Carpometacarpal ( C)


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Carpometacarpal ( C)

  1. 1. Carpometacarpal Joint Arthritis
  2. 2. Carpometacarpal (CMC) Arthritis
  3. 3. Carpometacarpal Joint Arthritis <ul><li>Most commonly surgically reconstructed area with OA in arm </li></ul><ul><li>Surgical indications </li></ul><ul><ul><li>- Refractory to non-operative treatment </li></ul></ul>
  4. 4. CMC Osteoarthritis <ul><li>Affects 16-25% of postmenopausal women </li></ul><ul><li>Causes pain swelling, instability, deformity & loss of motion </li></ul><ul><li>Radiographic evidence of basal joint arthritis </li></ul><ul><ul><li>1 in 4 women </li></ul></ul><ul><ul><li>1 in 12 men </li></ul></ul>
  5. 5. CMC Basic Science <ul><li>Four Articulations </li></ul><ul><ul><li>Trapeziometacarpal TM </li></ul></ul><ul><ul><li>Trapeziotrapezoid </li></ul></ul><ul><ul><li>Scaphotrapezial ST </li></ul></ul><ul><ul><li>Trapezium-Index Metacarpal </li></ul></ul><ul><li>CMC joint enables opposition & allows arcs of movement in 3 planes </li></ul><ul><ul><li>Flexion-extension </li></ul></ul><ul><ul><li>Abduction-adduction </li></ul></ul><ul><ul><li>opposition </li></ul></ul>
  6. 6. Saddle Joint <ul><li>Minimal osseous stability </li></ul><ul><li>Rely on static ligamentous constraints to limit MC base translation </li></ul><ul><li>5 stabilizing ligaments </li></ul><ul><ul><li>Anterior oblique </li></ul></ul><ul><ul><li>Posterior oblique </li></ul></ul><ul><ul><li>Anterior intermetacarpal </li></ul></ul><ul><ul><li>Posterior intermetacarpal </li></ul></ul><ul><ul><li>Dorsal radiocarpal </li></ul></ul>
  7. 7. Etiology <ul><li>Secondary to excessive basal joint laxity </li></ul><ul><li>Only the TM & ST joint lie along the longitudinal compression axis of the the thumb </li></ul><ul><ul><ul><li>Radiographic disease most commonly affects these 2 joints </li></ul></ul></ul>
  8. 8. Etiology <ul><li>During opposition axial rotation results in increased contact forces between opposing joint surfaces subjecting the cartilage to shear </li></ul>
  9. 9. Pathophysiologic Stages <ul><li>Cartilage is sheared & worn </li></ul><ul><li>Osteophytes in response to inflammation </li></ul><ul><li>Dorsoradial subluxation of the 1 st MC base </li></ul><ul><li>Excessive laxity & repetitive loading </li></ul><ul><li>MC adopts an adducted posture leading to functional deficits as the ability to spread the hand & palm compromised </li></ul><ul><ul><ul><li>Opening jars </li></ul></ul></ul><ul><ul><ul><li>Octave on a piano </li></ul></ul></ul><ul><li>Hyperextension at MCP joint as a result of this adduction deformity </li></ul><ul><li>Focal pain, diminished pinch strength, & narrowing of the functional hand width </li></ul>
  10. 10. Thumb Carpometacarpal Joint Arthritis <ul><li>Eaton classification of Radiographic stages of Thumb CMC OA </li></ul><ul><ul><li>1 - Normal appearance </li></ul></ul><ul><ul><li>2 - Joint space narrowing osteophytes < 2mm </li></ul></ul><ul><ul><li>3 - Sclerosis, Subchondral cysts osteophytes > 2mm </li></ul></ul><ul><ul><li>4 - Pantrapezial arthritis </li></ul></ul>
  11. 11. Demographics <ul><li>Incidence </li></ul><ul><ul><li>Prevalence in postmenopausal women </li></ul></ul><ul><ul><ul><li>Isolated carpometacarpal – 25% </li></ul></ul></ul><ul><ul><ul><li>Scaphotrapezial – 2% </li></ul></ul></ul><ul><ul><ul><li>Combined - 8% </li></ul></ul></ul><ul><ul><li>Symptomatic Arthritis </li></ul></ul><ul><ul><ul><li>28% isolated and 55% combined </li></ul></ul></ul><ul><li>Classification </li></ul><ul><ul><li>Interrater and intrarater variationof the Eaton Classification </li></ul></ul><ul><ul><ul><li>.6 </li></ul></ul></ul>
  12. 12. Clinical Findings <ul><li>Dorsoradial prominence of the thumb MC base secondary to subluxation, inflammation, & osteophytes </li></ul><ul><li>Adduction deformity later in disease </li></ul><ul><li>Point tenderness at CMC joint </li></ul><ul><li>MCP joint hyperextension & tenderness </li></ul><ul><li>Decreased ROM </li></ul><ul><li>Pinch strength decreased </li></ul><ul><li>TM Grind test (axial loading with MC rotation) </li></ul>
  13. 13. Thumb Carpometacarpal Joint Arthritis <ul><li>Differential diagnosis </li></ul><ul><ul><li>De Quervain’s (1 st compartment) tenosynovitis </li></ul></ul><ul><ul><li>Radial sensory neuritis </li></ul></ul><ul><ul><li>2 nd compartment dorsal tenosynovitis </li></ul></ul><ul><ul><li>Arthritis </li></ul></ul><ul><ul><ul><li>Metacarpophalangeal </li></ul></ul></ul><ul><ul><ul><li>Scaphtrapeziotrapezoid </li></ul></ul></ul><ul><ul><ul><li>Radiocarpal </li></ul></ul></ul>
  14. 14. Investigation <ul><li>Standard radiographic views of thumb (AP, lateral, oblique) </li></ul><ul><li>Provocatory views (lateral pinch) </li></ul><ul><li>Bone scan </li></ul><ul><li>Rule out other diagnosis </li></ul><ul><ul><li>Carpal tunnel </li></ul></ul><ul><ul><li>DeQuervains Tenosynovitis </li></ul></ul><ul><ul><li>Trigger Thumb </li></ul></ul>
  15. 15. Treatment Options Non-Operative <ul><li>Activity modification </li></ul><ul><li>Anti-Inflammatory medications </li></ul><ul><li>Splinting (Thumb spica) </li></ul><ul><ul><li>Study 114 thumbs </li></ul></ul><ul><ul><ul><li>Long thumb spica for 3-4 weeks continuously, then less </li></ul></ul></ul><ul><ul><ul><li>Stage 1 & 2 – 67% improved </li></ul></ul></ul><ul><ul><ul><li>Stage 3 & 4 – 54 % improved </li></ul></ul></ul><ul><ul><ul><li>At 6 months 55 % improvement in symptom severity </li></ul></ul></ul>
  16. 16. Various Splints
  17. 17. Intra-Articular steroid injections <ul><li>25 gauge from dorsoradial direction while traction on thumb (0.5 ml of steroid +/- local anaesthetic) </li></ul><ul><li>Ultrasound guided </li></ul>
  18. 18. Intra-articular injection <ul><li>Study </li></ul><ul><ul><li>Double blind randomized controlled trial of 5 mg triamcinolone vs saline </li></ul></ul><ul><ul><li>40 patients with OA </li></ul></ul><ul><ul><li>Assessments @ 4, 12, 24 weeks for joint tenderness, physician, patient global assessments </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>No clinical benefit in moderate to severe arthritis </li></ul></ul><ul><ul><li>Research should focus on the outcome of the first presentation of pain </li></ul></ul>
  19. 19. Treatment Options Surgical <ul><li>Indicated if pain persists & is severe enough to limit patients function & ADL’s…never for deformity alone </li></ul><ul><li>Generally </li></ul><ul><ul><ul><li>Osteotomy of thumb metacarpal </li></ul></ul></ul><ul><ul><ul><li>Resection arthroplasty with or without interposition of autologous material </li></ul></ul></ul><ul><ul><ul><li>Arthrodesis </li></ul></ul></ul>
  20. 20. Osteotomy of the Metacarpal <ul><li>Designed to offset the subluxing forces on the base of the MC </li></ul><ul><li>Usually closing wedge </li></ul>
  21. 21. Thumb Carpometacarpal Joint Arthritis Appearance of excised trapezium Courtesy of Donald H. Lee, MD
  22. 22. Volar Ligament Reconstruction <ul><li>Stage I : addresses laxity of the volar oblique ligament </li></ul><ul><li>Radial ½ of FCR is passed through hole made in MC base </li></ul><ul><li>Anchored with appropriate tension </li></ul>
  23. 23. Ligament Reconstruction Tendon Interposition (LRTI) <ul><li>Stage II / III / IV disease </li></ul><ul><li>Removal of the involved joint </li></ul><ul><ul><ul><li>partial trapeziectomy Stage II / III </li></ul></ul></ul><ul><ul><ul><li>Total trapeziectomy Stage IV </li></ul></ul></ul><ul><li>Slip of FCR to stabilize lax volar oblique ligament. </li></ul><ul><li>End of FCR then coiled and inserted into defect to maintain length and provide painless mobility. </li></ul>
  24. 25. Thumb Carpometacarpal Joint Arthritis <ul><ul><li>Excisional arthroplasty of trapezium with rolled tendon graft </li></ul></ul>
  25. 26. Tendon Interposition Arthroplasty <ul><li>Studies </li></ul><ul><ul><li>45 patients, follow-up 8 years; pain reduction in 93%, Function 90% of opposite hand, function improved in 90% . Damen et al, 1996 </li></ul></ul><ul><ul><li>28 patients, followup 3 years:; pain reduction very good in > 90%, 87% satisfaction, improved functional mobility but decreased key pinch. Rayan et al, 1997 </li></ul></ul>
  26. 27. Partial Trapeziectomy with ligament reconstruction and interposition costochondral graft <ul><li>Study </li></ul><ul><ul><li>41 patients, hemiresection arthroplasty, FCR, allograft costochondral reconstruction </li></ul></ul><ul><li>Result </li></ul><ul><ul><li>Absorption </li></ul></ul><ul><ul><li>90% improved </li></ul></ul>
  27. 28. Surgical Effects <ul><li>Thumb shortening </li></ul><ul><ul><li>In arthritis </li></ul></ul><ul><ul><li>More after surgery </li></ul></ul>
  28. 29. Arthrodesis <ul><li>Indications </li></ul><ul><ul><ul><li>when major correction of the position of the MC required & a procedure to correct MP Joint hyperextension </li></ul></ul></ul><ul><ul><ul><li>Young heavy labourers </li></ul></ul></ul><ul><li>Cartilage surfaces debrided, bone graft inserted, then K-Wire pinning, screw (cancellous lag) </li></ul><ul><li>40 0 abduction & 45 0 extension </li></ul><ul><li>Immobilize thumb spica </li></ul>
  29. 30. Trapeziometacarpal Arthrodesis <ul><li>Study: 49 patients, 7 year followup, fixation with K wires, use of a bone graft in most </li></ul><ul><li>Results: nonunion – 7%, pain – better, 20-25% developed peritrapezial arthrits </li></ul><ul><li>Recommended in isolated arthritis, care with thumb positioning, increased laxity of peritrapezial joints may cause laxity pain and arthritis </li></ul>
  30. 31. Carpometacarpal Joint Replacement <ul><li>De La Caffiniere </li></ul><ul><ul><li>Study – 93thumbs in 71 patients </li></ul></ul><ul><ul><li>Results – survival 89% @ 16 years, avoid in men < 65 </li></ul></ul><ul><li>Silicone </li></ul><ul><ul><li>84 % satisfaction in pain @ 16 years, strength improved </li></ul></ul><ul><ul><li>6 implant fractures, no frank silicone synovitis </li></ul></ul>
  31. 32. Arthroplasty <ul><li>Swanson Silicone Implant </li></ul><ul><li>Titanium Implants </li></ul>
  32. 33. Additional Surgical Options <ul><li>Replacement materials </li></ul><ul><ul><li>ePTFE (Goretex) , PTFE ( Marlex) </li></ul></ul><ul><ul><li>Tendons – FCR, Abd pollicis longus </li></ul></ul><ul><ul><li>Ceramic </li></ul></ul><ul><ul><li>Joint </li></ul></ul>
  33. 34. Comparison Studies Revision Pain (%) Procedure 0 71 Soft tissue arthroplasty 50 38 Hemiarthroplasty (Ashhworth-Blatt) 15 77 Swanson
  34. 35. Additional Surgical Considerations <ul><li>Scaphotrapezial arthriritis </li></ul><ul><li>Scaphotrapezoid arthritis </li></ul><ul><li>Hyperextension of the MCP joint </li></ul><ul><li>Subluxation of the thumb </li></ul><ul><li>Adduction contracture </li></ul>
  35. 36. Secondary MCPJ Deformity Hyperextension <ul><li>Less than 30 0 </li></ul><ul><ul><li>Transarticular K-Wire with joint in flexion for 4-5 weeks </li></ul></ul><ul><ul><li>Moving the extensor pollicis brevis from base of proximal phalanx to metacarpal shaft </li></ul></ul><ul><li>Greater than 30 0 </li></ul><ul><ul><li>Arthrodesis (unstable joint) </li></ul></ul><ul><ul><li>Volar capsulodesis </li></ul></ul>
  36. 37. End