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Surgical Treatment Options in Thumb Carpometacarpal Osteoarthritis: A Recent Literature Overview Searching for Practice Pattern with Special Focus on Total Joint Replacement Ingo Schmidt* Hospital Schleiz GmbH, Department of Hand Surgery, Berthold-Schmidt-Straße 7, 07907 Schleiz, Germany Abstract: Thumb carpometacarpal joint osteoarthritis is the most common site of non-rheumatic degenerative lesion in the hand, and there are special features in rheumatic patients. None of various surgical treatment options can be declared as "gold standard" recently. The surgical treatment depends on patient's age, patient's claims in work and leisure, local bone stock, possible allergies, local comorbities, and local deformities.

Keywords: Carpometacarpal joint thumb, resection arthroplasty, total joint fusion, total joint replacement. 1. ANATOMY, BIOMECHANIC, GRAPHIC DATA

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DEMO-

The thumb carpometacarpal (CMC 1) joint is the most common site of osteoarthritis (OA) in the hand [1]. Biomechanically, the CMC 1 joint is best described as a "twisted saddle" with two axis for abduction-adduction and extension-flexion; and there are several volar and especially the major strong dorsal ligaments that provide joint stability [2]. Unfortunately, the great mobility that is seen in-vivo in three axis like a "cardan joint" [3] makes that joint intrinsically unstable, and primary OA is "the price of an opposable thumb" [4]. Key pinch as well as object grasp demonstrate coupled motion: for key pinch the first metacarpal bone undergoes volar translation - internal rotation - flexion, for object grasp the first metacarpal bone undergoes ulnar translation - flexion - abduction [5]. The mean range of motion in CMC I joint of healthy subjects is 41° for extension - flexion, 51° for abduction - adduction, and 21° for axial rotation; associated with significant differences between females and males, but no differences between right and left hands [6]. This "cardan joint" is a result of evolution in hominid species as a functional adaption to stand upright, freeing the torso and upper limbs [5]. Demographic radiological studies revealed 6:1 female-to-male incidence of CMC 1 joint OA, although this difference decreases with age 75 year and older with 40 % in women and 25 % in men [7, 8]. One study has shown that thumb CMC I joint in women are less congruent, have smaller contact areas, and are likely to experience higher contact stresses than joints in men for similar activities in daily living that involve similar joint loads; although the articular contact area is not significantly different when accounting for thinning of the cartilage layer with age or disease [9]. *Address correspondence to this author at the Hospital Schleiz GmbH, Department of Hand Surgery, Berthold-Schmidt-Straße 7, 07907 Schleiz, Germany; Tel: 00491789503035; E-mail: [email protected] 17-/15 $58.00+.00

2. SURGICAL TREATMENT OPTIONS Surgical treatment options for advanced CMC 1 joint OA would include resection arthroplasty with or without tendon interposition or ligament reconstruction, total joint fusion, or total joint replacement [10]. Despite recent evidence that suggests neither ligament reconstruction nor tendon interposition confers any additional benefit over trapeziectomy alone [11, 12], only 3 % of hand surgeons in USA performed that simpler procedure in 2010 [13]. However, the loss of pinch strength in conjunction with a reduced physical functionality after resection-interposition arthroplasty should be discussed preoperatively with the patient to meet the expectations and to offer the best suitable treatment option [14]. The CMC 1 joint fusion reduce pain, provide grip and pinch strength, and revealed satisfactory long-term outcome [11, 15]. The problem is reported to be the non-union rate of 20 % when using Kirschner (K) - wires for fixation [16]. The CMC 1 joint fusion is recommended as primary procedure in case of irreducible Z - deformity (Fig. 1a) with closure of the first web and hyperextension in the thumb metacarpophalangel (MP) joint [17]; another options in that case would be a motion-preserving CMC I joint procedure combined with a sesamoidesis to the first metacarpal head [18], volar thumb MP joint capsulodesis [19], or thumb MP joint fusion [20] if ankylosis can be corrected by tightening the adductor muscle. In rheumatic patients, there is often observed a "reverse" Z - deformity that present hyperextension in CMC I joint, hyperflexion in MP joint, and hyperextension in interphalangeal (IP) joint of the thumb [21] (Fig. 1b). For surgical treatment, it must be considered the frequent or non-frequent symptomatically concomitant scaphotrapeziotrapezoidal (STT) OA (Fig. 1c). The CMC 1 joint replacement reduce pain, improve function, improve grip and pinch strength, and results in excellent patient satisfaction including faster re-employment if © 2015 Bentham Science Publishers

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Current Rheumatology Reviews, 2015, Vol. 11, No. 1

Ingo Schmidt

Fig. (1). Typical phenomena of CMC I joint OA. a) Anterior-posterior (AP) radiograph with typical Z - deformity (lines) in a non-rheumatic patient, b) AP radiograph with "reverse" Z - deformity (lines) in a rheumatic patient, c) AP radiograph with co-incidence of CMC I joint and STT joint OA in a non-rheumatic patient.

implants not be failed [11]. The first cemented ball-andsocket CMC 1 joint prosthesis has a straight metacarpal stem and was first published in France 1973 by de la Caffinière [22]. Due to the anatomically determined biomechanical imbalance in load transmission across the long lever of the first metacarpal bone onto the small cross-section at the trapezium, the main problem of all CMC 1 joint endoprostheses was and is the long-term osseointegration of its cups [11]. A tip pinch of 1 kg will generate 12 kg joint compression; for power grip the load may be as high as 120 kg [23]. The results with the first non-cemented type by using a cylindrical cup created by Ledoux in France 1990 were not uniformly good and it was withdrawn from the marketplace [24, 25]. The non-cemented ARPE implant with it metal-onpolyethylene (PE) bearing can be described as a "small hip prosthesis" and was also introduced in France 1991, respectively [26]. The hydroxyapatite (HA)-coated titanium ARPE stem reproduces the anatomical shape of the first metacarpal medullary space; and the hemispherical HA-coated titanium pressfit cup has three spikes for that one in-vitro study demonstrated a high primary stability [27]. Other ball-and-socket non-cemented types that are current use are the ELEKTRA [28], ROSELAND [29], IVORY [30], and ISIS [31]. Another concept revealed the inverse implant arthroplasty by using the RUBIS 2 prosthesis [32, 33]; or the new bipolar MOOVIS type without published results currently (Fig. 2). The results with the MOJE ceramic implant were unacceptable (Fig. 3); likewise, the spherical ceramic implants can

also no longer be recommended [34-36], and the manufacturer has supplied none despite a request [1]. Another question is, what is going on with the metal-on-metal bearing type ELEKTRA [1, 37]. Despite that the importance of total CMC 1 joint replacement was doubted by 90,3 % of hand surgeons from Germany in 2005 [38]; for patients with advanced CMC 1 joint OA that has not responded to non-operative management as splinting, use of analgetics, intra-articular corticosteroid injections, or manual therapy; none of the three possible surgical procedures can or should be declared recently as "gold standard"; and these procedures should be used according to their patient-related indications [1, 10, 11]. Maybe the clear-cut advice could be the real guiding force of one respondent in the survey of Brunton et al. (2010): "I think you should probably do what works best for you" [13]. 3. RECOMMENDATIONS FOR SURGICAL TREATMENT OPTIONS IN THE MANAGEMENT OF CMC 1 JOINT OA WITH SPECIAL FOCUS ON TOTAL JOINT REPLACEMENT The "optimal therapy" for CMC 1 joint OA would be the in-vivo transformation of biomechanically determined "saddle joint" in a anatomically stable "ball joint" with a third central axis for pronatoric rotation to perform a powerful circumduction by an endoprosthesis. The initial published short-term results of seven independent studies with the

Fig. (2). Total CMC I joint replacement by using the new MOOVIS type (Small Bone Innovations, Morrisville, Pennsylvania / USA). a) AP radiograph demonstrate advanced OA in 52-year-old female patient left, b) design and components of the bipolar prosthesis, c) clinical photos intraoperative with measurement of prosthesis alignment and after insertion of implant, d) AP radiograph postoperative.

Surgical Treatment Options in Thumb Carpometacarpal Osteoarthritis


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MAIA prosthesis with four spikes at the cup and fish-scale macrostructure at the proximal end of the stem to reduce the risk of subsidence; first published short- to mid-term results revealed survival rate ranging from 93,6 to 97,2 %, respectively [49-51]. The current long-term results with the ARPE implant [48] are comparable with those of outcomes in hip arthroplasty (standard reference) of 93,1 % [52]. The ARPE survival rate is also comparable to the implant survival after total elbow and ankle arthroplasty, which are more commonly used and less debatable procedures [53, 54].

Fig. (3). Complications with the MOJE ceramic implants (Moje, Petersberg / Germany). a) AP radiograph with subluxation due to loosening and migration of the metacarpal component (arrow), b) AP radiograph with subluxation due to loosening and dislocation of the trapezial component of an inverse type (arrow).

One salvage procedure following failed CMC 1 joint replacement is the resection arthroplasty [46-48, 55, 56] (Fig. 6); however, if a patient is unsatisfied after resection arthroplasty, there are no other therapeutic options in the future. The main problem of resection arthroplasty is the deterioration of pinch strength with time [11, 12, 14, 57, 58], and also a reduced circumduction compared to healthy subjects [59]. Thus, another salvage option following failed im-

Fig. (5). Early luxation of a ARPE prosthesis.

Fig. (4). Total CMC I joint replacement by using ARPE prosthesis (Biomet, Warsaw, Indiana / USA) in a 49-year-old female patient right. a) AP radiograph with advanced CMC I joint OA (arrow), b) AP radiograph after insertion of non-cemented pressfit components (arrows), c) AP radiograph one year postoperative without loosenings nor stem subsidence (arrows), d) clinical photos one year postoperative (arrows) demonstrate excellent abduction, circumduction, and object grasp compared to contralateral.

ARPE implant (Fig. 4) were excellent [39-45], and were confirmed in further independent two mid- and one longterm follow-up's with a survival rate for in-vivo functional implants ranging from 85 to 97 % [46-48]. None of all other ball-and-socket prostheses revealed a survival rate of 93,9 % at a 10-year follow-up [48]. Complications in detail with the ARPE implant are the dislocation rate of 5 - 9 % (Fig. 5), cup loosening, stem subsidence, trapezium fracture, and PE wear [39-48]. The further development of ARPE type is the

Fig. (6). Trapeziectomy with additional suspension following failed total replacement by using ELEKTRA type (Small Bone Innovations, Morrisville, Pennsylvania / USA). The stem must not be explanted if it concludes with the resection level at the metacarpal base (white arrow), for suspension the abductor pollicis longus (APL) tendon was sutured by using two micro anchors (black arrows), and temporary K - wire transfixation was performed (intraoperative AP fluoroscopy).

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plant arthroplasty is the total exchange replacement by using a cemented type [28], or non-cemented types with or without bone grafting if the bone stock is adequate [60, 61]. How-

Fig. (7). Trapeziectomy with additional suspension in a 72-year-old female patient right. a) AP radiograph with advanced CMC I joint OA and trapezium collapse (arrows), b) AP radiograph postoperative with correct length of the thumb (green arrow, yellow line) by using the APL tendon for suspension through two osseous tunnels of the first and second metacarpal base (yellow arrows) and temporary K - wire transfixation, c) AP radiograph one year postoperative demonstrate proximal shortening of the thumb despite additional suspension (arrows, line), d) clinical photos one year postoperative with sufficient abduction and circumduction.

Fig. (8). Trapeziectomy alone in a 79-year-old female patient right. a) Clinical photo preoperative demonstrate pronounced CMC I joint cysts (arrow) due to OA, b) magnet resonance image preoperative demonstrate pronounced cystic lesion (arrow) with skin thinning, c) AP radiograph one year postoperative demonstrate proximal shortening of the thumb (line), d) clinical photos six months postoperative demonstrate satisfactory function, complete healing of splitted skin graft (arrows), and early mobilization.

Ingo Schmidt

ever, associated hyperlaxity must be considered as a contraindication for implant arthroplasty [60]. For failed total exchange replacement, resection arthroplasty continues to be the salvage option; the outcome of secondary resection arthroplasty is reported to be identical to those after a primary procedure [62]. Whether tendon interposition with or without ligament reconstruction nor additional K- wire transfixation is able to avoid the proximal shortening of the thumb compared to trapeziectomy alone (Fig. 7 and 8) [63]. The proximal shortening of the thumb frequently induce a scaphometacarpal "pseudarthrosis" with radiologically increased degenerate-like lesions, however, without negative effects in clinical outcome at a 6-year follow-up [64]. Total CMC I joint replacement aims to preserve the length of the thumb, which is important for maintaining balance of the soft tissues (Fig. 2 and 4) [23, 65]. If a total wrist implant was inserted in the history, total CMC I joint replacement can be recommended to prevent stability in the distal carpal row for the radial fixation screw of carpal component into the second metacarpal bone as compared to trapeziectomy (Fig. 9). Another option would be CMC 1 joint fusion with or without bone grafting (Fig. 10), if a stable thumb and heavy power grip is needed by a younger patient and if OA in the other two thumb joints (Fig. 11a) is not present [66, 67]; but the loss of function after that procedure should be discussed preoperatively with the patient to find a decision whether surgical treatment for CMC 1 joint OA is desired [68]. Due to the high complication rate, CMC 1 joint fusion is not recommended for women aged 40 years and older [69]; and the patient's satisfaction is only high in 88 % when osseous fusion was obtained [70]. After thumb CMC I joint

Fig. (9). Combined replacements in a 59-year-old man right. a) Advanced stage of CMC 1 joint OA after combined total wrist arthroplasty (TWA) and ulnar head replacement, no pre-existing affection of trapezoid by the radial TWA screw (circle), b) intraoperative fluoroscopy showing correct positioning of ARPE prosthesis, c) lateral and AP radiographs one year postoperative revealed unchanged stable positioning of radial fixation screw into second metacarpal bone, no subluxation of ulnar head implant (arrows), and local bone resorption without loosening under the offset of radial TWA component (arrow).

Surgical Treatment Options in Thumb Carpometacarpal Osteoarthritis

Fig. (10). CMC I joint fusion in a 28-year-old male patient left. a) AP radiograph with advanced CMC I joint OA and radial subluxation of first metacarpal bone (arrows), b) AP radiograph postoperative with two intra-osseous Herbert compression screws and interposition of an iliac crest bone graft (arrow), c) AP radiograph one year postoperative demonstrate complete union of bone graft (arrow), d) clinical photos one year postoperative (arrows) demonstrate sufficient object grasp and tip pinch due to CMC I joint fusion in 70° abduction and 40° opposition.


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fusion, patients often compensate the loss of function by developing increased range of motion in STT and thumb MP joint [71]. The incidence of radiologically STT OA after CMC 1 joint fusion is reported to be 16,2 %; however, only 3,3 % are symptomatically, and resection arthroplasty is recommended as salvage procedure in these cases [15]. As compared to STT fusion, resection arthroplasty is less technically demanding, requires less prolonged immobilization, does not degrade the function in wrist joint, and has fewer complications [72]. The prevalence of radiologically primary non-postoperative in-vivo STT OA (Fig. 1c) is also reported to be 16 % (average), presented with an increase in age, a scapholunate ligament gap greater than 3 mm, and CMC 1 joint OA [73]. The question is, is there really a conjunction in incidence STT OA following CMC 1 joint fusion, or is this caused only by the age-related increase in prevalence. One study in 67 patients aged 50 years and older revealed no development of pantrapezial OA after CMC 1 joint fusion at a long-term follow-up [74]. However, the occurrence of primary STT joint OA that was observed in 83,3 % in human cadaverics aged 84 years [75] is much more higher than in radiographic in-vivo descriptions. For diagnostic assessment of CMC 1 joint OA by using the Eaton - Glickel staging [76], radiographs alone do not always represent a reliable system for classification of disease severity; computed tomography or arthroscopy can be helpful in these cases, and diagnosis and treatment of CMC 1 joint OA is based on the surgeon's qualitative assessment [77-79]. The presence of symptomatically STT OA associated with painful CMC 1 joint OA (Fig. 1c), trapezium height below 12 mm by using the 9 or 10 mm ARPE cups (Fig. 7a), CMC 1 joint hyperlaxity or irreducible Z - deformity (Fig. 1a), unstable soft tissue situation with or without infection (Fig. 8), high power claim at work and leisure (Fig. 10), allergy to metal components [80], and pre-existing affection of trapezium by other implants (Fig. 9a) must be considered as contraindications for total CMC 1 joint replacement. Poor bone stock with or without rheumatoidarthritis is a contraindication for all non-cemented types (Fig. 11b). 4. SPECIAL FEATURES IN RHEUMATIC PATIENTS

Fig. (11). Rheumatoidarthritis hand. a) AP radiograph in a 82-yearold male patient with adequate bone stock right demonstrate total MP joint replacements II-V (II / III / V: non-cemented constrained RM prostheses nine years postoperative, Mathys, Bettlach / Switzerland; IV: cemented unconstrained SR MCP one year postoperative after exchange RM prosthesis with a nine year survival rate, Small Bone Innovations, Morrisville, Pennsylvania / USA), and advanced CMC I joint OA right (red arrow). Note the joint fusion with complete union in MP and IP joint of the thumb with and without removal of internal fixations (yellow arrows), b) AP radiograph in a 74-year-old female patient with poor bone stock right demonstrate fusions in the wrist joint, IP joint of the thumb, and proximal interphalangeal joints II - IV. Note the silicone interposition arthroplasties in MP joints II - V, and advanced CMC joint OA with trapezium collapse (red arrow).

In rheumatic patients with CMC 1 joint OA associated with poor bone stock there are some differences. In initial stage with activated arthritis, one study revealed a satisfactory pain relief at a mean follow-up of 41 months by using the radiation synovectomy, whereas DIP joints were frequently resistant to therapy [81]. A motion-preserving surgical procedure in the thumb CMC I joint is absolutely required, because in concomitant rheumatic OA in the other two thumb joints there is only one surgical option for MP and IP joint fusion (Fig. 10). In advanced stage without trapezium collapse there is an option for total CMC 1 joint replacement by using the cemented de la Caffinière prosthesis, newer studies showed 87 % survival rate for in-vivo functional implants after 10 years including revision procedures [82], and 73,9 % after 26 years [83]. Another option in these cases is the cemented ball-and socket type GUEPAR II, a newer study revealed in 92 % of patients a satisfactory outcome with 94 % implant survival at a 50-months follow-up, however, all patients had non-rheumatic OA [84]. In case of

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Ingo Schmidt


trapezium collapse (Fig. 7a and 10b), trapeziectomy alone is the method of choice [85]. Despite recent evidence that suggests high long-term complication rate, the silicone interposition arthroplasty created and first published by Swanson in 1968 [86] can be applied unchanged as a salvage option [20, 87, 88]; poor radiographic changes that include scaphoid cysts in 56 % and metacarpal intramedullary radiolucency and / or cysts in 74 % do not always correlate with the patient's satisfaction in 84 % at a long-term follow-up [89]. The results with the first cemented anatomically surface replacement arthroplasty (SR trapeziometacarpal prosthesis, metalon-PE bearing), first published in 1999 [90], with 55 % loosenings at a 33-months follow-up were poor and only 40 % of patients rated their outcome as excellent or good in a independent study [91]; another independent study at a mean 36months follow-up revealed no postoperative improvements in range of motion, function, and strength if operated hands used alone [92]. Despite recent advances in medical therapy, surgical treatment still plays a role in rheumatic patients with hand dysfunctions for their independence and re-employment in activities of daily living. The weak point is that the majority of studies showed methodological flaws that prevented a clear definition of both surgical indications and criteria for choosing any specific procedure [93].

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5. CONCLUSION It is not the intention of this article to advocate for general use of CMC 1 total joint replacement. Poor long-term results of some types led to its withdrawn from the marketplace; on the other hand, newer ball- and-socket types that were introduced in the beginning of the 90th showing first acceptable mid-to-long-term survival rates ranging from 90 % to 95 % [94]. Nonetheless, there are sufficient data to conclude that, as yet, CMC 1 total joint replacement does not reliably give better results than trapeziectomy [95]. One weak point of several studies is their not comparable methodological quality; pain and function using the Outcome Measures in Rheumatology (OMERACT) score domains most frequently but quality of live (QoL) is underrepresented [96]. The use of the three surgical options should be individually customized to the patient's claims at work and leisure. CONFLICT OF INTEREST The author confirms that this article content has no conflict of interest. ACKNOWLEDGEMENTS

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Declared none. [24]

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Revised: February 17, 2015

Accepted: February 21, 2015