Five things to know about...carpometacarpal osteoarthritis of the thumb

Contribution of Soft Tissue Passive Forces in Thumb Carpometacarpal Joint Distraction

Thumb carpometacarpal joint space changes when the surrounding soft tissues including the capsule, ligaments, and tendons are stretched or pulled away. When at rest, joint forces originate from passive contraction of muscles and the involvement of joint capsule and ligaments. Previous biomechanical models of hand and finger joints have mostly focused on the assessment of joint properties when muscles were active. This study aims to present an experimental-numerical biomechanical model of thumb carpometacarpal joint to explore the contribution of tendons, ligaments, and other soft tissues in the passive forces during distraction. Five fresh cadaveric specimens were tested using a distractor device to measure the applied forces upon gradual distraction of the intact joint. The subsequent step involved inserting a minuscule sensor into the joint capsule through a small incision, while preserving the integrity of tendons and ligaments, in order to accurately measure the fundamental intra-articular forces. A numerical model was also used to calculate the passive forces of tendons and ligaments. Before the separation of bones, the forces exerted by tendons and ligaments were relatively small compared to the capsule force, which accounted for approximately 92% of the total applied force. Contribution of tendons and ligaments, however, increased by further distraction. The passive force contribution by tendons at 2-mm distraction was determined less than 11%, whereas it reached up to 74% for the ligaments. The present study demonstrated that the ligament-capsule complex plays significant contribution in passive forces of thumb carpometacarpal joint during distraction.

Management of a Traumatic Collapse of the First Carpometacarpal Joint After Trapeziectomy With Suture Suspensionplasty: A Case Report

Arthritis of the first carpometacarpal (CMC) joint is a common pathology hand surgeons encounter. Treatment begins with conservative measures, but when they fail, surgery is a viable option for providing relief to patients. The most widely used surgical technique is CMC arthroplasty with ligament reconstruction and tendon interposition (LRTI). However, more novel techniques such as trapeziectomy with suspensionplasty are gaining popularity. When surgical measures fail, it is important to identify the mechanism of failure and proper treatment options. There are multiple options for revision surgery at the surgeon's disposal, with no consensus on a superior technique. This case illustrates a patient with painful subsidence secondary to a traumatic collapse of the first CMC joint eight months status post suspensionplasty with trapeziectomy. After conservative measures failed to provide relief, it was decided that a surgical revision was appropriate. The surgeon chose to move forward with suture button suspensionplasty, as it has multiple advantages over LRTI. In the short-term follow-up after revision, the patient experienced improvements in pain and range of motion, along with radiographic evidence of proper alignment of the first metacarpal without subsidence. Regarding the treatment of a case such as this, the authors believe this case should serve as a reference that may be used by future physicians when deciding which surgical technique to employ for the revision of a traumatically collapsed first CMC joint after trapeziectomy with CMC joint suspensionplasty.

Three-dimensional ultrasound to investigate synovitis in first carpometacarpal osteoarthritis: A feasibility study

BACKGROUND

Synovitis is one of the defining characteristics of osteoarthritis (OA) in the carpometacarpal (CMC1) joint of the thumb. Quantitative characterization of synovial volume is important for furthering our understanding of CMC1 OA disease progression, treatment response, and monitoring strategies. In previous studies, three-dimensional ultrasound (3-D US) has demonstrated the feasibility of being a point-of-care system for monitoring knee OA. However, 3-D US has not been tested on the smaller joints of the hand, which presents unique physiological and imaging challenges.

PURPOSE

To develop and validate a novel application of 3-D US to monitor soft-tissue characteristics of OA in a CMC1 OA patient population compared to the current gold standard, magnetic resonance imaging (MRI).

METHODS

A motorized submerged transducer moving assembly was designed for this device specifically for imaging the joints of the hands and wrist. The device used a linear 3-D scanning approach, where a 14L5 2-D transducer was translated over the region of interest. Two imaging phantoms were used to test the linear and volumetric measurement accuracy of the 3-D US device. To evaluate the accuracy of the reconstructed 3-D US geometry, a multilayer monofilament string-grid phantom (10 mm square grid) was scanned. To validate the volumetric measurement capabilities of the system, a simulated synovial tissue phantom with an embedded synovial effusion was fabricated and imaged. Ten CMC1 OA patients were imaged by our 3-D US and a 3.0 T MRI system to compare synovial volumes. The synovial volumes were manually segmented by two raters on the 2D slices of the 3D US reconstruction and MR images, to assess the accuracy and precision of the device for determining synovial tissue volumes. The Standard Error of Measurement and Minimal Detectable Change was used to assess the precision and sensitivity of the volume measurements. Paired sample t-tests were used to assess statistical significance. Additionally, rater reliability was assessed using Intra-Class Correlation (ICC) coefficients.

RESULTS

The largest percent difference observed between the known physical volume of synovial extrusion in the phantom and the volume measured by our 3D US was 1.1% (p-value = 0.03). The mean volume difference between the 3-D US and the gold standard MRI was 1.78% (p-value = 0.48). The 3-D US synovial tissue volume measurements had a Standard Error Measurement (SEm ) of 11.21 mm3 and a Minimal Detectible Change (MDC) of 31.06 mm3 , while the MRI synovial tissue volume measurements had an SEM of 16.82 mm3 and an MDC of 46.63 mm3 . Excellent inter- and intra-rater reliability (ICCs = 0.94-0.99) observed across all imaging modalities and raters.

CONCLUSION

Our results indicate the feasibility of applying 3-D US technology to provide accurate and precise CMC1 synovial tissue volume measurements, similar to MRI volume measurements. Lower MDC and SEm values for 3-D US volume measurements indicate that it is a precise measurement tool to assess synovial volume and that it is sensitive to variation between volume segmentations. The application of this imaging technique to monitor OA pathogenesis and treatment response over time at the patient's bedside should be thoroughly investigated in future studies.

Comparison between intra-articular injections of corticosteroids, hyaluronic acid, PRP and placebo for thumb base osteoarthritis: A frequentist network meta-analysis

Background and aims

Current evidence for the use of intra-articular injections for thumb base osteoarthritis (TBOA) is equivocal. This study aims to investigate the efficacy of intra-articular corticosteroids, hyaluronic acid and platelet-rich plasma.

Methods

A Frequentist network meta-analysis was conducted comparing outcomes at short (≤3 months) and medium-term (>3-12 months) time points.

Results

Data from 7 RCTs and 1 non-RCT (446 patients) were collected, consisting of corticosteroids (n = 7), hyaluronic acid (n = 7), platelet-rich plasma (n = 2) and placebo (n = 2). At the short-term time point, no intra-articular injection demonstrated superiority over placebo at reducing pain. At the medium-term time point, superiority of platelet-rich plasma at reducing pain over placebo and corticosteroids was seen following sensitivity analysis (RCTs only) (SMD -1.48 95 % CI -2.71; -0.25). No injection proved superior at improving function at short or medium-term time points.

Conclusions

Overall, despite the promising result for platelet-rich plasma, the evidence quality was limited to two studies only justifying the need for further and larger methodologically robust trials investigating corticosteroids, hyaluronic acid and platelet-rich plasma vs each other and placebo.

Periosteal Dry Needling for Carpometacarpal Osteoarthritis: A Prospective Case Series

BACKGROUND

Carpometacarpal (CMC) osteoarthritis (OA) of the thumb is a painful condition that affects over 15% of individuals above the age of 30 and up to 30% of post-menopausal women. Dry needling (DN) has been found to reduce pain and disability in a variety of neuromusculoskeletal conditions; however, DN in the management of CMC OA has not been well studied.

METHODS

Consecutive patients with clinical and radiographic evidence of CMC OA were treated with DN. The primary outcome measure was pain using the Numerical Pain Rating Scale (NPRS) at 12 weeks. Secondary outcome measures were the Upper Extremity Functional Index (UEFI-20) and the Global Rating of Change (GROC) scale. Outcome measures were collected at baseline, 4 weeks, 8 weeks, and 12 weeks.

RESULTS

Nine patients were treated for six sessions of periosteal DN over 3 weeks. Compared to baseline, statistically significant and clinically meaningful improvements were observed in thumb pain (NPRS mean difference: 2.6; p = 0.029) and function (UEFI-20 mean difference: 21.3; p = 0.012) at 12 weeks.

CONCLUSION

Statistically significant and clinically meaningful within-group improvements in thumb pain and function were observed at 12 weeks following six sessions of periosteal DN treatment. DN may be a useful intervention in the management of patients with CMC OA of the thumb.

An Integrated Review of Carpal Tunnel Syndrome: New Insights to an Old Problem

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy characterized by pain, numbness, and impaired function of the hand due to compression of the median nerve at the level of the wrist. Although CTS can develop from repetitive strain, injury, or medical conditions, there are also congenital and genetic risk factors that can predispose individuals to the condition. With respect to anatomical factors, some individuals are born with a smaller carpal tunnel, which increases their susceptibility to median nerve compression. Variations in specific genes, such as those encoding proteins involved in extracellular matrix remodeling, inflammation, and nerve function, have also been linked to an increased risk for CTS. CTS is associated with a high cost of health care maintenance and loss of work productivity. Therefore, it is vital that primary care physicians fully understand the anatomy, epidemiology, pathophysiology, etiology, and risk factors of CTS, so they can be proactive in prevention, diagnosing, and guiding proper treatment. This integrated review also provides insights into how biological, genetic, environmental, and occupational factors interact with structural elements to determine who is most likely to acquire and suffer from CTS. Keeping health practitioners abreast of all the factors that could impact CTS should go a long way in decreasing the health care and socioeconomic burden of CTS.

Comparative study on the effectiveness of bone grafting for arthrodesis of the thumb carpometacarpal arthritis

The aim of this retrospective study was to assess the effectiveness of autogenous bone grafting for arthrodesis of the thumb carpometacarpal joint by comparing the bone union rates with and without bone grafting. We included 36 patients who underwent arthrodesis of the thumb carpometacarpal joint for arthritis (20 patients with bone grafts and 16 without bone grafts). Implants used for internal fixation were K-wire, tension band wiring, headless compression screw and locking plate. The presence of bone union and the time from surgery to bone union were evaluated. The bone union rate was 20/20 (100%) in the bone grafting group and 12/16 (75%) in the non-bone grafting group (p = 0.03). There were no significant differences between the two groups in the time from surgery to bone union and patient characteristics. In conclusion, autogenous bone grafting may contribute to the bone union in the arthrodesis of thumb carpometacarpal arthritis.Level of evidence: III.

Thumb carpometacarpal palmar and radial abduction in adults with thumb carpometacarpal joint pain: Inter-rater reliability and precision of the inter-metacarpal distance method

STUDY DESIGN

Psychometric study of inter-rater reliability.

INTRODUCTION

Functional use of the thumb can be limited in individuals with thumb carpometacarpal (CMC) osteoarthritis(OA), especially in the presence of a thumb adduction contracture. Goniometry is a common method of assessing palmar and radial abduction of the thumb base and can be used as a method of determining effectiveness of an intervention for adduction contracture. However, goniometry for the assessment of these motions has been shown to have low to moderate reliability. The intermetacarpal distance (IMD) measurement method has been shown to be the most reliable for measuring CMC palmar abduction in individuals with healthy hands but has not been studied in persons with thumb CMC OA.

PURPOSES

The purpose of this study was to determine the inter-rater reliability and precision of the inter-metacarpal distance method for measuring palmar and radial abduction in persons with symptoms of thumb CMC OA.

METHODS

Two trained hand therapists utilized the IMD method to measure palmar and radial abduction in the affected hands of 22 subjects (28 thumbs) with a physician-confirmed diagnosis or positive provocative test consistent with a diagnosis of thumb CMC OA. The intraclass correlation coefficient (ICC_2,2) was used to assess inter-rater reliability of the IMD method. To determine the precision of the measurements, the standard error of measurement (SEM), minimal detectable change (MDC), and MDC percent were calculated. Findings were supplemented with descriptive data on the IMD values as well as descriptive data on the sample.

RESULTS

Intraclass correlation coefficients for both radial and palmar abduction were found to be >.75, indicating excellent reliability. The precision of the IMD measurements were acceptable-to-excellent as evidenced by MDC% values of <30% and <10% for radial and palmar abduction respectively.

CONCLUSIONS

We present a new method for measuring thumb radial abduction. The inter-metacarpal distance method has excellent inter-rater reliability and acceptable-to-excellent precision when measuring palmar and radial abduction in individuals with or suspected to have thumb CMC OA. Currently, it is the most reliable tool for measuring thumb abduction.

That's my STYLEoideum - Symptomatic os styloideum in an adolescent male

We present a 15-year-old male patient with persistent localized pain on the dorsal side of the left wrist between the base of the 2nd and 3rd metacarpal bones and over the third carpometacarpal joint. It was diagnosed as an accessory metacarpal bone -Os styloideum. This entity may be detected on plain radiographs and in ultrasound examination and is often asymptomatic. Symptomatic os styloideum occurs more frequently in the dominant hand and may be treated conservatively with corticosteroid infiltration. A palpable prominence on the dorsal side of the wrist and focal pain evoked anxiety of the adolescent patient who searched medical consultation. In the clinical examination, a bony protrusion was confirmed and different possible diagnoses have been considered. After treatment with a corticosteroid infiltration of the third carpometacarpal joint under fluoroscopy the pain resolved completely. We would like to draw attention of clinicians and radiologists to this rare anatomical variant that normally is asymptomatic, and therefore not immediately recognized. Acquaintance with this entity and its early detection may lead to conservative treatment instead of surgical excision. A comprehensive literature search, review and discussion about os styloideum are provided in the article.