Chapter 19 Thumb Carpometacarpal Joint Arthroplasty

Carol Page, PT, DPT, CHT

Osteoarthritis, the most common type of arthritis, frequently affects the hands. The thumb carpometacarpal (CMC) joint is the second most frequently affected joint of the hand, following the distal interphalangeal (IP) joint. Thumb CMC joint osteoarthritis is more common in women than in men and is associated with aging. Thumb CMC joint osteoarthritis may be degenerative or posttraumatic in origin. The chief complaint is thumb pain, with joint stiffness being a later finding. The severity of symptoms may not correspond radiographically to the degree of change in the joint.

Initial treatment consists of nonoperative measures, such as splinting, education in joint protection principles, oral anti-inflammatory medications, and corticosteroid injections. Surgery is indicated when pain is no longer controlled by these nonoperative measures and when pain impairs sleep and functional use of the hand.

Surgical Overview

• The thumb CMC joint comprises the articulation of the trapezium and the first metacarpal. The scaphotrapezial joint may demonstrate degenerative changes as well.

• The most commonly performed surgery for thumb CMC osteoarthritis is resection arthroplasty of a portion of or the entire trapezium, with ligament reconstruction and use of filler for the excised bone.

• At the Hospital for Special Surgery (HSS), the two most commonly performed basal joint arthroplasties are ligament reconstruction tendon interposition (LRTI) arthroplasty and hematoma and distraction arthroplasty (HDA).

• LRTI arthroplasty involves excision of the distal portion of the trapezium, if the scaphotrapezial joint is in satisfactory condition. If not, the entire trapezium is excised.

1 The base of the thumb metacarpal is excised and a hole is made in the radial base.

2 Half of the flexor carpi radialis tendon is harvested, passed through the trapezial fossa into the medullary canal of the thumb metacarpal, and advanced through the hole in the metacarpal radial base.

3 The tendon slip is pulled tightly and sutured to the periosteum of the metacarpal, resurfacing the metacarpal base.

4 The remainder of the tendon slip is folded into the trapezial space to act as a spacer.

5 Some surgeons use one or more longitudinal Kirschner’s wires to stabilize the metacarpal in an abducted, distracted position.

6 LRTI arthroplasty has been shown to provide pain relief and thumb stability and restore grip-and-pinch strength for as long as 11 years after surgery.

• HDA involves excision of the entire trapezium without ligament reconstruction or tendon interposition.

1 A Kirschner’s wire is passed through the first metacarpal base into the trapezoid or second metacarpal with the thumb in palmar abduction, slight opposition, and distraction.

2 The Kirschner’s wire is left in place for approximately 5 weeks.

3 The hematoma filling the trapezial void becomes fibrotic, thus supporting the base of the second metacarpal.

Rehabilitation Overview

• The treatment guidelines that follow are designed for postoperative management of LRTI arthroplasty. However, they can be easily modified, as will be specified, for use following HDA.

• The goals of therapy after thumb CMC arthroplasty are to provide correct protective splinting; manage edema, pain, and the postoperative wound and resulting scar; and, ultimately, facilitate restoration of stable thumb and wrist motion and strength adequate to the functional demands of the individual.

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