First carpometacarpal joint arthritis. A comparison of two arthroplasty techniques

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.

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.

Evidence-based medicine: thumb carpometacarpal arthroplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Recount the epidemiology of basilar joint arthritis. 2. Understand how the anatomy and kinematics of this joint contribute to the development of the disease process. 3. Combine patient history, clinical examination, and radiographic findings to formulate a diagnosis and staging of the arthritis. 4. Incorporate conservative management into the patient treatment plan to aid in determining a patient's surgical candidacy. 5. Comprehend the basic principles of available surgical options, potential complications, and evidence pertaining to surgical outcome.

SUMMARY

This article has been prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured for physicians to comparatively evaluate their care of a patient with arthritis of the thumb carpometacarpal joint.

Long-term follow-up of trapeziectomy with abductor pollicis longus tendon interposition arthroplasty for osteoarthritis of the thumb carpometacarpal joint

PURPOSE

To evaluate the long-term clinical and radiographic outcomes of trapeziectomy with abductor pollicis longus tendon interposition arthroplasty for moderate to severe osteoarthritis of the thumb carpometacarpal joint (Eaton stages III-IV).

METHODS

We evaluated 13 patients (15 thumbs) who underwent trapeziectomy and abductor pollicis longus tendon interposition arthroplasty for end-stage osteoarthritis of the thumb carpometacarpal joint, at an average follow-up of 15 years. Subjective clinical outcomes evaluated included visual analogue scale scores and disability of arm shoulder and hand score questionnaires. Objective clinical evaluation included lateral pinch and grip tests, and a range of active and passive thumb movements. All patients underwent a radiological assessment by two independent senior radiologists. Wherever possible, results obtained from the operated thumbs were compared to the non-operated side.

RESULTS

At a mean of 15 years post operation (range 15-17 years), there was no statistical difference between the operated and non-operated hands with regards to grip and pinch strength. In all cases CMC and MCPJ range of motion in the operative hand was either equal to or greater than non-operative counterparts. Mean visual analogue scale score was 2.13 and mean DASH score was 16.85. Mean carpal height was 0.52 and mean trapezial space ratio was 0.163. There were no early or late complications recorded and no revision surgery was required.

CONCLUSION

It is the opinion of these authors that abductor pollicis longus tendon interposition arthroplasty is able to provide high-quality long-term results for patients who suffer from moderate to severe osteoarthritis of the thumb carpometacarpal joint.

LEVEL OF EVIDENCE

Therapeutic Level IV.

[Clinical and radiologic evaluation of a polylactic acid interposition arthroplasty after trapezectomy]

Surgical management of trapeziometacarpal osteoarthritis does not obey to strict rules. The use of interposition implants made of different materials leads to enrichment of surgeon's resources. This prospective study reports the radiological and clinical results of 45 patients treated by total trapeziectomy with polylactic acid interposition implant, with an average follow-up of 31 months. Thirty-seven surgical treatments were carried out after ineffective medical treatment. According to Dell classification, there were five stages II, 30 stages III and two stages IV. Mean age was 66 years. Dominant side was involved in 60%. Thumbs were pain free at 5 months in average and 81% of the patients reported good results (Alnot stages 0 and 1). The average opposition was 9.1/10, the average M1M2 angle was 40°, and the average key pinch strength was 4.4 kg. Six patients suffered from sympathetic dystrophy but neither infection nor local inflammatory reaction was observed. Collapse of the trapezium space was constant and the trapezium space ratio was 76% at the follow-up. Seventy-five per cent of patients returned back to their occupation. The satisfaction rate was 89%. The radioclinical results were very good in our series. The interposition of polylactic acid implant permits to avoid the presumed complications of tendon harvesting, and those of other types of material used in the same indication. Its safety seems excellent.

Morphometric and biomechanical comparison of tendons used for interposition arthroplasty in carpometacarpal arthritis of the thumb

PURPOSE

To identify the wrist tendon most effectively maintaining the trapezial space in interpositional arthroplasty in osteoarthritis of the carpometacarpal joint of the thumb.

METHODS

The morphometrics of the os trapezium and the tendons of the flexor carpi radialis, extensor carpi radialis longus, and abductor pollicis longus were determined. The stiffness and compressive loading characteristics of the rolled-up tendons were compared to the os trapezium.

RESULTS

No significant morphometric differences between the three tendons were found. The mass and volume of the trapezium was significantly larger when compared to the tendon balls. No significant differences in the compressive loading resistance were found between the tendons, but the mean stiffness was 85% lower when compared to the os trapezium.

CONCLUSIONS

Neither tendon material approached the volume nor the stiffness provided by the os trapezium. Any tendon is considered to insufficiently maintain the trapezial space following trapeziectomy.

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.

Partial trapeziectomy with ligament reconstruction--tendon interposition in thumb carpo-metacarpal osteoarthritis. A study of 112 cases

INTRODUCTION

We have performed arthroligamentoplasty with partial trapeziectomy since 1987. We compare the results of this technique with those of arthroligamentoplasty with total trapeziectomy.

MATERIAL AND METHODS

We reviewed 112 arthroligamentoplasties performed by the same surgeon, with a minimum follow-up of three years, comparing partial trapeziectomy (93 hands Eaton stage II-III of the disease and one with post-traumatic osteoarthritis), with total trapeziectomy (nine hands stage IV of the disease, eight hands requiring re-operation due to failure of total trapeziectomy and one with post-traumatic osteoarthritis).

RESULTS

Pain: all the patients have improved. Slight pain at moderate effort persisted in three cases (17%) of total trapeziectomy and in 14 cases (15%) of partial trapeziectomy but only one of these required revision surgery with arthrodesis. Key-Pinch strength: partial trapeziectomy: strength averaged 93% of preoperative strength. In the 34 bilaterally affected cases, the operated hand had 110% of the strength of the non-operated contralateral hand. Total trapeziectomy: strength averaged 85% of preoperative values. In the seven bilateral affection cases, the operated hand had 105% of the strength of the non-operated contralateral hand. Range of motion: we did not register relevant differences. Radiology: in relation to preoperative period, we registered 18% reduction of the scapho-metacarpal space associated with partial trapeziectomy, and 29% in scapho-metacarpal space associated with total trapeziectomy.

COMPLICATIONS

we have registered complications in 12 hands.

CONCLUSION

Both techniques resulted in indistinguishable outcomes. Given the goal of preventing the impairment of a healthy joint and a very hazardous surgical alternative in case of failure, the indication for total trapeziectomy should be restricted to the presence of damage in the two major surfaces of the trapezium.

An investigation into therapists' management of osteoarthritis of the carpometacarpal joint of the thumb in the UK

Objective

Osteoarthritis (OA) of the first carpometacarpal (CMC) joint is common and causes pain and loss of function. Conservative management is widely used to manage this condition and this study aimed to investigate the current conservative management employed by therapists in the UK.

Methods

A survey design was selected using a self-completed questionnaire as the data collection tool. The questionnaire was designed by the author and distributed to therapists by post to a range of therapy departments and to delegates attending a hand therapy course.

Results

A total of 115 out of 330 therapists (35%) responded with a completed questionnaire and the majority of the sample (97%) treated OA of the first CMC joint. Therapists used a variety of treatments for OA of the first CMC joint and the severity of the OA influenced the treatments used. Advice on activities of daily living, ergonomic advice, splints and exercise were the most commonly used treatment modalities. Therapists varied greatly in how effective they felt the different treatment modalities were in treating OA of the first CMC joint and how strong they felt the evidence base was to support their use. Most therapists used outcome measures, but many different ones were in use. Few therapists were aware of a classification system to grade the severity of OA of the first CMC joint.

Conclusions

There is a need for further research into the conservative management of this condition in order to establish the most effective treatments for each stage of the disease process.

CMC arthroplasty of the thumb: a review

Arthritis of the first carpometacarpal (CMC) joint of the hand is a common and often debilitating disease. Diagnosis can be readily made with history, physical exam, and radiographic evaluation. Patients with advanced disease who have failed conservative treatment modalities have multiple surgical options including ligament reconstruction, resection arthroplasty, silicone implantation, tendon interposition, or total joint arthroplasty. This article will describe the variety of approaches to treatment as well as the author's preferred method.

Joint kinematics after thumb carpometacarpal joint reconstruction: an in vitro comparison of various constructs

PURPOSE

Osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint causes pain and limits thumb motion. Different surgical procedures exist to treat thumb CMC OA; however, kinematic analyses of thumb reconstructions are limited. The purpose of this study was to evaluate kinematic changes of the thumb CMC joint as the result of different thumb reconstruction procedures.

METHODS

Fifteen cadaveric forearms were prepared and instrumented with an electromagnetic tracking device to measure the motion of the thumb metacarpal with respect to the trapezium (thumb trapeziometacarpal joint). Kinematics of the intact thumb and the thumb after trapeziectomy under passive motion were recorded. Specimens then had joint reconstruction consisting of either a ligament reconstruction with tendon interposition (LRTI), Weilby arthroplasty, or Thompson arthroplasty. The kinematic data collection analysis was repeated. The radius of joint motion and 3-dimensional (3D) work area were calculated for each surgery and were used for statistical analysis.

RESULTS

The type of surgical treatment significantly affected the joint radius of motion and the 3D work area. The Thompson and LRTI techniques produced a larger joint radius of motion than the other techniques (Weilby technique and total trapezial resection) and was similar to that of the intact joint. The Weilby and LRTI techniques produced a 3D work area similar to those of the intact joint and trapeziectomy and was also larger than that of the Thompson reconstruction.

CONCLUSIONS

Kinematic analysis of the thumb CMC joint is effective in differentiating surgical treatments used for end-stage of OA. Only the LRTI reconstruction produced a joint radius of motion and a 3D work area similar to the those of an intact thumb. Additional research is needed to define the optimal surgical techniques to treat the end-stage OA thumb CMC joint.

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.

Tendon interposition arthroplasty versus arthrodesis for the treatment of trapeziometacarpal arthritis: a retrospective comparative follow-up study

Long-term subjective and objective outcomes of 24 tendon interposition arthroplasties in 17 patients and 32 trapeziometacarpal (TMC) arthrodeses in 26 patients were compared retrospectively in a standardized manner. Tendon interposition arthroplasty led to complications less often (27%) than TMC arthrodesis (39%). Patients in the tendon interposition arthroplasty group reported significantly less pain, less temperature intolerance, and better thumb mobility and were more satisfied with pain symptoms than patients in the arthrodesis group. Patients undergoing tendon interposition arthroplasty had better thumb opposition, interphalangeal joint mobility, and radial and palmar TMC joint range of motion. No statistically significant differences were found in tip pinch, key pinch, and grip strength between the 2 groups. Proximal first metacarpal collapse occurred in the tendon interposition patients without affecting subjective or objective outcome. Seven of 25 patients with TMC arthrodesis had pseudarthrosis. Tendon interposition arthroplasty seems to be preferable to TMC joint arthrodesis for the treatment of TMC arthritis.

Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon

Fifty-eight patients (62 joints) with arthritis of the thumb carpometacarpal joint were treated with resection arthroplasty, ligament reconstruction, and tendon interposition with the entire flexor carpi radialis tendon. The mean age of the patients at the time of surgery was 58.4 years (range, 28-80 years), and the average followup was 42.5 months (range, 21-86 months). The entire flexor carpi radialis tendon was used for reconstruction and interposition. In 32 of the 62 joints, a partial trapezoidectomy was performed for scaphotrapezoidal arthritis. Finger-tip pinch improved by 88%, key pinch improved by 86%, and grip strength improved by 69%. Palmar and radial abduction also improved by 8% and 10%, respectively. Fifty-five (95%) patients reported excellent pain relief, whereas three patients reported only mild pain. No patients experienced an increase in pain. All thumbs were stable radiographically. This study indicated ligament reconstruction with tendon interposition, accompanied by partial trapezoidectomy when indicated, provides excellent pain relief and restoration of function. No morbidity was observed with use of the entire flexor carpi radialis tendon.

Histological study of resection arthroplasty with and without tendon ball interposition in dogs

We studied an experimental model of resection arthroplasty with or without tendon ball interposition in the wrist of dogs. Animals were divided into two groups. Animals in group A were treated by resection of the os carpi radiale with interposition of a ball made from the tendon of the extensor carpi radialis and the group B underwent bone resection alone. Animals were assessed 1, 6, 12 and 24 weeks after operation. In all of them the wrist joint was stable and had good mobility, allowing walking supported by the operated limb. In both groups biological material filled the cavity created by bone resection. A progressive repair process resulted in fibroplasia with areas of fibrocartilaginous metaplasia. The tendon ball showed complete ischaemic necrosis at the end of the first week, which delayed the healing process.