Long-term durability of tendon arthroplasty with excision of the trapezium in stage 1 osteoarthritis of the thumb CMC joint

Partial arthroscopic trapeziectomy and stabilisation by ligamentoplasty: Outcomes in patients younger than 60years

BACKGROUND

Thumb carpometacarpal joint (TCMJ) osteoarthritis is the fourth leading cause of referral to elective hand surgery. None of the available techniques has proved superior over the others. Some techniques carry unacceptable risks for younger patients, such as loss of strength and shortening of the thumb column after total trapeziectomy, or wear and loosening after total arthroplasty. Our objective was to assess outcomes after partial arthroscopic trapeziectomy (PAT) combined with suspensionplasty using the abductor pollicis longus (APL) tendon in patients younger than 60years of age.

HYPOTHESIS

PAT combined with suspensionplasty using the APL tendon in patients younger than 60years would restore strength in the medium-term without further surgery.

MATERIAL AND METHODS

We retrospectively included consecutive patients operated between 2007 and 2017, in a single centre, and aged less than 60years. All patients had isolated TCMJ osteoarthritis stage 1 to 3 according to Eaton and Glickel classification that remained symptomatic despite optimal conservative treatment. We collected pain intensity, range of motion, strength, the Nelson Hospital Score (NHS), and the Patient-Rated Wrist Evaluation (PRWE) score. Radiographs were reviewed.

RESULTS

We included 27 patients, of whom 6 had surgery on both thumbs, yielding 33 thumbs for the analysis. Mean follow-up was 64.7months (range: 10.6-136.5months). Pain intensity, grip strength, and key-pinch strength were significantly improved (p<0.001), with no difference between men and women. No differences were found for the Kapandji score (p=0.2) or TCMJ hyperextension (p=0.06). At last follow-up, the mean NHS was 83.2±19.4 and the mean PRWE was 15.4±17.9. Mean sick leave duration was 5.4weeks (range: 1-24weeks). Only 2 patients, both in manual jobs, were unable to return to work. The radiographs at last follow-up showed the development of moderate TCMJ narrowing in 14 patients and evidence of scapho-trapezio-trapezoid (STT) osteoarthritis in 10 patients. No patient experienced complex regional pain syndrome or injury to the sensory branch of the radial nerve. A single patient required further surgery for persistent pain.

DISCUSSION

Patients younger than 60years who are treated with this minimally invasive technique are likely to experience sustained improvements in both strength and pain intensity. Total trapeziectomy and pyrocarbon implant has also been evaluated in younger patients, who experienced pain relief and strength gains but had lower levels of satisfaction and developed complications inherent in the implants. The short time off work and low morbidity make our technique a procedure of choice in younger patients. To build on this study, a comparison of PAT and arthroplasty would be of interest.

LEVEL OF EVIDENCE

IV.

Total trapeziectomy

Total trapeziectomy has been extensively studied and has been used to treat thumb basal joint arthritis for decades. It remains a simple and reliable technique that every hand surgeon must learn and master, as a primary or revision procedure. Several techniques have been described, but none of them seems better than the others. Without the need for an implant and because of its long-lasting benefits, total trapeziectomy is currently the only surgical technique for thumb basal joint arthritis that can lay claim to being a potential life-long procedure.

Outcomes of Surgical Management for Thumb Basilar Arthritis in Patients 55 Years of Age and Younger

Background: Trapeziectomy with ligament reconstruction tendon interposition (LRTI) or suspensionplasty is an effective treatment in older patients with end-stage thumb basilar arthritis. However, the survivability of this procedure is unknown in younger patients who may impart more stress on their thumbs. Methods: A retrospective review was performed on all patients who underwent trapeziectomy and LRTI or suspensionplasty at 55 years of age or younger from 1992 to 2008. Objective clinical outcome measures included preoperative to postoperative changes in thumb range of motion, grip and pinch strength, a study-specific thumb function score, and the Buck-Gramcko subjective outcome score. Progressive metacarpal subsidence was evaluated on radiographs. Survivorship free from revision surgery was calculated with a Kaplan-Meier analysis. Results: A total of 57 wrists underwent trapeziectomy and LRTI (n = 18) or suspensionplasty (n = 39). The mean patient age at the time of surgery was 49.6 years (range: 38-55 years). Mean clinical and radiographic follow-up were 10.2 and 6.4 years, respectively. Overall, there were significant improvements in pain and grip strength despite progressive and metacarpal subsidence. Survivorship was 100% and 86% free from revision surgery at 10 and 15 years, respectively (n = 2 failures). Conclusions: Trapeziectomy and LRTI or suspensionplasty in patients less than or equal to 55 years of age can result in considerable improvements in pain and grip strength with a 10-year survivorship free from revision.

Optimal management of thumb basal joint arthritis: challenges and solutions

Up to 15% of the population older than 30 years suffers from symptomatic thumb carpometacarpal (CMC) osteoarthritis (OA), with the incidence increasing to ~33% in postmenopausal women. The thumb CMC joint has been reported as the most painful joint when compared to other hand joints affected by OA. It is therefore no surprise that this is a common chief complaint of patients and has a significant effect on work and life satisfaction. The purpose of this article was to review currently available literature to discuss nonoperative and operative techniques utilized to treat the various stages of thumb CMC arthritis. A variety of nonoperative and operative techniques have been described in the literature, each with its own benefits and pitfalls. This review concludes that while many treatment options exist, there remains no perfect treatment, but the goal of improving quality of life and patient satisfaction remains the same.

Percutaneous injection of autologous, culture-expanded mesenchymal stem cells into carpometacarpal hand joints: a case series with an untreated comparison group

In the present study, we describe six patients who received autologous mesenchymal stem cell (MSC) therapy for symptomatic carpometacarpal (CMC) joint and hand osteoarthritis (OA). Six patients who received injections of adult autologous culture expanded MSCs in their thumb CMC joints were followed for 1 year posttreatment, and matched with four procedure candidates who remained untreated. We observed positive outcomes in the treatment group for both symptoms and function related to the OA, compared with a reported worsening among the untreated controls. While these results should be interpreted with caution because of the small number of treated subjects and lack of placebo control and randomization, we find sufficient evidence for further investigation of MSC therapy as an alternative to more invasive surgery in patients with OA of the hand.

Review of thumb carpometacarpal arthritis classification, treatment and outcomes

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