a granulomatous foreign body giant cell reaction to the Artelon implant (Fig. 3). Additionally, Robinson and

OTHER TECHNIQUES

Metallic

Numerous metal total joint implan

been devised for the treatmen
replacement of TM arthritis, inc
combinations of metal and polyet
nents. The earliest implant was de
Caffinie`re and Aucouturier, which
ball-and-socket implant with a po
inserted into the trapezium a
chromium stem in the metacarpal
et Cye S.A., Baguaux,
The
ThumbFrance).
Arthroplas
reported their early results in 1979
that outcomes were not as good f
a primary complaint of stiffness
but superior outcomes in patients
cated for pain and instability.44 T
extensive experience with this pros
in the European literature since t
with overall good clinical results,
have been several cases of
radiographic loosening seen in
component.4550
Other data, however, brought u
thesis into question because som
found unacceptably high rates o
ening, which did eventually require
ularly in younger patients and in m
more stress on the prosthesis. va
colleagues48 examined the results
finie`re prostheses implanted for o
the TM joint. At 16 years, the sur
implant was 72%, and the overal
was 44% (Fig. 4). Half of the cas
(more common in men and yo
were treated with revision, and the
significantly poorer. De Smet an
conducted a retrospective surve
` re prostheses
Caffinie
in 40interp
pat
Fig. 16. Preoperative (A) and postoperative (B) radiograph of Pyrocardan
pyrolytic
carbon anatomic
a 70%
ra
implant. (Courtesy of Philippe Belleme`re, Nantes Assitance Main,patients
Clinique had
Jeanne
DArc,satisfaction
Nantes, Franc
permission.)
of motion, and increased postope
Fig. 3. Histopathologic
specimen with
demonstrating
Granulomatous
reaction
artelon pinch force, there was an alarmin
a granulomatous reaction to Artelon with numerous
loosening for this prosthesis (44
foreign body giant cells in the trapezium bone.
a relationship between loosenin

To maintain the thumb length: partial

trapeziectomy with interposition
(pyrocarbon, Artelon,) - No series
published
TM joint denervation

Muir.43 reported on 3 cases of pers

Artelon TM implant arthroplasty
removal of the implant and tra
resolve symptoms.43 In all 3 case
imen revealed a foreign-body typ
giant cells containing material that
to be Artelon.

Bony trabeculae are shown at left (arrows), and the

REMEMBER

Silicone implant have been abandoned

due to the high number of
complications including siliconitis

NOT TO FORGET:
WILSON
OSTEOTOMY

Stiff and painless thumb with severe deformity Do a re-orientation of the thumb

PREVENTIVE
TREATMENT ?
IS IT WORTH DOING IT ?

FOR WHICH PATIENTS ?

Young

Without (or limited)

cartilage alteration

TM instability +/trapezial dysplasia

PREVENTIVE TREATMENT

Section of anterior
aberrant fibers of the
APL (Zancolli)

No series published

Probably useless

PREVENTIVE TREATMENT

Ligamentoplasty in patients with instability

Le Viet reported 19 patients improved out of a

series of 25 but considered results as unpredictable

Eaton reported after 15 years that 80% of

patients (15 of 19) were at least 90% satisfied and
only 8% demonstrated arthritis radiographically

Eaton-Littler type

BRUNELLI LIGAMENTOPLASTY
(1974)

The APL is parallel to the plane of the nail plate

RESULTS OF BRUNELLIS
LIGAMENTOPLASTY AT198 MONTHS

D. Le Viet

TM JOINT ARTHROSCOPY

Debridement of synovitis

Shrinkage of TM ligaments

OSTEOTOMIES

Vascularized Joint transfer (Roux 2004)

Non-vascularized osteotomy (Goubeau 2005)

LOOK TO PUBLISHED DATA WITH SERENITY