Trapezium resection with suspension and interposition arthroplasty using acellular dermal allograft for thumb carpometacarpal arthritis

Long-Term Results of Suture-Button Suspensionplasty in the Treatment of Thumb Carpometacarpal Arthritis: A Minimum 10-Year Follow-Up

Purpose

Combined trapeziectomy and suture-button suspensionplasty (SBS) is a common and well-established surgical treatment for thumb carpometacarpal (CMC) osteoarthritis. Although short and mid-term follow-up studies have shown promising outcomes with patients retaining excellent range of motion and strength, long-term data are lacking. The aim of our study was to assess the long-term outcomes of patients who underwent SBS surgery for thumb CMC arthritis, with a minimum follow-up period of 10 years.

Methods

We evaluated 17 patients, at least 10 years after undergoing SBS surgery for thumb CMC arthritis. We measured grip and pinch strength, range of motion, and trapezial space height and compared it with the respective values measured on the routine postoperative 3-month follow-up visit. All patients have additionally completed the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire.

Results

The study included 11 women and 6 men with an average age of 60.3 ± 6.4 years and a mean follow-up of 137.4 ± 11.4 months after surgery. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 9 (range: 0-40.9) at the long-term follow-up, compared with 26.2 (range: 4.5-75) recorded 3 months after the surgery. Grip and pinch strengths were 116% and 111% of the 3-month postoperative value, respectively. Radial abduction and palmar abduction were 98% and 94% of the 3-month postoperative value, respectively. Kapandji scores were either equal or higher than the previously documented scores. Average height of the trapezial space was 69% of the previous postoperative measurement.

Conclusions

Our findings demonstrate that patients who underwent SBS surgery for thumb CMC osteoarthritis achieve excellent long-term outcomes by maintaining favorable subjective and objective results, despite some radiographic subsidence over time. These results indicate SBS to be an effective and durable technique for the long-term management of thumb CMC osteoarthritis.

Type of study/level of evidence

Therapeutic IV.

Indications for Ligament Reconstruction and Suspensionplasty in Carpometacarpal Arthroplasty

The trapeziometacarpal joint is the site that most commonly develops arthritis in the hand. Although optimal treatment requires careful consideration of history, physical examination, radiographs, and functional goals, many patients ultimately undergo surgical intervention. Several described techniques and approaches are highlighted in this article, especially pertaining to carpometacarpal arthroplasty with ligament reconstruction and tendon interposition. The rationale, benefit, and evidence for each approach are discussed and the author's preferred technique is described.

A Modified Suture Suspension Arthroplasty Technique for the Treatment of Basal Joint Arthritis: Short- to Intermediate-Term Outcomes

Background: To present a retrospective study on the outcomes of a modified version of suture suspension arthroplasty with trapeziectomy on patients with thumb basal joint arthritis and to evaluate the relationship between the degree of subsidence and functional outcome. Methods: We performed a chart review on 67 patients (75 thumbs) who were surgically treated for thumb carpometacarpal osteoarthritis with trapeziectomy and suture suspension arthroplasty from May 2010 to May 2016. Outcome measures included Disabilities of the Arm, Shoulder and Hand (DASH), grip strength, lateral/precision pinch strength, range of motion, and return to work/resumption of usual activities. Radiographic images were used to measure first metacarpal subsidence into the trapezial space. Results: Clinical outcomes were satisfactory, showing an initial postoperative DASH score of 45.94, which decreased to 27.93 at 6 months postoperatively and to 19.69 at 1 year postoperatively. Radiographic images revealed a mean first metacarpal subsidence of 39% compared with the preoperative images. Grip and pinch strengths showed steady improvement from initial postoperative to final follow-up visits, resulting in 90% recovery of gross grasp, 77% recovery of lateral pinch, and 79% recovery of precision pinch compared with the contralateral side. Conclusions: Our study has found that suture suspension arthroplasty with trapeziectomy is an effective treatment for thumb basal joint arthritis. Suture suspension arthroplasty allows for short immobilization time, avoids tendon sacrifice, avoids anchor use, and leaves a cosmetically appealing scar. Furthermore, a relationship of any significance between postoperative first metacarpal subsidence and functional outcomes does not appear.

Arthroplasty of the trapeziometacarpal joint with or without bioabsorbable polylactide scaffold (RegJoint™) interposition

The RegJoint™, a bioabsorbable polylactide scaffold, was introduced in 2011 for scaphometacarpal interposition following trapeziectomy for osteoarthritis. As previous clinical trials provided controversial results, we aimed to prove the non-inferiority of RegJoint™ interposition. In this retrospective study, first metacarpal suspension arthroplasty alone (SA) was compared to suspension with RegJoint™ interposition (RJ). Thirty-four patients with 37 treated thumbs (SA: 14; RJ: 23) were assessed clinically and radiologically at a mean follow-up of 5.3 ± 2.6 years (SA: 7.96; RJ: 3.73). Patient-reported outcomes were measured on three questionnaires (DASH, PRWE and PEM) and a visual analogue pain scale; there were no significant differences between the 2 groups. Clinical assessment comprised range of motion, opposition, pain, first-ray length, hand span, prominence, instability, force and sensitivity to touch. The RJ group showed significantly better palmar abduction (p = 0.026); the other outcome parameters were comparable in the 2 groups. Follow-up radiographs showed osteolysis in 2 SA hands and 3 RJ hands (p = 0.551). First-ray length had decreased by a mean 4.7 ± 2.7 mm at follow-up (SA: -3.8; RJ: -5.2; p = 0.056). No signs of adverse tissue reactions were observed. We conclude that RegJoint™ spacers do not produce more complications than suspension alone but provide no added benefit.

Biologic Tuberoplasty With an Acellular Dermal Allograft for Massive Rotator Cuff Tears

We present the technique of biologic tuberoplasty, where an acellular dermal allograft is used to cover the tuberosity in patients with massive irreparable cuff tears to prevent bone-to-bone contact between the tuberosity and acromion when active elevation is attempted. This technique can be performed in patients with massive rotator cuff tears who are low-demand and have significant medical comorbidities, poor bone quality, or who are not candidates for a reverse shoulder arthroplasty or who cannot tolerate a lengthy rehabilitation protocol. It is less time-consuming than a superior capsule reconstruction and more bone-sparing than traditional tuberoplasty. Patients with massive rotator cuff tears involving the supraspinatus and a portion of the infraspinatus lose their force couple, leading to superior humeral head migration with abutment of the tuberosity against the acromion upon deltoid activation. The center of rotation moves superiorly with deltoid contraction, developing an acromiohumeral articulation. This results in bone-to-bone contact between the acromion and humerus, leading to pain and acetabularization of the acromion over time. Coverage of the tuberosity with the acellular dermal allograft acts as an interpositional tissue and prevents bone-to-bone contact between the tuberosity and acromion.

Reporting Outcomes and Outcome Measures in Thumb Carpometacarpal Joint Osteoarthritis: A Systematic Review

PURPOSE

In the thumb carpometacarpal (CMC) joint osteoarthritis (OA) literature, there is substantial heterogeneity in outcome and outcome measure reporting. This could be rectified by a standardized core outcome set (COS). This study aimed to identify a comprehensive list of outcomes and outcome measures for thumb CMC joint OA, which represents the first step in developing a COS.

METHODS

A computerized search of MEDLINE, EMBASE, Cochrane, and CINAHL was performed to identify randomized controlled trials, as well as observational studies involving at least 50 participants aged greater than 18 years undergoing surgery for thumb CMC joint OA. Reported outcomes and outcome measures were extracted from these trials and summarized.

RESULTS

This search yielded 3,498 unique articles, 97 of which were used for analysis. A total of 33 unique outcomes and 25 unique outcome measures were identified. The most frequently used outcomes were complications (78), postoperative pain (73), radiologic outcomes (64), and grip strength (63). Within each reported outcome, there was substantial variation in how the outcome was measured. Of the 25 unique outcome measures, 10 were validated. Of the remaining 15, 12 were created ad hoc by the author. The Disabilities of the Arm, Shoulder, and Hand questionnaire was the most commonly reported outcome measure (34%).

CONCLUSIONS

There is a lack of consensus on critical outcomes after surgery for thumb CMC joint OA. A standardized COS created by stakeholder consensus would improve the consistency and therefore the quality of future research.

CLINICAL RELEVANCE

This systematic review of outcomes represents the first step in developing a core outcome set for thumb CMC joint OA.

Radiographic Outcomes in Treatment of Thumb Basal Joint Arthritis: Does Interposition of Acellular Dermal Allograft Prevent Metacarpal Settling?

Background  Osteoarthritis at the thumb carpometacarpal joint can have a profound impact on quality of life. Here, we evaluate radiographic outcomes in patients who have had open complete trapeziectomy, ligament reconstruction with tendon interposition, and acellular dermal matrix (GraftJacket) interposition-Group A, and compare them with those without GraftJacket interposition-Group B. Materials and Methods  Thirty patients who had undergone operative treatment for thumb basal joint arthritis by a single surgeon from 2009 to 2016 were identified, and charts were retrospectively reviewed for demographic data, surgical and radiographic outcomes, and complications. Results  There was no significant difference in pre- and postoperative radial abduction or pre- and postoperative palmar abduction. The difference in intraoperative joint space was significant ( p = 0.006), but the difference in postoperative joint space was not ( p = 0.310). The average amount of metacarpal settling was 6.9 versus 3.7 mm ( p = 0.035) (Groups A and B, respectively). Three patients in Group A developed an inflammatory reaction to the GraftJacket, and one required reoperation for allograft removal. Conclusion  This study suggests that thumb basal joint arthroplasty with GraftJacket interposition does not lead to more favorable radiographic outcomes at long-term follow-up. The increased costs associated with GraftJacket use may not be justified in light of these outcomes.

Trends in Trapeziometacarpal Implant Design: A Systematic Survey Based on Patents and Administrative Databases

Hand function is inseparably linked to the condition of the thumb. The trapeziometacarpal (TMC) joint that provides the different movements of opposition is one of the joints most affected by osteoarthritis, which causes an irreversible deformation of the bone. The ideal thumb carpometacarpal implant must restore range of movement, prevent complications, be biocompatible, and have good mechanical properties (ie, low wear, high corrosion resistance, and osteointegration properties where it is anchored in a bone). The integrity of the implant and the surrounding biological structures must be long-lasting and withstand constant stresses induced by the prosthesis. Three main types of implant systems for the thumb are currently clinically available; others are under investigation in human subjects. This systematic review is based on administrative databases, patents, the literature, and information from orthopedic companies. It provides a summary of strategies and design changes and an overview of the biomechanical characteristics of currently available carpometacarpal implants for treating osteoarthritis of the thumb.

Congenital Hypoplasia of the Extensor Tendons of the Fingers: A Case Report and Review of the Literature

We present a rare case and unusual presentation of digital extensor tendon congenital hypoplasia. A 34-year-old woman presented to our clinic with the inability to extend her index, middle, and ring fingers since birth. Her tendons were reconstructed using transfer of flexor digitorum superficialis tendons from the middle and ring fingers to the extensor aponeurosis of the index, middle, and ring fingers. An acellular dermal substitute was applied in a novel way to reconstruct the extensor retinaculum and promote a successful functional outcome.

Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review

PURPOSE

The purpose of the current review was to estimate failure rates of trapeziometacarpal (TMC) implants and compare against failure rates of nonimplant techniques for surgical treatment of TMC joint (basal thumb joint) arthritis.

METHODS

A systematic review was conducted to identify articles reporting on thumb implant arthroplasty and on nonimplant arthroplasty techniques for treatment of base of thumb arthritis in the English literature. The collected data were combined to calculate failure rates per 100 procedure-years. Failure was defined by the requirement for a secondary salvage procedure. The failure rates between different implant and nonimplant arthroplasty groups were compared directly and implants with higher than anticipated failure rates were identified.

RESULTS

One hundred twenty-five articles on implant arthroplasty and 33 articles on the outcome of nonimplant surgical arthroplasty of the TMC joint were included. The implant arthroplasty failure rates per 100 procedure-years were total joint replacement (2.4), hemiarthroplasty (2.5), interposition with partial trapezial resection (4.5), interposition with complete trapezial resection (1.7), and interposition with no trapezial resection (4.5). The nonimplant arthroplasty failure rates per 100 procedure-years were: trapeziectomy (0.49), joint fusion (0.52), and trapeziectomy with ligament reconstruction ± tendon interposition (0.23).

CONCLUSIONS

Several implant designs (arthroplasties) had high rates of failure due to aseptic loosening, dislocation, and persisting pain. Furthermore, some implants had higher than anticipated failure rates than other implants within each class. Overall, the failure rates of nonimplant techniques were lower than those of implant arthroplasty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Human Acellular Dermis as Spacer for Small-Joint Arthroplasty: Analysis of Revascularization in a Rabbit Trapeziectomy Model

BACKGROUND

Carpometacarpal joint osteoarthritis affects 8 to 12 percent of the general population. Surgical management provides symptomatic relief for 78 percent of patients who fail conservative therapy, but little consensus exists regarding which surgical procedure provides superior patient outcomes. Recent human trials substituted exogenous acellular dermal matrices in the bone space, but there are no quantitative histologic data on the outcome of acellular dermal matrices in this environment. The authors aimed to quantify the revascularization and recellularization of acellular dermal matrices in the joint space using a rabbit model.

METHODS

Bilateral lunate carpal bones were surgically removed in New Zealand rabbits. Acellular dermal matrix and autologous tissue were implanted in place of the lunate of the right and left wrists, respectively. Acellular dermal matrix was also implanted subcutaneously as a nonjoint control. Histologic and immunofluorescence analysis was performed after collection at 0, 6, and 12 weeks.

RESULTS

Quantitative analysis of anti-α-smooth muscle actin and CD31 immunofluorescence revealed a sequential and comparable increase of vascular lumens in joint space and subcutaneous acellular dermal matrices. In contrast, autologous tissue implanted in the joint space did not have a similar increase in α-smooth muscle actin-positive or CD31-positive lumens. Semiquantitative analysis revealed increased cellularity in both autologous and acellular dermal matrix wrist implants at each time point, whereas average cellularity of subcutaneous acellular dermal matrix peaked at 6 weeks and regressed by 12 weeks. Trichrome and Sirius red staining revealed abundant collagen at all time points.

CONCLUSION

The trapeziectomy joint space supports both cellular and vascular ingrowth into human acellular dermal matrix.

A systematic review and meta-analysis of arthroscopic assisted techniques for thumb carpometacarpal joint osteoarthritis

Arthroscopic management of thumb carpometacarpal (CMC) osteoarthrosis (OA) is an approach that has unclear results. We performed a systematic review encompassing three electronic databases up to May 2016 for studies describing arthroscopic-assisted techniques for thumb CMC OA. Meta-analyses of visual analogue scores (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) scores, grip strength and pinch strength before and after arthroscopy were performed for ten included non-randomized cohort studies comprising 294 patients. Based on Hedges' g measure, we found a large effect on VAS and DASH scores, a small effect on grip strength and no effect on pinch strength. On average, VAS improved by 4.1 cm, DASH by 22 points and grip strength by 2.8 kg. Complications were reported in 4% of patients. The use of arthroscopic-assisted techniques for thumb CMC OA is still limited; however, it may be a reasonable option for patients with thumb CMC OA who do not respond to non-operative treatment.

A Cadaveric Study of the Mean Distance of the Radial Artery During the Approach to the First Carpometacarpal Joint

Multiple surgical procedures have been described to treat first carpometacarpal (CMC) arthritis. Although the superiority of one procedure over the others continues to be a controversial topic, they all approach the trapezium and require careful attention to the surrounding structures. One potential complication is injury to the radial artery, which lies in close proximity to the trapezium and is often encountered during surgical approach. Using cadaveric specimens, the authors dissected to identify and isolate the radial artery as it travels in the forearm, wrist, and hand while being careful not to disturb its native course. The authors then measured the shortest distance interval from the radial artery to the first CMC joint and from the radial artery to the scaphotrapeziotrapezoidal joint. Descriptive statistics were calculated from these measurements and averaged over the various specimens. The mean distance of the radial artery to the closest segment of the volar CMC joint was 11.6±2.5 mm. The mean distance of the radial artery to the closest segment of the volar scaphotrapeziotrapezoidal joint was 1.6±1.8 mm. A precise understanding of nearby anatomy is paramount to a successful surgical treatment for first CMC arthritis and to avoid iatrogenic complications. The authors describe the mean distance from the radial artery to 2 major landmarks used during surgical treatment and provide insight to surgeons who perform these CMC reconstruction procedures to decrease the risk of intraoperative radial artery injury. [Orthopedics. 2018; 41(4):e541-e544.].

Trapeziectomy with Interpositional Arthroplasty using Acellular Dermal Matrix: Description of Technique and Early Outcomes

BACKGROUND

Trapeziectomy with interpositional arthroplasty using Repriza acellular dermal matrix is a novel technique to treat primary and secondary carpometacarpal joint arthritis. Early studies with nonautograft interposition indicate promising post-trapeziectomy space maintenance with results similar to ligament reconstruction with tendon interposition, without the potential risks and increased operating time of harvesting a tendon autograft.

METHODS

Eleven patients in a retrospective cohort were followed for a minimum of 6 weeks (mean, 12). Subjective and objective data were collected to assess pain, subjective improvement of symptoms, radiographic measurements of first metacarpal subsidence, key pinch strength, grip strength, and range of motion.

RESULTS

Early outcomes in our cohort compare favorably to other treatment series. On average, patients received a significant pain reduction of 63%, with 36% of patients admitting to complete pain resolution. One hundred percentage of patients admitted to overall subjective improvement in symptoms. Ninety-one percentage of patients achieved postoperative opposition of the thumb and fifth digit. Comparison with preoperative x-rays showed mean thumb metacarpal subsidence of 27%. Zigzag deformity and extra-articular acellular dermal matrix migration, due to lack of patient compliance with splint, were observed complications. Only 8.3% subsidence was observed with an impressive 45% pain reduction, in a salvage patient after revision surgery for a NuGrip implant.

CONCLUSIONS

In conclusion, this is a safe and effective primary or salvage technique for Eaton grades III and IV thumb carpometacarpal arthritis with a mean subsidence within the range observed with ligament reconstruction with or without tendon interposition. Long-term study with a larger sample size is needed to investigate this technique further.

Proximal Row Carpectomy Using Decellularized Dermal Allograft

Wrist arthritis is a common problem. When managed early, motion-sparing procedures can be performed with successful outcomes. Proximal row carpectomy (PRC) has demonstrated good functional results and high patient satisfaction with up to 20-year follow-up. The majority of patients with longer follow-up have, however, exhibited radiographic signs of progressive degeneration of the radiocapitate space. Although radiographic changes have not been shown to correlate with wrist pain and function, it remains a concern and questions the durability of the radiocapitate articulation with continued patient follow-up, especially those who underwent the original procedure at a younger age. Several modifications have been proposed and used to address this concern, including radiocapitate arthroplasty, with either distal radius hemiarthroplasty or tissue interposition grafts. Theoretical benefits to these adjuncts include minimizing wear and preserving the radiocapitate articulation as well as expanding the utility of a PRC even in the setting of a wrist with arthritis of the capitate head. We describe our surgical technique for managing radiocarpal arthritis with PRC and decellularized dermal allograft. Dermal matrix allografts have proved to be a safe adjunct in various orthopedic procedures, including those in the wrist and hand. This technique adds another surgical option for the treatment of radiocarpal arthritis and expands the indications for PRC to include select patients with degeneration of the capitate head.

Trapeziectomy With Suspension-Interposition Arthroplasty for Thumb Carpometacarpal Osteoarthritis: A Randomized Controlled Trial Comparing the Use of Allograft Versus Flexor Carpi Radialis Tendon

PURPOSE

The objective of this randomized controlled trial was to compare the 12-month postoperative Michigan Hand Outcomes Questionnaire (MHQ) total score between patients with osteoarthritis (OA) at the first carpometacarpal (CMC I) joint who underwent trapeziectomy with suspension-interposition arthroplasty using the flexor carpi radialis (FCR) tendon and those receiving a human dermal collagen template (allograft).

METHODS

We included 60 patients with CMC I OA who met the indications for surgery. They were randomized into 1 of 2 groups: trapeziectomy using the FCR tendon or trapeziectomy with the allograft for suspension-interposition. Patients completed a set of questionnaires including the MHQ and were clinically assessed at baseline, 6 weeks, and 3, 6, and 12 months after surgery. Complications were recorded.

RESULTS

We operated on 29 patients using the FCR tendon; 31 patients received an allograft. Baseline MHQ total scores significantly increased from 51 (95% confidence interval [CI], 46-56) to 83 (95% CI, 78-87) and 53 (95% CI, 47-58) to 76 (95% CI, 69-84) by 12 months in the FCR and allograft groups, respectively. We found similar outcomes for both groups at all follow-up assessments. Five complications occurred in the FCR group, and 10 in the allograft group. Revision surgery was required for one allograft patient.

CONCLUSIONS

The use of the FCR tendon or allograft for trapeziectomy with suspension-interposition arthroplasty in patients with CMC I OA leads to similar outcomes with more complications, mainly tendon irritations, associated with the latter. Therefore, we only use the allograft in cases of severe instability requiring a larger amount of suspension-interposition material or for revision procedures after failed suspension-interposition with the FCR tendon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Revision of the Failed Thumb Carpometacarpal Arthroplasty

PURPOSE

To evaluate the outcome of revision surgery for failed thumb carpometacarpal (CMC) arthroplasty.

METHODS

We retrospectively analyzed 32 patients with failed thumb CMC arthroplasty. The primary reason for revision was pain caused by metacarpal subsidence. Revision surgery included soft tissue interposition and distraction pinning to address the metacarpal subsidence. Additional ligament reconstruction was performed in patients with thumb instability. Eight patients required additional metacarpophalangeal joint fusion for concomitant joint hyperextension. Eleven required additional partial excision of the trapezoid for concomitant scaphotrapezoidal joint arthritis. All patients were evaluated clinically and radiographically.

RESULTS

Mean follow-up was 57 months (range, 24-121 months). Pain levels evaluated by visual analog scale were significantly reduced in all patients after revision surgery. Mean grip strength and key pinch strength significantly increased. Twenty-seven patients achieved good functional results; those for 5 patients were fair.

CONCLUSIONS

This study showed that revision surgery with distraction pinning and soft tissue interposition with or without ligament reconstruction was an effective treatment for failed CMC arthroplasty of the thumb.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The "Pillow" Technique for Thumb Carpometacarpal Joint Arthritis: Cohort Study With 10- to 15-Year Follow-Up

PURPOSE

Arthritis of the carpometacarpal joint of the thumb is common, and there are many studies regarding its treatment. We investigated the long-term outcome of interposition arthroplasty with a fascia lata allograft (pillow technique), without ligament reconstruction, to treat thumb carpometacarpal arthritis. The technique consisted of complete trapeziectomy, use of alloplastic tensor fascia lata, and K-wire immobilization for 5 weeks.

METHODS

The outcomes of 31 thumbs in 24 female patients were measured at a mean follow-up of 12.5 years (range, 10-15 years).

RESULTS

Grip strength, key pinch, pulp-to-pulp pinch, tripod pinch, and range of motion were all improved. The Disabilities of the Arm, Shoulder, and Hand median score, which was only measured postoperatively, was an average of 5 (range, 0-52.6). No extrusion of the graft material was noted, and no revisions were performed.

CONCLUSIONS

Our results indicate that a fascia lata allograft can be used as an interposition material in thumb carpometacarpal arthroplasty. This technique provides pain relief and satisfactory function at an average of 12.5 years after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Alloplastic adjuncts in breast reconstruction

BACKGROUND

There has been an increasing role of acellular dermal matrices (ADMs) and synthetic meshes in both single- and two-stage implant/expander breast reconstruction. Numerous alloplastic adjuncts exist, and these vary in material type, processing, storage, surgical preparation, level of sterility, available sizes and cost. However, there is little published data on most, posing a significant challenge to the reconstructive surgeon trying to compare and select the most suitable product. The aims of this systematic review were to identify, summarize and evaluate the outcomes of studies describing the use of alloplastic adjuncts for post-mastectomy breast reconstruction. The secondary aims were to determine their cost-effectiveness and analyze outcomes in patients who also underwent radiotherapy.

METHODS

Using the PRSIMA 2009 statement, a systematic review was conducted to find articles reporting on the outcomes on the use of alloplastic adjuncts in post-mastectomy breast reconstruction. Multiple databases were searched independently by three authors (Cabalag MS, Miller GS and Chae MP), including: Ovid MEDLINE (1950 to present), Embase (1980 to 2015), PubMed and Cochrane Database of Systematic Reviews.

RESULTS

Current published literature on available alloplastic adjuncts are predominantly centered on ADMs, both allogeneic and xenogeneic, with few outcome studies available for synthetic meshes. Outcomes on the 89 articles, which met the inclusion criteria, were summarized and analyzed. The reported outcomes on alloplastic adjunct-assisted breast reconstruction were varied, with most data available on the use of ADMs, particularly AlloDerm(®) (LifeCell, Branchburg, New Jersey, USA). The use of ADMs in single-stage direct-to-implant breast reconstruction resulted in lower complication rates (infection, seroma, implant loss and late revision), and was more cost effective when compared to non-ADM, two-stage reconstruction. The majority of studies demonstrated inferior outcomes in ADM assisted, two-stage expander-to-implant reconstruction compared to non-ADM use. Multiple studies suggest that the use of ADMs results in a reduction of capsular contracture rates. Additionally, the reported beneficial effects of ADM use in irradiated tissue were varied.

CONCLUSIONS

ADM assisted two-stage breast reconstruction was associated with inferior outcomes when compared to non-ADM use. However, alloplastic adjuncts may have a role in single stage, direct-to-implant breast reconstruction. Published evidence comparing the long-term outcomes between the different types of adjuncts is lacking, and further level one studies are required to identify the ideal product.

Comparison of clinical outcome with radiological findings after trapeziectomy with ligament reconstruction and tendon interposition

The aim of our study was to investigate if pre- and postoperative radiographic thumb carpometacarpal position is correlated with clinical and subjective outcomes. Radiographs of 105 patients undergoing trapeziectomy with ligament reconstruction and tendon interposition were analysed before, as well as 1 year after, surgery for dorsal subluxation and proximal migration of the thumb metacarpal bone. Furthermore, key pinch strength was measured and patients completed the Michigan Hand Outcomes Questionnaire. Baseline dorsal subluxation and scaphometacarpal distances significantly decreased from 8.2 mm and 11.0 mm to 5.2 mm and 5.1 mm at 1 year, respectively. There was no correlation between the amount of subluxation or proximal migration and the Michigan Hand Outcomes Questionnaire score or key pinch strength. These results suggest that postoperative position of the metacarpal base of the thumb does not affect clinical or subjective outcomes after trapeziectomy with ligament reconstruction and tendon reposition of the thumb carpometacarpal joint.

LEVEL OF EVIDENCE

Level 3.

Unacceptable failure of hemiarthroplasty combined with biological glenoid resurfacing in the treatment of glenohumeral arthritis in the young

BACKGROUND

Treatment of glenohumeral osteoarthritis in young patients is challenging. Total shoulder arthroplasty reliably addresses pain and dysfunction but compromises glenoid bone stock. Various efforts have been made to avoid a prosthetic glenoid component or to prevent glenoid erosion after hemiarthroplasty. Capsular interposition, meniscal allograft, and more recently, GraftJacket (Wright Medical Technology Inc, Arlington, TN, USA), a human dermal collagen allograft, have been proposed for interposition arthroplasty in young patients with glenohumeral osteoarthritis.

METHODS

From 2009 to 2010, GraftJacket was used for glenoid resurfacing combined with humeral resurfacing or a stemmed hemiarthroplasty in 6 patients with a mean age of 47 years (34-57 years). Before GraftJacket was available, 5 patients were treated with a meniscal allograft and 6 with capsular interposition arthroplasty.

RESULTS

At a mean of 16 months (9-22 months) after the GraftJacket was implanted, 5 of the 6 patients were revised to a total shoulder arthroplasty or a reverse total shoulder arthroplasty. The sixth patient was dissatisfied but declined further surgery. The mean relative, preoperative Constant score decreased from 35% (range, 13%-61%) to 31% (range, 15%-43%) at revision or latest follow-up. Of the 5 patients with meniscal allograft, 3 underwent revision at a mean of 22 months (range, 12-40 months), and 4 of the 6 patients with capsular interposition were revised at a mean of 34 months (range, 23-45 months). The mean relative Constant scores preoperatively and at revision or latest follow-up were 44% (range, 19%-68%) and 58% (range, 9%-96%) for the meniscal allograft patients and 47% (range, 38%-62%) and 63% (range, 32%-92%) for the capsular interposition cases.

CONCLUSION

In our hands, 3 different types of biological resurfacings combined with humeral hemiarthroplasty have an unacceptable early failure rate.

Meniscal allograft arthroplasty for the treatment of trapeziometacarpal arthritis of the thumb

BACKGROUND

Arthritis at the trapeziometacarpal joint of the thumb is common. Several surgical options exist showing favorable results. We report the outcomes after interposition of allograft knee meniscus for thumb trapeziometacarpal arthritis.

METHODS

Twenty-three patients (25 thumbs) had surgery for thumb trapeziometacarpal arthritis using knee meniscal allograft tissue. Eleven thumbs had a minimum follow-up of 24 months, 2 thumbs had a minimum of 12 months, and 12 thumbs had less than 6 months. Disabilities of arm, shoulder, and hand (DASH) questionnaire scores, pain levels, grip strength, pinch strength, range of motion, and radiographic measurements were performed.

RESULTS

Between the preoperative and 24-month follow-up measurements, patient pain levels were reduced. There was a significant improvement in DASH scores. Comparisons between preoperative and postoperative strength measurements showed increase in grip strength and key pinch strength. Trapeziometacarpal subsidence was 5.5 %, and subluxation index measurements decreased 3.9 %. There was no clinical or radiographic evidence of foreign body reaction and no other complications occurred.

CONCLUSIONS

The results of meniscal allograft arthroplasty are comparable to other surgical techniques for trapeziometacarpal arthritis with respect to pain, outcomes, strength, oppositional motion, complications, surgical time, cost, and return to work. The results suggest that meniscal allograft arthroplasty is a viable option in the surgical management of stages II and III arthritis of the TM joint. Further follow-up and clinical studies are warranted.

Determinants of patient satisfaction after surgery or corticosteroid injection for trapeziometacarpal osteoarthritis: results of a prospective cohort study

INTRODUCTION

The evaluation of patient satisfaction is becoming increasingly important in assessing treatment outcomes. The objective of this study was to analyze the determinants of treatment satisfaction in patients with trapeziometacarpal osteoarthritis (TMC OA) after surgery or corticosteroid injection.

MATERIALS AND METHODS

Prospective cohort study of patients with TMC OA who received surgery or corticosteroid injection was carried out. Socio-demographic and clinical data were recorded at baseline and 1 year after the intervention, and patients filled out the Michigan Hand Outcomes Questionnaire (MHQ). On a 5-point Likert scale, patients reported baseline expectations, expectation fulfillment at 1 year, as well as satisfaction with the treatment result. To identify determinants of satisfaction, we entered these variables into one ordered logistic regression model for surgical patients and another for patients with injection.

RESULTS

We included 146 patients, 88 of whom were treated surgically. With respect to satisfaction at 1 year, 87 % of the surgical patients were somewhat or very satisfied with the treatment result, whereas only 49 % of the patients with injection were satisfied. Expectations being fulfilled was the only determinant of treatment satisfaction in the surgical group. In the injection group, a more advanced Eaton stage of TMC OA and greater pain at 1 year were associated with reduced satisfaction.

CONCLUSIONS

Surgery for TMC OA leads to high patient satisfaction, whereas only half of the patients treated with corticosteroid injection were satisfied with the treatment result. An advanced stage of TMC OA and higher pain lead to reduced treatment satisfaction in the latter group, indicating that corticosteroid injection is only effective for patients in a lower stage of disease. As fulfillment of expectations was an important determinant of satisfaction in the surgical group, we emphasize the need to provide comprehensive information prior to surgery, so that the patient's expectations of treatment outcome are realistic.

Evolution of basal joint arthroplasty and technology in hand surgery

There are many surgical procedures that provide pain relief and improve function for trapeziometacarpal (TM) arthritis. The aim of this article is to review the history of surgical treatment of thumb basal joint arthritis and to discuss some of the recent advances based on evolving technology. Our preferred treatment is described, and explanation provided for why we have avoided the temptation to change to the "latest and greatest" treatment for this condition.

Human dermal allograft for massive rotator cuff tears

Previously published studies reported variable results using various suture techniques and reconstruction options for massive rotator cuff tears. Therefore, the current authors retrospectively studied 21 consecutive patients/shoulders with massive rotator cuff tears treated from January 2005 to October 2011 with a human dermal allograft through a mini-open approach. Mean patient age was 58 years (range, 33-72 years). Mean follow-up was 29 months (range, 18-52 months). Ten patients underwent revision repair for a failed rotator cuff repair. The authors measured the tendon gap (mean, 1.7 cm) and acromiohumeral interval (mean, 6.5 mm). They evaluated pain, shoulder range of motion (ROM) and function, patient satisfaction with the operation and outcome, and complications. At last follow-up, all patients experienced significant pain relief (P=.001) and improved ROM (P=.001) and American Shoulder and Elbow Surgeons (ASES) score (P=.001). Eighteen patients reported that they were satisfied or very satisfied and 3 reported that they were not satisfied with the operation and outcome. Comparison of outcomes between patients who underwent primary repair and those who underwent revision repair and between patients who had muscle atrophy and fatty infiltration grades 0 to II and those who had grades III to IV showed no statistically significant differences. A statistically significant correlation was observed between the size of the tendon gap and postoperative pain, ROM (except external rotation), and ASES score (P<.050). No significant correlation was observed between postoperative pain, ROM, and ASES score and the acromiohumeral interval (P>.050). Complications related to the dermal human allograft were not observed.

Preserving the posttrapeziectomy space with a human acellular dermal matrix spacer: a pilot case series of patients with thumb carpometacarpal joint arthritis

Supplemental Digital Content is available in the text.

Background:

Advanced thumb carpometacarpal arthritis is widely treated with trapeziectomy and tendon interposition despite donor-site morbidities. Trapeziectomy alone leaves a postresection space, leading to proximal metacarpal migration and scaphoid/trapezoid impingement. Prosthetic implants have been unsuccessful due to particulate debris, silicone synovitis, osteolysis, and migration. Recent studies have shown successful use of allograft for interposition material in the posttrapeziectomy space both in animal and human models. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using a spacer constructed from human acellular dermal matrix (HADM).

Methods:

Sixteen patients with Eaton stage III–IV thumb carpometacarpal osteoarthritis received the above procedure from the 2 senior authors. HADM was imbricated to fill the posttrapeziectomy space and secured to the volar capsule and metacarpal base. Pre- and postoperative trapezial space on radiograph, pain scores, and grip strength were recorded.

Results:

Six months postoperatively, radiographs showed an average joint space loss of 11%. Heights postoperatively were not significantly different from immediate postoperative heights (P ≥ 0.01). At 6 months, patients had improved pain and grip strength (P ≤ 0.01). No infections, foreign body reactions, or other complications occurred.

Conclusions:

HADM has been used extensively in other forms of reconstruction and has been shown to incorporate into surrounding tissues through neovascularization. Our early results illustrate that HADM can safely fill the dead space left by trapeziectomy.

Review of thumb carpometacarpal arthritis classification, treatment and outcomes

Thumb carpometacarpal osteoarthritis (CMC OA) is a common disease, affecting up to 11% and 33% of men and women in their 50s and 60s, respectively, which leads to pain, laxity and weakness of the CMC joint. Based on the staging of the CMC OA, different forms of treatment can be used, including both conservative and surgical measures. Surgical options include osteotomy, trapezial excision, ligament reconstruction with or without tendon interposition, and various prosthetic interpositional implants with or without trapezial excision. The present article reviews the staging of CMC OA, the evaluation of hand function using patient-reported questionnaires, and outcomes of both conservative and surgical treatments. The present review also introduces a commercially available interpositional spacer surgical technique for CMC OA and the early evidence that the literature has shown for improving hand function, strength and stability of the thumb CMC joint postoperatively.

Trapezium resection with mersilene suspension sling

The reason there are numerous techniques for thumb carpometacarpal arthroplasty is that none of them are perfect. Sometimes the simplest procedures work best. This article presents a simple alternative, using a readily available suture to stabilize the thumb after resection of the trapezium, with long-term success.

Acellular dermal matrices in hand reconstruction

BACKGROUND

The goal of this article is to review the current literature on the use of acellular dermal matrix in forearm, wrist, and hand reconstruction.

METHODS

A comprehensive literature search was performed using the Cochrane Database of Systematic Reviews, MEDLINE, PubMed, and Web of Knowledge. Articles were categorized as acellular dermal matrix used in soft-tissue repair and in ligament reconstruction. Search terms included "acellular dermal matrix," "biologic dressing," "skin replacement," "dermal allograft," "AlloDerm," "FlexHD," "Permacol," and "Strattice." These were all cross-referenced with "forearm," "wrist," and "hand." Data extraction focused on indications, surgical techniques, clinical outcomes, and complications. Exclusion criteria included regeneration templates, neonatal foreskin, and review articles.

RESULTS

More than 100 articles published between 1994 and 2011 were identified. Upon final review, five prospective case-control studies, three retrospective case-control studies, four case reports, one cross-sectional cohort, one prospective consecutive series, and one study type unknown were evaluated. Matrix was most commonly used in burn reconstruction. It has also been used in ligament and joint reconstruction for first carpometacarpal arthritis. One article illustrated the use of porcine matrix in basal joint arthritis, a practice that was abruptly terminated because of a concern over increased infections.

CONCLUSIONS

The clinical indications for acellular dermal matrix have increased throughout the last 15 years. Hand surgeons have been cautious but diligent in developing alternative treatment options in hand reconstruction, with a focused effort to reduce donor-site morbidity. Although acellular dermal matrices continue to find innovative uses to solve upper extremity surgical problems, more comparative prospective trials are needed.

Salvage reconstruction of failed interposition arthroplasty at the base of the thumb

We present an operative procedure designed to revise a failed arthroplasty at the base of the thumb. This report describes a reliable operation that corrects residual instability and malignment which results in thumbs that are weak and painful despite a previous procedure. The operation has also been used as a primary procedure for arthritis of the trapeziometacarpal joint where instability and subluxation was a major component of the problem requiring joint reconstruction. The unique features of this procedure include a reinforced double-thickness tendon graft, a unique tendon anchor, and a fascia lata allograft spacer. Significant functional improvement is anticipated when joint reconstruction provides increased proximal stability. Pinch and grip measurements improve. Pain scores also diminish after the operation. Hand function and patient satisfaction can be substantially improved with revision arthroplasty when the initial operation has failed to provide a thumb that is mobile, stable, and pain free. The technical features of the procedure address reduction of malignment, restoring of anatomic balance, and secure fixation of the proximal apex of the thumb metacarpal which restores thumb reduction position and digital balance.

Proximal row carpectomy with allograft scaffold interposition arthroplasty

The authors present a solution for motion preservation in severe wrist arthritis with intercarpal involvement. Acellular dermal allograft is used as an interposition arthroplasty in these situations, rather than local tissue flaps such as previously described. Proximal row carpectomy has been shown to be one of the most successful procedures to correct chronic destructive arthritis in the wrist, keeping useful motion. Traditionally, a contraindication for proximal row carpectomy includes an arthritis that invades the lunate-capitate joint. The authors describe a technique to extend the traditional indications by covering the eroded articular surfaces with dermal allograft scaffold.

Thumb basal joint arthroplasty using abductor pollicis longus tendon: an average 5.5-year follow-up

PURPOSE

The goal of this study was to evaluate the 4-year minimum (5.5-y average) results of trapeziectomy and ligament reconstruction using a modified Thompson technique with the abductor pollicis longus tendon for the primary treatment of advanced-stage basal joint arthritis (Eaton stages III and IV).

METHODS

We evaluated 25 thumbs in 18 patients after ligament reconstruction arthroplasty for surgical treatment of advanced thumb basal joint arthritis. Treatment consisted of piecemeal excision of the entire trapezium, ligament reconstruction and interposition using the abductor pollicis longus tendon, and 8 weeks of K-wire immobilization of the thumb metacarpal. We evaluated range of motion, lateral pinch, tip pinch, grip strength, and outcomes questionnaires including the Arthritis Impact Measurement Scales 2 Short Form before and at an average of 5.5 years after surgery.

RESULTS

Seventeen of 18 patients reported excellent or good relief of pain and were satisfied with their operation, and all of the patients would have the operation again. Of the 25 thumbs, 24 adducted fully into the plane of the palm and opposed to the fifth metacarpal head. Preoperative and postoperative strength comparisons demonstrated an average increase in grip, key pinch, and tip pinch strength of 14%, 12%, and 6%, respectively. The outcomes data demonstrated noteworthy improvement in writing, buttoning a shirt, turning a key/lock, and arthritis pain categories.

CONCLUSIONS

This technique restored a stable, pain-free thumb that yielded excellent strength and motion at an average of 5.5 years after the procedure. Compared with published reports of techniques that use hematoma distraction or harvest of all or part of the flexor carpi radialis tendon, this modified Thompson technique has similar pain relief, satisfaction, and motion but had less improvement in strength, which might have resulted from differences in the studied samples.

Suture button suspensionplasty after arthroscopic hemitrapeziectomy for treatment of thumb carpometacarpal arthritis

A myriad of techniques for reconstruction of the arthritic thumb carpometacarpal joint have been described. In the modern era, there has been a push, driven by both clinicians and patients, for more rapid rehabilitation after these procedures. A majority of the historically described techniques require pinning of the thumb ray for 4 weeks. Suture button placement between the thumb and index ray metacarpals has been shown in biomechanical studies to effectively resist subsidence of the thumb ray. We describe a novel technique of using a suture button for suspensionplasty of the thumb ray after arthroscopic partial trapeziectomy. This technique allows for early mobilization and may offer a potential improvement on current techniques. Early results of use of this technique are encouraging, but well-conducted follow-up studies are necessary.

Interposition arthroplasty options for carpometacarpal arthritis of the thumb

Carpometacarpal (CMC) arthritis of the thumb affects half of postmenopausal women and up to 25% of elderly men. This disease can cause significant disability in affected patients often necessitating surgical intervention. Various surgical options have been used to treat refractory CMC arthritis. Any successful surgical intervention must address three goals: removal of diseased joint surfaces, reconstruction of ligamentous stabilizers, and preservation of the joint space. In this article we will discuss various interposition arthroplasty options for CMC arthritis of the thumb.