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Basal Joint Arthritis of the Thumb Christian Veillette, MD, MSc, BSc(Hon) Orthopaedic Resident PGY-4 Upper Extremity Round...
Objectives <ul><li>Epidemiology </li></ul><ul><li>Etiology </li></ul><ul><li>Anatomy and Biomechanics </li></ul><ul><li>Pa...
Epidemiology <ul><li>Trapeziometacarpal joint  OA - common </li></ul><ul><ul><li>1 in 4 women </li></ul></ul><ul><ul><li>1...
Etiology <ul><li>Osteoarthritis </li></ul><ul><li>Inflammatory arthritis </li></ul><ul><li>Hypermobile laxity </li></ul><u...
Anatomy and Biomechanics <ul><li>Shallow saddle-joint architecture </li></ul><ul><ul><li>little intrinsic osseous stabilit...
Anatomy and Biomechanics <ul><li>Grasping and pinching functions of the thumb involve three arcs of motion: </li></ul><ul>...
Anatomy and Biomechanics <ul><li>Opposition </li></ul><ul><ul><li>Axial rotation at TM joint </li></ul></ul><ul><ul><li>Sh...
Role of palmar beak ligament <ul><li>Pellegrini  et. al Contact patterns in the trapeziometacarpal  joint:  The  role  of ...
Anatomy and Biomechanics <ul><li>Primary ligamentous stabilizers of TM joint </li></ul><ul><li>Anterior oblique or “volar ...
Anatomy <ul><li>Adductor pollicis longus spans the .V. between the thumb and index metacarpals </li></ul><ul><li>Abductor ...
Pathoanatomy <ul><li>Unique architecture of basal joint allows its varied  functions but predisposes it to unusual wear pa...
Pathoanatomy <ul><li>Progression theory </li></ul><ul><ul><li>Excessive laxity + repetitive loads </li></ul></ul><ul><ul><...
Diagnosis <ul><li>Typical patient </li></ul><ul><ul><li>50-70 year-old woman, radial-side hand or thumb pain </li></ul></u...
Clinical Exam <ul><li>“ Shoulder sign” = dorsoradial prominence </li></ul><ul><ul><li>Subluxation </li></ul></ul><ul><ul><...
Clinical Exam <ul><li>Focal tenderness </li></ul><ul><ul><li>dorsal + volar to APL/EPB </li></ul></ul><ul><ul><li>MP: vola...
Clinical Exam <ul><li>Special tests </li></ul><ul><ul><li>“ Grind Test”: axial load + MC rotation </li></ul></ul><ul><ul><...
Imaging <ul><li>“ Poor correlation between X-rays + symptomatic disease” </li></ul><ul><ul><li>Swanson JBJS-A (54) 1972 </...
Classification - Eaton <ul><li>Stage I </li></ul><ul><ul><li>TM – Precedes cartilage degeneration </li></ul></ul><ul><ul><...
Classification <ul><li>Stage II </li></ul><ul><ul><li>TM narrowing </li></ul></ul><ul><ul><li>TM contours still normal </l...
Classification <ul><li>Stage III </li></ul><ul><ul><li>TM joint destruction </li></ul></ul><ul><ul><li>TM joint sclerosis,...
Classification <ul><li>Stage IV </li></ul><ul><ul><li>Advanced disease TM and ST joints </li></ul></ul>Exact  risk  and  r...
Differential Diagnosis <ul><li>OA/RA </li></ul><ul><li>Hypermobile Laxity </li></ul><ul><li>Trauma </li></ul><ul><li>Infla...
Non-operative Treatment <ul><li>Education </li></ul><ul><li>Activity modification </li></ul><ul><ul><li>less forceful pinc...
Splinting <ul><li>Long Opponens/Thumb spica </li></ul><ul><ul><li>Full time    3-4 weeks </li></ul></ul><ul><ul><li>Part ...
Operative Indications <ul><li>Persistent pain  </li></ul><ul><li>Functional disability </li></ul><ul><li>Failure conservat...
Principles of Surgery <ul><li>Pain relief </li></ul><ul><li>Maintain function/strength </li></ul><ul><ul><li>Grip </li></u...
Procedures <ul><li>Trapezium Excision </li></ul><ul><li>Excision + Rolled Tendon Graft (ANCHOVY) </li></ul><ul><li>Silicon...
Algorithm JAAOS. 2000;8:314-323
Trapezium Excision <ul><li>Gervis WH  JBJS Br  1949;31:537-539. </li></ul><ul><ul><li>Excision of the trapezium for osteoa...
Arthrodesis – TM Joint <ul><li>Younger patients (<50 yrs) + High demand </li></ul><ul><li>Advantages </li></ul><ul><ul><li...
Arthrodesis – TM Joint <ul><li>Cavallazzi RM J. Hand Surg. 1986;11B </li></ul><ul><ul><li>Trapeziometacarpal arthrodesis t...
Anchovy <ul><li>Trapezium Excision </li></ul><ul><li>Rolled Tendon Graft </li></ul><ul><li>FCR tendon interposition </li><...
Silicone Arthroplasty <ul><li>Lower demand + Rheumatoid </li></ul><ul><li>Concerns: </li></ul><ul><ul><li>Weakness </li></...
Silicone Arthroplasty <ul><li>Sollerman J. Hand Surg. 13B 1988 </li></ul><ul><ul><li>12 year f/u </li></ul></ul><ul><ul><l...
Osteotomy <ul><li>Base of thumb metacarpal, unload volar portion TM joint </li></ul><ul><li>Wilson JBJS 65B:179, 1983 </li...
Volar Ligament Reconstruction <ul><li>Radial ½ FCR distal, ulnar ½ proximal </li></ul><ul><li>Hole in thumb MC base – dors...
Volar Ligament Reconstruction <ul><li>Eaton et. al. J. Hand Surg. 9A(5) 1984 </li></ul><ul><ul><li>Eaton Stage I-II </li><...
Volar Ligament Reconstruction <ul><li>Long-term results: 15 years </li></ul><ul><li>Freedman,Eaton,Glickel. J. Hand Surg. ...
Ligament Reconstruction with Tendon Interposition Arthroplasty (LRTI) <ul><li>Burton RI, Pellegrini VD. J. Hand Surg. 11A(...
 
LRTI - Results 8% 95% excellent 3 21 Horn resection Double LRTI Baron,Eaton J. Hand Surg 1998 13% 95% excellent 9 24 Excis...
Double Interposition Arthroplasty <ul><li>Eaton Stage IV </li></ul><ul><li>Maintains height ratio </li></ul><ul><ul><li>PP...
PubMed <ul><li>Search for “thumb arthritis randomized trial” </li></ul><ul><li>2 results: </li></ul><ul><li>Randomized, pr...
Ligament reconstruction with or without tendon interposition to treat primary thumb carpometacarpal osteoarthritis. A pros...
Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition. <ul><li>...
Recommendations <ul><li>Stage I (Laxity + Instability) </li></ul><ul><ul><li>Eaton Procedure (Volar Ligament Reconstructio...
Complications <ul><li>Neurologic </li></ul><ul><ul><li>Radial Nerve : Dorsal sensory branch </li></ul></ul><ul><ul><li>Med...
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Basal Joint Arthritis Of The Thumb

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Transcript of "Basal Joint Arthritis Of The Thumb"

  1. 1. Basal Joint Arthritis of the Thumb Christian Veillette, MD, MSc, BSc(Hon) Orthopaedic Resident PGY-4 Upper Extremity Rounds 2004 St. Michael’s Hospital
  2. 2. Objectives <ul><li>Epidemiology </li></ul><ul><li>Etiology </li></ul><ul><li>Anatomy and Biomechanics </li></ul><ul><li>Pathoanatomy </li></ul><ul><li>Diagnosis </li></ul><ul><li>Imaging </li></ul><ul><li>Classification </li></ul><ul><li>Treatment Options </li></ul><ul><li>Literature Review </li></ul><ul><li>Complications </li></ul>
  3. 3. Epidemiology <ul><li>Trapeziometacarpal joint OA - common </li></ul><ul><ul><li>1 in 4 women </li></ul></ul><ul><ul><li>1 in 12 men </li></ul></ul><ul><li>The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. Armstrong et al. J Hand Surg [Br]. 1994 Jun;19(3):340-1 </li></ul><ul><ul><li>143 post-menopausal women </li></ul></ul><ul><ul><li>radiological prevalence </li></ul></ul><ul><ul><ul><li>isolated carpometacarpal OA – 25% </li></ul></ul></ul><ul><ul><ul><li>Isolated scapho-trapezial OA – 2% </li></ul></ul></ul><ul><ul><ul><li>combined carpometacarpal and scapho-trapezial OA - 8% </li></ul></ul></ul><ul><ul><li>Symptomatic – basal thumb pain </li></ul></ul><ul><ul><ul><li>28% with isolated carpometacarpal OA </li></ul></ul></ul><ul><ul><ul><li>55% with combined carpometacarpal/scapho-trapezial OA </li></ul></ul></ul><ul><li>“ The most frequent site in the upper extremity in need of surgery for disabling osteoarthritic disease” Pellegrini Clin. Orthop 23(1) 1992 </li></ul>
  4. 4. Etiology <ul><li>Osteoarthritis </li></ul><ul><li>Inflammatory arthritis </li></ul><ul><li>Hypermobile laxity </li></ul><ul><ul><li>young females </li></ul></ul><ul><li>Connective tissue disorders </li></ul><ul><li>Failed reconstructive procedures </li></ul><ul><li>Trauma </li></ul><ul><ul><li>Bennett’s/Rolando Fractures </li></ul></ul><ul><ul><li>Dislocations </li></ul></ul><ul><ul><li>Ligamentous injuries </li></ul></ul><ul><li>No longitudinal natural history study has established clear etiology for basal joint disease </li></ul><ul><li>Strong association between excessive basal joint laxity  development of premature degenerative changes </li></ul>
  5. 5. Anatomy and Biomechanics <ul><li>Shallow saddle-joint architecture </li></ul><ul><ul><li>little intrinsic osseous stability </li></ul></ul><ul><ul><li>must rely on static ligamentous constraints </li></ul></ul><ul><li>Four trapezial articulations </li></ul><ul><ul><li>Trapeziometacarpal (TM) </li></ul></ul><ul><ul><li>Scaphotrapezial (ST) </li></ul></ul><ul><ul><li>Trapeziotrapezoid </li></ul></ul><ul><ul><li>Trapezium-Index metacarpal </li></ul></ul><ul><li>Only the TM and ST joints lie along the longitudinal compression axis of the thumb </li></ul><ul><li>Radiographic disease most commonly affects TM and ST joints </li></ul><ul><li>Term pantrapezial arthritis is somewhat misleading </li></ul>
  6. 6. Anatomy and Biomechanics <ul><li>Grasping and pinching functions of the thumb involve three arcs of motion: </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><ul><li>TM joint compression </li></ul><ul><ul><li>=12 x thumb-index pinch </li></ul></ul><ul><ul><li>Cooney 1977 JBJS </li></ul></ul><ul><li>Differential radius of curvature </li></ul><ul><ul><li>Maximal congruence at extremes Ab/Adduction </li></ul></ul>
  7. 7. Anatomy and Biomechanics <ul><li>Opposition </li></ul><ul><ul><li>Axial rotation at TM joint </li></ul></ul><ul><ul><li>Shear forces </li></ul></ul><ul><ul><li>Flexion-adduction  Volar articular surface concentration </li></ul></ul><ul><ul><li>Minimal dorsal contact </li></ul></ul><ul><ul><li>Palmar pattern joint surface wear </li></ul></ul>
  8. 8. Role of palmar beak ligament <ul><li>Pellegrini et. al Contact patterns in the trapeziometacarpal joint: The role of the palmar beak ligament. J Hand Surg [Am] 1993;18:238-244 </li></ul><ul><ul><li>23 cadaver forearm specimens </li></ul></ul><ul><ul><li>Loaded to simulate lateral pinch, and pressure-sensitive film used to record joint contact patterns in functional positions </li></ul></ul><ul><ul><li>palmar compartment of TM joint was primary contact area during flexion adduction </li></ul></ul><ul><ul><li>Simulation of dynamic pinch and release produced dorsal enlargement of contact pattern  physiologic translation of the metacarpal on the trapezium </li></ul></ul><ul><ul><li>Detachment of palmar beak ligament resulted in dorsal translation of the contact area  producing a pattern similar to that of cartilage degeneration seen in the osteoarthritic joint </li></ul></ul><ul><ul><li>End-stage osteoarthritic specimens had a nonfunctional beak ligament and demonstrated a pathologic total contact pattern of joint congruity </li></ul></ul>
  9. 9. Anatomy and Biomechanics <ul><li>Primary ligamentous stabilizers of TM joint </li></ul><ul><li>Anterior oblique or “volar beak” ligament </li></ul><ul><ul><li>Tethers base of thumb metacarpal to trapezium  1 o restraint to dorsoradial subluxation </li></ul></ul><ul><ul><li>Supported by clinical success of volar ligament reconstruction </li></ul></ul><ul><li>Dorsoradial ligament </li></ul><ul><ul><li>1 o restraint to dorsal translation </li></ul></ul><ul><ul><li>Supported by cadaver studies simulating acute dorsal TM joint dislocations </li></ul></ul>
  10. 10. Anatomy <ul><li>Adductor pollicis longus spans the .V. between the thumb and index metacarpals </li></ul><ul><li>Abductor pollicis longus inserts at the base of the thumb metacarpal and causes dorsal subluxation in absence of sufficient ligamentous stability </li></ul><ul><li>Intermetacarpal ligament is an extracapsular tether between the two metacarpals </li></ul><ul><li>Palmar (anterior) oblique ligament is eccentrically positioned and tightens with thumb metacarpal pronation </li></ul><ul><li>Flexor carpi radialis tendon </li></ul>
  11. 11. Pathoanatomy <ul><li>Unique architecture of basal joint allows its varied functions but predisposes it to unusual wear patterns when joint is unstable </li></ul><ul><li>Rate of degeneration influenced by the forces subjected to over the course of time </li></ul><ul><li>Repetitive thumb pinch are at greater risk for developing symptomatic basal joint disease than the average person </li></ul><ul><li>No consistent relationship between symptoms and degree of radiographic evidence basal joint degeneration </li></ul><ul><li>Series of steps in joint degeneration </li></ul>
  12. 12. Pathoanatomy <ul><li>Progression theory </li></ul><ul><ul><li>Excessive laxity + repetitive loads </li></ul></ul><ul><ul><li>Synovitis </li></ul></ul><ul><ul><li>Osteophytes + joint space narrowing </li></ul></ul><ul><ul><li>Attenuation/insufficient volar beak ligament </li></ul></ul><ul><ul><li>Dorsal radial subluxation of 1 st MC base </li></ul></ul><ul><ul><li>Adducted posture of 1 st MC </li></ul></ul><ul><ul><ul><li>Distal aspect tethered to 2 nd MC by adductor policis </li></ul></ul></ul><ul><ul><li>Metacarpophalangeal joint hyperextension </li></ul></ul><ul><li>Progressive functional deficit </li></ul><ul><ul><li>Decreased grip </li></ul></ul><ul><ul><li>Narrowed palm, functional hand width </li></ul></ul>
  13. 13. Diagnosis <ul><li>Typical patient </li></ul><ul><ul><li>50-70 year-old woman, radial-side hand or thumb pain </li></ul></ul><ul><ul><li>Insidious onset, duration from several months to several years </li></ul></ul><ul><ul><li>Exacerbated by common activities (handwriting, holding heavier books, turning doorknobs or keys in locks, doing needlepoint, using scissors) </li></ul></ul><ul><ul><li>Pain relieved by rest, NSAIDS, splint </li></ul></ul><ul><ul><li>Functional limitations vary depending on patient’s vocation and hand dominance </li></ul></ul><ul><ul><li>Older individuals complain of progressive inability to perform ADLs (opening jar tops by hand, opening cans with can opener) </li></ul></ul><ul><li>Less commonly </li></ul><ul><ul><li>women in 20s or 30s </li></ul></ul><ul><ul><li>pain in the thenar eminence due to TM joint synovitis </li></ul></ul><ul><ul><li>associated excessive joint laxity </li></ul></ul><ul><ul><li>pain may radiate up radial aspect of the forearm with certain activities, especially extensive writing </li></ul></ul><ul><ul><li>may complain of muscle cramping in the first web space and thenar eminence </li></ul></ul>
  14. 14. Clinical Exam <ul><li>“ Shoulder sign” = dorsoradial prominence </li></ul><ul><ul><li>Subluxation </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Osteophytes </li></ul></ul><ul><li>Adduction contracture </li></ul><ul><li>MP hyperextension collapse </li></ul>
  15. 15. Clinical Exam <ul><li>Focal tenderness </li></ul><ul><ul><li>dorsal + volar to APL/EPB </li></ul></ul><ul><ul><li>MP: volar plate + UCL </li></ul></ul><ul><ul><li>ST joint – 1 cm proximal to TM joint </li></ul></ul><ul><li>ROM </li></ul><ul><ul><li>Radial + palmar abduction </li></ul></ul><ul><ul><li>Active + passive pinch (MP hyperextension collapse) </li></ul></ul><ul><li>Laxity </li></ul><ul><ul><li>Dorsovolar: Beak ligament attenuated </li></ul></ul><ul><ul><li>Radioulnar </li></ul></ul><ul><ul><li>Generalized laxity testing </li></ul></ul><ul><li>Neurovascular </li></ul>
  16. 16. Clinical Exam <ul><li>Special tests </li></ul><ul><ul><li>“ Grind Test”: axial load + MC rotation </li></ul></ul><ul><ul><li>“ Crank Test” : axial load + flexion/extension </li></ul></ul><ul><ul><li>Pinch Test – MP hyperextension collapse </li></ul></ul><ul><ul><li>Distraction Test – relief of pain </li></ul></ul>
  17. 17. Imaging <ul><li>“ Poor correlation between X-rays + symptomatic disease” </li></ul><ul><ul><li>Swanson JBJS-A (54) 1972 </li></ul></ul><ul><li>X-rays- 3 views </li></ul><ul><ul><li>Pronated AP </li></ul></ul><ul><ul><li>Lateral </li></ul></ul><ul><ul><li>Oblique </li></ul></ul><ul><li>Special X-rays </li></ul><ul><ul><li>Stress view – basal joint subluxation </li></ul></ul><ul><ul><li>Pinch lateral - assess basal joint height, follow up measurements </li></ul></ul>
  18. 18. Classification - Eaton <ul><li>Stage I </li></ul><ul><ul><li>TM – Precedes cartilage degeneration </li></ul></ul><ul><ul><li>TM - Contours normal </li></ul></ul><ul><ul><li>TM - Joint space widening if effusion/synovitis </li></ul></ul><ul><ul><li>TM stress subluxation </li></ul></ul><ul><ul><li>ST joint normal </li></ul></ul>Eaton, Lane, Littler. J. Hand Surg. 9A 1984
  19. 19. Classification <ul><li>Stage II </li></ul><ul><ul><li>TM narrowing </li></ul></ul><ul><ul><li>TM contours still normal </li></ul></ul><ul><ul><li>TM joint osteophytes <2mm </li></ul></ul><ul><ul><li>ST joint Normal </li></ul></ul>
  20. 20. Classification <ul><li>Stage III </li></ul><ul><ul><li>TM joint destruction </li></ul></ul><ul><ul><li>TM joint sclerosis, cystic changes </li></ul></ul><ul><ul><li>TM joint osteophytes >2mm </li></ul></ul><ul><ul><li>ST joint normal </li></ul></ul>
  21. 21. Classification <ul><li>Stage IV </li></ul><ul><ul><li>Advanced disease TM and ST joints </li></ul></ul>Exact risk and rate of progression cannot be precisely delineated. No longitudinal studies
  22. 22. Differential Diagnosis <ul><li>OA/RA </li></ul><ul><li>Hypermobile Laxity </li></ul><ul><li>Trauma </li></ul><ul><li>Inflammation </li></ul><ul><ul><li>Dequervain’s </li></ul></ul><ul><ul><li>Stenosing flexor synovitis </li></ul></ul><ul><li>Carpal Tunnel </li></ul><ul><li>Trigger Thumb </li></ul><ul><li>Wrist ganglia </li></ul><ul><li>Carpal instability </li></ul><ul><li>Metabolic </li></ul><ul><li>Tumour </li></ul><ul><li>Infection </li></ul><ul><li>Referred pain </li></ul>
  23. 23. Non-operative Treatment <ul><li>Education </li></ul><ul><li>Activity modification </li></ul><ul><ul><li>less forceful pinching, alternating hand use, switching to larger diameter writing instruments and golf grips, using reading stand to hold books </li></ul></ul><ul><li>NSAIDS </li></ul><ul><li>Intra-articular steroid injections </li></ul><ul><li>Physiotherapy </li></ul><ul><ul><li>thenar/adductor stretching & strengthening </li></ul></ul><ul><li>Splinting </li></ul>
  24. 24. Splinting <ul><li>Long Opponens/Thumb spica </li></ul><ul><ul><li>Full time  3-4 weeks </li></ul></ul><ul><ul><li>Part time  3-4 weeks + night use </li></ul></ul><ul><ul><li>Prefabricated versions appear to be less effective and less comfortable than a well-fitted custom splint </li></ul></ul><ul><li>Swigart et al. J. Hand Surg. 24A(1)1999 </li></ul><ul><ul><li>Stage I-II – 76 % </li></ul></ul><ul><ul><li>StageIII-IV – 54 % </li></ul></ul><ul><ul><li>sufficient symptomatic relief to allow continued activities with intermittent time-limited splint use </li></ul></ul><ul><ul><li>19% progress to surgery </li></ul></ul>
  25. 25. Operative Indications <ul><li>Persistent pain </li></ul><ul><li>Functional disability </li></ul><ul><li>Failure conservative treatment </li></ul><ul><li>Compliant patient </li></ul>
  26. 26. Principles of Surgery <ul><li>Pain relief </li></ul><ul><li>Maintain function/strength </li></ul><ul><ul><li>Grip </li></ul></ul><ul><ul><li>Pinch </li></ul></ul><ul><li>Ligamentous stability </li></ul><ul><li>Carpal height </li></ul><ul><li>Hyperextension collapse at MCP joint </li></ul><ul><ul><li>Cause of failed surgical treatment </li></ul></ul><ul><li>Intraoperative Staging </li></ul><ul><ul><li>Assess cartilage erosion: T-M, S-T joints </li></ul></ul>
  27. 27. Procedures <ul><li>Trapezium Excision </li></ul><ul><li>Excision + Rolled Tendon Graft (ANCHOVY) </li></ul><ul><li>Silicone Arthroplasty </li></ul><ul><li>Arthrodesis </li></ul><ul><li>Osteotomy 1st MC </li></ul><ul><li>Volar Ligament Reconstruction (EATON Procedure) </li></ul><ul><li>Ligament Reconstruction + Tendon Interposition Arthroplasty (LRTI)(BURTON) </li></ul><ul><li>Double Interposition Arthroplasty </li></ul><ul><li>Interposition Costochondral Allograft </li></ul><ul><li>Cemented Arthroplasty </li></ul><ul><li>Cementless Arthroplasty </li></ul><ul><li>Ceramic Arthroplasty </li></ul>
  28. 28. Algorithm JAAOS. 2000;8:314-323
  29. 29. Trapezium Excision <ul><li>Gervis WH JBJS Br 1949;31:537-539. </li></ul><ul><ul><li>Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint </li></ul></ul><ul><li>Burton RI. Orthop. Clin North Am. 1986;17;493-503 </li></ul><ul><ul><li>Loss of pinch strength </li></ul></ul><ul><ul><li>Instability CMC joint </li></ul></ul><ul><ul><li>Proximal MC migration </li></ul></ul><ul><ul><li>MCP hyperextension instability </li></ul></ul><ul><li>Trapezium excision should be limited to the painfully arthritic TM joint in the low-demand elderly patient without evidence of significant subluxation </li></ul>
  30. 30. Arthrodesis – TM Joint <ul><li>Younger patients (<50 yrs) + High demand </li></ul><ul><li>Advantages </li></ul><ul><ul><li>Reliable pain reduction </li></ul></ul><ul><ul><li>Maintain ADL’s </li></ul></ul><ul><ul><li>Improved grip </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Adjacent joint arthrosis </li></ul></ul><ul><ul><li>ROM (key pinch) </li></ul></ul><ul><ul><li>Hand flattening </li></ul></ul><ul><ul><li>MCP hyperextension </li></ul></ul><ul><ul><li>Nonunion 13%-29% </li></ul></ul>
  31. 31. Arthrodesis – TM Joint <ul><li>Cavallazzi RM J. Hand Surg. 1986;11B </li></ul><ul><ul><li>Trapeziometacarpal arthrodesis today: why? </li></ul></ul><ul><ul><li>10 year f/u, 42 patients </li></ul></ul><ul><ul><li>Relief of pain, maintenance of stability </li></ul></ul><ul><ul><li>Good function </li></ul></ul><ul><ul><li>Patients pleased </li></ul></ul><ul><li>Primary indications </li></ul><ul><ul><li>Salvage of failed reconstruction </li></ul></ul><ul><ul><li>Treatment of manual laborer </li></ul></ul><ul><li>Optimal position of fusion for thumb CMC joint </li></ul><ul><ul><li>20 o of radial abduction </li></ul></ul><ul><ul><li>40 o of palmar abduction </li></ul></ul>
  32. 32. Anchovy <ul><li>Trapezium Excision </li></ul><ul><li>Rolled Tendon Graft </li></ul><ul><li>FCR tendon interposition </li></ul><ul><li>Froimson. Clin. Orthop. (70): 191-199 1970 </li></ul><ul><ul><li>30% Decrease pinch strength </li></ul></ul><ul><ul><li>50% Loss joint space @ 6 yrs </li></ul></ul><ul><li>APL tendon interposition </li></ul><ul><li>Robinson J. Hand Surg. 16A:504-9, 1991 </li></ul><ul><ul><li>39 patients </li></ul></ul><ul><ul><li>50% excellent (no pain, full ROM, normal grip) </li></ul></ul><ul><ul><li>35% good (75% ROM) </li></ul></ul>
  33. 33. Silicone Arthroplasty <ul><li>Lower demand + Rheumatoid </li></ul><ul><li>Concerns: </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Dislocation </li></ul></ul><ul><ul><li>Fracture </li></ul></ul><ul><ul><li>Deformation </li></ul></ul><ul><ul><li>Osteolysis </li></ul></ul><ul><ul><li>Synovitis </li></ul></ul><ul><ul><li>Immunologic alterations </li></ul></ul>
  34. 34. Silicone Arthroplasty <ul><li>Sollerman J. Hand Surg. 13B 1988 </li></ul><ul><ul><li>12 year f/u </li></ul></ul><ul><ul><li>51-84 % carpal erosion </li></ul></ul><ul><li>Pellegrini, Burton J. Hand Surg. 1996 20A </li></ul><ul><ul><li>4 year f/u </li></ul></ul><ul><ul><li>25% clinical failure </li></ul></ul><ul><ul><li>35% subluxation </li></ul></ul><ul><ul><li>50% loss of height </li></ul></ul>
  35. 35. Osteotomy <ul><li>Base of thumb metacarpal, unload volar portion TM joint </li></ul><ul><li>Wilson JBJS 65B:179, 1983 </li></ul><ul><ul><li>Eaton Stage II </li></ul></ul><ul><ul><li>23 osteotomies </li></ul></ul><ul><ul><li>30 o dorsal closing wedge </li></ul></ul><ul><ul><li>12 yrs f/u </li></ul></ul><ul><ul><li>no revisions </li></ul></ul><ul><ul><li>all patients satisfied </li></ul></ul><ul><ul><li>“ fully functional” </li></ul></ul><ul><li>Indications: </li></ul><ul><ul><li>High demand hand </li></ul></ul><ul><ul><li>Young laborer </li></ul></ul>
  36. 36. Volar Ligament Reconstruction <ul><li>Radial ½ FCR distal, ulnar ½ proximal </li></ul><ul><li>Hole in thumb MC base – dorsal to volar </li></ul><ul><li>Deep to APL </li></ul><ul><li>Deep to intact FCR </li></ul><ul><li>Final anchor point APL </li></ul>
  37. 37. Volar Ligament Reconstruction <ul><li>Eaton et. al. J. Hand Surg. 9A(5) 1984 </li></ul><ul><ul><li>Eaton Stage I-II </li></ul></ul><ul><ul><li>50 reconstructions </li></ul></ul><ul><ul><li>Avg age 45 yrs </li></ul></ul><ul><ul><li>f/u – 7 years </li></ul></ul><ul><ul><li>95% good-excellent result </li></ul></ul>
  38. 38. Volar Ligament Reconstruction <ul><li>Long-term results: 15 years </li></ul><ul><li>Freedman,Eaton,Glickel. J. Hand Surg. 25A(2) March 2000 </li></ul><ul><ul><li>23 patients </li></ul></ul><ul><ul><li>Avg age 33 yrs female </li></ul></ul><ul><ul><li>Eaton Stage I + Instability </li></ul></ul><ul><ul><li>15/23  90% satisfaction </li></ul></ul><ul><ul><li>8 % progressed on x-rays </li></ul></ul>
  39. 39. Ligament Reconstruction with Tendon Interposition Arthroplasty (LRTI) <ul><li>Burton RI, Pellegrini VD. J. Hand Surg. 11A(3) 324-32, 1986 </li></ul><ul><ul><li>Excision trapezium </li></ul></ul><ul><ul><li>Volar ligament reconstruction (FCR sling) </li></ul></ul><ul><ul><li>Interposition Arthroplasty (Anchovy) – FCR </li></ul></ul>
  40. 41. LRTI - Results 8% 95% excellent 3 21 Horn resection Double LRTI Baron,Eaton J. Hand Surg 1998 13% 95% excellent 9 24 Excised LRTI Tomaino,Pellegrini,Burton J. Hand Surg. 77A,1995 11% 92% excellent 2 24 Excised LRTI Burton,Pellegrini J. Hand Surg 1986 n/a 92% excellent 3 25 Partial LRTI Eaton,Glickel,Littler J.Hand Surg. 10A(5)1985 Migration/ Loss Height Results F/U (yr) n Trapezium Proced. Author
  41. 42. Double Interposition Arthroplasty <ul><li>Eaton Stage IV </li></ul><ul><li>Maintains height ratio </li></ul><ul><ul><li>PPx/MC-T </li></ul></ul><ul><li>Barron,Eaton. J.Hand Surg. 23A(2) 1998 </li></ul><ul><ul><li>95% good  excellent functional outcome </li></ul></ul><ul><ul><li>3 yr f/u </li></ul></ul>
  42. 43. PubMed <ul><li>Search for “thumb arthritis randomized trial” </li></ul><ul><li>2 results: </li></ul><ul><li>Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy. J Altern Complement Med. 2000 Aug;6(4):311-20. </li></ul><ul><li>Randomized controlled trial of nettle sting for treatment of base-of-thumb pain. J R Soc Med. 2000 Jun;93(6):305-9. </li></ul>
  43. 44. Ligament reconstruction with or without tendon interposition to treat primary thumb carpometacarpal osteoarthritis. A prospective randomized study. <ul><li>Kriegs-Au G, Petje G, Fojtl E, Ganger R, Zachs I. J Bone Joint Surg Am. 2004 Feb;86-A(2):209-18. </li></ul><ul><li>43 patients (52 thumbs) randomized </li></ul><ul><ul><li>trapezial excision with ligament reconstruction (n=15) </li></ul></ul><ul><ul><li>trapezial excision with ligament reconstruction combined with tendon interposition (n=16) </li></ul></ul><ul><li>mean follow-up period of 48.2 months </li></ul><ul><li>Group I had significantly better mean scores for palmar and radial abduction, cosmetic appearance, willingness to undergo surgery again under similar circumstances (p < 0.05) </li></ul><ul><li>mean scores for tip-pinch strength and mean subjective scores for pain, strength, daily function, dexterity, and overall satisfaction did not differ significantly between the groups </li></ul><ul><li>Both groups had satisfactory results with regard to performance of ADLs and ability to return to work </li></ul><ul><li>amount of proximal metacarpal migration, at rest and under stress, did not differ significantly between groups </li></ul>
  44. 45. Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition. <ul><li>Hartigan BJ, Stern PJ, Kiefhaber TR. J Bone Joint Surg Am. 2001 Oct;83-A(10):1470-8. </li></ul><ul><li>109 patients (141 thumbs), < 60 yo </li></ul><ul><li>retrospective review </li></ul><ul><li>subjective evaluation of pain, function, and satisfaction demonstrated no significant difference between the two groups </li></ul><ul><li>>90% of patients satisfied following either procedure </li></ul><ul><li>Grip strength did not differ between the groups, the arthrodesis group had significantly stronger lateral pinch (p < 0.001) and chuck pinch (p < 0.01) </li></ul><ul><li>Group treated with ligament reconstruction and tendon interposition had better ROM with regard to opposition (p < 0.05) and the ability to flatten the hand (p < 0.0001) </li></ul><ul><li>Higher complication rate in the arthrodesis group, with nonunion of the fusion site accounting for the majority of the complications </li></ul><ul><li>All of the patients with nonunion had improvement in their pain status compared with preoperatively, and all were very satisfied with the outcome </li></ul>
  45. 46. Recommendations <ul><li>Stage I (Laxity + Instability) </li></ul><ul><ul><li>Eaton Procedure (Volar Ligament Reconstruction) </li></ul></ul><ul><li>Stage II-III </li></ul><ul><ul><li>Low demand </li></ul></ul><ul><ul><ul><li>LRTI </li></ul></ul></ul><ul><ul><ul><li>Trapezium excision/interposition anchovy </li></ul></ul></ul><ul><ul><li>High demand </li></ul></ul><ul><ul><ul><li>Arthrodesis </li></ul></ul></ul><ul><ul><ul><li>MC osteotomy </li></ul></ul></ul><ul><li>Stage IV </li></ul><ul><ul><li>Double Interposition LR </li></ul></ul><ul><ul><li>LRTI + excision trapezium </li></ul></ul><ul><ul><li>Trapezium excision (low demand) </li></ul></ul>
  46. 47. Complications <ul><li>Neurologic </li></ul><ul><ul><li>Radial Nerve : Dorsal sensory branch </li></ul></ul><ul><ul><li>Median Nerve : Palmar cutaneous branch </li></ul></ul><ul><ul><li>Neuroma </li></ul></ul><ul><ul><li>RSD </li></ul></ul><ul><li>Vascular </li></ul><ul><ul><li>Superficial branch radial artery – volar to S-T Joint </li></ul></ul><ul><li>Infection </li></ul><ul><ul><li><1% (LRTI) </li></ul></ul><ul><li>Carpal Tunnel </li></ul><ul><ul><li>Postoperative decompression </li></ul></ul><ul><li>Silicone </li></ul><ul><ul><li>Fracture, synovitis, erosion, subluxation </li></ul></ul><ul><li>Fusion </li></ul><ul><ul><li>Nonunion </li></ul></ul><ul><li>Arthroplasty </li></ul><ul><ul><li>Loosening, fracture, dislocation, osteolysis, difficult revision </li></ul></ul>
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