Trapeziometacarpal Arthrosis

Genetics may affect the risk of undergoing surgery for rhizarthrosis

Osteoarthritis is a prevalent and severe disease. Involvement of the trapeziometacarpal joint is common and can lead to both pain and disability. Genetics are known to affect the risk of osteoarthritis, but it remains unclear how genetics affect disease trajectories. In this study, we investigated whether the genetic associations of trapeziometacarpal osteoarthritis (rhizarthrosis) vary with the need for surgical treatment. The study was conducted as a case-control genome-wide association study using individuals from the Copenhagen Hospital Biobank pain and degenerative musculoskeletal disease study and the Danish Blood Donor Study (N = 208,342). We identified patients diagnosed with rhizarthrosis and grouped them by treatment status, resulting in two case groups: surgical (N = 1083) and nonsurgical (N = 1888). The case groups were tested against osteoarthritis-free controls in two genome-wide association studies. We then compared variants suggestive of association (p < 10-6) in either of these analyses directly between the treatment groups (surgical vs. nonsurgical rhizarthrosis). We identified 10 variants suggestive of association with either surgical (seven variants) or nonsurgical (three variants) rhizarthrosis. None of the variants reached nominal significance in the opposite treatment group (p ≥ 0.14), and all 10 variants were significantly different between the treatment groups at a false discovery rate of 5%. These results suggest possible differences in the genetic associations of rhizarthrosis depending on surgical treatment. Clinical significance: Uncovering genetic differences between clinically distinct patient groups can reveal biological determinants of disease trajectories.

Predicting Contralateral Surgery for Trapeziometacarpal Arthrosis Within 5 Years

PURPOSE

Symptomatic trapeziometacarpal (TMC) joint arthritis is a common cause of hand pain. It is unknown how many patients ultimately elect to have bilateral surgery for TMC arthritis. In this study, we assessed the frequency and predictive factors for contralateral TMC surgery in patients who underwent prior TMC surgery.

METHODS

We identified 712 patients who underwent primary surgery for TMC arthritis with a follow-up period of 5 years. We collected demographic, surgical, and follow-up data. Prediction models for contralateral surgery using a training and testing data set were created with multivariable logistic regression and random forest classifier algorithms.

RESULTS

At the time of initial surgery, 230 patients had bilateral thumb pain (32%), but only 153 patients ultimately had an operation for TMC arthritis on the contralateral side within 5 years (21% of 712 total patients and 67% of 230 patients with bilateral pain). Common predictive factors between both models for contralateral surgery were younger age (odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.93-0.98), bilateral thumb pain (OR = 3.76; 95% CI, 2.52-5.65), and anxiety disorders (OR = 1.84; 95% CI, 1.11-3.03).

CONCLUSIONS

In our study, we found that the rate of contralateral surgery was 21% in patients who underwent prior TMC surgery. Predictive factors for future contralateral surgery included younger age, bilateral thumb pain, and anxiety disorder at the time of initial surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Clinical Outcomes of Trapeziometacarpal Arthrodesis with a Mean 3-Year Follow-up

Background  This paper's purpose was to analyze clinical results obtained with trapeziometacarpal arthrodesis and complications comparing different osteosynthesis systems. Methods  Thirty-seven trapeziometacarpal arthrodesis were performed in our center in a 7-year period, with a mean age of 52 years and 34 months of follow-up. The implants were distributed homogenously into three groups, using bone grafts in 12.5% of them. Results  A 75% achieved complete consolidation with a mean postsurgical Visual Analog Scale (VAS) of 2.4, Kapandji Opposition Score (KOS) of 8.1, lateral pinch strength of 12.1 kg, tripod pinch strength of 3.6 kg, and tip-to-tip strength of 1.5 kg. Consolidation was not achieved in nine patients, of which five were asymptomatic, three reoperated on trapeziectomy and tenosuspension, and one rearthrodesis. No statistical association was found between the implant used and pseudoarthrosis ( p  = 0.17), VAS ( p  = 0.06), or KOS ( p  = 0.45). Conclusions  Trapeziometacarpal arthrodesis reduces pain for well-chosen patients. Nonunion has low clinical significance in most cases and does not seem to depend on the use of allograft or the type of implant but on an appropriate surgical technique.

Accuracy of Wireless Hand-Held Guided Ultrasound Injections in the Trapeziometacarpal Joint: A Cadaveric Study

Background Symptomatic trapeziometacarpal osteoarthrosis can be treated with an ultrasound-guided injection in the early stages. This cadaveric study aimed to assess the hypothesis suggesting enhanced accuracy and reliability of hand-held ultrasound (HHUS) injections compared to blind injections into the trapeziometacarpal joint (TMC). Materials and method Our series included 20 fresh cadaveric hands, with a total of 20 TMC randomly assigned to two groups. In group A, 10 TMC received a blinded injection, and in group B, 10 TMC received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomical dissection was performed to assess the intra-articular location of the dye. The injection was considered accurate if the intra-articular synovial fluid was stained after opening the articular capsule on the dorsal approach. If there was no injection, it was inaccurate. A statistical analysis was performed, and p <.05 indicated a significant difference. Results Two thumbs were excluded during the study due to an existing trapeziectomy. In group A, 10 blind injections of TMC were performed, with 70% (7/10) of injections graded as accurate. In group B, eight ultrasound-guided injections were performed, with 75% (6/8) achieving accuracy. A Fisher's exact test was performed, and the results indicated no statistically significant difference in injection accuracy between the two groups (P = 1, odds ratio = 0.788). Conclusion Hand-held ultrasound guided TMC injections were not more accurate than blind injections performed by an experienced hand surgeon. Nonetheless, additional studies with a larger sample and comparative studies with conventional cart-based machines are necessary to evaluate the potential of this newly accessible device.

Biopsychosocial factors associated with pain severity and hand disability in trapeziometacarpal osteoarthritis and non-surgical management

BACKGROUND

Trapeziometacarpal osteoarthritis (TMO) is one of the most prevalent and painful forms of hand osteoarthritis.

PURPOSE

This study aimed at (1) describing the TMO pain experience, (2) identifying biopsychosocial factors associated with pain intensity and disability, and 3) documenting the use of non-surgical management modalities.

STUDY DESIGN

Cross-sectional.

METHODS

Participants who presented for care for TMO were recruited from 15 healthcare institutions. They completed a questionnaire addressing sociodemographic, pain, disability, psychological well-being, quality of life (QoL), productivity, and treatment modalities employed. Multivariable regression analyses identified biopsychosocial factors associated with pain intensity and magnitude of disability.

RESULTS

Among our 228 participants aged 62.6 years, 78.1% were women. More than 80% of the participants reported average pain of moderate to severe intensity in the last 7 days. Nearly 30 % of them scored clinically significant levels of anxiodepressive symptoms. The participants' norm-based physical QoL score on the SF-12v2 was 41/100. Among the 79 employed respondents, 13 reported having missed complete or part of workdays in the previous month and 18 reported being at risk of losing their job due to TMO. Factors independently associated with more intense pain included higher pain frequency and greater disability, accounting for 59.0% of the variance. The mean DASH score was 46.1 of 100, and the factors associated with greater magnitude of disability were higher pain intensity, greater levels of depression, female sex, and lower level of education, explaining 60.1% of the variance. Acetaminophen, oral non-steroid anti-inflammatory drugs, cortisone injections, orthoses, hand massage/exercises, and heat/cold application were the most frequently employed modalities. Most participants never used assistive devices, ergonomic techniques, and psychosocial services.

CONCLUSIONS

Patients with TMO can experience severe pain, disability, disturbed emotional well-being, limited QoL and reduced productivity. As disability is associated with TMO pain, and depressive symptoms with disability, reducing such modifiable factors should be one of the clinicians' priorities.

Effects of Magnetic Resonance Imaging With Axial Traction of the Thumb Carpometacarpal Joint on Articular Cartilage Visibility: A Feasibility Study

Objectives

The objective of this study was to verify the usefulness of magnetic resonance imaging (MRI) with axial traction of the thumb for observing articular cartilage.

Materials and methods

Eleven healthy adult volunteers (39.7 ± 7.4 years) without thumb carpometacarpal joint arthritis or trauma were included in this study. A 3-tesla (3T) MRI (Magnetom Skyra, Siemens Healthineers AG, Munich, Germany) of the right thumb with axial traction applied by a finger trap with three traction weights (0, 2, and 5 kg) was performed. A 3D T2* multiecho data imaging combination (MEDIC) was selected to visualize the articular cartilage. After multiplanar reconstruction, sagittal and coronal images of the thumb carpometacarpal joint were used to evaluate the articular cartilage visibility and joint space widths at five locations. Articular cartilage visibility was evaluated using our original classification method that used the percentage of the cartilage detectable area. The Friedman test was used to compare the differences between each traction weight and location.

Results

Articular cartilage visibility significantly improved with axial traction. The average joint space widths with the 5-kg application were 1.9 ± 0.8, 3.9 ± 0.6, 2.0 ± 0.9, 3.9 ± 1.1, and 2.5 ± 1.4 mm at the center, volar edge, dorsal edge, radial edge, and ulnar edge, respectively. The joint space widths significantly increased proportionally with the traction weight at all locations. The joint space widths at the volar and radial edges were significantly greater than those at other locations.

Conclusion

Applying axial traction to the thumb increased the joint space widths and improved the visibility of the articular cartilage in the carpometacarpal joint on MRI.

Joint Distraction for Thumb Carpometacarpal Osteoarthritis: 2-Year Follow-up Results of 20 Patients

Background  Joint distraction is a fairly new treatment for patients with symptomatic thumb carpometacarpal osteoarthritis (CMC1 OA). A previous pilot study of five patients showed that CMC1 joint distraction is technically feasible. The current study presents the results of CMC1 joint distraction in 20 patients with a 2-year follow-up period. Purposes  The primary study aim was to assess if patients with CMC1 OA have better physical function and less pain 2 years after CMC1 joint distraction. Second, we assessed the number of patients who achieved a minimal clinically important difference (MCID) in patient-reported outcome measures at each follow-up time point. Furthermore, this study sought differences on magnetic resonance imaging (MRI) of the CMC1 joint before and after distraction. Adverse events were noted and reported. Methods  Twenty patients (median age of 54 years) with symptomatic CMC1 OA and an established indication for a trapeziectomy were enrolled. An external distractor device was placed over the CMC1 joint and left in situ for 8 weeks. Disabilities of the Arm, Shoulder, and Hand (DASH) score, Michigan Hand Outcome Questionnaire (MHQ), visual analogue scale (VAS), and grip strength were recorded preoperatively and at 3, 6, 12, and 24 months postoperatively. Results  Two years after joint distraction, physical function and pain scores had improved significantly compared with baseline: DASH from 48 to 17, MHQ from 56 to 83, and VAS for pain from 50 to 18 mm. Fourteen of 19 patients (74%) reached an MCID in DASH and MHQ scores. One patient was not satisfied with treatment outcome and chose to proceed with a trapeziectomy 14 months after initial distraction therapy. Conclusions  This study demonstrates that CMC1 joint distraction can postpone more invasive surgical interventions (e.g., trapeziectomy) for at least 2 years. Larger comparative studies are needed to assess the value of CMC1 joint distraction in the treatment of CMC1 OA. Level of Evidence  This is a Level IV, prospective case series study.

Clinical evaluation of thumb base osteoarthritis: A scoping review

Introduction

Thumb base osteoarthritis (OA) is a prevalent hand OA phenotype, associated with specific risk factors, treatment strategies, and requiring a distinct subset of evaluative approaches. This paper aimed at surveying our clinical evaluative methods and identifying gaps in our ability to capture the thumb's unique attributes and how they could impact our treatment recommendations.

Methods

A scoping review was conducted in accordance with the Joanna Briggs Institute methodology to gather relevant published and non-published articles regarding clinical tests currently available to assess the physical presentation of thumb base OA with special consideration of its specific multifactorial parameters namely architecture, ligaments, biomechanics, neuromuscular control, and proprioception. A full search strategy of MEDLINE, CINAHL, EMBASE, Scopus, Google Scholar, and Clinical Trials.gov from their inception through May 2020 was performed.

Results

Of 1936 citation identified, 54 met the inclusion criteria. Fifty-two clinical physical tests for the evaluation of thumb base OA were extracted, most of which well suited to address research questions regarding efficacy of clinical intervention, however providing limited information regarding the underlying impairments of ligaments, biomechanics, neuromuscular or proprioceptive components.

Conclusions

The tests and measures specific to the basal thumb OA phenotype, and capable of isolating its multifactorial contributors are scarce. Our limited physical assessment repertoire impedes our ability to describe and answer explicative research questions. Without these we cannot evaluate the effect of conservative management and provide specific treatment recommendations. Further research is needed to develop and validate distinct clinical tools for this debilitating pathology.

Can we decrease the duration of basal thumb joint distraction for early osteoarthritis from 8 to 6 weeks? Study protocol for a non-inferiority randomized controlled trial

BACKGROUND

To our knowledge, to date, 52 patients with thumb carpometacarpal osteoarthritis (CMC1 OA) were treated with joint distraction. So far, most patients experienced improved physical function and less pain. After 2 years, only 1 patient proceeded to trapeziectomy. This study assesses if we can safely lower the distraction duration from 8 to 6 weeks for CMC1 joint distraction, maintaining the improvement in physical function and pain.

METHODS

This is a monocenter randomized controlled non-inferiority trial that includes patients younger than 65 years of age with ongoing symptoms of CMC1 OA and an established indication for surgery. All patients will be treated with CMC1 joint distraction. The primary outcome is to assess whether 6 weeks of joint distraction is not inferior to 8 weeks in terms of physical function at 1 year after surgery. Secondary outcomes will identify differences between groups at 1 year in pain intensity, patient satisfaction, hand health status, adverse event rates, treatment failure, differences in thumb strength and range of motion, and radiographic changes.

DISCUSSION

If safe, the duration of basal thumb joint distraction can be reduced to 6 weeks, reducing patient burden. Because this is a relatively new treatment, this trial will provide greater knowledge of potential adverse events. This knowledge allows for more informed decision making for patients considering CMC1 distraction treatment. Future studies can directly compare joint distraction to other treatments of CMC1 joint arthritis like splinting and trapeziectomy.

TRIAL REGISTRATION

Central Committee on Research Involving Human Subjects (CCMO), NL68225.100.18; registered on 9 August 2019. Medical Research Ethics Committees United (MEC-U), R19.003; registered on 9 August 2019. Netherlands Trial Register, NL8016 ; registered on 15 September 2019.

The effect of remaining trapezial space on outcomes after trapeziectomy with ligament reconstruction tendon interposition for trapeziometacarpal osteoarthritis

Ligament reconstruction and tendon interposition (LRTI) procedures for trapeziometacarpal osteoarthritis aim to prevent proximal metacarpal migration to improve thumb function. We sought to evaluate the effect of the remaining trapezial space on outcomes after trapeziectomy with LRTI. Forty-seven patients were included in this study. Patients were evaluated clinically and radiologically. They were divided into two groups according to the remaining trapezial space at last follow-up. Postoperative to preoperative trapezial space ratio was >50% in group 1 and <50% in group 2. Mean follow-up was 30.8 months. Mean age, sex, dominant side, preoperative stage, and follow-up were similar in both groups. The mean QuickDASH scores were significantly better in group 1 than group 2. Mean tip and key pinch were significantly stronger in group 1, than group 2. Trapeziectomy with LRTI is the most used surgical technique and it produces satisfactory results. Improved clinical outcomes can be achieved when more than 50% of the preoperative trapezial space remains.

Variation in Offer of Operative Treatment to Patients With Trapeziometacarpal Osteoarthritis

PURPOSE

Operative treatment of trapeziometacarpal osteoarthritis (TMC OA) is discretionary. There is substantial surgeon-to-surgeon variation in offers of surgery. This study assessed factors associated with variation in recommendation of operative treatment to patients with TMC OA. Secondarily, we studied factors associated with preferred operative technique and surgeon demographic factors variability in recommendation for operative treatment.

METHODS

We invited all hand surgeon members of the Science of Variation Group to review 16 scenarios of patients with TMC OA and asked the surgeons whether they would recommend surgical treatment for each patient and, if yes, which surgical technique they would offer (trapeziectomy, trapeziectomy with ligament reconstruction and/or tendon interposition, joint replacement, or arthrodesis). Scenarios varied in pain intensity, relief after injection, radiographic severity, and psychosocial symptoms.

RESULTS

Patient characteristics associated with greater likelihood to recommend surgical treatment were substantial pain, a previous injection that did not relieve pain, radiograph with severe TMC OA, and few symptoms of depression. Practice region was the only factor associated with preferred surgical technique and trapeziectomy with ligament reconstruction and/or tendon interposition the most commonly recommended treatment. There was low agreement among surgeons regarding treatment recommendations.

CONCLUSIONS

The notable variation in offers of operative treatment for TMC OA is largely associated with variable attention to subjective factors. Future studies might address the relative influence of surgeon incentives and beliefs, objective pathophysiology, and subjective patient factors on variation in surgeon recommendations.

CLINICAL RELEVANCE

Surgeons' awareness of the potential influence of subjective factors on their recommendations might contribute to efforts to ensure that patient choices reflect what matters most to them and are not based on misconceptions.

Suture Suspensionplasty Using Abductor Pollicis Longus and Flexor Carpi Radialis for Advanced Thumb Carpometacarpal Joint Arthritis

PURPOSE

Current operative treatment for advanced thumb carpometacarpal (CMC) joint arthritis mainly constitutes complete trapeziectomy with or without additional stabilizing procedures. However, it is unclear whether the additional procedures influence overall clinical outcomes. Therefore, the purpose of this study was to evaluate the effectiveness of our posttrapeziectomy suture suspensionplasty technique, performed using the abductor pollicis longus and flexor carpi radialis tendons, in patients with advanced thumb CMC arthritis.

MATERIALS AND METHODS

We evaluated 36 thumbs of 35 patients with advanced thumb CMC arthritis treated with combined operative excision of trapezium followed by a suture suspensionplasty using flexor carpi radialis and abductor pollicis longus tendons. We used a minimal volar approach to create a sling construct with a nonabsorbable suture material, which could support the thumb metacarpal base without pin fixation or tendon transfer. For radiographic evaluation, we used the ratio of the radial metacarpal subluxation to metacarpal articular width, estimated from the bilateral stress-view radiographic images of the thumb, and calculated the trapezial space ratio by dividing the trapezial space height by the proximal phalangeal length. The clinical outcomes were evaluated using the visual analog scale and disabilities of the arm, shoulder, and hand scores, along with evaluation of the improvement in both postoperative range of motion and strength recovery.

RESULTS

The mean duration of follow-up was 26 months (range, 18-60 months). The average visual analog scale and disabilities of the arm, shoulder, and hand scores decreased from 5.9 to 0.4 and from 51.6 to 27.0, respectively. The range of motion during palmar abduction and opposition of the metacarpophalangeal joint improved with an increase in mean value from 49.1 degrees to 54.1 degrees, and from 7.8 to 9.3 Kapandji score, respectively. The grip and key pinch strengths showed no significant changes from mean preoperative values of 13.3 kg and 3.8 kg to 13.2 kg and 3.2 kg, respectively, as measured at the 18-month follow-up.

CONCLUSIONS

Our suture suspensionplasty technique has several advantages including minimal invasive approach, short operative time, cost-effectiveness, and early mobilization. We suggest that it can be used as an effective, alternative stabilization method after a complete trapeziectomy.