Long-Term Outcomes in Female Patients With Carpometacarpal Arthroplasty and Metacarpophalangeal Fusion Compared With the Unoperated Side or Carpometacarpal Arthroplasty

PURPOSE

Patients with carpometacarpal (CMC) osteoarthritis (OA) often present with metacarpophalangeal (MP) hyperextension and/or thenar atrophy. This study hypothesizes that MP fusion (MPF) performed at the time of CMC arthroplasty (CMCA) for patients who have moderate-to-severe thenar atrophy, MP hyperextension >30°, or MP arthritis will have greater long-term pinch strength and improvements in the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score from preoperative values when compared with the unoperated side or those who had CMCA only.

METHODS

This study involved a retrospective review of long-term results from patients who underwent either CMCA or CMCA/MPF. The QuickDASH score, the pain visual analog scale (VAS), and an average of three pinch readings from each thumb were measured on the Baseline pinch gauge and recorded with a correction for hand dominance in right-handed patients.

RESULTS

Fifty-three female patients with 70 operated thumbs were included in the study. The mean age was 67.2 years. There were 29 CMCAs and 41CMCA/MPFs. The mean follow-up was 6.3 years (range 2-16.9 years). At the latest follow-up, the mean CMCA/MPF pinch strength (11.3 lbs) was significantly stronger than that of CMCA (8.0 lbs) and carpometacarpal osteoarthritis thumbs (8.9 lbs). There was no significant difference in pinch strength between patients who underwent a CMCA and CMCOA thumbs (8.0 lbs vs 8.9 lbs, respectively). Preoperative QuickDASH demonstrated worse function in the CMCA/MPF group (55.8 vs 36.5). At the latest follow-up, QuickDASH and VAS revealed similar values in both the CMCA/MPF (10.5 and 0.66) and CMCA (18.5 and 0.52) groups.

CONCLUSION

Long-term results demonstrate stronger pinch and greater improvement in QuickDASH scores in patients who underwent CMCA/MPF compared with those who underwent a CMCA or untreated carpometacarpal osteoarthritis thumbs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Carpometacarpal Joint Pathology in the Thumb and Hand: Evaluation and Management of Difficult Conditions

Thumb carpometacarpal arthroplasty with complete trapeziectomy with or without suspensionplasty, ligament reconstruction, and/or tendon interposition is largely considered equivalent techniques in providing pain relief and improving function for patients with thumb carpometacarpal arthritis. In cases of continued pain, instability, and dysfunction following an index surgery, one must first identify the cause of failure. Any options for revision surgery depend on addressing the specific cause of persistent symptoms with awareness of available options. Most of the patients undergoing revision surgeries can achieve good to fair outcomes.

Comparative study on the effectiveness of bone grafting for arthrodesis of the thumb carpometacarpal arthritis

The aim of this retrospective study was to assess the effectiveness of autogenous bone grafting for arthrodesis of the thumb carpometacarpal joint by comparing the bone union rates with and without bone grafting. We included 36 patients who underwent arthrodesis of the thumb carpometacarpal joint for arthritis (20 patients with bone grafts and 16 without bone grafts). Implants used for internal fixation were K-wire, tension band wiring, headless compression screw and locking plate. The presence of bone union and the time from surgery to bone union were evaluated. The bone union rate was 20/20 (100%) in the bone grafting group and 12/16 (75%) in the non-bone grafting group (p = 0.03). There were no significant differences between the two groups in the time from surgery to bone union and patient characteristics. In conclusion, autogenous bone grafting may contribute to the bone union in the arthrodesis of thumb carpometacarpal arthritis.Level of evidence: III.

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.

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.

Intermetacarpal M4-M5 arthrodesis (Dubert procedure) for fifth carpometacarpal joint osteoarthritis: long-term functional outcomes

The goal of this study was to describe the long-term functional outcomes of the procedure described by Dubert (stabilized arthroplasty with intermetacarpal arthrodesis) for painful carpometacarpal impingement of the little finger. Between 2005 and 2017, 8 patients (1 woman and 7 men) were operated on who had a mean age of 38 years (24-53 years). Seven cases were post-traumatic (malunion) and one was due to septic arthritis. A total of 5 patients were available for a retrospective clinical, functional, and radiological follow-up at a mean of 73 months (23-108 months). Clinical parameters included pain on VAS, grip strength, Quick Disability of Arm, Shoulder and Hand questionnaire, Patient-Rated Wrist Evaluation, and a subjective hand value (0-100%). Fusion was achieved in all cases. Of the 8 patients, one developed complex regional pain syndrome and one had persistent pain that required secondary proximal metacarpal resection. At the last follow-up, all patients were satisfied and reported a significant reduction in pain and improvement in strength. Mean Quick Disability of Arm, Shoulder, and Hand questionnaire, Patient-Rated Wrist Evaluation and subjective hand value were 19/100 points, 21/100 points and 75%, respectively. Our study suggests that the stabilized arthroplasty of the fifth finger, as describe by Dubert, is an efficient and reliable method to reduce pain and improve hand function in patients suffering from carpometacarpal impingement of the little finger. LEVEL OF EVIDENCE: retrospective series, IV.

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.

Thumb interphalangeal joint arthrodesis angles in patients with carpometacarpal osteoarthritis

Purpose

Previous studies have shown that thumb interphalangeal (IP) joint arthrodesis is typically performed between 0 and 30° of flexion, with a recent study in healthy subjects having recommended a range of 15-30° to be an ideal functional IP joint fusion angle for various activities of daily living. The current study aimed to evaluate the ideal thumb IP fusion angle in patients with thumb carpometacarpal (CMC) osteoarthritis (OA).

Methods

Twenty-seven patients with thumb CMC OA were evaluated; five patients had bilateral pathology, for a total of thirty-two thumbs included. Hand dominance was noted and baseline unsplinted measurements were obtained for power tasks, precision tasks, pinch, and grip strength testing. Patients' thumbs were then splinted at 0, 15, 30, and 45° with repeat measurements taken and compared to baseline. Outcomes were measured by use of a 10-point Visual Analogue Scale, timing of tasks, and a dynamometer. Outcomes were analyzed by Wilcoxon sign ranked tests for each category of trials.

Results

For significant outcomes, the most favorable simulated thumb fusion angles were 15° in the dominant hand and 0°, 15° in the nondominant hand (precision tasks); the least favorable position was found to be 45° in the dominant hand (precision tasks, pinch strength). When combining all outcomes that both reached and approached significance, the most favorable position was found to be 15° and least favorable position, 45°.

Conclusions

In patients with thumb CMC OA, an IP fusion angle of 15° is preferable, while a fusion angle of 45° is to be avoided.

Type of study/level of evidence

Therapeutic Study, Level III.

Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery

Truven MarketScan® Databases were used to identify patients with thumb carpometacarpal arthritis who underwent surgical treatment. Pre-operative corticosteroid or hyaluronic acid injections were identified, as were post-operative complications. Multivariable regressions assessed the relationship between injections and complications. Of 16,268 patients, 4462 had steroid injections and 252 received hyaluronic acid injections. Twenty-one per cent (3381 patients) had post-operative complications. Diabetes and smoking increased the odds of complications in all models. Odds of any complication, most notably infectious complications, were increased 20% by corticosteroids (OR 1.2; 95% CI: 1.1 to 1.3). More than three injections increased the odds of a complication by 70% (OR 1.7; 95% CI: 1.3 to 2.1). Hyaluronic acid increased the odds of wound-healing complications by 110% (OR 2.1; 95% CI: 1.3 to 3.4). Corticosteroid and hyaluronic acid injections for thumb carpometacarpal arthritis increase the odds of post-operative complications. Level of evidence: IV.

Long-term follow-up of first metacarpal extension osteotomy for early CMC arthritis

BACKGROUND

The purpose of this study was to evaluate long-term outcomes of first metacarpal extension osteotomy for early trapeziometacarpal arthritis.

METHODS

We retrospectively reviewed 13 patients who underwent first metacarpal extension osteotomy at our institution between 1996 and 2005 and obtained subjective and objective outcome data.

RESULTS

Mean follow-up was 9.9 years (range 6 to 14 years). Ten of the 13 patients (77 %) were either satisfied or very satisfied with their results. Mean pain level was 2.00 on a scale of 1 (nonexistent) to 7 (unbearable). Mean QuickDASH score was 24.17, with a median score of 9.09. Mean pinch strength was 13.1 lbs compared to 12.8 lbs in the nonoperative extremity. Mean radial abduction of the thumb was 45.5° which was equal to the nonoperative extremity. Of the eight patients who agreed to repeat radiographs, five had no progression of degenerative changes compared to pre-op radiographs.

CONCLUSIONS

Based on subjective and objective follow-up data, first metacarpal extension osteotomy can provide good long-term results in terms of patient satisfaction, pain relief, and upper extremity function. It is a reasonable alternative to ligament reconstruction in patients with early-stage trapeziometacarpal arthritis.