Radiologic Guide to Surgical Treatment of First Carpometacarpal Joint Osteoarthritis

Transcription

1 Musculoskeletal Imaging linical Perspective Khorashadi et al. Surgery of First arpometacarpal Joint Osteoarthritis Musculoskeletal Imaging linical Perspective Leila Khorashadi 1 lice S. Ha 2 Felix S. hew 2 Khorashadi L, Ha S, hew FS Keywords: arthroplasty, carpometacarpal, osteoarthritis DOI: /JR Received June 11, 2011; accepted after revision September 5, Presented as Educational Exhibit LL-MKE2606 at RSN Invited for RadioGraphics monograph issue. 1 Schatzki ssociates, Mount uburn Hospital, ambridge, M. 2 Department of Radiology, University of Washington, 4245 Roosevelt Way NE, ox , Seattle, W ddress correspondence to. S. Ha (aha1@uw.edu). ME This article is available for ME credit. JR 2012; 198: X/12/ merican Roentgen Ray Society Radiologic Guide to Surgical Treatment of First arpometacarpal Joint Osteoarthritis OJETIVE. The purpose of this article is to provide a radiologic guide to surgical treatment of first carpometacarpal osteoarthritis, a common problem especially in older women. ONLUSION. Knowledge of the indications, surgical technique, component design, normal postoperative imaging assessment, and imaging findings of complications is important to providing a meaningful radiologic evaluation of patients after first carpometacarpal joint surgeries, including arthroplasty and arthrodesis. T he first carpometacarpal joint is critical for primates ability to have an opposable thumb. It allows arclike movement of the first metacarpal away from the palm and around the other fingers. This degree of mobility and the stability of the first carpometacarpal joint enhances dexterity and provides a powerful pinch force. Stability of this joint relies on bony architecture, as well as ligamentous and tendinous support. Unfortunately, the first carpometacarpal joint is a common site of osteoarthritis, being second only to distal interphalangeal joints. However, because of the importance of the first digit in hand function, the first carpometacarpal joint is the most commonly operated site in the hand for arthritis [1]. In patients older than 75 years, the prevalence of radiographic degeneration of the first carpometacarpal ranges from 25% in men to 40% in women [2]. Severity of first carpometacarpal joint osteoarthritis is evaluated according to clinical and radiographic examinations. When nonsurgical therapies such as splinting and joint injection fail, there are several surgical options to restore function and decrease pain at the first carpometacarpal joint. It is important for radiologists to become familiar with radiographic appearance of commonly performed surgical techniques, normal postoperative appearance, and their related complications. Normal natomy The first carpometacarpal joint is a diarthrodial joint, made of reciprocal concave surfaces of the trapezium and the first metacarpal. It has also been described as a saddle joint because of its appearance as two saddles coming together at 90 angles [3, 4] (Fig. 1). This unique incongruous bony joint allows a wide range of motion, including flexion-extension, adduction-abduction, and opposition-reposition. ollectively, the joints about the trapezium are called the basal joint of thumb, which includes the first carpometacarpal joint, the scaphotrapeziotrapezoidal joint (Fig. 1), and an articulation between the trapezium and the second metacarpal base. Ligaments and tendons of the first carpometacarpal joint help stabilize the joint and contribute to the complex motion of the thumb (Fig. 2). The volar oblique ligament, also known as the beak ligament or the deep anterior oblique ligament, is the primary static stabilizer against dorsoradial migration of the first metacarpal. The beak ligament originates from the volar trapezial tubercle, is shaped like a beak, and inserts onto the articular margin of the ulnar side of the first metacarpal base. This intracapsular ligament runs diagonally from the proximal radial to the distal ulnar direction. Second, the dorsoradial ligament is the thickest and shortest ligament in the basal joint and works to prevent dorsal translation. Dorsoradial ligament traverses the radial aspect of the trapezium and the first metacarpal base. Third, the intermetacarpal ligament attaches on the ulnar side of the first metacarpal and inserts onto the radial aspect of the second metacarpal and restricts the radial translation of the first metacarpal. Deficiency of any of these ligaments may predispose the joint to synovitis and wear of 1152 JR:198, May 2012

2 Surgery of First arpometacarpal Joint Osteoarthritis the first carpometacarpal joint articular cartilage. Of the nine muscles and tendons that provide dynamic stability of the first carpometacarpal joint (Table 1), dorsal expansion of the abductor pollicis longus (PL) tendon is the most important stabilizer of the joint, especially during supination. Pathophysiology of Osteoarthritis rthritis of the first carpometacarpal joint is common and often debilitating, most commonly affecting postmenopausal women. The prevalence of first carpometacarpal joint osteoarthritis has been reported to be 8 12% in the general population [5]. mong women older than 75 years, the prevalence of radiographic degeneration of the first carpometacarpal osteoarthritis is as high as 40%, versus 20% for men of the same age group [2]. Intrinsic factors, such as ligament laxity due to hormonal influences, biomechanical differences between men and women, or posttraumatic causes, may contribute to sex-specific degeneration of the joint. natomically, the first carpometacarpal joints in women are less congruent with smaller contact areas than in men, with the trapezium being smaller and more concave Fig. 2 Volar view diagram (left) shows volar beak (V) ligament originating on distal trapezial tubercle and inserting onto ulnar base of first metacarpal (M). eak ligament is most important static stabilizer against dorsoradial subluxation of first metacarpal. Intermetacarpal (IM) ligament is noted between first and second metacarpal bases. Dorsal view diagram (right) shows dorsolateral (DL) ligament originating from dorsal surface of trapezium and inserting onto base of first metacarpal. (Drawing by Loomis S) [6, 7]. In both sexes, incompetence of volar beak ligament is thought to be a major inciting factor for degeneration of the basal joint. The most widely used staging system for first carpometacarpal osteoarthritis is the Eaton classification system (Table 2), first described in 1973 and subsequently modified in 1987 [8]. Eaton staging is independent of subjective and objective clinical data and relies solely on radiographic findings (Fig. 3). t stage I, the basal joint appears radiographically normal or minimally widened as a result of ligamentous laxity or joint effusion. Stage II exhibits small (< 2 mm) osteophytes Fig. 1 Osseous anatomy of first carpometacarpal (M) joint., Diarthrodial design is formed by two concave surfaces of trapezium and first metacarpal oriented at 90 from each other. Metacarpal articular radius is about 33% larger than trapezial surface, creating incongruous joint surface. (Drawing by Loomis S), 25-year-old woman. Oblique view of 3D volume rendering of wrist T shows basal joint of thumb, which includes saddle joint (white arrow) between first metacarpal and trapezium, scaphoid-trapeziumtrapezoidal joint (arrowhead), and articulation between trapezium and base of second metacarpal (blue arrow). and dorsoradial subluxation of the first metacarpal of less than one third of the joint space. With further joint space narrowing, osteophytosis, and subchondral cystic changes, stage III may show loose bodies in the thumb basal joint with first metacarpal subluxation greater than one third of the joint space width. Stage IV is pantrapezial arthritis due to additional degenerative involvement of the scaphotrapeziotrapezoidal joint. There is eventual fragmentation and loss of trapezial height with increased dorsoradial subluxation of the first metacarpal. Severe first carpometacarpal joint osteoarthritis leads to stiffness and adduction deformity at the basal joint, with accompanying compensatory hyperextension deformity at the first metacarpophalangeal joint. Treatment of First arpometacarpal Joint Osteoarthritis onservative therapies for first carpometacarpal osteoarthritis include activity modification, thenar muscle strengthening, splint JR:198, May

3 Khorashadi et al. TLE 1: Muscles That Support the First arpometacarpal Joint Muscle Origin Insertion bductor pollicis brevis Interosseous membrane Radial side of first metacarpal base Flexor pollicis brevis Tubercle of trapezium and flexor retinaculum ase of proximal first phalanx Opponens pollicis Flexor retinaculum and tubercle of trapezium Radial aspect of the entire first metacarpal Flexor pollicis longus Radius and interosseous membrane ase of distal first phalanx dductor pollicis apitate bone and tendon sheath of the flexor carpi radialis Ulnar side of the base of the proximal first phalanx as well as the bases of the second and third metacarpal bductor pollicis longus Interosseous membrane ase of the first metacarpal Extensor pollicis brevis Radius and interosseous membrane ase of the first metacarpal Flexor carpi radialis Medial humeral epicondyle ase of the second metacarpal and small slips to third metacarpal base Extensor pollicis longus Radius and interosseous membrane ase of the distal phalanx base immobilization of the thumb, nonsteroidal antiinflammatory drug therapy, and intraarticular corticosteroid injections [3]. Indications for operative intervention in first carpometacarpal joint osteoarthritis are similar to those for other joints and include persistent pain, joint instability, decreased function, and failure of conservative therapies. There are numerous operative techniques for various stages of first carpometacarpal osteoarthritis. For Eaton stage I disease, treatment options include beak ligament reconstruction, first carpometacarpal arthroscopy for synovectomy or thermal shrinkage of the capsule or lax beak ligament, and metacarpal excision osteotomy. Initially described by Eaton and Littler in 1973 [9], volar beak ligament reconstruction surgery uses a strip of autogenous flap of the flexor carpi radialis (FR) tendon. Metacarpal excision osteotomy uses a dorsal closing wedge osteotomy to reduce the load on the volar compartment of the basal joint. For Eaton stages II IV, the goal of the operation is to relieve pain and restore strength by recreating volar beak ligament and maintaining thumb height. The particular surgical approach will depend on patient symptoms and surgeon preference. Surgical therapies for stages II IV disease have evolved over the past 60 years. Gervis [10] first described trapeziectomy in However, simple trapeziectomy was complicated by significant functional problems such as loss of pinch strength and first digit length. Since then, methods have been developed to fill the trapeziectomy space with various materials such as hematoma, tendons (e.g., PL, FR, palmaris longus, and fascia lata allograft), silicone graft, fabric patch (Gore-Tex), and costochondral graft. Kuhns et al. [11] described a hematoma and distraction procedure whereby after trapeziectomy the thumb is held by a K-wire in wide abduction and opposition. In patients with stage II or III disease, there is an overall push to preserve trapezial height by performing only distal trapeziectomy. However, in patients with pantrapezial arthritis (i.e., Eaton stage IV), procedures that include complete trapeziectomy are preferred. In comparison with arthrodesis, arthroplasty at the basal joint aims to relieve symptoms while preserving the range of motion and decreasing the relative transfer of forces that contribute to degeneration of the surrounding joints as noted in arthrodesis. First carpometacarpal arthroplasties reviewed in this article include ligament reconstruction and tendon interposition, ligament reconstruction and costochondral allograft interposition, and implant placement. However, in cases of failed arthroplasties or young patients with heavy occupational demand, arthrodesis is preferred for providing pain relief and joint stability. Ligament Reconstruction and Tendon Interposition For Eaton stages II IV, ligament reconstruction and tendon interposition is a common procedure. In 1970, Froimson [12] first described folding in the slip of the FR tendon into the trapeziectomy space and coined the term anchovy procedure. Since then, urton and Pellegrini Jr. [13] combined reconstructing the volar beak ligament with tendon interposition (Fig. 4). The FR tendon is split longitudinally from the proximal end. The mobilized end of the FR tendon is then passed through a drill hole at the base of the first metacarpal base to reconstruct the beak ligament. The remaining FR tendon is folded into the empty trapeziectomy space. Normal postoperative radiographs show the trapeziectomy space maintained by radiolucent interposed tendons. drill hole in the base of the first metacarpal will also have been seen on the radiographs. Suspensionplasty is another surgical technique in which, after partial or complete trapeziectomy, the ulnar slip of the PL tendon TLE 2: Eaton Staging of First arpometacarpal Joint Osteoarthritis Stage Radiographic Findings I Normal joint space or contour or slightly widened trapeziometacarpal joint. If present, < 1/3 trapeziometacarpal articular surface subluxation. II Decreased trapeziometacarpal joint space. Small (< 2 mm) osteophytes or loose bodies. If present, < 1/3 trapeziometacarpal articular surface subluxation. III Further decrease in trapeziometacarpal joint space. Presence of subchondral cysts or sclerosis. Osteophytes or loose bodies 2 mm in diameter. t least 1/3 trapeziometacarpal articular surface subluxation. IV Findings in stage III in addition to involvement of the scaphotrapezial joint or less commonly the trapeziotrapezoid and trapeziometacarpal joint of the second digit JR:198, May 2012

4 Surgery of First arpometacarpal Joint Osteoarthritis Fig. 3 Eaton staging of first carpometacarpal joint osteoarthritis in frontal radiographs of radial wrist. Stage I is normal configuration of first carpometacarpal joint, with or without minimal joint space widening. In stage II, there is decreased first carpometacarpal joint space and osteophytes (< 2 mm) present at trapeziometacarpal joint. Stage III indicates presence of subchondral cysts or sclerosis at basal joint, osteophytes, or loose bodies (> 2 mm) and dorsoradial subluxation of first metacarpal greater than one third of joint space. Stage IV is pantrapezial arthritis with all findings of stage III plus scaphotrapeziotrapezoidal joint osteoarthritis. is detached proximally and passed in the drill holes of the first and sometimes also the second metacarpals and is either secured to the extensor carpi radialis longus tendon or woven into the tendon [14] (Fig. 5). This method can be used if the FR tendon is a suboptimal candidate because of excess fraying or degeneration due to primary disease process or iatrogenic causes. dvantages of suspensionplasty over ligament reconstruction and tendon interposition include relatively less complicated surgery and FR tendon preservation. Postoperative radiographs after suspensionplasty will show full or partial trapeziectomy space and drill holes in the first and second metacarpal bases. Ligament Reconstruction and ostochondral llograft Interposition Littler first developed a method whereby the trapeziectomy space was filled with a silicone graft in 1984 and coined the term the life saver technique for the shape of the graft [15]. However, because of increased complications with silicone, cadaveric costochondral allograft has been used [15]. This procedure is reserved for Eaton stage II or III disease. fter capsulotomy and confirmation of a disease-free scaphotrapeziotrapezoidal joint, the distal half of the trapezium is subperiosteally resected. The proximal FR tendon, at the level of the junction of the mid and distal third of the forearm, is split half its width, and a strip of the FR tendon is longitudinally dissected. The first metacarpal base and the remaining trapezium are drilled (Fig. 6). The prepared costochondral allograft is positioned into the trapeziectomy space, and the prepared slip of the FR tendon is passed through the remaining trapezium and the costochondral graft and is anchored through tunnels at the dorsal base of the first metacarpal (Fig. 6). The FR tendon is sutured back on itself, and the joint capsule is closed. Fig. 4 Ligament reconstruction and tendon interposition., Volar view diagram of first digit shows trapezial resection and drill hole placed at base of first metacarpal (M) (arrowhead). Native flexor carpi radialis (FR) tendon is shown inserting mostly on volar base of second metacarpal. Some slips may also attach to third metacarpal base (not shown). (Drawing by Loomis S), Flexor carpi radialis (FR) tendon is incised longitudinally, and radial slip is passed through drill hole in first metacarpal base (arrowhead, ). FR tendon is then passed around abductor pollicis longus, inserting onto first metacarpal base (image not shown) and remaining FR tendon. FR tendon is secured to base of first metacarpal. This reconstructs volar beak ligament. Dissected FR tendon is then folded into trapeziectomy space (arrow) to help maintain thumb height and prevent bone-on-bone contact. K-wires are used to reduce and stabilize first and second metacarpal joint space postoperatively. (Drawing by Loomis S), 51-year-old woman. nteroposterior radiograph of wrist shows changes from trapezium resection. There is drill hole in first metacarpal base for passing FR tendon. Suture anchors are noted at bases of first and second metacarpals. There is K-wire to stabilize digits in postoperative period. There is maintenance of first thumb height. There is no scaphotrapeziotrapezoidal joint osteoarthritis. JR:198, May

5 Khorashadi et al. Fig. 5 Suspensionplasty., Dorsal diagram shows how abductor pollicis longus (PL) tendon is split into two slips with ulnar slip of tendon being passed through drill hole in first metacarpal (M) base, and then tied around distal extensor carpi radialis longus (ERL) tendon. This reduces first carpometacarpal subluxation by restoring volar beak ligament function. Partial (in this case) or full trapeziectomy is usually performed. (Drawing by Loomis S) and, 53-year-old woman. nteroposterior () and lateral () radiographs of radial wrist show reduced first carpometacarpal joint with gross anatomic alignment of trapezium and first metacarpal. PL tendon was secured through first and second metacarpal bone tunnels (arrows) using radiolucent screws. Partial trapeziectomy space (arrowhead, ) was filled with tensor fascia lata tendon allograft to maintain thumb height. Fig. 6 Ligament reconstruction and costochondral allograft interposition., Volar diagram shows resection of distal trapezium with longitudinal flexor carpi radialis (FR) tendon dissection site marked by dashes. Drill holes (arrowheads) are noted in remaining proximal trapezium and first metacarpal (M) base. (Drawing by Loomis S), Volar diagram of thumb. ostochondral cartilage allograft (arrow) has been placed into partial trapeziectomy space, and split FR tendon is passed through three drill holes (arrowheads) (distal trapezium, cartilage graft, and first metacarpal base) before being secured. (Drawing by Loomis S), 50-year-old woman. nteroposterior radiograph of first carpometacarpal joint. Distal trapezium has been replaced by radiolucent costochondral allograft to preserve first metacarpal height. Drill tracks (arrows) at base of first metacarpal localize location of threaded FR tendon. one anchor was used to secure costochondral allograft to surrounding structures. In this patient, abductor pollicis longus tendon is used to mimic function of volar beak ligament to reduce first metacarpal to near anatomic alignment, and tendon is secured to second metacarpal base using radiolucent screw (arrowhead) into base JR:198, May 2012

6 Surgery of First arpometacarpal Joint Osteoarthritis Fig. 7 Implant arthroplasty and first carpometacarpal joint arthrodesis., 76-year-old woman with silicone implant for first carpometacarpal arthroplasty. On anteroposterior view of thumb, entire trapezium and base of first metacarpal have been resected, and stemmed silicone implant is inserted into metacarpal shaft. Prosthesis preserves height of metacarpal and articulates with scaphoid proximally., 66-year-old woman with trapezium implant. nteroposterior radiograph shows implant filling trapeziectomy space with stem secured in metacarpal diaphysis. Position of implant is secured by either competent joint capsule or, ideally, accessory abductor pollicis longus tendon. Suture anchor reflects ligament reconstruction to reduce degree of radial displacement and angulation of metacarpal after trapeziectomy., 67-year-old woman with ceramic implant. nteroposterior radiograph shows radiopaque ceramic implant and resurfaced distal trapezial and proximal first metacarpal articular surfaces (arrows). D, 46-year-old woman with arthrodesis of first carpometacarpal joint. nteroposterior radiograph of wrist shows side plate-and-screw fusion of trapezium with first metacarpal with osseous bridging at first carpometacarpal joint space (arrow). There is preserved joint space at scaphotrapeziotrapezoidal and first and second metacarpal joints, indicating absence of pantrapezial arthritis. D The advantage of the costochondral allograft technique is the lack of a need for temporary pin fixation after surgery with a shorter period of immobilization when compared with other surgical techniques. On radiographs, the costochondral graft is radiolucent (Fig. 6), therefore giving similar appearance to ligament reconstruction and tendon interposition cases. Implant rthroplasty Several prostheses are used in first carpometacarpal joint arthroplasty with partial or complete trapeziectomy. Silicone implants (Swanson, Wright Medical Technologies) have a long stem that extends into the first metacarpal shaft to give additional stability (Fig. 7). In general, silicone-based implants are used in patients with pantrapezial (first carpometacarpal and scaphotrapeziotrapezoidal joint) arthritis. ostochondral grafts are thought to be too thin to fill the full trapeziectomy space. Postoperative radiographs show radiodense implant in the trapeziectomy space. trapezium implant (Tie-in, Wright Medical Technologies) is an intramedullary stemmed silicone elastomere implant that is flexible (Fig. 7). The proximal end of the implant is secured by either an accessory PL tendon or a competent joint capsule. The trapezium implant will reduce the radial displacement of the first metacarpal and reduces the angulation of the first metacarpal after trapeziectomy. Radiographically, it is distinguishable from the silicone implant by the distinct indented waist at the midtrapezium level. ceramic implant (Orthosphere, Wright Medical Technologies) (Fig. 7) is a spherical interpositional device that serves as a dynamic mobile spacer, providing stability at the basal joint. The implant space is provided by resurfacing of the first metacarpal base and the distal trapezium. rthrodesis First carpometacarpal joint arthrodesis is reserved for patients with painful joint instability due to systemic ligament laxity, young patients with high-demand occupations, posttraumatic osteoarthritis in young patients, and after failed reconstruction arthroplasty. plate and screws are used to stabilize the first carpometacarpal joint until eventually bony fusion occurs (Fig. 7D). Despite its advantages of improved strength, pain relief, and joint stability, arthrodesis does lead to loss of mobility at the joint. There are other JR:198, May

7 Khorashadi et al. disadvantages of associated scaphotrapeziotrapezoidal or first metacarpophalangeal joint arthritis and relatively high rates of nonunion (13% in a compilation of 13 fusion studies) [16]. The preferred position for fusion is palmar abduction and radial abduction and extension. This position is otherwise described as thumb key pinch, where the thumb tip rests on the radial aspect of the second middle phalanx. omplications lthough clinical examination is critical, radiographic assessment plays a key role in postoperative assessment after first carpometacarpal joint surgeries. The most common complication after first carpometacarpal joint surgery is pain. Depending on the operative technique, causes of persistent pain may include the presence of a hypertrophic scar, sensory nerve irritation or damage, and cutaneous neuromas. Infection may occur at any time after arthroplasty and is generally diagnosed clinically. In advanced cases, radiographic evidence of infection may include soft-tissue swelling, perihardware lucency greater than 2 mm, and bony erosions at the infected joint indicating osteomyelitis (Fig. 8). In advanced cases, the prosthesis may be removed and an antibiotic spacer may interpose the trapeziectomy space, pending revision surgery. Dorsoradial subluxation of the first metacarpal from the first carpometacarpal joint is part of the natural disease process and can also occur after any of the arthroplasties (Fig. 9). There is gradual proximal radial displacement of the first metacarpal relative to the scaphoid and increased distance between the first and second metacarpals. Silicone implant usage has decreased over the years because of the high rate of complications, including implant dislocation (Figs. 10 and 10), implant fracture (Figs. 10 and 10D), and silicone-related synovitis [17] (Figs. 10E and 10F). In a long-term follow-up study, van appelle et al. [18] reported a 40% dislocation rate and a 27% revision rate. Silicone synovitis (Figs. 10E and 10F) is characterized by osteolysis and subchondral cystic changes. Silicone-induced synovitis typically Fig year-old woman with infection after first carpometacarpal arthroplasty. Immediate postoperative frontal radiograph (left) shows radial wrist after ligament reconstruction with costochondral allograft interposition. There is appropriate graft position and alignment of first metacarpal relative to second metacarpal and scaphoid. There is no soft-tissue swelling. Tunneled tracks are noted at base of first and second metacarpals for tendon interposition. t 2-week postoperative visit (middle), patient has clinical findings suspicious for cellulitis. Radiographs show nonspecific mild soft-tissue swelling. There is suggestion of cortical irregularity at base of first metacarpal. Patient was treated with débridement and removal of allograft (right). Methylmethacrylate spacer containing vancomycin was placed in trapeziectomy space. Fig year-old woman with dorsoradial subluxation of first metacarpal after ligament reconstruction and tendon interposition. nteroposterior radiographs of first carpometacarpal joint were obtained in July 2004 (left), pril 2007 (middle), and September 2009 (right). There has been progressive dorsoradial migration of first metacarpal. There is increased horizontal distance between first and second metacarpals (arrow) and decreased vertical distance between metacarpal and scaphoid. Note is made of prior arthrodesis of first metacarpophalangeal joint for hyperextension deformity at this joint. Given persistence of symptoms, there was arthrodesis of first carpometacarpal joint with plate and screws across first and second metacarpal and first metacarpaltrapezoid joint. presents more than 2 years after arthroplasty and may lead to implant failure. Synovitis can be arrested by synovectomy, implant removal, and curettage of the lytic lesions. With regard to ceramic implants, thwal et al. [19] reported low patient satisfaction (0%) at a mean followup of 33 months, with six of seven implants subsiding into the trapezium. There have been more favorable results in ceramic implant use in the tarsometatarsal joints [20]. There are ongoing controversies as to which surgical treatment method is the most effective in treating first carpometacarpal osteoarthritis. recent review by Martou et al. [21] of 44 studies of surgical therapies for first carpometacarpal osteoarthritis shows no clear winner. In addition, there are limitations to current postoperative evaluations after first carpometacarpal arthroplasties. recent prospective study showed no correlation between first metacarpal migration and functional outcome [22]. Further study, especially on correlating radiographic findings with clinical outcome, is required in this category of increasingly performed surgeries JR:198, May 2012

8 Surgery of First arpometacarpal Joint Osteoarthritis D Fig. 10 omplications after implant arthroplasty. and, 50-year-old woman with dislocation of trapezium implant. Patient presented with new bump palpable on dorsum of her hand and pain. On anteroposterior () and lateral () radiographs, there is foreshortening of thumb, with complete dislocation of prosthesis and overlap of prosthesis with scaphoid. and D, 67-year-old woman with fracture of silicone implant at first carpometacarpal joint. Patient presented with clicking and pain at first carpometacarpal joint. Frontal radiograph () shows mild soft-tissue swelling but intact implant. Given persistent symptoms, T scan was obtained, and reformatted T image in sagittal plane (D) shows complete fracture and dislocation (arrow, D) of silicone prosthesis at its waist. E and F, 80-year-old woman with silicone-related synovitis after silicone implant. Placement is characterized by osteolysis and subchondral cystic changes. Immediate postoperative images should appear as those in Figure 7. In this patient, on follow-up anteroposterior (E) and lateral (F) radiographs, there is loss of trapezial implant height with osteolysis and fragmentation of remaining trapezium (arrows) due to silicone synovitis. Suture anchors have changed in position. Incidentally noted is healed distal radial fracture with prior open reduction with internal fixation. E F JR:198, May

9 Khorashadi et al. Summary First carpometacarpal joint osteoarthritis is a common and debilitating disorder. The main contributor to the pathologic process is the laxity of the volar beak ligament, which will result in subluxation at the first carpometacarpal joint, eventual attenuation of the articular cartilage, joint space narrowing, and osteophyte formation. Numerous surgical techniques have been described with the goals to relieve pain and joint function by restoring normal tension of the volar beak ligament. Isolated reconstruction of the volar beak ligament may provide symptomatic relief in Eaton stage I of first carpometacarpal arthritis. Operative techniques designed to address the symptoms of stages II IV include ligament reconstruction and variations of tendon interposition and costochondral or prosthesis interposition versus arthrodesis. rthrodesis is typically used in cases of failed arthroplasty or in young patients with increased demands on the joint. Residual pain up to 6 months after surgery is a common reported symptom. However, longer persistence of pain should prompt further evaluation of complications related to the surgery. In radiographic evaluation of carpometacarpal arthroplasty, the radiologist should be cognizant of the degree of subluxation or subsidence of the first metacarpal relative to the scaphoid and the second metacarpal. When present, particular attention is warranted to the position of the prosthesis to exclude dislocation or fracture. Infection is an uncommon complication, and is often clinically evident. cknowledgment We thank Susanne Loomis, Project oordinator from REMS Media Services at Massachusetts General Hospital Imaging, for the illustrations. References 1. Pellegrini VD Jr. Osteoarthritis at the base of the thumb. Orthop lin North m 1992; 23: rmstrong L, Hunter J, Davis TR. The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. 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Ligament reconstruction with or without tendon interposition to treat primary thumb carpometacarpal osteoarthritis: a prospective randomized study. J one Joint Surg m 2004; 86-: FOR YOUR INFORMTION This article is available for ME credit. Log onto click on JR (in the blue Publications box); click on the article name; add the article to the cart; proceed through the checkout process JR:198, May 2012