Referring Physicians >> Newsletters >> March 2012 Plastic & Reconstructive Newsletter >> Basal Joint Arthritis: Evaluation, Treatment, and Postop Expectations
Review the clinical presentation of basal joint arthritis, conservative management strategies, when surgery is indicated, and what patients can expect after surgery.
The basal (carpometacarpal) joint is the second most common location for osteoarthritis in the wrist and hand, and is the most common arthritic condition of the upper extremity to be treated with surgery. Basal joint arthritis is usually seen in patients aged 50 to 70, and occurs more frequently in women than men.
Patients often present with pain, instability, or weakness associated with pinch motions or activities where the thumb bears weight. The most common early complaint involves difficulty opening jars or bottle screwcaps. Direct palpation usually reveals tenderness in the joint; depending on the stage of disease, the joint may appear swollen and/or the patient may have decreased range of motion. In late stages of the disease, the thumb may appear hyperextended at the metacarpophalangeal joint.
The “grind test,” in which the physician gently grasps the patient’s thumb and grinds it like a peppermill, elicits pain in patients with basal joint arthritis. Lack of pain with resisted thumb extension (Hitchhiker’s test) helps rule out DeQuervain’s (first dorsal compartment) tenosynovitis, another common cause of radial-sided thumb pain. Measurements of grip and pinch strength can also help determine disease severity. Plain radiographs should be ordered for definitive diagnosis and staging.
Nonsurgical and Surgical Treatment Options
Symptomatic patients with early-stage arthritis usually respond to behavior modification (e.g., limiting thumb motion), treatment with nonsteroidal anti-inflammatory medications, or splinting. Although commercially available thumb spica splints may suffice, a hand-based thumb spica splint fabricated by a certified hand therapist may be more comfortable for the patient and increase the likelihood of patient compliance. When these methods fail to control symptoms, intra-articular corticosteroid injections may also be used to reduce inflammation and relieve pain.
Patients who do not respond to nonsurgical treatments, and who experience significant daily pain and/or chronic disruption of activities of daily living, may be candidates for surgery.
The most common surgical treatment is trapeziectomy, often with autologous tendon interposition and ligament reconstruction. In this outpatient procedure, the surgeon excises the trapezium and transfers a tendon from the forearm to the trapezial space. The tendon used for the ligament reconstruction or suspension decreases the likelihood of joint collapse and bone-on-bone contact.
Trapeziometacarpal joint arthrodesis is usually reserved for the non-dominant hand in younger patients for whom pain reduction and long-term joint stability and strength are more important than mobility.
At the time of surgery, the patient will be placed in a short-arm splint. The splint will be removed at the first postoperative visit and replaced by a short arm thumb spica cast. Three to 4 weeks after the procedure, the cast is removed and active range-of-motion therapy begins. Strengthening begins around 6 to 8 weeks after surgery. The majority of patients return to most activities by 3 months after surgery. Full recovery of normal activities may require up to 6 months.
Most studies report high patient satisfaction rates and good short- and long-term pain relief after basal joint arthroplasty (1,2). Through rare, complications may include a small but permanent decrease in thumb strength or range of motion, and severe nerve pain.
Consultation and More Information
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