今日の臨床サポート

母指CM関節症

著者: 酒井昭典 産業医科大学 整形外科学教室

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2021/02/24
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。 

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 母指CM関節は、第1中手骨と大菱形骨の間にある鞍状の関節である。
  1. 手の使い過ぎや加齢に伴って、関節軟骨が摩耗し、関節の痛みを来す疾患である。瓶の蓋を開けるときやドアのノブをまわすときなど、つまみ動作や握り動作で痛みを生じる。
  1. 多くは一次性の変形性関節症であり、両側罹患が多い。発症のメカニズムは明らかではないが、関節への過度の力学的負荷が主因であると考えられている。女性は男性より、中手骨の掌背方向の凹面が浅く、大菱形骨の掌背方向の凸面が低いことが報告されている。この形状差は母指CM関節症が女性に多い理由の1つに挙げられている。
  1. Roland骨折やBennett骨折の変形治癒などに続発する二次性の変形性関節症もある。
  1. 女性に多く、40歳以降に多い。
 
手根骨部の解剖

a:手根骨部を背側からみた図
b:手根骨部を掌側からみた図

出典

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文献 

著者: J H KELLGREN, J S LAWRENCE
雑誌名: Ann Rheum Dis. 1957 Dec;16(4):494-502.
Abstract/Text
PMID 13498604  Ann Rheum Dis. 1957 Dec;16(4):494-502.
著者: R G Eaton, J W Littler
雑誌名: J Bone Joint Surg Am. 1973 Dec;55(8):1655-66.
Abstract/Text
PMID 4804988  J Bone Joint Surg Am. 1973 Dec;55(8):1655-66.
著者: W Zhang, R W Moskowitz, G Nuki, S Abramson, R D Altman, N Arden, S Bierma-Zeinstra, K D Brandt, P Croft, M Doherty, M Dougados, M Hochberg, D J Hunter, K Kwoh, L S Lohmander, P Tugwell
雑誌名: Osteoarthritis Cartilage. 2007 Sep;15(9):981-1000. doi: 10.1016/j.joca.2007.06.014. Epub 2007 Aug 27.
Abstract/Text PURPOSE: As a prelude to developing updated, evidence-based, international consensus recommendations for the management of hip and knee osteoarthritis (OA), the Osteoarthritis Research Society International (OARSI) Treatment Guidelines Committee undertook a critical appraisal of published guidelines and a systematic review (SR) of more recent evidence for relevant therapies.
METHODS: Sixteen experts from four medical disciplines (primary care two, rheumatology 11, orthopaedics one and evidence-based medicine two), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. Three additional experts were invited to take part in the critical appraisal of existing guidelines in languages other than English. MEDLINE, EMBASE, Science Citation Index, CINAHL, AMED, Cochrane Library, seven Guidelines Websites and Google were searched systematically to identify guidelines for the management of hip and/or knee OA. Guidelines which met the inclusion/exclusion criteria were assigned to four groups of four appraisers. The quality of the guidelines was assessed using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument and standardised percent scores (0-100%) for scope, stakeholder involvement, rigour, clarity, applicability and editorial independence, as well as overall quality, were calculated. Treatment modalities addressed and recommended by the guidelines were summarised. Agreement (%) was estimated and the best level of evidence to support each recommendation was extracted. Evidence for each treatment modality was updated from the date of the last SR in January 2002 to January 2006. The quality of evidence was evaluated using the Oxman and Guyatt, and Jadad scales for SRs and randomised controlled trials (RCTs), respectively. Where possible, effect size (ES), number needed to treat, relative risk (RR) or odds ratio and cost per quality-adjusted life year gained (QALY) were estimated.
RESULTS: Twenty-three of 1462 guidelines or consensus statements retrieved from the literature search met the inclusion/exclusion criteria. Six were predominantly based on expert opinion, five were primarily evidence based and 12 were based on both. Overall quality scores were 28%, 41% and 51% for opinion-based, evidence-based and hybrid guidelines, respectively (P=0.001). Scores for aspects of quality varied from 18% for applicability to 67% for scope. Thirteen guidelines had been developed for specific care settings including five for primary care (e.g., Prodigy Guidance), three for rheumatology (e.g., European League against Rheumatism recommendations), three for physiotherapy (e.g., Dutch clinical practice guidelines for physical therapy) and two for orthopaedics (e.g., National Institutes of Health consensus guidelines), whereas 10 did not specify the target users (e.g., Ontario guidelines for optimal therapy). Whilst 14 guidelines did not separate hip and knee, eight were specific for knee but only one for hip. Fifty-one different treatment modalities were addressed by these guidelines, but only 20 were universally recommended. Evidence to support these modalities ranged from Ia (meta-analysis/SR of RCTs) to IV (expert opinion). The efficacy of some modalities of therapy was confirmed by the results of RCTs published between January 2002 and 2006. These included exercise (strengthening ES 0.32, 95% confidence interval (CI) 0.23, 0.42, aerobic ES 0.52, 95% CI 0.34, 0.70 and water-based ES 0.25, 95% CI 0.02, 0.47) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ES 0.32, 95% CI 0.24, 0.39). Examples of other treatment modalities where recent trials failed to confirm efficacy included ultrasound (ES 0.06, 95% CI -0.39, 0.52), massage (ES 0.10, 95% CI -0.23, 0.43) and heat/ice therapy (ES 0.69, 95% CI -0.07, 1.45). The updated evidence on adverse effects also varied from treatment to treatment. For example, while the evidence for gastrointestinal (GI) toxicity of non-selective NSAIDs (RR=5.36, 95% CI 1.79, 16.10) and for increased risk of myocardial infarction associated with rofecoxib (RR=2.24, 95% CI 1.24, 4.02) were reinforced, evidence for other potential drug related adverse events such as GI toxicity with acetaminophen or myocardial infarction with celecoxib remained inconclusive.
CONCLUSION: Twenty-three guidelines have been developed for the treatment of hip and/or knee OA, based on opinion alone, research evidence or both. Twenty of 51 modalities of therapy are universally recommended by these guidelines. Although this suggests that a core set of recommendations for treatment exists, critical appraisal shows that the overall quality of existing guidelines is sub-optimal, and consensus recommendations are not always supported by the best available evidence. Guidelines of optimal quality are most likely to be achieved by combining research evidence with expert consensus and by paying due attention to issues such as editorial independence, stakeholder involvement and applicability. This review of existing guidelines provides support for the development of new guidelines cognisant of the limitations in existing guidelines. Recommendations should be revised regularly following SR of new research evidence as this becomes available.

PMID 17719803  Osteoarthritis Cartilage. 2007 Sep;15(9):981-1000. doi:・・・
著者: Sharon L Kolasinski, Tuhina Neogi, Marc C Hochberg, Carol Oatis, Gordon Guyatt, Joel Block, Leigh Callahan, Cindy Copenhaver, Carole Dodge, David Felson, Kathleen Gellar, William F Harvey, Gillian Hawker, Edward Herzig, C Kent Kwoh, Amanda E Nelson, Jonathan Samuels, Carla Scanzello, Daniel White, Barton Wise, Roy D Altman, Dana DiRenzo, Joann Fontanarosa, Gina Giradi, Mariko Ishimori, Devyani Misra, Amit Aakash Shah, Anna K Shmagel, Louise M Thoma, Marat Turgunbaev, Amy S Turner, James Reston
雑誌名: Arthritis Care Res (Hoboken). 2020 Feb;72(2):149-162. doi: 10.1002/acr.24131. Epub 2020 Jan 6.
Abstract/Text OBJECTIVE: To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA.
METHODS: We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations.
RESULTS: Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol.
CONCLUSION: This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

© 2020, American College of Rheumatology.
PMID 31908149  Arthritis Care Res (Hoboken). 2020 Feb;72(2):149-162. d・・・
著者: Marco Rizzo, Steven L Moran, Alexander Y Shin
雑誌名: J Hand Surg Am. 2009 Jan;34(1):20-6. doi: 10.1016/j.jhsa.2008.09.022.
Abstract/Text PURPOSE: Reported outcomes of trapeziometacarpal (TM) arthrodesis have been contradictory. The purpose of this paper is to review the long-term results of TM arthrodesis for arthritis with respect to clinical outcomes, union, development of adjacent joint arthritis, and complications.
METHODS: A retrospective review of TM arthrodeses performed between 1970 and 2003 was undertaken. Among a total of 241 arthrodeses performed, 126 thumbs in 114 patients (79 women, 35 men) treated for osteoarthritis were available for follow-up evaluation. Pre- and postoperative clinical and radiographic data were reviewed. The average age was 57 years (range 32-77). The dominant hand was involved in 76 cases. Supplemental bone graft was used in 90 thumbs. Preoperative appositional (key) pinch, oppositional (tip) pinch, and grip strengths were 3.0 kg, 2.7 kg, and 14 kg, respectively. The average pain score on a scale of 0-10 was 6.6 (range 4-10). The average follow-up was 11.2 years (range 3-28 years).
RESULTS: There were 17 nonunions. No correlation existed between the incidence of nonunion and the use of supplemental bone graft. Nine of 17 thumbs had re-operation, including revision arthrodesis (6) and interposition or suspensionplasty (3). The appositional pinch, oppositional pinch, and grip strengths improved to 5.9 kg, 5.4 kg, and 23 kg, respectively (p < .01). The average pain score improved to 0.4 (p < .01). Radiographic progression of scaphotrapeziotrapezoid arthritis occurred in 39 cases; however, only 8 of these were symptomatic. Development of metacarpophalangeal arthritis was noted in 16 thumbs; none have been clinically relevant.
CONCLUSIONS: For most patients TM arthrodesis reduces pain, improves function and results in excellent patient satisfaction. Despite the development of metacarpophalangeal and scaphotrapeziotrapezoid joint arthritis, intervention for these joints was rarely warranted.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

PMID 19121726  J Hand Surg Am. 2009 Jan;34(1):20-6. doi: 10.1016/j.jhs・・・
著者: Matthew M Tomaino
雑誌名: J Hand Surg Am. 2011 Jun;36(6):1076-9. doi: 10.1016/j.jhsa.2011.03.035. Epub 2011 May 14.
Abstract/Text Thumb metacarpal extension osteotomy provides effective treatment for the hypermobile trapeziometacarpal joint consistent with Eaton stage 1 disease. This procedure is a useful alternative to Eaton ligament reconstruction. Clinical outcomes are favorable and, should symptoms persist, the procedure does not jeopardize satisfactory execution of trapezial resection arthroplasty in the future.

Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
PMID 21571443  J Hand Surg Am. 2011 Jun;36(6):1076-9. doi: 10.1016/j.j・・・
著者: S Durand, O Gagey, A C Masquelet, P Thoreux
雑誌名: Surg Radiol Anat. 2005 Aug;27(3):165-70. doi: 10.1007/s00276-004-0310-7. Epub 2005 Mar 3.
Abstract/Text The aim of this study was to define the neurovascular relationships of the approaches used during arthroscopic total trapeziectomy with the Thompson "suspension-plasty." Fifteen fresh cadavers in which trapezio-metacarpal arthritis had been confirmed by preoperative radiographs were chosen. There were 12 women and 3 men (average age: 87 years), and small joint arthroscopy equipment was used. Two approaches for the trapezio-metacarpal joint were used: an ulnar approach situated at the ulnar border of the extensor pollicis brevis tendon and a radial approach placed at the middle of a line joining the tendons of the flexor carpi radialis and the abductor pollicis longus. A new transosseous approach at the base of the first metacarpal ("trans-M1" approach) is suggested and was used to do the ligamento-plasty. After the operation, a large skin flap was elevated in order to measure the distance between each surgical approach and the different neurovascular structures (radial artery, dividing branches of the superficial branch of the radial nerve and the end of the lateral cutaneous nerve of the forearm) and to verify the absence of neurovascular lesions. The different neurovascular structures at risk during this arthroscopic maneuver were the radial artery for the ulnar approach, the branches of the superficial branch of the radial nerve for all of the approaches and the ending of the lateral cutaneous nerve of the forearm for the radial and "trans-M1" approaches. The use of the approaches described allows arthroscopic trapeziectomy with the Thompson suspension-plasty without us having noted neurovascular lesion.

PMID 15744448  Surg Radiol Anat. 2005 Aug;27(3):165-70. doi: 10.1007/s・・・
著者: Lance M Brunton, Raymond A Wittstadt
雑誌名: Tech Hand Up Extrem Surg. 2011 Jun;15(2):115-8. doi: 10.1097/BTH.0b013e3181f8c94a.
Abstract/Text Few surgical techniques that address advanced thumb carpometacarpal osteoarthrosis specifically allow early mobilization postoperatively. After trapeziectomy, we carry out a ligament reconstruction using an absorbable interference screw to secure a flexor carpi radialis tendon autograft within the first metacarpal base. Theoretically, superior tendon graft fixation strength allows early mobilization within 2 weeks postoperatively. We have retrospectively compared our clinical results using this technique with another group of patients who underwent traditional ligament reconstruction and tendon interposition as described by Burton and Pellegrini. There were no differences in the verbal pain score, satisfaction rating, or DASH scores between groups. There was a statistically significant decrease in trapezial space ratio both at rest and with stress for the experimental group. Although the clinical significance of this finding is largely unknown, it did not correlate with clinical outcome in our patients. Although no conclusions could be drawn regarding early mobilization after thumb carpometacarpal arthroplasty, further studies are planned to investigate this intriguing aspect of postoperative care. In this article, we present the details of the surgical technique and postoperative rehabilitation.

PMID 21606785  Tech Hand Up Extrem Surg. 2011 Jun;15(2):115-8. doi: 10・・・
著者: R G Eaton, J W Littler
雑誌名: J Bone Joint Surg Am. 1969 Jun;51(4):661-8.
Abstract/Text
PMID 5783846  J Bone Joint Surg Am. 1969 Jun;51(4):661-8.
著者: H H Stark, J F Moore, C R Ashworth, J H Boyes
雑誌名: J Bone Joint Surg Am. 1977 Jan;59(1):22-6.
Abstract/Text During a twelve-year period, twenty-eight patients (thirty thumbs) were treated for painful idiopathic arthritis of the metacarpotrapezial joint of the thumb by fusion. Failure of fusion occurred in two thumbs, and in both instances a solid fusion followed a second procedure. Fusion of the metacarpotrapezial joint did not predispose to painful arthritis of the trapezioscaphoid joint, even in patients with pre-existing roentgenographic evidence of minor degenerative changes in this joint. The results after long-term follow-up were gratifying, the patients having painless and stable thumbs with excellent strength. Although patients noted a minor loss of thumb motion, they did not consider this a problem. Fusion is a satisfactory procedure for patients who need or desire a strong, painless thumb, and seems especially worth while in the dominant thumb when both thumbs require surgical treatment.

PMID 833170  J Bone Joint Surg Am. 1977 Jan;59(1):22-6.
著者: J van Rijn, T Gosens
雑誌名: J Hand Surg Am. 2010 Apr;35(4):572-9. doi: 10.1016/j.jhsa.2009.12.026. Epub 2010 Feb 24.
Abstract/Text PURPOSE: The purpose of this study was to evaluate a cemented prosthesis (Avanta SR TMC prosthesis; Avanta Orthopaedics, San Diego, CA) of the basal thumb joint on the outcomes of range of motion, strength, pain, function, and loosening.
METHODS: Between July 2004 and December 2007, a total of 15 prostheses in 13 patients were implanted, with an average follow-up period of 36 months (range, 21-63 mo). Before and during the follow-up, the following scores were recorded: Kapandji-score (range of opposition), strength (hand dynamometer and pinch meter), pain (sequential occupational dexterity assessment [SODA], and Michigan Hand Outcomes Questionnaire [MHQ]) and function (9-hole peg test, SODA and MHQ). Radiographs taken before and after surgery were reviewed.
RESULTS: The measurements of range of opposition and strength did not show any significant postoperative improvement. Pain during activities (SODA) decreased significantly, and the function with both hands (SODA and MHQ) improved significantly after surgery. The review of pre- and postoperative radiographs did not show any signs of implant loosening after surgery. One failure and one nerve injury occurred.
CONCLUSIONS: In this group of patients, the Avanta SR TMC prosthesis provided statistically significant improvements in function with both hands and in pain during activity, but no significant change in range of motion, strength, or in function of the operated hand used alone. Prosthesis loosening was not detected.

PMID 20185250  J Hand Surg Am. 2010 Apr;35(4):572-9. doi: 10.1016/j.jh・・・

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