Thumb carpal metacarpal arthritis

Registration of carpometacarpal arthroplasty in the Dutch arthroplasty register: Impacting factors and participation

The treatment of carpal- and carpometacarpal arthritis using arthroplasty is becoming more common in hand surgery. Trapeziectomy is regarded as the standard treatment. Complications of trapeziectomy like thumb shortening and reduced mobility may be less common in arthroplasty. However, arthroplasty may cause implant failure and possible revision surgery. The Dutch arthroplasty registry (LROI) has been registering hand and wrist implants since 2016. Data from the LROI from 2017 to 2022 was used aiming to assess descriptive data regarding carpal- and carpometacarpal arthroplasty to demonstrate associations between arthroplasty and possible risk factors. Furthermore, this study aims to demonstrate the potential of the LROI and assess registration completeness. The registry included 178 primary first carpometacarpal arthroplasties, along with 23 revision arthroplasties. About 69.1 % of primary surgeries was performed by plastic surgeons, the others by orthopedic surgeons. Primary surgery was performed in women in 74.2 % of cases. Revision arthroplasty was performed as often by plastic surgeons, as by orthopedic surgeons. Too few carpal implants were registered to assess these types of implants. Comparing the registrations in the LROI with the national healthcare claims database showed a completeness of 9.04 % for plastic surgeons, and 30.39 % for orthopedic surgeons. This low registration completeness did not allow for any definitive conclusions to be drawn. However, this study shows large-scale registries may provide useful insights, possibly guiding clinical decision-making. To improve registration completeness, efforts should be made to facilitate registration as quick as possible, while also boosting awareness among physicians that perform carpal- and carpometacarpal arthroplasty.

Safety and efficacy of platelet-rich plasma injections in basal thumb osteoarthritis; should we offer it or not?

Nonsurgical therapeutic approaches for thumb carpometacarpal (CMC) osteoarthritis (OA) often offer only inconsistent symptom relief and fail to restore hand function. Intra-articular platelet-rich plasma (PRP) injections have recently emerged as a promising alternative, with encouraging outcomes in knees and hips. This systematic review and meta-analysis aims to highlight the safety and efficacy of PRP injections in thumb CMC OA. A systematic review was completed using Medline, Embase, and Cochrane. Primary outcomes focused on patients with basal thumb osteoarthritis treated with intra-articular PRP injections. Patient characteristics, product administration, functional outcomes and complications were analyzed as means of central tendency. A meta-analysis was performed focusing on pain relief and improvement in hand function. Seven articles were included, comprising 115 patients with an average age of 62.6 years, predominantly female (67.0 %). Patients received an average of 1.4 PRP injections per joint, with an average follow-up of 14.1 months. Control groups were administered corticosteroids, normal saline, and hyaluronic acid. All PRP-treated patients resumed their prior activities of daily living with a satisfaction rate at 73.7 % (n = 76). Statistically significant pain reduction (n = 98) and improvement in pinch strength were reported, while no statistically significant improvement in grip strength was observed (n = 39). No adverse events occurred, with only one complication (a palmar wrist ganglion) reported. Intra-articular PRP injections in thumb CMC OA yields favorable outcomes for pain relief and hand function without major complications. However, procedural and data heterogeneity affect reliability. Further randomized controlled trials comparing PRP and cortisone injections are needed.

An Updated Survey of Trends in the Surgical Management of Thumb Carpometacarpal Arthritis - The Increasing Popularity of the Suture Suspension Arthroplasty

Background: The purpose of this study was to conduct an updated survey of American Society for Surgery of the Hand (ASSH) membership to evaluate current preferences for surgical management of thumb CMC arthritis. Past surveys have demonstrated LRTI to be the most preferred surgical technique. We hypothesised that current surgical preferences for thumb CMC arthritis have changed over the last several years due to rising popularity of high-strength suture implants. Methods: A 22-question survey inquired about the preferences for the surgical management of basal joint arthritis and was sent to the ASSH membership. Descriptive statistics were calculated on all survey questions. Chi-squared analysis was used to compare differences in thumb CMC arthroplasty preferences across respondents. Results: A total of 1,499 responses were available for analysis, yielding a response rate of 29.9%. For surgical management of basal joint arthritis in the primary setting, the largest percentage of respondents preferred open trapeziectomy with suture suspension arthroplasty (39.2%); amongst them, over half (56%) used a high-strength suture implant. This was followed by open trapeziectomy with LRTI (38.3%). In the revision setting, most respondents preferred open trapeziectomy with suture suspension arthroplasty (53.5%), followed by LRTI (24.6%). In determining the choice of procedure, respondents felt some form of metacarpal suspension and implant cost to be more important factors than ligament reconstruction and interposition. A higher proportion of international members (16.2%) utilised implant arthroplasty than US/Canadian members (1.1%; p < 0.01). Conclusions: Past surveys have demonstrated LRTI to be the most preferred surgical technique. The current survey demonstrates open trapeziectomy and suture suspension arthroplasty, especially using high-strength suture implants, gaining popularity amongst surgeons, while open trapeziectomy and LRTI decreasing in preference. Suture suspension arthroplasty is now the preferred surgical technique in both the primary and revision setting. Level of Evidence: Level IV (Therapeutic).

The intermetacarpal distance method for assessment of active thumb radial abduction has excellent test-retest agreement, reliability, and precision in persons with non-operative thumb carpometacarpal osteoarthritis

BACKGROUND

Limitations in thumb radial abduction (i.e., carpometacarpal extension) are commonly experienced by persons with thumb carpometacarpal osteoarthritis. Restoring this deficit is often a focus of surgical and rehabilitative interventions. Because of this, clinical measures of radial abduction are needed. The ''gold-standard'' assessment of thumb radial abduction is goniometry however it has modest reliability in persons with thumb carpometacarpal osteoarthritis. Conversely, the intermetacarpal distance (IMD) method of assessing radial abduction has promising reliability in healthy persons and excellent inter-rater reliability in those with thumb carpometacarpal osteoarthritis. However, to date, there has been no exploration of its test-retest reliability and precision in persons with thumb carpometacarpal osteoarthritis. Further, while multiple trials are often performed in various hand therapy assessments, it is common practice to take a single measurement of hand joint range of motion. Yet, we do not know if multiple trials might enhance the reliability of these range of motion measurements.

PURPOSE

The current study aimed to (1) assess the test-retest agreement, reliability, and precision of the IMD method when measuring thumb radial abduction and (2) compare these psychometric properties when reporting one trial, the mean of two trials, and the mean of three trials of the IMD method in people with thumb carpometacarpal (CMC1) osteoarthritis (OA).

STUDY DESIGN

Prospective Cohort study of test-retest reliability.

METHODS

Purposive sampling was used to recruit adults with radiographically confirmed CMC1 OA. Participants' radial abduction was assessed using the IMD method to measure radial abduction of the affected hand on two separate occasions approximately two weeks apart. Three trials of the assessment were administered at each visit. The Bland Altman method was uses to assess agreement, the intraclass correlation coefficient (ICC2,3) was calculated to examine the reliability, and the standard error of the measurement (SEM), minimum detectable change (MDC) and MDC percentage were calculated to determine the precision of the IMD method for one trial, the mean of two trials, and the mean of three. Descriptive data on demographics and IMD values of the sample were presented.

RESULTS

Forty persons with CMC1 OA participated. The mean difference between trials ranged from 0.21 to 0.30 mm, no significant fixed biases (p≥0.48) or proportional biases (p≥0.41) existed between mean test and retest scores, and 38/40 (95%) of test-retest differences fell within the 95% limits of agreement. The Intraclass Correlation Coefficient (ICC2,3) values were 0.942 (0.893-0.968), 0.970 (0.943-0.984), and 0.970 (0.942-0.984) for 1 trial, the mean of two trials, and then mean of three trials respectively. The ICC value of the mean of two trials was significantly higher than that of 1 trial indicating superior reliability however reliability for each approach fell into the excellent range (i.e., >0.90). The precision of one trial (MDC%=13.0) fell into the acceptable range while the precision of the mean of two (MDC%=9.1) and three trials (MDC%=9.1) fell into the excellent range.

CONCLUSIONS

The IMD method for assessing CMC1 radial abduction has acceptable agreement, excellent test-retest reliability, and acceptable-to-excellent precision when performing one trial, the mean of two or the mean of three trials in persons with CMC1 osteoarthritis. The precision and reliability of the mean of two or three trials were non-superior however the mean of two trials yielded superior reliability and precision to that of a single trial. Changes in IMD measurements of 1.9 mm and 1.4 mm are needed to exceed measurement error when administering one or two trials respectively and change must surpass 5.3 mm and 3.8 mm to exceed clinically meaningful thresholds for one or two trials respectively. We recommend taking the mean of two trials over a single trial when using the IMD method for assessing CMC1 radial abduction in persons with CMC1 OA.

Suture Suspensionplasty Compared With Ligament Reconstruction and Tendon Interposition for Surgical Treatment of Thumb Carpometacarpal Arthritis

Purpose

Thumb carpometacarpal (CMC) arthritis is the most common arthritis of the hand, with most studies demonstrating little difference in outcomes between various surgical treatment techniques. However, trapeziectomy, followed by ligament reconstruction and tendon interposition (LRTI), remains the technique of choice among hand surgeons in the United States. In 2009, suture suspensionplasty (SS) was first described as a less invasive alternative to LRTI. The purpose of this study was to compare surgical details as well as patient-reported and radiographic outcomes between SS and LRTI for thumb CMC arthroplasty.

Methods

Following Institutional Review Board approval, 111 extremities were retrospectively identified in 104 patients who underwent carpometacarpal arthroplasty. Two age-matched cohorts were developed for patients having undergone LRTI (n = 58) or SS (n = 53) by one of three fellowship-trained hand surgeons. Tourniquet times were compared, and outcome measures included first metacarpal scaphoid space (FMSS) measured on 2-week postoperative radiographs, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score and pain score on a 10-point visual analog scale (VAS) from the preoperative visit as well as at 2 weeks, 6 weeks, and 3 months following surgery.

Results

There were no demographic differences between the two cohorts. There was no statistical difference between cohorts in VAS scores at any point in time. The SS cohort reported better QuickDASH scores at the 6-week postoperative visit; otherwise, QuickDASH scores did not differ between cohorts. The SS technique had shorter tourniquet times, and patients had less radiographic subsidence as evidenced by larger postoperative FMSS.

Conclusions

The SS arthroplasty technique demonstrated comparable early clinical results to LRTI. Furthermore, SS arthroplasty, which alleviates the need for tendon transfers and additional incisions with LRTI, had shorter tourniquet time, with less subsidence of the first metacarpal in the first 2 weeks.

Type of study/level of evidence

Therapeutic IV.

[Translated article] Temporary work disability following trapezial resection and suspension arthroplasty for thumb carpometacarpal osteoarthritis

PURPOSE

The aim of this study is to assess the time to return to work (TRW) in patients undergoing trapezial resection using the Mini TightRope® system at our centre and to investigate factors that might delay return to work following this surgery.

MATERIAL AND METHODS

A retrospective study was conducted on patients who underwent Trapezial resection and suspensionplasty using the Mini TightRope® system between 2015 and 2016, with a minimum one-year follow-up. Telephone interviews were conducted along with a review of medical records and radiology reports, as well as temporary work disability documents, collecting epidemiological and occupational data. Groups were compared based on age, gender, dominant hand, biomechanical occupational requirements of the patients, and whether they had experienced prior temporary work disability.

RESULTS

A total of 36 patients (29 women and 7 men) with an average age of 55.7 years were included. The median time to return to work was 126 days. Self-employed workers re-entered the workforce 72 days earlier on average; workers who had experienced prior temporary work disability had a greater total temporary work disability duration and took 91 days longer to return to work compared to those who had not.

CONCLUSIONS

Patients employed by others and those who had experienced prior temporary work disability before the surgery had longer temporary work disability periods. In our study, no differences were observed based on gender, dominant hand, or biomechanical work demands of the intervened patients.

Temporary work disability following trapezial resection and suspension arthroplasty for thumb carpometacarpal osteoarthritis

PURPOSE

The aim of this study is to assess the time to return to work (TRW) in patients undergoing trapezial resection using the Mini TightRope® system at our center and to investigate factors that might delay return to work following this surgery.

MATERIAL AND METHODS

A retrospective study was conducted on patients who underwent Trapezial resection and suspensionplasty using the Mini TightRope® system between 2015 and 2016, with a minimum one-year follow-up. Telephone interviews were conducted along with a review of medical records and radiology reports, as well as temporary work disability documents, collecting epidemiological and occupational data. Groups were compared based on age, gender, dominant hand, biomechanical occupational requirements of the patients, and whether they had experienced prior temporary work disability.

RESULTS

A total of 36 patients (29 women and 7 men) with an average age of 55.7 years were included. The median time to return to work was 126 days. Self-employed workers re-entered the workforce 72 days earlier on average; workers who had experienced prior temporary work disability had a greater total temporary work disability duration and took 91 days longer to return to work compared to those who had not.

CONCLUSIONS

Patients employed by others and those who had experienced prior temporary work disability before the surgery had longer temporary work disability periods. In our study, no differences were observed based on gender, dominant hand, or biomechanical work demands of the intervened patients.

Surgeon preferences in the treatment of thumb carpometacarpal osteoarthritis

BACKGROUND

Primary thumb carpometacarpal (CMC) osteoarthritis is one of the most common conditions encountered by hand surgeons. Of the vast number of operations that have been proposed, none have demonstrated results significantly superior to trapeziectomy alone.

AIM

The purpose of our study was to determine why surgeons opt for their technique in treating CMC arthritis.

METHODS

A cross-sectional survey of active members of the American Society for Surgery of the Hand was conducted to evaluate the reasons behind their preferred technique in the treatment of isolated thumb CMC arthritis. Surgeons were contacted by e-mail once and provided with a link to a de-identified survey consisting of 5 treatment questions and 5 demographic questions.

RESULTS

Of 950 responses were received. 40.5% of surgeons preferred trapeziectomy + ligament reconstruction tendon interposition (LRTI), followed by trapeziectomy + suspensionplasty (28.2%), suture button suspension (5.9 %), trapeziectomy alone (4.6%), prosthetic arthroplasty (3.2%), arthrodesis (1.1%), and other (6.6%). Proponents of trapeziectomy + LRTI cited familiarity (73.2%), exposure during fellowship (48.8%) and less proximal migration (60%) to be the main reasons affecting their decision. Surgeons who preferred trapeziectomy + suspensionplasty most reported simplicity (74.9%), fewer complications (45.3%), less proximal migration (43.8%), and avoidance of autogenous tissue harvest (42.7%). Advocates of suture button suspension cited avoidance of autogenous tissue harvest (80.4%), shorter immobilization (76.8%), and quicker recovery (73.2%) with their technique. Advocates of trapeziectomy alone cited simplicity (97.7%), fewer complications (86.4%), and avoidance of autogenous tissue harvest (59.1%). In their comments, 45% of surgeons choosing trapeziectomy alone cited evidence as an additional rationale. Advocates of prosthetic arthroplasty cited improved pinch strength (83.3%) and improved range of motion (63.3%), while those preferring arthrodesis cited better pinch strength (90%) and frequently in their comments, durability. Of the surgeons who preferred a technique other than LRTI, 41.8% reported they had tried LRTI in the past, citing complexity of the procedure, flexor carpi radialis harvest, and longer operative time as reasons for moving on.

CONCLUSION

Our study provides an update on current treatment trends and offers new insight into the reasons behind surgeons' decision making in the management of thumb carpometacarpal osteoarthritis. Despite strong Level 1 evidence supporting the use of trapeziectomy alone, our findings demonstrate that most surgeons continue to supplement trapeziectomy with other techniques such as LRTI or suspensionplasty. Several factors including familiarity, personal experience (Level 4 evidence), and comfort may be more influential than Level 1 evidence in determining the techniques in a surgeon's armamentarium. Further prospective studies are needed to determine the optimal technique for surgical management of Eaton stages II-IV CMC arthritis and how these studies will affect surgeons' choice.

Reoperation Rate Following Thumb Basal Joint Arthroplasty: A Minimum Follow-Up Period of 5 Years

Purpose

Thumb basal joint arthroplasty (BJA) performed for thumb basal joint arthritis is associated with high patient satisfaction. However, complications requiring reoperation occur, with a previously reported early reoperation rate (within 2 years) of 1.5%. The purpose of this study was to determine the risk of and reasons for reoperation in the intermediate term, defined as within 5 years of the index surgery.

Methods

All cases of primary thumb BJA performed from 2014 to 2016 at a single private academic center were reviewed. For cases requiring reoperation, data regarding index surgical technique, reason for reoperation, time to reoperation, and reoperation technique were collected. Risk of reoperation (return to the operating room for any reason) and risk of revision arthroplasty (revision surgery for symptomatic subsidence or instability) within 5 years of the index surgery were calculated.

Results

A total of 686 primary thumb BJAs were performed in 637 patients. Risk of reoperation for any reason was 2.0% (14/686), and risk of revision arthroplasty for symptomatic subsidence or instability was 0.6% (4/686) within 5 years of surgery. The mean time between the index surgery and reoperation was 10.3 months (range, 16 days to 4.6 years) for all cases; however, for revision arthroplasty, the mean time was 9.6 months (range, 3.9-14.3 months).

Conclusions

The intermediate term (5 years minimum) rate of reoperation following thumb BJA for any reason was 2%, with only approximately one-fourth of reoperation cases requiring revision arthroplasty for symptomatic subsidence or instability. These data may provide useful information in the counseling of patients considering thumb BJA surgery.

Type of study/level of evidence

Prognostic IV.

Optimal Position of the Bone Anchor for the Internal Brace Suspensionplasty Technique for Thumb Basal Joint Arthroplasty

PURPOSE

Ligament reconstruction and tendon interposition is a common technique for thumb basal joint arthroplasty. Recently, a variation of this technique, a suture suspensionplasty, has been introduced. The goal of our study was to assess the optimal position of the bone anchor in the thumb metacarpal. We hypothesized that an anchor placed in the radial aspect of the thumb metacarpal base would provide improved stability and resist subsidence more effectively than an ulnar-based thumb anchor.

METHODS

Eight fresh-frozen cadaver arms were imaged fluoroscopically in anteroposterior and lateral views centered over the thumb carpometacarpal joint before and after trapeziectomy and after the placement of radial-based and ulnar-based bone anchors. The intermetacarpal angle between the thumb and index metacarpals was measured on all images after the application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, and adduction were measured. Subsidence was calculated as the percentage loss of the trapezial space.

RESULTS

Both radially and ulnarly placed internal brace constructs allowed more radial abduction, opposition, and palmar abduction than the pretrapeziectomy constructs. They both also reduced subsidence by approximately 20% to 29% compared with the posttrapeziectomy constructs. Comparing radial to ulnar constructs, motion and subsidence were similar.

CONCLUSIONS

There was immediate stability of the thumb with respect to axial load and subsidence after anchor placement, and this was independent of the anchor position. The position of the bone anchor in the thumb metacarpal base did not affect the range of motion. Although the device can limit subsidence, it does not appear to restrict any range of motion of the thumb, irrespective of anchor position.

CLINICAL RELEVANCE

This cadaver study can help hand surgeons understand the effect of positioning of bone anchors when performing a specific suture suspensionplasty technique.

The Role of the Flexor Carpi Radialis Groove in Trapeziometacarpal Osteoarthritis

BACKGROUND

Thumb carpometacarpal (CMC) osteoarthritis (OA) is a common condition. The contribution of surrounding ligaments and tendons to the stability of the CMC joint is likely altered in OA. The flexor carpi radialis (FCR) tendon runs in the trapezial FCR groove and is often noted to be frayed during CMC arthroplasty. We hypothesized that decreased integrity of the FCR tendon is related to FCR groove morphology and is associated with increased severity of CMC OA.

METHODS

We examined 3-dimensional surface models based on computed tomography (CT) scans of explanted trapezia from patients who underwent thumb CMC arthroplasty. Fraying of the FCR tendon was rated intraoperatively. Measurements were taken of the FCR groove to evaluate its morphology. Preoperative thumb CMC radiographs for each patient were scored using the modified Eaton classification system and the Thumb Osteoarthritis Index. Differences in the tendon groups were examined, and multivariable linear regression models were used to test the association between tendon group and FCR groove measurement.

RESULTS

There were 136 patients who were categorized into 4 tendon groups: intact, minor fraying, fraying, and ruptured. There were no differences between the tendon groups on any measures.

CONCLUSIONS

Our findings do not demonstrate a significant influence of FCR groove morphology on FCR tendon fraying in CMC arthroplasty patients. We also did not find a significant association between the FCR tendon state and degree of radiographic CMC OA. Further studies should investigate the in vivo FCR tendon to evaluate its tearing and inflammation in relation to basilar thumb pain.

Is increased trapezial slope a cause of early trapeziometacarpal osteoarthritis?

OBJECTIVES

Thumb carpometacarpal joint osteoarthritis is one of the most common forms of osteoarthritis in the hand. The underlying causes are multifactorial. We investigated whether increased trapezial slope could be a causal factor.

MATERIAL AND METHODS

We measured trapezial slope and 1st metacarpal slope in 37 patients with early thumb carpometacarpal joint osteoarthritis and compared results with 41 patients without osteoarthritis, using computer-supported 3D-analysis based on CT scans.

RESULTS

There was a significant intergroup difference in trapezial slope (111° in patients with osteoarthritis, and 107° in patients without) and in 1st metacarpal slope (17° versus 14°).

CONCLUSION

Steeper trapezial slope seemed to be a risk factor for thumb carpometacarpal joint osteoarthritis. Therefore, correction of trapezial slope by trapezium osteotomy could be a valuable surgical approach in early thumb carpometacarpal joint osteoarthritis.

Management of Scaphotrapeziotrapezoid Osteoarthritis: A Critical Analysis Review

» The scaphotrapeziotrapezoid (STT) joint is a common location of degenerative osteoarthritis (OA) in the wrist.» STT OA may occur in isolation or with concomitant thumb carpometacarpal joint (CMCJ) OA or scapholunate advanced collapse (SLAC) and other wrist OA patterns.» Nonoperative management strategies include activity modification, bracing, anti-inflammatory medications, occupational therapy, and injections.» Surgical treatment may be determined by whether the STT OA occurs in isolation or with concomitant thumb CMCJ or SLAC OA and includes STT arthrodesis, distal scaphoid excision with or without interposition or implant arthroplasty, trapeziectomy with proximal trapezoid excision, four-corner fusion in combination with scaphoid/radial column excision, and proximal row carpectomy.

Radiographic Thumb Metacarpal Subsidence Following Ligament Reconstruction With Tendon Interposition and Suture-Only Suspension Arthroplasty in the Treatment of Basal Joint Arthritis

BACKGROUND

The thumb carpometacarpal (CMC) joint is a common source of osteoarthritis. Following trapeziectomy, ligament reconstruction with tendon interposition (LRTI) is considered a "gold standard" treatment, but suture-only suspension arthroplasty (SSA) has recently emerged as a simpler alternative. Currently, there is no objective radiographic study comparing subsidence following these 2 techniques.

METHODS

This study is a retrospective review of 23 patients (10 LRTI, 13 SSA) that had at least 6 months of radiographic follow-up following thumb CMC arthroplasty. Posteroanterior radiographs at a preoperative timepoint, and at the 2-week and greater than 6-month postoperative timepoints were evaluated for actual trapezial height, as well as trapezial height normalized to capitate, thumb metacarpal, and proximal phalangeal heights. Normalized trapezial heights were calculated, and preoperative values were compared with greater than 6-month postoperative values. In addition, actual and normalized trapezial heights following LRTI and SSA were compared at each timepoint.

RESULTS

Mean trapezial height decreased from approximately 12 to 5 mm (reduction of ~60%, P < .05) in both groups with no differences when comparing LRTI and SSA at each timepoint. All normalized trapezial heights revealed differences from preoperative to greater than 6-month postoperative timepoints, but no differences between LRTI and SSA.

CONCLUSIONS

Ligament reconstruction with tendon interposition and SSA exhibit equivalent actual and normalized trapezial heights over a greater than 6-month postoperative time course.

Suture suspension sling arthroplasty in thumb carpometacarpal joint arthritis: A case series

INTRODUCTION AND IMPORTANCE

Thumb carpometacarpal (CMC) joint arthritis is the most common condition in older adults and an upper-extremity surgical reconstruction site. Multiple treatments for CMC arthritis have been developed. Among them, suspension sling arthroplasty provides great results without requiring a tendon graft or advanced implants. However, it is rarely used in Indonesia.

CASE PRESENTATION

The modified suture suspension sling arthroplasty technique developed by Arnold Peter C Weiss was performed on three patients with CMC joint arthritis. In this procedure, after trapeziectomy, a nonabsorbable suture is performed to create a hammock between the abductor pollicis longus and flexor carpi radialis tendon to rest the thumb base metacarpal. The rehabilitation protocol was then continued, and the postoperative clinical condition was observed. Three weeks postoperatively, none of the three patients complained of pain. At 3 months postoperatively, there were no signs of infection, and all patients continued the rehabilitation protocol. At 6 months postoperatively, thumb range of motion was excellent, with no sign of infection and an increased DASH score of <5.

CLINICAL DISCUSSION

Multiple treatments for CMC joint arthritis have been described in the literature but the indications and which treatment provides the best results were unclear. Among the various suspension sling methods, trapeziectomy is important for treating CMC joint arthritis.

CONCLUSION

Suture suspension arthroplasty for treating thumb CMC joint arthritis achieved excellent clinical results and has several advantages, including shorter surgical time, no additional incision, reduced cost, no tendon harvesting, and implant fixation.

Periosteal Dry Needling for Carpometacarpal Osteoarthritis: A Prospective Case Series

BACKGROUND

Carpometacarpal (CMC) osteoarthritis (OA) of the thumb is a painful condition that affects over 15% of individuals above the age of 30 and up to 30% of post-menopausal women. Dry needling (DN) has been found to reduce pain and disability in a variety of neuromusculoskeletal conditions; however, DN in the management of CMC OA has not been well studied.

METHODS

Consecutive patients with clinical and radiographic evidence of CMC OA were treated with DN. The primary outcome measure was pain using the Numerical Pain Rating Scale (NPRS) at 12 weeks. Secondary outcome measures were the Upper Extremity Functional Index (UEFI-20) and the Global Rating of Change (GROC) scale. Outcome measures were collected at baseline, 4 weeks, 8 weeks, and 12 weeks.

RESULTS

Nine patients were treated for six sessions of periosteal DN over 3 weeks. Compared to baseline, statistically significant and clinically meaningful improvements were observed in thumb pain (NPRS mean difference: 2.6; p = 0.029) and function (UEFI-20 mean difference: 21.3; p = 0.012) at 12 weeks.

CONCLUSION

Statistically significant and clinically meaningful within-group improvements in thumb pain and function were observed at 12 weeks following six sessions of periosteal DN treatment. DN may be a useful intervention in the management of patients with CMC OA of the thumb.

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.

Discrepancy between Radiographic and Arthroscopic Findings of Thumb Basilar Joint Arthritis: A Preliminary Clinical Report

The radiographic staging of arthritic changes in the thumb carpometacarpal (CMC) joint is known to have poor correlation with pain level. This may be due to the limited ability of radiographs to evaluate degenerative changes. The purpose of this study was to examine the relationship between radiographic versus arthroscopic findings of thumb CMC and scaphotrapeziotrapezoidal (STT) joint arthritis.

Methods

Twenty patients with symptomatic thumb CMC arthritis underwent arthroscopy of thumb CMC and STT joints with concomitant synovectomy or arthroplasty depending on the degree of articular degeneration found. All patients had preoperative radiographs of the thumb CMC and STT joints. Radiographic degeneration was graded based on the Eaton-Glickel classification. Intraoperative arthroscopic images were reviewed and graded based on the Brown grading system.

Results

At the thumb CMC joint, five patients had discordant radiographic and arthroscopic findings of arthritis. At the STT joint, one patient had discordant radiographic and arthroscopic findings of arthritis.

Conclusions

In comparing the two staging systems, we found a small subset of patients that demonstrated significant discrepancies. Clinical evaluation remains essential, and patients should be informed that radiographs may underestimate the actual severity of arthritis.

Dynamic stabilization home exercise program for treatment of thumb carpometacarpal osteoarthritis: A prospective randomized control trial

STUDY DESIGN

Randomized control trial.

INTRODUCTION

Thumb carpometacarpal (CMC) osteoarthritis (OA) is a common cause of hand pain and disability. Standard conservative therapy (SCT) for thumb CMC OA includes an orthosis and instruction in joint protection, adaptive equipment, and pain relieving modalities. The dynamic stability home exercise (HE) program is complementary conservative therapy designed to strengthen the stabilizing muscles of the thumb CMC.

PURPOSE OF THE STUDY

To investigate whether the addition of HE to SCT (SCT+HE) was more effective at reducing pain and disability in thumb CMC OA compared to SCT alone.

METHODS

The study compared 2 groups: SCT and SCT+HE. The SCT group received SCT with in-home pain management instructions, joint protection strategies with adaptive equipment, and a hand-based thumb-spica orthosis. The SCT+HE group received HE program instructions for adductor stretching and opponens and first dorsal interosseous strengthening in addition to SCT. Our primary outcome measure was the numerical rating scale (NRS) with secondary outcome measures of QuickDASH (shortened Disabilities of the Arm, Shoulder and Hand questionnaire), range of motion, grip strength, and pinch strength. Outcome measurements were assessed at first visit, 6 weeks, and 6 months.

RESULTS

There was no statistical difference between the 2 groups for NRS and QuickDASH at 6 weeks (P = .28 and P = .36, respectively) or 6 months (P = .52 and P = .97, respectively). However, there was a statistically significant decrease in NRS and QuickDASH scores at 6 weeks and 6 months within both groups.

CONCLUSIONS

Both SCT and SCT+HE are effective at reducing pain and disability in OA of the thumb CMC joint. Neither therapy program was superior to the other at improving NRS or QuickDASH scores at 6-week or 6-month follow-up.

Characterizing response to a dynamic stability modeled approach for thumb carpometacarpal joint pain: A retrospective study

STUDY DESIGN

Retrospective case series.

INTRODUCTION

Literature trends indicate that thumb dynamic stabilization may benefit clients with thumb carpometacarpal (CMC) joint pain and arthritis. There is minimal research investigating whether client characteristics predict responsiveness to hand therapy for thumb dynamic stabilization.

PURPOSE OF THE STUDY

1) To investigate how adults with thumb CMC joint pain responded to a hand therapy dynamic stabilization modeled intervention. 2) To determine if various client factors influenced responsiveness and to what extent.

METHODS

An electronic medical record search identified adults treated from August 2009 through December 2015 for thumb CMC joint pain. Radiographs were retrospectively staged. Outcome measures were 1) Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) total disability score and 2) Numerical Pain Rating Scale (NPRS). Paired t-tests were performed to compare pre and post treatment measures. Multivariate analyses were used to investigate predictive factors.

RESULTS

A total of 249 charts were analyzed. Large overall significant effects were noted for disability score (QuickDASH P <.001, X = 12.1, Cohen's d = 0.9). The average improvement of 2.1 (SD = 2.6) points exceeded the minimal clinically important difference (MCID) of 1.7 points on the NPRS pain scale. Significant predictors of QuickDASH Scores were radiographic staging, bilateral hand involvement and initial pain ratings. Significant predictors for change in pain scores (meeting or exceeding the minimal clinically important difference for the NPRS) were bilateral thumb involvement and initial "pain at worst" rating.

CONCLUSION

After completing hand therapy with a dynamic stabilization approach, clients had less pain and disability. Those who had unilateral thumb pain, or those who started with higher pain levels were most likely to have clinically meaningful improvements in pain. Clients in early CMC osteoarthritis (OA) stages responded better than those in later stages, indicating that early referral to therapy is important.

Evaluation of the PROMIS Upper Extremity Against Validated Patient-Reported Outcomes in Patients With Early Carpometacarpal Osteoarthritis

PURPOSE

Internal consistency, construct, and criterion validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) v1.2 were evaluated in patients with early-stage carpometacarpal (CMC) osteoarthritis (OA). We hypothesized that in patients with early CMC OA, PROMIS UE scores would: (1) be lower than those in asymptomatic controls; (2) correlate with established patient-reported outcomes; (3) correlate with pinch and grip strengths; and (4) not correlate with radiographic disease progression.

METHODS

Patients with early CMC OA (modified Eaton stage 0 or 1) and matched asymptomatic control patients completed the PROMIS UE, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation at 2 time points. The PROMIS UE's internal consistency was evaluated by Cronbach's alpha, construct validity by Spearman correlation coefficients among the patient-reported outcome measures, and criterion validity using measures of strength. A floor or ceiling effect was indicated if more than 15% of patients achieved the lowest or highest possible score.

RESULTS

The PROMIS UE had high internal consistency. Patients with early CMC OA had a lower score than healthy controls (average, 42 vs 54, respectively). We observed moderate to high correlations between the PROMIS UEv1.2, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation and good criterion validity when compared to key pinch and grip strengths. The PROMIS UE did not correlate to radiographic disease severity.

CONCLUSIONS

The PROMIS UE had a high correlation with Australian and Canadian Osteoarthritis Hand Index and a moderate correlation with Patient-Rated Wrist-Hand Evaluation. The PROMIS UE had high internal consistency and good criterion validity.

CLINICAL RELEVANCE

The PROMIS UE is a valid assessment for disability in patients with early CMC OA and can serve as a clinical adjunct to an outcome assessment.

Lessons Learned: Trapeziectomy and Suture Suspension Arthroplasty for Thumb Carpometacarpal Osteoarthritis

In this study, we describe refinements of an accepted technique made by a single surgeon for trapeziectomy and suture suspension arthroplasty for thumb carpometacarpal (CMC) osteoarthritis after 220 cases over 4 years. Results are derived from 77 patients who underwent treatment using this technique comparing postoperative results with preoperative assessment and had sufficient data for inclusion. The surgical technique is described, including tips and modifications to avoid known possible complications. All patients in this study had advanced Eaton stage III or IV osteoarthritis. Grip strength and key pinch showed statistically significant improvement, and the improvement in palmar pinch approached significance. Pain scores were significantly decreased with over 50% of the patients rating their pain at 0 postoperatively. The overall complication rate was very low, and improvements in technique were made to mitigate future occurrence. This surgical technique for the treatment of thumb CMC arthritis achieved pain relief and recreated ligamentous support of the base of the first metacarpal to resist proximal migration after trapeziectomy, providing an increase in grip strength and key pinch with return of range of motion early in the postoperative period. Refinements on this technique through a large volume single surgeon experience provide technical tips for optimizing outcomes.

Dynamic stabilization of the painful thumb: A historical and evidence-informed synthesis

STUDY DESIGN

Expert opinion INTRODUCTION: Thumb carpometacarpal joint (CMC) osteoarthritis is a common condition seen in the hand therapy clinic. Prevalence is generally higher in females, and the percentage rises for post-menopausal females. Patients typically present with pain and functional difficulties. Conservative management is recommended before a surgical consult. Evidence is mounting that a dynamic stability modeled approach has a significant effect on pain and improving function.

PURPOSE

The purpose of this paper is two-fold: first, to present the history and development of a dynamic stabilization model for treatment of the patient with thumb CMC osteoarthritis (OA), and second, to provide expert clinical commentary and recommendations for the treatment of thumb CMC OA in light of the best available evidence.

METHODS

Expert clinical commentary is based on an extensive review of relevant literature.

RESULTS

The current literature and expert opinion supports an evidence-informed multimodal intervention: modalities, pain relief techniques, manual release, joint mobilizations as deemed necessary, neuromuscular re-education through proprioceptive exercises, and education in joint protection principles.

CONCLUSION

A rationale for a dynamic stabilization approach is presented. The unique anatomy of the thumb deserves finely tuned care based on high quality research. To advance our knowledge and clinical skills we must not become stagnant, but continue to generate high level evidence. The standard for future thumb CMC OA studies should be well-defined intervention parameters, consistent documentation, and the use of appropriate patient-rated outcome measures.

Outcomes of Secondary Trapeziectomy Following Carpometacarpal Pyrocarbon Prosthetic Arthroplasty

PURPOSE

Pyrocarbon implant hemiarthroplasty is a treatment option for select patients with trapeziometacarpal joint arthritis. The long-term revision rates after implant arthroplasty can be as high as 30%. Revision to trapeziectomy has been described for patients who require implant removal; however, few studies have assessed outcomes in patients in this subgroup.

METHODS

This was a retrospective review of patients who underwent the conversion of a pyrocarbon carpometacarpal implant to trapeziectomy and suspensionplasty from 2003 to 2019. Patients who met the criteria were then compared with a matched cohort who underwent primary trapeziectomy and suspensionplasty. Patients were matched based on the revision procedure, age, and duration of follow-up. Data regarding demographic information, range of motion, grip and pinch strengths, and the need for subsequent procedures were collected.

RESULTS

Twenty-five patients underwent the removal of their pyrocarbon carpometacarpal implant. The patients underwent revision to Thompson suspensionplasty (n = 14), the Weilby procedure (n = 5), ligament reconstruction tendon interposition (n = 2), or a suture-based suspension procedure (n = 4). The age, sex, and preoperative range of motion and strength measures were similar between the 2 groups. All the patients complained of moderate-to-severe pain prior to surgery, which improved in both groups after surgery. Patients who underwent the removal of a pyrocarbon arthroplasty implant lost 6.4° of palmar abduction after surgery. The postoperative grip, opposition strength, apposition pinch strength, and radial and palmar abduction were similar between the 2 groups.

CONCLUSIONS

The removal of a pyrocarbon carpometacarpal implant using subsequent trapeziectomy successfully relieves pain in patients in whom pyrocarbon arthroplasty has failed. After revision, patients may lose abduction motion but have similar strength compared with those who undergo primary trapeziectomy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Diagnosis and Treatment of Carpometacarpal Instability

Hypermobility of the first CMC joint may adversely affect hand function and may lead to osteoarthritis later in life. It presents more commonly in younger women with generalized joint hypermobility or postmenopausal women with early stages of arthritis. It may follow trauma and deletive surgical interventions. Clinically, joint subluxation manifests with a prominent and unstable thumb base, and is radiographically confirmed by stress views. A variety of ligament reconstruction techniques are available to stabilize the CMC joint including open ligament reconstruction with or without temporary Kirschner-wire fixation, arthroscopic debridement with capsular shrinkage, metacarpal extension osteotomy, internal proprietary anchors, and arthrodesis.

Combined Treatment of Trapeziometacarpal Joint Arthritis and Scapholunate Advanced Collapse Wrist

PURPOSE

The combined treatment of trapeziometacarpal joint arthritis and scapholunate advanced collapse (SLAC) wrist presents unique challenges. The consequences of the loss of radial column support caused by scaphoidectomy and trapeziectomy are not well known. The purpose of this study was to evaluate the outcomes of the simultaneous and staged treatment of trapeziometacarpal joint arthritis and SLAC wrist.

METHODS

A retrospective review of patients who underwent surgery for both trapeziometacarpal joint arthritis and SLAC wrist was performed. The wrist and thumb range of motion; grip and pinch strength; pain; quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; and radiographs were analyzed.

RESULTS

Twenty-four patients who underwent both trapeziectomy and 1 of 3 procedures for SLAC wrist (4-corner fusion [n = 10]), proximal row carpectomy [n = 9], and total wrist arthroplasty [n = 5]) in a single stage (n = 10) or in 2 stages (n = 14) were included. The median age was 63 years. The median follow-up period was 35 months. Twelve (50%) patients underwent complete scaphoidectomy, and 12 (50%) patients underwent partial scaphoidectomy. All 3 procedures resulted in an improvement in pain at rest, pain during activity, and quick Disabilities of the Arm, Shoulder and Hand scores. The final range of motion, grip and pinch strength, and complication rates were consistent with those reported in the literature for isolated procedures.

CONCLUSIONS

Trapeziometacarpal joint arthritis and SLAC wrist may be treated either simultaneously or in stages.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Selective Thumb Carpometacarpal Joint Denervation for Painful Arthritis: Follow-Up of Long-Term Clinical Outcomes

Purpose

Thumb carpometacarpal (CMC) joint osteoarthritis is a common problem affecting up to 85% of patients over the age of 70. The most common presenting symptom for patients with CMC arthritis is pain with joint loading. Loss of function due to subluxation or joint destruction is comparatively rare. Carpometacarpal joint denervation is a relatively novel method for managing CMC arthritis, treating the most impactful symptom: pain.

Methods

In this paper, we present a 4- to 6-year follow-up case series on patients who underwent CMC denervation between 2015 and 2017.

Results

Denervation was safe, with less downtime than trapeziectomy with ligament reconstruction with tendon interposition and provided durable complete or partial relief of pain after 5 years in 5 of 9 patients. Four of 9 patients had recurrence of pain by 5 years. Of those with recurrent pain, 3 of 5 eventually underwent trapeziectomy with ligament reconstruction and tendon interposition; the secondary surgery occurred between 17 and 66 months after denervation.

Conclusion

Thumb CMC denervation provides effective relief of arthritis pain that was durable at 5+ years after surgery in more than half of our initial cohort of patients treated. Prospective studies with validated patient-reported and objective outcome measures between distinct treatment arms, such as denervation versus ligament reconstruction with tendon interposition, are needed to firmly establish the role of CMC denervation for patients with symptomatic thumb CMC osteoarthritis.

Type of study/level of evidence

Therapeutic/Level IV.

The Association of AUSCAN and PRWHE Patient-reported Outcome Measures With Radiographic Progression of Early Thumb Carpometacarpal Arthritis at 36-Month Follow-up Is Limited to Subtle Changes in the Pain Subscale

BACKGROUND

There is a paucity of literature that examines how patient-reported outcomes correspond to early radiographic progression of thumb carpometacarpal (CMC) osteoarthritis (OA). This study examines how Australian/Canadian Osteoarthritis Hand Index (AUSCAN) and Patient-Rated Hand and Wrist Evaluation (PRWHE) scores change over 36 months in subjects with early CMC OA.

METHODS

Ninety-one subjects with symptomatic early thumb CMC OA were enrolled. Differences in AUSCAN and PRWHE scores were measured between subjects at baseline and at 18-month follow-up, and between the subjects at baseline and at 36-month follow-up. Radiographic progression was defined as an increase in modified Eaton Stage. Differences in AUSCAN and PRWHE scores were compared between these 2 groups in order to determine if radiographic progression was associated with a greater change in AUSCAN and PRWHE at 18- and 36-month follow-up.

RESULTS

At 18- and 36-month follow-up visits, there were no significant differences in AUSCAN or PRWHE compared to baseline. Multivariable logistic regression analysis did not reveal any significant differences between subjects with radiographic progression to subjects without radiographic progression at 18-month follow-up. At 36-month follow-up, this analysis did demonstrate that subjects with evidence of radiographic progression had a significant increase in the PRWHE pain subscale.

CONCLUSION

AUSCAN and PRWHE scores were not found to significantly progress at 18-month and 36-month follow-up. However, when comparing the subset of subjects with and without radiographic OA, subjects with early CMC OA who had 1 stage of radiographic progression were found to have a significantly higher intensity of pain on the PRWHE pain subscale at 36-month follow-up.

Responsiveness of different pain measures and recall periods in people undergoing surgery after a period of splinting for basal thumb joint osteoarthritis

Background

Basal thumb joint osteoarthritis (OA) is a common painful condition of the hand often treated surgically if non-operative care does not provide sufficient pain relief. Many instruments are available to measure pain for this condition including single item and multidimensional measures. To inform our choice of instrument for the purpose of evaluating the value of surgery for people with thumb OA, the aim of this study was to compare the longitudinal validity and signal to noise ratio of a single item numeric rating scale (NRS) for pain and the Patient-rated Wrist and Hand Evaluation (PRWHE) pain subscale, and to assess if recall period affects longitudinal validity of the NRS pain and reported pain levels.

Methods

We invited 52 patients referred for surgical treatment of basal thumb joint OA to participate in this study. All wore a splint for six weeks followed by surgery. Pain during the past day, week, and month and the PRWHE were collected at baseline, operation day, and 3, 6, 9 and 12 months after surgery. Responsiveness was assessed with two methods: 1) using participant-reported global improvement and PRWHE function subscale as external anchors (longitudinal validity) and 2) comparing Standardized Response Means (SRM).

Results

The Spearman’s ρ between PRWHE pain and participant-reported global improvement was better (0.71) compared with NRS past day (0.55), past week (0.62), or past month (0.59). Similar findings were found with PRWHE function as anchor (Pearson’s r for PRWHE pain 0.78; NRS past day 0.68; past week 0.73; past month 0.69). The SRM of PRWHE pain subscale (2.8) and NRS past week (2.9) outperformed pain past day (2.3) and month (2.4). Mean pain was 0.3 points (on a 0 to 10 scale) worse during past week when compared with past day and 0.3 worse during past month than during past week.

Conclusions

All studied pain measures captured the change in pain over time. For clinical trials, we recommend PRWHE pain subscale or NRS past week due to their better signal noise ratio.

Trial registration

Retrospectively registered.

First Carpometacarpal Joint Anatomy and Osteoarthritis: MR Imaging Overview

The first carpometacarpal (CMC) joint consists of seven ligaments. The magnetic resonance imaging (MRI) examination of the first CMC joint should be performed in a high field 1.5/3 T MRI with a dedicated hand coil for high-resolution images. Degeneration of anterior oblique ligament (AOL) is the most important cause for the development of osteoarthritis of first CMC joint. Since the AOL undergoes a predictable pattern of alteration at its metacarpal attachment as degeneration proceeds, MRI imaging can provide an accurate assessment of this ligament.

Arthrodesis Versus Arthroplasty in Thumb Carpometacarpal Osteoarthritis: Impact on Maximal Voluntary Force, Endurance, and Accuracy of Pinch

PURPOSE

To investigate differences in pinch strength recovery among patients with first carpometacarpal joint osteoarthritis treated with either arthrodesis or suspension arthroplasty.

METHODS

Thirty-seven subjects who underwent arthrodesis or suspension arthroplasty for carpometacarpal osteoarthritis were included. Force exerted during maximal voluntary contraction (MVC) in a pinch task was measured. Maximal voluntary contraction was recorded using a haptic device equipped with a load cell from which an analog signal was acquired and digitized for visual feedback. Dynamic force was assessed by a task consisting of 10 repetitions, with a target of 70% of MVC. Endurance was assessed by the length of sustained pinch task at 30% of MVC. Task performance was quantified by mean distance and offset error from the target force as error indices, and standard deviation of force was used as index of force steadiness.

RESULTS

The arthrodesis group obtained considerably higher MVC values than the arthroplasty group. No notable differences were found for pinch endurance. The standard deviation for dynamic force was lower for arthroplasty, indicating greater force steadiness.

CONCLUSIONS

Arthrodesis is associated with greater pinch strength. Arthroplasty is associated with better pinch precision.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Precision of the Wilson corrective osteotomy of the first metacarpal base using specific planning and instruments for treatment of basal thumb arthritis

INTRODUCTION

Arthritis of the basal thumb is a relatively common condition also affecting younger patients. Wilson et al. described a 20°-30° closing wedge osteotomy of the first metacarpal bone to unload the trapeziometacarpal joint. It was the purpose of this study to analyze the clinical and radiographic outcome of patients who underwent proximal extension osteotomy of the first metacarpal bone using patient-specific planning and instruments (PSI).

METHODS

All patients who underwent proximal metacarpal osteotomy for basal thumb arthritis at our tertiary referral center were retrospectively included. The patients underwent preoperative planning using computed tomography and 3D segmentation to build patient-specific guides and instruments for the operative treatment. Stable fixation of the osteotomy was achieved by internal plating. The inclusion criterion was a minimum follow-up of 1 year with clinical examination, including the Michigan Hand Outcomes Questionnaire (MHQ), and computed tomography to validate the correction. Complications and reinterventions were recorded.

RESULTS

A total of eight Wilson osteotomies in six patients could be included at a mean follow-up duration of 33±16 months (range, 12 to 55 months). The patients were 49±8 years (range, 36 to 58 years) at the surgery and 88% were female. The postoperative MHQ for general hand function was 77±8 (range, 45 to 100) and the MHQ for satisfaction was 77±28 (range, 17 to 100). The working status was unchanged in 7/8 hands (6/7 patients). Radiographic analysis revealed successful correction in all cases with unchanged Eaton-Littler stage in 7/8 hands. No complications were recorded.

CONCLUSION

The combined extending and ulnar adducting osteotomy using patient-specific guides and instrumentation provides an accurate treatment for early-stage thumb arthritis.

LEVEL OF EVIDENCE

Type IV-retrospective, therapeutic study.

A Modified Suture Suspension Arthroplasty Technique for the Treatment of Basal Joint Arthritis: Short- to Intermediate-Term Outcomes

Background: To present a retrospective study on the outcomes of a modified version of suture suspension arthroplasty with trapeziectomy on patients with thumb basal joint arthritis and to evaluate the relationship between the degree of subsidence and functional outcome. Methods: We performed a chart review on 67 patients (75 thumbs) who were surgically treated for thumb carpometacarpal osteoarthritis with trapeziectomy and suture suspension arthroplasty from May 2010 to May 2016. Outcome measures included Disabilities of the Arm, Shoulder and Hand (DASH), grip strength, lateral/precision pinch strength, range of motion, and return to work/resumption of usual activities. Radiographic images were used to measure first metacarpal subsidence into the trapezial space. Results: Clinical outcomes were satisfactory, showing an initial postoperative DASH score of 45.94, which decreased to 27.93 at 6 months postoperatively and to 19.69 at 1 year postoperatively. Radiographic images revealed a mean first metacarpal subsidence of 39% compared with the preoperative images. Grip and pinch strengths showed steady improvement from initial postoperative to final follow-up visits, resulting in 90% recovery of gross grasp, 77% recovery of lateral pinch, and 79% recovery of precision pinch compared with the contralateral side. Conclusions: Our study has found that suture suspension arthroplasty with trapeziectomy is an effective treatment for thumb basal joint arthritis. Suture suspension arthroplasty allows for short immobilization time, avoids tendon sacrifice, avoids anchor use, and leaves a cosmetically appealing scar. Furthermore, a relationship of any significance between postoperative first metacarpal subsidence and functional outcomes does not appear.

Engaging Patients to Ask More Questions: What's the Best Way? A Pragmatic Randomized Controlled Trial

PURPOSE

Hand conditions are common, and often require a discussion of the tradeoffs of different treatment options. Our goal was to evaluate whether providing patients with a Question Prompt List (QPL) for common hand conditions improves their perceived involvement in care compared with providing patients with 3 generic questions.

METHODS

We performed a prospective, single-center, pragmatic randomized controlled trial. We created a QPL pamphlet for patients with common hand conditions. New patients with common hand conditions were enrolled between April 2019 and July 2019 and were randomized into either the QPL group (with 35 hand-specific questions) or the AskShareKnow group (3 generic questions: [1] What are my options? [2] What are the possible benefits and harms of those options? [3] How likely are each of these benefit and harms to happen to me?). Both groups received the questions prior to meeting with their surgeon. We used the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient participation in decision-making, as our primary outcome. The maximum PICS score is 13, and a higher score indicates higher perceived involvement.

RESULTS

One hundred twenty-six patients participated in the study, with 63 patients in the QPL group and 63 patients in the AskShareKnow group. The demographic characteristics were similar in the 2 groups. The mean AskShareKnow group PICS score was 8.3 ± 2.2 and the mean QPL PICS score was 7.5 ± 2.8, which was not deemed clinically significant.

CONCLUSIONS

The QPLs do not increase perceived involvement in care in patients with hand conditions compared with providing patients with 3 generic questions.

CLINICAL RELEVANCE

Various approaches have been evaluated to help improve patient involvement in their care. In hand surgery, 3 generic questions were no different than a lengthy QPL with respect to patient involvement in their care.

What Are the Patient-reported Outcomes of Trapeziectomy and Tendon Suspension at Long-term Follow-up?

BACKGROUND

There are multiple options for the treatment of thumb carpometacarpal joint osteoarthritis (CMC1 OA), with evidence for pain relief and improved function. Although simple trapeziectomy has the lowest complication risk, tendon suspension of the first metacarpal and interposition is still the most commonly used surgical procedure in patients with CMC1 OA. Although there are several reports of good short-term results after trapeziectomy and tendon suspension-interposition arthroplasty, few studies have evaluated long-term outcomes. This study is one of the largest and longest follow-up evaluations of a cohort of patients with CMC1 OA who were treated with trapeziectomy and suspension-interposition arthroplasty, capturing 96% of the original cohort for evaluation.

QUESTIONS/PURPOSES

(1) After trapeziectomy and tendon suspension surgery, what are the long-term, patient-reported outcomes and clinical measurements (strength and ROM); and in unilateral procedures, how do these parameters compare with those of the contralateral hand that was not operated on? (2) What is the mean subsidence (unloaded trapezial space), and does pinch strength correlate with the amount of subsidence?

METHODS

From 1998 to 2005, 130 patients underwent trapeziectomy and abductor pollicis longus (APL) suspension-interposition arthroplasty for CMC1 OA at one orthopaedic department. During this period, 15 patients were treated with CMC1 arthrodesis and four were treated with implant arthroplasty, for a total of 149 patients. The surgeons used APL suspensionplasty for most patients, based on age and expected postoperative function; they also employed this procedure to avoid hardware or implant failure issues. The 100 living patients were asked to participate in this retrospective study, 96% (96) of whom were enrolled. The mean age at surgery was 58 ± 7 years. The patients completed a two-item thumb pain scale (modified from the SF-36 body pain scale), a hand pain VAS (average level of pain experienced over the week preceding measurement), and the 11-item QuickDASH. Patient-reported outcomes data were obtained from all 96 patients, and 83% (80) of patients underwent bilateral hand radiography and a physical examination at a mean follow-up of 17 ± 2.4 years. We calculated outcome data for each patient, and in 39 patients with unilateral surgery and intact contralateral CMC1 joint, we compared the operated side with the contralateral side. We compared our outcome data with that from the Swedish National Quality Registry for Hand Surgery (HAKIR), noting comparable outcomes for pain and QuickDASH scores.

RESULTS

At long-term follow-up after trapeziectomy and APL suspension surgery, the mean thumb pain score was 19 ± 26, hand pain VAS score 23 ± 25, and QuickDASH score 26 ± 21. In the patients with unilateral surgery and intact contralateral CMC1 joint, the thumb pain score for the operated side was lower than the contralateral side, specifically 19 ± 25 compared with 29 ± 30 (mean difference -9.8 [95% CI -19.5 to -0.2]; p = 0.045); hand pain VAS score was 24 ± 23 versus 30 ± 25 (mean difference -6.1 [95% CI -15.2 to 3.1]; p = 0.19), and the QuickDASH score was 27 ± 19. Grip strength showed no differences between the operated and contralateral sides (mean 16.7 ± 7.3 kg versus 16.6 ± 6.9 kg, mean difference 0.1 [95% CI -1.6 to 1.8]; p = 0.90), while pinch was different (4.4 ± 1.4 versus 5.0 ± 1.5 kg, mean difference -0.6 [95% CI -0.9 to -0.3]; p = 0.001). The mean trapezial space was 4.4 ± 2.2 mm, and there was no association between the trapezial space and pinch strength (0.07 kg [95% CI -0.04 to 0.18] per mm of space; p = 0.17).

CONCLUSION

The finding of comparable pain and function between operated and unoperated sides at long-term follow-up suggests that trapeziectomy and tendon suspension-interposition arthroplasty provides predictable outcomes, and surgeons can use these data to counsel patients that surgery can potentially return them to comparable use. However, as patients often have asymptomatic radiographic OA on the contralateral side, future studies are needed to examine the impact of asymptomatic disease on function.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Thumb Carpometacarpal Joint Pathoanatomy-A Computed Tomography-Based Study

Background  Thumb carpometacarpal joint (CMCJ) osteoarthritis is common and can lead to significant morbidity making it a condition frequently treated by hand surgeons when initial conservative measures fail. The surrounding ligamentous structures are complex and important to maintain thumb CMCJ stability. Objectives  The aim of this study was to review the normal and arthritic anatomy of the thumb CMCJ, focusing on morphology and position of osteophytes and the gap between metacarpal bases, and the effect of these on intermetacarpal ligament integrity. This may be the sole ligament suspending the first metacarpal following trapeziectomy and could determine the need for further stabilization during surgery, avoiding potential future failures. Methods  Computed tomography (CT) scans of a normal cohort and those with arthritic changes who had undergone trapeziectomy following the scan were identified. The three-dimensional reconstructions were examined for osteophyte position on the saddle and the intermetacarpal distance. Results  A total of 55 patients, 30 normal and 25 arthritic, were identified and studied. The most common anatomic position for osteophytes was the intermetacarpal ulnar aspect of the trapezium. The intermetacarpal distance increased by an average of 2.1 mm in the presence of the arthritic process. Conclusions  The findings point to an increase in the intermetacarpal distance, and hence lengthening of the ligament with potential damage, possibly secondary to osteophyte formation and wear. Further prospective research is required to determine whether using preoperative CT scanning to define osteophyte position and measure the intermetacarpal distance would predict probable damage to the ligament, hence providing an indication for stabilization and reconstruction in trapeziectomy surgery. Level of Evidence  This is a Level III, retrospective cohort study.

Farrerol ameliorate adjuvant-induced ankle injury via alteration of PPAR-γ signal pathway

This study evaluated the anti-inflammatory activity against lipopolysaccharide (LPS)-mediated mouse macrophages (in vitro) and assessed the protective effect of farrerol on arthritis caused by complete freund adjuvant (CFA) in rats. For the evaluation of the pharmacological effect of farrerol on the activity of nitric oxide (NO) and cyclooxygenase, pro-inflammatory cytokines including interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and interleukin-1β, RAW 264.7 cells were used. A 0.1 ml CFA was injected subcutaneously for the induction of arthritis. The paw volume, body weight and arthritic score were estimated at regular intervals. Pro-inflammatory cytokines, inflammatory mediators, and antioxidant parameters were also estimated. Farrerol suppressed NO production and COX-catalyzed prostaglandin (PGE₂ ) in RAW 264.7. Farrerol also downregulated the p-p65, p-IκBα expression and upregulated the PPAR-γ expression in RAW 264.7 cells. Treatment of farrerol increased body weight substantially, and reduced paw edema and arthritic score. Farrerol treatment also significantly improved the level of hemoglobin (Hb), count of red blood cells (RBC), and decreased the rate of erythrocyte sedimentation (ESR), white blood cell (WBC) parameters, while the generation of pro-inflammatory cytokines inhibited. Together, farrerol also suppressed the pro-inflammatory cytokines TNF-α, IL-6, and IL-1β. Obtained results directed that the farrerol exerted its therapeutic effect against CFA-induced arthritic rats through anti-inflammatory mechanism by regulation of the PPAR-γ. PRACTICAL APPLICATIONS: Increase the arthritis disease worldwide day-by-day. The current research study showed the anti-arthritic effect of farrerol (flavonoid phytoconstituent) of Rhododendron dauricum Linn. In this study, farrerol considerably inhibited the NF-κB to show the anti-arthritic effect. The finding showed the potential effect against acute and chronic inflammation via inhibition of inflammatory mediators and oxidative stress. The result suggests the anti-inflammatory and antioxidant effect of farrerol. On the basis of result, we can say that farrerol can be the beneficial drug to treat the arthritis.

Determining Isolated Thumb Forces in Osteoarthritic and Healthy Persons

Carpometacarpal (CMC) osteoarthritis (OA) can dramatically impair thumb function resulting in the inability to complete basic tasks. Development of a method to detect thumb forces changes is essential to understand of the progression of carpometacarpal osteoarthritis and the effects of treatment. The goals of this study were to (1) develop a method to measure thumb forces in multiple directions, (2) perform an initial demonstration of this method on three populations, young healthy (YH), older healthy (OH), and older participants with carpometacarpal osteoarthritis, and (3) determine the effects of short-term exercises on thumb force production in these pilot groups. A multi-axis load cell with a custom-built apparatus and a hand grip dynamometer were used to measure thumb and grip forces. Forces were collected in four directions: radial abduction and adduction, and palmar abduction and adduction. All participants completed thumb and grip testing prior to (week 0), during (week 2), and following (week 6), a hand exercise regimen. Group differences and the effects of exercise on force production were determined. Hand exercises improved thumb forces in young healthy female participants during radial (p = 0.017) and palmar abduction (p = 0.031) and female participants with osteoarthritis during palmar abduction (p = 0.010). Exercise improved grip strength in young healthy males (p = 0.028), young healthy females (p = 0.041), and females with osteoarthritis (p = 0.027). This research demonstrates the successful use of a new device to determine isolated thumb forces, and its clinical utility to identify changes after a short exercise regimen.

Thumb Carpometacarpal Suspension Arthroplasty With Flexor Carpi Radialis Ligament Reconstruction and Tendon Interposition Using An Absorbable Interference Screw: A Volar Approach Technique

The goal of operative intervention for pantrapezial arthritis is to relieve pain, maintain or improve motion, stability, and strength, and restore function. The purpose of this article is to present a volar approach to thumb carpometacarpal suspension arthroplasty using an absorbable interference screw for flexor carpi radialis ligament reconstruction and tendon interposition in the treatment of pantrapezial arthritis. This technique allows for visualization of the volar beak and avoidance of the radial artery and the branches of the superficial radial nerve while allowing optimal surgical manipulation for suspensionplasty with interference screw fixation and tendon interposition at the carpometacarpal joint.

Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection

PURPOSE

Corticosteroid injections are commonly used to treat thumb carpometacarpal arthritis in adults. We aimed to define the timing of surgery following an initial corticosteroid injection and identify patient-specific factors that influence the likelihood of repeat injection or surgery.

METHODS

We performed a retrospective analysis of all patients who underwent a first-time corticosteroid injection for carpometacarpal arthritis between 2009 and 2017. Demographic information, radiographic classification, additional nonsurgical therapies, complications, and outcomes were collected. Primary outcomes were repeat injection and surgical reconstruction. Kaplan-Meier survival analysis was used to characterize the timing of surgical intervention and Cox regression modeling was used to identify predictors of subsequent intervention.

RESULTS

Two-hundred thirty-nine patients (average age, 62.9 years) were identified, of which 141 (59.0%) had a repeat injection and 90 (37.6%) underwent surgery. There were no patient-specific characteristics associated with repeat injection. Eaton stage III/IV arthritis at initial presentation, current smoking status, and prior ipsilateral hand surgery were associated with an increased likelihood of surgery. By Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis did not have surgery within a year and 66.7% of these patients did not have surgery within 5 years.

CONCLUSIONS

In this retrospective observational cohort study with 10-year follow-up from a 4-surgeon practice, advanced radiographic arthritis, current smoking status, and a history of ipsilateral hand surgery were patient-specific factors that predicted progression to surgery following injection. Of patients who presented with advanced radiographic arthritis, one-third underwent surgery within 5 years of initial injection. Although injection efficacy and causality cannot be inferred based on an observational longitudinal analysis, these data identify patient-specific factors that may have an impact on surgical decision-making and a potential timeframe for future intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Translating Hand Surgery Evidence to Policy and Practice

Hand surgery researchers should focus on developing high-quality evidence to support the development of health policies affecting surgical care. Policy-makers and leaders of national hand societies can help reduce the variation of care for patients receiving hand surgery by incorporating evidence into guidelines and policies. Comprehensive guidelines for perioperative care help encourage the translation of evidence into practice. Moreover, the identification of institutional-level barriers and facilitators of integration ensures the successful implementation of hand surgery-specific programs. The development of robust metrics to evaluate the effect of policy on practice helps examine the feasibility of clinical guidelines.

Complex thumb motions and their potential clinical value in identifying early changes in function

BACKGROUND

Early diagnosis and treatment of osteoarthritis of the thumb allows for early interventions that may mitigate osteoarthritis progression and decrease severity later in life. Early identification of motion changes is limited by the clinical reliance on single planar measurements using goniometry. Multi-planar measurements using motion capture can provide insights into joint function and pathophysiology that cannot be obtained from single-plane goniometry measurements. Thus, the goals of this research were 1) to determine differences in thumb motions across three groups of participants (young healthy (n = 23), older healthy (n = 11), and those with carpometacarpal osteoarthritis (n = 24)) and 2) to determine if multi-planar motions provided additional movement information in comparison to standard planar measures.

METHODS

In this study, a motion capture system was used to collect standard clinical ranges of motion and complex multi-planar tasks. Differences in motion patterns due to aging and osteoarthritis were identified. Motions tested included palmar adduction-abduction, radial adduction-abduction, metacarpophalangeal flexion-extension, interphalangeal flexion-extension, functional adduction-abduction, opposition, and circumduction.

FINDINGS

Results indicated that motion capture was capable of detecting changes in carpometacarpal mobility that were not detected using standard approaches. Our results suggested that use of multi-planar measurements have the potential to identify changes that are indicators of early stages of osteoarthritis.

INTERPRETATION

Early indicators are clinically useful as they will enhance patient treatment by permitting the application of treatment approaches sooner, potentially leading to reduced overall functional deficits.

Volume of the Thumb Carpometacarpal Joint

Background  The volume of the carpometacarpal joint of the thumb (TCMC) and its capacity to accommodate fluid injection is unknown. Questions/Purpose  The purpose of the present study is to assess the volume of the TCMC. Methods  Forty-two thumbs undergoing surgical treatment for symptomatic TCMCJ osteoarthritis (OA) were evaluated. Prior to the start of the surgical procedure saline was injected into the TCMC until resistance was felt and no further saline could be injected. The maximum volume (MaxVol) of injectate was measured and recorded. Results  Mean MaxVol among all patients was 0.9 cc (range: 0.2-3.0 cc). There were 15 patients with 1 cc or more injected, the rest were less than 1 cc. The mean MaxVol for Eaton 2 thumbs was 1.5 cc, for Eaton 3 thumbs 0.9 cc, and for Eaton 4 thumbs 0.7 cc, with negative correlation between Eaton stage and MaxVol. Conclusion  TCMC has limited capacity for injected fluid. Level of Evidence  This is a Level II, diagnostic study.

Suture Button Suspensionplasty in the Treatment of Carpometacarpal Arthritis: A Retrospective Analysis of One Surgeon’s Experience Over 9 Years

Purpose

Trapeziectomy with suture button suspensionplasty (SBS) to treat thumb carpometacarpal (CMC) arthritis has been proposed as an alternative to ligament reconstruction tendon interposition. There have been limited large-scale or long-term reports regarding SBS outcomes. Single-surgeon intermediate follow-up is reported.

Methods

We conducted a retrospective review of patients undergoing SBS procedures by a single surgeon. Implant manufacturer and postoperative immobilization protocol were recorded. Surgical outcomes, complications, and revision procedures were identified. Postoperative Disabilities of the Arm, Shoulder, and Hand scores were collected.

Results

A total of 242 SBS surgeries were included, involving 215 patients, average age 64.82 years (range, 42–86 years). Average follow-up was 35 ± 25 months. In all, 183 Arthrex and 59 Stryker systems were used, 42 of which were immobilized for 6 weeks after surgery and 200 of which were mobilized at 2 weeks afterward. Postoperative Disabilities of the Arm, Shoulder, and Hand surveys were completed by 122 patients (57%), with an average score of 12. No scaphometacarpal abutment was reported. Thirteen complications were reported (5%), 7 of which were implant-associated (3%) and 6 of which were not (2%). Implant-associated complications consisted of 3 suture button pull-outs, 2 thumb–index metacarpal abutments, one suture tail irritation, and one index metacarpal fracture. Operative revision was required in 4 of 7 implant-associated cases and 5 of 6 non–implant associated cases. No suture button pull-outs required revision surgery.

Conclusions

Results for a large series of SBS for CMC arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates.

Clinical relevance

Suture button suspensionplasty as an alternative to ligament reconstruction tendon interposition may be a viable option for treating thumb CMC arthritis. In addition, a technique to manage thumb–index metacarpal abutment is described.

Arthroscopic Abrasion Arthroplasty Is Not Superior to Ligament Reconstruction and Tendon Interposition for Thumb Carpometacarpal Arthritis

Background: A few arthroscopic options have been proposed for the treatment of early stages of the arthritis of the thumb carpometacarpal (CMC) joint. The purpose of this study was to compare the results of arthroscopic abrasion arthroplasty with ligament reconstruction and tendon interposition (LRTI). Methods: In this retrospective cohort study, 11 patients who underwent thumb CMC joint arthroscopic abrasion arthroplasty were compared with 15 patients who were randomly selected from a group of 80 LRTI arthroplasty patients during the same study period, with a minimum 1 year follow-up. Preoperative and postoperative evaluations included radiographs and measurements of grip strength, visual analog scale (VAS) pain scores, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The mean preoperative VAS score in both groups was 6.8. Mean preoperative DASH scores were 61.1 in the arthroscopy group and 67.4 in the LRTI group. Postoperative VAS score at final follow-up was 4.8 in the arthroscopy group and 1.2 in the LRTI group (P < .05). Postoperative DASH scores 9 months after surgery were 23 for the LRTI group and 55.2 for the arthroscopy group (P < .05). Eight patients in the arthroscopy group had a second surgery due to persistent pain. Conclusions: Patients undergoing arthroscopic abrasion arthroplasty had high revision rates, higher postoperative pain, and lower patient-rated outcomes than patients undergoing LRTI procedure. The poor results in the arthroscopy group may be secondary to the inherent instability of the CMC joint and lack of use of any biological or artificial interposition material.

A health utility assessment of trapeziectomy with ligament reconstruction and tendon interposition for thumb trapeziometacarpal osteoarthritis

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) for trapeziometacarpal joint osteoarthritis may have both postoperative benefits and complications. This study sought to determine the health state utility outcome measures of trapeziectomy with LRTI. Patients who underwent trapeziectomy with LRTI were invited to complete the brief Michigan Hand Questionnaire and utility questionnaires outcomes using a visual analogue scale , time trade-off and standard gamble. Quality-adjusted life years (QALYs) were derived from these utility measures. For this study 32 patients were recruited, with a mean age of 61. Most patients (27/32) perceived the procedure as successful. Utility measures and QALYs serve the purpose of comparing different surgical procedures in terms of their impact on the quality of life of patients as a function of the benefits and complications of each procedure. In this study, the utility of trapeziectomy with LRTI was less than has been described for open palmar fasciectomy but more than for total wrist arthrodesis. Level of evidence: IV.

Cartilage wear patterns in severe osteoarthritis of the trapeziometacarpal joint: a quantitative analysis

OBJECTIVE

The present quantitative study aimed to assess the three-dimensional (3-D) cartilage wear patterns of the first metacarpal and trapezium in the advanced stage of osteoarthritis (OA) and compare cartilage measurements with radiographic severity.

DESIGN

Using 19 cadaveric trapeziometacarpal (TMC) joints, 3-D cartilage surface models of the first metacarpal and trapezium were created with a laser scanner, and 3-D bone surface model counterparts were similarly created after dissolving the cartilage. These two models were superimposed, and the interval distance on the articular surface as the cartilage thickness was measured. All measurements were obtained in categorized anatomic regions on the articular surface of the respective bone, and we analyzed the 3-D wear patterns on the entire cartilage surface. Furthermore, we compared measurements of cartilage thickness with radiographic OA severity according to the Eaton grading system using Pearson correlation coefficients (r).

RESULTS

In the first metacarpal, the cartilage thickness declined volarly (the mean cartilage thickness of the volar region was 0.32 ± 0.16 mm, whereas that of the dorsal region was 0.53 ± 0.18 mm). Conversely, the cartilage evenly degenerated throughout the articular surface of the trapezium. Measurements of the categorized regions where cartilage thinning was remarkable exhibited statistical correlations with radiographic staging (r = -0.48 to -0.72).

CONCLUSIONS

Our findings indicate that cartilage wear patterns differ between the first metacarpal and trapezium in the late stage of OA. There is a need for further studies on cartilage degeneration leading to symptomatic OA in the TMC joint.

Ultrasound-guided intra-articular injection of hyaluronic acid and ketorolac for osteoarthritis of the carpometacarpal joint of the thumb: A retrospective comparative study

Intra-articular hyaluronic acid (HA) is widely used to treat symptomatic osteoarthritis (OA) in the carpometacarpal joint (CMCJ) of the thumb. However, although apparently effective and relatively safe, intra-articular HA injections act relatively slowly. Therefore, a nonsteroidal anti-inflammatory drug could be added for more prompt pain relief. The aim of this study was to compare the efficacy and safety of ultrasound (US)-guided intra-articular injection of HA and ketorolac with that of HA alone in patients with OA of the CMCJ of the thumb.Seventy-four patients identified by chart review to have a diagnosis of OA of the CMCJ of the thumb received either a US-guided intra-articular injection of 0.5 mL of sodium hyaluronate and 0.5 mL of ketorolac (n = 38) or 0.5 mL of sodium hyaluronate and 0.5 mL of saline (n = 36). Disabilities of the arm, shoulder, and hand (DASH) and verbal numeric scale (VNS) pain scores were recorded before and 1, 3, and 6 months after injection. Univariable analyses (using the chi-squared test) and multiple logistic regression analysis were performed to evaluate the relationship between potential predictors of the outcome (treatment allocation, patient age and sex, duration of pain, and Eaton-Littler classification) and therapeutic effects.The DASH and VNS scores were improved at 1, 3, and 6 months postinjection in both groups. The onset of pain relief was significantly more rapid (at 1 month) after the injection containing HA and ketorolac than after the injection containing HA alone. In 55.3% of cases, pain and function were improved postinjection compared with baseline and remained so for up to 6 months. The success rate was not significantly different between the assessments at 1, 3, and 6 months, and the univariable analyses did not identify any statistically significant potential predictors of the outcome. Multiple logistic regression analysis did not identify any independent predictors of a successful outcome at midterm follow-up.The onset of analgesic action was more rapid after an injection containing HA and ketorolac than after 1 containing HA alone in patients with OA of the CMCJ of the thumb. There were no serious complications.