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Hitchhiker's Guide to Basal Joint Arthritis

Thumb CMC arthritis, diagnosis, non operative and operative treatment
by

Michael Gordon

on 17 August 2017

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Transcript of Hitchhiker's Guide to Basal Joint Arthritis

Prevalence
Diagnosis of
CMC Arthritis:

Staging of Arthritis
Non Operative
Treatment

STAGE II-IV
Stage I
Operative Tx

IMPLANTS
Other Thoughts
Pain at the base of the thumb metacarpal
Activities: Opening Jar, Shaking Hands, Squeezing objects, pinching, gripping

ACTIVITY MODIFICATION
EATON LIGAMENT RECONSTRUCTION

WILSON METACARPAL EXTENSION OSTEOTOMY

ARTHROSCOPIC DEBRIDEMENT /STABILIZATION

Differential Diagnosis:
things not to misdiagnose . . .
CMC JOINT
DeQuervain's Tenosynovitis
Trigger Thumb
STT Arthritis
Scaphoid Fracture (non union)
SLAC wrist (radioscaphoid arthritis)
FCR Tendonitis
Ganglion Cyst
Stage I

Littler & Eaton Classification
RADIOGRAPHIC Characteris
tics 1973
Dell Classification 1978

Normal Xrays or
Widened TM Joint
TM Subluxation :

none
Normal Articular Contours
Stage II

Narrowing of cartilage space
TM subluxation < 1/3 of art. surf.
Osteophytes or loose bodies
LESS THAN 2 millimeters
Normal ST joint
STAGE III

Further TM narrowing
Subchondral cyst or sclerosis
Osteophytes > 2mm
Subluxation > 1/3 of joint
Normal ST joint
Stage IV
Advanced disease of TM

and ST joint
Pantrapezial arthritis
Two Biconcave
Saddle Joints
Joints Are NOT totally Congruent

Better Apposition in Extremes of Motion

This leads to Wear











Average arc of motion

53° for flexion-extension
42° for abduction-adduction
Ligamentous
Stability
Joints Are NOT totally Congruent

Better Apposition in Extremes of Motion

This leads to Wear











Average arc of motion

53° for flexion-extension
42° for abduction-adduction
AOL (SAOL & DAOL) is most significant capsular reinforcement

DAOL = BEAK LIGAMENT

Originates from the trapezium
Inserts into the volar beak of the thumb metacarpal
Key structure maintaining CMC joint stability
Resists dorsal radial subluxation during pinch
A reflection of transverse carpal ligament
Deep Ant Obl Lig
AKA—Beak ligament (Pellegrini)
Intra-articular ligament
Serves as a pivot point for rotation, specifically pronation
Stabilizes the thumb metacarpal against palmar subluxation
UCL
Extracapsular ligament
Taut in extension, abduction, and pronation
Slightly ulnar to the SAOL, which it partially covers
AOL most important ligament in joint stability and is commonly attenuated in cases of arthritis

IML, POL, and UCL are 2° stabilizers that become attenuated after failure of 1° stabilizer (AOL)

The DRL acts as a check-rein for gross radiodorsal subluxation or dislocation (Strauch, Behrman, Rosenwasser)
Palmar & Dorsal IML
Extracapsular ligaments
PIML: Taut in abduction, opposition supination
DIML: Taut in Pronation
Posterior Obl Lig
Capsular ligament
Partially covered by EPL
Resists ulnar translation of the metacarpal base during abduction and opposition
DORSAL RADIAL LIG
Capsular ligament
Widest and thickest of stabilizing ligaments of thumb CMC joint
Fan shaped
Appears to serve mainly as a check-rein to dorsal CMC subluxation or dislocation
Etiology
Primary Generalized Ostoearthritis
Rheumatoid Arthritis
Post Traumatic Arthritis
Gout
Congenital
Much more common in
Females > 60
25% Radiographically

Males less common
8% Radiographically
Suspensionplasty
(LRTI and Variants)

CAVEAT
Xray Findings do NOT necessarily indicate
level of pain
Splints/Orthotics
NSAIDs
Injections
EXERCISES / THERAPY
Key Covers, Knob enlargers
Special Tools
ABDUCTION
ISOMETRICS
Immobilize CMC Joint /
Decrease Stress on Joint
STRENGTHENING
Oral
Topical
Gel
Liquid
Patch
Steroids
Viscosupplementation (Supartz, Synvisc etc)
Stem Cells ?
Hylan Versus Corticosteroid Versus Placebo forTreatment of Basal Joint Arthritis: A Prospective,Randomized, Double-Blinded Clinical Trial
Heyworth et el JHS 2008

Conclusions: There were no
statistically significant differences
among hylan, steroid, and placebo injections for mostof the outcome measures at any of the follow-up time points. However, based on the durable relief of pain, improved grip strength, and the long-term improvement in symptoms compared with preinjection values,
hylan injections should be considered
in the management of basal joint arthritis of the thumb.
Volar ligament reconstruction
Eaton and Littler in 1973
Reconstruct the volar ligament with a strip of autogenous FCR tendon
Designed to stabilize the joint
Not a resurfacing procedure
Operative Treatment—Stage I (TM Joint Laxity)
Transverse arthrotomy made in CMC joint
Dorsovolar hole is made in base of thumb MC perpendicular to the long axis of MC and the plane of the thumbnail
Technique of Volar Ligament Reconstruction
FCR tendon
Technique of Volar Ligament Reconstruction
Rehabilitation after
Ligament Reconstruction
Immobilize for 4 weeks
Remove K Wire (if placed)
Splint for 1-2 weeks
Strengthening for 6-8 weeks
Options
Brunelli - Use APL instead of FCR
Outcomes
Eaton Technique:
72% no pain @ 5 years
28% rare discomfort
76% pich strength >=
contralateral side
Prevention of Arthritis
15/23 no progression @ 15 years
(Eaton JHS 1984)
(Glickel JHS 2000)
Wilson Osteotomy
Thumb Metacarpal Extension Osteotomy
Wilson & Bossley Br JBJS 1983
21 patients 2-17 yr f/u.
Mean age 48 years (38-67)
Indication—OA confined to the CMC joint
Improved “spread” of the hand and pain relief


Molitor, Emery & Meggitt Br J Hand Surg 1991
11 retrospective/5 prospective-all stages
Results in good pain relief and restoration of function
Wilson Osteotomy
Historical Perspective
"Stabilize the Joint & Prevent Future Subluxation"
Rehabilitation after Osteotomy

Splint for 10 days
Thumb spica cast vs orthoplast splint for 4 weeks (IP free)
K-wire removal @ 6 weeks
Grip/Pinch start at 8 weeks if
Xrays demonstrate healed
12 cases
F/U: 2.1 yrs
Results:
very satisfied: 8/12
satisfied: 3/12
dissatisfied: 1/12
Grip strength:
increased to 79% of contralateral
Pinch strength:
increased to 86% of contralateral
Tomaino. Hand Clinics 2001
Extension Osteotomy: Outcomes
1st CMC Joint
1st CMC Joint
1.9mm 30deg Short Barrel Arthroscope
2.0mm Shaving Instruments
Short Probe
20 Gauge Hypodermic Needle
Thermal Shrinking Probes
Arthroscopic Equipment
Minimally invasive
Feasible
Efficacious ??
Decision-making tool
Thumb CMC Arthroscopy
ARTHRITIC
Anterior Oblique Ligament
NORMAL
Arthrodesis
Arthroscopy
Trapeziectomy alone
Trapeziectomy with
Soft tissue Interposition
Suspension ligamentoplasty
Implant Arthroplasty

Ratio A/(A+B)
Day et al. (JHS 2004)
-prospective
-single steroid injection
-3 weeks of splinting
-30 patients with thumb CMC OA Stages I-IV

3 time points:
* once be- fore injection
* 6 weeks after injection
* minimum 18 months after the first examination.

Steroid injection with splinting for the treatment of thumb basal joint arthritis provided
short-term pain relief across stages for 1 month, but long-term relief was only reliably sustained in thumbs with Eaton-Glickel stage I disease.
37 patients age 20-50 (average: 33)
Follow-up average 4.2 years
Longest follow-up, 2004: 18 yrs
92% treated by another MD for a different diagnosis !!
Results:
Excellent: 67% (25 patients)
Good: 30% (11 patients)
Poor: 3% (1 patients)

Lane, LB JHS 2001
Ligament Reconstruction of the Non-arthritic Thumb CMC Joint
Criticisms
Predisposition to increased arthrosis at adjacent joints
Significant limitation in range of motion
Limited ability to flatten hand
Prolonged postoperative immobilization
Compensatory hyperextension of the MCP joint
Nonunion
13% rate
Late Stage II and Stage III
Arthrodesis
K-wires
Cerclage wires
Tension band wiring
Staples
Herbert screws
Internal Fixation Methods for Arthrodesis of Thumb CMC Joint
Distal phalanx of the thumb resting on the middle phalanx of the index finger of a fully clenched fist (Leach and Bolton)
Thumb MC in ~ 35-40° palmar abduction and ~ 10-15° extension
Position for Arthrodesis of Thumb CMC Joint
reliable
durable
useful for young, male laborers because
this preserves pinch strength
obviously, limits motion
transfers forces to neighboring joints
increased risk to develop DJD
Trapeziometacarpal Fusion
POST OP:

Immobilize for 6-8 weeks
K wire removal (if used)
Gentle ROM once fusion healed

OUTCOMES : ARTHRODESIS

14 pts
Union all cases
64% "excellent or very good"
Acta Chir Orthop Traumatol Cech 2006
OUTCOMES : ARTHROSCOPIC DEBRIDEMENT

FURIA (arthroscopy 2010)

Retrospective Cohort
Stage I-II
44 patients

Arthroscopy Control
VAS 65% decrease 3% decrease
DASH 55% decrease 2% decrease
pinch str. 50% INcrease 7% INcrease
HEMOTOMA DISTRACTION
ARTHROPLASTY
Pinning of MC to Scaphoid after
excision of Trapezium

Allows hematoma formation

Thought to prevent subsidence
TRAPEZIECTOMY
15 patients
13 Osteoarthritis
2 Inflamatory arthritis
Immediate mobilization
Results
OA : all did well
Inflamatory : “poorer results”
Gervis 1949
REHAB AFTER
TRAPEZIECTOMY
Immobilize for 6 weeks until pin removal
Short Opponens Splint for 2 more weeks
Begin AROM of thumb after k-wires removed
OUTCOMES: TRAPEZIECOMY
-Better with Pinning
-Less Subsidence
Some authors :
results similar to LRTI
outcomes
LRTI vs Simple Excision
65 pts randomly assigned
Stage III or IV
Both groups - Immobilized 4 weeks
Therapy 4-6 weeks post op
12 months: no difference between
pain scores
grip, key and pinch strenth
SHORT TERM F/U
Trapeziectomy
WITH
Soft tissue Interposition
Weilby Arthroplasty
Outcomes:
Post Op Protocol
106 pts followed
82% decrease VAS pain
75% increase pinch strenth
50% increase in grip strenth
82% "definitely worth" or
"largely worth"
time to recover
Boeckstyns JHS B 2009
No K-Wires (or removal)
4 weeks of immobilization
Therapy for 4-6 weeks
Currently favored technique of basal joint recontruction
Ligament Reconstruction with Tendon Interposition (LRTI) arthroplasty
Thumb MC base is stabilized by volar ligament
Burton and Pellegrini—1986
LRTI
interposition of tendon in open space always done

otherwise contact between 1st MC and trapezoid or scaphoid after 1st MC settles

settling or shortening of thumb almost always occurs over time

good long term results reported

Variations FCR, APL, ECRL
LRTI
Randomized prospective study of 153 thumbs with basal joint arthritis
(174 initially operated on)
Treated w/ simple trapeziectomy, trapeziectomy w/ PL interposition, or trapeziectomy w/ LRTI
Median 6 year f/u (5-18 years)
All Women – 1992 – 2001 (21 women bilateral surgery)
50 @ 5 years
81 @ 6-9 years
22 @ 10-18 years

Tim R C Davis JHS 2012
5 to 18 Year follow up on:
Excision vs
Excision w/ PL Interposition vs
Excision w/ LRTI
NO DIFFERENCES IN LONG TERM F/U

Pain
Strength (Grip Key Pinch)
Function
ROM
Complications

(slightly longer OR time for T+LRTI)
ALL THUMBS:
pinned through scaphoid
pins removed at 4 weeks
immobilized for 6 weeks
therapy with strengthening
STUDY LIMITATIONS
Pinning of Trapeziectomy alone (original description did not pin the space)

F/U not completely uniform (5-18 years)

NO xrays used in f/u - only functional and pain outcomes
Ligament Reconstruction with or without Tendon Interposition to Treat Primary Thumb Carpo-metacarpal Osteoarthritis
Ligament Reconstruction with or without Tendon Interposition to Treat Primary Thumb Carpo-metacarpal Osteoarthritis
Ligament Reconstruction with or without Tendon Interposition to Treat Primary Thumb Carpo-metacarpal Osteoarthritis
Ligament Reconstruction with or without Tendon Interposition to Treat Primary Thumb Carpo-metacarpal Osteoarthritis
Ligament Reconstruction with or without Tendon Interposition to Treat Primary Thumb Carpo-metacarpal Osteoarthritis
RESULTS 15 LR 16 LRTI
mean f/u 48 months
LR - better radial abduction, cosmesis
more willing to have 2nd surgery

Otherwise no significant differences...
Histocompatibility
Foreign body reaction
Mechanical compatibility
Implant material durability
Bone erosion: subsidence, loosening; dislocation
Revision options

PRICE $$$$
Concerns with Implant Arthroplasty
Dorsal Stabilized CMC Prosthesis
Proposed
Current
HemiSphere, Saddle and NuGrip PyroCarbon Implant Hemi-Arthroplasty for the Thumb CMC Joint
Silicone (Swanson, Niebauer)

Constrained v. non-constrained

Cemented v. press-fit

Cobalt chrome (de la Caffiniere)

Ceramic (Orthosphere)

Titanium

Pyrolytic Carbon (Beckenbaugh) - metacarpal resurfacing hemiarthroplasty
Implant Arthroplasty of the Thumb CMC Joint for stages II - IV
PyroCarbon Saddle Implant Hemi-Arthroplasty Right Thumb CMC Joint
2.5 years postop
PyroCarbon Saddle Implant Arthroplasty for Stage III Degenerative Arthritis Thumb CMCJ
PyroCarbon HemiSpheric Implant Arthroplasty Right Thumb CMC Joint
3.5 years postop
PyroCarbon HemiSpheric Implant Arthroplasty for stage III Degenerative Arthritis Thumb CMCJ Joint
Hemiarthroplasty
Ashworth-Blatt
Swanson silicone
Kessler stemmed
Niebauer
Eaton
Swanson titanium
Interposition Arthroplasty
Kessler silicone sheet
Kessler Proplast
Gore-tex
Sphere
Total joint arthroplasty
De la Caffiniere
Braun
Mayo
Steffee
Nahigian
Implant Menu
Current Trends in Nonoperative and Operative Treatment of Trapeziometacarpal Osteoarthritis: A Survey of US Hand Surgeons

SURVEY
mailed to 2326 surgeons
responded 1156
Hinging
No
Yes
Trapezioplasty
(Restoring the saddle shape by removing the palmar ridge osteophyte)
Correction of Subluxation
----------- FCR
FCR --------
Stage III
Palmar Ridge Osteophyte
110°
Palmar Ridge Osteophyte
----------
Palmar Ridge Osteophyte
Trapezial Deformity
Subchondral cysts at metacarpal base
Technically challenging
Bony healing
The need to pin the CMC x 4 wks
Difficulties
Persistent
Subluxation
1st MC Osteotomy
Pre-existing Subluxation
Does not correct subluxation
Stages 1&2 only
Alternatives to Resection
Implant replacement
1st MC osteotomy
Arthroscopic debridement
Arthrodesis
Full transcript