Development of an implantable trapezium carpal bone replacement for measuring in vivo loads at the base of the thumb

Understanding the loads that occur across musculoskeletal joints is critical to advancing our understanding of joint function and pathology, implant design and testing, as well as model verification. Substantial work in these areas has occurred in the hip and knee but has not yet been undertaken in smaller joints, such as those in the wrist. The thumb carpometacarpal (CMC) joint is a uniquely human articulation that is also a common site of osteoarthritis with unknown etiology. We present two potential designs for an instrumented trapezium implant and compare approaches to load calibration. Two instrumented trapezia designs were prototyped using strain gauge technology: Tube and Diaphragm. The Tube design is a well-established structure for sensing loads while the Diaphragm is novel. Each design was affixed to a 6-DOF load cell that was used as the reference. Loads were applied manually, and two calibration methods, supervised neural network (DEEP) and matrix algebra (MAT), were implemented. Bland-Altman 95% confidence interval for the limits of agreement (95% CI LOA) was used to assess accuracy. Overall, the DEEP calibration decreased 95% CI LOA compared with the MAT approach for both designs. The Diaphragm design outperformed the Tube design in measuring the primary load vector (joint compression). Importantly, the Diaphragm design permits the hermetic encapsulation of all electronics, which is not possible with the Tube design, given the small size of the trapezium. Substantial work remains before this device can be approved for implantation, but this work lays the foundation for further device development that will be required.

Early Detection of First Carpometacarpal Joint Osteoarthritis Using Magnetic Resonance Imaging Assessment in Women With High Hypermobility Scores

OBJECTIVE

The aim of this study was to explore association between hypermobility and osteoarthritis (OA) at the first carpometacarpal (CMC) joint, using magnetic resonance imaging (MRI) to identify early change in women at high risk of developing OA but without yet established diagnoses.

METHODS

For this observational study, 33 women (aged 30-50 years) with self-reported history of maternal hand OA but without personal diagnoses of OA were recruited. Participants completed a 5-point hypermobility questionnaire. The 20 participants with 2 or more positive responses were categorized with "high hypermobility scores." The remaining 13 were categorized with "low hypermobility scores." Data collection included functional index, hand pain measure, parity, smoking status, and body mass index. Each participant underwent dominant hand radiographic and MRI examination. Imaging studies were interpreted by assessors blinded to hypermobility score categorization.

RESULTS

No significant differences in age, body mass index, parity, functional index, or pain scores were observed between higher and lower hypermobility score groups. Similarly, there were no significant differences between groups for radiographic changes. However, significantly higher proportions of women with higher hypermobility scores were observed on MRI to have abnormalities of trapezium cartilage (75% vs. 38%), metacarpal cartilage (80% vs. 38%), and trapezium bone (70% vs. 31%); p < 0.05 for all.

CONCLUSIONS

First CMC joint structural abnormalities were more frequently observed in women with higher hypermobility scores. Identification of early preradiographic changes in this group supports the concept that early-life joint laxity may contribute to future OA predisposition. Magnetic resonance imaging may be a preferred imaging test for detection of early cartilage changes in people at high risk of CMC joint OA.

Trapeziectomy with ligament reconstruction and tendon interposition arthroplasty in a male cohort : a retrospective study

Osteoarthritis of the carpometacarpal joint of the thumb is a common disease, mostly affecting middle aged women. This article presents the results of a trapeziectomy with a ligament recontruction/tendon interposition procedure. We evaluated 60 male patients with 76 operated thumbs. The mean follow- up was 62 months (ranging from 13 to 133 months, with SD of 33 months). The outcome was measured with the disabilities of the arm, shoulder and hand score, a Nelson Hospital score, a Visual analogue scale score and range of motion. The preoperative height of the trapezium was measured and compared with the height of the trapezial space postoperativaly. The disabilities of the arm, shoulder and hand score improved from 25.6 to 16.1. The Visual analogue scale score for pain, satisfaction, dexterity and funcion were correlated with each other. On x-ray, there was an average loss of 67% of trapezial height compared preoperativaly with postoperativaly, but no correlation was found with clinical outcome parameters.

Basal Joint Arthritis A Review of Pathology, History, and Treatment

The basal joint is a collection of articulations at the base of thumb that serve an important function in the overall dexterity of the hand. The unique anatomy of the basal joint provided many evolutionary advantages to the human hand, but also made this joint susceptible to arthrosis and degenerative changes. Surgical treatment of basal joint arthritis has continued to evolve since it was first described in 1949, including excisional arthroplasty, tendon interposition, ligament reconstruction, implant arthroplasty, and arthroscopy. A review of the pathoanatomy, history, and surgical treatments are assessed including a critical review of the literature.

[Hand osteoarthritis]

Hand osteoarthritis (OA) is a common chronic disorder causing pain and limitation of mobility of affected joints. The prevalence of hand OA increases with age and more often affects females. Clinical signs obviously do not correlate with radiographic findings - symptomatic hand OA affects approximately 26 % of adult subjects, but radiographic changes can be found in up to two thirds of females and half of males older than 55 years.Disease course differ among individual patients. Hand OA is a heterogeneous disease. Nodal hand OA is the most common subtype affecting interphalangeal joints, thumb base OA affects first carpometacarpal joint. Erosive OA represents a specific subtype of hand OA, which is associated with joint inflammation, more pain, functional limitation and erosive findings on radiographs.Treatment of OA is limited. Analgesics and nonsteroidal anti-inflammatory drugs are the only agents reducing symptoms. New insights into the pathogenesis of disease should contribute to the development of novel effective treatment of hand OA.

Failure of artelon interposition arthroplasty after partial trapeziectomy: a case report with histologic and immunohistochemical analysis

Artelon is a degradable biomaterial used for the treatment of osteoarthritis in the carpometacarpal joint of the thumb. The device reportedly works through 2 modes of action-stabilization of the carpometacarpal joint by augmentation of the joint capsule and by formation of a new articular surface at the trapeziometacarpal interface. We present a patient with late failure of arthroscopic hemitrapeziectomy and Artelon interposition that required surgical excision of the Artelon implant and trapeziectomy 4 years postoperatively. Gross and histologic evaluation of the explanted Artelon implant and remaining trapezium revealed lack of articular resurfacing by hyaline ingrowth.

Prevalence of doctor-diagnosed thumb carpometacarpal joint osteoarthritis: an analysis of Swedish health care

OBJECTIVE

While the prevalence of radiographic thumb carpometacarpal (CMC1) osteoarthritis (OA) is well-described, little is known about clinically symptomatic disease presenting to physicians for care. We sought to determine the prevalence of doctor-diagnosed CMC1 OA.

METHODS

Using health care data from Skåne in southern Sweden (population 1.24 million), we identified all adults ages >20 years who consulted a physician at least once and received a diagnosis for CMC1 OA (International Classification of Diseases, Tenth Revision, code M18). Data from the 15-year period 1998–2012 were analyzed. Using cross-referencing with the Swedish population register to exclude subjects who were deceased or had relocated, we obtained point estimates of the proportion of the population consulting for CMC1 OA.

RESULTS

The prevalence of doctor-diagnosed CMC1 OA in adults was estimated at 1.4% (2.2% in women and 0.62% in men). The mean±SD age in the prevalent CMC1 cohort (n=11,111) was 67.7±11.4 years; 78.5% of diagnoses were in women. Prevalence peaked in women ages 70–74 years with an estimate of 5.3% and in men ages 80–84 years with an estimate of 1.7%. Age at initial diagnosis also differed, with women presenting between ages 60–69 years and men presenting between ages 70–79 years.

CONCLUSION

The clinically important prevalence of CMC1 OA is 3 to 4 times higher in women than men. By the end of2012, more than 1 in 20 elderly women had consulted a physician for CMC1 OA over the last 15 years. The high prevalence of this subset of hand OA is a concern in an aging population.

The prevalence of erosive osteoarthritis in carpometacarpal joints and its clinical burden in symptomatic community-dwelling adults

OBJECTIVE

To estimate the prevalence of erosive disease in first carpometacarpal joints (CMCJs) and investigate its clinical impact compared with radiographic thumb base (TB) osteoarthritis (OA).

PATIENT AND METHODS

Standardized assessments with hand radiographs were performed in participants of two population-based cohort studies in North Staffordshire with hand symptoms lasting ≥1 day in the past month. Erosive disease was defined as the presence of eroded or remodeled phase in ≥1 interphalangeal joint (IPJ) or first CMCJ following the Verbruggen-Veys classification. Hand pain and function were assessed with Australian/Canadian Hand Osteoarthritis Index (AUSCAN). Prevalence was estimated by dividing the number of persons with erosive lesions by population size. Linear and logistic regression analyses were used to contrast clinical determinants between persons with erosions and with radiographic TB OA. Results were presented as mean differences and odds ratios (ORs) with 95% confidence intervals (95% CI), adjusted for age, sex and radiographic severity.

RESULTS

1,076 participants were studied (60% women, mean age 64.7 years (SD 8.3); 24 persons had erosive disease in the TB. The prevalence of erosive disease in first CMCJs was 2.2% (95% CI 1.4, 3.3). Only 0.5% (95% CI 0.2, 1.2) had erosive disease affecting IPJs and first CMCJs combined. More persons with erosive disease of first CMCJs reported pain in their TB than persons with radiographic TB OA, AUSCAN pain and function scores were similar.

CONCLUSION

Erosive disease of first CMCJs was present in 2.2% of subjects with hand pain and was often not accompanied by erosions in IPJs. Erosive disease was associated with TB pain, but not with the level of pain, when compared with radiographic TB OA.

Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial

QUESTION

In people with thumb carpometacarpal osteoarthritis, does radial nerve mobilisation to the affected hand reduce pressure pain sensitivity in the contralateral hand?

DESIGN

Secondary analysis of data from a randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Sixty people with thumb CMC osteoarthritis in the dominant hand aged 70-90 years.

INTERVENTIONS

The experimental group received sliding mobilisation of the radial nerve and the control group received a non-therapeutic dose of intermittent ultrasound, on the affected side for six sessions over four weeks.

OUTCOME MEASURES

On the contralateral side, pressure pain thresholds at the lateral epicondyle, thumb CMC joint, tubercle of the scaphoid bone, and hamate bone were assessed before and after the intervention with follow-up at 1 and 2 months.

RESULTS

No important baseline differences were noted between groups. At the end of the intervention period, the experimental group had significantly a higher (ie, better) pressure pain threshold than the control group at the lateral epicondyle by 1.5kg/cm(2) (95% CI 0.2 to 2.2), CMC joint by 1.2kg/cm(2) (95% CI 0.5 to 2.0), scaphoid bone by 1.0kg/cm(2) (95% CI 0.2 to 1.8) and hamate bone by 1.9kg/cm(2) (95% CI 1.0 to 2.7). Although mean values in the experimental group remained better than the control group at all sites at both follow-up assessments, these differences were not statistically significant.

CONCLUSION

Radial nerve gliding applied to the symptomatic hand induced hypoalgesic effects on the contralateral hand in people with CMC osteoarthritis, suggesting bilateral hypoalgesic effects of the intervention.

In-situ imaging of articular cartilage of the first carpometacarpal joint using co-registered optical coherence tomography and computed tomography

Conventional imaging modalities are unable to depict the early degeneration of articular cartilage in osteoarthritis, especially in small joints. Optical coherence tomography has previously been used successfully in high-resolution imaging of cartilage tissue. This pilot cadaver study demonstrates the use of intra-articular optical coherence tomography in imaging of articular cartilage of the first carpometacarpal joint, producing high resolution images of the articular surface in which cartilage thickness and surface characteristics were assessed. Findings on optical coherence tomography were confirmed with histology. Furthermore, co-registration of optical coherence tomography and computed tomography was used to accurately determine the scanned trajectory and reconstruct a true-scale image overlay.

Localized component analysis for arthritis detection in the trapeziometacarpal joint

The trapeziometacarpal joint enables the prehensile function of the thumb. Unfortunately, this joint is vulnerable to osteoarthritis (OA) that typically affects the local shape of the trapezium. A novel, local statistical shape model is defined that employs a differentiable locality measure based on the weighted variance of point coordinates per mode. The simplicity of the function and the smooth derivative enable to quickly determine localized components for densely sampled surfaces. The method is employed to assess a set of 60 trapezia (38 healthy, 22 with OA). The localized components predominantly model regions affected by OA, contrary to shape variations found with PCA. Furthermore, identification of pathological trapezia based on the localized modes of variation is improved compared to PCA.

[Clinical presentation imaging and treatment of digital osteoarthritis]

Digital osteoarthritis relates to primarily the distal interphalangeal (DIP) and first carpometacarpal (CMC-I) joints. Heberden's nodes often accompany osteoarthritis of the DIP joints. Osteoarthritis of the PIP joints can be more painful and more inflammatory. It can be at the origin of Bouchard's nodes. The DIP and the PIP joints can be the seat of erosive lesions. Osteoarthritis of the MCP joints is rare. Osteoarthritis of the CMC-I joint is sometimes at the origin of a deformity of the thumb impairing its function and an atrophy of the thenar muscles. Treatment includes non-pharmacological and pharmacological modalities. Surgery is proposed after failure of the conservative approach.

[Treatment of osteoarthritis of the thumb basal joint]

Osteoarthritis in the carpometacarpal joint of the thumb (CMC1) is described in three patients who were all restricted in their daily activities by the disease. CMC1 osteoarthritis is a common disease affecting mainly postmenopausal women and individuals who use the joint intensively. Two of our patients, a 52-year-old female teacher and a 45-year-old male dentist, were treated by resection of the articular surfaces and interposition of a tendon or a polycarbon disc into the joint. To achieve a strong, stable thumb a 58-year-old sculptress had arthrodesis of the left CMC1. In her right hand, resection of the trapezium and ligament reconstruction of the CMC1 joint was necessary. There is no evidence-based guideline for treatment of osteoarthritis of the carpometacarpal joint of the thumb. Many non-surgical and surgical treatment options for CMC1 osteoarthrosis have been described. Optimal treatment is chosen depending on radiological staging of the disease and on the wishes and expectations of the patient.

Injectable hyaluronan for the treatment of carpometacarpal osteoarthritis: open label pilot trial

OBJECTIVE

Carpometacarpal osteoarthritis (CMC OA) is highly prevalent in older adults, and is often unresponsive to medical treatment. Intra-articular Hylan G-F 20 has been shown to improve pain and function in patients with knee OA; however, its effectiveness in CMC OA is less clear.

METHODS

32 patients with CMC OA were injected with Hylan G-F 20, once weekly for three consecutive weeks. Patients were assessed 4, 12, 20 and 26 weeks after the first injection. A last-value carried forward analysis was performed.

RESULTS

Average age was 64 years, (range 46-79), 69% were female and 97% Caucasian. Fifty-three percent had at least one previous corticosteroid injection in the affected CMC joint. At 26 weeks, mean visual analogue scale (VAS) for pain had improved significantly (15.2 mm; p-value = 0.006). Disabilities of the arm, shoulder and hand questionnaire (DASH) scores also improved significantly (12.6; p-value < 0.001). A DASH change of 10-14 is considered clinically meaningful. Neither key strength nor opposition grip strength improved. VAS scores for pain at 26 weeks showed good correlation with patient satisfaction (Spearman r = 0.52, p-value < 0.01). Adverse events potentially related to the injections included three episodes of post-injection pain and swelling, and one case of crystal proven pseudogout.

CONCLUSION

Intra-articular Hylan G-F 20 injections reduced pain and improved function in patients with CMC OA at 26 weeks in this small open label study. Limitations of this study include its small, open label design. Larger randomized controlled trials are needed to confirm these results, and to determine predictors of response to treatment.

CLINICAL TRIAL REGISTRATION

This study was approved by the Institutional Review Board at the Hospital for Special Surgery, New York, NY, USA and registered at (www.ClinicalTrials.Gov)# NCT00198029.

Spectrum of normal and pathologic findings in the region of the first extensor compartment of the wrist: sonographic findings and correlations with dissections

OBJECTIVE

The purpose of this presentation is to review pathologic conditions that lead to pain at the radial aspect of the distal radius and to address anatomic variations of the first extensor compartment that exist and may have diagnostic and therapeutic implications.

METHODS

Our presentation is based on a review of cases from teaching files and observations made in anatomic specimens.

RESULTS

The discussed conditions include de Quervain tenosynovitis, intersection syndrome, and Wartenberg syndrome. Sonographic diagnosis of these conditions is addressed, and correlations are provided with anatomic specimens.

CONCLUSIONS

Sonography is able to depict and differentiate between these conditions.

Interposition arthroplasty using an acellular dermal matrix scaffold

We have used arthroscopic debridement and interposition arthroplasty with an acellular dermal matrix allograft in treatment of first carpometacarpal joint arthritis successfully in a limited number of patients. The purpose of this investigation was to study the use of an acellular dermal matrix graft in a rabbit model of interposition arthroplasty. Eleven rabbits underwent excision of the lunate bone and interposition of extensor tendon (control) or dermal matrix graft (experimental). Radiographic analysis and either histological or vascular studies were performed. No adverse immunological response was noted. Increasing fibroblast like cells were noted over time in both groups with greater infiltration in control specimens. Vascular infusion showed infiltration in both arthroplasty groups. Both groups maintained the resection space and promoted cellular ingrowth without adverse immune response. Vascular infiltration occurred in both arthroplasty groups. These results support use of this graft in interposition arthroplasty.

Osteoarthritis of the thumb carpometacarpal joint in women and occupational risk factors: a case-control study

PURPOSE

Among other etiologic factors involved in first carpometacarpal (CMC) osteoarthritis (OA), occupational factors have been postulated as influencing the occurrence of this condition. Very few epidemiologic studies, however, have evaluated this topic. Determining the occupational risk factors is important in proposing preventive measures at the workplace. This case-control study was undertaken to explore whether there was a history of greater exposure to some occupational factors (eg, occupations, hand postures, tasks involving the CMC joint) in women requiring surgery for CMC OA compared with women with no CMC OA noted by history and physical examination.

METHODS

The case subjects were 61 women surgically treated for primary CMC OA and the control subjects were 120 aged matched women without history or features of CMC OA. A detailed structured interview was developed to elicit information about age, smoking habits, medical history, lifestyle history, and occupational factors. Occupational factors were based on a detailed history of jobs, coded according to the International Standard Classification of Occupations. For the main occupation/job held for the longest duration and during an average working day, subjects were asked about hand posture or tasks involving requirements presumed to cause a strain or a high load to the CMC joint and about certain work conditions.

RESULTS

Of the 61 case and 120 control subjects, 5 and 14, respectively, had never worked. There was no difference between the average number of jobs through the working lifetime of the group of case subjects compared with the group of control subjects. Logistic regression analysis showed that after adjustment for age, smoking status, obesity, CMC OA family history, hysterectomy history, parity, and occasional job, the following occupational factors were risk factors for CMC OA: occupations presumed to be associated with increased risk for CMC OA, occupations involving repetitive thumb use, and jobs perceived by the subject having not enough rest breaks during a day. The group of case subjects had a higher prevalence of hysterectomy history and family CMC OA history compared with the group of control subjects.

CONCLUSIONS

Although previous studies have reported that work and exposure history may lack precision as risk factors, our results give further evidence to support the role of certain occupational factors in the occurrence of CMC OA in women.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Recurrent Low- to Intermediate-Grade Chondrosarcoma of the Thumb with Lung Metastases: An Objective Response to Trofosfamide

BACKGROUND

Low- to intermediate-grade chondrosarcoma is usually a slow-growing and highly chemotherapyresistant tumor type.

CASE REPORT

The 76-year-old female patient presented with low- to intermediate-grade chondrosarcoma of the distal phalanx of the right thumb in 1993 and was treated with an excision of the carpometacarpal joint. Approximately 10 years later, the patient presented with recurrent local disease at the trapezoid bone, which was resected. Eight months later she presented with local recurrence at the carpal joint and lung metastases. Subsequently she was treated chemotherapeutically with pegylated liposomal doxorubicin as part of a clinical trial. Due to tumor progression after 2 cycles, she was switched to oral trofosfamide (150 mg daily). A follow-up CT scan after 8 months demonstrated a partial remission that was confirmed by a second scan after 9 months of treatment. The treatment was well tolerated. After 18 months of continued treatment, she was still in remission and on trofosfamide.

CONCLUSION

Trofosfamide at a daily dose of 150 mg may be effective in low- to intermediate-grade chondrosarcoma.