Magnetic Resonance Imaging of Thumb Carpometacarpal Arthroplasty: Preoperative Evaluation and Postoperative Imaging

• Abstract
• Anatomy
• Basal Joint Osteoarthrosis
• Surgical Techniques
• Volar Ligament Reconstruction of the Anterior Oblique Ligament (Palmar Beak)
• Ligament Reconstruction: Tendon Interposition Procedure
• Tendon Suspensionplasty
• Guide to Reading a Postoperative MRI after a First CMC Joint Arthroplasty
• Conclusion
• References

Abstract

In this review we discuss the magnetic resonance imaging (MRI) appearance of thumb carpometacarpal (CMC) arthroplasty, both the preoperative evaluation and particularly the postoperative MRI of different surgical options for patients with advanced degenerative disease of the basal joint of the thumb. The first CMC joint is one of the most frequently involved articulations in the hand and wrist in the setting of degenerative osteoarthrosis and certainly a pain generator and important cause of disability due to its significant impact on hand function. It is the most common joint for which surgery is sought in the wrist. Radiologists interpreting imaging studies of patients with first CMC joint arthroplasty must be familiar with the normal and abnormal preoperative appearance of the thumb basal joint. Moreover, knowledge of the normal postoperative MRI findings, as well as the appearance of patterns of failure and complications, is of paramount importance.

Nonsurgical management can provide relief, especially in early stages of the degenerative osteoarthritic process of the first carpometacarpal (CMC) joint. However, surgery is an important consideration when conservative options are no longer working or in more advanced stages of the disease. A variety of surgical procedures can reliably improve thumb function and pain, resulting in positive outcomes with high patient satisfaction.

Such arthroplasty techniques mainly constitute partial or complete trapeziectomy with or without additional stabilizing procedures. Simple volar ligament reconstruction without resection of the trapezium can be attempted in the unstable first CMC joint with minimal degenerative changes. More complex surgical techniques are used in patients with an unstable first CMC joint and advanced degenerative changes.

In this review we focus on ligament reconstruction and tendon interposition (LRTI), as well as suspensionplasty techniques and some of its variations and combinations. We emphasize the normal and abnormal postoperative magnetic resonance imaging (MRI) appearances of commonly performed surgical procedures, as well as some of the complications and patterns of failure. A standard checklist for assessing MRI studies of patients with a first CMC joint arthroplasty is also proposed.

Other surgical procedures, such as artificial implants or prosthetic arthroplasties (e.g., silicone, Artelon, metal, ceramic, pyrocarbon, etc.), corrective osteotomies, complete joint replacement, and arthrodesis or fusion of the first CMC joint, are beyond the scope of this review. Of note, some of those techniques are no longer used (e.g., Dacron and silicone spacer arthroplasties, due to foreign body reaction and induced particulate synovitis); others have mixed results. In addition, some of those other procedures are not frequently imaged with MRI due to the presence of metallic hardware and implant-related artifacts. Lastly, this review focuses on the preoperative and postoperative MRI of the first CMC joint in the setting of degenerative osteoarthrosis, hence imaging of traumatic injuries or other conditions that may result in joint instability are not reviewed here either.

Anatomy

The first CMC joint, also called the trapeziometacarpal joint or the basal joint, is the base on which the thumb has a large range of motion. However, the so-called basal joints of the thumb actually consist of four trapezial articulations: the trapeziometacarpal, trapeziotrapezoid, scaphotrapezial, and trapezium-index metacarpal joints. Of those, the trapeziometacarpal and scaphotrapezial are the only two that lie along the longitudinal compression axis of the thumb, with basal joint degenerative osteoarthrosis most commonly affecting these two articulations. This review focuses on the trapeziometacarpal or first CMC joint because it is the principal articulation involved in basal joint degeneration and the most common target of surgical intervention in the hand and wrist.[1] [2] [3] [4] [5] [6] [7] [8]

The CMC joint of the thumb is often designated as an incongruous double saddle joint with a biconcave-convex shape on both sides of the articulation. This unique morphology between the trapezium and first metacarpal base allows a wide range of multiplanar motions, such as flexion-extension, adduction-abduction, and opposition-reposition. Due to this exceptional anatomy, the first CMC joint is lax and incongruent in the resting thumb position, whereas it is stable and tightly congruent at the extremes of motion including the final phase of thumb opposition. The paradox is that this unique anatomy and biomechanics, although allowing ample range of motion, also renders the joint susceptible to degeneration with relatively little osseous support. Hence rather than relying on bone geometry, the joint must rely on static capsuloligamentous restraints.

Although as many as 16 ligaments have been identified as stabilizing the basal joint, only five of them are implicated directly in stability of the trapeziometacarpal joint: the anterior oblique ligament (AOL/beak ligament), the posterior oblique ligament, the dorsoradial ligament (DRL), the intermetacarpal ligament (IML), and the ulnar collateral ligament ([Fig. S1]). Several of the surgical techniques used in first CMC joint arthroplasty try to recreate the function of some of the ligaments just described. Although the debate on the importance of these ligaments persists, the AOL, followed by the DRL and IML, are generally considered the prime stabilizers of the first CMC joint.[1] [2] [3] [4] [5] [6] [7] [8]

Basal Joint Osteoarthrosis

The most widely used staging system for osteoarthrosis of the basal joint is the Eaton-Littler classification system, first described in 1973 and later modified in 1987.[9] [10] This system has four stages and relies solely on radiographic findings, independent of any clinical criteria ([Fig. S2]). Although initially developed on conventional radiographs, it can certainly serve as a guide to grade the extent of degenerative osteoarthrosis in the basal joint on MRI ([Fig. S3]). More recently, dedicated studies have been published proposing MRI techniques in the assessment of thumb base osteoarthrosis as well as MRI scoring systems for synovitis, bone marrow lesions, subchondral bone defects, cartilage space loss, osteophytes, and first CMC joint subluxation.[11] [12] [13]

Surgical Techniques

A multitude of surgical techniques are available to treat osteoarthrosis of the first CMC joint when conservative measures fail. These interventions are mainly used in patients with Eaton-Littler stages II to IV osteoarthrosis of the basal joint, but some techniques may be employed in selected patients with stage I disease.

Ligamentous reconstructions aim to recreate the deficient stabilizing ligaments of the first CMC joint, mainly the AOL, DRL, and IML. Tendon interpositions fill the submetacarpal space left by the resected trapezium to try and avoid the proximal migration of the first metacarpal base, via a so-called spacer effect. Other non-tendon interposed material or artificial spacers are still used occasionally, such as Gelfoam and acellular dermal allograft, among others.

Suspensionplasty refers to the creation of a sling that suspends the first metacarpal base precluding its subsidence or proximal migration, like a hammock effect, avoiding impingement on the nearby osseous structures. Suspensionplasty can be done with tendon, suture, tape, or FiberWire. Multiple variations and combinations of the main surgical techniques are described, but the principles and main rationale behind each of those are similar.[14] [15] [16] [17]

Volar Ligament Reconstruction of the Anterior Oblique Ligament (Palmar Beak)

In 1973, the volar ligament reconstruction technique was introduced by Eaton and Littler, in which a strip of the flexor carpi radialis (FCR) tendon was passed through an extra-articular drill hole at the first metacarpal base from medial to lateral, looped around the remaining FCR, and secured back over the lateral (radial) side of the joint. The trapezium is not resected in this technique ([Fig. 1]). Eaton and Littler's ligament reconstruction and its variants remain one of the most studied and used procedures to this day. Various modifications to their procedure or other tendon-looping techniques have been described for patients with Eaton-Littler stage I, with minimal chondral damage, or posttraumatic thumb CMC instability. In some of those variations in addition to the AOL, the DRL is also reconstructed or reinforced dorsally.[9] [18] [19] [20]

Ligament Reconstruction: Tendon Interposition Procedure

In 1970, Froimson reported using a rolled-up slip of the FCR tendon as an interposition arthroplasty but without ligament reconstruction, which did not stabilize the thumb or prevent its proximal migration.[21] In 1985, Eaton et al combined several procedures and reported on a new technique of tendon interposition arthroplasty with ligament reconstruction using a slip of the FCR tendon passed through a bone tunnel in the first metacarpal base.[22] In 1986, Burton and Pellegrini also described such a technique but using half of the FCR tendon instead.[23] To date, many variations of this procedure exist. Of note, in 1978 Weilby published an alternative technique that did not require the use of bone tunnels, in which a portion of the FCR tendon is harvested and looped around the abductor pollicis longus (APL) to create a suspension and interposition arthroplasty.[24] To this day, most current LRTI techniques involve drilling a tunnel on the first metacarpal base.

The LRTI procedure is generally indicated for Eaton stages II to IV degenerative disease; stage I disease is a contraindication. The trapezium is usually excised completely, although partial trapeziectomy with LRTI has been described in the literature. The FCR is the most common harvested tendon in this technique, although the APL has been used as well.[24] [25] [26] [27] [28] [29] [30] [31]

In the original technique, just a slip of the FCR was harvested and rolled up to interpose it in the space between the first metacarpal base and the distal scaphoid pole. However, subsequent studies reported the use of half the tendon and then use of the entire FCR tendon with full-thickness harvesting at the level of the forearm without residual functional deficit or associated morbidity.[32] [33] The radiologist must interpret these studies to determine if there was a partial- or full-thickness harvesting of the FCR because it can affect the interpretation of the imaging findings.[34]

After the tendon is harvested, it is subsequently passed through a tunnel on the first metacarpal base from medial to lateral and then looped and sutured back on itself, creating a lasso. The remaining harvested tendon is rolled up in an accordion-type fashion creating an anchovy shape that is then interposed and further secured in the space between the first metacarpal base and the distal scaphoid pole ([Fig. 2]).

LRTI is a generally successful procedure with satisfactory improvements in pain and function for the treatment of first CMC joint osteoarthrosis. Long-term studies report up to 81 to 95% satisfactory pain relief. Some of the reported causes of LRTI failure include sensory disturbances, tendinitis, graft displacement, persistent pain, untreated scaphotrapezial osteoarthrosis, instability, subsidence of the first metacarpal base, complex regional pain syndrome, infection, and implant migration.[35] [36] [37]

Specific patterns of failure requiring revision arthroplasty include disruption of the sutures at the anchovy itself or at the lasso stitching site. Any of these can result in migration of the anchovy in different directions and resultant subsidence of the first metacarpal base vertically or dorsoradial migration, which can result in impingement or abutment upon the trapezoid and distal scaphoid pole, leading to mechanical pain as well as focal or regional synovitis ([Fig. 3]). Attritional degeneration and tearing of the interposed rolled-up tendon can also be occasionally seen. In cases of revision or salvage procedures from a failed LRTI where the FCR is no longer a viable alternative, other tendons used for the revision include the APL and the extensor carpi radialis longus (ECRL), among others.[35] [36] [37]

Tendon Suspensionplasty

In 1986, Thompson described a tendon, the APL, for the first time for suspensionplasty of the first metacarpal without tendon interposition.[38] His original technique was initially described for revision surgery of cases of painful first metacarpal-scaphoid impingement after a trapeziectomy without either LRTI or with the removal of failed silicone arthroplasties, but it was later used successfully for primary arthroplasties. His technique consisted of transecting the APL tendon at its musculotendinous junction, passing it through osseous tunnels in the first and second metacarpal bases to reconstruct the intermetacarpal ligament, and finally securing it into the extensor carpi radialis brevis or the ECRL.

Numerous variations of this technique have since been developed, with or without drilling bone tunnels, the latter avoiding known related tunnel complications such as fracture and osteolysis.[39] [40] [41] [42] [43] Among those techniques is the frequently used APL to FCR suspensionplasty, simply weaving a slip of APL around the FCR and sewing it back dorsally to itself or the periosteum, avoiding the need to drill tunnels ([Fig. 4]). Some surgeons may place an absorbable gelatin sponge (Gelfoam) in the former surgical bed of the excised trapezium as a spacer. Other variations of the technique include an APL lasso suspensionplasty using a single slip of APL looped and tensioned around the base of the second metacarpal instead of the FCR and without needing to drill a bone tunnel.[44] [45]

Complications in the postoperative period of APL suspensionplasty are similar to those reported with other previously discussed techniques of first CMC arthroplasty: persistent pain, infection, radial sensory neuropraxia, digital neuropraxia, and tendon adhesions. Extrusion of Gelfoam has also been reported.[39] [40] [41] [42] [43] Failure of the APL to FCR tendon suspensionplasty itself can occur due to tendon degeneration or tearing, with loss of the hammock or sling effect, resulting in subsidence and proximal migration of the first metacarpal base with narrowing of the submetacarpal space and the potential for impingement on the adjacent structures ([Fig. 5]).

In addition to a tendon suspensionplasty, a similar hammock or sling effect can be achieved with multiple loops of suture material around the APL and FCR tendons. In 2009, DelSignore and colleagues introduced this technique with a nonabsorbable FiberWire suture ([Fig. 6]). Over the years, this procedure has evolved with minor modifications, including the use of stronger suture material (multistrand high-molecular-weight polyethylene core with a braided polyester jacket) and the addition of locking stitches into the FCR insertion. Overall, good to excellent long-term outcomes were reported with this suture suspensionplasty technique in a 12- to 14-year follow-up study.[46] [47]

Advantages of this suture suspensionplasty technique include the fact that it does not require sacrificing of donor tendons, avoiding the need for drilling bone tunnels, suture anchors, tendon transfer, and/or pin fixation. Potential complications are similar to other previously mentioned surgical techniques: persistent pain, infection, and nerve injury. Tendon rupture could occur, as in other techniques that involve looping or passing a tendon sling around or through another tendon.[46] [47] Persistent failure to approximate the base of the first metacarpal to the second metacarpal and failure to maintain the arthroplasty space can also occur due to loosening or failure of the suture construct, resulting in proximal migration of the first metacarpal ([Fig. 7]).

More recently, a suture button suspensionplasty technique was described, either with a partial or a complete trapeziectomy, and placement of a FiberWire suture (Arthrex Mini TightRope) looped between two stainless steel buttons in tunnels on the first and second metacarpal bases ([Fig. 8]). Short- and midterm studies have reported promising results with a mean 5-year follow-up. A long-term study with a minimum 10-year follow-up confirmed the encouraging results of the prior studies.[48] [49] [50] Similar to the other described techniques, failure of the construct can occur with resulting subsidence and proximal migration of the first metacarpal base.

Guide to Reading a Postoperative MRI after a First CMC Joint Arthroplasty

• - Is there a trapeziectomy, yes or no?

• - If yes, is it partial or complete?

• - Is there an associated trapeziectomy?

• - Are there intraosseous tunnels, yes or no?

• - If yes, is there a normal tendon graft passing through the tunnel, yes or no ([Fig. S4])?

• - If no tendon graft is seen within the tunnel, is it torn or migrated? Where is the tendon stump?

• - What tendon was the source of the graft?

• - Is there an interposed tendon or anchovy filling the submetacarpal space/trapeziectomy surgical bed?

• - If yes, is the anchovy normal in appearance and location or not?

• - If not, where is the displaced or migrated anchovy?

• - Be aware that surgeons sometimes may use other “spacers” instead of an interposed tendon (i.e., Gelfoam, acellular dermal allograft, etc.) or no “spacer” at all (i.e., hematoma distraction arthroplasty).

• - If no tunnels and no tendon interposition, is there a suspensionplasty or sling under the first and second metacarpal bases?

• - Is the hammock or sling a tendon, FiberWire, or tape, or a suture suspensionplasty?

• - If yes, is the suspensionplasty intact or not? Look for proximal migration of the first metacarpal and/or narrowing of the submetacarpal space.

• - Look for imaging findings of impingement (exuberant osteophytes, bone marrow edema, focal synovitis, or soft tissue edema between the proximally migrated first metacarpal base and the adjacent second metacarpal base, or to the distal scaphoid pole, or to any residual trapezium, and to the trapezoid).

• - If no tendon interposition and no sling or hammock is seen underneath the metacarpal bases, look for tunnels and cortical buttons in the first and second metacarpals for a button suspensionplasty with a tightrope (may be done with partial or complete trapeziectomy).

• - If available, read the operative report, talk to hand surgeons, and try to observe some of these surgeries.

Conclusion

The radiologist interpreting postoperative imaging studies of patients with arthroplasty of the thumb CMC joint must be familiar with the different surgical techniques, as well as with the normal and abnormal imaging appearance of such procedures, along with the findings of complications and patterns of failure that can be seen in this setting. MRI is an excellent tool for evaluating first CMC joint arthroplasty procedures, particularly when there is no significant metallic hardware or implants that can cause artifact. In some of these cases, metal artifact reduction techniques can be useful, and the MRI studies can still provide valuable information for the hand surgeon, especially for preoperative planning in cases of revision or salvage procedures.

Conflict of Interest

None declared.

Acknowledgments

The authors would like to acknowledge and thank Dr. Matthew Skalski for his beautiful artistic drawings used in the article.

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Address for correspondence

Publication History

Article published online:
11 February 2025

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• References

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