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FIRST CMC JOINT ARTHRITIS

CHRISTIAN DUMONTIER, MD, PHD

BASICS: OSTEO-ARTHRITIS

Frequent, disabling, costly disease

Prevalence 15% (1990)

➢ 18% (2020)

2,8% of disability (1990) ➢ 3,6% (2020)

1% of IP (USA)

BASICS - OSTEOARTHRITIS OF
THE HAND AND FINGERS

Hand arthritis is frequent

67% ♀ 55% ♂ after 55 years of age do have a
radiological OA

Symptomatic in 20% of cases

Without radio-clinical correlation neither at one day, or
during evolution

Important functional deficit, same as RA (Spacek 2004)

« RHIZARTHROSIS »
- 1ST CMC JOINT OA

Forestier (1937)

2nd OA in frequency (< IPD)

Age-adjusted prevalence: 15% ♀;
7% ♂ - rare before 50 yrs (8% of
women)

57% of CMC-1 OA after 60

71-100 yrs : symptomatic 26%
females, 14% males (Zhang 2002)]

♀ 48 ans

Age-specific prevalence rates

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

ETIOLOGY
Preventive treatment ?

Ligamentous laxity

Hormonal

Articular hypermobility (Jönsson 1995, 2008)

Idiopathic

Marfan, Ehler –Danlos

Functional overload (males, XVIth century)

Trauma : Articular fracture, luxation

Hypoplasia of trapezium

IT IS SO
FREQUENT, IS
THERE
SOMETHING I
SHOULD KNOW
THAT I AM NOT
AWARE OF ?

BIOMECHANICS

The 1st CMC joint is a complex one

Compared to a saddle on a scoliotic horse

BIOMECHANICS

The joint is inherently unstable ☞ Role of ligaments

TM JOINT INSTABILITY

Favored by dysplasia of the trapeze and the pull of
tendons (APL +++)

BIOMECHANICS

Highly constrained joint: a 1kg pulp
pinch ☞ shearing loads of 13 kg

➚ chondral constraints, ☞ dorsoradial subluxation, ☞ 1st web
shortening, ☞ MP joint mechanical
consequences

IT IS A REGIONAL DISEASE

Isolated TM joint involvement
is rare

TM + STT(30-60%), TzTzoïde (35%), Tz-2nd
metacarpal (86%)

If STT is involved ☞ TM (90%)

IT IS A REGIONAL DISEASE

Regional joint instability:

MP +++: Frontal or sagittal instability -

cause of failure of surgical treatment [De Smet, 2006] -

Stabilisation if MP extension > 30°

1st web space : Closure - cause of failure of

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

IT IS A REGIONAL DISEASE

Soft-tissue regional disease: Carpal tunnel: 4-46%
of cases; Tendinitis: FCR, De Quervain’s, trigger
finger

CLINICAL
EXAMINATION

Signs of OA:

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

Pain at palpation, griding test +,

Synovitis, deformity,...

Loss of strength

Thenar atrophy

Do not forget to examine the MP joint

RADIOLOGY

Special X-rays
incidences (Kapandji)

Signs of OA:
condensation,
sclerosis, joint
narrowing,
osteophytes (1st
web), subluxation,…

Special imaging techniques are useless

Eaton (1973, 1984)

Dell (1978, 1990)

Comtet (2001)

Stade 0

Instabilité. Interligne normal
ou élargi. Subluxation
réductible

Stade 1

Contours articulaires
normaux

Interligne normal ou minime
pincement ou légère
Minime pincement.
ostéocondensation sousOsteophytes. Subluxation non
chondrale. Pas de subluxation,
réductible
ou d’ostéophyte

Stade 2

Minime pincement ou légère
ostéocondensation souschondrale. Ostéophytes ou
corps étrangers < 2mm

Pincement, ostéocondensation
sous-chondrale. Ostéophytes.

Stade 3

Pincement marqué, géodes et
ostéocondensation souschondrales. Subluxation
variable. Fragments
articulaires > 2mm

Pincement marqué, géodes et
ostéocondensation souschondrales. Osteophytes.
Subluxation > 1/3 surface
articulaire métacarpienne.
Atérations STT.

Stade 4

Arthrose TM + STT

Arthrose TM et STT.

Subluxation < 1/3 surface
articulaire métacarpienne

Détérioration TM,
hyperextension MP réductible

Détérioration TM et MP,
hyperextension MP non
réductible

Arthrose TM et STT

TREATMENT

Medical

Pharmacological TTT (Pain-killers, NSAID, slow-action
anti-arthritis medication like sodium chondroietin
sulfate), orthosis +++, Physical TTT (paraffin, heat,…)

Steroid injections, Hyaluronic acid injections

Is said to be efficient in 90% of cases - pain relief in
8-11 years (Amor)

ORTHOSES

76% of patients with moderate involvement and 54% with
severe disease have a 60% improvement with an orthosis
(Swigart, 1999)

➡ Benefice is immediate (or never)

The type of orthesis +/- physiotherapy has no influence on
the evolution at 6 weeks (Wajon, Aust J Physiother 2005) - Patients prefer

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

No difference between short (wrist is free) or long orthoses, but
patients preferred short orthoses (Weiss, J Hand Ther 2000)

No difference between rigid or supple orthosis, but patients
preferred the more supple one (Buurke, Clin Rehab 1999)

TREATMENT

EULAR Recommandations (Zhang ARD 2007):
Surgery is an efficient treatment for CMC joint
arthroses and can be done in patients who are
painful or with a important functional deficit after
failure of more conservative treatments (FDR =
68).

SURGERY

Many techniques

Symptomatic treatment

Arthrodesis (Muller, 1949)

Osteotomy (Wilson, 1973)

Articular resection (i.e. trapezectomy w/wo stabilisation,
interposition,…) [Gervis, 1949; Froimson, 1970; Eaton 1973]

Prostheses - implants [Swanson, 1972] or prosthesis [De la Caffinière,
1974]

Preventive Treatment ?

Arthrodesis –13 yrs FU

TM ARTHRODESIS

Usually proposed in young people (to maintain
their strength) with some loss of mobility

No difference in results in the (rare, retrospective)
comparative studies

84% satisfactory results (25 years FU)

40% re-intervention [Chamay] (Hardware removal,
Nonunion 4%, De-arthrodesis 6%)

« Cultural » indications that diminish

TRAPEZIECTOMY

Partial or complete

With / wo interposition

W/wo stabilisation

Trapeziectomy always lead to a
diminution of key-pinch strength
[Vandenbroucke, 1997].

➡ All patients will complain of a loss of
strength after trapeziectomy +++

www.maitrise-orthop.com

A

POTENTIAL PROBLEMS
B

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

Trapézial Space Ratio = A/B
Kadiyala & Downing, JHS, 1996.

EBM: TRAPEZIECTOMY +/- INTERPOSITION
+/- STABILISATION (DAVIS - PROSPECTIVE
STUDIES)

183 patients, with 3 & 12 months FU
82% good results, 68% sufficient strength

Long recovery (6 months). « Normal »
Mobility

No difference between groups

➡ No correlation between the metacarpal
shortening and key-pinch strength

COCHRANE DATABASE
SYST REV 2005

7 studies (5 techniques) with 384 patients were
eligibles

Gain of pain of 27-57/100, of functional deficit
18-24/100

No difference between techniques

Less complications in the simple trapeziectomy
group (p<0.001)

11% more complications in the LRTI group
(p=0.03)

TM PROSTHESES

Many designs

Mostly French

1st case, De La Caffinière,
1974

ADVANTAGES OF TM
PROSTHESES

7 ans

Early recovery (2-3 months) - No rehabilitation

No thumb shortening (Can be used even if MP
hyperextension) - esthetic

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

COMPLICATIONS

About 15%, that increase with time

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

C/I: Trapezial dysplasia, short or thin trapezium,
MP arthrodesis, MCL insuffisiency (MP), STT
arthroses (young patient)

SURVIVAL OF TM PROSTHESES

Survival rate between : 68 to 89% (de
la Caffinière, 2001; Nicholas et Calderwod, 1992; Van
Capelle et al., 1999; Chakrabati et al., 1997; Apard et
Saint-Cast, 2007; Skyta et al., 2005; Wachtl et al., 1997;
Comtet, 2000; Brutus et Kinnen, 2004; Jacoulet, 2005;
Schuhl, 2001; Ledoux, 1997; Badia et Sambandam,
2006)

16% re-operation at 41 months FU
(Apard et Saint-Cast, 2007)

Most re-operation are done within
the first year (Apard et Saint cast, 2007, Comtet,
2000)

OTHER TECHNIQUES

To maintain the thumb length: partial
trapeziectomy with interposition (pyrocarbon,
Artelon,…) - No series published
TM joint denervation

REMEMBER

Silicone implant have been abandoned
due to the high number of
complications including siliconitis

RHIZARTHROSE

Le traitement de référence reste la trapézectomie (et ses
variantes)

Résultats satisfaisants (85%), manque de force,
récupération longue

La prothèse est indiquée chez les sujets plus âgés (en
l’absence de c/i) - bons résultats qui se maintiennent.
10-15% de complications à long terme.

Les autres techniques sont en évaluation (garder la
longueur du pouce = esthétique et fonction)

NOT TO FORGET:
WILSON
OSTEOTOMY

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

PREVENTIVE
TREATMENT ?
IS IT WORTH DOING IT ?

FOR WHICH PATIENTS ?

Young

Without (or limited)
cartilage alteration

TM instability +/trapezial dysplasia

PREVENTIVE TREATMENT

Section of anterior
aberrant fibers of the
APL (Zancolli)

No series published

Probably useless

PREVENTIVE TREATMENT

Ligamentoplasty in patients with
instability

Le Viet reported 19 patients
improved out of a series of 25 but
considered results as un-predictable

Eaton-Littler type

BRUNELLI LIGAMENTOPLASTY
(1974)

The APL is parallel to the plane of the nail plate

RESULTS OF BRUNELLI’S
LIGAMENTOPLASTY AT198 MONTHS

D. Le Viet

TM JOINT ARTHROSCOPY

Debridement of synovitis

Shrinkage of TM ligaments

OSTEOTOMIES

Vascularized Joint transfer (Roux 2004)

Non-vascularized osteotomy (Goubeau 2005)

THANK YOU FOR YOUR INVITATION