Treatment of advanced CMC joint disease: trapeziectomy and implant arthroplasty (silastic-metal-synthetic allograft)

Double trapeziometacarpal and scaphotrapeziotrapezoidal pyrocarbon interposition implants for pantrapezial arthritis: Midterm results and surgical technique

BACKGROUND

Pantrapezial osteoarthritis of the thumb (OA) includes involvements of scaphotrapezoidtrapezoidal (STT) and trapeziometacarpal (TM) joints which are source of disabling pain and function loss. Whilst radical procedures or arthroplasties are available, more conservative techniques have been developed recently and have gain popularity. They aim of this study was to know the midterms results of patients presenting peritrapezial OA treated with a double interposition pyrocarbon implant at the STT and TM joints. Our hypothesis was that patients suffering from pantrapezial OA treated with this technique would improve their functional scores at the last follow-up.

PATIENTS AND METHODS

This descriptive, retrospective, observational study analysed 31 patients treated with a double STT and TM pyrocarbon interposition implant ("Burger arthroplasty") between 2009-2018. Patients were clinically and radiologically diagnosed with pantrapezial OA before surgery (Eaton stage I or II). The primary endpoint was the comparison of the preoperative and postoperative values of the functional scores QuickDASH and PRWE. Epidemiological data and radiological results were reported. Pain, range of motion, pinch and grip strength, were analysed with standardised tools. The surgical technique was described in detail and reinforced with a didactic supplementary video.

RESULTS

Eighteen patients were available for analysis (58%) with a mean age of 62 years (range: 49-79). At last follow-up (44 months, range: 9-95) we found significant reduced pain, significant improvement of QuickDASH and PRWE scores and of pinch strength (p<0.05). Range of motion, grip and pinch strength did not improve significantly (p>0.05). Two patients required revision surgery.

DISCUSSION

The double STT and TM pyrocarbon interposition offer good results at midterm on patient suffering from early stages of pantrapezial OA with preserved trapezium structure.

LEVEL OF EVIDENCE

IV.

One-Year Outcomes of Intraarticular Fat Transplantation for Thumb Carpometacarpal Joint Osteoarthritis: Case Review of 99 Joints

BACKGROUND

This study aims to present a new therapeutic option for the treatment of thumb carpometacarpal joint osteoarthritis. Knowing that autologous fat may be beneficial for osteoarthritis through antiinflammatory and chondroprotective effects, the authors transplanted autologous adipose fat into the thumb carpometacarpal joint with the objective of postponing definite resection arthroplasty surgery.

METHODS

In this pilot study, the authors performed surgery on 99 joints. The study population consisted of patients with symptomatic and radiologically confirmed osteoarthritis of the thumb carpometacarpal joint. After harvesting abdominal adipose tissue, 1 to 2 ml of fat without physical or enzymatic manipulation were transplanted into the thumb carpometacarpal joint. Surgical outcome was quantified by use of the Michigan Hand Outcomes Questionnaire in addition to strength and pain measurements during a 12-month follow-up consultation. We conducted Friedman's analysis of variance to gauge the differences over time regarding Michigan Hand Outcomes Questionnaire and pain under stress.

RESULTS

From 2 weeks on, there was pain relief, both under stress and at rest. Friedman's analysis of variance revealed a significant change in pain under stress [chi-square (5) = 68.52; p < 0.001]. Postoperative Michigan Hand Outcomes Questionnaire Scores improved significantly over 12 months [chi-square (5) = 90.56; p < 0.001].

CONCLUSION

The authors' preliminary findings suggest that intraarticular autologous fat transplantation is a promising alternative treatment of carpometacarpal joint osteoarthritis of the thumb.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Clinical Evaluation of the Articulinx Intercarpometacarpal Cushion for the First CMC Joint: A Feasibility Study

Background The Intercarpometacarpal Cushion (ICMC; Articulinx, Cupertino, CA, USA) is an implantable spacer designed as a less invasive surgical treatment for osteoarthritis (OA) of the first carpometacarpal joint (CMC-1). Description of Technique Following local anesthesia and exposure of the joint capsule the ICMC, attached to a needle and suture tethers, is guided into the joint space under fluoroscopic visualization through a dorsal approach. The needle is pulled through the thenar eminence to the opposite side of the hand and, once proper device placement is confirmed, cut free and the joint capsule closed. Patients and Methods Eight female patients (median age 56 years; range, 42-83) were treated and followed for 6 to 24 months. Safety of the implant procedure was evaluated intraoperatively. Pain, joint function, and strength were evaluated at 6 weeks, 3, 6, 12 and 24 months with a Visual Analog Scale (VAS) for pain, the QuickDASH inventory, Canadian Occupational Performance Measure (COPM), and pinch and grip strength measurements. Results At 2 years (n = 6), mean VAS pain scores decreased from 6.3 (± 1.5) to 2.2 (± 1.1) (p < 0.001), mean QuickDASH scores improved from 47 (± 15) to 31 (± 11) (p < 0.10), mean COPM performance scores improved from 5.0 (± 1.2) to 5.5 ( ± 1.3) (p = NS). Mean pinch and grip strength measurements also improved compared with baseline. No serious adverse events occurred. Two device removals occurred, associated with a traumatic event and Stage IV OA with device displacement, at 6 and 9 months respectively. Conclusion The ICMC can be implanted safely. Effectiveness needs to be confirmed in future studies.

Review of thumb carpometacarpal arthritis classification, treatment and outcomes

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. Based on the staging of the CMC OA, different forms of treatment can be used, including both conservative and surgical measures. Surgical options include osteotomy, trapezial excision, ligament reconstruction with or without tendon interposition, and various prosthetic interpositional implants with or without trapezial excision. The present article reviews the staging of CMC OA, the evaluation of hand function using patient-reported questionnaires, and outcomes of both conservative and surgical treatments. The present review also introduces a commercially available interpositional spacer surgical technique for CMC OA and the early evidence that the literature has shown for improving hand function, strength and stability of the thumb CMC joint postoperatively.

Reconstruction for failed trapeziometacarpal implant

Trapeziometacarpal prosthesis by metallic implant is used to treat thumb carpometacarpal osteoarthritis. Many causes of failure have been described whereas revision techniques still remain a challenging surgery. In this article, we describe a revision strategy in a failed metallic cemented trapeziometacarpal implant with major first metacarpal shortening.

Trapezio-metacarpal arthritis: The price of an opposable thumb!

Trapezio-metacarpal arthritis is the most common arthritic problem of the hand for which patients seek surgical treatment. The current article reviews the etio-pathogenesis, epidemiology, classification and management of this widespread problem. The anatomy and unique biomechanics of this joint are also reviewed. In addition, the article provides a detailed description of our preferred method of trapezio-metacarpal arthroplasty.

Comparison of trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition: a systematic literature review

BACKGROUND

Trapeziectomy with ligament reconstruction and tendon interposition is currently the most popular technique for operative treatment of trapeziometacarpal osteoarthritis. Based on the evidence, however, it is uncertain whether the addition of ligament reconstruction and tendon interposition to trapeziectomy confers any advantage. The aim of this study was to systematically review the literature and determine which procedure, trapeziectomy or trapeziectomy with ligament reconstruction and tendon interposition, offers the best results to patients.

METHODS

A literature search was undertaken of the following electronic databases: Cochrane, AMED, EMBASE, HaPI, HealthSTAR, MEDLINE, TRIP, and Proceedings First (2002 to 2009). Studies were selected by two independent assessors if (1) the study population included patients with trapeziometacarpal osteoarthritis and (2) the study was a randomized controlled trial or systematic review comparing the two procedures. Objective (i.e., range of motion, grip strength, pinch strength, health cost, and postoperative complications) and subjective (i.e., pain relief, hand function, overall satisfaction, and quality of life) outcomes were extracted. Statistical pooling and power analyses were performed with available data.

RESULTS

Two systematic reviews and four randomized controlled trials were identified and included. There were no statistically significant differences in postoperative grip strength (p = 0.77); tip pinch strength (p = 0.72); key pinch strength (p = 0.90); pain visual analogue scale score (p = 0.34); Disabilities of the Arm, Shoulder and Hand score (p = 0.75); and number of adverse events (p = 0.13). No studies reported health costs or quality of life.

CONCLUSION

Neither procedure produced greater benefit in terms of outcomes investigated.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.(Figure is included in full-text article.).

Suture button suspensionplasty after arthroscopic hemitrapeziectomy for treatment of thumb carpometacarpal arthritis

A myriad of techniques for reconstruction of the arthritic thumb carpometacarpal joint have been described. In the modern era, there has been a push, driven by both clinicians and patients, for more rapid rehabilitation after these procedures. A majority of the historically described techniques require pinning of the thumb ray for 4 weeks. Suture button placement between the thumb and index ray metacarpals has been shown in biomechanical studies to effectively resist subsidence of the thumb ray. We describe a novel technique of using a suture button for suspensionplasty of the thumb ray after arthroscopic partial trapeziectomy. This technique allows for early mobilization and may offer a potential improvement on current techniques. Early results of use of this technique are encouraging, but well-conducted follow-up studies are necessary.

Arthroscopic debridement and synovectomy for treating basal joint arthritis

PURPOSE

To determine whether arthroscopic debridement and synovectomy of the thumb carpometacarpal joint improves subjective and objective outcomes in patients with stage I and stage II basal joint arthritis.

METHODS

Twenty-three patients with stage I or stage II basal joint arthritis were treated with arthroscopic synovectomy and joint debridement. Twenty-one age- and gender-matched patients were treated with additional forms of nonoperative therapy (control group). Change in visual analog scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH), and subjective scores and change in pinch strength were evaluated 12 months after treatment.

RESULTS

The pretreatment mean VAS, DASH, and subjective scores for the surgical and control groups were 7.7 and 7.5, respectively (P = .3); 55.6 and 54.4, respectively (P = .3); and 4 and 4, respectively (P = .9). At follow-up, the mean VAS, DASH, and subjective scores for the surgical and control groups were 2.7 and 7.3, respectively (P < .001); 26 and 53.1, respectively (P < .001); and 1.8 and 3.8, respectively (P < .001). At follow-up, mean pinch strength for the surgical and control groups was 6.2 +/- 1.3 kg and 4.9 +/- 1.1 kg, respectively (P < .001). Eighty-three percent of the surgical patients reported their result as either good or excellent. There were no significant complications.

CONCLUSIONS

This study shows that arthroscopic debridement and synovectomy improve pain scores, functional scores, subjective outcome, and pinch strength more so than traditional nonoperative therapy.