What is the recommended treatment for severe arthritis of the thumb carpometacarpal joint, triscaphe joint, and radiocarpal joint with moderate distal radioulnar joint degeneration?

Treatment of Severe Multi-Joint Wrist and Thumb Arthritis

For this pattern of severe, multi-joint arthritis involving the thumb base, triscaphe joint, radiocarpal joint, and moderate DRUJ degeneration, surgical intervention is the definitive treatment, specifically radioscapholunate arthrodesis with distal scaphoidectomy for the radiocarpal/triscaphe disease, thumb carpometacarpal arthroplasty (trapeziectomy) for the thumb base, and DRUJ arthroplasty or salvage procedures for the DRUJ pathology. 1, 2, 3, 4

Rationale for Surgical Management

The severity and multi-joint involvement described makes this a surgical case from the outset. While guidelines recommend stepwise conservative management for isolated thumb CMC arthritis, the presence of severe arthritis across multiple joints (thumb base, triscaphe, radiocarpal) with moderate DRUJ involvement indicates advanced disease that has likely already failed conservative measures. 1, 5

Surgical Algorithm by Anatomic Region

Radiocarpal and Triscaphe Joint Disease

Radioscapholunate (RSL) arthrodesis combined with distal scaphoidectomy is the procedure of choice for severe radiocarpal degenerative arthritis. 4

• This combination provides superior outcomes compared to RSL arthrodesis alone, with complete pain relief in 63% of patients and only slight pain during strenuous activity in another 19%. 4
• The distal scaphoidectomy prevents secondary midcarpal DJD that commonly develops after RSL fusion alone. 4
• Expected postoperative range of motion: 32° flexion, 35° extension, 14° radial deviation, 19° ulnar deviation. 4
• This approach specifically addresses both the radiocarpal and triscaphe joint pathology simultaneously. 4

Thumb Carpometacarpal Joint Disease

Simple trapeziectomy (without ligament reconstruction or tendon interposition) is the recommended surgical approach for severe thumb base OA. 1

• Cochrane systematic review evidence demonstrates that combined procedures (trapeziectomy + ligament reconstruction + tendon interposition) offer no advantage over simple trapeziectomy for pain relief (ES = -0.17,95% CI -0.57 to 0.24) or functional improvement (ES = 0.03,95% CI -0.37 to 0.44). 1
• Combined procedures have a 2.12 times higher complication rate (RR = 2.12,95% CI 1.24 to 3.60), including tendon rupture/adhesion, scar tenderness, sensory changes, neurological complications, instability, and complex regional pain syndrome. 1
• Total joint replacement offers no benefit over simpler procedures. 1

Distal Radioulnar Joint Disease

For moderate DRUJ degeneration in the context of multiple wrist surgeries, DRUJ replacement with a semiconstrained prosthesis is effective for restoring function. 3

• DRUJ replacement significantly improves range of motion, weight-bearing ability, and pain scores (DASH scores improved significantly at median 5.6-year follow-up). 3
• This can be performed simultaneously with wrist arthrodesis procedures or as a staged procedure. 3
• Be aware that surgical scarring and advanced bone deformities from multiple procedures make implant positioning more challenging and require additional surgical exposure. 3
• Complication rate includes infection, heterotopic ossification (requiring reoperation in 2 of 14 patients), and potential pisotriquetral arthritis development (5 of 14 patients required pisiform or triquetrum excision). 3

Surgical Staging Considerations

Given the multi-joint involvement, staged procedures may be necessary rather than attempting all interventions simultaneously. 3

• Consider performing RSL arthrodesis with distal scaphoidectomy and thumb CMC arthroplasty as the first stage. 4, 1
• DRUJ arthroplasty can be performed simultaneously or as a second stage depending on the severity of DRUJ symptoms and surgical complexity. 3

Post-Operative Rehabilitation

Hand therapy is essential after arthroplasty around the wrist to achieve pain-free function. 6

• Structured rehabilitation protocols should address each surgical site specifically. 6
• Therapy goals include pain relief, restoration of function, and optimization of strength within the limitations of the arthrodesis. 6

Common Pitfalls to Avoid

• Do not perform combined thumb CMC procedures (ligament reconstruction + tendon interposition with trapeziectomy) as they increase complications without improving outcomes. 1
• Do not delay surgical referral in severe multi-joint disease—this patient has already progressed beyond conservative management candidacy. 1
• Do not underestimate surgical complexity in multi-joint wrist procedures, particularly with DRUJ involvement requiring additional exposure. 3
• Do not overlook potential pisotriquetral arthritis development after DRUJ procedures, which may require subsequent intervention. 3