Symposium 10. International Symposium - Thumb Carpometacarpal Joint Arthrosis

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1 Saturday, September 20, 2008 Room: Grand Ballroom 9:20-10:05 AM Symposium 10 International Symposium - Thumb Carpometacarpal Joint Arthrosis Moderator: Christian A. Dumontier, MD; Joseph M. Failla, MD Faculty: Pierre Desmoineaux, MD; Jean F. Goubau, MD; Patrick Lorea, MD; Pierre-Jean Regnard, MD 63 rd Annual Meeting of the American Society for Surgery of the Hand Extending Our Reach Through Ethics, Education and Engagement

2 Arthroscopic Treatment of Thumb Basilar Joint Arthritis Desmoineaux P, Bouchard A Centre Hospitalier Versailles Arthroscopic Hemitrapeziectomy Since thumbs (average follow up time: 24 months) Results: - 43 % experiencing no pain - strength and mobility increased - No complex regional pain syndrome - delay of recovery : 17 weeks - instability: 15 % Interposition in the space of trapeziectomy ligamentoplasty using APL Suspensioplasty M1 Stabilisation intermetacarpal ligaments reconstruction 1

3 sont requis pour visionner cette image. Arthroscopic technique B.R.Anesthesia tourniquet 2 kgf traction 30,short,2.7 mm arthroscope Acess portals: - needle - distension - discision (superficial branch of radial nerve) Partial trapeziectomy QuickTime et un sont requis pour visionner cette image. Foreign body QuickTime et un Medial osteophyte Ligament reconstruction -identifying the base of M 2 -Arthroscope ulnar portal mm drill - 1cm blind Tunnel at the base of M2 2

4 sont requis pour visionner cette image. APL slip insert into first metacarpal base QuickTime et un sont requis pour visionner cette image Anatomic variations of APL distal insertion : - insertion into M 1 always present - 70 % of cases :insertion also into the trapezium Harvested Tendon s length QuickTime et un Ligament recontruction with APL QuickTime et un sont requis pour visionner cette image. 3

5 QuickTime et un sont requis pour visionner cette image. QuickTime et un sont requis pour visionner cette image. Ligament recontruction with APL Ligament recontruction with APL Patients Between april 2006 and april patients / 16 thumbs average age : 62 years (49-80 years) Average follow up time: 11 months (6-18 months) 12 bilateral carpometacarpal arthritis ( 3 controlateral arthroscopic partial trapeziectomie without ligament reconstruction) In 3 cases :endoscopic carpal tunnel release during the same operation 4

6 Dell classification method clinical and radiographic examination subjective assessment : Nelson Hospital Score N Citron. A self- administered questionnaire for basal osteoarthritis of the thumb. The journal of hand surgery Vol 32E No. 5 oct 2007 Résults 50% pain free (2 thumbs painful during effort) Average Nelson score: 81/100 (46-100) no complex regional pain syndrome 1 painfull swelling of FCR average time of recovery : 15 weeks (2-24 weeks) 5

7 opposition Kapandji - Pre surg. : After surg.: 9.3 M1-M2 M2 abduction - Pre surg. : 49 - After surg.: 53 Hyperextension MCP - Pre surg : After surg: 25.7 Résults: mobility Résults: strength Key pinch Kg/cm - pre surg. : post surg.: instable thumb Radiographic results - Space of joint is re-established after surgery - Dorsal subluxation: inconsistent results 6

8 Discussion - Same time of recovery ( 15 weeks) - 15 stables thumbs -MCP hyper-extension didn t increase -Intermetacarpal ligaments reconstruction -No ant. palmar oblique lig. reconstruction Conclusions 6 years experience : arthroscopic treatement of thumb osteoarthritis 70 cases partial trapeziectomy with or without Ligament reconstruction few cases total trapeziectomy or double arthroplasty( stt joint) conclusions Arthroscopic Trapeziectomy is effective Too early to conclude on the need for a ligament reconstruction 7

9 Thank you 8

10 Double Osteotomy for Treatment of early CMC Joint Arthritis Jean F. Goubau M.D. Symposium 10 International Symposium Thumb Carpometacarpal Joint Arthrosis September 20, 2008 Rhizarthropathy is an invalidating condition long before radiological changes appear. Treatment is often conservative and tries to diminish he symptoms and concomitant functional impairment. Unfortunately, an unstable base of the first metacarpal combined with a dysplastic trapezium, often resists conservative treatment, due to its dynamic feature. The fundamental problem is instability and function tempts to increase the symptomatology. Moreover, most of the patients are young and demanding. Surgical treatment options are relatively classic, starting with a ligamentoplasty of the base of the first metacarpal (Eaton Littler type) or (eventually followed by) arthrodesis of the trapezometacarpal joint for ineffective ligamentoplasty or osteoarthritis of the joint. Other options are less or not valid due to their incapacity to withstand the forces applied by a demanding type of patient.(pelligrini-burton, Weilby, ) The idea arose around the millenium change to combine two techniques described previously. In 1973,Wilson published his technique of abduction osteotomy of the first metacarpal as a treatment for rhizarthritis. A wedge removed at the proximal metaphysis of the first metacarpal in order to put it in abduction improved the symptomatology and decreased the radiological deterioration of the rhizarthrosis. In 2002, Kapandji and Heim published their opening wedge osteotomy of the trapezium in order to correct the slope of a dysplastic trapezium. This technique tried to improve the dysplasia of the lateral rim of the trapezium. Drawback was the closing of the first web with this technique. The combination of both of these techniques avoids the closing of the first web by performing an abduction osteotomy of the first metacarpal. Moreover, the opening wedge osteotomy corrects the dysplastic lateral rim of the trapezium by correcting its slope. The removed wedge at the metacarpal level is then inserted in an anterolateral fashion in the trapezium to achieve this. We have been performing this technique since 2001 in 20 patients. The midterm results are encouraging in normal to pre arthrotic trapeziometacarpal joints.the described technique has the advantage of preserving the trapeziometacarpal joint. It is far more easier to perform than other described techniques of vascularised rotation of the articular trapezometacarpal complex. Moreover, it leaves the gate open for other techniques if it eventually should fail in the long term. Notes

11 1.Osteotomy of the first metacarpal for osteoarthrosis of the basal joints of the thumb. Jan Holmberg, Goran Lundborg Scand.J.Plast.Reconstr.Hand Surg. 30: 67-70, Stabilisation of the trapezio-metacarpal joint. G.Brunelli, L.Monini,F.Brunelli Journal of Hand Surgery (British Volume,1989)14 B: L ostéotomie de réorientation de la selle trapezienne. Adalbert.Kapandji, Urs F.A.Heim Chirurgie de la main2002 ; 21 : Arthrodesis of the first metacarpal joint. 33 Cases of arhrosis. Alberts K.A., Engkvist O. Acta Orthopedica Scand. 1989; 60: Fusion of the first metacarpotrapezial joint for degenerative arthritis. Stark H.H.,Moore J.F.,Ashworth CR,Boyes JH. Journal Bone Joint Surg ;59A : Ligament reconstruction for the painfull thumb carpometacarpal joint. Eaton R.G.,Littler J.W. Journal Bone Joint Surg.1973 ;55A : Basal osteotomy of the first metacarpal in the treatment of arthritis of the metacarpal joint of the thumb. J.N.Wilson Brit.J.Surg, 1973, Vol 60,No 11,November 8.Osteotomy in the treatment of osteoarhritis of the first carpometacarpal joint. Wilson J.N.,Bossley C.J. Journal Bone Joint Surg.19783; 65B: Rotation chirurgicale vascularisée du complex bi-articulaire trapézoïde-trapézometacarpien pour le traitement de la rhizarthrose gave du pouce. A.Messina Chir.Main 2000 ; 19 : Les transfers osseux vascularisés au poignet et à la main. J.L.Roux Chirurgie de la main 22 (2003) ; Arthroplastie trapézo-métacarpienne par rotation trapézo-métacarpienne en îlot. étude anatomique et technique opératoire J.-L. Roux Chir Main, 2004 avril;23(2): Anatomie et physiologie de l articulation trapézométacarpienne humaine M. Rongières Chirurgie de la main 23 (2004) ;

12 ASSH Symposium 10 International Symposium - Thumb Carpometacarpal Joint Arthrosis Patrick Lorea, MD REFERENCES 1: Loréa PD. First carpometacarpal joint denervation: anatomy and surgical technique. Tech Hand Up Extrem Surg Mar;7(1): : Loréa P, Foucher G. [Joint denervations in hand surgery: a plea] Ann Chir Plast Esthet Apr;50(2): Epub 2005 Jan 8. Review. French. 3: Loréa P, Dury M, Marin Braun F, Dekkaï T, De Mey A, Foucher G. [Trapeziometacarpal denervation. Description of surgical technique and preliminary results from a prospective series of 14 cases] Chir Main Jul;21(4): French. 4: Lorea DP, Berthe JV, De Mey A, Coessens BC, Rooze M, Foucher G. The nerve supply of the trapeziometacarpal joint. J Hand Surg [Br] Jun;27(3):232-7.