Osteoarthritis: Carpometacarpal Joint (Ligament Reconstruction with Tendon Interposition)

Vincent Ruggiero and Andrew K. Palmer

History and Clinical Presentation

A 55-year-old right hand dominant woman presents with the complaint of pain of 3 years’ duration in the right thumb. The pain has progressed to the point where it now interferes with her activities of daily living in her house and garden. She complains of weakness of both pinch and grasp. She denies any numbness or tingling in her fingertips or loss of motion of the hand or wrist.

Physical Examination

There is tenderness and swelling about the basal joint of the thumb. Axial compression causes pain and palpable grating at the basal joint of the thumb. The thumb carpometacarpal (CMC) joint is unstable to stress testing. Her thumb metacarpal is adducted and the metacarpophalangeal (MP) joint of the thumb hyperextends 15 degrees on stress testing. Her pinch and grip strengths are decreased by one-half of her nondominant side. She has negative Phalen’s, Tinel’s, and Finkelstein’s tests.

Diagnostic Studies

Figure 68–2.  Maximum pinch view demonstrating mild subluxation of the CMC joint with degenerative change (arrow).

Differential Diagnosis

Carpometacarpal arthritis

Carpal tunnel syndrome

De Quervain’s tendinitis

Flexor carpi radialis tendinitis

Trigger thumb

Diagnosis

Carpalmetacarpal Arthritis: Pan Trapezial

Note the scaphotrapezial joint has arthritic changes also.

Carpometacarpal arthritis is a common condition that has a predilection for middle-aged women. This may be a sequela of idiopathic hypermobility of the CMC joint. It can also be associated with trauma or inflammatory diseases. Activities that require strength and/or mobility of the thumb are difficult to perform. Examples are key pinch and opening a jar.

Eaton has classified CMC arthritis into four stages. Stage I is characterized by no joint degeneration and articular contours that are normal. There may actually be widening of the joint space secondary to an effusion. Stage II is characterized by slight narrowing of the trapeziometacarpal joint on radiographs. If any joint debris is present, it is less than 2 mm in size. Stage III is characterized by significant trapeziometacarpal joint destruction radiographically. Sclerotic and cystic changes are noted in the bone. Stage IV is characterized by scaphotrapezial degenerative arthritis in addition to the changes seen in stage III.

Ligament reconstruction with tendon interposition (LRTI) is our preferred treatment for the late stages of CMC arthritis. The reconstruction of the volar beak ligament prevents thumb ray shortening and instability. The arthroplasty helps to prevent collapse of the thumb. We usually perform a complete trapezial resection, as most of our patients have some degree of scaphotrapezial arthritis that may not be evident on radiographs.