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Hitchhiker's Guide to Basal Joint Arthritis

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

Michael Gordon

on 24 January 2013

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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 Characteristics 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
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