Radiographic Stage Does Not Correlate With Symptom Severity in Thumb Basilar Joint Osteoarthritis

Prospective Treatment of First Carpometacarpal Osteoarthritis With Autologous Fat Transfer

Background

The purpose of this study was to analyze the effect of autologous fat transfer on outcomes in patients with basilar thumb arthritis.

Methods

Twenty-three patients with carpometacarpal (CMC) arthritis underwent autologous fat transfer under fluoroscopic guidance. Autologous fat was harvested from the abdomen and separated with nonadherent gauze (Telfa). After processing, 2 mL of fat was injected into the CMC joint. All patients were placed in a prefabricated thermoplastic splint for 2 weeks postoperatively. Patients completed the Disability of Arm-Shoulder-Hand Questionnaire (DASH) questionnaire both preoperatively and postoperatively at 1, 6, and 12 months. Paired t tests were used to compare pretreatment to posttreatment DASH scores. Significance was set at a P value less than 0.05 (95% confidence interval [CI]).

Results

The average preoperative DASH score was 51.81 (95% CI, 45.85-57.76). Average postoperative DASH score at 1-month follow-up was 26.16 (95% CI, 19.76-32.57), followed by a DASH score at 6-month follow-up of 22.49, 95% CI (15.41-29.54), and a DASH score at 12-month follow-up of 26.62 (95% CI, 17.68-35.56). Improvements in DASH score were as follows: 26.49 at 1 month postoperatively (P < 0.01), 30.64 at 6 months postoperatively (P < 0.01), and 26.89 at 12 months postoperatively (P < 0.01). No major adverse events were observed.

Conclusions

Autologous fat transfer for the treatment of CMC osteoarthritis significantly improved hand function in our cohort. Additional studies of fat transfer are warranted to better understand the physiologic mechanisms and therapeutic benefits.

A multi-modal evaluation of experimental pain and psychological function in women with carpometacarpal osteoarthritis

Objective

Thumb carpometacarpal osteoarthritis (CMC1 OA) is a prevalent and debilitating condition that lacks effective treatments. Understanding the multidimensional pain experience across CMC1 OA disease stages is crucial to improving treatment outcomes. This study examined how radiographic CMC1 OA severity is associated with physical, psychological, and somatosensory function.

Method

Thirty-one women with early-stage (Eaton-Littler 1-2) or end-stage (Eaton-Littler 3-4) radiographic CMC1 OA completed validated questionnaires to assess pain, disability, and psychological function. Additionally, experimental pain was measured in each participant using quantitative sensory testing (QST) (mechanical, pressure, vibratory, thermal) at seven body sites (thenar, hypothenar, brachioradialis bi-laterally; quadriceps on affected side). Cohort differences (early-vs. end-stage) across all variables were analyzed using a multivariable modeling approach that included fixed effects and interactions; notably, age was controlled as a confounder.

Results

End-stage CMC1 OA participants had higher scores in the pain (p ​= ​0.01) and function (p ​= ​0.02) portions of the AUSCAN assessment, self-reported disability of the DASH questionnaire (p ​= ​0.04), and painDETECT scores (p ​= ​0.03), indicating greater pain and disability compared to early-stage participants. Additionally, end-stage CMC1 OA participants demonstrated reduced vibratory detection and heat pain thresholds at multiple body sites (p's ​< ​0.05), with significant interactions observed across the mechanical and cold stimuli.

Conclusion

Findings revealed women with end-stage CMC1 OA exhibited increased neuropathic pain characteristics and somatosensory loss compared to those with early-stage CMC1 OA. These results underscore the importance of addressing both peripheral and centralized pain mechanisms and the need for multimodal approaches in the treatment of CMC1 OA.

Systematic Comparison of Ligament Reconstruction With Tendon Interposition and Suture-Button Suspensionplasty for Trapeziometacarpal Osteoarthritis

Ligament reconstruction tendon interposition (LRTI) and suture-button suspensionplasty (SBS) are both common treatment options for trapeziometacarpal osteoarthritis. The primary purpose of this systematic review was to compare the subjective improvement in patient-reported outcomes in regard to disability for patients undergoing LRTI and SBS for trapeziometacarpal osteoarthritis. A secondary purpose was to compare the subjective improvement, objective outcome scores, and complication rates following both procedures. We performed a systematic review using PubMed, Scopus, and Embase to compare the clinical outcomes of LRTI and SBS. Inclusion criteria were level I-IV evidence articles reporting postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) or QuickDASH scores. Study methodological quality, risk of bias, and recommendation strength were assessed. This systematic review included 31 studies for final analysis with 1289 thumbs undergoing LRTI (25 studies) and 113 thumbs undergoing SBS (6 studies). Both procedures demonstrated similar improvement in DASH and/or QuickDASH scores, while key pinch and grip strength inconsistently improved following both procedures. Complication rate was similar between the 2 procedures; LRTI 12% and SBS 13%. Although both LRTI and SBS seem to provide improved short-term patient-reported functional improvement and objective strength, there was significant heterogeneity within the included studies, and those studies discussing SBS were of lower quality evidence than those of LRTI. Thus, to truly delineate whether a difference exists between these 2 techniques for the treatment of first carpometacarpal joint arthritis, larger prospectively designed studies of high-quality evidence are necessary.

Factors Influencing Surgical Decision Making in Trapeziometacarpal Osteoarthritis

Purpose

With trapeziometacarpal osteoarthritis (TMC OA), the relationship between disease severity and pretreatment dysfunction, patient expectations, and preferred patient treatment and management remains unclear. This study aimed to assess the association between functional status, pretreatment expectations, and demographic and clinical characteristics of TMC OA patients who decide to undergo operative management.

Methods

Patients diagnosed with TMC OA (n = 96) were administered the Thumb Arthritis Expectations Survey and the Brief Michigan Hand Questionnaire (bMHQ) during their initial office visit. Demographic data (sex, age, race, education level, marital status, comorbidities, and hand dominance) and clinical characteristics (prior injury, and therapeutic interventions including splinting, steroid injections, therapy, and anti-inflammatory medication) were collected. Multiple logistic regression was used to assess the association between surgical treatment and expectation scores.

Results

Our logistic regression model found that lower bMHQ scores, high thumb arthritis expectation survey scores, and prior treatments for TMC OA were associated significantly with the surgical treatment of TMC OA. After controlling for all possible covariates, the odds of having surgery was 3.9 times higher among patients with high expectations (above median) compared to patients with low expectations (adjusted odds ratio [AOR], 3.9; 95% confidence interval [CI], 1.3-11.2). Patients with average function, as measured by bMHQ scores, were 74.5% less likely to elect for surgery than those with the lowest bMHQ (AOR, 0.3; 95% CI, 0.1-0.9). Patients treated previously with steroids were 13 times more likely to elect for surgery than those who were never treated for TMC arthritis (AOR,13.1; 95% CI, 2.2-77.0).

Conclusions

Patients with TMC OA who elect to proceed with surgical management have lower bMHQ (greater perceived dysfunction) and higher expectations, and have had prior treatment. Age was not a significant predictor of surgical management of TMC OA.

Type of study/level of evidence

Prognostic IV.

Effectiveness and Safety of Intra-arterial Imipenem/Cilastatin Sodium Infusion for Patients with Hand Osteoarthritis-Related Interphalangeal Joint Pain

PURPOSE

To evaluate the effectiveness and safety of intra-arterial imipenem/cilastatin sodium (IPM/CS) infusion for painful interphalangeal joint osteoarthritis (OA).

MATERIALS AND METHODS

Fifty-eight patients with interphalangeal joint OA who underwent intra-arterial IPM/CS infusion were retrospectively evaluated. Intra-arterial infusions were performed via percutaneous wrist arterial access. The Numerical Rating Scale (NRS), Functional Index for Hand Osteoarthritis (FIHOA), and Patient Global Impression of Change (PGIC) scale scores were assessed at intervals of 1, 3, 6, 12, and 18 months. Clinical success was evaluated based on PGIC.

RESULTS

All patients were followed up for at least 6 months after treatment. Of them, 30 and 6 patients were followed up for 12 and 18 months, respectively. No severe or life-threatening adverse events were encountered. The mean NRS score was 6.0 ± 1.4 at baseline, which significantly decreased to 2.8 ± 1.4, 2.2 ± 1.9, and 2.4 ± 1.9 at 1, 3, and 6 months after treatment, respectively (all P < .001). The mean NRS scores were 2.8 ± 1.7 and 2.9 ± 1.9 at 12 and 18 months, respectively, in the remaining patients. The mean FIHOA score significantly decreased from 9.8 ± 5.0 at the baseline to 4.1 ± 3.5 at 3 months (P < .001). The mean FIHOA score was 4.5 ± 3.3 at 12 months in the remaining 30 patients. The clinical success rates based on PGIC at 1, 3, 6, 12, and 18 months were 62.1%, 77.6%, 70.7%, 63.4%, and 50.0%, respectively.

CONCLUSIONS

Intra-arterial IPM/CS infusion is a potential treatment option for interphalangeal joint OA refractory to medical management.

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.

Physical Examination and Radiographic Staging of Thumb Carpometacarpal Arthritis

This article reviews the key components of a complete history and physical examination for a patient presenting with thumb pain. The history should include the location and severity of pain, alleviating and exacerbating factors, and impact of disability. Physical examination consists of joint palpation; assessment for laxity or stiffness; inspection for swelling, subluxation, or deformity; and provocative maneuvers. Further workup includes plain radiographs with possible dedicated thumb views. Last, we review the Eaton-Littler classification system, a commonly used radiographic grading system, and some of its limitations.

Effects of Magnetic Resonance Imaging With Axial Traction of the Thumb Carpometacarpal Joint on Articular Cartilage Visibility: A Feasibility Study

Objectives

The objective of this study was to verify the usefulness of magnetic resonance imaging (MRI) with axial traction of the thumb for observing articular cartilage.

Materials and methods

Eleven healthy adult volunteers (39.7 ± 7.4 years) without thumb carpometacarpal joint arthritis or trauma were included in this study. A 3-tesla (3T) MRI (Magnetom Skyra, Siemens Healthineers AG, Munich, Germany) of the right thumb with axial traction applied by a finger trap with three traction weights (0, 2, and 5 kg) was performed. A 3D T2* multiecho data imaging combination (MEDIC) was selected to visualize the articular cartilage. After multiplanar reconstruction, sagittal and coronal images of the thumb carpometacarpal joint were used to evaluate the articular cartilage visibility and joint space widths at five locations. Articular cartilage visibility was evaluated using our original classification method that used the percentage of the cartilage detectable area. The Friedman test was used to compare the differences between each traction weight and location.

Results

Articular cartilage visibility significantly improved with axial traction. The average joint space widths with the 5-kg application were 1.9 ± 0.8, 3.9 ± 0.6, 2.0 ± 0.9, 3.9 ± 1.1, and 2.5 ± 1.4 mm at the center, volar edge, dorsal edge, radial edge, and ulnar edge, respectively. The joint space widths significantly increased proportionally with the traction weight at all locations. The joint space widths at the volar and radial edges were significantly greater than those at other locations.

Conclusion

Applying axial traction to the thumb increased the joint space widths and improved the visibility of the articular cartilage in the carpometacarpal joint on MRI.

Investigating Molecular Signatures Underlying Trapeziometacarpal Osteoarthritis Through the Evaluation of Systemic Cytokine Expression

Purpose

Non-operative management of trapeziometacarpal osteoarthritis (TMOA) demonstrates only short-term symptomatic alleviation, and no approved disease modifying drugs exist to treat this condition. A key issue in these patients is that radiographic disease severity can be discordant with patient reported pain, illustrating the need to identify molecular mediators of disease. This study characterizes the biochemical profile of TMOA patients to elucidate molecular mechanisms driving TMOA progression.

Methods

Plasma from patients with symptomatic TMOA undergoing surgical (n=39) or non-surgical management (n=44) with 1-year post-surgical follow-up were compared using a targeted panel of 27 cytokines. Radiographic (Eaton-Littler), anthropometric, longitudinal pain (VAS, TASD, quick DASH) and functional (key pinch, grip strength) data were used to evaluate relationships between structure, pain, and systemic cytokine expression. Principal Component Analysis was used to identify clusters of patients.

Results

Patients undergoing surgery had greater BMI as well as higher baseline quick DASH, TASD scores. Systemically, these patients could only be distinguished by differing levels of Interleukin-7 (IL-7), with an adjusted odds ratio of 0.22 for surgery for those with increased levels of this cytokine. Interestingly, PCA analysis of all patients (regardless of surgical status) identified a subset of patients with an “inflammatory” phenotype, as defined by a unique molecular signature consisting of thirteen cytokines.

Conclusion

Overall, this study demonstrated that circulating cytokines are capable of distinguishing TMOA disease severity, and identified IL-7 as a target capable of differentiating disease severity with higher levels associated with a decreased likelihood of TMOA needing surgical intervention. It also identified a cluster of patients who segregate based on a molecular signature of select cytokines.

Update on Thumb Basal Joint Arthritis Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance.

SUMMARY

Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

Factors Associated With Surgical Intervention for Osteoarthritis of the Thumb Carpometacarpal Joint

PURPOSE

This retrospective study aimed to analyze the initial clinical factors associated with surgical intervention for osteoarthritis of the thumb carpometacarpal (CMC) joint.

METHODS

The study included patients who first visited our hand surgery clinic, were given the diagnosis of osteoarthritis of the thumb CMC joint between May 2012 and January 2015, and were observed for more than 3 years. Patients were classified into 2 groups according to whether they had undergone surgery during the follow-up period. The following variables were extracted and included in a bivariate analysis: sex, age, age at onset, disease duration, dominant hand, pain visual analog scale (VAS) scores at rest and during use, night pain, Eaton classification, use of an orthosis, number of injections, tender area, range of motion, grip strength, pinch strength, Kapandji abduction index, palmar abduction distance, grind test results, CMC joint shape on radiographs, dorsal subluxation ratio, volar tilt of the metacarpal, presence or absence of ossicles, and the surgeon who recommended the surgery. Variables with P values less than .05 in the bivariate analysis were included in a logistic regression model.

RESULTS

The study included 80 thumbs of 48 patients. Pain scores at rest and during use, and the dorsal subluxation ratio were identified as factors significantly associated with surgical intervention in the bivariate analysis. The subsequent logistic regression analysis including these factors as explanatory variables also identified the VAS score at rest and dorsal subluxation ratio as significantly associated with surgical intervention.

CONCLUSIONS

The VAS score at rest and the dorsal subluxation ratio at the first clinical visit were associated with the likelihood of future surgical intervention within 3 years in patients with osteoarthritis of the thumb CMC joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial

Various systematic reviews have recently shown that intra-articular platelet-rich plasma (IA-PRP) can lead to symptomatic relief of knee osteoarthritis for up to 12 months. There exist limited data on its use in small joints, such as the trapeziometacarpal joint (TMJ) or carpometacarpal joint (CMCJ) of the thumb. A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the TMJ (grades: I-III according to the Eaton and Littler classification) was conducted. Group A patients (16 patients) received 2 ultrasound-guided IA-PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval. Patients were evaluated prior to and at 3 and 12 months after the second injection using the visual analogue scale (VAS) 100/100, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH), and patient's subjective satisfaction. No significant differences between the baseline clinical and demographic characteristics of the 2 groups were identified. After 12 months' follow-up, the IA-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of VAS score (P = 0.015), Q-DASH score (P = 0.025), and patients' satisfaction (P = 0.002). Corticosteroids offer short-term relief of symptoms, but IA-PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic TMJ arthritis.

Misperception of Disease Onset in People with Gradual-Onset Disease of the Upper Extremity

BACKGROUND

Misperception that an established, gradual-onset disease such as osteoarthritis started when the symptoms were first noticed might lead to testing and treatment choices that are inconsistent with what matters most to a patient. In the present study, the primary null hypothesis was that there are no factors associated with patient-reported symptom duration (in months). The secondary null hypotheses were that there are no factors independently associated with (1) a sudden versus gradual perception of disease onset, (2) an event or injury-related versus age-related perceived cause of disease onset, and (3) the magnitude of physical limitations.

METHODS

In this cross-sectional study, 121 patients with an atraumatic, established, gradual-onset condition of the upper extremity completed a demographic questionnaire, measures of mental health (symptoms of depression and anxiety, worst-case thinking, and self-efficacy [the ability to adapt and continue with daily activity] when in pain), measurement of the magnitude of upper extremity-specific limitations, and questions about the perceived course and cause of the disease.

RESULTS

The median patient-reported symptom duration was 12 months (interquartile range, 3 to 36 months). Twenty-two patients (18%) perceived their disease as new, and 29 patients (24%) believed that the condition was related to ≥1 event (injury) rather than being time and age-related. In multivariable analysis, patients with Medicare insurance were independently associated with longer reported symptom duration (in months). Greater self-efficacy was associated with longer symptom duration in bivariate, but not multivariable, analysis. No factors were independently associated with a sudden versus gradual onset of symptoms. Hispanic ethnicity and federal, county, or no insurance were independently associated with the perception that the problem was caused by an injury or event.

CONCLUSIONS

Approximately 1 in 5 patients misperceived new symptoms as representing a new disease, often as a type of injury. Misperception of the pathology as new had a limited association with unhealthy thoughts and is likely generally responsive to reorientation. We speculate that gentle, strategic reorientation of misperception can protect patients from choices inconsistent with their values.

Trapeziometacarpal Joint Arthritis: Is Duration of Symptoms a Predictor of Surgical Outcomes?

PURPOSE

Great effort has been placed on determining the optimal surgical treatment for trapeziometacarpal joint arthritis (TMA). However, a paucity of literature exists concerning the optimal timing of surgical intervention. We hypothesized that an increased duration of TMA symptoms before operative intervention would negatively affect surgical outcomes.

METHODS

We performed a retrospective review on 109 adult patients with 121 joints with symptomatic TMA treated with trapeziectomy and ligament reconstruction with tendon interposition (LRTI) from 2006 to 2017. Outcome measures included Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, complication rates, and surgical revision rates.

RESULTS

Among 109 patients, average QuickDASH score at initial presentation was 41.1 ± 17.9. Patients had symptoms of TMA for an average of 3.2 years (median, 2.1 years) before undergoing operative intervention. Patients were divided into 2 groups: those with symptoms less than 2 years and those with symptoms greater than 2 years. Patients who underwent LRTI after less than 2 years of symptoms achieved a significantly greater degree of improvement in the QuickDASH score compared with patients with symptoms greater than 2 years (26.2 vs 5.3).

CONCLUSIONS

Patients with less than 2 years of symptomatic TMA before LRTI can expect the greatest improvement in patient-reported disability impairment compared with those with more than 2 years of symptoms. This can be used to counsel patients regarding the optimal timing of surgery if nonsurgical treatment has failed to provide durable symptomatic relief.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Association of Clinical Assessments of Hand Function and Quantitative Ultrasound Metrics in First Carpometacarpal Osteoarthritis

BACKGROUND

Thumb carpometacarpal (CMC) osteoarthritis (OA), a degenerative condition affecting hand use, is typically evaluated through radiographs and clinical examination. Although this can determine treatment, it is difficult to evaluate functional limitations. Shear wave elastography (SWE) is a quantitative ultrasound technique that characterizes tissue stiffness.

QUESTIONS/PURPOSES

This pilot study aimed to establish data of the SWE findings in the thenar eminence muscles in patients with first CMC OA and correlate these findings with the clinical tests of hand function.

METHODS

This cross-sectional study correlated the SWE stiffness of thenar eminence muscles to clinical tests of hand function in patients with first CMC OA and in asymptomatic control subjects, using Spearman's correlation coefficient. Mean SWE values of the thenar eminence muscles in patients were compared with those in control subjects. The study was performed in a non-profit tertiary care hospital setting. Patients and control subjects were recruited on a volunteer basis.

RESULTS

SWE values in the abductor pollicis brevis and flexor pollicis brevis muscles showed moderate to very strong correlation with multiple measures of hand function. Mean SWE values of the thenar eminence muscles in first CMC OA patients were lower than those in asymptomatic control subjects.

CONCLUSIONS

Correlations between mean SWE values in the thenar eminence muscles and clinical measures of hand function suggest decreased function in subjects with less stiff thenar eminence muscles.

Equivalent PROMIS Scores after Nonoperative or Operative Treatment of Trapeziometacarpal Osteoarthritis

Background

Patient-Reported Outcomes Measurement Information System (PROMIS) scores can quantify symptoms and limitations after upper extremity surgery. Our objective was to determine how these scores compare amongst patients with trapeziometacarpal osteoarthritis treated either nonoperatively or operatively.

Methods

In this retrospective comparative study, we compared PROMIS scores (upper extremity function [UEF], pain interference, and depression) between 43 patients who underwent nonoperative treatment (nonsteroidal anti-inflammatory drugs/splinting/injections) and 33 patients who underwent trapeziectomy with ligament reconstruction and tendon interposition for trapeziometacarpal osteoarthritis (minimum 6-month recovery period) by 4 surgeons from 2014-2018. PROMIS scores were compared across all patients by Eaton-Littler staging. We used linear regression to assess correlations between time-since-surgery and each PROMIS domain. Multivariable linear regression was used to identify patient and disease factors independently associated with PROMIS scores.

Results

Surgery was not associated with better UEF (37 vs. 40, P=0.23), less pain interference (58 vs. 56, P=0.42), or fewer symptoms of depression (47 vs. 46, P=0.59). Similarly, no differences were observed across all patient by Eaton-Littler stage for UEF (P=0.49), pain (P=0.48), or depression (P=0.90). For the operative group, greater time-since-surgery, or patient recovery period, correlated moderately with worse UEF (R=0.41) and increased pain (R=0.37).

Conclusion

In small retrospective comparative cohorts, surgery was not associated with better UEF, pain, or depression scores compared with nonoperative treatment for trapeziometacarpal osteoarthritis.

Thumb Disability Examination (TDX) as a New Reliable Tool for Basal Joint Arthritis

Background  The general assessment of basal joint arthritis (BJA) is limited using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This has been shown to be insensitive to pain and disability levels, leading to the development and validation of the thumb disability examination (TDX) as a specific tool for BJA in 2014. Objective  The goal of this study was to evaluate the reliability, sensitivity, and specificity of the TDX score for BJA. Methods  A multicenter BJA database was established in 2007 to collect prospective data. We evaluated the correlation between the TDX score, visual analog pain scale with activity (A-VAS), Eaton-Littler score, and grip strength using a Pearson test. Additionally, we evaluated the pre- and postintervention scores to assess their predictive values. Results  A total of 109 thumbs of 74 patients with TDX scores were evaluated. Females were more commonly affected (75.2%), and the mean age was 65.39 years (standard deviation: 10.04). The majority of participants were white (90.8%). A high correlation between TDX and A-VAS score (Pearson's correlation = 0.520; p  < 0.001) and between grip strength (Pearson's correlation = -0.336; p  < 0.005) and Eaton-Littler score (Pearson's correlation = 0.353' p  < 0.01) was identified. Additionally, when comparing pre- and post-intervention for all treatment groups and for operative intervention, significant differences in TDX scores were observed (both p ≤ 0.01). No significant differences could be identified for DASH score or A-VAS when assessing these same groups. Conclusion  The TDX score correlates to high Pearson's correlation values and p -values, especially in grip strength, Eaton-Littler score, A-VAS score, and pre-/postintervention for all treatment groups combined and when specifically assessing the surgical intervention group. As a result, it can be concluded that the TDX score is a specific tool for the assessment of BJA. Level of Evidence  This is a Level II, prospective comparative study.

Effect of Partial and Complete Trapezoid Excision on Radiographic and Functional Results After Abductor Pollicis Longus Suspensionplasty

PURPOSE

We hypothesized that adding complete or partial trapezoid excision is associated with greater radiographic carpal collapse and worse functional outcomes compared with a simple trapeziectomy and abductor pollicis longus suspensionplasty.

METHODS

A total of 69 patients had abductor pollicis longus suspensionplasty (79 hands), 87% of whom were female, mean age 64 years. Scaphotrapezium-trapezoid arthritis noted at surgery was treated with an additional proximal trapezoid excision (PT) in 21 (27%) or complete trapezoid resection (CT) in 22 hands (28%). No trapezoid was excised in 36 hands. The primary outcome was final radiolunate (RL) extension of 15° or greater on lateral radiographs. Logistic regression (for change in RL angle) and linear regression (for continuous variables) with robust variance estimate to account for within-subject correlation (generalized estimating equation method) were used to investigate whether the trapezoid excision groups had an effect on the outcomes of interest. Models were adjusted for age and sex.

RESULTS

Median follow-up was 92 months. Complete trapezoid resection had the most increase in RL angle, but PT had a higher incidence (29% vs 26%) of final RL angle of 15° or greater compared with CT. When stratified into groups with a final RL greater than or less than 15°, the former group had worse total function (Patient-Rated Wrist Evaluation) and Quick-Disabilities of the Arm, Shoulder, and Hand scores. Symptomatic index metacarpal migration was seen in 4 CT and 2 PT wrists (18% and 10%, respectively) and was considered to indicate failure.

CONCLUSIONS

Compared with no trapezoid excised, both PT and CT had a greater incidence of lunate extension of 15° or greater, consistent with radiographic nondissociative-dorsal intercalated carpal instability, which was associated with inferior functional scores. Symptomatic proximal collapse of the index metacarpal was seen in both CT and PT. Further studies should evaluate whether routine excision of the proximal trapezoid is necessary for scaphotrapezoid arthritis, because any disruption of the scaphotrapezoid ligament complex appears to increase risk for developing carpal instability nondissociative-dorsal intercalated carpal instability over time and may be associated with inferior functional results. Complete trapezoid excision is not recommended.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Psychological factors are more strongly associated with pain than radiographic severity in non-invasively treated first carpometacarpal osteoarthritis

BACKGROUND

The aim of this study was to investigate to what extent psychological factors are related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint.

METHODS

We included patients (n = 255) at the start of non-invasive treatment for osteoarthritis of the first carpometacarpal joint who completed the Michigan Hand Outcome Questionnaire. Psychological distress, pain catastrophizing behavior and illness perception was measured. X-rays were scored on presence of scaphotrapeziotrapezoid osteoarthritis. We used hierarchical linear regression analysis to determine to what extent pain levels could be explained by patient characteristics, X-ray scores, and psychological factors.

RESULTS

Patient characteristics and X-ray scores accounted for only 6% of the variation in pre-treatment pain levels. After adding the psychological factors to our model, 47% of the variance could be explained.

CONCLUSIONS

Our results show that psychological factors are more strongly related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint than patient characteristics and X-ray scores, which implies the important role of these factors in the reporting of symptoms. More research is needed to determine whether psychological factors will also affect treatment outcomes for patients treated non-invasively for osteoarthritis of the first carpometacarpal joint.IMPLICATIONS FOR REHABILITATIONPain is the most important complaint for patients with osteoarthritis of the first carpometacarpal joint.Psychological factors are strongly associated with pain levels prior to treatment.Pain catastrophizing behavior appears to be a promising target for complementary treatment in patients with osteoarthritis of the first carpometacarpal joint.

Clinical Assessments of Hand Function in First Carpometacarpal Osteoarthritis Do Not Appear to Correlate with Radiographic Findings

BACKGROUND

Thumb carpometacarpal (first CMC) osteoarthritis (OA), a degenerative process affecting hand use, is typically assessed by clinical examination and radiographs. This assessment determines treatment, but it may not reflect functional limitations.

QUESTIONS/PURPOSES

We aimed to explore the relationship between measures of hand function and radiographs in individuals with and without first CMC OA.

METHODS

We designed a cross-sectional, observational pilot study, enrolling five patients with first CMC OA (nine thumbs with modified Eaton-Littler grades ranging from 1 to 4, using retrospective radiographic data) and nine healthy controls. They underwent evaluation of hand function using four patient-reported outcome measures (PROMs)-the Patient-Specific Functional Scale (PSFS); the Patient-Rated Wrist/Hand Evaluation (PRWHE); the Disabilities of the Arm, Shoulder, and Hand (DASH); and the Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH)-and one performance measure, the Arthritis Hand Function Test (AHFT). Spearman's ρ with 95% subject clustered bootstrapped confidence intervals was calculated to assess for correlations between radiographic findings and measures of hand function.

RESULTS

Only the DASH work score showed strong positive correlation with radiographic OA grade, with PSFS, PRWHE, M-SACRAH, and AHFT scores demonstrating low to moderate correlations. Notable differences were found between patients and control subjects in median scores of the DASH, PSFS, PRWHE, and M-SACRAH, as well as in the grip, pinch, and button scores of the AHFT.

CONCLUSION

While only the DASH work score strongly correlated with radiographic grade of first CMC OA, several measures detected considerable differences in functional hand use between patients and control subjects. The findings of this pilot study suggest that hand function scores be considered in addition to radiographs when determining severity of first CMC OA. The findings can also inform the design of a larger, powered study.

Effects of Baseline Opioid Medication Use on Patient-Reported Functional and Psychological Impairment Among Hand Clinic Patients

PURPOSE

To test the null hypothesis that baseline opioid use is not associated with functional or psychological impairment among new hand surgery clinic patients, as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) instruments.

METHODS

New adult (≥ 18 years) patient visits to a tertiary academic orthopedic nonshoulder hand and upper extremity clinic between February 2014 and April 2018 were eligible. Collected outcomes include the question, "Are you currently taking narcotic pain medications?", the PROMIS Upper Extremity (UE) computerized adaptive testing (CAT), abbreviated version of the Disorders of the Arm, Shoulder, and Hand (QuickDASH), PROMIS Physical Function (PF) CAT, PROMIS Pain Interference (PI) CAT, PROMIS Depression CAT, and PROMIS Anxiety CAT. Patients responding to the opioid question, plus the UE CAT or QuickDASH, were included. Bivariate and multivariable logistic regression modelling were used to assess factors associated with baseline scores.

RESULTS

Of 5997 included patients, 1,046 (17.4%) reported baseline opioid use. Patients in the opioid group demonstrated significantly worse scores on all patient-reported outcomes, and a significantly greater proportion of patients with PROMIS Depression CAT scores exceeding 60 (associated with a clinical diagnosis of depression; 29.5% vs 15.5%). Lower functional scores were observed in the opioid group after controlling for age, sex, other activity-limiting comorbidities, and either depression (UE CAT -7.0; QuickDASH +18.1; and PF CAT -6.6 points), anxiety (UE CAT -6.3; QuickDASH +16.4; PF CAT -6.3), or PI (UE CAT -3.7; QuickDASH +9.5; and PF CAT -4.2 points). Pain interference was greater among opiate users when controlling for age, sex, other activity-limiting comorbidities, and baseline function or psychological status: PI was 2.5, 5.0, or 4.3 points greater when controlling for the PROMIS UE CAT, Depression CAT, or Anxiety CAT.

CONCLUSIONS

New patients presenting to a hand surgery clinic who endorse use of opioid medications at baseline report significantly decreased physical function, increased psychological burden, and greater levels of pain interference than nonusers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Evaluation of the PROMIS Upper Extremity Computer Adaptive Test Against Validated Patient-Reported Outcomes in Patients With Basilar Thumb Arthritis

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) computer adaptive test was developed to reduce test burden and improve precision. We hypothesized that, in patients with thumb basilar joint arthritis (BJA), (1) PROMIS UE would correlate with established patient-outcomes (PROs), (2) PROMIS UE would require less time and fewer questions than current metrics, (3) there would be no floor or ceiling effects, and (4) PROMIS UE would not correlate with radiographic disease severity.

METHODS

Patients presenting with a primary diagnosis of thumb BJA completed the Quick Disabilities of the Arm Shoulder and Hand (QuickDASH), Thumb Disability Examination (TDX), Patient-Rated Wrist Hand Evaluation (PRWHE), and PROMIS UE. Radiographic disease severity as described by the Eaton scoring system was recorded. The relationships among PROs were described with Spearman correlation coefficients. The presence of a floor or ceiling effect was confirmed if greater than 15% of patients achieved the lowest or the highest possible score, respectively.

RESULTS

One hundred patients with thumb BJA formed the sample for this study. A good to excellent correlation was identified between PROMIS UE and QuickDASH. There were good correlations between PROMIS UE and TDX as well as PRWHE. The PROMIS UE was significantly less time consuming (average: 58.5 seconds vs QuickDASH, 92.2; TDX, 62.6; and PRWHE, 144.7), and required fewer questions than current metrics (average: 4.9 questions vs QuickDASH, 11; TDX, 20; and, 15). In addition, there were no appreciable floor or ceiling effects. Radiographic disease severity did not correlate with PROMIS UE.

CONCLUSIONS

The PROMIS UE has a good to excellent correlation with QuickDASH and good correlations with PRWHE and TDX. In addition, PROMIS UE required less time and fewer questions than established PROs. There were no floor or ceiling effects. Used as a single PRO, PROMIS UE may be a practical alternative to legacy scales in patients with thumb BJA.

CLINICAL RELEVANCE

The PROMIS UE PRO instrument may be a valuable addition in the assessment of patients with basilar thumb arthritis.

[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.

Assessment of Dorsal Subluxation in Thumb Carpometacarpal Osteoarthritis

Background Although dorsal subluxation is a typical finding for osteoarthritis of the thumb carpometacarpal (CMC) joint, it is difficult to evaluate the subluxation after trapeziectomy and the significance of its surgical correction combined with trapeziectomy is still controversial. The purpose of this study was to develop a method to evaluate dorsal subluxation without using landmarks on the trapezium. Methods Thirty patients with thumb CMC arthritis and 13 normal patients were included in this study. Dorsal subluxation of the CMC joint was evaluated by measuring the distance between the volar tip of the thumb metacarpal base and dorsoradial border of the index metacarpal base (M1M2 overlap) on the X-ray true lateral view of the thumb as well as previously reported methods. Intraclass correlation coefficient (ICC) was used to assess inter- and intraobserver reliability for the measurement of M1M2 overlap by six examiners of different level of expertise. Dorsal subluxation was also evaluated after trapeziectomy with ligament reconstruction. Results There were almost perfect interobserver (ICC = 0.94) and intraobserver (ICC = 0.95 for an expert and 0.97 for a novice) reliabilities for the measurement of M1M2 overlap. There was a weak correlation between our method and previously reported methods. M1M2 overlap of the normal patients and the patients were 4.6 ± 1.2 mm and 2.3 ± 2.3 mm (mean ± SD), respectively. M1M2 overlap was corrected significantly after trapeziectomy with ligament reconstruction. Conclusion Dorsal subluxation of the thumb CMC joint could be evaluated by M1M2 overlap before and after trapeziectomy.

Survival and Long-Term Outcomes of Thumb Metacarpal Extension Osteotomy for Symptomatic Carpometacarpal Laxity and Early Basal Joint Arthritis

PURPOSE

To evaluate the survival and long-term outcomes of thumb metacarpal extension osteotomy for early carpometacarpal (CMC) arthritis.

METHODS

Patients who underwent a thumb extension osteotomy between years 2000 and 2011 were identified. Patient demographics, complications, and reoperations were recorded. The Kaplan-Meier survival analysis was used with subsequent CMC surgery defined as failure. Patients who had undergone surgery 10 years or more before the study date underwent radiographic assessment, grip and pinch strength testing, and completed the Patient Rated Wrist/Hand Evaluation (PRWHE) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires.

RESULTS

Thirty-two procedures in 7 males and 21 females were performed (mean age, 44.8 y). There were no cases of nonunion. Nine of 32 thumbs developed pin site erythema and were treated with oral antibiotics. Two thumbs developed osteomyelitis. Seven of 32 thumbs (22%) required reoperation. The Kaplan-Meier analysis indicated a 70% probability that patients who have this procedure will not require additional CMC surgery up to 14 years. Seven patients with a mean follow-up of 12.3 years (minimum 10 y) returned for clinical evaluation. The mean PRWHE and QuickDASH scores were 32.1 and 27.7, respectively. Examination revealed 124% pinch and 98% grip strength relative to the preoperative values. One thumb did not progress from stage II disease; 2 thumbs progressed from stage I to stage II; 1 thumb progressed from stage II to stage III; 1 thumb progressed from stage II to stage IV; 1 thumb did not have disease progression at the CMC joint, but developed scaphotrapeziotrapezoidal arthritis.

CONCLUSIONS

Although reoperation rates and superficial infections with the described method of fixation were relatively high, thumb metacarpal osteotomy provides some degree of pain relief and improvement of function. This procedure may have utility as a temporizing measure in younger patients as it does not compromise future reconstructive procedures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Teleology of the Thumb: On Purpose and Design

The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a midcareer researcher dedicated to advancing patient care in the field of hand surgery. The Weiland Medal for 2017 was presented to the author at the annual meeting of the American Society for Surgery of the Hand. The purpose of this article is to present current evidence on how biomechanics and morphology influence the pathophysiology of thumb carpometacarpal joint osteoarthritis.

Hallux Rigidus Grade Does Not Correlate With Foot and Ankle Ability Measure Score

INTRODUCTION

Classification systems for hallux rigidus imply that, as radiographic changes progress, symptoms will concurrently increase in severity. However, symptom intensity and radiographic severity can be discordant for many patients. We studied the correlation between hallux rigidus grades and the Foot and Ankle Ability Measure (FAAM) scores to better understand this relationship.

METHODS

We retrospectively reviewed weight-bearing radiographs of the foot and FAAM Activities of Daily Living (ADL) questionnaires for 84 patients with hallux rigidus. The Spearman rank coefficient was used to correlate clinical-radiographic hallux rigidus grade with FAAM ADL scores.

RESULTS

In 84 patients, the clinical-radiographic grade for hallux rigidus showed no relationship with FAAM ADL score (r = -0.10; P = 0.36) but did show moderate correlation with patient age (r = 0.63; P < 0.001).

DISCUSSION

Advancing radiographic changes in hallux rigidus did not correspond with patient symptoms as measured via FAAM ADL scores.

CONCLUSION

The reliability and validity of current grading criteria for hallux rigidus may require further exploration.

LEVEL OF EVIDENCE

Level III.

QuickDASH Score Is Associated With Treatment Choice in Patients With Trapeziometacarpal Arthrosis

BACKGROUND

Trapeziometacarpal (TMC) arthrosis has a variety of treatment options, including nonoperative (eg, education, splint, injection) and operative management. Symptoms and limitations vary greatly among patients. The purpose of this study was to determine an association of symptoms and limitations, quantified using the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, with treatment choice in patients newly diagnosed with TMC arthrosis. We also addressed the association of the QuickDASH score with radiographic severity and sought factors associated with higher QuickDASH scores.

METHODS

As part of the routine new patient intake paperwork, all new patients completed a QuickDASH form. We included 81 new patients with newly diagnosed TMC arthrosis visiting the office of 1 of 5 orthopedic hand surgeons between March 1, 2015, and November 30, 2015. Eight patients were excluded because of incomplete QuickDASH forms.

RESULTS

Based on QuickDASH tertiles, patients with a low QuickDASH score were more likely to choose education alone than patients with intermediate and high QuickDASH scores; no patients in the lowest QuickDASH tertile chose injection or surgery. Patients who chose education alone also had a lower mean QuickDASH score than patients who chose splint or surgery. Radiographic severity and other patient-related factors were not associated with greater symptoms and limitations.

CONCLUSIONS

More adaptive patients (lower QuickDASH) are less likely to choose injection or surgery, irrespective of disease severity. The psychosocial factors known to correlate with greater symptoms and limitations might lead patients to feel they have fewer options or to choose more interventional options than they would if they were more at ease. In other words, inadequate attention to psychosocial factors may increase the risk of misdiagnosis of patient preferences.

Orthopaedic management of the Ehlers-Danlos syndromes

The role of orthopedic surgery in Ehlers-Danlos syndrome is inherently controversial, opaque to most patients and many medical providers, and difficult to discern from available medical literature. Non-operative treatment is preferable, but for carefully selected patients, specific joint stabilization and nerve decompression procedures can provide symptomatic relief when conservative measures fail. © 2017 Wiley Periodicals, Inc.