STT arthritis - Hand - Orthobullets (2022)

Updated: Jul 30 2021

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Summary
  • Scaphotrapeziotrapezoidal (STT) arthritis is the second most common location for carpal arthritis, and a strong association exists between STT and thumb carpal-metacarpal joint arthritis.
  • STT arthritis us diagnosed clinically with with pain and weakness in grip strength with radiographs showing narrowing and subchondral sclerosis at the STT articulations.
  • Treatment is initially nonsurgical, with surgery being reserved only for those who fail initial nonoperative management.
Science
  • Epidemiology
    • Incidence
      • 16% of US population
    • Demographics
      • Most common among females
      • >50 years
    • Location
      • Junction of Scaphoid, Trapezoid, and Trapezium (STT)
      • Only the radioscaphoid joint is more commonly affected with OA in the carpus
    • Risk factors
      • STT arthritis often found with concomitant basilar thumb arthritis
  • Pathophysiology
    • Rigidity of STT joint restricts motion to primarily flexion-extension. Any change to the restricted kinematic pattern fosters an environment which predisposes to the development of STT arthritis
    • Combination of morphology of the Trapezium, wide circumduction of motion, strenuous use, and high compressive forces during pinch and grasp exhibited at STT joint lead to cartilage erosion and subsequent development of arthritis
    • Instability at the STT joint or within the carpus (particular DISI and midcarpal instability), is associated with STT arthritis
    • Wrists with type II lunates, which confer more rigid carpal kinematics, is associated with STT arthritis
  • Associated orthopedic conditions
    • Basilar thumb arthritis
    • Carpal instability, specifically DISI
      • Every one stage increase in the Eaton-Glickel stage in STT arthritis is associated with an average change in capitolunate angle of 7 degrees.
  • Prognosis
    • Nonsurgical measures are the mainstay of treatment. However, there is little prospective evidence which has demonstrated the effectiveness of nonsurgical management
Anatomy
  • Osteology
    • Scaphoid bridges the proximal and distal carpal rows on its radial side.
  • Ligaments
    • Trapeziotrapezoid
    • Trapezoid-capitate
    • STT ligaments
      • Major anatomic stabilizer of the STT joint
    • Capitate-trapezium
  • Biomechanics
    • Scaphoid articulates with scaphoid fossa of distal radius, the lunate, the capitate, the trapezium and the trapezoid
    • Trapezoid articulates with the trapezium and the scaphoid, in addition to the capitate and the base of the second metacarpal
Classification
White and Colleagues
Stage I• Joint narrowing when compared to other intercarpal joints in the same radiograph, with or without subcortical sclerosis
Stage II

• Stage I changes, in addition to cyst-like lucencies, with or without osteophyte formation

Stage III• Complete joint space obliteration with bone-on-bone articulation, with no apparent joint-space within the cartilage
Presentation
  • History
      • Pain and weakness in grip strength
      • Atraumatic in nature
      • Often presents in a patient's sixth or seventh decade of life
    • Symptoms
      • Pain
        • Sharper than the pain associated with basilar thumb arthritis
        • Can have tendonitis along the flexor carpi radialis tendon
    • Physical exam
      • inspection
        • Painful bony prominence just distal to the radioscaphoid joint
          • Can be confused with the prominence observed in SLAC wrist
          • Prominence in STT arthritis is slightly more distal and ulnar than the changes seen in SLAC wrist
      • Motion
        • Range of motion is grossly preserved
      • Provocative tests
        • Radial grind test: pain along the STT articulation with radial deviation of the wrist
    Imaging
    • Radiographs
      • recommended views
        • AP, lateral and oblique views of the wrist
      • optional views
        • STT view, in which the wrist in placed in maximal extension and ulnar deviation with the palm facing the cassette
        • Amount of arthritis is best conferred when beam is directed perpendicular and approximal 2.5 cm medial to the base of the thumb carpometacarpal joint
      • findings
        • STT joint space narrowing
        • STT osteophyte formation
    Differential
    • Differentiating between concomitant basilar thumb arthritis and STT arthritis can be difficult
      • Concomitant basilar thumb arthritis and STT arthritis occurs in up to 60% of cadaver specimens
      • Basilar thumb pain in STT arthritis is typically more proximal and medical than the trapezial-metacarpal symptoms
      • Provocative examination maneuvers for basilar thumb arthritis are typically negative in STT arthritis (i.e. hyperadduction/hyperextension or the thumb CMC grind test
      • Can also utilize focal injection of local corticosteroid to aid in differentiation
    Treatment
    • Nonoperative
      • Brace use, NSAID, injection
        • Indications include patients seen initially with STT arthritis
        • Limited long-term evidence
        • Exhaustion of nonoperative management should be reached prior to progressing to operative treatment
    • Operative
      • Distal pole of scaphoid excision
        • Indications
          • Patients desiring preservation of range or motion and not amenable to prolonged immobilization
          • Patients at higher risk of nonunion
        • Outcomes
          • As compared to contralateral wrist: Flexion/extension (79-88%), radioulnar deviation (100-85%), grip strength (85%), and pinch strength (93%)
          • At average follow-up of three years, no patients demonstrated increased symptoms of progression of degenerative changes
          • Mean pain VAS improvement from 7.5 to 0.6
          • May predispose to carpal instability (DISI posture and development of CL arthritis)
          • Complications include persistent pain (mild: 44%) and capitate AVN
      • STT fusion
        • Indications
          • STT fusion is ideal treatment for young, heavy laborer
          • Most common surgical treatment for STT arthritis
        • Techniques
          • Kirschner wires
          • Headless compression screws
          • Staple fixation
          • Circular plate
        • Outcomes
          • As compared to contralateral wrist: Flexion/extension ROM (93%), radioulnar deviation ROM (81%), grip strength (80%), and pinch strength (70%)
          • Overall complications rate ranges from 13-78% and include nonunion (4-31%), persistent pain (mild: 30% and moderate: 5%), FCR tendonitis, radial styloid overgrowth, pin tract infections and loss of ROM
          • Most common reason for return to OR is secondary radial styloidectomy from radial styloid overgrowth
      • Pyrocarbon implant arthroplasty
        • Indications
          • Theoretically decreasedrisk of carpal instability as scaphoid length is preserved, improved grip strength, technically less complex as compared to STT fusion
        • Outcomes
            • Significant increases in DASH, VAS, grip/pinch strength, and ROM.
            • Very limited series have not reported complications and have short follow-up and small sample sizes
      Techniques
      • Distal pole of scaphoid excision
        • Technique
          • Removes arthritic articulation
          • May be backfilled with tendon interposition
          • Approach: volar, dorsal or arthroscopic
        • Complications
          • May predispose to carpal instability, specifically DISI posture and development of capitolunate arthritis
          • Persistent pain (44% of patients have residual mild pain)
          • Avascular necrosis of the capitate
          • Flexor tendon Rupture
      • STT fusion
        • Options
          • Kirschner wires are the most common method of internal fixation
          • Alternative techniques include headless compression screws, staples and plate/screw constructions
          • Headless compression screws are gaining in popularity
          • Ideal radioscaphoid angle in which to fuse varies between 45 and 60 degrees of palmar flexion
        • Technique
          • Kirschner Wires
            • 6-8cm dorsal incision centered over the STT joint
            • The dorsal capsule is incised between ECRL and ECRB
            • The articular surface is removed and decorticated, including the volar lip of the scaphoid
            • The scaphoid is positioned at 45-60 degrees of flexion and the wrist is placed in maximal radial deviation
              • It is not necessary to correct abnormal rotation of the lunate
            • Cancellous bone graft is packed into the STT joint
            • TheScaphotrapezoid joint is pinned proximal to distal while theScaphotrapezial joint is pinned radial to ulnar
            • The wrist is then immobilized for 6-8 weeks
          • Staple Fixation
            • Scaphotrapezial and Scaphotrapezoid joints reduced with k-wires then compressed with staples
          • Circular Plate
            • A 4-corner fusion plate can be used to fuse the STT joint
        • Complications
          • Nonunion
          • Radial styloid impingement
          • Adjacent joint arthrosis and degeneration
          • Reflex Sympathetic Dystrophy
      • Pyrocarbon Implant Arthroplasty
        • Indications
          • Patients with a desire to maintain relatively normal carpal kinematics
        • Technique
          • Ensure implant is sized correctly
          • Resent approximately 3-4mm of distal scaphoid
          • Identify and protect the sensory branch of the radial nerve
        • Complications
          • Implant loosening
          • Scaphoid bone loss
      Complications
      • Flexor Tendon Rupture
        • Associated withdistal scaphoid excision
        • Thought to be associated with sharp bony remnant of distal scaphoid
      • Dorsal Intercalated Segment Instability and Midcarpal Misalignment
        • Occurs with distal scaphoid excision, often in the setting of comorbid midcarpal instability
        • Lower incidence with pyrocarbon implant
      • Nonunion
        • Nonunion rates in STT fusion vary from 4% to 31%
        • Can use vascularized bone graft from the distal radius to augment the fusion
      • Radial Styloid Impingement
        • Occurs in 33% of STT fusions
        • Incidence is higher in patients treated for rotary subluxation of scaphoid
        • Can treat with partial radial styloidectomy
          • Can perform prophylactically with all STT fusions
      • Adjacent Joint Arthrosis and Degeneration
        • Occurs at the radiocarpal joint in 42% of patients and at the trapezial-metacarpal joint in 28% of patients following STT fusion
      • Reflex Sympathetic Dystrophy
        • Occurs following STT fusion
        • Incidence is approximately 3.6%
        • Can prevent with high-dose vitamin C

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      FAQs

      What is the STT joint in the hand? ›

      The STT joint is really a set of small joints on the thumb side of the wrist (see picture below). The three bones involved in the joint are the Scaphoid, the Trapezium, and the Trapezoid, hence STT joint.

      How is STT arthritis treated? ›

      Conservative treatment includes splinting and corticosteroid injections. Operative treatment consists primarily of fusion of the STT joint, although alternatives include trapeziectomy, fibrous arthroplasty, and prosthetic replacements.

      What is severe STT? ›

      The most common symptom of osteoarthritis of the carpometacarpal (CMC) joint or scapho-trapezium/trapezoid (STT) joint, is pain at the bottom of the thumb. The pain can be worse with activities that require pinching, such as opening jars, turning door knobs or keys, and writing.

      What is Stage 4 CMC arthritis? ›

      Eaton and Littler originally described Stage IV CMC arthrosis with advanced degenerative changes, including substantial subluxation, joint space narrowing, and subchondral cysts and sclerosis (Fig. 1D). They stated that this stage was “generally applicable to rheumatoid arthritis” [12].

      What causes STT osteoarthritis? ›

      Scaphotrapeziotrapezoidal (STT) joint osteoarthritis has been estimated to account for 13% of all wrist arthritis cases and can cause significant pain and limitation of function [4-6]. Common predisposing factors are trauma, an abnormal trapezio-trapezoidal inclination and laxity of the capitotrapezial ligament [4-6].

      What is the STT joint of the thumb? ›

      The STT joint is one of the intercarpal joints and involves multiple articulations, including those between the scaphoid and trapezium bone, and between the scaphoid and trapezoid bone.

      What is STT fusion? ›

      STT fusion involves joining the three bones together to prevent movement at the joint. The operation involves the surgeon removing the surfaces of the joint. A small bone-graft is taken from the hip-bone (ileum) and this is packed into the STT joint to encourage the bone surfaces to join together.

      What is STT arthroplasty? ›

      Aim of pyrocarbon STT arthroplasty is to relieve pain and preserve wrist motion and function by maintaining height and kinematic of the scaphoid. Severe midcarpal instability associated with STT joint destruction is a contraindication of pyrocarbon interposition.

      What is severe Triscaphe osteoarthritis? ›

      Triscaphe degenerative arthritis is the second most common type of degenerative arthritis in the wrist. The most common is the pattern of destruction associated with a scapholunate advanced collapse (SLAC) wrist. The diagnosis is relatively easy when radiographs confirm the isolated joint destruction to the STT joint.

      Is arthritis the same as arthrosis? ›

      Arthritis vs. Arthrosis. Arthritis is an inflammatory condition involving one or more joints throughout the body that causes pain, swelling and warmth in the affected areas. Arthrosis is a non-inflammatory degenerative condition associated with aging.

      Is scaphoid hand or wrist? ›

      The scaphoid bone is one of the carpal bones on the thumb side of the wrist, just above the radius. The bone is important for both motion and stability in the wrist joint. The word "scaphoid" comes from the Greek term for "boat." The scaphoid bone resembles a boat with its relatively long, curved shape.

      What Is Basal thumb arthritis? ›

      Basal joint arthritis is a very common type of arthritis that affects the part of the thumb that's right next to your wrist. It occurs when cartilage wears away from the ends of the bones that form the joint at the base of your thumb. It causes pain, especially when you try to pinch or grab things.

      What is end stage CMC arthritis? ›

      Hyperextension at the MCP seen in end stage CMC arthritis occurs to compensate for the loss of motion at the CMC joint. Diagnosis: CMC arthritis is diagnosed through physical exam and radiographic evaluation. CMC treatment is deter- mined by the stage of the disease.

      How painful is CMC surgery? ›

      You will generally have no pain, and the numbing medication usually lasts about 8 or more hours, so you will leave the surgery center with no pain.

      How many people have CMC arthritis? ›

      Thumb carpometacarpal osteoarthritis (CMC OA) is a common disease, affecting up to 11% and 33% of men and women in their 50s and 60s, respectively, which leads to pain, laxity and weakness of the CMC joint.

      Why does my PIP joint hurt? ›

      The most common symptoms of osteoarthritis are stiffness, swelling, and pain. Bony nodules may develop at the middle (PIP) and end (DIP) joints of the finger. A deep, aching pain at the base of your thumb is typical of osteoarthritis in the basilar joint.

      Why does my MCP joint hurt? ›

      Causes of Metacarpophalangeal (MCP) Joint Arthritis

      Inflammation (mainly rheumatoid arthritis) Traumatic injury leading to broken bone or loss of cartilage (Post-traumatic arthritis) Routine wear and tear of the MCP joint (osteoarthritis) Certain medical conditions (gout, pseudogout, psoriasis, etc.)

      Where is the CMC joint located? ›

      The CMC joints are located between the distal carpal row and the metacarpal bones (Fig. 13.54). Each metacarpal and its associated phalanges make up a ray of the hand. The CMC joints are enclosed by a single joint capsule.

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