CURRENT CONCEPTS
Management of Osteoarthrosis of the Thumb Joints Aaron J. Berger, MD, PhD, Roy A. Meals, MD
We present current concepts and evidence to optimize diagnosis and management of osteoarthritis in the thumb joints. Numerous options and controversies exist for surgical treatment of carpometacarpal joint arthritis. Fewer options exist for metacarpophalangeal joint arthritis. Surgical treatment for interphalangeal arthritis is mainly arthrodesis. (J Hand Surg Am. 2015;40(4):843e850. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Thumb, arthritis, arthrodesis, implant, arthroplasty.
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EPIDEMIOLOGY Primary osteoarthritis of the thumb joints is most commonly encountered in the trapeziometacarpal (TMC) joint and less commonly in the interphalangeal (IP) and metacarpophalangeal (MCP) joints. The prevalence of primary osteoarthritis in the TMC joint is reported to be as high as 15% in adults over age 30, and as many as one-third of postmenopausal women are affected by the condition.2e4 Little information is available regarding the prevalence of primary osteoarthritis occurring in the IP and MCP joints of the thumb. Reports have suggested that chronic repetitive trauma in patients with heavy From the Division of Plastic Surgery, Florida International University College of Medicine & Miami Children’s Hospital, Miami, FL; and the Department of Orthopedic Surgery, University of California at Los Angeles, Los Angeles, CA. Received for publication September 17, 2014; accepted in revised form November 19, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Roy A. Meals, MD, Department of Orthopedic Surgery, University of California at Los Angeles, 1033 Gayley Avenue, Suite 104, Los Angeles, CA 90024; e-mail: [email protected]. 0363-5023/15/4004-0039$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.11.026
labor occupations may contribute to the development of MCP joint osteoarthritis.5 Mechanical stress is also implicated in the development of thumb IP joint osteoarthritis, and chopstick use has been implicated in IP joint arthritis in China.6 RELEVANT ANATOMY The thumb lacks a middle phalanx and possesses a unique carpometacarpal joint configuration. Based at the TMC joint, the thumb is pronated and flexed relative to the other metacarpals, with the trapezium and scaphoid longitudinal axis oriented at a 45 angle relative to the index metacarpal and the carpus.7 This position, unique to humans, allows opposition and prehension but hastens the development of basal joint arthritis. Factors characterizing arthritis in the thumb joints include joint surface shape changes and ligament deterioration, followed by cartilage eburnation and bone spur formation. The TMC joint is classified as a sellar joint, with articular surfaces that are convex in one plane and concave in the second plane, with the planes oriented perpendicular to each other.7 Although primary movements may occur in 2 orthogonal planes (flexionextension and abduction-adduction), the articular shape also allows axial rotation (pronation-supination), which is especially important for pulp-to-pulp pinch between the thumb and adjacent digits. The MCP joint of the thumb is classified as an ellipsoid joint characterized by an oval convex surface proximally that is opposed to an elliptical concavity distally. It is slightly different in architecture from the MCP joints of the other fingers in that its curvature in
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approximately 40% of hand function and nearly one-fourth of overall bodily function,1 injuries and arthritis have serious implications for patients’ overall well-being. This review provides insight into recent publications and their relevance for treatment of osteoarthritis of the thumb joints. ECAUSE
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the anteroposterior plane is flatter; its dorsal side is slightly wider than its palmar side; its articular surface is divided into 2 zones, one that articulates with the proximal phalanx and the other, more palmar, with the sesamoids in the palmar plate; and the radial condyle of the metacarpal head has greater dorsal-palmar height than the ulnar condyle, which allows some pronation of the proximal and distal phalanges during flexion.7 The IP joint of the thumb, much like the IP joints of the other digits, is a uniaxial bicondylar hinge joint. It is typically stable in all positions owing to a strong supporting ligamentous architecture and symmetric side-by-side condyles.
positive Finkelstein testing suggests TMC osteoarthritis. An x-ray would help confirm this diagnosis. The EatoneGlickel8 classification system is most commonly used for radiographic staging of TMC arthritis. It is summarized below: Stage 1. Slight joint widening. Stage 2. Slight joint narrowing, minimal subchondral sclerosis, and joint debris (osteophytes or loose bodies) less than 2 mm. Stage 3. Marked narrowing or obliteration of joint space, cystic changes, sclerotic bone, varying degrees of dorsal subluxation, and joint debris greater than 2 mm. Stage 4. Stage 3 deterioration plus scaphotrapezial joint narrowing with sclerosis and cystic changes.
CLINICAL PICTURE Thumb TMC arthritis The history (typically pain with forceful pinch), physical examination, and x-rays guide diagnosis of TMC arthritis. Tenderness is at the TMC joint most easily accessible dorsally where it is not covered with muscle. Modification of activity, placement of an orthosis, and use of nonsteroidal anti-inflammatory medication and steroid injections may suffice. If not, surgery may help.
TREATMENT Treatment starts with modification of activity, placement of an orthosis, and use of nonsteroidal anti-inflammatory medication and steroid injections followed with surgery if necessary. Surgical treatment options for thumb TMC arthritis Root treatment for TMC joint arthritis is most often trapeziectomy performed alone, combined with tendon interposition (TI), ligament reconstruction (LR), or both (LRTI). Other procedures include volar ligament reconstruction, metacarpal osteotomy, carpometacarpal arthrodesis, and joint replacement. No study has conclusively demonstrated the superiority of one procedure in terms of patient outcome measures. A systematic literature review through 2001, which included 8 reviews and 18 comparative studies, demonstrated that each technique (arthrodesis, trapeziectomy with or without biological or synthetic interposition, metacarpal osteotomy, and joint replacement) had unique benefits and risks. The review suggested LRTI superiority, but most included studies had methodological flaws precluding conclusive recommendations. Studied comparative studies (randomized or nonrandomized) indicated that LRTI provided no benefit over TMC joint arthrodesis or trapeziectomy with or without TI.9 A Cochrane Collaboration systematic review in 2009 included 9 randomized or quasi-randomized trials (477 patients). The study compared trapeziectomy alone, trapeziectomy with TI, trapeziectomy with LR, trapeziectomy with LRTI, Artelon joint resurfacing, TMC arthrodesis, and joint replacement. Patients had stage II to IV osteoarthritis and wide-ranging improvement in pain and function. No procedure demonstrated superiority regarding pain, physical function, patient
Thumb MCP arthritis Thumb MCP joint osteoarthritis may develop after collateral ligament injuries or result from TMC joint arthritis.5 Here, basal joint flexion with dorsal and radial subluxation of metacarpal base causes MCP joint hyperextension before arthritis. Thumb IP arthritis Mechanical stress causes degenerative changes at all IP joints including the thumb; osteophyte formation with mucous cysts is common.
Current Concepts
DIAGNOSIS Insidious onset and progression of pain are typically the presenting symptoms for osteoarthritis, whereas symptoms of gout, rheumatoid arthritis, and infections tend to develop rapidly. Passive joint motion under axial load is a sensitive test for diagnostic confirmation along with assessment of static and dynamic deformities. A Finkelstein test would likely cause pain at an arthritic TMC joint, and a positive Finkelstein test would have to be carefully interpreted. If there is tenderness at the TMC and none at the first dorsal compartment and if there is no thickening at the first dorsal compartment, pain on J Hand Surg Am.
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TRAPEZIECTOMY In 1949, Gervis17 described trapeziectomy for TMC joint arthritis without wire or pin metacarpal stabilization and with movement beginning the following day. Goldner and Clippinger18 described adjuncts to trapeziectomy including gelatin sponge interposition and K-wire metacarpal support for several weeks. Murley19 immobilized thumbs in plaster for 3 weeks. Trapeziectomy with K-wire fixation (also known as hematoma-distraction arthroplasty [HDA]) demonstrates almost universal pain relief and often improved strength.20e26 Comparative studies have indicated equally successful outcomes of HDA and more complex procedures. However, recent surveys of United States hand surgeons indicate that only 3% to 8% perform this technique routinely.27,28
global assessment, or motion arc. A total of 22% of LRTI patients had scar tenderness, tendon adhesion or rupture, sensory change, or complex regional pain syndrome (CRPS-1) compared to 10% who underwent trapeziectomy alone.10 A more recent systematic review with less stringent inclusion criteria identified 35 articles, including 9 that had previously been unanalyzed, and assessed the outcomes of volar ligament reconstruction, metacarpal osteotomy, arthrodesis, joint replacement and trapeziectomy with TI, LR, and LRTI. Again, no surgical procedure was superior to another.11 Li et al12 specifically compared isolated trapeziectomy and trapeziectomy with LRTI in an analysis of 2 systematic reviews and 4 randomized controlled trials. Outcome measures included motion, grip and pinch strength, health costs, complications, pain relief, hand function, overall satisfaction, and quality of life. Neither procedure proved superior for the outcome measures investigated. Almost all investigators conclude that there is at best minimal difference in outcomes over simple trapeziectomy and more complex procedures have more complications.
Trapeziectomy with suspension arthroplasty As an adjunct to trapeziectomy, various techniques suspend the first metacarpal. These techniques typically fill the trapezial void and/or route local tendons (usually the FCR and/or APL) through the first metacarpal base to suspend it. Cox et al35 described a suture button technique for suspensionplasty that achieves stability similar to Kwire fixation36 but allows mobilization after 10 days. After 2 years, the only major complications were individual cases of CRPS and index metacarpal fracture. Subjective and objective outcome measures were similar to other techniques.37 This technique’s major benefit is mobilization beginning at 10 days compared with 4 to 6 weeks for K-wireebased techniques.
Authors’ opinion More and longer-term data are needed for arthroscopic debridement to become routine for TMC arthritis, especially advanced pantrapezial disease. Smaller skin scars and preservation of the articular capsule are questionably worth the cost in operative time and equipment along with risk to neurovascular structures.
Prosthetic TMC joint replacement (with or without trapeziectomy) Most prosthetic devices for TMC joint arthroplasty have ultimately demonstrated failures requiring revision.34e37 Swanson38 developed a trapezial spacer based on his original concept of silicone prostheses for the MCP r
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Trapeziectomy with autologous interposition graft In the 1970s, many surgeons adopted techniques to fill the trapezial void after excision. Most of these techniques used autologous tissues, usually tendon, and also reconstructed or reinforced the TMC joint ligaments. Burton29 and Tomaino et al30 used the flexor carpi radialis (FCR) for LRTI. Others have used the palmaris longus31 or abductor pollicis longus (APL).32 Many authors also created a sling between the APL and FCR33 or a suspensionplasty between the bases of the first and second metacarpals.34
ARTHROSCOPIC DEBRIDEMENT Arthroscopic treatment of TMC joint arthritis is relatively new and a paucity of clinical reports note its efficacy.13 Indications for TMC joint arthroscopy include assessment of cartilage integrity, synovectomy, and loose body removal. Partial or total trapeziectomy performed arthroscopically is possible.14 Adams’14 systematic review of arthroscopy for TMC arthritis identified 11 articles describing arthroscopic debridement or partial trapeziectomy. Patient outcomes were satisfactory across series. Most series suggested improvement in pinch and grip strength, although one15 demonstrated no difference in preoperative and postoperative values. All series suggested reduced pain and improved satisfaction, which were similar to improvement documented in open studies. Results were durable over time, although the longest average follow-up over all series was 7.6 years.16
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and proximal interphalangeal joints. The prosthesis rested on the scaphoid with a distal stem inserted into thumb metacarpal. This prosthesis became widely accepted.39 Eaton40 described a modified implant with a transverse hole for passage of an FCR strip. Silicone synovitis proved to be a major complication noted on long-term follow-up. Implant degradation, reactive synovitis, bone cyst formation, and pain often required implant removal.41 Metal and/or ceramic trapezial implants appeared in the 1970s and 1980s. Design concepts included constrained ball and socket joints, total joint prostheses, and hemi-joint arthroplasties. De la Caffiniere and Aucouturier’s42 ball-and-socket replacement fell out of favor owing to complications, including a 44% loosening rate.43 However, satisfactory power, thumb mobility, and pain relief were present in 74% of patients at long-term follow-up.43,44 In 1997, Calandruccio and Jobe45 introduced a spherical implant made of yttrium-stabilized zirconia, called the Orthosphere. Based on nearly universal adverse radiographic findings at medium-term follow-up, the inventors discontinued use of the implant.46 Pyrocarbon implants were introduced more recently.47 Early follow-up suggests reasonable results.48 It is too early to determine whether these implants will experience similar failures encountered with implants composed of other materials.49
allowing the hematoma to turn into a large and dense cushion of scar tissue. In addition, the volume of tendon graft used in the “anchovy” procedures pales compared with the volume of the trapezium. The average trapezium is 3.7 cm3, the average palmaris longus anchovy is 0.9 cm3 (less than 25% of trapezial volume), and the average two-thirds slip of FCR anchovy is 1.0 cm3 (less than 33% of trapezial volume).51 Moreover, there are no major long-term differences in outcomes among these techniques.9e11 Trapeziectomy alone has the lowest incidence of complications10 and the shortest operative time.23,52 ISOLATED VOLAR LIGAMENT RECONSTRUCTION Eaton40 and Littler used the FCR for volar ligament reconstruction to treat early-stage disease. Eaton et al53 and Lane and Eaton54 reported excellent long-term pain relief and restoration of pinch with no radiographic degeneration. After 15 years, 80% of patients (15 of 19) were at least 90% satisfied and only 8% of thumbs demonstrated arthritis radiographically.55 A similar technique using the APL tendon also demonstrated favorable results.56 This technique is appropriate for early-stage disease, and articular surfaces must be normal. Isolated volar LR has a role in patients with symptomatic volar ligament laxity and normal radiographic appearance. When conservative treatment fails for hypermobile patients, volar LR alleviates pain and may prevent or retard degenerative disease.
Authors’ opinion Hentz noted in a recent review:
Current Concepts
Of the many surgical techniques described over the last 60 þ years to treat TMC joint arthritis, no one technique has yet been firmly established as superior in terms of the metric most important to most patients, namely, relief of pain. What is common to all resection arthroplasty procedures is the creation of a sufficiently stable pseudarthrosis. One can argue that, as long as this is achieved, further surgical interventions may be considered superfluous until proven otherwise by properly designed randomized trials.50
ARTHRODESIS Although rarely performed, TMC joint arthrodesis preserves the thumb’s osseous foundation and provides a reasonable alternative for high-demand patients, such as young laborers.57,58 Arthrodesis works best for moderate TMC arthritic changes without scaphotrapezial arthritis. The procedure transfers axial loading to the scaphotrapezial joint. METACARPAL OSTEOTOMY Extension osteotomy, also not commonly preformed, may benefit patients with mild to moderate TMC joint arthritis. A closing wedge osteotomy places the thumb metacarpal base in 30 extension without the need for soft tissue reconstruction.13 Patients with hypermobile TMC joints may benefit from this procedure. The mechanism for pain relief is unknown but probably involves load transfer and diminished laxity.59 Gwynne-Jones et al60 reported on 26 patients with metacarpal extension osteotomy
We believe that simple trapeziectomy with HDA is as effective as more complicated procedures.21 Although it seems unsettling to remove the trapezium and not fill the void, the body has remarkable capacities of self-healing. Trapeziectomy denervates the area and provides pain relief. The development of a robust scar in the trapezial void cushions the thumb metacarpal against the adjacent bones. We think immobilization in a distracted position is critical to J Hand Surg Am.
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K-wire fixation. Patients then wore a thumb spica orthosis or cast for 5 to 6 weeks. The K-wire and cast were removed simultaneously and patients gradually resumed function over the following 6 weeks. Beginning in 2011, in an effort to simplify the procedure and eliminate K-wire problems, the senior author adopted a variation of Weilby’s technique, in which a strip of distally attached FCR is wound around the APL and the remaining FCR is fixed at the thumb MCP joint base. We achieve the same suspension and stabilization with a heavy nonabsorbable suture drawing the APL and the FCR into the trapezial void. The patient wears a plaster orthosis for 2 weeks and then a removable thermoplastic brace for 4 weeks. Anecdotally, these patients seem to recover and function identically to those whose MCP joints were temporarily supported with a K-wire. Essentially, tendon tethering accomplishes the same goal (maintaining a large gap between the thumb metacarpal base and the scaphoid and holding the thumb and index MCP joint bases in close proximity) as the technique of Davis and Pace63 of suturing the dorsal capsule to the FCR tendon. With either K-wire distraction or APLeextensor pollicis brevis tethering, external immobilization for 5 to 6 weeks is necessary to allow a scar cushion to develop.
for stage II/III disease; 79% had good or excellent results after an average of 3 years. AREAS OF CONTROVERSY Metacarpophalangeal joint hyperextension With longstanding TMC joint arthritis and adduction contracture, MCP joint hyperextension may develop and contribute to weakness and further MC base instability. Mild MCP joint hyperlaxity may resolve spontaneously after correction of TMC joint subluxation. If hyperextension exceeds 30 , volar plate capsulodesis or extensor pollicis brevis transfer followed by fixation of the MCP joint in slight flexion for 4 weeks with use of an orthosis or a K-wire provides stability. For extreme hyperextension, volar plate capsulodesis or MCP joint arthrodesis is recommended.61 Management of failed primary basilar thumb joint reconstructions Numerous etiologies may cause failure of TMC arthroplasty,62 which is typically procedure-specific. For trapeziectomy, causes of failure include infection, sensory nerve injury, CRPS, and impingement between the thumb MCP joint and scaphoid or second MCP joint. For implant techniques, causes of failure include loosening, dislocation-subluxation, peritrapezial arthritis, implant fragmentation, and foreign body reaction. For arthrodesis, causes of failure include nonunion, peritrapezial arthritis, MCP joint instability or arthritis, and hardware impingement.61 One should first distinguish neurogenic (nonmechanical) from mechanical causes of failure before treating a failed TMC joint arthroplasty. Mechanical failures causing persistent pain or thumb base instability may be the best indications for revision surgery. Patients typically report grinding or instability with pinch or grip, and examination often reveals painful crepitation at the MCP base with loading or grinding maneuvers. Selection of the appropriate revision procedure depends on what technique was originally used and its presumed cause of failure. The pathology encountered intraoperatively may alter the plan. Our preferred technique for revision of failed implant arthroplasty is arthrodesis, and for most soft tissue arthroplasties, the HDA.23
SURGICAL TREATMENT OPTIONS FOR THUMB MCP ARTHRITIS Options for surgical treatment of arthritis in the MCP include arthroscopic synovectomy, arthroplasty, and arthrodesis.
ARTHROPLASTY Silicone implants are available but are rarely used for thumb MCP arthroplasty given the high loads placed on the joint. Beckenbaugh and Steffee65 introduced a 2-part (polyethylene and metal) joint in the 1970s. Survival of the implant was 93% at 5 years and 89% at 10 years, with 4 failures in 54 thumbs.66 More recently, pyrocarbon implants have been introduced for MCP and IP degenerative joint disease, but their use in the thumb has been limited. ARTHRODESIS Arthrodesis is a well-recognized effective treatment of thumb MCP arthritis. Motion is sacrificed to preserve r
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ARTHROSCOPIC DEBRIDEMENT Shin and Osterman64 described arthroscopic debridement and synovectomy of the MCP joint with a 2.0-mm shaver (or radiofrequency probe).
AUTHORS’ CURRENT PREFERRED TECHNIQUE FOR TMC ARTHROPLASTY For over 25 years, the senior author (R.A.M.) treated almost every case of TMC arthritis with HDA and J Hand Surg Am.
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REFERENCES
stability and reduce pain. Techniques include K-wire fixation,67 tension band wiring,68 bone screws,69,70 and plate fixation.71 The ideal position of MCP fixation is approximately 5 to 20 flexion with approximately 15 internal rotation.72e74
1. Moran SL, Berger RA. Biomechanics and hand trauma: what you need. Hand Clin. 2003;19(1):17e31. 2. Armstrong AL, Hunter JB, Davis TR. The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. J Hand Surg Br. 1994;19(3):340e341. 3. Haara MM, Heliovaara M, Kroger H, et al. Osteoarthritis in the carpometacarpal joint of the thumb: prevalence and associations with disability and mortality. J Bone Joint Surg Am. 2004;86(7): 1452e1457. 4. Sodha S, Ring D, Zurakowski D, Jupiter JB. Prevalence of osteoarthrosis of the trapeziometacarpal joint. J Bone Joint Surg Am. 2005;87(12):2614e2618. 5. Feldon P, Belsky MR. Degenerative diseases of the metacarpophalangeal joints. Hand Clin. 1987;3(3):429e447. 6. Hunter DJ, Zhang Y, Nevitt MC, et al. Chopstick arthropathy: the Beijing Osteoarthritis Study. Arthritis Rheum. 2004;50(5):1495e1500. 7. Doyle JR, Botte MJ. Surgical Anatomy of the Hand and Upper Extremity. Philadelphia, PA: Lippincott, Williams & Wilkins; 2003. 8. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rationale for treatment. Hand Clin. 1987;3(4):455e471. 9. Martou GMS, Veltri KMS, Thoma AMD. Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review. Plast Reconstr Surg. 2004;114(2):421e432. 10. Wajon A, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2009;(4):CD004631. 11. Vermeulen GM, Slijper H, Feitz R, Hovius SER, Moojen TM, Selles RW. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am. 2011;36(1): 157e169. 12. 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;128(1): 199e207. 13. Barron OA, Catalano LW. Thumb basal joint arthritis. In: Wolfe SWW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier, Churchill Livingstone; 2010. 14. Adams J. Does arthroscopic débridement with or without interposition material address carpometacarpal arthritis? Clin Orthop. 2014;472(4):1166e1172. 15. Adams JE, Merten SM, Steinmann SP. Arthroscopic interposition arthroplasty of the first carpometacarpal joint. J Hand Surg Eur Vol. 2007;32(3):268e274. 16. Hofmeister EP, Leak RS, Culp RW, Osterman AL. Arthroscopic hemitrapeziectomy for first carpometacarpal arthritis: results at 7-year follow-up. Hand (N Y). 2009;4(1):24e28. 17. Gervis WH. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint. J Bone Joint Surg Br. 1949;31(4):537e539. 18. Goldner JL, Clippinger FW. Excision of the greater multangular bone as an adjunct to mobilization of the thumb. J Bone Joint Surg Am. 1959;41(4):609e625. 19. Murley AHG. Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint. J Bone Joint Surg Br. 1960;42(3):502e507. 20. Davis TRC, Brady O, Barton NJ, Lunn PG, Burke FD. Trapeziectomy alone, with tendon interposition or with ligament reconstruction? A randomized prospective study. J Hand Surg Br. 1997;22(6):689e694. 21. Mahoney JD, Meals RA. Trapeziectomy. Hand Clin. 2006;22(2): 165e169. 22. Jones NF, Maser BM. Treatment of arthritis of the trapeziometacarpal joint with trapeziectomy and hematoma arthroplasty. Hand Clin. 2001;17(2):237e243. 23. Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective, singlesurgeon study including outcomes measures. J Hand Surg Am. 2003;28(3):381e389.
Authors’ opinion Similar to arthroscopy and implant arthroplasty for TMC arthritis, we feel that more data are needed before these techniques can be recommended for routine treatment of the thumb MCP joint. The thumb MCP joint requires stability to lateral and axial forces, and arthrodesis is reliable and effective.
Current Concepts
SURGICAL TREATMENT OPTIONS FOR THUMB IP ARTHRITIS Aside from arthrodesis, few options exist for surgical treatment of thumb IP joint arthritis. The ideal position for the thumb IP joint is 0 to 15 flexion although this position may be amended to fit the patient’s needs.72 Similar to MCP arthrodesis, methods of IP arthrodesis include K-wires, headless compression screws, and external devices.75e77 In conclusion, treatment of TMC arthritis has essentially come full circle. Treatment began with simple trapezial excision to eliminate contact between the arthritic joint surfaces, evolved into several more technically complex procedures, and to some degree has returned to its origins. Early on, Gervis17 described simple trapeziectomy and demonstrated favorable long-term patient satisfaction.78 Concern about residual pain and shortening with less predictable patient satisfaction led to the development of various ligament stabilization procedures with and without trapezial excision.53,79,80 Methods of TMC arthroplasty expanded to include implementation of silicone, metal, polyethylene, and biologic materials.40,42,81 Outcomes and complications to date favor reconstructive procedures that rely on autogenous tissue only.82e84 In addition, comparative studies have found no significant difference in outcomes between simple excision and more complex LR and TI procedures.80,85,86 Based on diminished operative time, complexity, and complication risk, we recommend a minimal HDA or APLeFCR suture suspensionplasty. Surgical options for thumb MCP and IP arthritis are limited. Arthrodesis is the primary treatment option for both joints although arthroscopic synovectomy and implant arthroplasty may have a role in the treatment of MCP joint arthritis. J Hand Surg Am.
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46. Adams BD, Pomerance J, Nguyen A, Kuhl TL. Early outcome of spherical ceramic trapezial-metacarpal arthroplasty. J Hand Surg Am. 2009;34(2):213e218. 47. Woodward JF, Heller JB, Jones NF. Pyrocarbon implant hemiarthroplasty for trapeziometacarpal arthritis. Tech Hand Up Extrem Surg. 2013;17(1):7e12. 48. Mariconda M, Russo S, Smeraglia F, Busco G. Partial trapeziectomy and pyrocarbon interpositional arthroplasty for trapeziometacarpal joint osteoarthritis: results after minimum 2 years of follow-up. J Hand Surg Eur Vol. 2014;39(6):604e610. 49. Vitale MA, Taylor F, Ross M, Moran SL. Trapezium prosthetic arthroplasty (silicone, Artelon, metal, and pyrocarbon). Hand Clin. 2013;29(1):37e55. 50. Hentz V. Surgical treatment of trapeziometacarpal joint arthritis: a historical perspective. Clin Orthop Relat Res. 2014;472(4): 1184e1189. 51. Gray KV, Meals R. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up. J Hand Surg Am. 2007;32(1):23e29. 52. Park MJ, Lichtman G, Christian JB, et al. Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995-2005. Hand (N Y). 2008;3(4):304e310. 53. Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment. J Hand Surg Am. 1984;9(5):692e699. 54. Lane LB, Eaton RG. Ligament reconstruction for the painful “prearthritic” thumb carpometacarpal joint. Clin Orthop Relat Res. 1987;(220):52e57. 55. Freedman DM, Eaton RG, Glickel SZ. Long-term results of volar ligament reconstruction for symptomatic basal joint laxity. J Hand Surg Am. 2000;25(2):297e304. 56. Roberts SNJ, Brown JN, Hayes MG, Saies A. The early results of the Brunelli procedure for trapeziometacarpal instability. J Hand Surg Br. 1998;23(6):758e761. 57. Fulton DB, Stern PJ. Trapeziometacarpal arthrodesis in primary osteoarthritis: a minimum two-year follow-up study. J Hand Surg Am. 2001;26(1):109e114. 58. Rizzo M, Moran SL, Shin AY. Long-term outcomes of trapeziometacarpal arthrodesis in the management of trapeziometacarpal arthritis. J Hand Surg Am. 2009;34(1):20e26. 59. Tomaino MM. Thumb by metacarpal extension osteotomy: rationale and efficacy for Eaton stage I disease. Hand Clin. 2006;22(2): 137e141. 60. Gwynne-Jones DP, Penny ID, Sewell SA, Hughes TH. Basal thumb metacarpal osteotomy for trapeziometacarpal osteoarthritis. J Orthop Surg (Hong Kong). 2006;14(1):58e63. 61. Mitchell SA, Meals RA. Surgical options for failed thumb basal joint arthroplasty. In: Duncan SFM, ed. Reoperative Hand Surgery. New York, NY: Springer; 2012:67e77. 62. Wagner WF. Why ligament reconstruction, tendon interposition arthroplasty fails, and salvaging failed ligament reconstruction, tendon interposition arthroplasty. Curr Opin Orthop. 2006;17(4): 288e294. 63. Davis TRC, Pace A. trapeziectomy for trapeziometacarpal joint osteoarthritis: is ligament reconstruction and temporary stabilisation of the pseudarthrosis with a Kirschner wire important? J Hand Surg Eur Vol. 2009;34(3):312e321. 64. Shin EK, Osterman AL. Treatment of thumb metacarpophalangeal and interphalangeal joint arthritis. Hand Clin. 2008;24(3):239e250. v. 65. Beckenbaugh RD, Steffee AD. Total joint arthroplasty for the metacarpophalangeal joint of the thumb—a preliminary report. Orthopedics. 1981;4(3):295e298. 66. McGovern RM, Shin AY, Beckenbaugh RD, Linscheid RL. Longterm results of cemented Steffee arthroplasty of the thumb metacarpophalangeal joint. J Hand Surg Am. 2001;26(1):115e122. 67. Bicknell RT, MacDermid J, Roth JH. Assessment of thumb metacarpophalangeal joint arthrodesis using a single longitudinal K-wire. J Hand Surg Am. 2007;32(5):677e684.
24. Gibbons CE, Gosal HS, Choudri AH, Magnussen PA. Trapeziectomy for basal thumb joint osteoarthritis: 3- to 19-year follow-up. Int Orthop. 1999;23(4):216e218. 25. Downing ND, Davis TRC. Trapezial space height after trapeziectomy: mechanism of formation and benefits. J Hand Surg Am. 2001;26(5):862e868. 26. Taylor EJ, Desari K, D’Arcy JC, Bonnici AV. A comparison of fusion, trapeziectomy and Silastic replacement for the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg Br. 2005;30(1):45e49. 27. Brunton LM, Wilgis EFS. A survey to determine current practice patterns in the surgical treatment of advanced thumb carpometacarpal osteoarthrosis. Hand (N Y). 2010;5(4):415e422. 28. Wolf JM, Delaronde S. Current trends in nonoperative and operative treatment of trapeziometacarpal osteoarthritis: a survey of US hand surgeons. J Hand Surg Am. 2012;37(1):77e82. 29. Burton RI. Basal joint arthritis: fusion, implant, or soft tissue reconstruction? Orthop Clin North Am. 1986;17(3):493e503. 30. Tomaino M, Pellegrini V, Burton R. Arthroplasty of the basal joint of the thumb: long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am. 1995;77(3):346e355. 31. Dell PC, Brushart TM, Smith RJ. Treatment of trapeziometacarpal arthritis: results of resection arthroplasty. J Hand Surg Am. 1978;3(3):243e249. 32. Rocchi L, Merolli A, Cotroneo C, Morini A, Brunelli F, Catalano F. Abductor pollicis longus hemitendon looping around the first intermetacarpal ligament as interposition following trapeziectomy: a oneyear follow-up study. Orthop Traumatol Surg Res. 2011;97(7): 726e733. 33. Varley GW, Calvey J, Hunter JB, Barton NJ, Davis TR. Excision of the trapezium for osteoarthritis at the base of the thumb. J Bone Joint Surg Br. 1994;76(6):964e968. 34. Diao E. Trapezio-metacarpal arthritis: trapezium excision and ligament reconstruction not including the LRTI arthroplasty. Hand Clin. 2001;17(2):223e236. ix. 35. Cox CA, Zlotolow DA, Yao J. Suture button suspensionplasty after arthroscopic hemitrapeziectomy for treatment of thumb carpometacarpal arthritis. Arthroscopy. 2010;26(10):1395e1403. 36. Yao J, Zlotolow DA, Murdock R, Christian M. Suture button compared with K-wire fixation for maintenance of posttrapeziectomy space height in a cadaver model of lateral pinch. J Hand Surg Am. 2010;35(12):2061e2065. 37. Yao J, Song Y. Suture-button suspensionplasty for thumb carpometacarpal arthritis: a minimum 2-year follow-up. J Hand Surg Am. 2013;38(6):1161e1165. 38. Swanson AB. Disabling arthritis at the base of the thumb: treatment by resection of the trapezium and flexible (silicone) implant arthroplasty. J Bone Joint Surg Am. 1972;54(3):456e471. 39. Swanson AB, Herndon JH. Flexible (silicone) implant arthroplasty of the metacarpophalangeal joint of the thumb. J Bone Joint Surg Am. 1977;59(3):362e368. 40. Eaton RG. Replacement of the trapezium for arthritis of the basal articulations: a new technique with stabilization by tenodesis. J Bone Joint Surg Am. 1979;61(1):76e82. 41. Carter PR, Benton LJ, Dysert PA. Silicone rubber carpal implants: a study of the incidence of late osseous complications. J Hand Surg Am. 1986;11(5):639e644. 42. De la Caffiniere JY, Aucouturier P. Trapezio-metacarpal arthroplasty by total prosthesis: the hand 1979;11(1):41e46. 43. Van Cappelle HGJ, Elzenga P, van Horn JR. Long-term results and loosening analysis of de la Caffinière replacements of the trapeziometacarpal joint. J Hand Surg Am. 1999;24(3):476e482. 44. Johnston P, Getgood A, Larson D, Chojnowski AJ, Chakrabarti AJ, Chapman PG. De la Caffinière thumb trapeziometacarpal joint arthroplasty: 16e26 year follow-up. J Hand Surg Eur Vol. 2012;37(7):621e624. 45. Calandruccio JH, Jobe MT. Arthroplasty of the thumb carpometacarpal joint. Semin Arthroplasty. 1997;8(2):135e147.
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78. Gervis WH, Well T. A review of excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint after twenty-five years. J Bone Joint Surg Br. 1973;55(1):56e57. 79. Barron OA, Eaton RG. Save the trapezium: double interposition arthroplasty for the treatment of stage IV disease of the basal joint. J Hand Surg Am. 1998;23(2):196e204. 80. Davis TRC, Brady O, Dias JJ. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition. J Hand Surg Am. 2004;29(6):1069e1077. 81. Nicholas R, Calderwood J. De la Caffiniere arthroplasty for basal thumb joint osteoarthritis. J Bone Joint Surg Br. 1992;74(2):309e312. 82. Athwal GS, Chenkin J, King GJ, Pichora DR. Early failures with a spheric interposition arthroplasty of the thumb basal joint. J Hand Surg Am. 2004;29(6):1080e1084. 83. Minami A, Iwasaki N, Kutsumi K, Suenaga N, Yasuda K. A longterm follow-up of silicone-rubber interposition arthroplasty for osteoarthritis of the thumb carpometacarpal joint. Hand Surg. 2005;10(1):77e82. 84. Blount AL, Armstrong SD, Yuan F, Burgess SD. Porous polyurethaneurea (Artelon) joint spacer compared to trapezium resection and ligament reconstruction. J Hand Surg Am. 2013;38(9): 1741e1745. 85. Belcher HJ, Nicholl JE. A comparison of trapeziectomy with and without ligament reconstruction and tendon interposition. J Hand Surg Br. 2000;25(4):350e356. 86. Field J, Buchanan D. To suspend or not to suspend: a randomised single blind trial of simple trapeziectomy versus trapeziectomy and flexor carpi radialis suspension. J Hand Surg Eur Vol. 2007;32(4): 462e466.
68. Tsang C, Hunter AR, Sorene ED. Bilateral thumb metacarpophalangeal joint fusions for severe hyperextension deformities in conjunction with carpometacarpal joint reconstructions. Hand Surg. 2013;18(2):257e260. 69. Schmidt CC, Zimmer SM, Boles SD. Arthrodesis of the thumb metacarpophalangeal joint using a cannulated screw and threaded washer. J Hand Surg Am. 2004;29(6):1044e1050. 70. Messer TM, Nagle DJ, Martinez AG. Thumb metacarpophalangeal joint arthrodesis using the AO 3.0-mm cannulated screw: surgical technique. J Hand Surg Am. 2002;27(5):910e912. 71. Rao SB. Arthrodesis of the thumb metacarpophalangeal joint with plate fixation. Tech Hand Up Extrem Surg. 2012;16(4): 215e217. 72. Carroll RE, Hill NA. Small joint arthrodesis in hand reconstruction. J Bone Joint Surg Am. 1969;51(6):1219e1221. 73. Inglis AE, Hamlin C, Sengelmann RP, Straub LR. Reconstruction of the metacarpophalangeal joint of the thumb in rheumatoid arthritis. J Bone Joint Surg Am. 1972;54(4):704e712. 74. Rizzo M. Metacarpophalangeal joint arthritis. J Hand Surg Am. 2011;36(2):345e353. 75. Katzman SS, Gibeault JD, Dickson K, Thompson JD. Use of a Herbert screw for interphalangeal joint arthrodesis. Clin Orthop Relat Res. 1993;(296):127e132. 76. Leibovic SJ. Instructional Course Lecture: arthrodesis of the interphalangeal joints with headless compression screws. J Hand Surg Am. 2007;32(7):1113e1119. 77. Wyrsch B, Dawson J, Aufranc S, Weikert D, Milek M. Distal interphalangeal joint arthrodesis comparing tension-band wire and Herbert screw: a biomechanical and dimensional analysis. J Hand Surg Am. 1996;21(3):438e443.
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Management of Osteoarthrosis of the Thumb Joints Aaron J. Berger, MD, PhD, Roy A. Meals, MD
We present current concepts and evidence to optimize diagnosis and management of osteoarthritis in the thumb joints. Numerous options and controversies exist for surgical treatment of carpometacarpal joint arthritis. Fewer options exist for metacarpophalangeal joint arthritis. Surgical treatment for interphalangeal arthritis is mainly arthrodesis. (J Hand Surg Am. 2015;40(4):843e850. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Thumb, arthritis, arthrodesis, implant, arthroplasty.
THE
THUMB
PROVIDES
EPIDEMIOLOGY Primary osteoarthritis of the thumb joints is most commonly encountered in the trapeziometacarpal (TMC) joint and less commonly in the interphalangeal (IP) and metacarpophalangeal (MCP) joints. The prevalence of primary osteoarthritis in the TMC joint is reported to be as high as 15% in adults over age 30, and as many as one-third of postmenopausal women are affected by the condition.2e4 Little information is available regarding the prevalence of primary osteoarthritis occurring in the IP and MCP joints of the thumb. Reports have suggested that chronic repetitive trauma in patients with heavy From the Division of Plastic Surgery, Florida International University College of Medicine & Miami Children’s Hospital, Miami, FL; and the Department of Orthopedic Surgery, University of California at Los Angeles, Los Angeles, CA. Received for publication September 17, 2014; accepted in revised form November 19, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Roy A. Meals, MD, Department of Orthopedic Surgery, University of California at Los Angeles, 1033 Gayley Avenue, Suite 104, Los Angeles, CA 90024; e-mail: [email protected]. 0363-5023/15/4004-0039$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.11.026
labor occupations may contribute to the development of MCP joint osteoarthritis.5 Mechanical stress is also implicated in the development of thumb IP joint osteoarthritis, and chopstick use has been implicated in IP joint arthritis in China.6 RELEVANT ANATOMY The thumb lacks a middle phalanx and possesses a unique carpometacarpal joint configuration. Based at the TMC joint, the thumb is pronated and flexed relative to the other metacarpals, with the trapezium and scaphoid longitudinal axis oriented at a 45 angle relative to the index metacarpal and the carpus.7 This position, unique to humans, allows opposition and prehension but hastens the development of basal joint arthritis. Factors characterizing arthritis in the thumb joints include joint surface shape changes and ligament deterioration, followed by cartilage eburnation and bone spur formation. The TMC joint is classified as a sellar joint, with articular surfaces that are convex in one plane and concave in the second plane, with the planes oriented perpendicular to each other.7 Although primary movements may occur in 2 orthogonal planes (flexionextension and abduction-adduction), the articular shape also allows axial rotation (pronation-supination), which is especially important for pulp-to-pulp pinch between the thumb and adjacent digits. The MCP joint of the thumb is classified as an ellipsoid joint characterized by an oval convex surface proximally that is opposed to an elliptical concavity distally. It is slightly different in architecture from the MCP joints of the other fingers in that its curvature in
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approximately 40% of hand function and nearly one-fourth of overall bodily function,1 injuries and arthritis have serious implications for patients’ overall well-being. This review provides insight into recent publications and their relevance for treatment of osteoarthritis of the thumb joints. ECAUSE
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the anteroposterior plane is flatter; its dorsal side is slightly wider than its palmar side; its articular surface is divided into 2 zones, one that articulates with the proximal phalanx and the other, more palmar, with the sesamoids in the palmar plate; and the radial condyle of the metacarpal head has greater dorsal-palmar height than the ulnar condyle, which allows some pronation of the proximal and distal phalanges during flexion.7 The IP joint of the thumb, much like the IP joints of the other digits, is a uniaxial bicondylar hinge joint. It is typically stable in all positions owing to a strong supporting ligamentous architecture and symmetric side-by-side condyles.
positive Finkelstein testing suggests TMC osteoarthritis. An x-ray would help confirm this diagnosis. The EatoneGlickel8 classification system is most commonly used for radiographic staging of TMC arthritis. It is summarized below: Stage 1. Slight joint widening. Stage 2. Slight joint narrowing, minimal subchondral sclerosis, and joint debris (osteophytes or loose bodies) less than 2 mm. Stage 3. Marked narrowing or obliteration of joint space, cystic changes, sclerotic bone, varying degrees of dorsal subluxation, and joint debris greater than 2 mm. Stage 4. Stage 3 deterioration plus scaphotrapezial joint narrowing with sclerosis and cystic changes.
CLINICAL PICTURE Thumb TMC arthritis The history (typically pain with forceful pinch), physical examination, and x-rays guide diagnosis of TMC arthritis. Tenderness is at the TMC joint most easily accessible dorsally where it is not covered with muscle. Modification of activity, placement of an orthosis, and use of nonsteroidal anti-inflammatory medication and steroid injections may suffice. If not, surgery may help.
TREATMENT Treatment starts with modification of activity, placement of an orthosis, and use of nonsteroidal anti-inflammatory medication and steroid injections followed with surgery if necessary. Surgical treatment options for thumb TMC arthritis Root treatment for TMC joint arthritis is most often trapeziectomy performed alone, combined with tendon interposition (TI), ligament reconstruction (LR), or both (LRTI). Other procedures include volar ligament reconstruction, metacarpal osteotomy, carpometacarpal arthrodesis, and joint replacement. No study has conclusively demonstrated the superiority of one procedure in terms of patient outcome measures. A systematic literature review through 2001, which included 8 reviews and 18 comparative studies, demonstrated that each technique (arthrodesis, trapeziectomy with or without biological or synthetic interposition, metacarpal osteotomy, and joint replacement) had unique benefits and risks. The review suggested LRTI superiority, but most included studies had methodological flaws precluding conclusive recommendations. Studied comparative studies (randomized or nonrandomized) indicated that LRTI provided no benefit over TMC joint arthrodesis or trapeziectomy with or without TI.9 A Cochrane Collaboration systematic review in 2009 included 9 randomized or quasi-randomized trials (477 patients). The study compared trapeziectomy alone, trapeziectomy with TI, trapeziectomy with LR, trapeziectomy with LRTI, Artelon joint resurfacing, TMC arthrodesis, and joint replacement. Patients had stage II to IV osteoarthritis and wide-ranging improvement in pain and function. No procedure demonstrated superiority regarding pain, physical function, patient
Thumb MCP arthritis Thumb MCP joint osteoarthritis may develop after collateral ligament injuries or result from TMC joint arthritis.5 Here, basal joint flexion with dorsal and radial subluxation of metacarpal base causes MCP joint hyperextension before arthritis. Thumb IP arthritis Mechanical stress causes degenerative changes at all IP joints including the thumb; osteophyte formation with mucous cysts is common.
Current Concepts
DIAGNOSIS Insidious onset and progression of pain are typically the presenting symptoms for osteoarthritis, whereas symptoms of gout, rheumatoid arthritis, and infections tend to develop rapidly. Passive joint motion under axial load is a sensitive test for diagnostic confirmation along with assessment of static and dynamic deformities. A Finkelstein test would likely cause pain at an arthritic TMC joint, and a positive Finkelstein test would have to be carefully interpreted. If there is tenderness at the TMC and none at the first dorsal compartment and if there is no thickening at the first dorsal compartment, pain on J Hand Surg Am.
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TRAPEZIECTOMY In 1949, Gervis17 described trapeziectomy for TMC joint arthritis without wire or pin metacarpal stabilization and with movement beginning the following day. Goldner and Clippinger18 described adjuncts to trapeziectomy including gelatin sponge interposition and K-wire metacarpal support for several weeks. Murley19 immobilized thumbs in plaster for 3 weeks. Trapeziectomy with K-wire fixation (also known as hematoma-distraction arthroplasty [HDA]) demonstrates almost universal pain relief and often improved strength.20e26 Comparative studies have indicated equally successful outcomes of HDA and more complex procedures. However, recent surveys of United States hand surgeons indicate that only 3% to 8% perform this technique routinely.27,28
global assessment, or motion arc. A total of 22% of LRTI patients had scar tenderness, tendon adhesion or rupture, sensory change, or complex regional pain syndrome (CRPS-1) compared to 10% who underwent trapeziectomy alone.10 A more recent systematic review with less stringent inclusion criteria identified 35 articles, including 9 that had previously been unanalyzed, and assessed the outcomes of volar ligament reconstruction, metacarpal osteotomy, arthrodesis, joint replacement and trapeziectomy with TI, LR, and LRTI. Again, no surgical procedure was superior to another.11 Li et al12 specifically compared isolated trapeziectomy and trapeziectomy with LRTI in an analysis of 2 systematic reviews and 4 randomized controlled trials. Outcome measures included motion, grip and pinch strength, health costs, complications, pain relief, hand function, overall satisfaction, and quality of life. Neither procedure proved superior for the outcome measures investigated. Almost all investigators conclude that there is at best minimal difference in outcomes over simple trapeziectomy and more complex procedures have more complications.
Trapeziectomy with suspension arthroplasty As an adjunct to trapeziectomy, various techniques suspend the first metacarpal. These techniques typically fill the trapezial void and/or route local tendons (usually the FCR and/or APL) through the first metacarpal base to suspend it. Cox et al35 described a suture button technique for suspensionplasty that achieves stability similar to Kwire fixation36 but allows mobilization after 10 days. After 2 years, the only major complications were individual cases of CRPS and index metacarpal fracture. Subjective and objective outcome measures were similar to other techniques.37 This technique’s major benefit is mobilization beginning at 10 days compared with 4 to 6 weeks for K-wireebased techniques.
Authors’ opinion More and longer-term data are needed for arthroscopic debridement to become routine for TMC arthritis, especially advanced pantrapezial disease. Smaller skin scars and preservation of the articular capsule are questionably worth the cost in operative time and equipment along with risk to neurovascular structures.
Prosthetic TMC joint replacement (with or without trapeziectomy) Most prosthetic devices for TMC joint arthroplasty have ultimately demonstrated failures requiring revision.34e37 Swanson38 developed a trapezial spacer based on his original concept of silicone prostheses for the MCP r
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Trapeziectomy with autologous interposition graft In the 1970s, many surgeons adopted techniques to fill the trapezial void after excision. Most of these techniques used autologous tissues, usually tendon, and also reconstructed or reinforced the TMC joint ligaments. Burton29 and Tomaino et al30 used the flexor carpi radialis (FCR) for LRTI. Others have used the palmaris longus31 or abductor pollicis longus (APL).32 Many authors also created a sling between the APL and FCR33 or a suspensionplasty between the bases of the first and second metacarpals.34
ARTHROSCOPIC DEBRIDEMENT Arthroscopic treatment of TMC joint arthritis is relatively new and a paucity of clinical reports note its efficacy.13 Indications for TMC joint arthroscopy include assessment of cartilage integrity, synovectomy, and loose body removal. Partial or total trapeziectomy performed arthroscopically is possible.14 Adams’14 systematic review of arthroscopy for TMC arthritis identified 11 articles describing arthroscopic debridement or partial trapeziectomy. Patient outcomes were satisfactory across series. Most series suggested improvement in pinch and grip strength, although one15 demonstrated no difference in preoperative and postoperative values. All series suggested reduced pain and improved satisfaction, which were similar to improvement documented in open studies. Results were durable over time, although the longest average follow-up over all series was 7.6 years.16
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and proximal interphalangeal joints. The prosthesis rested on the scaphoid with a distal stem inserted into thumb metacarpal. This prosthesis became widely accepted.39 Eaton40 described a modified implant with a transverse hole for passage of an FCR strip. Silicone synovitis proved to be a major complication noted on long-term follow-up. Implant degradation, reactive synovitis, bone cyst formation, and pain often required implant removal.41 Metal and/or ceramic trapezial implants appeared in the 1970s and 1980s. Design concepts included constrained ball and socket joints, total joint prostheses, and hemi-joint arthroplasties. De la Caffiniere and Aucouturier’s42 ball-and-socket replacement fell out of favor owing to complications, including a 44% loosening rate.43 However, satisfactory power, thumb mobility, and pain relief were present in 74% of patients at long-term follow-up.43,44 In 1997, Calandruccio and Jobe45 introduced a spherical implant made of yttrium-stabilized zirconia, called the Orthosphere. Based on nearly universal adverse radiographic findings at medium-term follow-up, the inventors discontinued use of the implant.46 Pyrocarbon implants were introduced more recently.47 Early follow-up suggests reasonable results.48 It is too early to determine whether these implants will experience similar failures encountered with implants composed of other materials.49
allowing the hematoma to turn into a large and dense cushion of scar tissue. In addition, the volume of tendon graft used in the “anchovy” procedures pales compared with the volume of the trapezium. The average trapezium is 3.7 cm3, the average palmaris longus anchovy is 0.9 cm3 (less than 25% of trapezial volume), and the average two-thirds slip of FCR anchovy is 1.0 cm3 (less than 33% of trapezial volume).51 Moreover, there are no major long-term differences in outcomes among these techniques.9e11 Trapeziectomy alone has the lowest incidence of complications10 and the shortest operative time.23,52 ISOLATED VOLAR LIGAMENT RECONSTRUCTION Eaton40 and Littler used the FCR for volar ligament reconstruction to treat early-stage disease. Eaton et al53 and Lane and Eaton54 reported excellent long-term pain relief and restoration of pinch with no radiographic degeneration. After 15 years, 80% of patients (15 of 19) were at least 90% satisfied and only 8% of thumbs demonstrated arthritis radiographically.55 A similar technique using the APL tendon also demonstrated favorable results.56 This technique is appropriate for early-stage disease, and articular surfaces must be normal. Isolated volar LR has a role in patients with symptomatic volar ligament laxity and normal radiographic appearance. When conservative treatment fails for hypermobile patients, volar LR alleviates pain and may prevent or retard degenerative disease.
Authors’ opinion Hentz noted in a recent review:
Current Concepts
Of the many surgical techniques described over the last 60 þ years to treat TMC joint arthritis, no one technique has yet been firmly established as superior in terms of the metric most important to most patients, namely, relief of pain. What is common to all resection arthroplasty procedures is the creation of a sufficiently stable pseudarthrosis. One can argue that, as long as this is achieved, further surgical interventions may be considered superfluous until proven otherwise by properly designed randomized trials.50
ARTHRODESIS Although rarely performed, TMC joint arthrodesis preserves the thumb’s osseous foundation and provides a reasonable alternative for high-demand patients, such as young laborers.57,58 Arthrodesis works best for moderate TMC arthritic changes without scaphotrapezial arthritis. The procedure transfers axial loading to the scaphotrapezial joint. METACARPAL OSTEOTOMY Extension osteotomy, also not commonly preformed, may benefit patients with mild to moderate TMC joint arthritis. A closing wedge osteotomy places the thumb metacarpal base in 30 extension without the need for soft tissue reconstruction.13 Patients with hypermobile TMC joints may benefit from this procedure. The mechanism for pain relief is unknown but probably involves load transfer and diminished laxity.59 Gwynne-Jones et al60 reported on 26 patients with metacarpal extension osteotomy
We believe that simple trapeziectomy with HDA is as effective as more complicated procedures.21 Although it seems unsettling to remove the trapezium and not fill the void, the body has remarkable capacities of self-healing. Trapeziectomy denervates the area and provides pain relief. The development of a robust scar in the trapezial void cushions the thumb metacarpal against the adjacent bones. We think immobilization in a distracted position is critical to J Hand Surg Am.
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K-wire fixation. Patients then wore a thumb spica orthosis or cast for 5 to 6 weeks. The K-wire and cast were removed simultaneously and patients gradually resumed function over the following 6 weeks. Beginning in 2011, in an effort to simplify the procedure and eliminate K-wire problems, the senior author adopted a variation of Weilby’s technique, in which a strip of distally attached FCR is wound around the APL and the remaining FCR is fixed at the thumb MCP joint base. We achieve the same suspension and stabilization with a heavy nonabsorbable suture drawing the APL and the FCR into the trapezial void. The patient wears a plaster orthosis for 2 weeks and then a removable thermoplastic brace for 4 weeks. Anecdotally, these patients seem to recover and function identically to those whose MCP joints were temporarily supported with a K-wire. Essentially, tendon tethering accomplishes the same goal (maintaining a large gap between the thumb metacarpal base and the scaphoid and holding the thumb and index MCP joint bases in close proximity) as the technique of Davis and Pace63 of suturing the dorsal capsule to the FCR tendon. With either K-wire distraction or APLeextensor pollicis brevis tethering, external immobilization for 5 to 6 weeks is necessary to allow a scar cushion to develop.
for stage II/III disease; 79% had good or excellent results after an average of 3 years. AREAS OF CONTROVERSY Metacarpophalangeal joint hyperextension With longstanding TMC joint arthritis and adduction contracture, MCP joint hyperextension may develop and contribute to weakness and further MC base instability. Mild MCP joint hyperlaxity may resolve spontaneously after correction of TMC joint subluxation. If hyperextension exceeds 30 , volar plate capsulodesis or extensor pollicis brevis transfer followed by fixation of the MCP joint in slight flexion for 4 weeks with use of an orthosis or a K-wire provides stability. For extreme hyperextension, volar plate capsulodesis or MCP joint arthrodesis is recommended.61 Management of failed primary basilar thumb joint reconstructions Numerous etiologies may cause failure of TMC arthroplasty,62 which is typically procedure-specific. For trapeziectomy, causes of failure include infection, sensory nerve injury, CRPS, and impingement between the thumb MCP joint and scaphoid or second MCP joint. For implant techniques, causes of failure include loosening, dislocation-subluxation, peritrapezial arthritis, implant fragmentation, and foreign body reaction. For arthrodesis, causes of failure include nonunion, peritrapezial arthritis, MCP joint instability or arthritis, and hardware impingement.61 One should first distinguish neurogenic (nonmechanical) from mechanical causes of failure before treating a failed TMC joint arthroplasty. Mechanical failures causing persistent pain or thumb base instability may be the best indications for revision surgery. Patients typically report grinding or instability with pinch or grip, and examination often reveals painful crepitation at the MCP base with loading or grinding maneuvers. Selection of the appropriate revision procedure depends on what technique was originally used and its presumed cause of failure. The pathology encountered intraoperatively may alter the plan. Our preferred technique for revision of failed implant arthroplasty is arthrodesis, and for most soft tissue arthroplasties, the HDA.23
SURGICAL TREATMENT OPTIONS FOR THUMB MCP ARTHRITIS Options for surgical treatment of arthritis in the MCP include arthroscopic synovectomy, arthroplasty, and arthrodesis.
ARTHROPLASTY Silicone implants are available but are rarely used for thumb MCP arthroplasty given the high loads placed on the joint. Beckenbaugh and Steffee65 introduced a 2-part (polyethylene and metal) joint in the 1970s. Survival of the implant was 93% at 5 years and 89% at 10 years, with 4 failures in 54 thumbs.66 More recently, pyrocarbon implants have been introduced for MCP and IP degenerative joint disease, but their use in the thumb has been limited. ARTHRODESIS Arthrodesis is a well-recognized effective treatment of thumb MCP arthritis. Motion is sacrificed to preserve r
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ARTHROSCOPIC DEBRIDEMENT Shin and Osterman64 described arthroscopic debridement and synovectomy of the MCP joint with a 2.0-mm shaver (or radiofrequency probe).
AUTHORS’ CURRENT PREFERRED TECHNIQUE FOR TMC ARTHROPLASTY For over 25 years, the senior author (R.A.M.) treated almost every case of TMC arthritis with HDA and J Hand Surg Am.
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stability and reduce pain. Techniques include K-wire fixation,67 tension band wiring,68 bone screws,69,70 and plate fixation.71 The ideal position of MCP fixation is approximately 5 to 20 flexion with approximately 15 internal rotation.72e74
1. Moran SL, Berger RA. Biomechanics and hand trauma: what you need. Hand Clin. 2003;19(1):17e31. 2. Armstrong AL, Hunter JB, Davis TR. The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. J Hand Surg Br. 1994;19(3):340e341. 3. Haara MM, Heliovaara M, Kroger H, et al. Osteoarthritis in the carpometacarpal joint of the thumb: prevalence and associations with disability and mortality. J Bone Joint Surg Am. 2004;86(7): 1452e1457. 4. Sodha S, Ring D, Zurakowski D, Jupiter JB. Prevalence of osteoarthrosis of the trapeziometacarpal joint. J Bone Joint Surg Am. 2005;87(12):2614e2618. 5. Feldon P, Belsky MR. Degenerative diseases of the metacarpophalangeal joints. Hand Clin. 1987;3(3):429e447. 6. Hunter DJ, Zhang Y, Nevitt MC, et al. Chopstick arthropathy: the Beijing Osteoarthritis Study. Arthritis Rheum. 2004;50(5):1495e1500. 7. Doyle JR, Botte MJ. Surgical Anatomy of the Hand and Upper Extremity. Philadelphia, PA: Lippincott, Williams & Wilkins; 2003. 8. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rationale for treatment. Hand Clin. 1987;3(4):455e471. 9. Martou GMS, Veltri KMS, Thoma AMD. Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review. Plast Reconstr Surg. 2004;114(2):421e432. 10. Wajon A, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2009;(4):CD004631. 11. Vermeulen GM, Slijper H, Feitz R, Hovius SER, Moojen TM, Selles RW. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am. 2011;36(1): 157e169. 12. 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;128(1): 199e207. 13. Barron OA, Catalano LW. Thumb basal joint arthritis. In: Wolfe SWW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier, Churchill Livingstone; 2010. 14. Adams J. Does arthroscopic débridement with or without interposition material address carpometacarpal arthritis? Clin Orthop. 2014;472(4):1166e1172. 15. Adams JE, Merten SM, Steinmann SP. Arthroscopic interposition arthroplasty of the first carpometacarpal joint. J Hand Surg Eur Vol. 2007;32(3):268e274. 16. Hofmeister EP, Leak RS, Culp RW, Osterman AL. Arthroscopic hemitrapeziectomy for first carpometacarpal arthritis: results at 7-year follow-up. Hand (N Y). 2009;4(1):24e28. 17. Gervis WH. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint. J Bone Joint Surg Br. 1949;31(4):537e539. 18. Goldner JL, Clippinger FW. Excision of the greater multangular bone as an adjunct to mobilization of the thumb. J Bone Joint Surg Am. 1959;41(4):609e625. 19. Murley AHG. Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint. J Bone Joint Surg Br. 1960;42(3):502e507. 20. Davis TRC, Brady O, Barton NJ, Lunn PG, Burke FD. Trapeziectomy alone, with tendon interposition or with ligament reconstruction? A randomized prospective study. J Hand Surg Br. 1997;22(6):689e694. 21. Mahoney JD, Meals RA. Trapeziectomy. Hand Clin. 2006;22(2): 165e169. 22. Jones NF, Maser BM. Treatment of arthritis of the trapeziometacarpal joint with trapeziectomy and hematoma arthroplasty. Hand Clin. 2001;17(2):237e243. 23. Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective, singlesurgeon study including outcomes measures. J Hand Surg Am. 2003;28(3):381e389.
Authors’ opinion Similar to arthroscopy and implant arthroplasty for TMC arthritis, we feel that more data are needed before these techniques can be recommended for routine treatment of the thumb MCP joint. The thumb MCP joint requires stability to lateral and axial forces, and arthrodesis is reliable and effective.
Current Concepts
SURGICAL TREATMENT OPTIONS FOR THUMB IP ARTHRITIS Aside from arthrodesis, few options exist for surgical treatment of thumb IP joint arthritis. The ideal position for the thumb IP joint is 0 to 15 flexion although this position may be amended to fit the patient’s needs.72 Similar to MCP arthrodesis, methods of IP arthrodesis include K-wires, headless compression screws, and external devices.75e77 In conclusion, treatment of TMC arthritis has essentially come full circle. Treatment began with simple trapezial excision to eliminate contact between the arthritic joint surfaces, evolved into several more technically complex procedures, and to some degree has returned to its origins. Early on, Gervis17 described simple trapeziectomy and demonstrated favorable long-term patient satisfaction.78 Concern about residual pain and shortening with less predictable patient satisfaction led to the development of various ligament stabilization procedures with and without trapezial excision.53,79,80 Methods of TMC arthroplasty expanded to include implementation of silicone, metal, polyethylene, and biologic materials.40,42,81 Outcomes and complications to date favor reconstructive procedures that rely on autogenous tissue only.82e84 In addition, comparative studies have found no significant difference in outcomes between simple excision and more complex LR and TI procedures.80,85,86 Based on diminished operative time, complexity, and complication risk, we recommend a minimal HDA or APLeFCR suture suspensionplasty. Surgical options for thumb MCP and IP arthritis are limited. Arthrodesis is the primary treatment option for both joints although arthroscopic synovectomy and implant arthroplasty may have a role in the treatment of MCP joint arthritis. J Hand Surg Am.
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46. Adams BD, Pomerance J, Nguyen A, Kuhl TL. Early outcome of spherical ceramic trapezial-metacarpal arthroplasty. J Hand Surg Am. 2009;34(2):213e218. 47. Woodward JF, Heller JB, Jones NF. Pyrocarbon implant hemiarthroplasty for trapeziometacarpal arthritis. Tech Hand Up Extrem Surg. 2013;17(1):7e12. 48. Mariconda M, Russo S, Smeraglia F, Busco G. Partial trapeziectomy and pyrocarbon interpositional arthroplasty for trapeziometacarpal joint osteoarthritis: results after minimum 2 years of follow-up. J Hand Surg Eur Vol. 2014;39(6):604e610. 49. Vitale MA, Taylor F, Ross M, Moran SL. Trapezium prosthetic arthroplasty (silicone, Artelon, metal, and pyrocarbon). Hand Clin. 2013;29(1):37e55. 50. Hentz V. Surgical treatment of trapeziometacarpal joint arthritis: a historical perspective. Clin Orthop Relat Res. 2014;472(4): 1184e1189. 51. Gray KV, Meals R. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up. J Hand Surg Am. 2007;32(1):23e29. 52. Park MJ, Lichtman G, Christian JB, et al. Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995-2005. Hand (N Y). 2008;3(4):304e310. 53. Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment. J Hand Surg Am. 1984;9(5):692e699. 54. Lane LB, Eaton RG. Ligament reconstruction for the painful “prearthritic” thumb carpometacarpal joint. Clin Orthop Relat Res. 1987;(220):52e57. 55. Freedman DM, Eaton RG, Glickel SZ. Long-term results of volar ligament reconstruction for symptomatic basal joint laxity. J Hand Surg Am. 2000;25(2):297e304. 56. Roberts SNJ, Brown JN, Hayes MG, Saies A. The early results of the Brunelli procedure for trapeziometacarpal instability. J Hand Surg Br. 1998;23(6):758e761. 57. Fulton DB, Stern PJ. Trapeziometacarpal arthrodesis in primary osteoarthritis: a minimum two-year follow-up study. J Hand Surg Am. 2001;26(1):109e114. 58. Rizzo M, Moran SL, Shin AY. Long-term outcomes of trapeziometacarpal arthrodesis in the management of trapeziometacarpal arthritis. J Hand Surg Am. 2009;34(1):20e26. 59. Tomaino MM. Thumb by metacarpal extension osteotomy: rationale and efficacy for Eaton stage I disease. Hand Clin. 2006;22(2): 137e141. 60. Gwynne-Jones DP, Penny ID, Sewell SA, Hughes TH. Basal thumb metacarpal osteotomy for trapeziometacarpal osteoarthritis. J Orthop Surg (Hong Kong). 2006;14(1):58e63. 61. Mitchell SA, Meals RA. Surgical options for failed thumb basal joint arthroplasty. In: Duncan SFM, ed. Reoperative Hand Surgery. New York, NY: Springer; 2012:67e77. 62. Wagner WF. Why ligament reconstruction, tendon interposition arthroplasty fails, and salvaging failed ligament reconstruction, tendon interposition arthroplasty. Curr Opin Orthop. 2006;17(4): 288e294. 63. Davis TRC, Pace A. trapeziectomy for trapeziometacarpal joint osteoarthritis: is ligament reconstruction and temporary stabilisation of the pseudarthrosis with a Kirschner wire important? J Hand Surg Eur Vol. 2009;34(3):312e321. 64. Shin EK, Osterman AL. Treatment of thumb metacarpophalangeal and interphalangeal joint arthritis. Hand Clin. 2008;24(3):239e250. v. 65. Beckenbaugh RD, Steffee AD. Total joint arthroplasty for the metacarpophalangeal joint of the thumb—a preliminary report. Orthopedics. 1981;4(3):295e298. 66. McGovern RM, Shin AY, Beckenbaugh RD, Linscheid RL. Longterm results of cemented Steffee arthroplasty of the thumb metacarpophalangeal joint. J Hand Surg Am. 2001;26(1):115e122. 67. Bicknell RT, MacDermid J, Roth JH. Assessment of thumb metacarpophalangeal joint arthrodesis using a single longitudinal K-wire. J Hand Surg Am. 2007;32(5):677e684.
24. Gibbons CE, Gosal HS, Choudri AH, Magnussen PA. Trapeziectomy for basal thumb joint osteoarthritis: 3- to 19-year follow-up. Int Orthop. 1999;23(4):216e218. 25. Downing ND, Davis TRC. Trapezial space height after trapeziectomy: mechanism of formation and benefits. J Hand Surg Am. 2001;26(5):862e868. 26. Taylor EJ, Desari K, D’Arcy JC, Bonnici AV. A comparison of fusion, trapeziectomy and Silastic replacement for the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg Br. 2005;30(1):45e49. 27. Brunton LM, Wilgis EFS. A survey to determine current practice patterns in the surgical treatment of advanced thumb carpometacarpal osteoarthrosis. Hand (N Y). 2010;5(4):415e422. 28. Wolf JM, Delaronde S. Current trends in nonoperative and operative treatment of trapeziometacarpal osteoarthritis: a survey of US hand surgeons. J Hand Surg Am. 2012;37(1):77e82. 29. Burton RI. Basal joint arthritis: fusion, implant, or soft tissue reconstruction? Orthop Clin North Am. 1986;17(3):493e503. 30. Tomaino M, Pellegrini V, Burton R. Arthroplasty of the basal joint of the thumb: long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am. 1995;77(3):346e355. 31. Dell PC, Brushart TM, Smith RJ. Treatment of trapeziometacarpal arthritis: results of resection arthroplasty. J Hand Surg Am. 1978;3(3):243e249. 32. Rocchi L, Merolli A, Cotroneo C, Morini A, Brunelli F, Catalano F. Abductor pollicis longus hemitendon looping around the first intermetacarpal ligament as interposition following trapeziectomy: a oneyear follow-up study. Orthop Traumatol Surg Res. 2011;97(7): 726e733. 33. Varley GW, Calvey J, Hunter JB, Barton NJ, Davis TR. Excision of the trapezium for osteoarthritis at the base of the thumb. J Bone Joint Surg Br. 1994;76(6):964e968. 34. Diao E. Trapezio-metacarpal arthritis: trapezium excision and ligament reconstruction not including the LRTI arthroplasty. Hand Clin. 2001;17(2):223e236. ix. 35. Cox CA, Zlotolow DA, Yao J. Suture button suspensionplasty after arthroscopic hemitrapeziectomy for treatment of thumb carpometacarpal arthritis. Arthroscopy. 2010;26(10):1395e1403. 36. Yao J, Zlotolow DA, Murdock R, Christian M. Suture button compared with K-wire fixation for maintenance of posttrapeziectomy space height in a cadaver model of lateral pinch. J Hand Surg Am. 2010;35(12):2061e2065. 37. Yao J, Song Y. Suture-button suspensionplasty for thumb carpometacarpal arthritis: a minimum 2-year follow-up. J Hand Surg Am. 2013;38(6):1161e1165. 38. Swanson AB. Disabling arthritis at the base of the thumb: treatment by resection of the trapezium and flexible (silicone) implant arthroplasty. J Bone Joint Surg Am. 1972;54(3):456e471. 39. Swanson AB, Herndon JH. Flexible (silicone) implant arthroplasty of the metacarpophalangeal joint of the thumb. J Bone Joint Surg Am. 1977;59(3):362e368. 40. Eaton RG. Replacement of the trapezium for arthritis of the basal articulations: a new technique with stabilization by tenodesis. J Bone Joint Surg Am. 1979;61(1):76e82. 41. Carter PR, Benton LJ, Dysert PA. Silicone rubber carpal implants: a study of the incidence of late osseous complications. J Hand Surg Am. 1986;11(5):639e644. 42. De la Caffiniere JY, Aucouturier P. Trapezio-metacarpal arthroplasty by total prosthesis: the hand 1979;11(1):41e46. 43. Van Cappelle HGJ, Elzenga P, van Horn JR. Long-term results and loosening analysis of de la Caffinière replacements of the trapeziometacarpal joint. J Hand Surg Am. 1999;24(3):476e482. 44. Johnston P, Getgood A, Larson D, Chojnowski AJ, Chakrabarti AJ, Chapman PG. De la Caffinière thumb trapeziometacarpal joint arthroplasty: 16e26 year follow-up. J Hand Surg Eur Vol. 2012;37(7):621e624. 45. Calandruccio JH, Jobe MT. Arthroplasty of the thumb carpometacarpal joint. Semin Arthroplasty. 1997;8(2):135e147.
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68. Tsang C, Hunter AR, Sorene ED. Bilateral thumb metacarpophalangeal joint fusions for severe hyperextension deformities in conjunction with carpometacarpal joint reconstructions. Hand Surg. 2013;18(2):257e260. 69. Schmidt CC, Zimmer SM, Boles SD. Arthrodesis of the thumb metacarpophalangeal joint using a cannulated screw and threaded washer. J Hand Surg Am. 2004;29(6):1044e1050. 70. Messer TM, Nagle DJ, Martinez AG. Thumb metacarpophalangeal joint arthrodesis using the AO 3.0-mm cannulated screw: surgical technique. J Hand Surg Am. 2002;27(5):910e912. 71. Rao SB. Arthrodesis of the thumb metacarpophalangeal joint with plate fixation. Tech Hand Up Extrem Surg. 2012;16(4): 215e217. 72. Carroll RE, Hill NA. Small joint arthrodesis in hand reconstruction. J Bone Joint Surg Am. 1969;51(6):1219e1221. 73. Inglis AE, Hamlin C, Sengelmann RP, Straub LR. Reconstruction of the metacarpophalangeal joint of the thumb in rheumatoid arthritis. J Bone Joint Surg Am. 1972;54(4):704e712. 74. Rizzo M. Metacarpophalangeal joint arthritis. J Hand Surg Am. 2011;36(2):345e353. 75. Katzman SS, Gibeault JD, Dickson K, Thompson JD. Use of a Herbert screw for interphalangeal joint arthrodesis. Clin Orthop Relat Res. 1993;(296):127e132. 76. Leibovic SJ. Instructional Course Lecture: arthrodesis of the interphalangeal joints with headless compression screws. J Hand Surg Am. 2007;32(7):1113e1119. 77. Wyrsch B, Dawson J, Aufranc S, Weikert D, Milek M. Distal interphalangeal joint arthrodesis comparing tension-band wire and Herbert screw: a biomechanical and dimensional analysis. J Hand Surg Am. 1996;21(3):438e443.
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