Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint of the thumb

Thumb Arthroplasty as Reliable Long-term Solution for Trapeziometacarpal Osteoarthritis: A Minimum of 15 Years of Follow-up

BACKGROUND

In patients with symptomatic trapeziometacarpal (TMC) joint arthritis resistant to conservative treatment, surgical treatment can be advised. One of the many surgical treatment options is TMC arthroplasty. The Arpe prosthesis is one example of these TMC arthroplasties.

METHODS

This retrospective study evaluated patients who underwent TMC arthroplasty with the Arpe prosthesis after a minimum of 15 years of follow-up. Clinical, radiologic, and qualitative outcomes were assessed for 43 Arpe arthroplasties in 41 patients, of whom 2 had bilateral arthroplasties. The female to male ratio was 39:4. The mean follow-up time was 197 months (range = 180-225).

RESULTS

The cumulative survival rate after a mean of 16.5 years was 84%. Seven failures (16%) were registered, of which 5 during the first 3 years after primary surgery. All patients were successfully converted to a trapeziectomy. Quick Disabilities of the Arm, Shoulder and Hand score improved with 44.9 points and visual analogue pain score with 97% and 91% at rest and during exercise, respectively.

CONCLUSIONS

This series demonstrates that thumb arthroplasty is a reliable long-term solution for thumb base arthritis, with significant pain reduction and functional improvement, even after 15 years of follow-up.

Reverse homodigital dorsal wraparound flap for reconstruction of distal thumb

Reconstruction of degloving injury or amputation of distal thumb with no indication of replantation has always been a challenging problem for hand surgeons. In this study, a reverse homodigital dorsal wraparound flap innervated by the dorsal digital nerve was devised to repair degloving injury or amputation of distal thumb in 20 consecutive cases. In nine cases of thumb amputation, we skeletonized the phalanxes of the amputated part as a free cortical bone with Kirschner wires. All flaps survived uneventfully. The radiographs showed bone healing in all the patients of thumb amputation within 6 weeks postoperatively. At final follow-up, the appearance of the reconstructed thumb was acceptable and flap sensation and range of joint motion were satisfactory. This flap is a simple and reliable alternative method for degloving injury or amputation of distal thumb when replantation is impossible and patients refuse to donate tissues from toes. Type of study/level of evidence Therapeutic IV.

Efficacy of Surgical Interventions for Trapeziometacarpal (Thumb Base) Osteoarthritis: A Systematic Review

Purpose

This systematic review (SR) aimed to identify the surgical interventions available for trapeziometacarpal osteoarthritis and document their efficacy on pain, physical function, psychological well-being, quality of life, treatment satisfaction, and/or adverse events.

Methods

This PROSPERO-registered SR's protocol was developed based on the Cochrane intervention review methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

Among 9049 potential studies identified, 1 SR, 18 randomized controlled trials, and 40 nonrandomized controlled trials were included. We identified 11 categories of surgical techniques: first metacarpal osteotomy, first metacarpal and trapezium partial resection, arthrodesis, trapeziectomy (T), T+ligament reconstruction (LR), T+tendon interposition (TI), T+ligament reconstruction and tendon interposition (LRTI), hematoma distraction arthroplasty (HDA), chondrocostal graft interposition, autologous fat injection, and manufactured implant use. These findings supported by low-quality evidence revealed moderately or largely superior effects of the following interventions: (1) trapeziectomy over T+LRTI using ½ flexor carpi radialis (FCR) and metacarpal tunnel (MT) or using abductor pollicis longus (APL) and FCR for adverse events; (2) trapeziectomy over T+TI using palmaris longus (PL) for pain; (3) T+LR with ½FCR-MT over T+LRTI with ½FCR-MT for physical function; (4) trapeziectomy by anterior approach over that by posterior approach for treatment satisfaction and adverse events; (5) T+LRTI using ½FCR-MT over T+TI with PL for pain; and (6) T+HDA over T+LR using APL-MT-FCR for pain, physical function, and adverse events. GraftJacket (Wright Medical Group, Memphis, TN), Swanson (Wright Medical Group, Letchworth Garden City, UK), and Permacol (Tissue Science Laboratories, Aldershot, UK) implants and hardware (plate/screw) would cause more complications than an autograft. The effect estimates of other surgical procedures were supported by evidence of very low quality.

Conclusions

This SR provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis. Some interventions showed a moderate-to-large superior effect on the studied outcome(s) compared with others. However, these findings must be interpreted with caution because of low-quality evidence. To provide stronger evidence, more randomized controlled trials and methodological uniformization are needed.

Type of study/level of evidence

Therapeutic I.

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.

Treatment of Bennett fractures with tension-band wiring through a small incision under loupes and a headlight

PURPOSE

The aim of the study was to present a novel treatment strategy for Bennett fractures using a tension-band wiring technique performed through a small incision with loupes and a headlight. Additionally, this study compared this technique with the conventional percutaneous pinning technique.

METHODS

Between January 2014 and January 2017, the tension-band wiring technique was used in 37 patients with Bennett fractures (study group). The range of motion, pinch and grip strengths, and hand function were assessed at the final follow-up. A control group comprising 35 patients treated with the percutaneous pinning technique was included in the study for comparison. A p-value <0.05 was considered statistically significant. (Clinical Trial Registration number: ISRCTN64894535 at http://www.isrctn.com/ISRCTN64894535 ) Results: No fixation failure or infection occurred in either group. Radiographic fracture healing was achieved in all cases. Follow-up lasted over 1 year. The mean Kapandji opposition score was 9.31 (range 8-10) points in the study group and 8.45 (range 7-10) points in the control group (p < 0.05). The mean Disabilities of the Arm, Shoulder, and Hand score was 1.06 (range 0-2) in the study group and 1.77 (range 0-3) in the control group (p < 0.05). The mean Smith and Cooney Score were 90 (range 80-100) in the study group and 85 (range 75-100) in the control group (p < 0.05).

CONCLUSIONS

The tension-band wiring technique using loupes and headlights enables reduction and fixation of Bennett fractures under direct visualization of the deep operative field. Restoration of thumb function using the tension-band wiring technique is significantly better than that observed with the conventional percutaneous pinning technique.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

WITHDRAWN: Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement). We did not find any studies that compared surgery with sham surgery or surgery with non-surgical interventions.Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery or to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Outcomes of denervation, joint lavage and capsular imbrication for painful thumb carpometacarpal joint osteoarthritis

Pain reduction remains the main aim in the treatment of thumb carpometacarpal joint osteoarthritis. We performed a retrospective analysis of a case series of patients with symptomatic thumb carpometacarpal joint arthritis treated with denervation, joint lavage and capsular imbrication. A total of 60 patients participated in this study. Follow-up, including a clinical examination, was performed on 37 patients at a mean of 46 months (range 12 to 81); an additional 23 patients were followed-up by telephone at a mean of 52 months (range 14 to 93) post-operatively. The patients assessed in person showed a significant decrease in pain and a significant improvement in thumb function. The information gathered by telephone gave similar results. The findings of our study indicate that the presented treatment approach could be a good alternative to more invasive surgical options in patients with earlier stages of thumb carpometacarpal joint osteoarthritis. Advantages include the low rate of complications and invasiveness, as well as short recovery times.

LEVEL OF EVIDENCE

IV.

A new surgical technique for the treatment of scaphotrapezial arthritis associated with trapeziometacarpal arthritis: the narrow pseudoarthrosis

We describe a technique for treating Eaton stage IV osteoarthritis of the first ray, which is a development of our previously published technique for treating trapeziometacarpal arthritis. This simple technique is based on a limited resection arthroplasty of the first trapeziometacarpal and the scaphotrapezial joints, with the aim of inducing the formation of a narrow pseudoarthrosis at both sites. A total of 26 consecutive patients were treated for Eaton stage IV arthritis at a mean follow-up of 4.7 years (range 3.2-6.6). There were statistically significant improvements in all clinical parameters: mean appositional and oppositional pinch strength, mean DASH score (65 points pre-operatively to 8.7 points at final follow-up), and in mean visual analogue scale score (8.6 to 0.2 points). Although a larger cohort and a longer follow-up will be necessary to evaluate this new technique fully, these results encourage us to believe that the limited excision arthroplasty of the trapeziometacarpal and scaphotrapezial joints is a viable alternative to the existing surgical treatments for stage IV thumb arthritis.

LEVEL OF EVIDENCE

4.

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps

PURPOSE

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed.

METHODS

From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days.

RESULTS

All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery.

CONCLUSION

Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

Long-Term Outcome of Arthroscopic Resection Arthroplasty With or Without Interposition for Thumb Basal Joint Arthritis

PURPOSE

To report results on 144 cases following arthroscopic resection arthroplasty (ARA) with or without interposition for basal joint arthritis.

METHODS

Cases undergoing ARA for thumb carpometacarpal osteoarthritis between 2004 and 2011 were prospectively enrolled (n = 178). Data were collected before surgery and after surgery at 1, 3, 6, and 12 months and annually thereafter. Patients were excluded for less than 1-year follow-up or concomitant procedures that interfered with evaluation of the variable of interest (interposition). Human acellular dermal matrix (GRAFTJACKET) was the most commonly used interposition. Outcomes on 19 cases of interposition using collagen bioimplant (OrthADAPT) and porous polyurethaneurea (Artelon) scaffolds were also reported. Comparative analyses were performed on 52 patients with GRAFTJACKET interposition and on 73 without. Mean follow-up was 7.4 and 5.6 years with and without interposition, respectively. Descriptive statistics were evaluated on all baseline variables. Raw change scores of grip, pinch, and pain outcomes were evaluated. Confounding variables at a significance level of P less than .05 were adjusted for in linear mixed models, and an analysis of covariance was employed through an unstructured type of variance-covariance matrix.

RESULTS

Change scores from baseline to 1 year for the interposition group for pain (numerical rating scale, 0-10), pinch, and grip was -5.8, 3.3, and 7, respectively, and -5.1, 2.1, and 9 for the noninterposition group. Postoperative mean satisfaction was 4.7 and 4.4 for the with- and without-interposition groups, respectively. There were 4 failures with and 2 without interposition. Artelon and OrthADAPT did poorly with unacceptably high failure rates.

CONCLUSIONS

This study suggested that interposition is not necessary following ARA for thumb basal joint arthritis. Because arthroscopic interposition of material contributes to health care costs in terms of patient and facility costs without clear benefit to the patient, routine use of expensive interposition products should be abandoned or carefully evaluated with a prospective randomized controlled trial.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Rigid versus semi-rigid orthotic use following TMC arthroplasty: a randomized controlled trial

INTRODUCTION

The trapeziometacarpal (TMC) joint of the human thumb is the second most common joint in the hand affected by osteoarthritis. TMC arthroplasty is a common procedure used to alleviate symptoms. No randomized controlled trials have been published on the efficacy of different post-operative orthotic regimes.

METHOD

Fifty six participants who underwent TMC arthroplasty were allocated to either rigid orthotic or semi-rigid orthotic groups. Both groups started an identical exercise program at two weeks following surgery. Outcome measures were assessed by an assessor blinded to group allocation. The primary outcome was the Patient Rated Wrist and Hand Evaluation (PRWHE) and secondary outcomes included the Michigan Hand Questionnaire (MHQ), thumb palmar abduction, first metacarpophalangeal extension and three point pinch grip. Measures were taken pre-operatively, at six weeks, three months and one year post-operatively. Between-group differences were analyzed with linear regression.

RESULTS

Both groups performed equally well. There was no significant between-group difference for PRWHE scores (0.47, CI -11.5 to 12.4), including subscales for pain and function, or for any of the secondary outcomes at one year follow-up.

CONCLUSION

We found no difference in outcomes between using a rigid or semi-rigid orthosis after TMC arthroplasty. Patient comfort, cost and availability may determine choice between orthoses in clinical practice.

LEVEL OF EVIDENCE

1b RCT.

Basal joint osteoarthritis of the thumb: comparison of suture button versus abductor pollicis longus suspensionplasty

BACKGROUND

Our purpose was to compare the outcomes of patients with severe basilar thumb osteoarthritis treated with trapeziectomy and suspensionplasty using abductor pollicis longus (APL) tendon versus a suture button device.

METHODS

A retrospective study was performed for patients undergoing trapeziectomy and suspensionplasty with APL tendon or suture button fixation. Outcome measures included disabilities of the arm, shoulder, and hand (DASH); visual analog score (VAS); grip strength; key pinch; tip pinch; and thumb opposition. Radiographic measurements, surgical times, and complications were recorded.

RESULTS

Thirty-three patients in the APL tendon group and 27 patients in the suture button group had a minimum 6-month follow-up. VAS, DASH, and functional measurements improved after surgery for both groups. Mean operative time was 68 min for the APL tendon group and 48 min for the suture button group. Complications were similar between groups.

CONCLUSIONS

The use of suture button fixation when compared to APL tendon suspensionplasty offers similar clinical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. We excluded trials that compared non-surgical interventions with surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement).Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.We did not find any studies that compared any other combination of the other techniques mentioned above or any other techniques including a sham procedure.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery and we excluded studies that compared surgery to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Treatment of complex soft-tissue defects at the metacarpophalangeal joint of the thumb using the bilobed second dorsal metacarpal artery-based island flap

BACKGROUND

The purpose of this study is to report on reconstruction of complex soft-tissue defects around the metacarpophalangeal joint of the thumb using a bilobed second dorsal metacarpal artery-based island flap taken from the dorsum of the proximal phalanges of the index and long fingers.

METHODS

From March of 2007 to October of 2009, the bilobed second dorsal metacarpal artery-based island flap was transferred in 13 patients. There were two defects on the metacarpophalangeal joint of the thumb. The mean size of the dorsal defects was 2.4 × 3.2 cm; the mean size of the volar defects was 2.6 × 4.0 cm. The mean size of the flaps taken from the index and long fingers was 2.6 × 3.4 cm and 2.8 × 3.2 cm, respectively. The mean pedicle length was 4.9 cm.

RESULTS

All flaps survived completely. At a mean follow-up of 14 months, the mean active motion arc of the thumb metacarpophalangeal joints was 42 degrees. The motion of the donor fingers was similar to that on the opposite side. The mean values of static two-point discrimination of the donor sites of the index and long fingers were 6 and 7 mm, respectively.

CONCLUSION

Transferring the bilobed second dorsal metacarpal artery-based island flap is a useful and reliable technique for reconstructing complex defects around the metacarpophalangeal joint of the thumb.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic IV.

Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application

PURPOSE

Reconstruction of the thumb with exposure of bone and tendon is challenging. We designed a bipedicle island flap from the dorsum of the index finger to repair thumb defects. One pedicle includes the radial proper palmar digital artery (PDA) of the index finger, another pedicle includes the first dorsal metacarpal artery (FDMA). The aim of the study was to investigate the anatomical basis and clinical application of this flap.

METHODS

Eleven fresh cadaver hands were dissected, the FDMA and the radial proper PDA were exposed. Their origin, distribution and diameter in different locations, especially in the dorsum of the proximal phalanx of the index finger, were examined. Ten patients (11 hands) underwent thumb reconstruction using this flap. During follow-up, the flap survival and hand function were evaluated.

RESULTS

The origin of the FDMA in three cadaver hands was abnormal. The FDMA was mainly distributed in the proximal area of the dorsum of the proximal phalanx. The radial proper PDA of the index finger formed one constant dorsal branch, mainly distributing in the middle and distal area of the dorsum of the proximal phalanx. All flaps survived. At follow-up, the span of the first web and the range of motion of the thumbs and index fingers reached more than 94 % of the contralateral finger. All patients were satisfied with the hand function according to the Michigan Hand Outcomes Questionnaire (MHQ).

CONCLUSIONS

The bipedicle island flap has two arterial systems to provide sufficient blood supply. This technique provides another option for thumb reconstruction when a large supercharged FDMA island flap needs to be designed, or when there is an additional injury to the radial side of the dorsum of the hand or if there are anatomical variations of the FDMA, or if damage to the FDMA occurs during surgery.

The effect of custom-made splints in patients with the first carpometacarpal joint osteoarthritis

BACKGROUND

Pain, reduced grip strength, loss of range of motion, and joint stiffness, leading to impaired hand function, and difficulty with daily activities are documented symptoms of first carpometacarpal joint osteoarthritis. Splinting is a common type of conservative treatment for this injury.

OBJECTIVES

The aim of this study was to evaluate the effect of custom-made thumb splints on pain, function, grip strength, and key pinch in patients with first carpometacarpal joint osteoarthritis.

STUDY DESIGN

Quasi experimental.

METHODS

Patients with first carpometacarpal grade I and II osteoarthritis (n = 18) participated in a repeated measure study. The patients all wore custom-made thumb splints. All parameters were measured at baseline, and also after 30, 60, and 90 days from initial supply. A visual analogue scale, along with a disability of the arm, shoulder, and hand questionnaire, a dynamometer and pinch gauge were used to assess pain, function, grip strength, and pinch, respectively.

RESULTS

After 60 days of splint usage, grip strength was improved. However, a reduction in pain was demonstrated after only 30 days and this continued to improve with time. Function and pinch strength also increased significantly and continued to do so during the study period when compared to baseline.

CONCLUSIONS

The use of a custom-made splint for patients with osteoarthritis of the first carpometacarpal joint produced decreased pain and increased grip strength, pinch strength, and hand function. Clinical relevance Custom-made splints may be recommended for the treatment of first carpometacarpal joint osteoarthritis.

The use of a third metacarpal base osteoarticular flap for treatment of metacarpophalangeal joint traumatic defects

PURPOSE

To describe the use of a pedicled osteoarticular flap harvested from the base of the third metacarpal for the treatment of traumatic defects of the metacarpophalangeal (MCP) joints.

METHODS

From February 2006 to January 2008, we included in the study 15 patients with posttraumatic defects of the MCP joints. The mean age of the patients was 35 years. The injured MCP joints were located in the thumb (n = 6) and index (n = 4), middle (n = 4), and ring fingers (n = 1). Of the 15 patients, 10 presented with acute injuries and 5 with old injuries. At follow-up, we assessed active motion and pinch strength and compared all measurements with those from the opposite hand. In patients with old MCP joint injuries, we also compared preoperative and postoperative motion and pinch strength. We assessed hand function using the Disabilities of the Arm, Shoulder, and Hand questionnaire.

RESULTS

At the final follow-up (mean, 28 mo), the mean motion arc of the reconstructed MCP joints and the opposite joints was 46° and 91°, respectively, and the mean pinch strength of the injured and opposite sides was 5.4 and 7.1 kg, respectively. For the 5 patients with old injuries to the fingers, the mean preoperative and postoperative motion arc was 2° and 43°, and the mean preoperative and postoperative pinch strength was 1.6 and 5.3 kg, respectively. The mean Disabilities of the Arm, Shoulder, and Hand score of the entire patient series was 9, whereas the mean preoperative and postoperative scores of the 5 patients with old injuries were 44 and 17, respectively.

CONCLUSIONS

The use of a pedicled osteoarticular flap harvested from the base of the third metacarpal is a reliable technique for the treatment of traumatic defects of the MCP joints.

Treatment of a Bennett fracture using tension band wiring

PURPOSE

To describe and assess a tension band wiring technique for the treatment of Bennett fractures and to compare this technique of open reduction and internal fixation versus closed reduction and percutaneous pinning.

METHODS

From July 2005 to April 2008, we treated 56 Bennett fractures in 56 patients using tension band wiring. The mean age of the patients was 32 years. There were 37 dominant hands and 19 nondominant hands. The mean time between the injury and operation was 5 days. In this open tension band fixation group, the mean joint surface involvement was 39%, and all injuries were associated with carpometacarpal joint subluxation. At final follow-up, we assessed the thumbs for range of motion and assessed the hands for pinch and grip strength. For comparison, we also included 21 patients who were treated using closed reduction and percutaneous pin fixation from January 2003 to May 2005.

RESULTS

We noted no fixation failures in the open reduction internal fixation group. Radiographic fracture healing was achieved in all patients at a mean time of 4 weeks. Patient follow-up averaged 39 months. At final follow-up, the mean extension-flexion arc of the first carpometacarpal joint was 49°. Mean thumb abduction was 82° and mean pinch and grip strength of the injured hands were 7.4 and 43.0 kg, respectively. There were no significant differences between groups regarding the extension-flexion arc of the first carpometacarpal joint and grip strength. The 2 groups were similar in thumb abduction and pinch strength.

CONCLUSIONS

Open tension band wiring is a useful and reliable technique and presents another fixation option for the treatment of Bennett fractures.

TREATMENT OF BASAL JOINT ARTHRITIS OF THE THUMB: TRAPEZIECTOMY WITH OR WITHOUT TENDON INTERPOSITION/LIGAMENT RECONSTRUCTION

This prospective study compared the outcome — subjective, objective and radiographic — of two surgical techniques for treating basal joint arthritis of the thumb: a "simple" trapeziectomy (group I) and a ligament reconstruction/tendon (group II) interposition technique. There were respectively 22 patients in group I and 34 in group II, all women with primary osteoarthritis.

Both techniques gave favourable results and there were no significant differences for pain relief, patient satisfaction, mobility, DASH-score, key pinch force and gripping force. However in group II, the trapezial height was better preserved indicating that the proximal migration of the thumb was prevented or limited. There was also a significant correlation between the remaining trapezial space and key pinch force.

Abductor pollicis longus hemitendon looping around the first intermetacarpal ligament as interposition following trapeziectomy: a one-year follow-up study

BACKGROUND

Trapeziectomy and ligament reconstructions are favoured by surgeons concerned that telescoping of the thumb may reduce its function. However, theoretically ligamentoplasties are at risk to develop tendinosis or tendon rupture or trigger a complex regional pain syndrome type 1.

HYPOTHESIS

Authors tested the looping of a slip from the abductor pollicis longus (APL) tendon around the first intermetacarpal ligament. They intended to use a surgical treatment which does not require bone tunnelling or looping around a tendon. Their results support the hypothesis that this new technique is a valid addition among treatments for carpometacarpal arthritis.

PATIENTS AND METHODS

Forty-two patients were followed up to one year. Each patient had subjective assessment for: pain; function (DASH score); overall satisfaction. An objective assessment was used for: first web span angle; abduction and opposition; key pinch; grip strength. Tests were performed prior to surgery, then at three, six and 12 months. X-ray films were taken to monitor thumb height.

RESULTS

A substantial improvement in all these parameters was measured in all patients. X-ray films showed the mantainance of a physiological heigth after one year. We recorded one complication of keloid and two of temporary dysesthesia but no case of tendinosis, delayed rupture, or CRPS 1. Mean operative time was 27 minutes.

DISCUSSION

Simplification and search for a technique which avoids the looping around a tendon is why the authors undertook this study. Advantages are the small number of required steps, short time of surgery and comfortable postoperative rehab regimen for the patient. The technique provides a distal anchoring point (without bone tunnelling). It is quite respectful of anatomy and physiology, in minimizing the re-routing of functioning tendons. We propose it as an effective procedure both to expand the armamentarium for treating the thumb carpometacarpal joint osteoarthritis and/or to simplify the ligamentoplasties already in use.

Trapeziometacarpal joint osteoarthritis after proximal row carpectomy: treatment with a total joint arthroplasty

The authors report a case of trapeziometacarpal osteoarthritis in a 58-year-old woman with low functional demand. The patient had a proximal row carpectomy for posttraumatic radiocarpal arthritis. The authors decided to perform arthroplasty using a total GUEPAR trapeziometacarpal prosthesis to conserve carpal stability of the first column. Eight years after the surgery, the patient is free of pain and her thumb movement is similar to the opposite thumb. No radiographic changes were observed. No similar cases have been reported in the literature. Prosthesis insertion could be a reasonable option for this indication to give long-term painless mobility and stability.

Comparison of trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition: a systematic literature review

BACKGROUND

Trapeziectomy with ligament reconstruction and tendon interposition is currently the most popular technique for operative treatment of trapeziometacarpal osteoarthritis. Based on the evidence, however, it is uncertain whether the addition of ligament reconstruction and tendon interposition to trapeziectomy confers any advantage. The aim of this study was to systematically review the literature and determine which procedure, trapeziectomy or trapeziectomy with ligament reconstruction and tendon interposition, offers the best results to patients.

METHODS

A literature search was undertaken of the following electronic databases: Cochrane, AMED, EMBASE, HaPI, HealthSTAR, MEDLINE, TRIP, and Proceedings First (2002 to 2009). Studies were selected by two independent assessors if (1) the study population included patients with trapeziometacarpal osteoarthritis and (2) the study was a randomized controlled trial or systematic review comparing the two procedures. Objective (i.e., range of motion, grip strength, pinch strength, health cost, and postoperative complications) and subjective (i.e., pain relief, hand function, overall satisfaction, and quality of life) outcomes were extracted. Statistical pooling and power analyses were performed with available data.

RESULTS

Two systematic reviews and four randomized controlled trials were identified and included. There were no statistically significant differences in postoperative grip strength (p = 0.77); tip pinch strength (p = 0.72); key pinch strength (p = 0.90); pain visual analogue scale score (p = 0.34); Disabilities of the Arm, Shoulder and Hand score (p = 0.75); and number of adverse events (p = 0.13). No studies reported health costs or quality of life.

CONCLUSION

Neither procedure produced greater benefit in terms of outcomes investigated.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.(Figure is included in full-text article.).

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.

Use of a bilobed second dorsal metacarpal artery-based island flap for thumb replantation

PURPOSE

An extensive traumatic defect at the level of the proximal phalanx of the thumb presents difficulty in replantation. We report bilobed second dorsal metacarpal artery-based island flap harvested from both the index and middle fingers for reconstruction of the defect and preservation of the normal thumb length.

METHODS

From March 2004 to October 2008, 15 patients (11 men and 4 women; mean age, 35 y; range, 18 to 55 y) with completely or incompletely amputated thumbs associated with extensive defects in the proximal phalanx had replantation and reconstruction. In all cases, a bilobed second dorsal metacarpal artery-based island flap was used due to the large size of the defect. After flap transfer, anastomoses between the veins of the distal part of the thumb and the flap were performed. At the final follow-up, we assessed the mean active range of motion of the metacarpophalangeal and interphalangeal joints of the thumb and the span of the first web in the thumbs that survived. Active motion of the donor fingers was also assessed.

RESULTS

In this series, 13 thumbs survived and 2 failed. All flaps survived completely. At the mean follow-up of 27 months (range, 24 to 29 mo), the mean active motion arcs of metacarpophalangeal and interphalangeal joints were 32° (range, 15° to 45°) and 31° (range, 0° to 47°), respectively. Full active range of motion was observed in all patients in both the metacarpophalangeal and the proximal interphalangeal joints of the donor index and middle fingers.

CONCLUSIONS

Bilobed second dorsal metacarpal artery-based island flap transfer is a useful and reliable technique for thumb replantation when there is an extensive defect in the proximal phalanx and when a single-digit dorsal metacarpal artery island flap is too small.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review

The aim of this article is to provide an updated systematic review on the 8 most commonly used surgical procedures to treat trapeziometacarpal osteoarthritis. A thorough literature search was performed using predetermined criteria. A total of 35 articles fulfilled the inclusion criteria. Nine of these 35 articles were not included in previous systematic reviews. Systematic evaluation demonstrated the following: (1) there is no evidence that trapeziectomy or trapeziectomy with tendon interposition is superior to any of the other techniques. However, when interposition is performed, autologous tissue interposition seems to be preferable. (2) Trapeziectomy with ligament reconstruction or trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is not superior to any of the other techniques. However, follow-up in the studies with a higher level of evidence was relatively short (12 mo); therefore, long-term benefits could not be assessed. In addition, trapeziectomy with LRTI seems associated with a higher complication rate. (3) Because the studies on thumb carpometacarpal (CMC) arthrodesis were of less methodological quality and had inconsistent outcomes, we are not able to conclude whether CMC arthrodesis is superior to any other technique. Therefore, high-level randomized trials comparing CMC arthrodesis with other procedures are needed. Nevertheless, findings in the newly included studies did show that nonunion rates in the literature are on average 8% to 21% and, complications and repeat surgeries are more frequent following CMC arthrodesis. (4) A study on joint replacement showed that total joint prosthesis might have better short-term results compared to trapeziectomy with LRTI. However, high-level randomized trials comparing total joint prosthesis with other procedures are needed. In addition, there is no evidence that the Artelon spacer is superior to trapeziectomy with LRTI. We conclude that, at this time, no surgical procedure is proven to be superior to another. However, based on good results of CMC arthrodesis and total joint prostheses, we postulate that there could be differences between the various surgical procedures. Therefore randomized clinical trials of CMC arthrodesis and total joint prostheses compared to trapeziectomy with long follow-up (>1 y) are warranted.

Arthroscopic total trapeziectomy

Trapeziometacarpal osteoarthritis is a common pathology resulting in severe impairments in daily living activities. Many procedures have been described in the treatment of stages Eaton II, III and IV. Bibliographical research evidences that other techniques could not improve the results of the simple trapeziectomy. A surgical technique with an arthroscopically assisted total resection of the trapezium is described. This technique is carried out with a 2.7-mm arthroscope, using the conventional portals (1R and 1U) and a fluoroscan. Surgery ends with soft dressings and rehabilitation begins immediately. In the last 9 years, we treated more than 70 patients. Video-assisted total trapeziectomy offers a simple technique with sufficient postoperative comfort that allows an early return to the daily living activities.

Treatment of thumb tip degloving injury using the modified first dorsal metacarpal artery flap

PURPOSE

This study reports repair of a thumb tip degloving injury using the modified first dorsal metacarpal artery (FDMA) flap, including both dorsal branches of the proper digital nerve (DBPDNs).

METHODS

From May 2006 to February 2008, the modified FDMA flap was used in 11 thumbs in 11 patients. All patients suffered a degloving injury to the thumb tip, and 4 had associated bone loss ranging from 1 to 3 mm (mean, 2 mm) in length. The size of the soft tissue defects was 2.6 to 4.6 cm (mean, 3.5 cm) in length and 1.8 to 2.2 cm (mean, 2.0 cm) in width. The flaps ranged in size from 2.7 × 2.2 cm to 4.8 × 2.1 cm (mean, 3.6 × 2.1 cm). The mean pedicle length was 7.2 cm (range, 6.8-7.5 cm). Neurorrhaphy between the DBPDN and the proper digital nerve was performed in both sides in all cases. Patient follow-ups ranged from 26 to 47 months (mean, 32 mo). Sensibility of the reconstructed thumb was evaluated by static 2-point discrimination. The range of motion of the donor fingers was measured. The data were compared to those of the opposite sides.

RESULTS

All flaps survived completely. At the final follow-up, the mean values of static 2-point discrimination were 5 mm (range, 4-8 mm) and 6 mm (range, 4-8 mm) on the radial and ulnar sides of the distal portion of the flap, respectively. The mean values of the radial and ulnar distal portions of the flaps reached 75% and 72% of those of the opposite sides. The mean range of motion of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of the donor fingers were 73°, 101°, and 70°, respectively.

CONCLUSIONS

The modified FDMA flap, including both DBPDNs, is useful for restoration of sensation on the thumb tip and maintenance of adequate length of the thumb.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Outcomes of trapeziectomy with a modified abductor pollicis longus suspension arthroplasty for the treatment of thumb carpometacarpal joint osteoarthritis

PURPOSE

Various arthroplasty procedures have been described for the treatment of thumb carpometacarpal joint osteoarthritis. The purpose of this study was to determine the outcomes of patients treated with trapeziectomy and a variation of abductor pollicis longus suspension arthroplasty.

METHODS

Eighteen consecutive patients were treated by a single surgeon (K.C.C.) with trapeziectomy and abductor pollicis longus suspension arthroplasty (21 thumbs). Prospective outcomes data were collected before the operation and at 3, 6, and 12 months after surgery. Outcomes were assessed with x-rays, grip/key pinch strength, the Jebsen-Taylor test, and the Michigan Hand Outcomes Questionnaire.

RESULTS

Immediately after surgery, a 32 percent loss in carpometacarpal joint height was observed and an additional 11 percent proximal metacarpal migration was observed at 1 year. The mean grip strength was 11.1 kg preoperatively and 7.7, 14.3, and 16.7 kg at 3 months, 6 months, and 1 year postoperatively, respectively. Michigan Hand Outcomes Questionnaire results demonstrated improvements in all domains. Statistically significant improvements were noted in the domains of overall score, from 41 to 67 (p = 0.03); activities of daily living, from 43 to 66 (p = 0.01); work, from 41 to 65 (p = 0.05); patient satisfaction, from 25 to 68 (p = 0.01); and pain, which decreased from 73 to 30 (p < 0.01).

CONCLUSIONS

Abductor pollicis longus suspension arthroplasty is a faster and technically easier technique that avoids any additional deficit by using an accessory tendon. This procedure gives acceptable patient-rated outcomes, especially in pain relief and satisfaction.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

This is an update of a Cochrane Review first published in 2005. Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To compare the effect of different surgical techniques in reducing pain and improving physical function, patient global assessment, range of motion and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, to investigate whether there was any improvement or deterioration in outcomes between the 12-month review and five year follow up.

SEARCH STRATEGY

We searched:(CENTRAL) (The Cochrane Library 2008, issue 1), MEDLINE (1950 to Dec 2008), CINAHL (1982 to Dec 2008), AMED (1985 to Dec 2008) and EMBASE (1974 to Dec 2008), and performed handsearching of conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Randomised or quasi-randomised trials where the intervention was surgery and pain, physical function, patient global assessment, range of motion or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse effects. We contacted trial authors for missing information.

MAIN RESULTS

We included nine studies involving 477 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint resurfacing, arthrodesis and joint replacement). Studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement for pain and physical function. The majority of studies included in this review had an unclear risk of bias which raises some doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment or range of motion. Of participants who underwent trapeziectomy with ligament reconstruction and tendon interposition, 22% had adverse effects (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1)) compared to 10% who underwent trapeziectomy. Trapeziectomy with ligament reconstruction and tendon interposition is therefore associated with 12% more adverse effects (RR = 2.21, 95% CI 1.18 to 4.15).

AUTHORS' CONCLUSIONS

Although it appears that no one procedure produces greater benefit in terms of pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy has fewer complications than trapeziectomy with LRTI.

Second dorsal metacarpal artery flap from the dorsum of the middle finger for coverage of volar thumb defect

PURPOSE

The second dorsal metacarpal artery flap from the middle finger is a reconstructive technique that can be used to repair extensive volar defects in a normal-length thumb. However, few reports advocate using it for coverage of volar thumb defects. In this article, an anatomic study of 9 flaps used for resurfacing thumb defects is presented along with the clinical experience of the authors.

METHODS

From 2004 to 2006, 9 patients (6 men and 3 women; mean age, 33 years; range, 18-51 years) with extensive volar defects of their normal-length thumbs had reconstruction using the described technique. In all cases, the first dorsal metacarpal artery flap technique was unable to be used because of injury. Donor sites were covered using full-thickness skin grafts. After surgery, the thumb was immobilized with a splint, followed by rehabilitation. During the follow-up period, which lasted 24 to 30 months, flap-site skin quality, scar contractures, and finger mobility were assessed. The range of motion of the hand was measured by a goniometer. Sensibility was evaluated by the 2-point discrimination test and the Semmes-Weinstein monofilament test. Cold intolerance was also assessed.

RESULTS

Patient postoperative courses were uneventful, and all flaps survived completely without complication. Good coverage was obtained in all cases. Full active range of motion was observed in all patients in both the donor finger and the thumb. The mean Semmes-Weinstein sensitivity and 2-point discrimination scores of the flap were 4.02 g and 8.4 mm, respectively. Mild cold intolerance was observed in all of the thumbs.

CONCLUSIONS

The second dorsal metacarpal artery flap from the middle finger is a single-stage flap that produces good results. Although its pedicle length is limited, it is reliable and can be used as an alternative for reconstruction of extensive thumb-pulp defects, especially when the first dorsal metacarpal artery flap cannot be used.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Basal joint osteoarthritis of the thumb treated with Weilby arthroplasty: a prospective study on the early postoperative course of 106 consecutive cases

One hundred and six consecutive cases of osteoarthritis of the trapeziometacarpal joint, treated by tendon interposition arthroplasty as described by Weilby, were followed prospectively, with assessment of pain, mobility, pinch and grip strength at 6, 12, 26 and 52 weeks. Patient satisfaction was reviewed at 26 and 52 weeks. Preoperative visual analogue scores for pain averaged 65 and decreased postoperatively to an average of 12 at 52 weeks. The main decrease in pain occurred during the first 3 months after operation. Mobility was improved or unaltered in 82%. Average grip and pinch strength reached preoperative values (41 kPa and 20 kPa respectively) between 12 and 26 weeks after surgery and were significantly greater (58 kPa and 34 kPa) at 52 weeks. Recovery after suspension arthroplasty takes 3-6 months, which may be a disadvantage to be considered when advising patients who are considering operative treatment.

Trapeziectomy for trapeziometacarpal joint osteoarthritis: is ligament reconstruction and temporary stabilisation of the pseudarthrosis with a Kirschner wire important?

This randomised prospective study compared two operations for trapeziometacarpal joint osteoarthritis: trapeziectomy with Flexor carpi radialis ligament reconstruction, tendon interposition and Kirschner wire insertion followed by splintage for 6 weeks (T+LRTI) and excision of the trapezium with no Kirschner wire and immobilisation of the thumb in a soft bandage for only 3 weeks (T). Sixty-seven thumbs with trapeziectomy (T) and 61 with trapeziectomy and ligament reconstruction and tendon interposition (T+LRTI) were assessed preoperatively and at 3-months and 1-year after surgery. Forty-seven percent and 73% of patients reported no pain or only aching after use at 3-months and 1-year respectively and the DASH and Patient Evaluation Measure (PEM) outcome scores reduced postoperatively indicating improved function. However the pain, DASH and PEM scores, and also key and tip thumb pinch and all the other clinical outcome measures, did not differ significantly between the two groups at either 3-months or 1-year after surgery.

Treatment of advanced carpometacarpal joint disease: trapeziectomy and hematoma arthroplasty

Some surgical treatment options of painful basal joint arthritis do not require complex arthroplasty or suspensionplasty techniques. Simple trapeziectomy with temporary pinning of a slightly overdistracted thumb metacarpal can provide reliable pain relief, good motion, and functional stability. Recent literature supports alternative options when compared with formal ligament reconstruction or suspensionplasty procedures. Simple trapeziectomy is associated with less morbidity due to shorter operative times and the lack of need for graft harvest and ligament reconstruction.

The pain associated with intraarticular hyaluronic acid injections for trapeziometacarpal osteoarthritis

Trapeziometacarpal osteoarthritis predominantly affects middle-aged women. Most cases with rhizarthrosis can be managed successfully by conservative means. The purpose of this prospective study was to evaluate pain and tolerability of viscosupplementation therapy with hyaluronic acid (HA) for trapeziometacarpal osteoarthritis. Groups A and B consisted of eight patients each with Eaton stage 3 or 4 rhizarthrosis, who underwent one cycle of three injections of (one per week) 0.3 cm3 sodium hyaluronate. The injections for group A were under fluoroscopy control, but fluoroscopy was not used in group B. Pain and tolerability of both groups A and B were measured and compared. The patients of the groups were also asked to evaluate the tolerability of the treatment. The results suggested that HA injection in the carpometacarpal joint is a tolerable procedure but the patients complained of pain and discomfort during the injections. The pain in group A was much greater than in group B. Viscosupplementation for the treatment of trapeziometacarpal osteoarthritis is a viable treatment option for stages 3 and 4 patients when they do not want to be operated on. It is a tolerable but not a painless procedure especially when it is done without fluoroscopy control. We recommend giving injections under fluoroscopy control.

Basal thumb metacarpal osteotomy for trapeziometacarpal osteoarthritis

PURPOSE

To review the subjective and functional results of basal thumb metacarpal osteotomy for the treatment of trapeziometacarpal osteoarthritis.

METHODS

Between July 1993 and November 1998, 35 thumb osteotomies without internal fixation were performed on 33 patients in the Christchurch Hospital, New Zealand. Records of 28 thumbs (13 right and 15 left) of 26 patients (17 women and 9 men) were available for review. Patients were reviewed using strength testing and the Michigan Hand Outcomes Questionnaire.

RESULTS

The mean age of the 26 patients was 54 years (range, 30-69 years). Of the 28 thumbs, 22 (21 patients) had good or excellent results, 2 fair, one poor. The remaining 3 thumbs (3 patients) required further revision and were classified as failures. The mean follow-up period of the 25 thumbs (24 patients) not requiring revision was 34 months (range, 12-73 months). Good thumb motion was present in all hands with no trapeziometacarpal instability seen. Compared with the normative data, the strengths of key pinch, pulp pinch, and tripod pinch of our patients were significantly lower (22-32% lower), but not the grip strength. Michigan Hand Outcomes Questionnaire scores increased 28 (range, 1-56) points after surgery, with significant improvement especially in pain (+44 points), activities of daily living (one-handed tasks, +41 points), and satisfaction (+35 points).

CONCLUSION

Basal thumb metacarpal osteotomy is a straightforward, conservative procedure that should be considered for grades II and III trapeziometacarpal osteoarthritis.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To investigate the effect of surgery in reducing pain and improving physical function, patient global assessment, range of motion, and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, it was the reviewers intention to investigate whether there was any improvement or deterioration in outcomes between the 12 months review and a 5 year follow-up.

SEARCH STRATEGY

We searched the the following databases in the Cochrane Library 2004, Issue 4: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE) as well as MEDLINE (1966-Dec 2004), CINAHL (1982-Dec 2004), AMED (1985-Dec 2004), and EMBASE (1974-Dec 2004). Database searches were supplemented by hand searching conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Studies were included if they were: randomised, quasi-randomised or controlled trials; intervention was surgery; and pain, physical function, patient global assessment, range of motion, or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two independent reviewers examined the identified studies according to the inclusion criteria. Included studies were assessed for methodological quality and then data, including adverse effects, was extracted and cross-checked. Authors were contacted to provide missing information.

MAIN RESULTS

Seven studies involving 384 participants were included. Studies of five surgical procedures were identified (trapeziectomy, trapeziectomy with interpositional arthroplasty, trapeziectomy with ligament reconstruction, trapeziectomy with ligament reconstruction and tendon interposition (LRTI), and joint replacement). All studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement across all stages of 27 to 57 mm on a 0-100 VAS scale for pain and 18-24 mm on a 0-100 VAS scale for physical function. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment, range of motion or strength. However, participants who underwent trapeziectomy had 16% fewer adverse effects (p=0<.001) than the other commonly-used procedures studied in this review; conversely, those who underwent trapeziectomy with ligament reconstruction and tendon interposition had 11% more (p=0.03) (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1).

AUTHORS' CONCLUSIONS

No one procedure produced greater strength than any other. Although this also appears to be the case for pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy is safer and has fewer complications than the other procedures studied in this review, and conversely trapeziectomy with LRTI has more.

Treatment of Idiopathic Postmenopausal Osteoarthrosis of the Trapeziometacarpal Joint With the Epping Resection Arthroplasty Technique

Surgical treatment of idiopathic postmenopausal osteoarthrosis of the trapeziometacarpal joint with the Epping resection arthroplasty was performed in 57 cases in 49 women. Data show good pain relief (between 58% and 76%), very good subjective results with 89% patient satisfaction and Disability of Arm, Shoulder, Hand (DASH) scores in the lower third of the scale after 35 months' follow-up. Good functional results with respect to radial abduction (51 degrees) and palmar flexion (45 degrees), as well as improvement in strength measurements, could be achieved. Some patients (13%) reported remaining problems with occasional pain during performance of activities of daily life and work. A significant proximal metacarpal migration (31%) without correlation to objective or subjective outcome was found. The Epping procedure has proven to be a valuable alternative procedure to treat idiopathic postmenopausal trapeziometacarpal arthrosis after a midterm follow-up period. Still, careful patient selection is important and sufficient preoperative information necessary.

[Short term results of total carpometacarpal joint replacement surgery using the ARPE implant for primary ostearthritis of the thumb]

INTRODUCTION

We have reviewed the short-term results of the ARPE arthroplasty of the first carpometacarpal joint for osteoarthritis of the thumb.

MATERIAL AND METHODS

One hundred and eighteen patients have been operated on in our department between June 1999 and June 2003, by the same surgeon. Sixty-three of these patients had been followed for a minimum of six months and were included in this retrospective study. We have evaluated functional results as pain, key-pinch, mobility and patient satisfaction. The occurrence of complications was investigated.

RESULTS

The results of this procedure were found to be excellent for pain, mobility and strength. Recovery was judged fast and patient satisfaction was high. The most frequent complication was implant luxation in six cases. Implant loosening was seen in three.

DISCUSSION

Functional results of this type of arthroplasty are excellent. We consider it to be superior to trapeziectomy for recovery (rehabilitation is unnecessary) and strength. Most common complications have a relatively simple surgical solution. Trapeziectomy remains possible thanks to a minimal shortening of the metacarpal bone.

CONCLUSION

The ARPE arthroplasty can be considered as a good surgical option for treatment of thumb osteoarthritis. A longer follow up is necessary to predict the long-term behaviour of the prosthesis.

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition

PURPOSE

To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improved the outcome of excision of the trapezium for the treatment of painful osteoarthritis of the trapeziometacarpal joint.

METHODS

183 thumbs with trapeziometacarpal osteoarthritis were randomized for treatment by either simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void during each of the 183 surgeries to hold the base of the thumb metacarpal at the level of the index carpometacarpal joint and was retained for 4 weeks in every case. All patients wore a thumb splint for 6 weeks. Each patient had subjective and objective assessments of thumb pain, stiffness, and strength before surgery and at 3 months and 1 year after surgery.

RESULTS

The 3 treatment groups were well matched for age, dominance, and presence of associated conditions. Complications were distributed evenly among the 3 groups and no cases of subluxation/dislocation of the pseudarthrosis were observed. Of the 183 thumbs 82% achieved good pain relief and 68% regained sufficient strength to allow normal activities of daily living at the 1-year follow-up evaluation. Neither of these subjective outcomes nor the range of thumb movement was influenced by the type of surgery performed. Thumb key-pinch strength improved significantly from 3.5 kg before surgery to 4.6 kg at 1 year but the improvement in strength was not influenced by the type of surgery performed.

CONCLUSIONS

The outcomes of these 3 variations of trapeziectomy were very similar at 1-year follow-up evaluation. In the short term at least there appears to be no benefit to tendon interposition or ligament reconstruction.

Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review

In most cases of basal joint osteoarthritis, surgery becomes an option at stages II, III, and IV, as classified by Eaton. Controversy exists regarding which technique achieves the best outcome. This systematic review was undertaken to address the question of which technique, if any, offers the best outcome to patients with osteoarthritis of the first carpometacarpal joint greater than stage II. A thorough search of the electronic databases Cochrane, Cinahl, Healthstar, and MEDLINE/PubMed was undertaken to identify reviews and articles on primary comparative studies of the different surgical options. The methodological quality of the retrieved articles was assessed on the basis of specific criteria. Inclusion criteria were applied to 44 of 254 possibly relevant articles. Eight reviews and 18 comparative studies met the criteria and were reviewed. Each of the techniques, arthrodesis, trapeziectomy with or without biological/synthetic interposition, osteotomy, and joint replacement, was associated with unique benefits and risks. There was great variability in outcome measurements. The majority of retrieved review articles claim that ligamentous reconstruction and tendon interposition may represent the best option; however, validity assessment of these studies revealed methodological flaws. Furthermore, results from the articles on comparative studies indicate that ligamentous reconstruction and tendon interposition may provide no additional benefit when compared with arthrodesis and trapeziectomy alone or with tendon interposition. There is no consensus as to which clinical outcomes are most important in thumb basal joint surgery and how these should be measured. This renders the appraisal and comparison of such studies a challenging task. Until large randomized controlled trials that compare techniques in similar populations with respect to staging and prognostic factors are undertaken and the clinical outcomes are clearly defined, surgeons will continue to claim superiority of one technique over another without supporting evidence.

[Anchovy dacron arthroplasty in the treatment of basal osteoarthritis of the thumb: long term results]

INTRODUCTION

Fifteen patients were treated for arthritis of the base of the thumb by trapieziumectomy and anchovy interposition using Dacron[symbol: see text]. The results are described.

METHODS

The 15 patients were between 42- and 68-years-old at the time of operation. The mean postoperative follow-up was 3 years. Pain, pinch strength, opposition, opening of the first web space and height of the space formerly occupied by the trapezium were clinically and radiologically evaluated.

RESULTS

Pain had completely disappeared in more than 80% of the patients. The mean post-surgical opposition was 8.9/10 (Kapandji score). The pinch strength and first web-space opening were improved, whereas the height of the trapezium site was always reduced by 25%. The only complication was one case of reflex sympathetic dystrophy: no case of foreign body reaction was reported. Eleven of the 15 patients were satisfied with the operation, and noted better thumb function in everyday life.

DISCUSSION

The treatment of arthritis of the base of the thumb by means of trapieziumectomy and anchovy interposition is effective with respect to pain in all the studies previously published, whatever the technique used. Mobility is preserved, contrary to arthrodesis, and grip strength remains compatible with the patient's daily life. The choice of a synthetic anchovy such as Dacron[symbol: see text] allows a quicker operation and better than the ones involving sacrifice of a tendon at the wrist. Anchovy interposition remains the preferred alternative among other procedures in the treatment of basal osteoarthritis of the thumb.

The carpometacarpal joint of the thumb: stability, deformity, and therapeutic intervention

The carpometacarpal (CMC) of the thumb is a saddle joint that permits a wide range of motion and is largely responsible for the characteristic dexterity of human prehension. This joint, located at the very base of the thumb, is subject to large physical stresses throughout life. Osteoarthritis (posttraumatic or idiopathic), rheumatoid arthritis, and postmenopausal laxity of the capsular ligaments can predispose structural instability and impairment of this important joint. The instability is characterized by varying and often progressive dislocation of the joint surfaces, resulting in a displaced axis of rotation and abnormal actions of thumb muscles. The main consequence of the instability is most often pain and weakness, most notably during pinch and grasping actions. This paper is conceptually divided into 2 sections. The first section describes the anatomic structures that maintain stability in the normal CMC joint of the thumb and how disease or trauma can cause instability and ultimate deformity. The second section describes both nonsurgical and surgical interventions that are most often used to treat an unstable CMC joint. This paper is intended primarily as an overview for the physical therapist who does not specialize in the treatment of the hand, although desires basic information on this important topic.

Swanson versus APL arthroplasty in the treatment of osteoarthritis of the trapeziometacarpal joint: a prospective and randomized study in 26 patients

Twenty-six patients were operated because of osteo-arthritis of the trapeziometacarpal joint. After excision of the trapezium, they were randomized to receive either a Swanson silicone trapezium implant or a tendon interposition arthroplasty using a strip of the abductor pollicis longus tendon (APL). No infection or clinical silicone synovitis occurred and no major radiographic cyst formation was found. Two endoprostheses dislocated early. All 13 patients in the Swanson group and 11 of the 13 in the APL group were subjectively satisfied at 2-5 year (mean, 43 months) follow-up. All patients were free of pain at rest and at light work, but half of the patients in each group still experienced pain with heavy work. Thumb pinch strength and range of motion were not significantly different in the two groups. The trapezial space decreased both with load and length of follow-up in both groups. Five endoprostheses subluxed during stressed pinch. In conclusion, both methods gave good, but not complete, pain relief and neither produced better results than the other in the short term.

Results following trapeziometacarpal arthroplasty of the thumb

A retrospective follow-up study was performed on patients with degenerative joint disease (DJD) who underwent trapeziometacarpal arthroplasty of the thumb with 3-week immobilization and without the use of K-wire fixation. Pre- and post-operative pain, activities of daily living (ADLs), grip strength, and pinch strength were compared. Data were collected on 25 hands in 23 patients, 7 hands with full trapezium resections and 18 with hemi-trapezium resections. The median age was 60 years, with a range of 39 to 73 years, and the median follow-up period was 1 year 11 months, with a range of 3 months to 11 years. Grip and pinch strength were measured pre- and postoperatively. Pain was assessed on a visual analog scale (VAS), and ADLs were assessed by means of a 15-item survey. Both pain and ADLs were evaluated postoperatively with recall of preoperative status. Following surgery, all thumbs were immobilized in a static splint for 3 weeks and then allowed progressive use. Median improvements in hemi-trapezium resections included grip, 22.5 lb; pinch, 4.7 lb; and ADLs, 33%. Pain was reduced a median of 7.0 cm on the VAS. Median improvements in full trapezium resection included grip, 29.5 lb; pinch, 0 lb; ADLs, 60%; and pain reduction, 8 cm on the VAS. This follow-up study suggests that satisfactory results can be achieved in pain reduction, strength, and ADLs with an immobilization period of only 3 weeks and without the use of K-wires following carpometacarpal (CMC) arthroplasty.

Adverse effect of porcine collagen interposition after trapeziectomy: a comparative study

Twenty-six hands in 26 adults with osteoarthrosis of the thumb trapeziometacarpal joint were randomised to undergo either trapeziectomy alone (control) or with the interposition of porcine dermal collagen xenograft (Permacol). The study was terminated prematurely because of apparent reactions to the implants in six of 13 patients. The collagen interposition group required more frequent review on clinical grounds and were discharged later after surgery. Three of the implants have been removed and histology revealed foreign body reactions in all. There was no difference in thumb movement or power after surgery between the two groups. However, improved grip strength was observed and improved function were reported only in the control group. Permacol patients reported greater pain and were less satisfied with their operations than control patients. We conclude that interposition of Permacol is detrimental to the results of trapeziectomy.

A comparison of trapeziectomy with and without ligament reconstruction and tendon interposition

Forty-three patients were randomly allocated to undergo either trapeziectomy alone (control) or with a ligament reconstruction and tendon interposition (LRTI) using an abductor pollicis longus tendon slip. The patients were reviewed at a median 13 (range, 7-29) months after surgery. The demographic characteristics, severity of disease and pre-operative clinical measurements of the two study groups were indistinguishable but LRTI lengthened the operation by approximately 15 minutes. Both groups expressed equal satisfaction with the operation and there were no significant differences between the two treatment groups. Simple trapeziectomy is an effective operation for osteoarthrosis at the base of the thumb and the addition of a ligament reconstruction was not shown to confer any additional benefit.