[Long-term results after resection arthroplasty in patients with arthrosis of the thumb carpometacarpal joint: comparison of abductor pollicis longus and flexor carpi radialis tendon suspension]

Biomechanical Analysis of Abductor Pollicis Longus Lasso Suspensionplasty for Trapeziectomy

PURPOSE

Multiple methods of ligament reconstruction and tendon interposition (LRTI) or suspension have been described to prevent first metacarpal subsidence following trapeziectomy. An abductor pollicis longus (APL) lasso is a newly described technique of suspensionplasty, which aims to obviate concerns regarding previously described methods. The purpose of this study was to compare subsidence between the APL lasso and 2 other common methods, APL sling and flexor carpi radialis LRTI, after trapeziectomy in cadaveric forearms.

METHODS

Ten cadaveric forearms were prepared on a custom-made plinth to recreate pinch grip upon the loading of previously identified muscles. A sequence of procedures was performed, with radiographs taken after each to assess the subsidence.

RESULTS

The APL lasso was superior to simple trapeziectomy and flexor carpi radialis LRTI in preventing subsidence.

CONCLUSIONS

The APL lasso was superior to simple trapeziectomy and flexor carpi radialis LRTI in preventing subsidence, and it may be a viable alternative when considering suspension methods after trapeziectomy.

CLINICAL RELEVANCE

The APL lasso may be considered when trying to prevent subsidence after trapeziectomy.

Efficacy of Abductor Pollicis Longus Suspensionplasty Compared to Ligament Reconstruction and Tendon Interposition

Background: Multiple surgical techniques are described for basal joint osteoarthritis. This study compares clinical outcomes and patient satisfaction with trapeziectomy and abductor pollicis longus (APL) suspensionplasty compared to trapeziectomy with ligament reconstruction and tendon interposition (LRTI) when performed by 2 fellowship-trained hand surgeons. Methods: A retrospective review of 51 consecutive patients undergoing APL suspensionplasty (53 hands) was performed. With this technique, a distally based APL slip is brought through and sewn to the flexor carpi radialis (FCR). The remaining APL is placed in the trapeziectomy void. This technique was compared to 151 patients (166 hands) who underwent LRTI using the FCR tendon. Outcomes assessed included postoperative pain relief, grip and pinch strength, complications, and need for reoperation. Two-tailed, Fisher's exact test was used for data analysis. Results: APL suspensionplasty resulted in postoperative pain relief in 92.5% (n = 49) compared to 94.0% (n = 156) with LRTI (P = .758). Mean postoperative grip and pinch strengths with APL suspensionplasty were 41.2 and 10.4 kg, respectively. With LRTI, average grip strength was 42.0 kg, and pinch was 10.1 kg. Both techniques were well tolerated with minimal complications. In the APL group, 1 patient had a postoperative infection requiring drainage. Among the LRTI cases, 1 wound dehiscence required closure, and 2 minor postoperative wound infections resolved with oral antibiotics. Mean follow-up time among APL suspensionplasty patients was 3.3 months compared to 8.4 months following LRTI. Conclusions: APL suspensionplasty is a safe, effective procedure which provides similar pain relief and functional outcomes compared to LRTI.

[A prospective Study about medium-term Results after autologous Fat Transplantation into arthritic CMC-I-joints]

PURPOSE

Prospective study to evaluate the midterm results after transfer of autologous fat into osteoarthritic CMC-I-joints.

PATIENTS AND METHODS

23 out of 27 patients (22 females and 5 men) with an average age of 59,8 (49-83) years with osteoarthritis of the CMC I joint were treated with a fat transfer into the damaged joints. The follow-up was 45,3 (39,3-50,9) months. 4 patients were excluded from the follow-up because of a resection arthroplasty in the meantime. Grip strength and pinch strength, DASH questionnaires and pain (VAS) were analysed.

RESULTS

The average pinch strength increased from preoperatively 3,7 kg to 5,1 kg postoperatively (p = .052). The average grip strength increased minimally from preoperatively 22,2 kg to 22,8 kg at follow-up (p = .506). The average DASH score improved significantly from preoperatively 50,8 to 29,6 postoperatively (p = 0,000). The average pain level decreased significantly from preoperatively 5,9 to 1,9 at follow up (p = .000). Patients with an advanced osteoarthritis of the CMC-I-joint had similar results as patients with a minor osteoarthritis.

CONCLUSION

The autologous fat transfer into the osteoarthritic CMC-I-joint showed in midterm follow-up good to very good clinical results regarding pinch strength, pain and DASH score. It is a safe minimal invasive promising alternative to accepted surgical therapies in the treatment of osteoarthritis of the CMC-I-joint.

Total trapeziectomy

Total trapeziectomy has been extensively studied and has been used to treat thumb basal joint arthritis for decades. It remains a simple and reliable technique that every hand surgeon must learn and master, as a primary or revision procedure. Several techniques have been described, but none of them seems better than the others. Without the need for an implant and because of its long-lasting benefits, total trapeziectomy is currently the only surgical technique for thumb basal joint arthritis that can lay claim to being a potential life-long procedure.

Simplified abductor pollicis longus suspension interposition arthroplasty for thumb carpometacarpal joint osteoarthritis

Purpose

The primary treatment goals for advanced-stage thumb carpometacarpal (CMC) joint osteoarthritis are complete pain relief and restoration of thumb strength. The purpose of the present study was to introduce a variation of the abductor pollicis longus (APL) suspension arthroplasty using a single looping of a radial slip from the APL tendon around the flexor carpi radialis (FCR) tendon combined with RegJoint™ interposition and to determine its efficacy in the treatment of thumb CMC joint osteoarthritis.

Methods

Between 2015 and 2017, 21 patients were included. The average age was 60.8 years (range 48–79). The mean follow-up was 27.7 months (range 8–50). Evaluation included pain, radial and palmar abduction, tip pinch and grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Results

Pain averaged 0.3 (range 0–4) at rest and 1.4 (range 0–4) on exertion. The radial and palmar abduction were 97% and 99% compared to the contralateral side. The tip pinch and grip strength were 4.1 kg (range 3–6.5) and 22 kg (range 13.3–40), respectively. The DASH score accounted for 18.5 (range 0.8–41.7).

Conclusion

The modified APL suspension interposition arthroplasty was an efficient and simplified option for the treatment of thumb CMC joint osteoarthritis, with results comparable or better than other published procedures. The APL suspension technique was easy to perform avoiding difficult bone tunneling and incision of the FCR tendon. The RegJoint™ interposition as spacer prevented impingement of the first metacarpal base on the second metacarpal base or the trapezoid bone.

APL Lasso Suspensionplasty for Trapeziectomy

Base of thumb arthritis is a common pathology, with late-stage disease often treated by trapeziectomy and a form of ligament reconstruction or suspension. No therapeutic option for suspension or ligament reconstruction has proven to be superior to others, with risks inherent to all. Here, the authors describe a novel technique utilizing an accessory slip of abductor pollicis longus looped around the second metacarpal base to suspend the metacarpal and prevent subsidence after trapeziectomy. This technique aims to mitigate some of the risks seen in other methods, while providing similar biomechanical strength. Early clinical results are also presented.

Suture Suspension Arthroplasty for the Treatment of Thumb Carpometacarpal Arthritis

PURPOSE

Most studies have demonstrated little difference in the outcome of the various techniques proposed for the surgical treatment of thumb carpometacarpal (CMC) arthritis. However, the difficulty and time required to perform each technique vary widely. In addition, the introduction of recent implants has increased the cost of the overall procedure. We hypothesize that using a simple, yet stable, suture suspension technique without tendon interposition or ligament reconstruction yields similar results to conventional approaches with less operative time.

METHODS

Three hundred twenty consecutive patients underwent thumb CMC arthroplasty by trapezial excision and metacarpal suspension using #2 high-strength orthopedic suture locked weave alone passed from the distal most abductor pollicis longus and flexor carpi radialis insertions without K-wire fixation or tendon transfer. Average duration of preoperative symptoms was 17.8 months. Patient radiographs were graded for arthritis severity and a visual analog scale (VAS) pain score (scale 0-10) obtained. Postoperative clinical and radiological follow-up averaged 5.4 years (minimum, 24 months).

RESULTS

The average age at surgery was 57.3 years and there were 221 women (243 procedures) and 65 men (77 procedures). Average total operative time was 23.4 minutes. The dominant hand was involved in 52% of patients. All had prior treatment including orthoses and nonsteroidal anti-inflammatory drugs with 312 having had at least 1 steroid injection. Five patients had stage 1, 134 had stage 2, 164 had stage 3, and 17 had stage 4 disease on radiographs. Average trapezial space height on final follow-up radiographs was 0.8 cm. Two patients had complete trapezial space collapse and required a revision procedure. The average VAS score was 0.6 with pain eliminated in 269 thumbs, minimal in 49, and unchanged/worse in 2. All patients that were employed at the time of surgery returned to work at an average of 2.3 months (range, 3-16 weeks).

CONCLUSIONS

Suture suspension thumb CMC arthroplasty provides comparable clinical results and several advantages over many current techniques that are described in the literature. The advantages include shortened operative time, inherent stability of the thumb metacarpal height, and no necessity for K-wire fixation, tendon transfers, or implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Basal joint osteoarthritis of the thumb]

The basal joint of the thumb (articulatio carpometacarpalis pollicis) is the joint of the hand most frequently affected by arthritis. Arthritis of the basal joint of the thumb typically occurs in the second half of life and more frequently in women. The clinical symptoms are pain, joint swelling, reduced strength and limited hand function with a reduced hand span. When clinical symptoms first appear a conservative treatment is initially indicated. If these measures do not lead to an improvement of the complaints, various operative measures are possible depending on the stage of the disease detected by radiological imaging.

Compression plate arthrodesis for osteoarthritis of the first carpometacarpal joint: A retrospective study of 77 cases

Osteoarthritis of the first carpometacarpal joint (CMCJ1) is a common, painful condition with positive radiological findings in up to 32% of people over 50 years of age and up to 91% of people over 80 years of age. Currently, there is insufficient evidence to recommend one surgical treatment option over the others. We conducted a retrospective review of 77 patients treated for CMCJ1 osteoarthritis with plate arthrodesis between 1979 and 1996. The review included physical examination, including range of motion (ROM) of the thumb interphalangeal joint, metacarpophalangeal joint and CMCJ1, pinch grip, key grip and power grip strength, and a questionnaire on subjective outcomes (appearance, dexterity, load bearing, pain, strength, subjective overall result and if patients would choose the procedure again). The complication rate was 26%. However, the general patient satisfaction was high with 88% of patients saying they would choose to have the procedure done again. There was a significant decrease (side-to-side difference) in the ROM for palmar and radial abduction as well as opposition when compared to the opposite hand. Furthermore, there was a significant reduction (side-to-side difference) in pinch, key grip and power grip strength. ROM did not seem to have any influence on pain (and vice versa), load bearing, and the subjective overall result. No gender differences were noted. Despite the high complication rate, CMCJ1 arthrodesis remains a viable option for the treatment of CMCJ1 osteoarthritis in select patients requiring good thumb stability.

Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Study

BACKGROUND

Most operations for carpometacarpal joint osteoarthritis of the thumb irreversibly alter or destroy the anatomy. There is a high demand for minimally invasive alternatives. The authors report the results of autologous fat transfer for treatment of thumb carpometacarpal joint osteoarthritis.

METHODS

In a prospective study, 50 patients with thumb carpometacarpal joint osteoarthritis were observed for 1 year after autologous fat transfer. Manual liposuction and centrifugation were performed. Pain rating according to visual analogue pain scale; objective force of pinch grip and fist closure; and Disabilities of the Arm, Shoulder, and Hand questionnaire scores before and after treatment were analyzed.

RESULTS

The average pain in stage 2 patients preoperatively was 7.7 ± 1.3; it was 1.8 ± 1.9 after 6 months and 2.4 ± 3.1 after 12 months. Patients with stage 2 osteoarthritis demonstrated a superior benefit from this treatment compared with patients with either stage 3 or stage 4 thumb carpometacarpal joint osteoarthritis. There were similar improvements for the parameters strength and Disabilities of the Arm, Shoulder, and Hand questionnaire score. No serious adverse events were observed.

CONCLUSIONS

Autologous fat transplantation is an appealing alternative, especially in early-stage basal joint osteoarthritis of the thumb. The low invasiveness of the procedure and early recovery of patients compared with classical procedures such as trapeziectomy, and the superior long-term results compared with classical injection therapy, make this approach feasible as a first-line therapy in early-stage basal joint osteoarthritis of the thumb.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

WITHDRAWN: Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement). We did not find any studies that compared surgery with sham surgery or surgery with non-surgical interventions.Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery or to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

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.

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.

Long-term results after modified Epping procedure for trapeziometacarpal osteoarthritis

INTRODUCTION

Thumb trapeziometacarpal joint (TMJ) arthritis is among the most common degenerative joint diseases of the hand and predominantly affects patients in their fifth or sixth decade of life. Mid-term results of the most common surgical procedures were inconclusive regarding the superiority of one particular treatment method. This study presents the long-term outcomes of a modified Epping procedure.

METHODS

Seventy-one patients underwent a modified Epping procedure with a flexor carpi radialis (FCR) tendon sling stabilizer. After a mean follow-up of 13 years, 39 patients were followed by questionnaire and 15 patients presented for clinical examination. Outcomes were evaluated by objective clinical measurements, radiographic evaluations, performance in DASH, as well as patients' perceived level of handicap during defined exercises.

RESULTS

Mean DASH score was 32.39. Within the cohort, 66.7 % of the patients were free of complaints. Among patients reporting complaints, perceived loss of strength was the main concern for the majority (15.4 %) of study participants. Grip and pinch strengths and range of motion did not differ significantly between operated and non-operated hands. One patient suffered rupture of ligament plasty and needed revision surgery.

CONCLUSION

Despite relatively high DASH scores, the overall outcome of the modified Epping procedure is encouraging. Subjective loss of strength is a main complaint among patients, whereas instability is less of concern.

[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.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. We excluded trials that compared non-surgical interventions with surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement).Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.We did not find any studies that compared any other combination of the other techniques mentioned above or any other techniques including a sham procedure.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery and we excluded studies that compared surgery to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

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.

Long-term follow-up of trapeziectomy with abductor pollicis longus tendon interposition arthroplasty for osteoarthritis of the thumb carpometacarpal joint

PURPOSE

To evaluate the long-term clinical and radiographic outcomes of trapeziectomy with abductor pollicis longus tendon interposition arthroplasty for moderate to severe osteoarthritis of the thumb carpometacarpal joint (Eaton stages III-IV).

METHODS

We evaluated 13 patients (15 thumbs) who underwent trapeziectomy and abductor pollicis longus tendon interposition arthroplasty for end-stage osteoarthritis of the thumb carpometacarpal joint, at an average follow-up of 15 years. Subjective clinical outcomes evaluated included visual analogue scale scores and disability of arm shoulder and hand score questionnaires. Objective clinical evaluation included lateral pinch and grip tests, and a range of active and passive thumb movements. All patients underwent a radiological assessment by two independent senior radiologists. Wherever possible, results obtained from the operated thumbs were compared to the non-operated side.

RESULTS

At a mean of 15 years post operation (range 15-17 years), there was no statistical difference between the operated and non-operated hands with regards to grip and pinch strength. In all cases CMC and MCPJ range of motion in the operative hand was either equal to or greater than non-operative counterparts. Mean visual analogue scale score was 2.13 and mean DASH score was 16.85. Mean carpal height was 0.52 and mean trapezial space ratio was 0.163. There were no early or late complications recorded and no revision surgery was required.

CONCLUSION

It is the opinion of these authors that abductor pollicis longus tendon interposition arthroplasty is able to provide high-quality long-term results for patients who suffer from moderate to severe osteoarthritis of the thumb carpometacarpal joint.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Abductor pollicis longus hemitendon looping around the first intermetacarpal ligament as interposition following trapeziectomy: a one-year follow-up study

BACKGROUND

Trapeziectomy and ligament reconstructions are favoured by surgeons concerned that telescoping of the thumb may reduce its function. However, theoretically ligamentoplasties are at risk to develop tendinosis or tendon rupture or trigger a complex regional pain syndrome type 1.

HYPOTHESIS

Authors tested the looping of a slip from the abductor pollicis longus (APL) tendon around the first intermetacarpal ligament. They intended to use a surgical treatment which does not require bone tunnelling or looping around a tendon. Their results support the hypothesis that this new technique is a valid addition among treatments for carpometacarpal arthritis.

PATIENTS AND METHODS

Forty-two patients were followed up to one year. Each patient had subjective assessment for: pain; function (DASH score); overall satisfaction. An objective assessment was used for: first web span angle; abduction and opposition; key pinch; grip strength. Tests were performed prior to surgery, then at three, six and 12 months. X-ray films were taken to monitor thumb height.

RESULTS

A substantial improvement in all these parameters was measured in all patients. X-ray films showed the mantainance of a physiological heigth after one year. We recorded one complication of keloid and two of temporary dysesthesia but no case of tendinosis, delayed rupture, or CRPS 1. Mean operative time was 27 minutes.

DISCUSSION

Simplification and search for a technique which avoids the looping around a tendon is why the authors undertook this study. Advantages are the small number of required steps, short time of surgery and comfortable postoperative rehab regimen for the patient. The technique provides a distal anchoring point (without bone tunnelling). It is quite respectful of anatomy and physiology, in minimizing the re-routing of functioning tendons. We propose it as an effective procedure both to expand the armamentarium for treating the thumb carpometacarpal joint osteoarthritis and/or to simplify the ligamentoplasties already in use.

Outcomes of trapeziectomy with a modified abductor pollicis longus suspension arthroplasty for the treatment of thumb carpometacarpal joint osteoarthritis

PURPOSE

Various arthroplasty procedures have been described for the treatment of thumb carpometacarpal joint osteoarthritis. The purpose of this study was to determine the outcomes of patients treated with trapeziectomy and a variation of abductor pollicis longus suspension arthroplasty.

METHODS

Eighteen consecutive patients were treated by a single surgeon (K.C.C.) with trapeziectomy and abductor pollicis longus suspension arthroplasty (21 thumbs). Prospective outcomes data were collected before the operation and at 3, 6, and 12 months after surgery. Outcomes were assessed with x-rays, grip/key pinch strength, the Jebsen-Taylor test, and the Michigan Hand Outcomes Questionnaire.

RESULTS

Immediately after surgery, a 32 percent loss in carpometacarpal joint height was observed and an additional 11 percent proximal metacarpal migration was observed at 1 year. The mean grip strength was 11.1 kg preoperatively and 7.7, 14.3, and 16.7 kg at 3 months, 6 months, and 1 year postoperatively, respectively. Michigan Hand Outcomes Questionnaire results demonstrated improvements in all domains. Statistically significant improvements were noted in the domains of overall score, from 41 to 67 (p = 0.03); activities of daily living, from 43 to 66 (p = 0.01); work, from 41 to 65 (p = 0.05); patient satisfaction, from 25 to 68 (p = 0.01); and pain, which decreased from 73 to 30 (p < 0.01).

CONCLUSIONS

Abductor pollicis longus suspension arthroplasty is a faster and technically easier technique that avoids any additional deficit by using an accessory tendon. This procedure gives acceptable patient-rated outcomes, especially in pain relief and satisfaction.

Anatomic study of the abductor pollicis longus: a source for grafting material of the hand

Interposition grafting material is used frequently to treat osteoarthritis of the base of the thumb or tendinous and ligamentous injuries of the hand. The observation of duplicated tendons in the first dorsal compartment of the hand prompted us to explore the possibility of using the accessory abductor pollicis longus (AAPL) tendon as grafting material. Based on dissections of 78 cadaveric upper limbs, we describe the number of tendons in the first dorsal compartment of the hand, the number of muscle bellies, their innervation, their insertion site, and the tendon dimensions to determine whether the AAPL can be considered a true tendon. The AAPL was present in 85% of the hands. Average length, width, and thickness (in millimeters) of the APL were of 69.3, 5.2, and 2.1, respectively. Average length, width, and thickness (in millimeters) of the AAPL were of 69.2, 3.3, and 1.6, respectively. No differences in dimension of the tendons were found between the APL and the AAPL. The dimensions of the tendinous portion of the AAPL are similar to those of the APL and can be considered a true tendon. When present, the AAPL is a suitable source of local grafting material.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

This is an update of a Cochrane Review first published in 2005. Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To compare the effect of different surgical techniques in reducing pain and improving physical function, patient global assessment, range of motion and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, to investigate whether there was any improvement or deterioration in outcomes between the 12-month review and five year follow up.

SEARCH STRATEGY

We searched:(CENTRAL) (The Cochrane Library 2008, issue 1), MEDLINE (1950 to Dec 2008), CINAHL (1982 to Dec 2008), AMED (1985 to Dec 2008) and EMBASE (1974 to Dec 2008), and performed handsearching of conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Randomised or quasi-randomised trials where the intervention was surgery and pain, physical function, patient global assessment, range of motion or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse effects. We contacted trial authors for missing information.

MAIN RESULTS

We included nine studies involving 477 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint resurfacing, arthrodesis and joint replacement). Studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement for pain and physical function. The majority of studies included in this review had an unclear risk of bias which raises some doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment or range of motion. Of participants who underwent trapeziectomy with ligament reconstruction and tendon interposition, 22% had adverse effects (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1)) compared to 10% who underwent trapeziectomy. Trapeziectomy with ligament reconstruction and tendon interposition is therefore associated with 12% more adverse effects (RR = 2.21, 95% CI 1.18 to 4.15).

AUTHORS' CONCLUSIONS

Although it appears that no one procedure produces greater benefit in terms of pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy has fewer complications than trapeziectomy with LRTI.

Using an evidence-based approach to measure outcomes in clinical practice

Evaluation of the outcome of evidence-based practice decisions in individual patients or patient groups is step five in the evidence-based practice approach. Outcome measures are any measures that reflect patient status. Status or outcome measures can be used to detect change over time (eg, treatment effects), to discriminate among clinical groups, or to predict future outcomes (eg, return to work). A variety of reliable and valid physical impairment and disability measures are available to assess treatment outcomes in hand surgery and therapy. Evidence from research studies that includes normative data, standard error of measurement, or comparative scores for important clinical subgroups can be used to set treatment goals, monitor recovery, and compare individual patient outcomes to those reported in the literature. Clinicians tend to rely on impairment measures, such as radiographic measures, grip strength, and range of motion, although self-report measures are known to be equally reliable and more related to global effects, such as return-to-work. The process of selecting and implementing outcome measures is crucial. This process works best when team members are involved and willing to trial new measures. In this way, the team can develop customized outcome assessment procedures that meet their needs for assessing individual patients and providing data for program evaluation.

Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis

PURPOSE

Osteoarthritis of the thumb basal joint is a common and disabling condition. This clinical follow-up study compares the efficacy of total basal joint replacement surgery with that of tendon interposition arthroplasty.

METHODS

Ninety-eight patients (mean age, 60 years +/- 1) with severe trapeziometacarpal joint osteoarthritis (Eaton-Littler stage 2.4 +/- 0.1) were included in this prospective follow-up study. Based on written and verbal information, the patients could choose either a cementless, unconstrained, hydroxyapatite-coated trapeziometacarpal joint prosthesis or abductor pollicis longus tendon interposition arthroplasty. Clinical outcome parameters were determined preoperatively and at 3, 6, and 12 months postoperatively. Furthermore, osteo-integration and osteo-fixation of the implants were radiologically analyzed after 12 months.

RESULTS

Joint replacement surgery resulted in faster and better pain relief, stronger grip functions, improved range of motion, and faster convalescence than did tendon interposition arthroplasty. After 12 months, patients with joint prostheses had regained the same strength and range of motion as in the asymptomatic contralateral thumb. After 12 months, osteolysis had developed in the vicinity of 2 cups, but there were no signs of implant loosening. The prosthesis surgery was not associated with more complications than occurred with tendon interposition arthroplasty.

CONCLUSIONS

This study demonstrates that patients with joint prostheses achieve faster convalescence with better patient comfort and improved strength and range of motion without any increased risk of complications than do patients treated with tendon interposition arthroplasty at 1-year follow up. However, a randomized clinical trial with long-term follow-up is required.

Die Suspensionsarthroplastik am Daumensattelgelenk

PURPOSE

A modified surgical technique using suspension arthroplasty against primary osteoarthritis of the thumb carpometacarpal joint was analysed.

MATERIAL AND METHODS

This retrospective analysis focused on 41 patients who underwent suspension arthroplasties with a modified technique between 1997-2005. With the help of this technique, a long-range preparation of the flexor carpi radialis tendon can be avoided. Only the ca. 3 cm of tendon which is visible in the site was split in half and cut off proximally. This half tendon was provided with a suture in baseball-stitch technique. It was then press-fit fixed with a suture in a sloping drill hole of the MC 1 basis. The patients required a cast for only 3 weeks postoperatively. Afterwards, they received an orthesis for 2-3 weeks with increasing mobilisation. The postoperative course was clinically and radiologically analysed. The results were analysed at 3 months and 1-7 years after surgery. All patients were operated as outpatients.

RESULTS

Of the 41 patients, 40 had a high subjective satisfaction. A total of 45 operations showed excellent results. There were no poor results. Only one patient would not undergo the surgery again. The radiological distance between metacarpal 1 and the distal scaphoid lay between 4 mm and 9 mm after 3 months and 1-7 years.

CONCLUSION

The described modification of suspension arthroplasty with a short-range mobilisation of the flexor carpi radialis tendon reduced the morbidity of preparation and led to stable suspension. Thus, immobilisation over 3 weeks was not necessary. Patients obtained good, early functional results.