The CMC Joint. Disclosures. Epidemiology 11/9/15

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Marianna McCormick
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1 The CMC Joint Michael J Garcia, MD November 7, 2015 Florida Orthopaedic Institute Shriner s Hospital for Children: Tampa University of South Florida Disclosures I am a paid consultant for Arhtrex In this talk I will discuss the Arthrex Tight-Rope as a treatment option for CMC DJD I receive no royalties from the use of the Tight- Rope I am not being reimbursed for this presentation Epidemiology Most common site of osteoarthritis Female predominance: : 1 Greater curvature, less congruity, smaller surface areas 15% female incidence (Haara JBJS 1994) 25% post-menopausal women (Armstrong 1994) Greater in Asian and white populations Other factors Occupational, family history, obesity, ligamentous laxity, hormonal differences, trauma Ehlers-Danlos: avg age of CMC arthrosis is 15 yrs (Gamble 1989) 1

Radiographs Eaton and Littler (JBJS 1973) Stage 1 Normal articular contours, slight widening of joint space, < 1/3 subluxation in any plane Stage 2 Osteophytes < 2mm, slight narrowing of joint space,

2 Radiographs Eaton and Littler (JBJS 1973) Stage 1 Normal articular contours, slight widening of joint space, < 1/3 subluxation in any plane Stage 2 Osteophytes < 2mm, slight narrowing of joint space, instability with stress views, > 1/3 subluxation in any plane Stage 3 Osteophytes > 2mm, joint space narrowing, > 1/3 subluxation in any plane Stage 4 Advanced degenerative changes, joint space is very narrow with cystic and sclerotic changes, pantrapezial arthrosis Stage 1 Normal articular contours Slight widening < 1/3 subluxation Stage 2 Osteophytes < 2mm Slight narrowing Instability with stress views > 1/3 subluxation 2

is very narrow Cystic and sclerotic changes Stage 5?

3 Stage 3 Osteophytes > 2mm, Joint space narrowing > 1/3 subluxation Stage 4 Advanced degenerative changes Joint space is very narrow Cystic and sclerotic changes Stage 5??? No mention in Eaton s classification Scaphotrapezoidal arthrosis (Pan-trapezial) 3

4 Treatment Non-operative Activity modification NSAIDs Injections Opponens splints Thenar muscle conditioning Non-operative Treatment Swigart et al (JHS 1999) 114 patients, 130 thumbs 76% improvement for stage 1-2 with splinting 54% improvement for stage 3-4 with splinting 54% and 61% improvement at 6 months after splinting Berggren et al (SJPRS 2001) 33 patients over 7 years Occupational therapy and splinting were successful in helping 70% (23/33) to avoid surgery in first 7 months Only 2 of 19 ultimately had surgery at 7 years Non-Operative Treatment Day et al. (JHS 2004) Prospective study of 30 thumbs Steroid injection + 3 weeks of splinting Long term relief with Stage 1 disease (5/6) Less reliable with Stage 2/3 (6/17) or Stage 4 (1/7) 40% regardless of staging had long term relief 4

5 Surgical Treatment #1 RELIEF OF PAIN #2 FUNCTION AND STRENGTH Surgical Treatments Ligament reconstruction Simple trapeziectomy / hematoma-distraction Abduction-Extension Osteotomy Arthrodesis Implant Arthroplasty Ligament Reconstruction and Tendon Interposition (LRTI) Suspensionplasty Tightrope or APL Ligament Reconstruction Eaton and Littler (JBJS 1973) Reconstruction of the palmar beak ligament with FCR tendon Predicated on pre-arthritic joint Indicated with hypermobile joint radial subluxation Initial studies showed goodexcellent results (Eaton 1984, Lane 1987) Freedman (JHS 2000) 23 thumbs, 15 year follow-up 90% long term satisfaction 8% showed radiographic changes 108% pinch and 105% grip strength 5

Extension Osteotomy Extension Osteotomy: Unloads Palmar Portion of the CMC Joint Alters Force Vectors During Pinch Effective in Early stage disease Doesn t burn bridges for later arthroplasty

6 Extension Osteotomy Extension Osteotomy: Unloads Palmar Portion of the CMC Joint Alters Force Vectors During Pinch Effective in Early stage disease Doesn t burn bridges for later arthroplasty Trapeziometacarpal Arthrodesis Indications: Painful instability < 50 years old in high-demand profession Affords joint stability, strength, pain relief Key Pinch position Palmar Abduction Radial Abduction Complications: Adjacent joint degeneration Compensatory hypermobility Non-union Immobilization Trapeziectomy Simple Trapeziectomy Initially described in 1949 Good pain relief Can lead to weakness/instabilit y Interposition Arthroplasty Fromison 1970 ½ of FCR or PL Hematoma and Distraction Arthroplasty Addressed metacarpal migration No long term studies Kuhns (2003): 96% satisfaction rate at 2 yrs Gray and Meals (2007): 6.5 yr f/u. Comparable results to other tx. 6

Ligament Reconstruction and Tendon Interposition (LRTI) Reconstruction of beak ligament 3 Principles 1- Trapeziectomy 2- Anterior oblique ligament reconstruction 3- Interposition to reduce

7 Ligament Reconstruction and Tendon Interposition (LRTI) Reconstruction of beak ligament 3 Principles 1- Trapeziectomy 2- Anterior oblique ligament reconstruction 3- Interposition to reduce impingement/migration Evolution of the procedure over time Gervis: Trapeziectomy Fromison: Anchovy procedure Eaton and Littler: Ligament reconstruction Burton and Pellegrini: LRTI LRTI Burton and Pellegrini (1986) 25 procedures are reviewed with average follow-up of 2 years LRTI improved pinch strength, grip strength endurance, and restored thumb web space better than silicone implant arthroplasty Proximal migration averaged only 11% with LRTI (vs 50%) Subluxation averaged only 7% with LRTI (vs 35%) Excellent results were achieved in 23 thumbs or 92% of cases No deterioration of function or stability with 2 year follow-up 7

the 2 nd Metacarpal Acts to prevent proximal migration of the 1 st

8 Thompson (1989) APL Suspensionplasty Tightrope Fixation Technique of Suspensionplasty using an implant to suspend the 1 st metacarpal to the 2 nd Metacarpal Acts to prevent proximal migration of the 1 st metacarpal during healing Can lead to faster recovery times and earlier rehab 8

9 Tightrope Outcomes Yao, J et al. Suture-Button Suspensionplasty for Thumb Carpometacarpal Arthritis: A Minimum. 2-Year Follow-Up. JHS patients at a minimum of 2 year follow up Outcomes were similar to other procedures historically descirbed Faster rehabilitation and return to function Similar complication rates Tightrope Complications Khalid, M et al. Index Metacarpal Fracture After Tightrope Suspension Following Trapeziectomy: Case Report. J Hand Surg Report of index metacarpal through suture button hole Unique complication of tightrope 9

10 Surgical Outcomes Tomaino et al (JBJS 1995) Key pinch strength took at least 6 years to equal preoperative value Average follow-up of 9 years 24 thumbs in 22 patients average grip strength increased 93% from pre-op average key pinch strength increased 34% tip pinch strength increased 65%. Stress radiographs showed an average subluxation of the metacarpal base of 11% and subsidence of only 13%. Kreigs-Au et al. (JBJS 2004) Prospective randomized study 31 patients, 48 month follow-up Trapeziectomy and ligament reconstruction with and without interposition No difference in strength or pain scores No difference in proximal migration at rest or stress Davis et al (2004) 183 thumbs Evaluate trapeziectomy, PL interposition, and LRTI 1 yr follow-up 82% had good pain relief 68% had return to activities by 1 yr No differences between treatment options at 1 year 10

Complications Proximal migration / Impingment MCP hyperextention >30 - consider stabilization procedure <30 - observation vs pinning Nerve injury: dorsal sensory branches of radial n.

Trapeziectomy with/without tendon interposition not better than other techniques. Arthrodesis not better than other techniques (non-union 8-20%).

11 Complications Proximal migration / Impingment MCP hyperextention >30 - consider stabilization procedure <30 - observation vs pinning Nerve injury: dorsal sensory branches of radial n. Radial artery injury Infection (<1%) CRPS (as much as 8% with LRTI) Does It Matter What We Do? Treatment..Does it matter? Trapeziectomy with/without tendon interposition not better than other techniques. Arthrodesis not better than other techniques (non-union 8-20%). LRTI not better than other techniques (some studies, higher complications). Implant arthroplasty may be better in short term; no long term f/u studies. * They all do well as long as the arthritic TZ is excised and concomittant STT arthritis is addressed. J Hand Surgery, Jan 2011; pp Cooney et al. The kinesiology of the thumb trapeziometacarpal joint. JBJS 1981; 63: Zhang Y, Niu J, Kelly-Hayes M, et al. P reval en ce o f symp to mati c h an d o steo arth ri ti s an d i ts imp act o n fun cti o nal status amo n g the el d erl y: Th e Framingham Study. Am J Epidemiol 2002;156(11): Armstro n g AL, Hun ter JB, Davi s TRC. Th e p reval en ce o f d egen erati ve arth ri ti s o f th e b ase o f th e th umb i n p ostmen o p ausal wo men. J Han d Surg 1994; 19B: Heywo rth BE et al. Hyl an Versus Co rti co stero i d Versus P l aceb o fo r Treatmen t o f Basal Jo i n t Arth ri ti s: A P ro specti ve, Ran d o mi zed, Do ub l e-blinded Clinical Trial. J Hand Surg 2008;33A: Bad ia A. Trap ezio metacarp al arth ro sco p y: a classificatio n an d treatmen t algo rith m. Han d Clin 2006;22: Day CS, Gel b erman R, P atel AA, et al. Basal j o i n t o steo arth ri tis o f the th umb : a p ro specti ve tri al o f stero i d in j ecti o n an d splinti n g. J Han d Surg [ Am] 2004; 29: Tomaino MM, Pellegrini VD, Burton RI: Arthroplasty of the basal joint of the thumb: Long-term fo l l ow up after l i gamen t reco n struction with tendon interposition. J Bone JointSurg Am 1995;77: Doerschuk SH, Hicks DG, Chinchilli VM, Pellegrini VD Jr: Histopathology of the palmar beak ligament in trapeziometacarpal osteo arth ritis. J Hand S urg [Am] 1999; 24: Betti n ger P C, L i n sch ei d RL, Berger RA, Co o n ey W P III, An KN: An an ato mi c stud y o f th e stab i l izi n g l i gamen ts o f th e trap ezi um an d trap ezi o metacarp al joint. J Hand S urg [Am] 1999; 24: Burton RI, Pellegrini VD. Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with ten do n interposition arthroplasty. J Hand Surg [Am] 1986;11A: Trumble et al. Thumb Trapeziometacarpal Joint Arthritis: Partial Trapeziectomy With Ligament Reconstruction and InterpositionCo stochondral Al l o grafthan d Surg 2000; 25A: Sirotakova et al. A New Abductor Pollicis Longus Suspension Arthroplasty. J Hand Surg 2007;32A: Van Heest AE and Kallemeier P. Thumb Carpal Metacarpal Arthritis. J Am Acad Orthop Surg 2008;16: Kriegs-Au et al. Ligament Reconstruction with or without Tendon Interposition to Treat Primary Thumb Carpometacarpal Osteoarthritis. A P ro sp ecti ve Randomized Study. JBJS-A., F eb 2004; 86: Kuhns CA, Emerson ET, Meals RA: Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: A prospective, sin gl e-surgeo n stud y in clud in g o utco mes measures. J Han d Surg [Am] 28: , Gray KV an d M eal s RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year fo l l o w-up evaluation. J Han d Surg [ Am] Jan ; 32(1):

CMC Arthroscopy. Jeffrey Yao, MD Associate Professor Department of Orthopaedic Surgery Stanford University Medical Center

CMC Arthroscopy. Jeffrey Yao, MD Associate Professor Department of Orthopaedic Surgery Stanford University Medical Center CMC Arthroscopy Jeffrey Yao, MD Associate Professor Department of Orthopaedic Surgery Stanford University Medical Center Disclosures The following relationships exist: 1. Grants American Foundation for