A review of osteoarthritis of the trapeziometacarpal joint (TMJ)
Nicole Murphy
Bhoomiah Dasari
Jo Adams
Introduction
Osteoarthritis (OA) is a degenerative joint disease of diarthrodial joints,
characterised by deterioration of articular cartilage and the formation of new
bone growth at joint margins and joint surfaces (Tortora and Grabowski 2003).
It is an age associated, mechanically driven disorder that is likely to increase in
prevalence in the coming years (Dieppe 2000). It is the most common joint
disorder in the western world, present in the majority of people aged 65 years
and in 80% of those aged 70 years and over (Arden et al 2006), Autopsy has
shown universal evidence of osteoarthritis changes in the over 65s but yet only
60-70% of those present themselves for medical treatment highlighting that
osteoarthritis is more of a problem than just those currently receiving treatment
(Kraus 1997). Estimates suggest that 16-22% of females and 2-5% of men have
OA (Swiggart et al 1999).
The disease frequently involves hand joints, in particular the carpometacarpal
joint of the thumb (CMJ) (Creamer and Hochberg 1997) and the incidence of
hand OA increases with age (Wilder et al 2006). Women have higher rates of
hand OA than men (Szoeke et al 2006), in part because women tend to have
more severe polyarticular OA that frequently affect the hands and knees (Hirsh
1996,
Wilder
et
al
2006,
Stevens
and
Finlayson
2005).The
distal
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interpahlangeal, proximal interphalangeal and carpometacarpal joints of the
hand may all be affected in OA (Wilder et al 2006) and of all individuals
diagnosed with osteoarthritis of the hand 25% have isolated osteoarthritis of the
Trapeziometacarpal joint (TMJ) of the thumb (Mannoni et al 2000).
Healthy men with the strongest grip strengths have an increased risk of
developing OA at both the thumb base joints and the proximal interphalangeal
and metacarpophalangeal joints (Chaisson et al 1999). Joint hyper mobility
does not appear to be a risk factor in developing OA at any hand joint (Kraus et
al 2004). Current estimates suggest that OA affects the carpometacarpal joints
of 21% of healthy community dwelling women aged over 40 years (von
Schroeder 2003, Wilder et al 2006).
The progressive nature of TMJ can produce symptoms of pain over the thenar
eminences, swelling, and stiffness of the thumb, weakness and in more chronic
cases deformity. All these symptoms ultimately lead to a gradual loss of
dexterity, precision grip strength and hand function (Roberts et al 2001,
Dominick et al 2005). Despite the vast amount of research into the aetiology of
osteoarthritis the aetiology remains elusive (Creamer and Hochberg 1997)
Disease Severity
Osteoarthritis of the Carpometacarpal joint has been classified into four
subgroups which classify the severity of the disease (Table 1).
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Management of the TMJ of the thumb
There are three main areas in the management of osteoarthritis of the
Carpometacarpal joint of the thumb. These being hand therapy (splinting,
patient education, exercise, joint protection and acupuncture), drug therapy
(NSAIDs and steroid injections) and surgery (Arthrodesis and Arthroplaty)
(Creamer et al 1998, Swigart et al 1999, Damen et al,2001, Stamm et al 2002,
Meenagh et al, 2004, Degreef and De Smet 2006). Currently there are no
guidelines into the management of osteoarthritis of the carpometacarpal joint of
the thumb
Splinting
Splinting appears to be the preferred conservative treatment for OA of the
carpometacarpal joint (Berggren et al 2001; Weiss et al 2000). However there is
limited evidence into their use with most of the studies being retrospective
rather than randomised controlled trials.
Swigart et al’s study (1999) examined retrospectively the effects of splinting on
130 thumbs with varying stages of carpometacarpal joint osteoarthritis. Some
patients received surgical intervention. Patients were excluded if they had been
treated with exercise or steroid injections making it one of the few studies
looking at the effects of a single technique.
The intervention consisted of
splinting the thumb with a long thumb stabilizer for 3-4weeks, with 3-4weeks
period of weaning. In milder forms of OA, stages I and II, 76% benefited from
some symptomatic improvement. In the more severe cases of OA, stages III
3
and IV, 54% benefited from some symptomatic improvement. The benefits were
maintained in the short term, 60% feeling the benefits immediately and 59% still
benefiting 6months later. Although retrospective the study provided some
evidence that splinting may delay or prevent the need for surgical intervention.
Day et al (2004) investigated the effectiveness of a single corticosteroid
injection followed by a three week period of splinting. This study looked at 30
thumbs and evaluated improvements in both self-reported functional ability
using the Disabilities of the Arm, shoulder and Hand questionnaire (Hudak et al
1996) and visual analogue scales for pain scores. This study discovered that
long term relief from the symptoms of OA could be achieved in stage I OA but
less than 25% of those suffering with stage IV benefited from a one off
corticosteroid injection. Overall 40% of participants received symptomatic
improvement that was considered sufficient and sustained irrespective of their
stage.
Joint Protection & Exercise
Joint protection is a well-recognised technique in the management of
rheumatoid arthritis but has not been widely reported as being used in other
musculoskeletal conditions.
There is limited published evidence of the
effectiveness of applying joint protection techniques in osteoarthritis. Stamm et
al (2002) carried out the initial randomised controlled trial. Forty patients were
recruited onto the trial.
The control group was provided with non-slip matting
which they were to use when opening jars as well as oral and written
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information on OA. The intervention group received both oral and written
information on joint protection and a hand exercise programme. The joint
protection instruction and training lasted for 30 minutes per patient. Assistive
devices for Activities of Daily Living were also provided.
Assessment of grip
strength and self-report functional ability were carried out at baseline and at
three months post intervention. There were statistically significant more patients
who improved grip strength by at least 10% changes in the joint protection
group than in the control group, although self-report pain levels and general
functional ability was no different between groups. Although unlikely to be fully
powered this randomised controlled trial does provide early evidence that
straightforward, uncomplicated joint protection advice and home hand exercises
does have the potential to impact on hand function in OA affecting the hand.
Surgical management
TMJ of the thumb is the most common site for which surgery is sought because
of the profound impact on hand function and disabling symptoms (Pellegrini
1992), making it difficult to do simple household tasks, such as turn door knobs
and open jars. As most of the surgical treatments offer satisfactory results with
respect to relieving pain, restoring stability and strength, choosing the
appropriate surgical technique can be challenging to both hand surgeons and
the hand therapists.
The first line of treatment of the TM joint arthritis is the use of nonsurgical
modalities such as drug therapy, rest, splinting and patient education. When
5
such measures are no longer sufficient to control the progressive nature of the
osteoarthritis or to keep symptoms at an acceptable level, surgical procedures
become an option. In order to deal with such problems as pain, swelling and
decreased strength and range of motion, a number of surgical alternatives have
been developed to improve patient’s function and quality of life. It is shown that
surgery has been responsible for a dramatic improvement in the quality of many
with osteoarthritis (Turner, Foster and Johnson 2004).
In most cases of osteoarthritis of the TM joint, surgery becomes an option at
stages II, III, and IV, as classified by Eaton and Glickel (1987). The available
surgical treatments include arthrodesis and excision of part or the entire
trapezium combined with interposition of fascia, tendon, Gortex, silicon or metal
implants (Belcher and Nicholl 2000). Gervis (1949) first reported the use of
trapeziectomy for this condition and many other have reported high success
since then (See for example, Gervis 1973, Iyer 1981, Dhar et al 1994, Hollevoet
et al 1996, Vandenbroucke et al 1997). The evidence however suggests that
although trapeziectomy is the method of choice for treating osteoarthritis at the
base of the thumb, it has a reputation for causing instability, weakness and loss
of power of the thumb (Murley 1960, Kvarnes and Reikeras 1985, Burton and
Pellegrini 1986, Necking and Eiken 1986).
The review of the literature suggests that despite many improvements in the
surgical techniques, controversy still exists regarding which technique achieves
the best outcome (Glyka, Karen and Achilleas 2004) and as such there is no
6
consensus in the literature as to which clinical outcomes are most important in
thumb basal joint surgery and how these should be measured and documented.
To address the question, Glyka, Karen and Achilleas (2004) undertook a
systematic review. Based on their search strategies, these authors concluded
that for stage II, the arthrodesis seems to be the choice of treatment, especially
for young, posttraumatic, high-demand hand. This is followed by the osteotomy
and trapeziectomy with or without interposition/ligament reconstruction. As far
stage III & IV are concerned, the majority of their reviews support the same
choice as the stage II except osteotomy, which was replaced by total joint
arthroplasty. Overall, ligamentous reconstruction and tendon interposition
appeared to be the most popular choice for stages III & IV.
From the review, it is also noted that some studies have indicated that there is
no difference in outcome between the techniques with the chosen technique
often being at the surgeon’s discretion (Schroder et al 2002, Martou et al 2004,
Taylor et al, 2005). Current research has suggested that there are a number of
predisposing factors that will affect the outcome of surgery. Evidence has found
that age, the presence of MCP hyperextension and web angle retraction,
provide poorer results (Degreef and De Smet, 2006). With several of these
factors being secondary complications of OA earlier intervention appears to
provide more satisfactory results.
While recognising the importance of systematic reviews & standardised
protocols, authors of this paper believes that no conclusions on the superiority
7
of a single technique over other techniques are drawn without properly
conducted comparative studies and randomised controlled trails, preferably with
large sample size.
Implications for Practice
Evidence has suggested that although conservative management will not cure
OA of the carpometacarpal joint of the thumb it appears to provide some form of
symptomatic relief in most patients. The evidence suggests that the
management technique chosen will reflect the stage of osteoarthritis for each
individual. In early stage OA conservative management such as splinting,
corticosteroid injections, joint protection and exercise appears to be beneficial.
However in later stage OA, although conservative management can be
attempted, there is a poorer outcome of surgery if secondary affects of OA have
developed. In these cases it has been suggested that surgery is a more
beneficial option.
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Table 1: Stages of disease severity for OA of the CMCJ
Stage
Description
Stage 1
Normal articular contours; joint space may be widened due to
effusion or laxity of the ligamentous support of the basal joint.
Stage 2
Joint space slightly narrowed. Minimal sclerosis of the
subchondral bone. Mild/moderate subluxation. Osteophyte
formation may be present.
Stage 3
Further narrowing. Osteophyte formation. Moderate
subluxation. Hyperextension at MCP joint.
Stage 4
Presentation similar to stage III. Thumb immobile. Little pain
experienced. Scaphotrapezial joint often shows osteoarthritis
changes.
(Eaton and Glickel 1987)
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