Ultrastructure and innervation of thumb carpometacarpal ligaments in surgical patients with osteoarthritis

Wrist proprioception-An update on scientific insights and clinical implications in rehabilitation of the wrist

The field of wrist proprioception, as it relates to rehabilitation and surgery, has gone through a period of intense growth in the past decade. From being primarily focused on the function of the joint and ligaments in patients with wrist trauma or after wrist surgery, the understanding is now that of a greater complexity in treating not just the wrist but the hand and arm as a whole. Proprioception is derived from the Latin words "proprius" - belonging to (oneself) and "-ception" to sense. In other words, how to sense ourselves. To have a complete sense of self, multiple sensory afferents originating from joints, ligaments, muscles, tendons, nerves, skin, vision, and hearing work together to orchestrate a balanced integration of sensorimotor functions, with the true goal to perceive and adapt to the physical world around us. In this update on wrist proprioception, we review current developments in the understanding of proprioception, with an implication for our everyday work as hand therapists and hand surgeons. Each contributing sense-joint, ligaments, muscles, skin, and brain-will be reviewed, and the clinical relevance will be discussed. An updated wrist rehabilitation protocol is proposed where the therapist is guided to rehabilitate a patient after wrist trauma and/or surgery in 4 stages: (1) basic hand and wrist rehabilitation with a focus on reducing edema, pain, and scar formation; (2) proprioception awareness to improve the sense of joint motion and position; (3) conscious neuromuscular rehabilitation where isometric exercises of muscles that are beneficial for a particular injury are promoted, whereas others that are potentially harmful are avoided; and (4) unconscious neuromuscular rehabilitation with training of the reflex and joint protective senses.

Psychometric properties of body structures and functions measures in non-surgical thumb carpometacarpal osteoarthritis: A systematic review

BACKGROUND

Measurement of treatment outcomes and change in health status over time is a critical component of clinical practice and research for people with osteoarthritis. Numerous clinical tools are used to assess the structures and function of the thumb in persons with thumb carpometacarpal osteoarthritis however their psychometrics have not yet been systematically explored.

PURPOSE

The purpose of this study was to explore the psychometric properties of clinical tools used in persons with non-surgical thumb carpometacarpal osteoarthritis to objectively measure thumb structures and function, evaluate the quality of such studies, and subsequently make clinical and future research recommendations.

STUDY DESIGN

Systematic review.

METHODS

A systematic search and screening was conducted across nine databases. Original research published between 2002 and 2022 that involved the assessment of psychometric properties (validity, reliability, precision, responsiveness, sensitivity, specificity, and minimal clinically important difference) of clinical tools were included. Sample characteristics, methods, and psychometric findings from each study were compiled. The methodological quality of included studies was evaluated using the COnsensus-based Standards for the selection of health Measurement Instruments' checklist. Two independent researchers screened articles and assessed methodological quality and when not in agreement, a third party was consulted.

RESULTS

Eleven studies were included in the review. The mean age of all participants in the studies was 69 years of age. The study designs included prospective case-control, prospective cohort, and cross-sectional to determine the psychometric properties of the measurements and tools. The included studies examined techniques to assess range of motion, strength, and pain-pressure thresholds, and screen for arthritis (ie, provocative tests). The intermetacarpal distance method, Kapandji index, pain-pressure threshold test, and pain-free grip and pinch dynamometry demonstrate excellent reliability and acceptable precision. Metacarpal extension, adduction, and pressure-shear provocative tests have superior sensitivity and specificity and the extension and adduction tests have excellent reliability. Other assessments included in the review yielded less robust psychometric properties. Studies were of variable methodological quality spanning from inadequate to very good.

CONCLUSIONS

Based on the available literature on the psychometric properties of assessments of body structures and functions in persons with non-operative thumb carpometacarpal osteoarthritis, we offer a limited set of recommendations for use when screening for arthritis symptomology and measuring hand strength, thumb mobility, and pain thresholds. Additional psychometric research is needed in these domains as well as in dexterity, sensation, and objective measures of hand function. Future research should employ best practices in psychometric research.

Joint capsule innervation does not explain the difference in symptoms between scaphotrapezial and trapeziometacarpal osteoarthritis

OBJECTIVES

Peritrapezial osteoarthritis (OA) includes scaphotrapezial and trapeziometacarpal OA. In clinical practice, scaphotrapezial OA seems better tolerated than trapeziometacarpal OA, with fewer complaints and better tolerance. The difference in pain could be linked to a difference in joint capsule innervation, perhaps with fewer nerve fibers in the scaphotrapezial than the trapeziometacarpal joint.

MATERIALS AND METHODS

We performed a histologic evaluation of these two joints to compare their respective innervation in 17 cadaveric specimens with peritrapezial OA. Radiographic scoring confirmed the presence of peritrapezial OA. Mean Kellgren-Lawrence score was 2.2 ± 1.1 in the trapeziometacarpal joint and 1.5 ± 0.7 in the scaphotrapezial joint (p = 0.08).

RESULTS

There was no difference between scaphotrapezial and trapeziometacarpal joints in number of neurofilaments: 5.2 ± 3.9 and 4.4 ± 4.5, respectively (p = 0.20). A significant difference was found in S100 staining (myelinated structures), with a higher rate in the scaphotrapezial joint: 11.8 ± 7.5 vs 6.6 ± 5.2 (p = 0.005).

CONCLUSION

The present study suggests that lower tolerance of trapeziometacarpal OA is not due to a difference in joint capsule innervation. On the contrary, we found a higher rate of myelinated tissues in the scaphotrapezial joint. These results suggested other pain pathways to explain clinical observations.

Proprioception and Mechanoreceptors in Osteoarthritis: A Systematic Literature Review

PURPOSE

Osteoarthritis (OA) is one of the most common chronic diseases in the world. It is frequently accompanied by high levels of persistent pain, as well as substantial impairments in function and functional capacity. This review aims to systematically analyze the changes in proprioception and related mechanoreceptors in OA patients.

METHODS

Studies from September 2013 to September 2023 were identified by conducting searches on the PubMed, Web of Science, and Scopus electronic databases following the PRISMA statement. One reviewer independently assessed and screened the literature, extracted the data, and graded the studies. The body of evidence underwent an evaluation and grading process using the ROBINS-I tool, which was specifically designed to assess the risk of bias in non-randomized studies of interventions. Results were summarized using descriptive methods.

RESULTS

A search through 37 studies yielded 14 clinical studies that were ultimately included. The primary focus of the studies was on the knee joint, particularly the posterior cruciate ligament (PCL). The studies found that PCL in OA patients had impaired proprioceptive accuracy, possibly due to changes in mechanoreceptors (Ruffini, Pacini, and Golgi Mazzoni corpuscles). This suggests that dysfunctional articular mechanoreceptors, especially in severe cases of OA, may contribute to reduced proprioception. Dynamic stabilometry also identified significant proprioceptive deficits in patients with knee articular cartilage lesions, underscoring the impact of such lesions on knee proprioception.

CONCLUSIONS

Literature data have shown that proprioceptive accuracy may play an important role in OA, particularly in the knee PCL and cartilage. However, the role of proprioception and related mechanoreceptors needs to be further clarified. Future studies focusing on the relationship between proprioception, OA disease, and symptoms, considering age and gender differences, and exploring OA joints other than the knee should be conducted to improve clinical and surgical outcomes in cases where proprioception and mechanoreceptors are impaired in OA patients.

Effectiveness of proprioception training in functional recovery of thumb osteoarthritis. Single, multicenter, non-blind randomized clinical trial

BACKGROUND AND OBJECTIVES

Osteoarthritis at the base of the thumb (CMC-1 OA) is a pathology that mainly affects postmenopausal women. The main symptoms including pain, decreased hand-thumb strength and fine motor capacity. Although a proprioceptive deficit has already been demonstrated in people with CMC-1 OA, there is insufficient evidence regarding the effects of proprioceptive training. The main objective of this study is to determine the effectiveness of proprioceptive training in functional recovery.

MATERIALS AND METHODS

A total of 57 patients were included in the study, 29 in the control group and 28 in the experimental group. Both groups underwent the same basic intervention programme, but the experimental group included a proprioceptive training protocol. Variables of the study were pain (VAS), perception of occupational performance (COMP), sense position (SP) and force sensation (FS).

RESULTS

Statistically significant improvement was observed in the experimental group in pain (p < .05) and occupational performance (p < .001) after 3 months of treatment. No statistical differences were found in sense position (SP) or sensation of force (FS).

DISCUSSION AND CONCLUSIONS

The results concord with previous studies focussing on proprioception training. The incorporation of a proprioceptive exercise protocol reduces pain and significantly improves occupational performance.

Effect of a stabilization exercise program versus standard treatment for thumb carpometacarpal osteoarthritis: A randomized trial

STUDY DESIGN

Randomized, interventional trial with 1 year follow-up.

INTRODUCTION

Though recommended, evidence is lacking to support specific exercises to stabilize and strengthen the first carpometacarpal (CMC) joint for cases of osteoarthritis (OA).

PURPOSE OF THE STUDY

To determine in a naturalistic setting, whether standard treatment plus a home exercise program (ST+HEP) is more effective than standard treatment (ST) alone in improving Quick Disabilities of Arm, Shoulder and Hand (qDASH) scores, and secondarily, in other patient-centered (pain, function) and clinical outcomes (range of motion, strength).

METHODS

A total of 190 patients from a hand therapy practice in northwestern PA were enrolled by informed consent and randomized into ST or ST+HEP groups. Average age was 60 years, most were female (78%) with sedentary occupations most common (36%). ST group received orthotic interventions, modalities, joint protection education and adaptive equipment recommendations, while the ST+HEP group received a home exercise program in addition to ST for 6-12 months. Follow-up occurred at 3, 6, and 12 months. Outcomes included grip strength, pinch strength, range of motion (ROM), qDASH, Patient Specific Functional Scale (PSFS) and pain ratings. At the 6 month mark, all subjects could change groups if desired. Efficacy data analysis included both parametric and non-parametric tests. The threshold for statistical significance was 0.05 and adjusted for multiple comparisons.

RESULTS

Repeated measures ANOVA failed to show a statistically significant difference in strength and ROM assessments between treatment groups over the 12 month follow-up (P ≥ .398). Differences between groups did not exceed 13%. Both the ST and ST+HEP groups evidenced improvement over time in most patient-focused assessments (P ≤ .011), including improvements exceeding reported clinically important differences in pain with activity and PSFS scores. Scores for these measures were similar at each follow-up period (P ≥ .080) in each group. The presence of CTS exerted no effect on outcomes; longer treatment time was weakly related to poorer qDASH and PSFS scores initially. Of those enrolled, 48% of subjects completed the study.

CONCLUSIONS

The addition of a high-frequency home exercise program did not improve clinical or patient-centered outcomes more so than standard care in our sample however, study limitations are numerous. Both groups had decreased pain with activity and improved PSFS scores, meeting the established minimally clinically important difference (MCID) of each at 6 and 12 months. Adherence with the home program was poor and/or unknown.

Trapeziometarpal joint arthritis in the young patient

Initial management of symptomatic trapeziometacarpal joint arthritis is generally non-operative. Though the aetiology of trapeziometacarpal arthritis remains controversial, unrecognized joint incongruity in early-stage arthritis (Eaton stage 1 or 2) is likely to lead to progression of joint degeneration. In established arthritis, salvage procedures can successfully alleviate symptoms and return of function; however the long-term outcome of these procedures has not been determined, and this is of particular concern in the younger patient. Recognition of the joint incongruity in these patients with early-stage disease can lead to measures which may prevent or delay the progression of joint degeneration.Level of evidence: V.

Characterizing response to a dynamic stability modeled approach for thumb carpometacarpal joint pain: A retrospective study

STUDY DESIGN

Retrospective case series.

INTRODUCTION

Literature trends indicate that thumb dynamic stabilization may benefit clients with thumb carpometacarpal (CMC) joint pain and arthritis. There is minimal research investigating whether client characteristics predict responsiveness to hand therapy for thumb dynamic stabilization.

PURPOSE OF THE STUDY

1) To investigate how adults with thumb CMC joint pain responded to a hand therapy dynamic stabilization modeled intervention. 2) To determine if various client factors influenced responsiveness and to what extent.

METHODS

An electronic medical record search identified adults treated from August 2009 through December 2015 for thumb CMC joint pain. Radiographs were retrospectively staged. Outcome measures were 1) Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) total disability score and 2) Numerical Pain Rating Scale (NPRS). Paired t-tests were performed to compare pre and post treatment measures. Multivariate analyses were used to investigate predictive factors.

RESULTS

A total of 249 charts were analyzed. Large overall significant effects were noted for disability score (QuickDASH P <.001, X = 12.1, Cohen's d = 0.9). The average improvement of 2.1 (SD = 2.6) points exceeded the minimal clinically important difference (MCID) of 1.7 points on the NPRS pain scale. Significant predictors of QuickDASH Scores were radiographic staging, bilateral hand involvement and initial pain ratings. Significant predictors for change in pain scores (meeting or exceeding the minimal clinically important difference for the NPRS) were bilateral thumb involvement and initial "pain at worst" rating.

CONCLUSION

After completing hand therapy with a dynamic stabilization approach, clients had less pain and disability. Those who had unilateral thumb pain, or those who started with higher pain levels were most likely to have clinically meaningful improvements in pain. Clients in early CMC osteoarthritis (OA) stages responded better than those in later stages, indicating that early referral to therapy is important.

The biomechanics of osteoarthritis in the hand: Implications and prospects for hand therapy

BACKGROUND

The unique anatomy of the human hand makes it possible to carefully manipulate tools, powerfully grasp objects, and even throw items with precision. These apparent contradictory functions of the hand, high mobility for manual dexterity vs high stability during forceful grasping, imply that daily activities impose a high strain on a relatively instable joint. This makes the hand susceptible to joint disorders such as osteoarthritis. Both systemic (eg, genetics, hormones) and mechanical factors (eg, joint loading) are important in the development of osteoarthritis, but the precise pathomechanism remains largely unknown. This paper focuses on the biomechanical factors in the disease process and how hand therapists can use this knowledge to improve treatment and research.

CONCLUSION

Multiple factors are involved in the onset and development of osteoarthritis in the hand. Comprehension of the biomechanics helps clinicians establish best practices for orthotics intervention, exercise, and joint protection programs even in de absence of clear evidence-based guidelines. The effect and reach of hand therapy for OA patients can be expanded substantially when intervention parameters are optimized and barriers to early referrals, access reimbursement, and adherence are addressed. Close and early collaboration between hand therapists and primary care, women's health, rheumatology, and hand surgery providers upon diagnosis, and with hand surgeons pre and postoperatively, combined with advances in the supporting science and strategies to enhance adherence, appear to be a promising way forward.

Dynamic stabilization of the painful thumb: A historical and evidence-informed synthesis

STUDY DESIGN

Expert opinion INTRODUCTION: Thumb carpometacarpal joint (CMC) osteoarthritis is a common condition seen in the hand therapy clinic. Prevalence is generally higher in females, and the percentage rises for post-menopausal females. Patients typically present with pain and functional difficulties. Conservative management is recommended before a surgical consult. Evidence is mounting that a dynamic stability modeled approach has a significant effect on pain and improving function.

PURPOSE

The purpose of this paper is two-fold: first, to present the history and development of a dynamic stabilization model for treatment of the patient with thumb CMC osteoarthritis (OA), and second, to provide expert clinical commentary and recommendations for the treatment of thumb CMC OA in light of the best available evidence.

METHODS

Expert clinical commentary is based on an extensive review of relevant literature.

RESULTS

The current literature and expert opinion supports an evidence-informed multimodal intervention: modalities, pain relief techniques, manual release, joint mobilizations as deemed necessary, neuromuscular re-education through proprioceptive exercises, and education in joint protection principles.

CONCLUSION

A rationale for a dynamic stabilization approach is presented. The unique anatomy of the thumb deserves finely tuned care based on high quality research. To advance our knowledge and clinical skills we must not become stagnant, but continue to generate high level evidence. The standard for future thumb CMC OA studies should be well-defined intervention parameters, consistent documentation, and the use of appropriate patient-rated outcome measures.

Anatomy and Biomechanics of the Thumb Carpometacarpal Joint

This review discusses the anatomy and biomechanics of the thumb carpometacarpal (CMC) joint. This articulation between the trapezium and first metacarpal is integral for opposition and other complex movements necessary for pinch and grasp maneuvers. Fortunately, this joint is well equipped to handle the extreme forces imposed by these movements, as it is stabilized by an elaborate arrangement of ligaments and muscles. Without this stability, thumb subluxation would occur with loading during pinch and grasp, and human prehension would be impossible. Understanding the interactions occurring within this joint is essential for adequately treating pathology arising in this crucial joint.

Alteration of Ligamento-Muscular Reflex Patterns After Cutaneous and Periarticular Desensitization of the Basal Thumb Joint: An Electromyographic Study

PURPOSE

Stimulation of the dorsoradial ligament (DRL) of the first carpometacarpal joint (CMC-1) has shown a ligamento-muscular reflex pathway between the DRL and CMC-1 stabilizing muscles in healthy volunteers. However, it remains unclear how this ligamento-muscular reflex pattern is altered after anesthetizing sensory skin receptors and administering a further periarticular block around the CMC-1 joint, which may influence the dynamic aspects of joint stability.

METHODS

Ligamento-muscular reflexes were obtained from the extensor pollicis longus, abductor pollicis longus, abductor pollicis brevis, and the first dorsal interosseous muscles in 10 healthy participants after establishing superficial anesthesia of the skin around the CMC-1. The DRL was stimulated with a fine wire electrode while EMG activities were recorded during isometric tip, key, and palmar pinch. The measurements were repeated after an additional periarticular CMC-1 block using 5 ml of 1% lidocaine. Average EMG values were analyzed to compare the prestimulus and poststimulus activity.

RESULTS

Statistically significant changes in poststimulus EMG activity were observed in all 4 muscles and all 3 tested thumb positions. A markedly reduced activity in all 4 muscles was observed in the palmar position, followed by the tip and key pinch positions. Almost no reactions were observed in the first 20 ms poststimulus for all muscles in all positions.

CONCLUSIONS

Superficial skin anesthesia and an additional periarticular CMC-1 block anesthesia resulted in a reduced ligamento-muscular reflex pattern in all 4 muscles.

CLINICAL RELEVANCE

Ligamento-muscular reflexes play an important role in dynamic CMC-1 joint stability. The elimination of early reactions, those considered joint-protective reflexes, is a potential risk factor for developing osteoarthritis or injury because it results in an inability to adequately protect and stabilize the joint in sudden movements.

Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study

STUDY DESIGN

This study has a descriptive-comparative, cross-sectional design.

INTRODUCTION

Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA).

PURPOSE OF THE STUDY

This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test.

METHODS

The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non-CMC OA group with the healthy control group.

RESULTS

The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96.

CONCLUSIONS

Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.

Anatomy and biomechanics of healthy and arthritic trapeziometacarpal joints

Understanding the biomechanics of the trapeziometacarpal (TMC) or first carpometacarpal (CMC1) joint, the pathophysiology of basal thumb arthritis, the design and performance of surgical procedures require a solid anatomical basis. This review of literature summarizes the most recent data on the descriptive, functional, and comparative anatomy of healthy and arthritic TMC joints.

Is Thumb Proprioception Decreased in Patients With Trapeziometacarpal Joint Osteoarthritis?

Proprioception is thought to be essential for normal joint homeostasis, and its decreased function has been associated with an increased risk of joint diseases. However, only a few studies have been performed on the association between proprioceptive function in the trapeziometacarpal joint (TMCJ) and osteoarthritis. The purpose of this study was to compare TMCJ proprioceptive function in elderly women with radiographic TMCJ osteoarthritis relative to age-matched control women without osteoarthritis. We enrolled 19 women (mean age, 66 years) with symptomatic, radiographic Eaton and Littler grade 2, 3, and 4 TMCJ osteoarthritis and 19 age-matched control women without osteoarthritis. We evaluated thumb proprioception by using a joint-position reproduction test and compared the reposition error (RE) between the groups. We carried out a multivariate analysis for factors potentially associated with increased RE, such as age, body mass index, hand dominance, the presence of diabetes, pain level, and the presence of osteoarthritis. Also, a logistic regression analysis was performed for factors associated with the occurrence of TMCJ osteoarthritis. Patients with TMCJ osteoarthritis had greater RE than did the control patients in the joint-position reproduction test at 20°, 30°, and 40° of thumb palmar abduction. The multivariate analysis indicated that increased RE was associated with the presence of osteoarthritis, but not with the other factors assessed. The occurrence of TMCJ osteoarthritis was associated with increased RE at 20°, 30°, and 40° of thumb palmar abduction. This study showed that decreased proprioceptive function was associated with the presence of osteoarthritis in the TMCJ, although the causality remains unknown. Further studies on the role of proprioception in the pathogenesis of TMCJ osteoarthritis and the potential role of its training for disease prevention or treatment are required.

Hand osteoarthritis: clinical phenotypes, molecular mechanisms and disease management

Osteoarthritis (OA) is a highly prevalent condition, and the hand is the most commonly affected site. Patients with hand OA frequently report symptoms of pain, functional limitations and frustration in undertaking everyday activities. The condition presents clinically with changes to the bone, ligaments, cartilage and synovial tissue, which can be observed using radiography, ultrasonography or MRI. Hand OA is a heterogeneous disorder and is considered to be multifactorial in aetiology. This Review provides an overview of the epidemiology, presentation and burden of hand OA, including an update on hand OA imaging (including the development of novel techniques), disease mechanisms and management. In particular, areas for which new evidence has substantially changed the way we understand, consider and treat hand OA are highlighted. For example, genetic studies, clinical trials and careful prospective imaging studies from the past 5 years are beginning to provide insights into the pathogenesis of hand OA that might uncover new therapeutic targets in the disease.

Ligamento-Muscular Reflex Patterns Following Stimulation of a Thumb Carpometacarpal Ligament: An Electromyographic Study

PURPOSE

The dorsoradial ligament (DRL) is essential for stability of the first carpometacarpal joint (CMC1) and is innervated with nerve endings and mechanoreceptors known to contribute to joint proprioception. The influence of these nerve endings on the neuromuscular stability of CMC1 is not yet known. This study investigated whether a ligamento-muscular reflex pathway is present between the DRL and CMC1 muscles.

METHODS

Ten healthy subjects (5 women and 5 men, mean age 28 years; range, 24-37 years) were included. Four primary CMC1 stabilizing muscles were investigated: the extensor pollicis longus, abductor pollicis longus (APL), abductor pollicis brevis, and first dorsal interosseous. Needle electrodes were inserted into each muscle and a fine-wire electrode was inserted into the DRL. The DRL was stimulated at 200 MHz while EMG activities in the muscles were recorded during isometric tip, key, and palmar pinch. Average EMG values were analyzed to compare prestimulus (t₁) with post-stimulus (t₂) activity.

RESULTS

Poststimulus changes were observed in all 4 muscles and 3 positions tested. During tip pinch we observed mass inhibition with a decrease in all muscle amplitudes. In key pinch we observed a rapid co-contraction response. Rapid inhibitory response of antagonistic musculature was observed during palmar pinch. The APL was the only muscle to react within 20 ms after stimulation.

CONCLUSIONS

We identified CMC1 ligamento-muscular reflexes. The mass inhibition of activity observed during tip pinch indicated a protective ligamento-muscular relation that affects all 4 muscles. The co-contractions observed promote joint stability. The fast response in the APL, coupled with its neuroanatomical proximity to the DRL, indicate a particular role in CMC1 proprioception.

CLINICAL RELEVANCE

Proper ligamentous support and retained innervation is likely important for adequate joint function; their innate functions ought to be considered when planning surgical or orthotic treatments.

Wide-awake Anesthesia No Tourniquet Trapeziometacarpal Joint Prosthesis Implantation

Wide awake local anesthesia no tourniquet (WALANT) hand surgery is a rapidly growing in popularity. WALANT has been used by hand surgeons when operating on bones, tendons, ligaments, nerve entrapments. We offer a case report of the first case in the literature describing WALANT technique when performing trapeziometacarpal joint arthroplasty with prosthesis implantation. We offer technical points on how to perform this procedure and the advantages that are associated with using WALANT for prosthesis arthroplasty.

Effectiveness of Superficial Radial Nerve Block on Pain, Function and Quality of Life in Patients With Hand Osteoarthritis: A Prospective, Randomized and Controlled Single-Blind Study

Objectives

This study aims to investigate the effects of ultrasound-guided superficial branch of the radial nerve block on pain, function and quality of life in patients with hand osteoarthritis.

Patients and methods

In this prospective, randomized and controlled single-blind study, 50 female patients (mean age 59.0±5.1 years; range, 46 to 64 years) diagnosed with hand osteoarthritis were randomized into two groups. Group 1 (n=25) was administered an ultrasound-guided superficial branch of the radial nerve injection (with a combination of 2 mL 0.25% bupivacaine and 1 mL methylprednisolone acetate) + exercise, while group 2 (n=25) only exercised. Patients were assessed with a visual analog scale for pain, hand grip strength, finger grip strength, Quick Disability of the Arm, Shoulder and Hand questionnaire, Duruöz Hand Index and Short-form 12. Data were obtained before treatment (W0), in the second week after treatment (W2) and in the fourth week after treatment (W4).

Results

In group 1, a statistically significant improvement was obtained in all parameters at both W2 and W4 compared to the values recorded at W0 (p<0.05). In group 2, a statistically significant improvement was observed only in the parameters of hand grip strength and finger grip strength at W2 and W4 (p<0.05). A comparison of the scores of the two groups showed statistically significant superior improvement in group 1 in all parameters at both W2 and W4 (p<0.05).

Conclusion

The findings of our study showed that an ultrasound-guided superficial branch of the radial nerve block combined with exercise is a significantly superior treatment to exercise-only regarding the improvements in the parameters of pain, function and quality of life in hand osteoarthritis patients.

The Teleology of the Thumb: On Purpose and Design

The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a midcareer researcher dedicated to advancing patient care in the field of hand surgery. The Weiland Medal for 2017 was presented to the author at the annual meeting of the American Society for Surgery of the Hand. The purpose of this article is to present current evidence on how biomechanics and morphology influence the pathophysiology of thumb carpometacarpal joint osteoarthritis.

Therapy management of thumb carpometacarpal osteoarthritis: Exploring UK therapists’ perceptions of joint instability

Introduction

Carpometacarpal joint osteoarthritis is a common and painful condition associated with ligament laxity, subluxation and joint instability. Therapy management includes several interventions targeting the symptoms associated with instability and subluxation. This study aimed to explore the perceptions of experienced therapists, about their understanding of joint instability in carpometacarpal joint osteoarthritis and its relationship with laxity, subluxation and strength, and the perceived effectiveness of exercise interventions.

Methods

A qualitative research design, consisting of individual semi-structured interviews was conducted with nine therapists. Interviews were transcribed and analysed using a thematic analysis.

Results

Three themes were identified: (a) relationships between instability and laxity – the terms laxity and instability were often used interchangeably. Instability was associated with laxity, subluxation and disease progression, and was perceived to be a problem that includes the whole thumb column; (b) clinical reasoning by stage of disease – conflicting opinions were expressed regarding instability being present in pre-arthritic lax joints, early disease or all stages of disease; (c) the role of exercise in management – there was disagreement as to whether instability could be modified by developing muscle strength, or whether treatment should be focussed on compensating for instability.

Conclusion

Different perceptions of instability were reflected in wide-ranging opinions regarding the need to manage instability, and regarding the potential for altering instability. The impact of instability on function, and the concept of instability were not easily identified. A clearer definition of instability would facilitate the development and assessment of interventions for instability.

Surgical stabilization for symptomatic carpometacarpal hypermobility; a randomized comparison of a dorsal and a volar technique and a cohort of the volar technique

BACKGROUND

Hypermobility of the first carpometacarpal joint is mostly surgically treated with a volar approached stabilization by Eaton, but recent studies indicate the importance of the dorsoradial and intermetacarpal ligaments (DRL and IML) for carpometacarpal joint stability. The aim of this study was to compare a dorsal and volar technique for primary carpometacarpal hypermobility regarding pain and functional outcome.

METHODS

Patients with non-degenerative, painful carpometacarpal hypermobility were included and were randomly assigned to either the volar technique using the FCR, or a dorsal technique using the ECRL. After premature termination of the trial, we followed all patients treated with the volar approach. Pain, strength, and ADL function using DASH and Michigan Hand Questionnaires (MHQ) were measured at baseline and 3 and 12 months after surgery.

RESULTS

After including 16 patients, the randomized trial comparing the volar and dorsal technique was terminated because of significant increased pain in the dorsal group. Although none of the other outcome measures were significant in the underpowered comparison, in line with the pain scores, all variables showed a trend towards a worse outcome in the dorsal group. Between 2009 and 2012, 57 thumbs were surgically stabilized. We found significant better pain and MHQ scores, and after 1 year improved grip and key pinch strength. Patients returned to work within 8 (±7) weeks, of which 85 % in their original job.

CONCLUSIONS

Surgical stabilization of the thumb is an effective method for patients suffering from hypermobility regarding pain, daily function, and strength. We recommend a volar approach. Level of Evidence: Level I, therapeutic study.

Altered Innervation Pattern in Ligaments of Patients with Basal Thumb Arthritis

Purpose The population of mechanoreceptors in patients with osteoarthritis (OA) lacks detailed characterization. In this study, we examined the distribution and type of mechanoreceptors of two principal ligaments in surgical subjects with OA of the first carpometacarpal joint (CMC1). Methods We harvested two ligaments from the CMC1 of eleven subjects undergoing complete trapeziectomy and suspension arthroplasty: the anterior oblique (AOL) and dorsal radial ligament (DRL). Ligaments were divided into proximal and distal portions, paraffin-sectioned, and analyzed using immunoflourescent triple staining microscopy. We performed statistical analyses using the Wilcoxon Rank Sum test and ANOVA with post-hoc Bonferroni and Tamhane adjustments. Results The most prevalent nerve endings in the AOL and DRL of subjects with OA were unclassifiable mechanoreceptors, which do not currently fit into a defined morphological scheme. These were found in 11/11 (100%) DRLs and 7/11 (63.6%) AOLs. No significant difference existed with respect to location within the ligament (proximal versus distal) of mechanoreceptors in OA subjects. Conclusion The distribution and type of mechanoreceptors in cadavers with no to mild OA differ from those in surgical patients with OA. Where Ruffini endings predominate in cadavers with no to mild OA, unclassifiable corpuscles predominate in surgical patients with OA. These findings suggest an alteration of the mechanoreceptor population and distribution that accompanies the development of OA. Clinical Relevance Identification of a unique type and distribution of mechanoreceptors in the CMC1 of symptomatic subjects provides preliminary evidence of altered proprioception in OA.

Immunohistochemical Mapping of Sensory Nerve Endings in the Human Triangular Fibrocartilage Complex

BACKGROUND

The triangular fibrocartilage complex is the main stabilizer of the distal radioulnar joint. While static joint stability is constituted by osseous and ligamentous integrity, the dynamic aspects of joint stability chiefly concern proprioceptive control of the compressive and directional muscular forces acting on the joint. Therefore, an investigation of the pattern and types of sensory nerve endings gives more insight in dynamic distal radioulnar joint stability.

QUESTIONS/PURPOSES

We aimed to (1) analyze the general distribution of sensory nerve endings and blood vessels; (2) examine interstructural distribution of sensory nerve endings and blood vessels; (3) compare the number and types of mechanoreceptors in each part; and (4) analyze intrastructural distribution of nerve endings at different tissue depth.

METHODS

The subsheath of the extensor carpi ulnaris tendon sheath, the ulnocarpal meniscoid, the articular disc, the dorsal and volar radioulnar ligaments, and the ulnolunate and ulnotriquetral ligaments were dissected from 11 human cadaver wrists. Sensory nerve endings were counted in five levels per specimen as total cell amount/cm(2) after staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, and S-100 protein and thereafter classified according to Freeman and Wyke.

RESULTS

All types of sensory corpuscles were found in the various structures of the triangular fibrocartilage complex with the exception of the ulnolunate ligament, which contained only Golgi-like endings, free nerve endings, and unclassifiable corpuscles. The articular disc had only free nerve endings. Furthermore, free nerve endings were the predominant sensory nerve ending (median, 72.6/cm(2); range, 0-469.4/cm(2)) and more prevalent than all other types of mechanoreceptors: Ruffini (median, 0; range, 0-5.6/cm(2); difference of medians, 72.6; p < 0.001), Pacini (median, 0; range, 0-3.8/cm(2); difference of medians, 72.6; p < 0.001), Golgi-like (median, 0; range, 0-2.1/cm(2); difference of medians, 72.6; p < 0.001), and unclassifiable corpuscles (median, 0; range, 0-2.5/cm(2); difference of medians, 72.6; p < 0.001). The articular disc contained fewer free nerve endings (median, 1.8; range, 0-17.8/cm(2)) and fewer blood vessels (median, 29.8; range, 0-112.2/cm(2); difference of medians: 255.9) than all other structures of the triangular fibrocartilage complex (p ≤ 0.001, respectively) except the ulnolunate ligament. More blood vessels were seen in the volar radioulnar ligament (median, 363.62; range, 117.8-871.8/cm(2)) compared with the ulnolunate ligament (median, 107.7; range, 15.9-410.3/cm(2); difference of medians: 255.91; p = 0.002) and the dorsal radioulnar ligament (median, 116.2; range, 53.9-185.1/cm(2); difference of medians: 247.47; p = 0.001). Free nerve endings were obtained in each structure more often than all other types of sensory nerve endings (p < 0.001, respectively). The intrastructural analysis revealed no differences in mechanoreceptor distribution in all investigated specimens with the numbers available, showing a homogenous distribution of proprioceptive qualities in all seven parts of the triangular fibrocartilage complex.

CONCLUSIONS

Nociception has a primary proprioceptive role in the neuromuscular stability of the distal radioulnar joint. The articular disc and ulnolunate ligament rarely are innervated, which implies mainly mechanical functions, whereas all other structures have pronounced proprioceptive qualities, prerequisite for dynamic joint stability.

CLINICAL RELEVANCE

Lesions of the volar and dorsal radioulnar ligaments have immense consequences not only for mechanical but also for dynamic stability of the distal radioulnar joint, and surgical reconstruction in instances of radioulnar ligament injury is important.

Sensorimotor interventions and assessments for the hand and wrist: a scoping review

STUDY DESIGN

Scoping review.

INTRODUCTION

Sensorimotor deficits can impair function and may be present in individuals with common upper extremity conditions.

PURPOSE OF THE STUDY

To provide clinicians with an understanding of the usefulness of the assessments to evaluate sensorimotor function and the interventions reported in the literature to effect positive change in our patients with sensorimotor deficits affecting the hand and wrist.

METHODS

A systematic search produced seventeen studies involving sensorimotor retraining and assessment of sensorimotor performance for the upper extremity.

RESULTS

Sensorimotor interventions and assessments found in the literature vary in regards to their effectiveness in restoring sensorimotor function in subjects with a number of conditions that affect hand and wrist function.

CONCLUSIONS

There is a potential value of sensorimotor interventions for individuals with specific upper extremity conditions. There is a need for further studies to improve treatment of sensorimotor deficits and understanding of sensorimotor interventions.

Ulnar digits contribution to grip strength in patients with thumb carpometacarpal osteoarthritis is less than in normal controls

BACKGROUND

Grip testing is commonly used as an objective measure of strength in the hand and upper extremity and is frequently used clinically as a proxy measure of function. Increasing knowledge of hand biomechanics, muscle strength, and prehension patterns can provide us with a better understanding of the functional capabilities of the hand. The objectives of this study were to determine the contribution of ulnar digits to overall grip strength in individuals with thumb carpometacarpal (CMC) osteoarthritis (OA).

METHODS

Thirty-seven subjects participated in the study. This group consisted of 19 patients with CMC OA (aged 60-88 years) and 18 healthy subjects (60-88 years). Three hand configurations were used by the subjects during grip testing: use of the entire hand (index, middle, ring, and little fingers) (IMRL); use of the index, middle, and ring fingers (IMR); and use of only the index and middle fingers (IM).

RESULTS

Grip strength findings for the two groups found that compared to their healthy counterparts, CMC OA patients had, on average, a strength deficiency of 45.6, 35.5, and 28.8 % in IMRL, IMR, and IM, respectively. The small finger contribution to grip is 14.3 % and the ring and small finger contribute 34 % in subjects with CMC OA.

DISCUSSION

Grip strength decreases as the number of digits contributing decreased in both groups. The ulnar digits contribution to grip strength is greater than one third of total grip strength in subjects with CMC OA. Individuals with CMC OA demonstrate significantly decreased grip strength when compared to their healthy counterparts.

Thumb ligament injuries

Thumb ligament injuries are common, particularly those involving the metacarpophalangeal joint. Our understanding and treatment of these injuries continues to evolve. This article provides a comprehensive review of recent literature with updates pertaining to the anatomy, function, diagnosis, and treatment of thumb ligament injuries.

The 2014 ABJS Nicolas Andry Award: The puzzle of the thumb: mobility, stability, and demands in opposition

BACKGROUND

The paradoxical demands of stability and mobility reflect the purpose and function of the human thumb. Its functional importance is underscored when a thumb is congenitally absent, injured, or afflicted with degenerative arthritis. Prevailing literature and teaching implicate the unique shape of the thumb carpometacarpal (CMC) joint, as well as its ligament support, applied forces, and repetitive motion, as culprits causing osteoarthritis (OA). Sex, ethnicity, and occupation may predispose individuals to OA.

QUESTIONS/PURPOSES

What evidence links ligament structure, forces, and motion to progressive CMC disease? Specifically: (1) Do unique attributes of the bony and ligamentous anatomy contribute to OA? (2) Can discrete joint load patterns be established that contribute to OA? And (3) can thumb motion that characterizes OA be measured at the fine and gross level?

METHODS

We addressed the morphology, load, and movement of the human thumb, emphasizing the CMC joint in normal and arthritic states. We present comparative anatomy, gross dissections, microscopic analysis, multimodal imaging, and live-subject kinematic studies to support or challenge the current understanding of the thumb CMC joint and its predisposition to disease.

RESULTS

The current evidence suggests structural differences and loading characteristics predispose the thumb CMC to joint degeneration, especially related to volar or central wear. The patterns of degeneration, however, are not consistently identified, suggesting influences beyond inherent anatomy, repetitive load, and abnormal motion.

CONCLUSIONS

Additional studies to define patterns of normal use and wear will provide data to better characterize CMC OA and opportunities for tailored treatment, including prevention, delay of progression, and joint arthroplasty.