11/9/15

1

The CMC JointMichael J Garcia, MDNovember 7, 2015

Florida Orthopaedic InstituteShriner’s Hospital for Children: Tampa

University of South Florida

Disclosures

n I am a paid consultant for Arhtrexn In this talk I will discuss the Arthrex Tight-Rope

as a treatment option for CMC DJDn I receive no royalties from the use of the Tight-

Ropen I am not being reimbursed for this presentation

Epidemiologyn Most common site of osteoarthritisn Female predominance: 10-15 : 1

n Greater curvature, less congruity, smaller surface areasn 15% female incidence (Haara JBJS 1994)n 25% post-menopausal women (Armstrong 1994)n Greater in Asian and white populationsn Other factors

n Occupational, family history, obesity, ligamentous laxity, hormonal differences, trauma

n Ehlers-Danlos: avg age of CMC arthrosis is 15 yrs (Gamble 1989)

11/9/15

2

Radiographs

n Eaton and Littler (JBJS 1973)n Stage 1 – Normal articular contours, slight widening of joint

space, < 1/3 subluxation in any planen Stage 2 – Osteophytes < 2mm, slight narrowing of joint

space, instability with stress views, > 1/3 subluxation in any plane

n Stage 3 – Osteophytes > 2mm, joint space narrowing, > 1/3 subluxation in any plane

n Stage 4 – Advanced degenerative changes, joint space is very narrow with cystic and sclerotic changes, pantrapezial arthrosis

Stage 1

n Normal articular contoursn Slight wideningn < 1/3 subluxation

Stage 2

n Osteophytes < 2mmn Slight narrowing n Instability with stress viewsn > 1/3 subluxation

11/9/15

3

Stage 3

n Osteophytes > 2mm, n Joint space narrowingn > 1/3 subluxation

Stage 4

n Advanced degenerative changesn Joint space is very narrown Cystic and sclerotic changes

Stage 5 ???

n No mention in Eaton’s classificationn Scaphotrapezoidal arthrosis (Pan-trapezial)

11/9/15

4

Treatment

n Non-operativen Activity modificationn NSAIDsn Injectionsn Opponens splintsn Thenar muscle conditioning

Non-operative Treatmentn Swigart et al (JHS 1999)

n 114 patients, 130 thumbsn 76% improvement for stage 1-2 with splintingn 54% improvement for stage 3-4 with splintingn 54% and 61% improvement at 6 months after splinting

n Berggren et al (SJPRS 2001)n 33 patients over 7 yearsn Occupational therapy and splinting were successful in helping

70% (23/33) to avoid surgery in first 7 monthsn Only 2 of 19 ultimately had surgery at 7 years

Non-Operative Treatment

n Day et al. (JHS 2004)n Prospective study of 30 thumbsn Steroid injection + 3 weeks of splintingn Long term relief with Stage 1 disease (5/6)n Less reliable with Stage 2/3 (6/17) or Stage 4 (1/7)n 40% regardless of staging had long term relief

11/9/15

5

Surgical Treatment

n #1 RELIEF OF PAIN

n #2 FUNCTION AND STRENGTH

Surgical Treatments

n Ligament reconstructionn Simple trapeziectomy / hematoma-distractionn Abduction-Extension Osteotomyn Arthrodesisn Implant Arthroplastyn Ligament Reconstruction and Tendon

Interposition (LRTI)n Suspensionplasty – Tightrope or APL

Ligament Reconstructionn Eaton and Littler (JBJS 1973)

n Reconstruction of the palmar beak ligament with FCR tendon

n Predicated on pre-arthritic joint

n Indicated with hypermobile joint – radial subluxation

n Initial studies showed good-excellent results (Eaton 1984, Lane 1987)

n Freedman (JHS 2000)n 23 thumbs, 15 year follow-upn 90% long term satisfactionn 8% showed radiographic changesn 108% pinch and 105% grip strength

11/9/15

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 Arthrodesisn Indications:

n Painful instabilityn < 50 years old in high-demand profession

n Affords joint stability, strength, pain reliefn “Key Pinch” position

n 30-40° Palmar Abductionn 10-20° Radial Abduction

n Complications:n Adjacent joint degenerationn Compensatory hypermobilityn Non-unionn Immobilization

Trapeziectomyn Simple Trapeziectomy

n Initially described in 1949n Good pain reliefn Can lead to weakness/instabi lit y

n Interposition Arthroplastyn Fromison 1970n ½ of FCR or PL

n Hematoma and Distraction Arthroplastyn Addressed metacarpal migrationn No long term studiesn Kuhns (2003): 96% satisfaction rate at 2 yrsn Gray and Meals (2007): 6.5 yr f/u. Comparable results to other tx.

11/9/15

7

Ligament Reconstruction and Tendon Interposition – (LRTI)

n Reconstruction of beak ligamentn 3 Principles

n 1- Trapeziectomyn 2- Anterior oblique ligament reconstructionn 3- Interposition to reduce impingement/migration

n Evolution of the procedure over timen 1949 - Gervis: Trapeziectomyn 1970 - Fromison: “Anchovy” proceduren 1973 - Eaton and Littler: Ligament reconstructionn 1986 - Burton and Pellegrini: LRTI

LRTI

n Burton and Pellegrini (1986)n 25 procedures are reviewed with average follow-up of 2 yearsn LRTI improved pinch strength, grip strength endurance, and

restored thumb web space better than silicone implant arthroplasty

n Proximal migration averaged only 11% with LRTI (vs 50%)n Subluxation averaged only 7% with LRTI (vs 35%) n Excellent results were achieved in 23 thumbs or 92% of casesn No deterioration of function or stability with 2 year follow-up

11/9/15

8

n Thompson (1989)n APL Suspensionplasty

Tightrope Fixation

n Technique of Suspensionplasty using an implant to suspend the 1st metacarpal to the 2nd

Metacarpaln Acts to prevent proximal migration of the 1st

metacarpal during healingn Can lead to faster recovery times and earlier

rehab

11/9/15

9

Tightrope Outcomes

n Yao, J et al. Suture-Button Suspensionplastyfor Thumb Carpometacarpal Arthritis: A Minimum. 2-Year Follow-Up. JHS 2013n 21 patients at a minimum of 2 year follow upn Outcomes were similar to other procedures

historically descirbedn Faster rehabilitation and return to functionn Similar complication rates

Tightrope Complications

n Khalid, M et al. Index Metacarpal Fracture After Tightrope Suspension Following Trapeziectomy: Case Report. J Hand Surg2012.n Report of index metacarpal through suture

button holen Unique complication of tightrope

11/9/15

10

Surgical Outcomes

n Tomaino et al (JBJS 1995)n Key pinch strength took at least 6 years to equal

preoperative valuen Average follow-up of 9 years n 24 thumbs in 22 patients

n average grip strength increased 93% from pre-op n average key pinch strength increased 34%n tip pinch strength increased 65%.n Stress radiographs showed an average subluxation of the

metacarpal base of 11% and subsidence of only 13%.

n Kreigs-Au et al. (JBJS 2004)n Prospective randomized studyn 31 patients, 48 month follow-upn Trapeziectomy and ligament reconstruction with and

without interpositionn No difference in strength or pain scoresn No difference in proximal migration at rest or stress

n Davis et al (2004)n 183 thumbsn Evaluate trapeziectomy, PL interposition, and LRTIn 1 yr follow-up

n 82% had good pain reliefn 68% had return to activities by 1 yr

n No differences between treatment options at 1 year

11/9/15

11

Complicationsn Proximal migration / Impingmentn MCP hyperextention

n >30° - consider stabilization procedure

n <30° - observation vs pinning n Nerve injury: dorsal sensory branches of radial n.n Radial artery injuryn Infection (<1%)n CRPS (as much as 8% with LRTI)

Does It Matter What We Do?n Treatment…..Does it matter?

n Trapeziectomy with/without tendon interposition not better than other techniques.n Arthrodesis not better than other techniques (non-union 8-20%). n LRTI not better than other techniques (some studies, higher complications).n 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 157-169.

n Co o n ey et al . Th e kin esio lo gy o f th e th umb trap ezio metacarp al jo in t. JBJS 1981;63:1371-1381n Zh an g Y, Niu J, Kel ly-Hayes M , et al . Prevalen ce o f symp to matic h an d o steo arth ri ti s an d i ts imp act o n fun ctio nal status amo n g the eld erly: Th e

Framin gh am Stud y. Am J Ep id emio l 2002;156(11): 1021– 7.n Armstro n g AL, Hun ter JB, Davis TRC. Th e p revalen ce o f d egen erative arth ri ti s o f th e b ase o f th e th umb in p ostmen o p ausal wo men . J Han d Surg

1994;19B:340 – 341.n Heywo rth BE et al . Hylan Versus Co rtico stero id Versus P laceb o fo r Treatmen t o f Basal Jo in t Arth ri ti s: A Pro spective, Ran d o mized , Do ub le-Bl in ded

Cl in ical Trial . J Han d Surg 2008;33A:40– 48.n Bad ia A. Trap ezio metacarp al arth ro sco p y: a classi fi catio n an d treatmen t algo ri th m. Han d Cl in 2006;22:153– 63.n Day CS, Gelb erman R, Patel AA, et al . Basal jo in t o steo arth ri tis o f the th umb : a p ro spective tri al o f stero id in jectio n an d sp l intin g. J Han d Surg [Am] 2004;

29:247– 51.n To main o M M , Pel legrin i VD, Burto n RI: Arthro p lasty o f th e b asal jo in t of th e thumb : Lo n g-term fo l low up after l i gamen t reco n structio n wi th ten do n

in terp o si tio n . J Bo ne Jo in t Surg Am 1995;77:346-355.n Do ersch uk SH, Hicks DG, Ch in ch i l l i VM , Pel l egrin i VD Jr: Histo path o lo gy o f th e palmar b eak l igamen t in trap ezio metacarp al o steo arth ri ti s. J Hand S urg

[Am] 1999;24:496-50 4. n Bettin ger PC, Lin sch eid RL, Berger RA, Co o n ey WP III, An KN: An an ato mic stud y o f th e stab i l izin g l igamen ts o f th e trap ezium an d trap ezio metacarp al

jo in t. J Hand S urg [Am] 1999;24:786-798.n Burto n RI, Pel l egrin i VD. Surgical man agemen t o f b asal jo in t arth ri ti s o f th e th umb . Part II. Ligamen t reco n structio n wi th ten do n in terp osi tion arthroplasty.

J Han d Surg [Am] 1986;11A:324– 32.n Trumb le et al . Th umb Trap ezio metacarp al Jo in t Arth ri ti s: Parti al Trap eziecto my With Ligamen t Reco n structio n an d In terp o si tio nCo sto ch on dral

Al lo graftHan d Surg 2000;25A:61– 76.n Si ro tako va et al . A New Ab d ucto r Po l l i ci s Lo n gus Susp en sio n Arth ro p lasty. J Han d Surg 2007;32A: 12– 22.n Van Heest AE an d Kal lemeier P . Th umb Carp al M etacarp al Arth ri ti s. J Am Acad Orth o p Surg 2008;16:140-15 1.n Kriegs-Au et al . Ligamen t Reco n structio n wi th o r wi th o ut Ten d on In terp osi tion to Treat Primary Th umb Carp o metacarp al Osteo arth riti s. A Pro sp ective

Ran d o mized Stud y. JBJS-A. , Feb 2004; 86: 209 - 218.n Kuh n s CA, Emerso n ET, M eals RA: Hemato ma an d d i stractio n arth ro p lasty fo r th umb b asal jo in t osteo arth ri ti s: A p ro sp ective, sin gle-surgeo n stud y

in clud in g o utco mes measures. J Han d Surg [Am] 28:381-389, 2003.n Gray KV an d M eals RA. Hemato ma an d d i stractio n arth ro p lasty fo r th umb b asal jo in t osteo arth ri ti s: min imum 6.5-year fo l lo w-up evaluatio n . J Han d Surg

[Am]. 2007 Jan ;32(1): 23-9