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Review Question - QID 217857

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QID 217857 (Type "217857" in App Search)
A 35-year-old auto mechanic presents to your clinic for evaluation of his thumb pain. He states that the pain has gradually worsened and has been refractory to anti-inflammatories, bracing, and two corticosteroid injections. On exam, he has pain with axial pressure across his carpometacarpal (CMC) joint. A radiograph of his thumb is seen in Figure A. He has read about many different potential surgeries to address his problem and asks about the various complications of each. Which of the following is a complication of the most indicated surgery for this patient?
  • A

Damage to the superficial sensory branch of the radial nerve while making the 1R arthroscopic portal

5%

50/976

Implant fracture or loosening

5%

52/976

Nonunion of the first metacarpal osteotomy

2%

18/976

Nonunion of the CMC joint

28%

272/976

Subsidence of the thumb metacarpal

59%

571/976

  • A

Select Answer to see Preferred Response

The most indicated surgery for a manual laborer with stage III arthritic changes of the thumb CMC joint is a CMC arthrodesis. A common complication of this surgery is nonunion of the fusion site.

Basilar thumb arthritis can be a debilitating condition, causing pain with pinching and grasping. The diagnosis can be made with the presence of pain with CMC grind testing and arthritic changes on a hyperpronated radiograph. Treatment should start with conservative management including anti-inflammatories, bracing, and injections. When these fail, there are several surgical options including arthroscopic debridement, 1st metacarpal osteotomy, trapeziectomy with or without suspension or tendon interposition, CMC prosthetic arthroplasty, and CMC arthrodesis.

Goldfarb and Stern discussed indications and techniques for thumb CMC arthrodesis. They discuss the two main etiologies of basilar thumb arthritis include elderly women with volar beak ligament attenuation and manual laborers after an intra-articular fracture. They report good results with arthrodesis, but state STT arthritis is a contraindication to the procedure. They also state that the nonunion rate is around 13%.

Rizzo et al. retrospectively reviewed their series of 126 thumb CMC arthrodeses. They found significant improvements in pain, function, and patient satisfaction. However, 17 patients developed nonunion, 39 developed STT arthritis, and 16 developed MCP arthritis. Only 8 of the patients with STT arthritis and none of the patients with MCP arthritis were symptomatic.

Figure A is a radiograph of the thumb CMC joint demonstrating stage III arthritic changes.

Incorrect Answers:

Answer 1: Arthroscopic debridement is a viable option for young patients with very early-stage basilar thumb arthritis, but not with stage III changes.
Answer 2: The use of silicone implants has been proposed, but would not be the most indicated surgery in a young manual laborer.
Answer 3: A closing wedge dorsal extension osteotomy of the 1st metacarpal can redirect forces in the CMC joint in stage I and II disease.
Answer 5: Subsidence of the metacarpal is a complication after trapeziectomy, but a young manual laborer is better served with a CMC arthrodesis.

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