CMC Arthritis Syllabus
2014-02-12
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2/11/2014 Ruth Jackson Orthopaedic Society presents The Little Joint with Big Problems Anatomy, Treatment, and Challenges in CMC Arthritis Amy L. Ladd MD Professor & Chief, Chase Hand Center Department of Orthopaedic Surgery Assistant Dean, Stanford School of Medicine Disclosures Related Funding NIH RO1 2011-16 NIH SBIR 1,2 2005-08, 2009-11 OREF/RJOS/DePuy 2010 Royalties & Stock options- Extremity Medical, Articulinx Unrelated Royalties - OrthoHelix Stock, stock options - OsteoSpring, Illuminoss RJOS President 2013-14 Assistant Dean of Medical Advising Overview of Webinar Current, clinically relevant information on CMC arthritis: Why is it such a problem? – Ladd Trapeziectomy and various approaches – Weiss Less invasive procedures – Kakar Role of instability - Wolf 1 2/11/2014 Introduction Why is thumb CMC arthritis such a problem? Anatomy review Treatment – consensus and lack of consensus Challenges in treatment and prevention How does this joint wear out? Normal Osteoarthritic Anatomy – its not simple Shape Load Movement 2 2/11/2014 Morphology Trapezium The joint surfaces are eccentric. Eccentric shape Out of plane from fingers Both permit rotation and opposition Ligament stability Stability is part structure and part proprioception. Ligaments may only contribute part of stability. 3 2/11/2014 Dorsal ligament complex Ladd, Lee, Hagert: JBJS 2012 Zhang, Hagert, van Nortwick, Ladd ASSH 2011, JWS 2013 Volar ligament complex Ladd, Lee, Hagert: JBJS 2012 Zhang, Hagert, van Nortwick, Ladd ASSH 2011, JWS 2013 Load Articular and trabecular wear patterns infer biomechanical loading. Abnormal loading may contribute to patterns of arthritis. 4 2/11/2014 Clinical examples of wear patterns Trapezial wear patterns Saddle 47% 36 specimens • 27 Female (75%) • 9 male (25%) • age 64 (33-76) Dish 33% • • Cirque 19% Intra-rater reliability 0.97 Inter-rater reliability 0.95 Van Nortwick, Berger, Cheng, Lee, Ladd: J Wrist Surgery 2013 1- Retained saddle • Retains concavo-convex surface • Partial eburnation • Few osteophytes 47% Van Nortwick, Berger, Cheng, Lee, Ladd: J Wrist Surgery 2013 5 2/11/2014 2-Dish shape A mortar and pestle • Trapezium = mortar • Metacarpal = pestle •Full eburnation •Rimming osteophytes 33% Van Nortwick, Berger, Cheng, Lee, Ladd: J Wrist Surgery 2013 3-Cirque • Volar eroded concave facet • Retained convexity dorsally • - half a saddle 19% Movement Understanding micro-motion in normal and arthritic populations suggest better ways to predict and treat arthritis. 6 2/11/2014 24 subjects 12 male (ave age 38) 12 female (ave age 43) Ladd, Weiss, Crisco, Hagert, Wolf, Yao, Glickel: AAOS ICL 2012 CMC contact pinch grasp jar opening 1 mm interbone distance contours Putting it together 7 2/11/2014 Treatment Dilemmas CMC end-stage disease Treatment stuck in the 1950s Lessons to be learned from the big joints! http://www.orthobullets.com/upload/5034/images/xray %20ap%20hip%2 0arthro desis.jpg Can we do better than this? 8 2/11/2014 The role of the MP joint Challenges Where else can we find clues? As in other joints, what is the role of: Instability - imbalance Impingement Proprioception 9 2/11/2014 Summary - Ultimate goal • Apply what we know about anatomy and disease • Decipher the paradox of mobility and stability • Use this to predict, prevent, and treat thumb arthritis Thank you 10 2/11/2014 Thumb CMC Arthroplasty Suture Suspension Technique Arnold-Peter C. Weiss, M.D. R. Scot Sellers Scholar of Hand Surgery Professor of Orthopaedics Disclosure None Why should I care? Most studies show equal outcomes Gerwin, Kriegs-Au, Davis Third most common joint requiring surgery Most common reconstructive hand surgery BUT… Surgical times can differ Eliminating K-wire Cost factors 1 2/11/2014 Surgical Factors to Consider • Time of procedure: Less is better Surgical Factors to Consider • Eliminating K-wire: Less discomfort post-op • Possibility of collapse: Longer term issue • Cost: Lower is better • Tendon: Do we really need it? Study Question • Standard complete trapeziectomy • Suspend by a “weave” of #2 Fiberwire between the APL and FCR at their distal most insertions • No tendon graft • Casted for 4 weeks • Standard post-op hand therapy protocol 2 2/11/2014 Suture Suspension Technique (n=65) • Complete trapeziectomy Suture Suspension Technique (n=65) • #2 Fiberwire through distal APL insertion then through distal FCR then back through APL and once more through FCR Suture Suspension Technique (n=65) 3 2/11/2014 Suture Suspension Technique (n=65) Suture Suspension Technique (n=65) • Tie the suture ends and test longitudinal stability NO – don’t tether the two tendons 4 2/11/2014 Results • Minimum of 2 year follow-up examination • Age: 51.3 yrs • Average OR time = 23 minutes • No radiographic collapse in any patient • Pinch & grip strength plateau at 4 months • Pain: VAS score of 0.2 (0 – 10) at final F/U exam Discussion • Clinical results and outcomes equal to other reported techniques • Shortened operative time; Inexpensive • Intrinsic & immediate stability • A viable alternative to time intensive techniques • Data is preliminary but promising Thank You 5 “Minimally” Invasive Options & Role of Tightrope in the Management of Basilar Thumb Arthritis SOMOS SL Symposium Summary.pptx Sanj Kakar MD, MRCS Associate Professor of Orthopaedic Surgery Mayo Clinic, Rochester Disclosures • Basic Science Research Grants • ASSH • Mayo Foundation • Consulting • Arthrex • Skeletal Dynamics No financial relationship with Tightrope Anatomy of 1st CMC Jt • Biconcave saddle shaped joint • Little osseous stability • Semi-constrained, relatively incongruent • Motion: • Flex-extension • Abduction-adduction • Rotation 1 Forces to Consider • Forces across TM joint – Simple pinch – 12 kg force – Strong grasp – 120 kg force – Important consideration especially in a young patient Cooney WP. JBJS 1977 Ideal surgical procedure for 1st CMC arthritis • Pain relief • CMC motion / position • MP joint (hyperextension) • Pinch and grip strength • Minimal complications • Reproducible • Long lasting Treatment: Operative • • • • Trapezial resection alone Trapeziectomy & suspension Arthrodesis Implant arthroplasty • Altering normal anatomy & mechanical function • ↓ span of hand & dexterity with fine manipulation (fusion) • Prolonged recovery • What’s the salvage when they fail ? e.g. young pt, manual labourer 2 Are there minimally invasive treatment options? Can we maintain the trapezium? Denervation of CMC Joint Proposed Advantages • Pain relief • Without compromise of ROM & strength • Minimal rehabilitation • Doesn’t burn bridges for future tx 3 Innervation of Thumb CMC Jt • SBRN 1. 2. 3. 4. 5. dorso-radial collateral of thumb Lejar’s branch dorso-ulnar collateral of thumb dorso-radial collateral of index Anastomoses between 3 & 4 • LABCN • Cruveilhier’s branch • Median nerve • • Thenar branch Palmar cutaneous nerve • Branch of deep motor ulnar nerve Innervation Pattern Highly Variable DeMooj, Berger & Kakar 2014 (in works) Table 1 - Innervation Patterns of the Trapezio-Metacarpal Joint Author Year Limbs Right side Male Posterior Interosseous Nerve Sup. Rad. N. not otherwise specified Dorso-radial collateral of the thumb Dorso-ulnar collateral of the thumb Dorso-radial collateral of the first finger Lejars branch Dorsal articular nerve of Winckler's first interosseous space Lateral Antebrachial Nerve Cruveilhier's branch Anterior Interosseous Nerve Palmar Cutaneous branch Thenar Branch Median branch Intra-canal branch of thenar branch Motor Branch of Ulnar Nerve -: did not look at this nerve or branch +: looked at this nerve or branch, but did not note a number of articulation branches 0: looked at this nerve or branch, but did not find any articulating branches Cozzi 1991 500 100% 70% + + 30% Loréa et al 2002 10 0 10 (100%) + + + - Poupon et al 2004 15 8 15 (100%) 15 (100%) 3 (20%) 1 (7%) 14 (93%) Miki et al 2011 19 10 7 11 (58%) - * - (5%) * - (5%) - **9 (90%) + 10 (100%) 0 9 (90%) 9 (90%) 2 (20%) 0 ***3 (20%) 11 (73%) 13 (87%) 5 (30%) - 0 9 (47%) 9 (47%) * estimation by author ** originated from dorso–ulnar digital nerve of the thumb in 2, dorso-radial digital nerve of the index finger in 3 and for the bifurcation between these branches in 4 *** derived from dorso-radial collateral of the first finger • Two incisions (palmar & dorsal) • Denervated • • • • Superficial Radial Nerve Lateral Antebrachial Nerve Palmar Cutaneous Branch of Median Nerve Thenar Branch of Median Nerve • 43 pts (mean age: 60 yrs [range 30-77]) • 3 heavy manual labour & 2 factory workers • Improved rest pain (90%) > ADL (86%) > heavy work (82%) • ↑ Kapandji score & key pinch • 42/43 pts were satisfied • No charcot joint 4 • Wagner approach • Denervated • • • • Tech Hand & Upper Extrem Surg 2012 Superficial Radial Nerve Lateral Antebrachial Nerve Palmar Cutaneous Branch of Median Nerve Thenar Branch of Median Nerve • 16 pts (18 thumbs) • 14/16 pts → satisfied or very satisfied • NO formal pain assessment/?degree of arthritis • Complications: 2 pts → painful HT scar 1 pt → hypoaesthesia over dorsum thumb Thumb Metacarpal Osteotomy Ligament Laxity Theory of Thumb Arthritis • Volar beak ligament degenerates & detaches • Abnormal shear stresses across anterior compartment of joint causes CMC arthritis - Degeneration of palmar metacarpal cartilage - Exacerbated by pinching (flexion & adduction of 1 st metacarpal) • Extension osteotomy of 1st metacarpal Pelligrini VD Jr. et al - Palmar contact unloaded & contact pressure moved dorsally - Indications: Eaton stage 1 disease Pelligrini VD Jr. et al J Hand Surg, 1991;16A:967-974 Pelligrini VD Jr. et al J Hand Surg, 1996;21A:1623 5 • Prospective study (12 pts, Eaton stage 1) • Average f/up 2.1 yrs • 300 metacarpal extension osteotomy • Results • Union at 7 wks • 11/12 pts satisfied • ↑ grip & pinch strength • All pts returned to work • 8 pts (3 Eaton stage 1, 3 Eaton stage 2 & 2 Eaton stage 3) • Average f/up 9 yrs • Results • ↑ grip strength (108% of contralateral side) • ↑ appositional pinch strength (129%) • ↑ oppositional pinch strength (103%) • 6/8 pts → excellent functional outcomes • Eaton stage preserved 5/8 pts Arthroscopic Treatment 6 Arthroscopy for CMC OA • Technique - Berger, JHS, 1997 • Portals (locate with 18 g needle +/- fluoro) • 1R (radial to APL at CMC jt) • 1U (ulnar to EPB at CMC jt) • Dangers • SBRN, radial artery • Equipment • • • • Thumb in txn (5-10lbs) Insufflate jt (2mls 1U portal) 1.9mm short barrel scope 2mm shaver through 1R to debride synovitis (use 2.9mm burr once space ↑ within a 3.5mm sheath to prevent clogging during trapeziectomy) • Replace 1R with thenar portal • Arthroscope in 1U portal • Thenar portal 900 to 1U portal • Results (thenar portal) • Good working portal • ↓ sword fighting • Didn’t violate the dAOL • Further away from sensory nerves than 1R • 23mm away from recurrent motor branch median nerve Advantages of CMC Arthroscopy Menon 1996 • ↓ invasion compared to open approach • ↓ postop pain & stiffness • Quicker rehabilitation • Doesn’t burn any bridges 7 • Stage 1 • Synovitis & ligamentous laxity • Synovectomy +/- thermal shrinkage • Stage 2 • Cartilage loss on ½ trapezium • Metacarpal extension osteotomy • Arthroscopic tx • Stage 3 • Diffuse cartilage loss • Arthroscopic hemitrapeziectomy What Does The Literature Show As To Efficacy of Tx !!! • 23 pts (Eaton stage 1 & 2) • Arthroscopic synovectomy & debridement & splint 1wk • Control grp: 21 pts non op tx • Evaluated 1 yr later • Results • 83% surgical pts → good to exc results • Surgical pts: • ↓ pain, ↑ DASH & pinch strength • Complications • Wound infection (1) • DSRN irritation (1R) 8 • 23 pts (Eaton stage 3) • Hemitrapeziectomy (3-4mm) • CMC jt pinned (3-4 wks) • >4 year follow up • Results • 19/23 pts pleased with results • ↑ DASH & pinch & grip strength • Proximal migration ~ 3mm • Complications • 1 Wound infection • 1 DSRN irritation (1R) • 1 pt → LRTI • 14 pts (Eaton 2 & 3) • Hemitrapeziectomy & interposition (PL, FCR) • F/up: 11 months (3.3-17.3) • Results • VAS ↓8.6→ 1.8 (p<0.005) • 90% restoration grip & pinch strength • 10/11 pts → “much better” • Complications • 1 CRPS • ? 1Graft extrusion Tightrope Suspension Arthroplasty 9 • Suture button compared with k wire fixation for maintenance of post-trapeziectomy space Yao et al. 2010 • Cadaveric study • Maintenance of suspension (lateral, cyclic, dynamic pinch) • Suture button suspensionplasty after arthroscopic hemitrapeziectomy for thumb CMC arthritis Cox et al. 2010 • 16 pts (Eaton II-III) • ROM & splint at 2 weeks • At 1 yr → “promising results” Suture Button Suspension Arthroplasty for Thumb CMC Arthritis Yao & Song 2012 • 21 pts (f/up >24 M) – Tightrope & 2.7mm drill (8 arthro hemi & 13 open trapeziectomies) – ROM & splint at 10 days post op • Results – – – – – All pts → full ROM Quick DASH: 10 +/- 9 Grip & pinch strength: 86% & 89% contralateral side Trapezial height → 74% of contralateral side 1 CRPS & 1 frx 2nd metacarpal Had experience with mini Tightrope in revision cases • 55F 6 months post op (tx elsewhere) 10 ECRL suspension, tightrope and graft jacket interposition • 18 months post op My Initial Thoughts Tightrope: - Skeptical - Concerns of breakage BUT gives immediate stability If doing a trapeziectomy and suspensionplasty: - Tightrope - Imbricate FCR to APL 11 58F CMC & STT jt involvement • Work in plane between APL & EPB & isolate and protect radial artery 12 • Remove trapezium with care not to injure underlying FCR tendon!!! • Inspect ST joint & debride if arthritic 13 • ST joint debrided • Dorsal approach base of 2nd metacarpal • Ensure debridement of osteophytes at base of 1st & 2nd metacarpal bases to ↓ impingement • Free hand or with guide place k wire from base of 1st to 2nd metacarpal…..ensure you are through 4 cortices!!!!! • Extend 1st metacarpal base and palmar abduct when passing wire 14 • Can place 1 or 2 wires!!! • Maintains space between 1-2 metacarpal bases & prevents over tightening • Pull endobutton down onto 1st metacarpal and tie down 2nd button. Repeat steps for 2nd tightrope if desired • Close periosteal flap over 2nd metacarpal to ↓ symptomatic hardware 15 • Imbricate FCR to APL tendon • Extends base 1st metacarpal • Belt & braces Post Op Protocol • 2 weeks thumb spica post op splint • If comfortable, start AROM at 2 weeks (protect with thumb spica splint for 24 weeks) • Grip strengthening at 6 weeks • Apposition pinching at 12 weeks Mayo Experience Kakar and Parry 2014 • 11 pts (1M,10F) • 60yrs (43-73) • 2 mini tightropes & FCR to APL imbrication • Follow up 18 months (range:13-26 months) 16 Mayo Experience Kakar and Parry 2013 • Post operative outcome questionnaires: • DASH 19 • MHQ 75 • PRWE 21 • Radiographs: • Maintenance of trapezial space • Complications: • 1 CRPS • 3 DSRN irritation (resolved) Summary • Minimally invasive procedures have a role in management of thumb CMC OA • Young pts • Manual labourers • Maintain the length of thumb (power) • Denervation procedures • Minimal morbidity without burning bridges 17 • Arthroscopy • Similar results to open tx • No PRCT compared to open tx • Eaton 1: • Debridement & synovectomy • Metacarpal extension osteotomy • Eaton 2-3: • Hemitrapeziectomy +/- interposition +/tightrope • Eaton 4: • Trapeziectomy +/- tightrope Thank You For Your Attention Email: Kakar.sanjeev@mayo.edu 18 2/11/2014 VuMEDI: Why Do Men Get Thumb CMC Arthritis? Jennifer Moriatis Wolf, MD Associate Professor Department of Orthopedic Surgery University of Connecticut Disclosures Grant Funding – AFSH, OREF, University of Connecticut Salary – Deputy Editor of Journal of Hand Surgery, Elsevier Updates Editor Overview Epidemiology Sex Differences 1 2/11/2014 Epidemiology Incidence of thumb CMC OA increases with increasing age in both sexes Women >> Men Radiographic Clinical Radiographic Differences Haara et al – large Finnish population study Incidence of Kellgren-Lawrence grade 3/4 OA of the TM joint JBJS-A, 2004 14.5% in women 10% in men Sodha et al – large study of ED radiographs for fracture JBJS-A, 2005 Noted increasing rate of TM OA with age In worst TM OA – 66% prevalence in women compared to 23% of men Symptomatic Differences Framingham study – prevalence in TM joint 5% in women 2.5% in men Zhang et al, Am J Epidemiol, 2002 Physician-diagnosed TM OA in Sweden Primarily captured public health system Overall prevalence of 2.2% in women and 0.69% in men Men diagnosed over a decade later than women Wolf et al, Arthr Care Res, 2013 2 2/11/2014 Why the Sex Difference? Not known Anatomy Biomechanics Hormones Occupation Genetics Anatomy Saddle-shaped joint Stabilized by ligaments to provide mobility and stability Ligaments have been studied for strength Best recent data indicates dorsoradial ligament (DRL) major stabilizer Ladd, Hagert JBJS-A, 2012 As opposed to thinner AOL JAAOS, 2010 Sex Difference in Bony/ Ligamentous Anatomy Study in 18 female and 13 male cadavers Average age 71.4 years Used micro-calipers to measure Metacarpal width Trapezial width Ligament thickness Men had greater width of metacarpal and trapezium (mean 18.83 mm vs. 16.65 mm) Men had thicker DRL, sAOL Gerhardt, Baldini, Wolf, unpublished data 3 2/11/2014 Biomechanical Differences Bettinger et al – studied material properties of TM stabilizing ligaments in 10 male and 10 female cadavers Ultimate load and stress of AOL significantly higher in men Ultimate strain of DT-II MC ligament greater in women Bettinger et al, J Hand Surg Am, 1994 Role of laxity Women have greater overall laxity than males Larsen et al, Arthr Rheum, 1987 Possible abnormal loading playing a greater role in women Men and TM Subluxation Hunter et al – Framingham study Osteoarth Cartilage, 2005 203 men and 431 women Hand radiographs in 1967 and 1993 Evaluated for TM subluxation Noted that baseline TM subluxation correlated with development of later TM OA in men only Occupation No studies evaluating occupation directly between sexes Framingham study – evaluated grip strength and associated development of hand OA Chaisson et al, Arthr Rheum, 1999 453 eligible subjects over 30 years Highest maximal grip strength in men associated with increased risk of PIP, MCP, and thumb CMC OA Women’s grip showed correlation with MCP OA only 4 2/11/2014 Hormones Sex hormones attractive target Estrogen Progesterone Testosterone Relaxin Primary evidence in animal studies of OA Relaxin levels higher in post-menopausal women than age matched men Wolf et al, J Hand Surg Am, 2013 Further studies ongoing Genetics Multiple studies have shown genetic component in hand OA in general Ishimori et al showed osteophyte distribution to be genetically linked Arthr Res Ther, 2010 Mutations in matrilin-3 (ECM protein gene) linked to more severe form of TM OA Eliasson et al, Scand J Rheumatol, 2006 Conclusions Men with TM OA Present later than women Possibly different mechanism ?more direct joint load vs. ligament attenuation Anatomic differences in men and women Interaction between anatomy, genetics, and environment may be different in men 5 2/11/2014 THANK YOU 6
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