Ligament reconstruction arthroplasty for primary thumb carpometacarpal osteoarthritis (weilby technique): prospective cohort study

[Base-of-thumb osteoarthritis: aspects to be considered with the indication of trapeziectomy and CMC I prosthesis]

Base-of-thumb osteoarthritis is the most frequent osteoarthritis of the hand requiring surgical treatment, although conservative treatment options should be exhausted before surgery. If the wear process progresses with continuing pain-related loss of thumb function, thus leading to a loss of function of the whole hand, surgical treatment is indicated. In 1947, Gervis published results after trapeziectomy and heralded the development of a multitude of different surgical procedures. The long time needed for rehabilitation is a major problem of trapeziectomy with or without tendon interposition and/or suspension. After the implementation of the first CMC I prosthesis by De la Caffiniere 50 years ago, a rapid development took place, leading to the current modular bipolar implants. Especially in the German-speaking world, there is still some scepticism regarding these prostheses, which is why this review aims to illuminate both surgical procedures with a special focus placed on the aspects of indication.

Comparison of Surgical Outcomes for Arthrodesis and Arthroplasty for Thumb Carpometacarpal Osteoarthritis in Female Workers

Background

Both arthrodesis and trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI) arthroplasty are reliable surgical procedures for thumb carpometacarpal (CMC) osteoarthritis. Here, we compared surgical outcomes between arthrodesis and T + LRTI for female workers aged over 40 years with thumb CMC osteoarthritis to determine an optimal procedure.

Patients and Methods

Fourteen thumbs of 13 patients who underwent arthrodesis with locking plates and 11 thumbs of 10 patients who underwent T + LRTI and were followed up for at least 12 months were retrospectively analyzed. For the two groups, we investigated the range of motion (ROM) of the thumb, grip strength, pinch strength, disabilities of the arm, shoulder, and hand (DASH) score, Hand20 score, and visual analog scale (VAS) scores for pain at 1-year follow-up and compared them between the two groups. In addition, we investigated surgical complications and resumption of work.

Results

Both procedures provided similar subjective outcomes in terms of Hand20 and VAS scores; however, arthrodesis provided significantly larger ROM of the metacarpophalangeal and interphalangeal joints of the thumb, grip and pinch strength, and DASH score, whereas T + LRTI provided a significantly better palmar abduction at 1-year follow-up. There were three and four postoperative complications in the arthrodesis and T + LRTI groups, respectively. One patient in the arthrodesis group had resigned, whereas two patients in T + LRTI had changed their jobs to less physically demanding ones postoperatively.

Conclusion

Both procedures satisfy female workers aged over 40 years with thumb CMC osteoarthritis. Nevertheless, arthrodesis can provide favorable outcomes that are equal to or better than T + LRTI.

Trapeziectomy versus Maïa Prosthesis in Trapeziometacarpal Osteoarthritis

Background  Osteoarthritis at the base of the thumb is the most frequent osteoarthritis of the hand. Trapeziectomy in a broad variety of surgical methods have been proposed to achieve pain reduction and improvement of thumb function. A well-known disadvantage is the long recovery time. Arthroplasty of the thumb carpometacarpal joint is a competing new method for this indication with different revision and complication rates reported. Purposes  The aim of this study is to assess whether there are significant differences in outcome during the first 12 months and time return to work after either, implant of a Maïa joint prosthesis, or trapeziectomy with tendon interposition after Weilby. Patients and Methods  This clinical follow-up study compares the efficacy of total basal joint replacement using the Maïa prosthesis with tendon interposition arthroplasty in 59 thumbs. Clinical, functional, and radiological results at preoperative, 3-, 6-, and 12-month postoperative are presented. Results  We found a significant shorter return to work in the prosthesis group with 4.5 compared with 8.6 weeks. In addition to a significant difference in pain reduction with a better Mayo wrist score in the Maïa group after 3 months. The scores are closer after 6 months and nearly match after 12 months. Measurement of the pinch grip showed a parallel course. A radiological loosening of the cup in two patients was detected after 12 months. Conclusion  Implantation of Maïa prosthesis enables a significant shorter recovery but is associated with the risk of loosening and higher costs. Level of Evidence  Level IV, case-control study.

Return to Sports and Recreational Activities Following Arthroplasty of the Basal Joint of the Thumb: A Retrospective Review

Purpose

Arthroplasty of the basal, or carpometacarpal, joint of the thumb has been shown to decrease pain, improve strength, improve range of motion, and allow return to work. This study sought to assess whether basal joint arthroplasty also allows for a return to sports and recreational activities.

Methods

A survey assessing participation in sports and recreational activities, timing of return to play after surgery, enjoyment, and the presence of pain and limitations was mailed to patients who had undergone an arthroplasty of the basal joint of the thumb over a 3-year period.

Results

Of the 333 patients who underwent thumb carpometacarpal arthroplasty, met the criteria, and responded, 73% were able to successfully return to sports and recreational activities, with decreased pain and at the same or increased level of play, frequency of participation, and level of enjoyment for their sport or recreational activity. Patients were more likely to successfully return to sports and recreational activities if they had undergone surgery on their nondominant hand, did not stop their sport or recreational activity before surgery, were able to return within 9 months of surgery, and reported no postoperative limitations. Successful return to sports and recreational activities was not related to age, sex, surgeon, level of play, or the type of sport or recreational activity.

Conclusions

Most patients who replied to our survey reported successful return to sports and recreational activities after arthroplasty of the basal joint of the thumb.

Type of study/level of evidence

Prognostic IV.

Prevalence of complications and association with patient-reported outcomes after trapeziectomy with a Weilby sling: A cohort study

PURPOSE

The primary aim of this study was to report complications during the first year after trapeziectomy with Weilby sling using a standardized tool designed by the International Consortium for Health Outcome Measures. The secondary aim was to determine the association of complications and patient-reported outcomes 12 months after surgery.

METHODS

We included patients who underwent trapeziectomy with Weilby sling between November 2013 and December 2018. All complications during the first year were scored using the International Consortium for Health Outcomes Measurement Complications in Hand and Wrist conditions (ICHAW) tool. Pain and hand function were measured before surgery and 12 months after surgery using the Michigan Hand Outcomes Questionnaire (MHQ). Minimally Important Change thresholds of 18.6 for MHQ pain and 9.4 for MHQ function were used to determine clinical importance.

RESULTS

Of 531 patients after trapeziectomy with Weilby sling, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced Grade 2 or 3 deviations, including requiring antibiotics, corticosteroid injections, or additional surgery. On average, patients improved in pain and hand function, even in the presence of ICHAW events. Although all ICHAW grades were associated with poorer patient-reported outcomes 12 months after surgery, Grade 2 and 3 exceeded the Minimally Important Change threshold for pain and/or function.

CONCLUSIONS

In 531 patients, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced grade 2 or 3 deviations. We recommend describing Grade 1 as "adverse protocol deviations" and grade 2 and 3 as complications, because of clinically relevant poorer patient-reported outcomes 12 months after surgery. The ICHAW is a promising tool to evaluate systematically and compare complications in hand surgery, although we recommend further evaluation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Trapeziectomy with ligament reconstruction and tendon interposition arthroplasty continuously improves hand functions up to 5-year postoperatively

INTRODUCTION

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) arthroplasty is a reliable surgical procedure for the treatment of thumb carpometacarpal osteoarthritis, which provides good long-term outcomes. However, it remains unclear when the greatest benefit of this procedure can be obtained, and how long these benefits will continue. Therefore, we investigated the middle- to long-term advantages of this procedure by analysing the chronological changes in clinical outcomes by following the same patients from 1 year to a median 5 years after trapeziectomy with LRTI.

MATERIALS AND METHODS

Sixteen thumbs that completed consecutive clinical and radiographic evaluations preoperatively, 1 year, 2 years, 3 years, and median 5 years (range 4-8 years) after trapeziectomy with LRTI were included in this study. We investigated grip strength, pinch strength, range of motion (ROM) of the thumb, a visual analogue scale for pain, Disabilities of Arm, Shoulder and Hand (DASH) score, Hand20 questionnaire score, trapezial space height, and trapezial space ratio at every time point.

RESULTS

Hand strength (grip, pulp, and lateral pinch), palmar abduction, DASH score, and Hand20 questionnaire score were improved at 1 year postoperatively while the radial abduction showed significant improvement at the final follow-up. Moreover, pulp pinch strength, DASH score, and Hand20 questionnaire score continued to improve significantly from 1 year postoperatively to the final follow-up. Conversely, trapezial space height and ratio continuously decreased up to the final follow-up.

CONCLUSIONS

Trapeziectomy with LRTI consecutively improved the pinch strength, ROM of the thumb, DASH score, and Hand20 questionnaire score up to 5 years postoperatively. It also maintained the improvement of the other clinical outcomes up to 5 years postoperatively except for radiological findings.

A Meta-analysis of Surgical Interventions for Base of Thumb Arthritis

Background  There is a myriad of available surgical options for thumb carpometacarpal joint (CMCJ) arthritis and no robust evidence exists to guide the decisions of treating surgeons. Our aim was to assess the comparative effectiveness of different surgical interventions available for the treatment of thumb CMCJ arthritis. Methods  We performed a systematic review, pairwise, and network meta-analysis of all randomized studies comparing surgical interventions for thumb CMCJ arthritis. Our primary outcomes were pain, function, and key pinch strength at long-term follow-up (> 6 months). Risk of bias and certainty of evidence were assessed for each outcome measure of compared interventions separately. Clinical recommendations were based on evidence of strong or moderate certainty. Results  A total of 17 randomized studies were included in the systematic review. Where possible, pairwise and network meta-analyses were performed. Based on evidence of moderate certainty, trapeziectomy with a concomitant ligament reconstruction and tendon interposition (LRTI) does not appear to be associated with any long-term clinical benefits compared with simple trapeziectomy (function: mean difference [MD] -3.72 [-9.15, 1.71], p  = 0.64 favoring simple trapeziectomy; key pinch strength: MD 0.07 kg [-0.28, 0.43], p  = 0.68 favoring trapeziectomy with LRTI). Treatment rankings from the network meta-analysis favored trapeziectomy with and without LRTI, joint replacement, and arthrodesis. Trapeziectomy with LRTI appears to be associated with fewer major complications compared with joint replacement and arthrodesis, and more minor complications compared with simple trapeziectomy. Conclusion  Until further high-quality research indicates otherwise, simple trapeziectomy should be the preferred surgical modality for base of the thumb arthritis. Level of Evidence  This is a Level 1 study.

Effect of Tendon Strip (FCR vs APL) on Outcome of CMC Thumb Joint Arthroplasty With Pyrocarbon Disk Interposition

BACKGROUND

Pyrocarbon disk interposition for carpometacarpal (CMC) thumb joint osteoarthritis can be performed with a flexor carpi radialis (FCR) or abductor pollicis longus (APL) tendon strip. With the FCR technique, a ligament reconstruction is performed in addition to disk fixation, whereas with the APL technique the disk is simply secured in place. Our aim is to compare long-term postoperative outcomes between both techniques.

METHODS

In this observational study, we included 106 patients in 2 centers operated on between 2006 and 2011. We assigned patients to the FCR group or the APL group based on the respective tendon strip used. As a primary outcome, we analyzed postoperative key pinch. In addition, we analyzed postoperative tip pinch and tripod pinch, grip strength, range of motion, thumb height maintenance, and patient-reported outcome measures (PROMs).

RESULTS

The analysis showed clinically important stronger key pinch for the APL group (β = 1.28 kg). Tip pinch and grip strength showed higher outcome for the FCR group (β = 1.22 kg and 5.14 kg, respectively). Palmar abduction was in favor of the FCR group and opposition in favor of the APL group, but these were interpreted as not clinically relevant. Radiological thumb height maintenance and PROMs showed no clinical difference.

CONCLUSIONS

Pyrocarbon disk interposition arthroplasty for CMC thumb joint osteoarthritis can be secured with an APL or FCR tendon strip. At long-term follow-up, use of an APL tendon strip results in significantly higher key pinch and better opposition. Tip pinch, grip strength, and palmar abduction were better after use of the FCR tendon strip. The choice of the tendon strip can be based on outcomes considered most important for the individual patient.

Functional Recovery Following Trapeziectomy and Ligament Reconstruction and Tendon Interposition: A Prospective Longitudinal Study

PURPOSE

Patients undergoing surgery for trapeziometacarpal (TMC) joint arthritis require preoperative counseling on the expectations of surgery. This study aims to document the objective and functional recovery over the initial 12 months following trapeziectomy and ligament reconstruction with tendon interposition (LRTI).

METHODS

We prospectively followed 55 patients with symptomatic TMC joint osteoarthritis after trapeziectomy and LRTI. Patients were assessed on functional outcome measures, pain, and objective outcomes of grip, tip and key pinch strength, and range of motion. Outcomes were recorded preoperatively and at 3, 6, 9, and 12 months after surgery.

RESULTS

Outcome measures of Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and pain, improved significantly after surgery at each 3-month interval up to 9 months. Palmar and radial abduction were significantly improved compared to their preoperative ranges, but opposition was unchanged. Power grip significantly exceeded the preoperative strength at 6 months and further increased at 9 months. Tip pinch significantly exceeded the preoperative strength at 12 months. There was no difference in the key pinch strength compared to the preoperative strength.

CONCLUSIONS

Over a follow-up period of 12 months, trapeziectomy and LRTI is an effective treatment in significantly reducing pain in 80% of patients. Although normal patient-reported outcome measures of DASH and PRWE are not regained, when compared to normative values, these measures are significantly improved; the improvement plateaus at 9 months. Patients can expect to attain 37% and 46% of their eventual measured DASH and PRWE scores, respectively, at 3 months, and 82% and 79% of their eventual measured DASH and PRWE scores, respectively, at 6 months. Grip strength exceeded the preoperative strength by 15% at 6 months and by 30% at 9 months. Tip pinch strength significantly exceeded the preoperative strength by 20% at 9 months.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Prosthetic Replacement Has a Clinical Outcome Superior to That of Trapeziectomy With Ligament Reconstruction and Tendon Interposition: A Meta-Analysis

A meta-analysis was performed to compare trapeziectomy with ligament reconstruction and tendon interposition (LRTI) vs prosthetic replacement for first carpometacarpal joint osteoarthritis. Seven prospective and retrospective comparison trials were retrieved. A total of 459 patients receiving trapeziectomy with LRTI and 374 patients receiving prosthesis replacement with a follow-up of 12 to 69 months were identified. There were no differences in visual analog scale scores or complications. However, the mean Disabilities of the Arm, Shoulder and Hand score was 3.73 points lower and the mean pinch power was 1.16 points higher in the prosthesis replacement group, and this was significant. Prosthetic replacement led to a superior clinical outcome compared with trapeziectomy with LRTI, with no difference in complications. [Orthopedics. 2021;44(2):e151-e157.].

Functional outcome of ligament reconstruction with tendon interposition after failed first carpometacarpal joint prosthesis

The purpose is to determine if ligament reconstruction with tendon interposition (LRTI) is a recommendable salvage option for failed total joint prosthesis of the first carpometacarpal joint. Twenty-two patients in our database met the in- clusion criteria for this retrospective study, with at least 6 months follow-up. Fourteen participated and were invited for a clinical examination and asked to fill out two questionnaires. They were evaluated for pain (VAS), impairment (NHS), disability (Quick DASH), opposition (Kapandji test) and grip strength (hydraulic dynamometer). Results of the questionnaires were compared to a cohort study of primary LRTI’s. Kapandji test and grip strength were compared to the contralateral side. Compared to primary LRTI’s, revision surgery showed mild deterioration of impairment and disability. The average VAS score was 2.9 out of 10. Twelve patients mentioned a sense of strength loss, which could be quantified with the dynamometer : a mean of 15.1 kg (operated thumb) versus 20.5 kg (contralateral). There was a relatively small decline of opposition with Kapandji 8.6 versus 9.9. The overall satisfaction was good for 8 patients, fair for 3 and poor for the remaining 3 (mainly based on strength loss). One patient needed a second revision. Failed first carpometacarpal joint replacement can be salvaged by ligament reconstruction with tendon interposition, providing an acceptable functional outcome in 79% of cases studied. However, compared to the functional outcome of primary LRTI’s, mild aggravation of impairment and disability should be taken into account.

Geographical differences in carpometacarpal joint osteoarthritis treatment of the thumb: A survey of 1138 hand surgeons from the USA and Europe

BACKGROUND

Carpometacarpal osteoarthritis of the thumb (CMC OA) is treated with various therapeutic approaches. However, the literature remains inconclusive regarding the ideal procedure for each disease stage. In this study, we assessed the international application of surgical treatment options including CMC I implants and non-surgical treatment options for CMC OA depending on the disease stage, with a strong focus on the detection of geographical disparities.

METHODS

We conducted a large international online survey with members of hand surgical societies of the International Federation of Societies for Surgery of the Hand (IFSSH). The first part of the survey asked about general therapy options of CMC OA depending on the severity of the disease, whereas the second part specifically dealt with the use of prostheses.

RESULTS

We could include 10 of 56 IFSSH member societies (6807 surgeons) and received answers from 1138 members (16.7%). Significant differences were detected in an increased use of corticosteroid injections in the USA, and a growing frequency of fat injections in Europe. Regarding use and frequency of the resection arthroplasty, we found similar results in all participating countries. Prosthetic implantation showed a significant difference between the USA and Europe, with far larger numbers stated by European hand surgeons.

CONCLUSION

CMC OA is treated differently in the participating countries depending on the stage of the disease. We give an insight into geographical differences in treatment paradigms, with corticosteroid injections being more prevalent in the USA, and prosthesis implantation being more frequently chosen in the selected European countries.

Partial Versus Total Trapeziectomy With Interposition Arthroplasty for Trapeziometacarpal Osteoarthritis Grade II to III Eaton-Littler: A Clinical Trial

Purpose

Total trapeziectomy is the most widely used technique to treat isolated thumb trapeziometacarpal joint osteoarthritis. However, this technique has been associated with proximal migration of the thumb metacarpal, which has led some physicians to consider partial trapeziectomy as a valid alternative. The purpose of this study was to assess whether partial trapeziectomy improves final key pinch strength compared with total trapeziectomy.

Methods

We randomized 34 patients with basal thumb osteoarthritis into 2 groups to undergo partial or total trapeziectomy with interposition arthroplasty. Key pinch strength at 12 months was the primary outcome measure. Other variables measured included trapezial space height, range of motion, grip strength, change in key pinch strength, patient-reported outcome measures, and pain.

Results

No difference between groups was detected regarding final pinch strength, trapezial space height, grip strength, range of motion, change in pinch strength, patient-reported outcomes (Quick–Disabilities of the Arm, Shoulder, or Hand), or pain.

Conclusions

We cannot conclude that partial trapeziectomy provides an advantage over total trapeziectomy at 1 year after surgery. Although trapeziometacarpal space was substantially preserved in the partial trapeziectomy group at 12 months, this difference was not statistically or clinically significant.

Type of study/level of evidence

Diagnostic III.

Chronological changes in surgical outcomes after trapeziectomy with ligament reconstruction and tendon interposition arthroplasty for thumb carpometacarpal osteoarthritis

BACKGROUND

Despite satisfactory mid-term and long-term outcomes of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) procedures for thumb carpometacarpal osteoarthritis, there is limited literature describing detailed chronological changes in early-phase postoperative outcomes. We investigated chronological changes of subjective, objective, and radiological outcomes within 1 year post-trapeziectomy with LRTI using a longitudinal evaluation and analyzed clinical factors associated with patient-reported subjective outcomes.

HYPOTHESIS

Some parameters influence patient-reported subjective outcomes during the early postoperative period.

PATIENTS AND METHODS

Nineteen patients (mean age, 67.3 years) who underwent trapeziectomy with LRTI were evaluated preoperatively and at 3, 6, and 12 months postoperatively to investigate objective (grip strength, pinch strength, range of motion [ROM] of the interphalangeal [IP] joint, metacarpophalangeal [MP] joint, and carpometacarpal [CMC] joint, Kapandji score), subjective (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Hand20 questionnaire score, and visual analog scale [VAS] for pain), and radiological outcomes (trapezial space height and its ratio). Factors affecting DASH and Hand20 scores were analyzed.

RESULTS

Grip strength and pinch strength were decreased at 3-month follow-up. It required 6 months to recover preoperative strength and 12 months for significant improvement. VAS for pain, DASH, and Hand20 scores were significantly improved at 3-month follow-up, continuing to improve until 12 months. The trapezial space height and its ratio decreased approximately 50% at 3-month follow-up, with no further changes at 6 or 12 months. Both DASH and Hand20 scores were strongly correlated with VAS for pain during activity within 6 months post-surgery and moderately correlated with ROM of the thumb at 3 months post-surgery; however, they were not correlated with grip and pinch strength as well as the trapezial space height ratio within 12 months post-surgery.

DISCUSSION

Trapeziectomy with LRTI for thumb carpometacarpal osteoarthritis provided early subjective improvements in outcomes as early as 3 months post-procedure. However, more than 6 months are required to determine objective improvements in outcomes. To obtain early patient-reported satisfactory outcomes, we should focus not on improving hand and finger strength, but on treating postoperative surgical site pain and preventing thumb stiffness.

LEVEL OF EVIDENCE

IV, retrospective therapeutic study.

Outcomes of Surgical Management for Thumb Basilar Arthritis in Patients 55 Years of Age and Younger

Background: Trapeziectomy with ligament reconstruction tendon interposition (LRTI) or suspensionplasty is an effective treatment in older patients with end-stage thumb basilar arthritis. However, the survivability of this procedure is unknown in younger patients who may impart more stress on their thumbs. Methods: A retrospective review was performed on all patients who underwent trapeziectomy and LRTI or suspensionplasty at 55 years of age or younger from 1992 to 2008. Objective clinical outcome measures included preoperative to postoperative changes in thumb range of motion, grip and pinch strength, a study-specific thumb function score, and the Buck-Gramcko subjective outcome score. Progressive metacarpal subsidence was evaluated on radiographs. Survivorship free from revision surgery was calculated with a Kaplan-Meier analysis. Results: A total of 57 wrists underwent trapeziectomy and LRTI (n = 18) or suspensionplasty (n = 39). The mean patient age at the time of surgery was 49.6 years (range: 38-55 years). Mean clinical and radiographic follow-up were 10.2 and 6.4 years, respectively. Overall, there were significant improvements in pain and grip strength despite progressive and metacarpal subsidence. Survivorship was 100% and 86% free from revision surgery at 10 and 15 years, respectively (n = 2 failures). Conclusions: Trapeziectomy and LRTI or suspensionplasty in patients less than or equal to 55 years of age can result in considerable improvements in pain and grip strength with a 10-year survivorship free from revision.

Arthroscopic treatment of basal joint arthritis by partial trapeziectomy with ligament reconstruction: Short-term results from a prospective study of 20 patients

Partial trapeziectomy for basal joint arthritis is an alternative to total trapeziectomy that preserves the height of the thumb column. Using arthroscopy reduces the incidence of periarticular lesions and the risks of complications. The purpose of this prospective single-center study was to evaluate the results of arthroscopic partial trapeziectomy combined with suspension and interposition ligament reconstruction using half of the abductor pollicis longus tendon. Twenty patients (18 women, 2 men) with a mean age of 55 years (43-65 years) were operated using this technique between November 2013 to February 2015. Patients were evaluated clinically and radiologically at 1 month, 3 months, 6 months and 12 months after surgery. The 20 patients were reviewed after 12 months. The subjective QuickDASH score improved from the 3rd post-operative month (P = 0.0029) from 50.6 preoperatively to 30.3 after 3 months, 17.6 after 6 months and 9.6 after 12 months. Pain was reduced in the 1st month post-operative (P < 0.0001). The Kapandji Score and pinch strength improved from the 3rd month (P = 0.034). Return to work was possible for 19% of employed patients after 1 month, 44% after 3 months and 87.5% after 6 and 12 months. Eighty-eight percent of the patients were satisfied or very satisfied after 3 months and 95% after 6 and 12 months. Pain levels, range of motion and QuickDASH Score are similar to those of open partial trapeziectomy described in the literature. However, recovery seems to be faster with this arthroscopic technique. Arthroscopic treatment of basal joint arthritis, which limits capsule and ligament lesions, leads to good short- and medium-term results in terms of pain relief and thumb motion while preserving strength. LEVEL OF EVIDENCE: 4 (Prospective, non-randomized).

Exercise Therapy in Addition to an Orthosis Reduces Pain More Than an Orthosis Alone in Patients With Thumb Base Osteoarthritis: A Propensity Score Matching Study

OBJECTIVE

To compare the effect of exercises and orthotics with orthotics alone on pain and hand function in patients with first carpometacarpal joint (CMC-1) osteoarthritis (OA) and to predict outcomes on pain and hand function of exercises and orthotics.

DESIGN

Prospective cohort study with propensity score matching.

SETTING

Data collection took place in 13 outpatient clinics for hand surgery and hand therapy in The Netherlands.

PARTICIPANTS

A consecutive, population-based sample of patients with CMC-1 OA (N=173) was included in this study, of which 84 were matched on baseline demographics and baseline primary outcomes.

INTERVENTIONS

Exercises and orthotics versus orthotics alone.

MAIN OUTCOME MEASURES

Primary outcomes included pain and hand function at 3 months, measured using visual analog scale (VAS, 0-100) and the Michigan Hand Outcomes Questionnaire (MHQ, 0-100).

RESULTS

A larger decrease in VAS pain at rest (11.1 points difference; 95% confidence interval, 1.9-20.3; P=.002) and during physical load (22.7 points difference; 95% confidence interval, 13.6-31.0; P<.001) was found in the exercise + orthotic group compared to the orthotic group. In addition, larger improvement was found for the MHQ subscales pain, work performance, aesthetics, and satisfaction in the exercise + orthotic group. No differences were found on other outcomes. Baseline scores of metacarpophalangeal flexion, presence of scaphotrapeziotrapezoid OA, VAS pain at rest, heavy physical labor, and MHQ total predicted primary outcomes for the total exercise + orthotic group (N=131).

CONCLUSIONS

Non-surgical treatment of patients with CMC-1 OA should include exercises, since there is a relatively large treatment effect compared to using an orthosis alone. Future research should study exercises and predictors in a more standardized setting to confirm this finding.

Partial Versus Total Trapeziectomy Thumb Arthroplasty: An Expertise-based Feasibility Study

Supplemental Digital Content is available in the text.

Background:

There are numerous surgical techniques for the treatment of first carpometacarpal joint osteoarthritis, however, controversy exists as to whether outcomes differ between techniques. This feasibility study aimed to determine if a large-scale, health-related quality of life and functional outcomes study comparing 2 surgical techniques, complete trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI) versus partial trapeziectomy and tendon interposition (PT + TI) arthroplasty, is possible.

Methods:

Patients with advanced stage arthritis (Eaton stages II–IV) of the thumb were invited to undergo either T + LRTI or PT + TI at 1 of the 2 hand surgery practices. Feasibility outcomes included: (1) Process: recruitment rate; (2) Resources: eligibility rate, eligibility criteria, retention, and compliance rates (completion of health-related quality of life questionnaires, Disabilities of the Arm, Shoulder, and Hand, EuroQol-5D-3L, and SF-36, and functional measurements, grip, key pinch, and tip pinch strength, at 1-week preoperatively and 1, 3, 6, and 12 months postoperatively); (3) Management: determining the practices’ commitment to the study; and (4) Scientific: calculation of the variances and treatment effect sizes (ES) of differences between procedures. Data from baseline measurements and 6-month follow-up were used for analysis.

Results:

Sixty patients were screened, of which 34 (57%) were eligible for surgery. Twenty-one (81%) of the 26 ineligible patients were excluded due to previous or additional planned surgical procedures on the same hand, particularly carpal tunnel release (n = 17). Twenty patients consented; 12 in the T + LRTI and 8 in the PT + TI group. The highest completion rate for the 3 questionnaires and the functional measurements, for both groups was at 6-month time point. Compliance rates for questionnaire completion at 6-months were calculated at 50% and 75% for the T + LRTI and PT + TI group, respectively. Functional measurement completion rate was 50% and 63% for T + LRTI and PT + TI groups, respectively. Treatment ES were group dependent, with Disabilities of the Arm, Shoulder, and Hand, EuroQol-5D-3L usual activities and anxiety/depression showing a large ES in the PT + TI group; the T + LRTI group showed large ES in EQ-5D state of health today.

Conclusions:

Authors conclude that a large-scale study is feasible and dependent on: (1) increasing sample size to account for the high attrition rate; (2) liberalizing inclusion criteria to include patients with carpal tunnel syndrome; (3) allotting more time at follow-up visits to ensure completion of all measurements; and (4) increasing staff involvement (ie, develop rapport with patients and maintain stability with research assistants).

Long-term Outcomes of Partial Trapeziectomy With Capsular Interposition Arthroplasty for Osteoarthritis of the Thumb Basal Joint

The purpose of this study was to describe long-term outcomes of partial trapeziectomy with capsular interposition (PTCI) arthroplasty for patients with osteoarthritis of the basal joint of the thumb. A total of 27 patients (20 women, 7 men; 32 thumbs) with a mean age of 61 years (range, 47-74 years) agreed to return for follow-up and were included in the study. Mean postoperative follow-up was 64.3 months (range, 28-112 months). Evaluation included tests for grip and pinch strength; range of motion of the metacarpophalangeal joint; measurement of the first web space; completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; visual analog scale (VAS) measurements; and radiographic examination of the hand. A paired, 2-tailed t test was used to determine statistical significance (P<.05) of pre- and postoperative values. Postoperative values for grip strength were significantly increased from preoperative values. No significant loss of pinch strength was noted. Excessive hyperextension of the metacarpophalangeal joint did not occur, and the first web space was maintained. The mean DASH questionnaire and VAS scores were 5.06 (range, 0-26.5) and 0.32, respectively. Use of PTCI arthroplasty resulted in minimal loss in thumb height (7%) and significantly reduced thumb metacarpal subluxation (13%). There were no reported complications. The low DASH questionnaire and VAS scores compare well with other studies and indicate good functional outcomes. In treating thumb basal joint osteoarthritis, use of PTCI arthroplasty may result in improved thumb stability and grip strength, minimal subsidence of the thumb metacarpal, and reduced joint subluxation. [Orthopedics. 2018; 41(2):e228-e233.].

Functional Outcomes of Thumb Trapeziometacarpal Arthrodesis With a Locked Plate Versus Ligament Reconstruction and Tendon Interposition

PURPOSE

To compare standardized functional and patient-reported early outcomes following trapeziometacarpal arthrodesis (TMA) using a locking cage plate construct with trapezial excision, ligament reconstruction, and tendon interposition (LRTI).

METHODS

This prospective cohort enrolled 50 consecutive patients with trapeziometacarpal osteoarthritis undergoing TMA or LRTI. Demographic data, objective measurements, Sollerman function testing, and patient-reported outcomes were collected before surgery and at various time intervals up to 12 months after surgery. The study was powered to detect a minimally clinically important difference on the Michigan Hand Questionnaire between groups at 12 months. To account for selection bias, we performed between-group statistical analysis of the magnitude of change from preoperative to postoperative data. All complications were recorded.

RESULTS

There were no significant differences in the amount of change in grip or pinch strength, patient-reported outcomes, or functional hand testing between TMA and LRTI. The TMA group had significantly increased thumb tip opposition distance. The TMA group was complicated by a 26% overall nonunion rate of which 8% were symptomatic. The LRTI group (Wagner incision) had a significantly increased incidence of superficial branch of the radial nerve paresthesia. The incidence of complications was similar between operative groups, but revision surgery was more common after TMA.

CONCLUSIONS

Compared with LRTI, TMA failed to demonstrate superior improvement in strength, standardized functional performance, or patient-reported function and is associated with an increased likelihood of revision surgery in the first 12 months. Trapeziometacarpal arthrodesis with a locking plate and screw construct does not ensure union, although most radiographic nonunions were asymptomatic. Wagner incisions are associated with a significantly increased incidence of superficial branch of the radial nerve paresthesia compared with dorsal trapeziometacarpal exposure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Radiographic and surgical considerations in arthritis surgery of the hand

Indications for hand surgeries include unremitting joint pain, deformity and stiffness, often secondary to arthritis. Several surgical options are available, including arthrodesis (fusion) and joint arthroplasty. Classically arthrodesis is performed in situations with poor bone stock and supporting soft tissues. Arthroplasty is reserved for patients and joints in which preservation of function is important and bone stock and soft tissue support are adequate. In this article we will review various techniques for arthrodesis and arthroplasty, their post-surgical imaging appearance, including key findings important to surgeons, and the findings that indicate post-surgical complications. Radiographs are the mainstay for postoperative evaluation and will be the focus of the imaging portions of this review. Advanced imaging modalities will be reviewed when applicable.

Locking Plate Arthrodesis Compares Favorably with LRTI for Thumb Trapeziometacarpal Arthrosis: Early Outcomes from a Longitudinal Cohort Study

BACKGROUND

Trapeziometacarpal arthrodesis (TMA) has been complicated by nonunion and hardware failure.

QUESTIONS/PURPOSES

We hypothesized that modification of the TMA technique with a locking cage plate construct would afford reliable bony union while producing greater hand function than trapeziectomy with ligament reconstruction and tendon interposition (LRTI) at early follow-up.

METHODS

We enrolled 36 consecutive patients with trapeziometacapal osteoarthritis (14 TMA patients (15 thumbs), 22 LRTI patients (22 thumbs)). The study was powered to detect a minimal clinically important difference on the QuickDASH questionnaire between groups. Secondary outcomes included Michigan Hand Questionnaire (MHQ), VAS-pain, and EQ-5D-3L scores. Patients were examined to evaluate thumb motion and strength. TMA patients were evaluated clinically and radiographically for union.

RESULTS

Mean follow-up was 15.6 months, and the mean age was 59.2 years. Union was achieved in 14/15 (93%) of TMA thumbs. Improvement in QuickDASH scores was similar after TMA and LRTI (49 to 28 and 50 to 18, respectively). Postoperative patient-rated upper extremity function, health status, and pain were similar between groups. Pinch strength was significantly greater after TMA (5.9 vs 4.7 kg). No differences in thumb or wrist range of motion were observed postoperatively with the exception of greater total metacarpophalangeal joint motion after TMA. Complications after TMA included nonunion (7%), development of symptomatic scaphotrapezotrapezoidal (STT) arthrosis (7%), symptomatic hardware (7%), and superficial branch of the radial nerve (SBRN) paresthesia (7%). Complications after LRTI included subsidence (5%), MP hyperextension deformity (5%), and SBRN paresthesias (5%).

CONCLUSIONS

At early follow-up, patient-rated function was similar among patients undergoing TMA and LRTI. TMA produced 25% greater pinch strength compared with LRTI. Despite historical concerns regarding global loss of ROM with arthrodesis, motion was similar between groups. Our observed TMA nonunion rate of 7% is low relative to historically reported nonunion rates (7-16%). Locking cage plate technology affords rigid fixation for TMA with promising early results noting reliable bony union while minimizing complications.

Outcomes of denervation, joint lavage and capsular imbrication for painful thumb carpometacarpal joint osteoarthritis

Pain reduction remains the main aim in the treatment of thumb carpometacarpal joint osteoarthritis. We performed a retrospective analysis of a case series of patients with symptomatic thumb carpometacarpal joint arthritis treated with denervation, joint lavage and capsular imbrication. A total of 60 patients participated in this study. Follow-up, including a clinical examination, was performed on 37 patients at a mean of 46 months (range 12 to 81); an additional 23 patients were followed-up by telephone at a mean of 52 months (range 14 to 93) post-operatively. The patients assessed in person showed a significant decrease in pain and a significant improvement in thumb function. The information gathered by telephone gave similar results. The findings of our study indicate that the presented treatment approach could be a good alternative to more invasive surgical options in patients with earlier stages of thumb carpometacarpal joint osteoarthritis. Advantages include the low rate of complications and invasiveness, as well as short recovery times.

LEVEL OF EVIDENCE

IV.

Measurement of quality of life among patient undergoing arthroplasty of the thumb to treat CMC arthritis

OBJECTIVE

To present the clinical and functional results, including measurement of quality of life, of patients undergoing trapeziometacarpal arthroplasty.

METHOD

This was a prospective evaluation on 45 patients (53 thumbs) with a diagnosis of idiopathic rhizarthrosis who underwent resection arthroplasty and interposition of an uncemented Ascension(®) implant, made of pyrocarbon. The clinical and functional results were analyzed through radiography, range of motion (ROM) in degrees (°), visual analog scale (VAS) for pain and the disability of arm, shoulder and hand (DASH) questionnaire for quality of life. In the group analyzed, 38 were women and seven were men, and their mean age was 63.17 years (range: 50-78). Eight patients were treated bilaterally.

RESULTS

After 42.08 months of follow-up (range: 8-73), the subjective pain evaluation (VAS) score was 1.37 (range: 1-4). The complete ROM of the thumb increased to 95.75% (range: 75-100%) in relation to the contralateral side. The mean DASH questionnaire score was 9.98 (range: 1-18). The complication rate (negative events) was 11.32%. Five patients presented dislocation of the thumb prosthesis. All of them were reoperated by means of dorsal capsuloplasty using a portion of the retinaculum of the extensors as a graft, and good clinical evolution was achieved in these cases. One patient presented fracturing of the metacarpal and was treated by means of osteosynthesis using Kirschner wires.

CONCLUSION

This method is effective for treating rhizarthrosis, according to the measurements made on the clinical and functional results, even after taking the complication rate into consideration. Moreover, it provides an improvement of quality of life for these patients.

Retrospective Study of a Series of 20 Ivory Prostheses in the Treatment of Trapeziometacarpal Osteoarthritis

Background Many surgical treatment options for osteoarthritis (OA) of the trapeziometacarpal (TMC) joint exist. However, no procedure has been proven superior. Good results have been described for TMC joint replacement. Purpose To analyze the results of the Ivory prosthesis in the treatment of symptomatic TMC OA. Patients and Methods A retrospective single-center follow-up study was performed. Visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Michigan Hand Outcomes Questionnaire (MHQ), active range of motion, strength, and radiological outcomes were assessed and analyzed. Differences between the operated and nonoperated hand were analyzed using paired t-tests. Twenty patients were included with a mean follow-up duration of 37.0 months. Results Patients experienced minimal pain with a mean VAS pain score of 1.9. DASH and MHQ scores indicated mild to moderate impairments. Eighty-five percent of patients assessed the operation excellent or good. Significant differences were found in measurements of extension and palmar thumb abduction in favor of the contralateral hand. No significant differences in strength between both hands were found. Two patients had a dislocation of the prosthesis; one patient required open reduction and tightening of the joint capsule. The other dislocation was treated with trapeziectomy and interposition of a fascia lata allograft. One patient had a collapse of the trapezium requiring a revision procedure. Conclusion Ivory prosthesis TMC arthroplasty can achieve good results in patients with symptomatic isolated TMC OA. In this series, however, revision surgery was required in 3 of 20 cases.

Painful thumb carpometacarpal joint osteoarthritis: Results of a novel treatment approach

BACKGROUND

Pain reduction as well as preservation and improvement in range of motion remain the main aims in the treatment of thumb carpometacarpal (CMC) osteoarthritis (OA). We performed a retrospective outcome analysis of patients with symptomatic stage II-III thumb CMC joint arthritis treated with denervation, joint lavage and capsular imbrication.

METHODS

73 patients with stage II to III OA of the thumb CMC-joint underwent the described technique. A total of 42 patients complied with follow-up assessment and were included in this study. Mean follow-up was 41.2 (range 12-81) months.

RESULTS

Mean operative time was 28.4 (±6.5) minutes. The follow-up assessments showed a significant decrease in pain (preoperative Numerical Rating Scale (NRS): 7.5 - postoperative NRS: 1.1) (p < 0.0001) and a significant improvement in function of the thumb (preoperative DASH-Score: 46.8; Cooney-Wrist-Score: 35.4; Krimmer-Wrist-Score: 38.3 - postoperative DASH-Score: 18.1; Cooney-Wrist-Score: 73.7; Krimmer-Wrist-Score: 80.0) (p < 0.0001).

CONCLUSION

The findings of our study indicate that the presented treatment approach could be a good alternative to more invasive surgical options in patients with stage II-III CMC OA of the thumb, without impairing more invasive surgical options like trapeziectomy or arthroplasty for the future.

[Comparative clinical study of 2 surgical techniques for trapeziometacarpal osteoarthritis]

OBJECTIVE

In trapeziometacarpal osteoarthritis (or rhizarthrosis), there is great controversy over the surgical technique to choose: simple trapeziectomy, resection-interposition arthroplasty, interposition arthroplasty suspension-or arthroplasty with implant or prosthesis. These latter 2 are the most used without consensus in the literature on the technique to choose and without sufficient comparative studies. The objective is to compare the 2 techniques most used today: suspension-interposition arthroplasty and arthroplasty with prosthesis.

MATERIAL AND METHOD

A prospective study was conducted on 15 patients diagnosed with grade 2-3 rhizarthrosis treated with interposition arthroplasty-suspension (group 1) and 15 with prosthesis (group 2) showing clinical outcomes, advantages and disadvantages of each. The study variables were the visual analogue scale (VAS), the DASH questionnaire, the grip strength, the strength of end to end and end-lateral clamp, the joint balance adduction-abduction and preemption-retropositioning, and the opposition. The 2 groups are from 2 different hospitals operated on by a hand surgeon from the Hand Unit. The follow-up time for all patients included in the study was 12 months.

RESULTS

The VAS, DASH and grip strength at 12 months did not show significant differences. As regards the strength of end to end and end-lateral clamp, group 2 showed the highest values in all follow-up periods with statistically significant differences.

CONCLUSIONS

Patient selection and surgical experience is essential, given the satisfactory results of both techniques. Arthroplasty prosthesis is reserved for grades 2 and 3, middle-aged patients, good trapezium architecture, and experienced surgeons.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions

PURPOSE

To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.

METHODS

A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.

RESULTS

Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.

CONCLUSIONS

Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

High incidence and treatment of flexor carpi radialis tendinitis after trapeziectomy and abductor pollicis longus suspensionplasty for basal joint arthritis

We reviewed the incidence and treatment of flexor carpi radialis tendinitis in 77 patients (81 thumbs) who had trapeziectomy and abductor pollicis longus suspensionplasty for thumb carpometacarpal joint arthritis. Eighteen patients, 20 wrists (25%) had flexor carpi radialis tendinitis. The onset was 2-10 months (mean 4.7) after surgery. Two cases had preceding trauma. Eight cases (40%) responded to splinting and steroid injection. Ten patients, 12 wrists (60%) underwent surgery after failing non-operative treatment. Eleven wrists had frayed or partially torn flexor carpi radialis tendon and one had a complete tendon rupture with pseudotendon formation. Flexor carpi radialis tenotomy and pseudotendon excision were performed. All operated patients obtained good pain relief initially post-operatively. However, the pain recurred in two patients after 8 months. One required a local steroid injection for localized tenderness at the site of the proximal tendon stump. The other patient required a revision operation for scaphotrapezoid impingement. Both obtained complete pain relief. Our study has shown a high incidence of flexor carpi radialis tendinitis following trapeziectomy and abductor pollicis longus suspensionplasty. Patients should be warned about this potential complication.

Five to eight years follow-up for trapeziectomy and Weilby ligament reconstruction for the treatment of trapeziometacarpal osteoarthritis

Trapeziectomy and Weilby ligament reconstruction is a recognized treatment for osteoarthritis of the trapeziometacarpal joint. Studies published using this procedure have limited follow-up post-surgery. In this series of 24 cases assessed objectively and 36 subjectively with a minimum follow-up of five years, patients continue to have pain relief and function comparable to the opposite non-operated hand. Patient satisfaction is high at 92% and the rate of complications is low. Despite these encouraging results the need for interposition arthroplasty and/or ligament reconstruction in addition to trapeziectomy alone is discussed.

Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial

BACKGROUND

Both trapeziectomy with ligament reconstruction and tendon interposition and trapeziometacarpal arthrodesis are commonly performed procedures for the treatment of trapeziometacarpal osteoarthritis. The purpose of this study was to compare the outcomes of both treatments for symptomatic osteoarthritis of the thumb trapeziometacarpal joint in a randomized trial.

METHODS

Women who were forty years of age or older were randomized either to trapeziectomy with ligament reconstruction and tendon interposition or to arthrodesis with plate and screws. Patients were evaluated preoperatively and at three and twelve months postoperatively with respect to pain, function (Patient-Rated Wrist/Hand Evaluation [PRWHE] and Disabilities of the Arm, Shoulder and Hand [DASH] questionnaires), joint motion, strength, complication rate, and patient satisfaction.

RESULTS

Forty-three patients were enrolled. Since we found significantly more moderate and severe complications following arthrodesis compared with trapeziectomy with ligament reconstruction and tendon interposition (71% versus 29%; p = 0.016), the study was prematurely terminated before the sample size necessary to validly compare the two groups was reached. The higher complication rate for arthrodesis led to an increase in revision surgery (two of seventeen patients). Significantly more patients in the ligament reconstruction and tendon interposition group (86%) than in the arthrodesis group (53%) indicated they would consider the same surgery again under the same circumstances (p = 0.025). In both groups, PRWHE and DASH scores significantly improved over time; however, comparison of the groups showed that the results were similar.

CONCLUSIONS

Women who are forty years or older with trapeziometacarpal osteoarthritis have fewer moderate and severe complications after trapeziectomy with ligament reconstruction and tendon interposition and are more likely to consider the surgery again under the same circumstances than are those who undergo arthrodesis. Twelve months after surgery, the PRWHE and DASH scores were similar in both groups. We do not recommend routine use of arthrodesis with plate and screws in the treatment of women who are forty years or older with stage-II or III trapeziometacarpal osteoarthritis.

Modified technique for basilar thumb osteoarthritis

The arthroplasty described by Weilby is a reliable procedure for the treatment of stage 2 and 3 basal thumb osteoarthritis. Although the technique provides good pain relief, optimal thumb mobility, and acceptable levels of grip and pinch strength in most cases, it is common to see the thumb collapsing because the interposed knot has disassembled. We have found a more effective way to prepare and stabilize that interposition material. With this modification, we have had less thumb subsidence than with the original technique.

Evidence-based medicine: thumb carpometacarpal arthroplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Recount the epidemiology of basilar joint arthritis. 2. Understand how the anatomy and kinematics of this joint contribute to the development of the disease process. 3. Combine patient history, clinical examination, and radiographic findings to formulate a diagnosis and staging of the arthritis. 4. Incorporate conservative management into the patient treatment plan to aid in determining a patient's surgical candidacy. 5. Comprehend the basic principles of available surgical options, potential complications, and evidence pertaining to surgical outcome.

SUMMARY

This article has been prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured for physicians to comparatively evaluate their care of a patient with arthritis of the thumb carpometacarpal joint.

Midterm results after modified Epping procedure for trapeziometacarpal osteoarthritis

BACKGROUND AND PURPOSE

Various surgical procedures have been proposed for the treatment of trapeziometacarpal joint (TMJ) osteoarthritis. Despite an overall satisfactory outcome in most cases, some patients complain about inadequate performance at work, due to instability of the TMJ. We present a cross-sectional study of patients with TMJ arthritis who underwent a modified Epping procedure for increased TMJ stability.

METHODS

71 patients underwent a modified Epping procedure with a flexor carpi radialis tendon sling stabilizer. 59 patients were followed up after a mean time of 38 months. Residual pain was evaluated by visual analog scale. Functional outcome was quantified by pinch and grip strength, static two-point discrimination test, as well as DASH outcome scoring. Quality of life measures included patients' perceived satisfaction, activities of daily living (ADL), grip/pinch force and manual performance at work.

RESULTS

85 % of the patients regained full or partial manual performance during labor. Strength and ADL improved or remained the same in 81 %. In cases of a unilateral treatment, no difference in grip between the operated and nonoperated hand was observed. Mean tip pinch strength was 2.8 kg for the operated and 3.6 kg for the nonoperated hand. Mean pain level during rest was 0.98, 0.95 during mild activity, and 3.70 during strenuous activity. Mean DASH score was 26.6.

CONCLUSION

The great majority of patients who underwent this novel procedure benefited from an unaffected or improved work performance, due to good TMJ stability combined with adequate motion for ADL. Less favorable results were seen in patients with accompanying hand pathologies.

Rehabilitation protocol after suspension arthroplasty of thumb carpometacarpal joint osteoarthritis

STUDY DESIGN

Retrospective case series.

INTRODUCTION

When conservative modalities and therapies fail to control symptoms of thumb carpometacarpal (CMC) joint osteoarthritis, surgery may be indicated.

PURPOSE OF THE STUDY

To present a rehabilitation protocol used in a series of patient cases after suspension arthroplasty and to evaluate outcomes.

METHODS

Twenty-seven patients with CMC osteoarthritis were treated by the same arthroplasty technique and the same rehabilitation program. Patients were evaluated before and 12th week after surgery, and at the last follow-up using a visual analog scale; the Disability of the Arm, Shoulder, and Hand questionnaire; strength measurements; range of motion evaluations; and radiographic assessment.

RESULTS

Average follow-up period was 31.5 months. There was a decreasing trend in both subjective scores during follow-ups (p=0.0001). Thirty-three percent and 30% improvements on radial and palmar abductions, respectively, and 29% improvement on pinch strengths were recorded at the final follow-up. Postoperative grip improvement was not preserved at the last follow-up.

CONCLUSIONS

The results demonstrate a high degree of patient satisfaction suggesting the efficacy of this surgical technique and postoperative rehabilitation protocol.

LEVEL OF EVIDENCE

Level 4.

Trapezium resection with mersilene suspension sling

The reason there are numerous techniques for thumb carpometacarpal arthroplasty is that none of them are perfect. Sometimes the simplest procedures work best. This article presents a simple alternative, using a readily available suture to stabilize the thumb after resection of the trapezium, with long-term success.

An alternative suspension technique after trapeziectomy for advanced thumb carpometacarpal osteoarthritis

Osteoarthritis of the first carpometacarpal joint is often treated by (partial) trapeziectomy and tendon interposition or suspension arthroplasty procedures. In this article, an alternative suspension technique, using 2 osseous tunnels (through the first and second metacarpal) and a flexor carpi radialis tendon strip, is described.