Keywords
arthroplasty - carpometacarpal joints - osteoarthritis - thumb - trapezium bone
Palavras-chave
articulações carpometacarpais - artroplastia - osteoartrite - polegar - trapézio
Introduction
The prevalence of thumb basal joint arthritis increases with age and affects the ability
to perform daily life activities (DLAs).[1] The number of patients seeking treatment for this condition is likely to increase.[2] However, there is no consensus regarding the prevention of total trapeziectomy in
stage-III arthritis, according to the Eaton classification III.
There is doubt regarding the increase in complications and costs due to the complexity
of the surgery.[2] Total joint arthroplasty (TJA) in trapeziometacarpal joint osteoarthritis can be
a safe procedure in patients older than 60 years of age and in stage III after failure
of the first non-surgical treatment.[3]
[4]
[5]
[6]
In these cases, TJA is convenient; it does not hinder the performance of other techniques
in case of failure, and it is a reproducible method that avoids stiffness, preserves
the length of the thumb, increases the initial range of motion (RoM), enables a faster
recovery, and it is an alternative to total trapeziectomy.[7]
The objective of the present study was to present the postoperative clinical outcomes
of ATJ,[2] including patient-reported time to return to DLAs, radiographic features and hand
grip strength, in patients with stage-III rhizarthrosis.
Increased Cost
The need for an implant (Maia prosthesis, Groupe Lepine) increases the cost of the
treatment and makes health insurers reluctant to provide coverage to the patients,
despite the growing evidence of its benefits.
Methods
The current research followed the ethical standards and was approved by the institutional
Ethics Committee on Human Experimentation. An informed consent form was provided to
all research participants, who read and signed it according to their will.
In the present single-center prospective study, we analyzed TJA with an uncemented
metal-on-polyethylene prosthesis (Maia, Groupe Lepine). The institutional Ethics in
Research committee approved the free and informed consent form, which the patients
signed before being included in the study. The inclusion criteria were patients with
stage-III carpometacarpal (CMC) joint osteoarthritis, aged > 60 years, initially treated
through non-surgical procedures. The exclusion criteria were patients presenting mental
illness, alcohol abuse, and rheumatological arthritis.
During the study period (from January 2018 to December 2023), 34 patients met the
selection criteria. Three eligible patients received a different implant, and two
were simultaneously submitted to surgery in another joint (metacarpophalangeal joint
with Z-deformity); these subjects were not included in the study.
Post-hoc Analysis
The post-hoc analysis showed that 29 of the patients included did not show differences
regarding age, sex, or CMC joint arthritis stage, with a statistical power of 85%
according to a two-sided test and level of significance of 5%.[8]
[9] The sample was composed of 25 women and 4 men with a mean age of 64 (range: 60–74)
years. Rhizarthrosis was classified according to the Eaton classification.[10] Follow up period was 25.1 [12-66] months.
Surgical Technique
The goal of the treatment is to improve the balance between the mobility and stability
of the CMC joint. Total joint arthroplasty must be perfectly positioned/fixated to
enable osteointegration.[7]
The dorsal approach was chosen ([Fig. 1]). The first step was to remove the joint surface of the base of the thumb, including
the volar and medial beak osteophytes. Next, we prepared the medullary canal of the
metacarpal with specific maneuver drills of increasing size until achieving press-fit
stability and proper stem alignment along the metacarpal axis. The final implant was
inserted, flush with the metacarpal base ([Fig. 2]). Subsequently, we performed the cup placement in the trapezium taking care to avoid
mechanical fixation of the cementless cup with the central subchondral bone and distal
articular surface of the trapezium. The cup must be perfectly centered in the trapezium
and in the center of motion of the CMC joint. To pass guide wire into trapezium center
and the best direction that guide wire is 30° radially between the longitudinal axis
of the diaphyses of the first and second metacarpals (coronal plane) and the anterior
axis (sagittal plane), aided by fluoroscopy ([Figs. 3]
[4]). Partial resection of the joint capsule was performed, with removal of free bodies
and preservation of the palmar ligaments. A balance between soft tissues and implants
is necessary to improve stabilization and avoid stiffness. The length of the thumb
CMC joint can be assessed by comparing the length of the first and second rays before
and after implanting the components. This can also be assessed by fluoroscopy, with
analysis of the congruence of the first metacarpal arch on anteroposterior views with
the thumb in 45° abduction, such as the “gothic arc” ([Fig. 5]).
Fig. 1 Dorsal thumb approach between the abductor pollicis longus and the short extensor
tendons.
Fig. 2 Metacarpal component.
Fig. 3 Trapezium component: center of motion of the carpometacarpal joint (procedure assisted
by fluoroscopy).
Fig. 4 Trapezium component: the cup needs to be well centered and fixed (“press fit”) in
the trapezium.
Fig. 5 “Gothic arc”: congruency of the first and second metacarpal arches on anteroposterior
view with the thumb at 45° of abduction.
Total joint arthroplasty allows the restoration of the length ([Video 1]), tendon balance, stabilization of the CMC joint and increases the best range of
motion of the thumb.[7]
Video 1 Thumb dynamic fluoroscopy: total joint arthroplasty enables the restoration of the
length of the thumb and of tendon balance, the stabilization of the base of the thumb,
and the increase in thumb abduction.
Postoperative Care
A long thumb thumb splint was applied at the end of surgery and maintained for two
weeks postoperatively. Skinsutures were removed so that the patient could actively
move the thumb. A removable short thumb plaster cast was placed to be worn at nighttime
and during DLAs. Pinching movement should be encouraged after 3 weeks, after which
patients have no further restrictions.
All patients were assessed radiographic and clinically at 6 weeks, and again at 6
and 12 months after the procedure.[11] Range of motion (RoM) was evaluated with a single tool (goniometer). Grip strength
was measured with a specific Jamar hand dynamometer (Sammons Preston, Bolingbrook,
IL) and value obtained was expressed as a percentage of that presented on the opposite
side.[12]
[13] These values were classified into 4 groups according to the grip strength quartiles
to in relation to the time of return to DLAs.[14]
The clinical outcomes were assessed using the Visual Analog Scale (VAS) for pain (range:
1–10, according to which 1 indicates no pain). Quality of life was determined by the
Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire (range: 0–100,
according to which 1 indicates the best result).[15]
[16] The rate of complications was assessed 6 weeks, and again at 6 and 12 months after
the procedure.
Radiographic Parameters
The main parameters were dorsal subluxation, implants aspect, and metacarpal subsidence
(to maintain the trapezium-metacarpal joint space), which were evaluated at 6 weeks,
and 6 and 12 months after the surgery.
Statistical Methods
[Table 1] shows the baseline demographics and the details of the injuries of the sample. The
data were presented as mean or median according to the type of variable and its distribution.
The objective and patient-reported outcomes are presented in [Table 2]. The mean VAS and QuickDASH scores were of 1 point. The RoM was 81% compared with
the nonaffected side. Radiographic examination to preserve the initial parameters
(implants without dislocation and without failure) showed metacarpal subsidence in
100% of patients. Complications were observed in 2 (6.9%) patients. These included
trapezium fracture during surgery, which was treated with K-wire fixation and bone
consolidation. Another patient presented pain and decreased thumb abduction and was
treated with rehabilitation exercises, but maintained VAS = 3.
Table 1
Demographics of the sample, side of the lesions, and associated diseases
|
Identification
|
Age (years)
|
Profession
|
Side
|
Sex
|
Associated diseases
|
|
1
|
69
|
Cook
|
Right
|
Female
|
—
|
|
2
|
63
|
Secretary
|
Right
|
Female
|
—
|
|
3
|
64
|
Designer
|
Right
|
Female
|
—
|
|
4
|
63
|
Designer
|
Left
|
Female
|
—
|
|
5
|
61
|
Secretary
|
Left
|
Female
|
—
|
|
6
|
60
|
Teacher
|
Left
|
Female
|
—
|
|
7
|
63
|
Teacher
|
Right
|
Female
|
—
|
|
8
|
60
|
Businesswoman
|
Right
|
Female
|
—
|
|
9
|
66
|
Accountant
|
Left
|
Female
|
—
|
|
10
|
62
|
Secretary
|
Left
|
Female
|
—
|
|
11
|
66
|
Nurse
|
Left
|
Female
|
—
|
|
12
|
60
|
Saleswoman
|
Right
|
Female
|
CTS
|
|
13
|
63
|
Dressmaker
|
Right
|
Female
|
—
|
|
14
|
70
|
Judge
|
Left
|
Female
|
—
|
|
15
|
64
|
Businesswoman
|
Left
|
Female
|
CTS
|
|
16
|
67
|
Maid
|
Right
|
Female
|
—
|
|
17
|
62
|
Maid
|
Right
|
Female
|
De Quervain tenosynovitis
|
|
18
|
63
|
Cook
|
Right
|
Female
|
—
|
|
19
|
67
|
Accountant
|
Right
|
Female
|
—
|
|
20
|
70
|
Judge
|
Right
|
Male
|
De Quervain tenosynovitis
|
|
21
|
64
|
Pastry chef
|
Right
|
Female
|
—
|
|
22
|
60
|
Driver
|
Right
|
Male
|
—
|
|
23
|
62
|
Seller
|
Right
|
Female
|
Ganglion
|
|
24
|
60
|
Businesswoman
|
Left
|
Female
|
—
|
|
25
|
70
|
Judge
|
Left
|
Male
|
CTS
|
|
26
|
64
|
Maid
|
Left
|
Female
|
De Quervain tenosynovitis
|
|
27
|
63
|
Designer
|
Left
|
Female
|
DIP arthritis
|
|
28
|
66
|
Maid
|
Right
|
Female
|
CTS
|
|
29
|
62
|
Businessman
|
Right
|
Male
|
—
|
Abbreviations: CTS, carpal tunnel syndrome; DIP, distal interphalangeal.
Table 2
Objective and patient-reported outcomes
|
Identification
|
Follow-up (months)
|
RoM (% opposite side) at 12 months
|
Quick DASH score
|
VAS score
|
Grip strength (% opposite side)
|
|Return to ADLs (months)
|
Complications
|
|
1
|
39
|
81
|
1
|
1
|
96
|
1
|
—
|
|
2
|
40
|
90
|
1
|
1
|
97
|
2
|
—
|
|
3
|
34
|
84
|
1
|
1
|
94
|
1
|
—
|
|
4
|
34
|
88
|
1
|
1
|
96
|
1
|
—
|
|
5
|
31
|
91
|
1
|
1
|
94
|
2
|
—
|
|
6
|
31
|
90
|
1
|
1
|
94
|
2
|
—
|
|
7
|
29
|
82
|
1
|
1
|
98
|
1
|
—
|
|
8
|
29
|
78
|
1
|
1
|
97
|
2
|
—
|
|
9
|
20
|
82
|
1
|
1
|
99
|
1
|
—
|
|
10
|
66
|
88
|
1
|
2
|
83
|
5
|
Trapezium fracture
|
|
11
|
76
|
91
|
1
|
1
|
91
|
1
|
—
|
|
12
|
36
|
80
|
1
|
1
|
96
|
1
|
—
|
|
13
|
14
|
78
|
1
|
1
|
92
|
1
|
—
|
|
14
|
12
|
74
|
1
|
1
|
94
|
2
|
—
|
|
15
|
17
|
79
|
1
|
1
|
96
|
1
|
—
|
|
16
|
16
|
82
|
1
|
1
|
98
|
1
|
—
|
|
17
|
18
|
83
|
1
|
1
|
87
|
2
|
—
|
|
18
|
19
|
91
|
1
|
1
|
98
|
2
|
—
|
|
19
|
14
|
90
|
1
|
2
|
96
|
1
|
—
|
|
20
|
14
|
90
|
1
|
1
|
96
|
1
|
—
|
|
21
|
14
|
82
|
5
|
3
|
87
|
6
|
—
|
|
22
|
24
|
88
|
1
|
1
|
96
|
1
|
—
|
|
23
|
21
|
73
|
1
|
1
|
91
|
1
|
—
|
|
24
|
20
|
89
|
1
|
2
|
83
|
1
|
—
|
|
25
|
12
|
70
|
11
|
2
|
82
|
5
|
Pain
|
|
26
|
12
|
64
|
1
|
1
|
81
|
1
|
—
|
|
27
|
12
|
63
|
1
|
1
|
96
|
2
|
—
|
|
28
|
12
|
66
|
1
|
1
|
92
|
1
|
—
|
|
29
|
12
|
62
|
1
|
1
|
97
|
1
|
—
|
|
Mean
|
25.10
|
81
|
1
|
1
|
87.75
|
2
|
|
Abbreviations: ADL, activities of daily living; DASH, Disabilities of the Arm, Shoulder and Hand;
RoM, range of motion; VAS, visual analog scale.
Discussion
In recent years, several studies have considered the outcomes of multiple total trapeziectomy
techniques with suspensionplasty to be successful. However, recent studies[1]
[2]
[11] have proven unsuccessful and suggested other procedures (which do not prevent other
techniques from being performed in case of failure) to allow for faster recovery,
with less pain and greater thumb strength, such as arthroscopy/button suture or total
arthroplasty..
Grip strength is a valid and reliable method used to evaluate objective outcomes and
is an independent predictor of of patients' inability to perform DLAs. Grip strength
in the lower quartiles (first or second) increases the risk of inability to perform
DLAs compared to strength in the higher quartiles (third or fourth).[13]
[14] In the present study, all patients showed values in the fourth quartile.
Bricout and Rezzouk[17] reported a failure rate of 7.7% in the implementation of the MAIA prosthesis in
a series of 156 patients. Maeda et al.[11] showed a complications rate of 9.3%. We observed a lower incidence of complications
(6.9%), and the clinical outcomes showed best RoM, shorter return time to DLAs, and
a lower VAS than other studies.[2]
[6]
[7]
A criticism of the reduction in pain, complication, and costs of traditional total
trapeziectomy is clear, but nowadays, it is not only about reducing pain but also
maintaining grip strength, range of motion and functional capacity to perform ADLs
is to maintain trapezialmetacarpal length and reducing the dorsal subluxation of the
thumb metacarpal[18] because increasing grip strength and it is appropriate to perform procedures that
preserve the biomechanics of the thumb joint and, if it fails, we can perform another
salvage procedure, such as preserving the trapezium by performing this prosthesis
and, if this fails, a total trapeziectomy can be performed and thus we do not skip
treatment steps. (“no burnt bridges” concept). Newton and Talwalkar,[2] Duerinckx and Verstreken,[7] and this study have demonstrated that TJA has certain advantages over other options,
including stabilization and alignment of the CMC joint and preservation of the ability
to perform DLAs and thumb length. Hustedt et al.[8] showed that the time of return to work was 4.5 months in patients who had undergone
total trapeziectomy. In our study, 93.1% of those who underwent the procedure returned
to work within 2 months.
Farkash et al.[19] reported a failure rate 11,32%, with these failed procedures in patients treated
with partial arthroplasty of the CMC joint. The disadvantages of this method include
costs, technical difficulty of the surgery, and the possible complication rate.
Currently, the concept “no burnt bridges” is accepted, and early definitive surgery
in CMC joint arthritis, such as, total trapeziectomy, is controversial, because their
exhausts surgical treatment options. This concept recommends the use of thumb arthroscopy
or arthroplasty[20]
[21] whenever possible. This approach improves the patients' quality of life and reduces
recovery time for DLAs and work-related activities. In addition, in case of failure,
all surgical revision methods can be performed.
The present study is a prospective clinical trial, and all patients were operated
on by a single hand surgeon, constituting a uniform group with complete follow-up.
Nonetheless, some limitations need to be recognized. The present study is a case series
and not a randomized clinical trial, the inclusion criterion was stage III according
to the Eaton classification, and the sample size was small for QuickDASH, VAS, and
grip strength analysis.
The increased cost is the main reason behind the difficulty in performing TJA. The
method and implant for the treatment of thumb arthritis have evolved exponentially,
generating excellent and are an option before comparative studies can consider them
the gold standard and procedure of choice.[21]
Conclusion
The choice of TJA to treat active patients > 60 years old, with stage-III CMC joint
arthritis, helps to preserve independence to perform DLAs and improve the patients'
life quality in the first 12 months after the procedure.
Bibliographical Record
Marcio Aurelio Aita, Giulia Cordeiro Aita, Cleyton Rocha, Sullivan Savaris, Mauricio
Leite, Samuel Pajares Cabanilla. Arthroplasty in Thumb (CMC Joint) Osteoarthritis:
Avoiding Trapeziectomy. Rev Bras Ortop (Sao Paulo) 2025; 60: s00451812997.
DOI: 10.1055/s-0045-1812997
