Surgical Options for Thumb Carpometacarpal (CMC) Joint Degeneration
For symptomatic thumb CMC osteoarthritis that has failed conservative management, surgical intervention should be selected based on disease stage: ligament reconstruction for early disease (Eaton stages I-II), trapeziectomy with ligament reconstruction and tendon interposition (LRTI) for moderate disease (stage III), and total joint arthroplasty for advanced disease (stages III-IV) in older, low-demand patients.
Conservative Management Before Surgery
Hand orthoses are strongly recommended as first-line treatment for thumb CMC joint osteoarthritis, with rigid or neoprene splints providing pain relief and functional improvement 1. Physical therapy combining strengthening exercises with orthotic use for ≥3 months provides optimal outcomes, though benefits disappear without continued exercise 2.
Surgical Decision Algorithm by Disease Stage
Early Disease (Eaton Stages I-II)
Ligament reconstruction is the procedure of choice for early-stage thumb CMC arthritis with painful instability 3. This technique:
- Routes a portion of the flexor carpi radialis (FCR) tendon through the base of the thumb metacarpal to restore stability 3
- Achieves good or excellent results in 95% of patients with minimal articular changes 3
- Prevents progression: 100% of stage I cases and 82% of stage II cases showed no recognizable degeneration on radiographs up to 13 years postoperatively 3
- Reduces pain and potentially retards joint degeneration in patients with painful instability 3
Moderate to Advanced Disease (Eaton Stages III-IV)
Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) remains the most commonly performed procedure for advanced thumb CMC arthritis 4. Alternative options include:
- Arthroscopic partial trapeziectomy for selected cases 4
- Metacarpal extension osteotomy in specific circumstances 4
- Total joint arthroplasty for older patients with low activity demands 5
Total Joint Arthroplasty Considerations
Total joint arthroplasty should be reserved for stage III and early stage IV osteoarthritis in older patients with low activity demands 5. This approach:
- Provides improved motion (average 60° thumb abduction), strength (85% of nonaffected side), and pain relief 5
- Results in 24 of 25 patients being pain free at average 59-month follow-up 5
- Carries risk of posttraumatic loosening requiring revision 5
- Shows no signs of atraumatic implant loosening on long-term radiographic follow-up 5
Critical Selection Factors
The surgical approach must account for 6, 4:
- Patient age: Younger, high-demand patients require more durable reconstructive procedures rather than arthroplasty 5, 6
- Activity level: Low-demand patients tolerate arthroplasty better than high-demand workers 5, 6
- Local bone stock: Adequate bone quality is essential for implant fixation 6
- Comorbidities and deformities: Local anatomic factors influence technique selection 6
Common Pitfalls to Avoid
- Performing arthroplasty in young, high-demand patients increases risk of implant failure and need for revision 5
- Delaying surgery in early-stage disease when ligament reconstruction could prevent progression and preserve the joint 3
- Ignoring the 74% success rate even in advanced disease (stages III-IV) with appropriate surgical selection 3
Key Clinical Point
No single surgical technique serves as the "gold standard" for all patients with thumb CMC arthritis 6. The choice depends on radiographic stage, patient age, activity demands, and local anatomic factors, with ligament reconstruction offering the unique advantage of potentially preventing disease progression when performed early 3, 6.