Viêm khớp gốc ngón tay cái Thông tin In-depth

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Basal thumb arthritis is a common condition where a comprehensive history and clinical examination are sufficient for diagnosis [1].
• Osteoarthritis is likely to remain the most common indication for basal joint arthroscopy [7].
• Chronic pain and inflammation are useful indications for metacarpophalangeal arthroscopy [7].
• The CMC joint defines the workspace of the thumb in all three dimensions [9].
• The MCP joint acts as a force transmitter and is the linked bar to the IP joint [9].
• The IP joint provides fine motor skills and should be stable enough to interact with the index and middle finger in pinching [9].
• Active mobility of the IP joint is strongly correlated with hand function [9].
• Thumb deformities have a negative impact on grasp and pinch function [9].
• The thumb–finger relationship is essential for activities of daily living [9].
• Deformities of the thumb in rheumatoid arthritis occur in the majority of affected patients [9].
• Nalebuff and colleagues classified thumb deformities based on joint involvement and deformity pattern [9].
• Six distinguished types of thumb deformities are described in the Nalebuff classification [9].
• For more common types of thumb deformities, various disease stages have been categorized in the Nalebuff classification [9].
• The Nalebuff classification helps to understand the pathology and set the surgical strategy for treatment [9].
• Treatment concepts in rheumatoid arthritis patients should be considered in line with functional aspects of the thumb [9].
• The surgeon must consider the patient’s needs and desires when contemplating treatment options for rheumatoid hand surgery [9].

Anatomy & Pathophysiology

Joint Anatomy and Biomechanics

• The thumb carpometacarpal (CMC) joint is a biconcave, reciprocating saddle joint with little inherent stability [85].
• The thumb CMC joint has 16 surrounding ligaments that impart stability [85].
• The thumb metacarpal is 34% smaller than the distal articular surface of the trapezium [85].
• The trapeziometacarpal joint has two longitudinal axes and two degrees of freedom, functioning like a universal joint [31].
• Flexion of the thumb CMC joint is necessarily accompanied by pronation, and extension by supination, due to the asymmetrical articular surfaces [31].
• The shape of the trapeziometacarpal articular surface provides good stability only in anteposition and pronation [31].
• The radial side of the trapeziometacarpal joint has a much weaker ligament than the ulnar side, creating intrinsic instability at the level of high pressure [31].
• Joint compression forces during simple pinch averaged 3.0 kg at the interphalangeal joint, 5.4 kg at the metacarpophalangeal joint, and 12.0 kg at the carpometacarpal joint [31].
• Compression forces of up to 120 kg may occur at the carpometacarpal joint during strong grasp [31].
• High compressive forces across the thumb CMC during pinch may reach in excess of 12 times the applied load and may approach 20 times the applied load during maximum grasp [85].
• Shear forces created by cantilever bending are highest at the volar half of the joint’s articular surface [85].
• Flexion of the thumb metacarpophalangeal (MCP) joint produces unloading of the volar portion of the trapeziometacarpal joint [85].
• The thumb CMC ray is anterior to the plane of the other metacarpals and makes an angle of about 47 degrees with the second ray [31].
• The interphalangeal articulation is a trochlear type allowing mainly flexion and extension, with flexion accompanied by a slight degree of rotation in pronation [31].
• The metacarpophalangeal articulation is of a condylar type capable of small lateral movements, especially to the radial side [31].
• Flexion of the thumb MCP joint is always accompanied by radial deviation and pronation, which stretches the ulnar metacarpophalangeal ligament [31].
• The MCP joint acts as a force transmitter and is the linked bar to the IP joint, which provides fine motor skills [9].

Ligaments

• The primary stabilizer of the thumb CMC joint is the deep anterior oblique ligament, also known as the palmar “beak” ligament [85].
• The deep anterior oblique ligament is an intracapsular ligament emanating from the volar tubercle of the trapezium and inserting on the ulnar volar aspect of the first metacarpal [85].
• The deep anterior oblique ligament tightens with pronation, abduction, and extension, preventing ulnar translation and dorsal translation of the first metacarpal relative to the trapezium [85].
• The obliquely oriented fibers of the deep anterior oblique ligament create a center of rotation about which the CMC joint may rotate [85].
• The superficial anterior oblique ligament tightens with pronation and extension of the thumb [85].
• The dorsoradial ligament stabilizes and inhibits dorsal translation of the thumb CMC joint [85].
• The posterior oblique ligament inhibits ulnar translation of the thumb CMC joint [85].
• The dorsal intermetacarpal ligament of the thumb prevents radial translation of the thumb metacarpal as well as proximal migration of the thumb metacarpal following trapeziectomy [85].
• The abductor pollicis longus tendon provides dynamic stability to the thumb CMC joint only when the first metacarpal is abducted [31].
• In adduction, the abductor pollicis longus increases the risk of subluxation of the thumb CMC joint [31].
• Ultrastructural analysis of the deep anterior oblique ligament in patients with osteoarthritis found disorganized connective tissue, with little evidence of collagen fibers and few signs of innervation [85].
• Mechanoreceptors were identified in the dorsoradial ligament, which was found to be innervated to a much greater extent than the anterior oblique ligament [85].
• The collagen bundles of the dorsoradial ligament were found to be better organized than those of the deep anterior oblique ligament [85].
• The oblique ligaments of the thumb CMC joint tighten and become efficient stabilizers in complete pronation of the thumb, i.e., in the position of the thumb–digital grip [31].

Pathophysiology and Etiology

• The pathophysiology of basal thumb joint arthritis includes both intrinsic and extrinsic factors [4].
• The prevalence of radiographic thumb CMC arthritis increases with age, rising from 6.6% in individuals aged 40 to 49 years to 36.4% in individuals aged 80 years [4].
• With the exception of the youngest age group, women uniformly had a higher prevalence of thumb CMC arthritis than men [4].
• Female sex is a risk factor for the development of thumb CMC osteoarthritis, with up to a sixfold increased incidence compared with men [4].
• The increased incidence in women may be associated with an increased risk of ligamentous laxity [4].
• Thumb CMC morphology is similar between men and women after controlling for size, implying that physiology rather than anatomy is the predominant risk factor [4].
• The relaxin hormone, which increases laxity in pelvic ligaments, may play a role in ligamentous laxity through a matrix metalloproteinase pathway [4].
• Degeneration associated with relaxin may play a role in the development of CMC arthritis, especially in women [4].
• Hormonal regulation and pathophysiology involving relaxin receptors in surrounding ligaments have not been well established [4].
• Prolactin and estrogen have been implicated as risk factors for thumb CMC arthritis [4].
• Patients with generalized ligamentous laxity, such as Ehlers-Danlos syndrome, have a considerably higher incidence of thumb CMC arthritis and exhibit radiographic changes at a younger age [4].
• A higher Beighton score is positively associated with increased mobility of the CMC joint [4].
• Patients whose occupations involve repetitive thumb use and heavy manual labor have been found to have an increased risk of thumb CMC arthritis [4].
• There is no longitudinal natural history study that has established a clear etiology for basal joint disease [8].
• There is a strong association between excessive basal joint laxity and the development of premature degenerative changes [8].
• Clinical observations of basal joint laxity are corroborated by findings of degenerative arthritis in other joints characterized by abnormal degrees of laxity [8].
• Articular degeneration consistently involved a greater portion of the surface area of the trapezium compared with the metacarpal by a ratio of 3:1 [85].
• A decrease in the ratio of trapezial to metacarpal articular degeneration is associated with more advanced disease [85].
• Degeneration of the volar half of the thumb CMC joint is associated with a diminishment in the integrity of the deep anterior oblique ligament [85].
• The dorsal cartilage is relatively spared, even in cases of advanced osteoarthritis [85].
• Altered thumb rotation patterns during pinch may contribute to joint misalignment and the development of osteoarthritis [80].
• An atrophic first dorsal interosseous muscle may not be an efficient dynamic stabilizer in patients with trapeziometacarpal osteoarthritis [68].
• The first sign of degenerative change in thumb metacarpophalangeal arthritis is synovitis [107].
• In patients with chronic collateral ligament insufficiency, there may also be a coronal deformity of the thumb metacarpophalangeal joint [107].

Classification

• The Eaton classification divides degeneration of the trapeziometacarpal joint into four stages based on radiographic findings [48].
• Stage I of the Eaton classification is characterized by normal articular contours and a potentially widened joint space due to effusion, preceding cartilage degeneration [48].
• Stage II of the Eaton classification presents with slight narrowing of the trapeziometacarpal joint while maintaining articular contours, with joint debris less than 2 mm in size [48].
• The Eaton-Littler classification is used to categorize arthritis severity into Stages I through IV [97].
• In a cohort of 33 patients, the distribution of Eaton-Littler stages was 6% Stage I, 18% Stage II, 48% Stage III, and 27% Stage IV [97].
• Radiological classification systems do not describe all stages of carpometacarpal joint osteoarthritis accurately enough to permit reliable and consistent communication between clinicians [44].
• A systematic review indicates that while radiographs assist in assessing CMC joint disease, there is no reliable system for classifying disease severity [46].
• Roentgenographic evaluation of basal joint arthritis tends to overdiagnose the extent of disease due to osteophytes projecting across adjacent facets [48].
• In cadaver studies, the index and trapezoid facets are rarely involved (1%) in thumb CMC arthritis, whereas scaphotrapezial facets are involved in 46% of cases with arthritic CMC facets [48].
• Ulnar instability should be included in the classification of thumb CMC joint osteoarthritis stages and considered in treatment options [92].
• The metacarpal surface of the trapezium demonstrates three distinct patterns of wear in arthritic surgical specimens [45].

Clinical Presentation

Diagnosis and History

• A comprehensive history and clinical examination are sufficient for the diagnosis of basal thumb arthritis [1].
• Patients may present with pain localized to the thumb base or with vague complaints of throbbing or burning in the radial aspect of the hand [103].
• The high prevalence of other symptomatic disorders of the hand requires a complete and standardized clinical examination to consider these conditions during surgical planning [34].

Physical Examination Findings

• Inspection of patients with advanced osteoarthritis often reveals a thumb adduction contracture and a compensatory thumb metacarpophalangeal (MCP) joint hyperextension deformity [103].
• The thumb MCP joint in patients with advanced disease may exhibit laxity in hyperextension, and the degree of this instability can have implications for surgical management when trapeziectomy is indicated [103].
• The CMC grind test is performed by stabilizing the wrist and applying axial loading to the thumb axis, which may elicit pain and crepitus as degenerative articular surfaces are compressed [103].
• The CMC subluxation test, also known as the lever test, involves gently forcing the CMC joint to sublux to assess whether this motion elicits a pain response or crepitus [103].
• Pinch strength testing, such as the two-point key pinch or three-point pinch, is part of the physical examination for thumb CMC osteoarthritis [103].
• Clinical signs of first CMC joint involvement include joint tenderness on palpation, a positive grind test, a positive pressure-shear test, and a step-off sign [61].
• A reduction in cylindrical grasp strength is associated with early symptomatic and radiographic CMC osteoarthritis, whereas gross grasp is not associated with early thumb CMC OA [19].
• In patients with established hand osteoarthritis, clinical involvement of the thumb basal joint is associated with a higher clinical burden [22].
• Radiological involvement of the thumb basal joint in patients with established hand osteoarthritis is associated with older age and more structural abnormalities [22].

Risk Factors and Etiology

• The prevalence of thumb CMC arthritis increases with age, rising from 6.6% in individuals aged 40 to 49 years to 36.4% in individuals aged 80 years [4].
• Women have a higher prevalence of thumb CMC arthritis than men, with female sex shown to be a risk factor with up to a sixfold increased incidence compared with men [4].
• Female sex as a risk factor may be associated with an increased risk of ligamentous laxity [4].
• The relaxin hormone, which increases laxity in pelvic ligaments, may play a role in ligamentous laxity through a matrix metalloproteinase pathway, potentially contributing to CMC arthritis development in women [4].
• Patients with generalized ligamentous laxity, such as Ehlers-Danlos syndrome, have a considerably higher incidence of thumb CMC arthritis and exhibit radiographic changes at a younger age than those without generalized laxity [4].
• A higher Beighton score, a measure of generalized laxity, is positively associated with increased mobility of the CMC joint [4].
• Occupations involving repetitive thumb use and heavy manual labor are associated with an increased risk of thumb CMC arthritis [4].
• Although traumatic causation has been documented, no longitudinal natural history study has established a clear etiology for basal joint disease [8].

Imaging and Staging

• Radiographs to profile the thumb CMC joint include PA, lateral, and oblique views of the hand or PA and lateral views of the wrist [17].
• A Robert view of the thumb CMC joint is helpful as it provides a true PA view of the joint [17].
• The Robert view requires specific positioning including shoulder flexion, shoulder internal rotation, and wrist hyperpronation, which some patients with limited or painful shoulder motion may find difficult [17].
• Advanced imaging studies such as MRI or CT scanning are seldom necessary for operative procedures or surgical decision making about the thumb CMC joint [17].
• The Eaton staging system for thumb CMC joint degenerative arthritis includes Stage I (normal or slight widening of the joint shadow due to synovitis), Stage II (mild joint shadow narrowing with osteophyte formation of 2 mm or less), Stage III (marked joint shadow narrowing with osteophyte formation of more than 2 mm), and Stage IV (Stage III disease with scaphotrapeziotrapezoidal osteoarthritis) [17].
• The Eaton staging system has never shown correlation with the intraoperative extent of disease or treatment outcome [103].
• Subjects presenting with early CMC OA had significantly lower bone density as assessed with Hounsfield units at the thumb CMC joint, specifically at the trapezium and first metacarpal base [10].
• Musculoskeletal ultrasound power Doppler has a significant relationship with pain severity in thumb base OA, suggesting it might be a useful tool in understanding pain etiology [36].

Functional Assessment

• A change of 0.7 to 0.9 cm on the Visual Analogue Scale (VAS) is clinically meaningful in the context of long-term osteoarthritis of the thumb [28].

Investigations

Clinical Assessment

• Patients with generalized ligamentous laxity, such as Ehlers-Danlos syndrome, have a considerably higher incidence of thumb CMC arthritis and exhibit radiographic changes at a younger age than counterparts without generalized ligamentous laxity [4].
• In patients with established hand osteoarthritis, radiological involvement of the thumb basal joint is associated with older age and more structural abnormalities [22].
• A reduction in cylindrical grasp strength is associated with early symptomatic and radiographic CMC osteoarthritis [19].
• Gross grasp strength is not associated with early thumb CMC osteoarthritis [19].
• A negative grind test does not necessarily reflect negative radiographic evidence of thumb CMC osteoarthritis [113].

Radiographic Imaging

• Radiographs to profile the thumb CMC joint include PA, lateral, and oblique views of the hand or, alternatively, PA and lateral views of the wrist [17].
• The Robert view is a true PA view of the thumb CMC joint that requires special positioning including shoulder flexion, shoulder internal rotation, and wrist hyperpronation [17].
• The Eaton radiographic staging system for thumb CMC joint degenerative arthritis includes Stage I (normal or slight widening of the joint shadow due to synovitis), Stage II (mild joint shadow narrowing with osteophyte formation of 2 mm or less), Stage III (marked joint shadow narrowing with osteophyte formation of more than 2 mm), and Stage IV (Stage III disease with scaphotrapeziotrapezoidal osteoarthritis) [17].
• The radiological classification for carpometacarpal joint osteoarthritis does not describe all stages accurately enough to permit reliable and consistent communication between clinicians [44].
• There is not a reliable system for the classification of disease severity in CMC joint disease based on radiographs [46].
• Wrist radiographs demonstrate a 47% sensitivity and 94% specificity in predicting end-stage scaphotrapezoid joint arthritis [105].
• Radiographic development of trapeziometacarpal arthrosis is an expected part of human aging, although clinically significant, functionally limiting trapeziometacarpal arthrosis is less common [106].

Advanced Imaging and Biomarkers

• Subjects presenting with early CMC osteoarthritis had significantly lower bone density as assessed with Hounsfield units at the thumb CMC joint (trapezium and first metacarpal base) [10].
• The significant relationship of power Doppler with pain severity in thumb base osteoarthritis suggests this might be a useful tool in understanding pain aetiology [36].

Treatment

Non-Operative Management

• Non-surgical treatments of thumb carpometacarpal arthritis provide adequate pain relief for the majority of patients, particularly in the early stages of disease [64].
• The European League Against Rheumatism (EULAR) 2018 treatment guidelines recommend surgery for thumb CMC arthritis only if pain persists following non-pharmacologic treatment [64].
• The American College of Rheumatology strongly recommends splinting for thumb CMC arthritis but does not mention the role of surgical management in its guidelines [64].
• Various studies have demonstrated that non-surgical treatments, such as hand therapy and splinting, can delay or obviate the need for surgical management [64].
• The first phase of management for patients with osteoarthritis of the thumb CMC joint is nonoperative treatment [69].
• Nonoperative treatment may include thumb spica splinting, which may be forearm or hand based but preferably leaves the thumb IP joint free for patient comfort [69].
• NSAIDs may be used orally or topically for nonoperative treatment of thumb CMC osteoarthritis depending on patient tolerance or physician preference [69].
• Outpatient hand therapy for thumb CMC osteoarthritis may consist of ultrasound, paraffin wax, heat, and deep tissue massage, along with activity modifications [69].
• Sustained benefit from splinting and corticosteroid injections has been demonstrated by several authors [69].
• One randomized controlled, blinded trial showed no difference in scores on the visual analog pain scale at 24 weeks when comparing a group treated with a thumb CMC joint steroid injection and another group treated with saline injection [69].
• According to scientific evidence of moderate quality, steroid intra-articular injections would not be more effective than saline injections for trapeziometacarpal osteoarthritis [75].
• The efficacy for pain reduction and/or improvement of physical function of saline injections in tender subcutaneous areas, custom-made thermoplastic thumb, custom-made thermoplastic hand-based trapeziometacarpal joint orthosis, radial nerve mobilization and a combination of hand exercises, TM-joint/nerve mobilization is supported by scientific evidence of low quality [75].
• Patients with trapeziometacarpal osteoarthritis usually receive non-surgical interventions and 15-36% of them may end up with surgery 2-7 years later [75].
• The use of anti-inflammatories, splinting, and corticosteroid injections serve only as palliative measures, with none of them altering joint mechanics or affecting the articular surface itself in any manner [20].
• The use of injectable steroids can accelerate cartilage loss and worsen capsular attenuation [20].
• One study reported that 68% of patients referred for consideration of surgery did not undergo surgery during the following 2 years [66].
• The author has found it sensible to delay surgery for at least 3–6 months after the onset of intolerable pain, or even longer, to see if the restrictive pain is due to a temporary flare up of the osteoarthritis that will settle spontaneously or with non-operative treatment [66].
• Prior to surgery, all patients in a specific cohort had had appropriate non-operative treatment for at least six months including one or more of the following: activity modification, splinting, nonsteroidal anti-inflammatory drugs, or steroid injections [76].

Operative Management: Indications and General Principles

• Surgery is presently the mainstay of treatment for severely symptomatic osteoarthritis [66].
• The present indication for surgical treatment is generally described as ‘troublesome painful osteoarthritis which restricts thumb and hand function and has not been adequately managed with non-operative treatments’ [66].
• When conservative treatment has been exhausted, there are a wide range of surgical options to choose from [20].
• Treatment should be tailored to the individual patient [20].
• Basal joint osteoarthritis of the thumb has many different clinical presentations, and one technique cannot be used for all of the different stages and all patients' individual needs [20].
• Degenerative arthritis of the thumb CMC joint is a common treatable condition where nonoperative modalities are effective for early stages, while surgical options are reserved for cases refractory to conservative measures [89].
• The multiplicity of treatment modalities for carpometacarpal joint arthritis shows that the underlying trapezium excision is probably the prime factor in patients' clinical improvement [43].
• Thumb index metacarpal stabilization needs to be based on each individual clinical scenario [43].
• Despite 70 years of research and numerous treatment options, the best management for trapeziometacarpal arthritis remains debated, with a constant proportion of patients remaining unhappy or symptomatic post-surgery [93].
• The fact that so many different surgical options exist for basal joint osteoarthritis attests to the fact that none of them has an optimal success rate [20].
• It may be that the majority of treatment options work to the satisfaction of the surgeon; hence the clinician continues to use his favorite technique, despite the fact that it may not be the most appropriate method for a particular stage of disease [20].
• This study demonstrates health state utility gains after basal thumb osteoarthritis surgery regardless of surgical techniques used [6].

Operative Management: Specific Procedures

• A 30-degree closing wedge, extension osteotomy of the thumb metacarpal has been theorized to unload the volar segment of the thumb CMC joint by redistributing the load through the more dorsal segment of the joint [69].
• The first metacarpal osteotomy is indicated for patients with stage I or II disease but contraindicated in patients with hypermobility, fixed subluxation, or hyperextension of the joint [69].
• In 1999, Tomaino et al. reported on 12 patients with stage I disease treated with extension osteotomy of the thumb metacarpal [69].
• All osteotomies in the Tomaino et al. study healed within 7 weeks [69].
• 11 of the 12 patients in the Tomaino et al. study were satisfied with the outcome [69].
• All patients in the Tomaino et al. study had increased grip and pinch strength at 2 years of follow-up [69].
• Parker and colleagues and more recently Bachoura et al. have reported similar results to Tomaino et al. regarding extension osteotomy [69].
• For patients with stage I or II disease of the thumb CMC joint, ligament reconstruction alone may be preferred over other salvage techniques [69].
• Instability of the volar ligamentous complex of the joint, particularly the deep anterior oblique ligament, has been proposed as the potential cause of osteoarthritis of the joint [69].
• In a biomechanical study, Koff and coworkers have shown that ligament reconstruction improved stability of the joint [69].
• Ligament reconstruction has been typically reserved for patients with very mild articular changes and is contraindicated in patients with stages III and IV disease [69].
• The majority of reconstructive procedures for thumb CMC osteoarthritis involve resection arthroplasty of the trapezium, with removal of the articular base of the first metacarpal with or without ligament reconstruction and with or without interposition of autograft material [69].
• Resection arthroplasty is typically reserved for patients with stage III or IV disease [69].
• Durability of resection arthroplasty has been reported in a younger population with stage I disease [69].
• In 1984, Burton and Pellegrini described a technique for “advanced osteoarthritis of the thumb CMC joint,” in part based on the procedure described by Eaton and Littler for reconstruction of the deep anterior oblique ligament [69].
• The Burton and Pellegrini procedure involves resection of the trapezium and base of the first metacarpal, along with a stabilization procedure they termed the flexor carpi radialis sling suspension interposition [69].
• A portion of the flexor carpi radialis (FCR) tendon is used to reconstruct the deep anterior oblique ligament (or perhaps more accurately, the intermetacarpal ligament) and to create an interposition arthroplasty, filling the void left by trapezium resection [69].
• Theoretically, this interposition and deep anterior oblique ligament reconstruction provides support and resists subsidence of the thumb metacarpal [69].
• Shah et al. have shown in a cadaver study that wrist biomechanics are altered following trapeziectomy, and the ligament reconstruction and tendon interposition (LRTI) procedure helps restore wrist biomechanics [69].
• Weilby has reported on a technique that involves passing half of the FCR tendon around the abductor pollicis longus (APL) tendon, making a suspension lattice in the void created by the trapezium resection [69].
• Routing a slip of the APL tendon around the extensor carpi radialis longus (ECRL) or passing half of the FCR around the ECRL has also been described to gain suspension and may be beneficial in revision procedures [69].
• Kuhns and colleagues have described a procedure whereby no interposition material or ligament reconstruction was employed, termed the hematoma and distraction arthroplasty [69].
• Excision of the trapezium alone without stabilization of any kind has been reported by Gervis as well as others [69].
• Long-term clinical outcomes of trapeziectomy for basal thumb arthritis are very positive [5].
• Interpositioning as an isolated procedure appears, clinically, to be the preferred treatment despite greater radiological degradation when compared to suspensionplasty [5].
• Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term [2].
• Patients who underwent suture-button suspensionplasty (SBS) surgery for thumb CMC osteoarthritis achieve excellent long-term outcomes by maintaining favorable subjective and objective results, despite some radiographic subsidence over time [24].
• The findings demonstrate that patients who underwent SBS surgery for thumb CMC osteoarthritis achieve excellent long-term outcomes by maintaining favorable subjective and objective results, despite some radiographic subsidence over time [25].
• This series demonstrates that thumb arthroplasty is a reliable long-term solution for thumb base arthritis, with significant pain reduction and functional improvement, even after 15 years of follow-up [27].
• The ISIS® prosthesis is a reliable implant for treating disabling thumb basal joint arthritis, with a low complication rate and long-lasting clinical and functional improvements [29].
• This paper focuses on the surgical techniques and outcomes of pyrocarbon implants for the treatment of basal thumb arthritis [12].
• Due to an unacceptably high complication rate, the authors no longer use the Artelon CMC Spacer for the management of basal joint arthritis of the thumb [14].
• Due to findings in a specific study, the authors have abandoned the use of porous polyurethaneurea (Artelon) joint spacer for treatment of basilar thumb osteoarthritis [26].
• The study found good medium-term results and high satisfaction rates, advocating Swanson silastic interposition arthroplasty as an effective treatment option for revision thumb-base surgery provided other treatable causes of poor outcome are excluded [21].
• Arthroscopic total trapeziectomy appears to be a safe and effective treatment for end-stage arthrosis of the thumb basal joint [38].
• The use of arthroscopic-assisted techniques for thumb CMC OA is still limited; however, it may be a reasonable option for patients with thumb CMC OA who do not respond to non-operative treatment [96].
• Osteoarthritis will likely remain the most common indication for basal joint arthroscopy while chronic pain and inflammation are useful indications for metacarpophalangeal arthroscopy [7].
• The findings indicate that the treatment approach of denervation, joint lavage and capsular imbrication could be a good alternative to more invasive surgical options in patients with earlier stages of thumb carpometacarpal joint osteoarthritis, with advantages including a low rate of complications, low invasiveness, and short recovery times [35].
• Arthrodesis of the thumb MCP joint is routinely performed in cases of primary osteoarthritis or posttraumatic arthritis [95].
• The preferred position for arthrodesis of the thumb MCP joint is 20 degrees of flexion [95].
• The article reviews the most common complications after surgery for basal thumb arthritis, emphasizing resection arthroplasty, joint replacement, and joint fusion, and highlights possible management strategies for the different types of complications [3].
• Trapeziectomy is an effective, simple, and low-cost procedure, and the most common of surgical treatment for basal osteoarthritis of the thumb in the UK [67].
• Recovery from trapeziectomy can be lengthy and complications include subsidence of the thumb metacarpal, instability, and weakness [67].
• New designs of thumb carpometacarpal joint arthroplasty (CMCJA) show promising early results with low complication rates and a quick return to function, but the implants are expensive and high-quality evidence about the outcome is lacking [67].
• The Surgery versus Conservative OsteOarthritis of Thumb Trial (SCOOTT) is a multicentre, three-arm, randomized controlled trial which is currently being undertaken, comparing the clinical outcomes and cost-effectiveness of an enhanced package of non-surgical management, trapeziectomy, and thumb CMCJA [67].

Complications

• The Artelon CMC Spacer is no longer used for the management of basal joint arthritis of the thumb due to an unacceptably high complication rate [14].
• Failure to recognize and treat the accompanying hyperextension deformity of the metacarpophalangeal joint in basal joint arthritis may lead to suboptimal results [101].
• The ISIS prosthesis for trapeziometacarpal arthritis is associated with a low complication rate [29].
• Simultaneous dual prosthetic replacement of the trapeziometacarpal and scaphotrapezial-trapezoid joints achieves a low complication rate [23].
• Long-term outcomes of suture-button suspensionplasty for thumb carpometacarpal osteoarthritis are maintained despite some radiographic subsidence over time [24, 25].

Recovery

• A change of 0.7 to 0.9 cm on the Visual Analogue Scale is clinically meaningful in the context of long-term osteoarthritis of the thumb [28].
• Increased degenerate-like changes at the pseudarthrosis site after trapeziectomy do not influence clinical outcome [114].
• Interpositioning as an isolated procedure appears to be the clinically preferred treatment for basal thumb arthritis despite greater radiological degradation compared to suspensionplasty [5].
• Health state utility gains occur after basal thumb osteoarthritis surgery regardless of the surgical technique used [6].
• Patients undergoing suture-button suspensionplasty for thumb carpometacarpal osteoarthritis achieve excellent long-term outcomes with favorable subjective and objective results, despite some radiographic subsidence over time [24, 25].
• Thumb arthroplasty provides significant pain reduction and functional improvement for thumb base arthritis, even after 15 years of follow-up [27].
• Swanson silastic interposition arthroplasty in revision thumb-base surgery for failed trapeziectomy yields good medium-term results and high satisfaction rates, provided other treatable causes of poor outcome are excluded [21].
• Simultaneous dual prosthetic replacement of trapeziometacarpal and scaphotrapezial-trapezoid joints in pantrapezial osteoarthritis achieves favorable functional outcomes and a low complication rate by preserving carpal stability and thumb function [23].

Key Evidence

• [L4] Basal thumb arthritis is a common condition where a comprehensive history and clinical examination are sufficient for diagnosis. [1] (10.1136/pgmj.2006.046300)
• [L3] Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term. [2] (10.1186/s13018-021-02856-x)
• [L5] The article reviews the most common complications after surgery for basal thumb arthritis, emphasizing resection arthroplasty, joint replacement, and joint fusion, and highlights possible management strategies for the different types of complications. [3] (10.1177/17531934231197787)
• [L5] [4] (10.5435/jaaos-d-17-00374)
• [L3] Long-term clinical outcomes of trapeziectomy for basal thumb arthritis are very positive, with interpositioning as an isolated procedure appearing, clinically, to be the preferred treatment despite greater radiological degradation when compared to suspensionplasty. [5] (10.1016/j.otsr.2016.08.014)
• [L3] This study demonstrates health state utility gains after basal thumb osteoarthritis surgery regardless of surgical techniques used. [6] (10.1177/1753193420909753)
• [L5] Osteoarthritis will likely remain the most common indication for basal joint arthroscopy while chronic pain and inflammation are useful indications for metacarpophalangeal arthroscopy. [7] (10.1016/j.jhsa.2007.02.020)
• [L5] [8] (10.5435/00124635-200807000-00007)
• [L2] Subjects presenting with early CMC OA had significantly lower bone density as assessed with HU at the thumb CMC joint (trapezium and first metacarpal base). [10] (10.1016/j.jhsa.2017.09.004)
• [L4] This paper focuses on the surgical techniques and outcomes of pyrocarbon implants for the treatment of basal thumb arthritis. [12] (10.1016/j.hansur.2020.08.012)
• [L4] Due to an unacceptably high complication rate, we no longer use the Artelon CMC Spacer for the management of basal joint arthritis of the thumb. [14] (10.1016/j.jht.2013.12.001)
• [L3] A reduction in cylindrical grasp is associated with early symptomatic and radiographic CMC OA, whereas gross grasp is not associated with early thumb CMC OA, suggesting that cylindrical grasp may be a better tool to detect changes in thumb and hand function seen during early disease stages. [19] (10.1007/s11999-016-5151-2)
• [L5] [20] (10.1016/j.hcl.2006.02.006)
• [L4] The study found good medium-term results and high satisfaction rates, advocating the technique as an effective treatment option for revision thumb-base surgery provided other treatable causes of poor outcome are excluded. [21] (10.1177/1753193412447496)
• [L3] In patients with established hand OA clinical involvement of the TBJ is associated with a higher clinical burden whereas radiological involvement of the TBJ is associated with older age and more structural abnormalities. [22] (10.1016/j.jht.2014.01.006)
• [L4] By preserving carpal stability and thumb function, this approach achieves favorable functional outcomes and a low complication rate, making it a potentially superior alternative for patients with high functional demands or those requiring durable long-term results. [23] (10.1016/j.jhsa.2025.12.013)
• [L4] Patients who underwent SBS surgery for thumb CMC osteoarthritis achieve excellent long-term outcomes by maintaining favorable subjective and objective results, despite some radiographic subsidence over time. [24] (10.1016/j.jhsg.2023.12.002)
• [L4] Our findings demonstrate that patients who underwent SBS surgery for thumb CMC osteoarthritis achieve excellent long-term outcomes by maintaining favorable subjective and objective results, despite some radiographic subsidence over time. [25] (10.1016/j.jhsg.2025.100855)
• [L3] Due to these findings, we have abandoned its use for treatment of basilar thumb osteoarthritis. [26] (10.1016/j.jhsa.2013.05.013)
• [L4] This series demonstrates that thumb arthroplasty is a reliable long-term solution for thumb base arthritis, with significant pain reduction and functional improvement, even after 15 years of follow-up. [27] (10.1177/15589447241233367)
• [Paper] The authors propose that a change of 0.7 to 0.9 cm on the VAS is clinically meaningful in the context of long-term OA of the thumb. [28] (10.1177/15589447241235344)
• [L4] The ISISVR prosthesis is a reliable implant for treating disabling thumb basal joint arthritis, with a low complication rate and long-lasting clinical and functional improvements. [29] (10.1177/17531934221123166)
• [L3] The high prevalence of other symptomatic disorders of the hand requires a complete and standardized clinical examination of the hand, as they must be considered during surgical planning. [34] (10.1177/17531934231220644)
• [L4] The findings indicate that the presented treatment approach could be a good alternative to more invasive surgical options in patients with earlier stages of thumb carpometacarpal joint osteoarthritis, with advantages including a low rate of complications, low invasiveness, and short recovery times. [35] (10.1177/1753193416632149)
• [L4] The significant relationship of power Doppler with pain severity in thumb base OA suggests this might be a useful tool in understanding pain aetiology. [36] (10.1186/s12891-019-2610-4)
• [L2] Arthroscopic total trapeziectomy appears to be a safe and effective treatment for end-stage arthrosis of the thumb basal joint. [38] (10.1177/15589447241262055)
• [L5] The multiplicity of treatment modalities for carpometacarpal joint arthritis shows that the underlying trapezium excision is probably the prime factor in patients' clinical improvement, and thumb index metacarpal stabilization needs to be based on each individual clinical scenario. [43] (10.1016/j.jhsa.2007.02.013)
• [L3] The radiological classification does not describe all stages of carpometacarpal joint osteoarthritis accurately enough to permit reliable and consistent communication between clinicians. [44] (10.1016/j.jhsa.2014.09.007)
• [L3] The metacarpal surface of the trapezium demonstrates three distinct patterns of wear in arthritic surgical specimens. [45] (10.1055/s-0033-1350088)
• [L1] Review of the literature demonstrates that radiographs assist in the assessment of CMC joint disease, but there is not a reliable system for classification of disease severity. [46] (10.1007/s11999-013-3208-z)
• [L4] [48] (10.1016/j.jhsa.2025.01.018)
• [L2] [61] (10.1177/17589983261444954)
• [L2] [64] (10.1177/1753193420950600)
• [L5] [66] (10.1177/1753193420970343)
• [L2] [67] (10.1302/0301-620x.108b1.bjj-2025-0483.r1)
• [L4] Thumbs in patients with TMC-OA and healthy thumbs have different kinematics during FDI maneuvers, and an atrophic FDI may not be an efficient dynamic stabilizer. [68] (10.1016/j.jhsa.2024.12.018)
• [L1] [75] (10.1002/acr.24084)
• [L4] [76] (10.1177/1753193412469127)
• [L3] Altered thumb rotation patterns during pinch may contribute to joint misalignment and the development of osteoarthritis. [80] (10.1177/17531934251383073)
• [Paper] Degenerative arthritis of the thumb CMC joint is a common treatable condition where nonoperative modalities are effective for early stages, while surgical options are reserved for cases refractory to conservative measures. [89] (10.1016/j.hcl.2008.03.001)
• [L3] The authors suggest that ulnar instability should be included in the classification of thumb CMCj osteoarthritis stages and considered in treatment options. [92] (10.1055/s-0039-1697650)
• [L5] The author notes that despite 70 years of research and numerous treatment options, the best management for trapeziometacarpal arthritis remains debated, with a constant proportion of patients remaining unhappy or symptomatic post-surgery. [93] (10.1177/17531934221122987)
• [L1] The use of arthroscopic-assisted techniques for thumb CMC OA is still limited; however, it may be a reasonable option for patients with thumb CMC OA who do not respond to non-operative treatment. [96] (10.1177/1753193418757122)
• [L2] [97] (10.1097/corr.0000000000003328)
• [L5] [101] (10.1016/j.jhsa.2011.12.012)
• [L3] Wrist radiographs demonstrate a 47% sensitivity and 94% specificity in predicting end-stage ST joint arthritis, emphasizing the importance of directly visualizing the ST joint after trapeziectomy. [105] (10.1177/1558944718765246)
• [L5] Radiographic development of trapeziometacarpal arthrosis is an expected part of human aging, although clinically significant, functionally limiting trapeziometacarpal arthrosis is less common, and its development may be unrelated to hand use. [106] (10.1016/j.jhsa.2015.04.038)
• [L5] [107] (10.5435/jaaos-d-18-00683)
• [L3] However, a negative grind test does not necessarily reflect negative radiographic evidence of thumb CMC osteoarthritis. [113] (10.1016/j.jht.2010.02.001)
• [L2] Increased degenerate-like changes were observed after simple excision of the trapezium but these did not influence the clinical outcome. [114] (10.1007/s11999-013-2956-0)

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