CMC Arthritis Syllabus

: Pdf Cmc Arthritis Syllabus CMC_Arthritis_Syllabus 2 2014 pdf

Open the PDF directly: View PDF .
Page Count: 39

2/11/2014

1

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

2/11/2014

2

Introduction

Why is thumb CMC arthritis such a problem?

Anatomy review

Treatment – consensus and lack of consensus

Challenges in treatment and prevention

Normal Osteoarthritic

How does this joint wear out?

Anatomy – its not simple

Shape

Load

Movement

2/11/2014

3

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.

2/11/2014

4

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.

2/11/2014

5

Clinical examples of wear patterns

Trapezial wear patterns

Dish 33% Cirque 19%

Saddle 47%

•Intra-rater reliability 0.97

•Inter-rater reliability 0.95

36 specimens

•27 Female (75%)

• 9 male (25%)

•age 64 (33-76)

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

2/11/2014

6

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.

2/11/2014

7

Ladd, Weiss, Crisco, Hagert, Wolf, Yao, Glickel: AAOS ICL 2012

24 subjects

12 male (ave age 38)

12 female (ave age 43)

CMC contact

pinch grasp jar opening

1 mm interbone distance contours

Putting it together

2/11/2014

8

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?

2/11/2014

9

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

2/11/2014

10

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

2/11/2014

1

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

2/11/2014

2

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

2/11/2014

3

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)

2/11/2014

4

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

2/11/2014

5

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

1

“Minimally” Invasive Options & Role

of Tightrope in the Management of

Basilar Thumb Arthritis

Sanj Kakar MD, MRCS

Associate Professor of Orthopaedic Surgery

Mayo Clinic, Rochester

SOMOS SL Symposium Summary.pptx

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

2

Forces to Consider

Cooney WP. JBJS 1977

•Forces across TM joint

–Simple pinch

–12 kg force

–Strong grasp

–120 kg force

–Important consideration

especially in a young

patient

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

3

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

4

Innervation of Thumb CMC Jt

•SBRN

1. dorso-radial collateral of thumb

2. Lejar’s branch

3. dorso-ulnar collateral of thumb

4. dorso-radial collateral of index

5. Anastomoses between 3 & 4

•LABCN

•Cruveilhier’s branch

•Median nerve

•Thenar branch

•Palmar cutaneous nerve

•Branch of deep motor ulnar nerve

Table 1 - Innervation Patterns of the Trapezio-Metacarpal Joint

Author

Cozzi

Loréa et al

Poupon et al

Miki et al

Year

1991

2002

2004

2011

Limbs

500

10

15

19

Right side

-

-

8

10

Male

-

-

-

7

Posterior Interosseous Nerve

-

0

-

-

Sup. Rad. N. not otherwise specified

100%

10 (100%)

15 (100%)

11 (58%)

Dorso-radial collateral of the thumb

70%

+

15 (100%)

-

Dorso-ulnar collateral of the thumb

+

+

3 (20%)

-

Dorso-radial collateral of the first finger

+

+

1 (7%)

-

Lejars branch

30%

-

14 (93%)

-

Dorsal articular nerve of Winckler's first

interosseous space

-

**9 (90%)

***3 (20%)

-

Lateral Antebrachial Nerve

-

+

-

-

Cruveilhier's branch

-

10 (100%)

-

-

Anterior Interosseous Nerve

-

0

-

-

Palmar Cutaneous branch

* - (5%)

9 (90%)

11 (73%)

0

Thenar Branch Median branch

* - (5%)

9 (90%)

13 (87%)

9 (47%)

Intra-canal branch of thenar branch

-

2 (20%)

5 (30%)

-

Motor Branch of Ulnar Nerve

-

0

-

9 (47%)

-: 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

* 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

DeMooj, Berger & Kakar 2014 (in works)

Innervation Pattern Highly Variable

•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

5

•Wagner approach

•Denervated

•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

Tech Hand & Upper Extrem Surg 2012

Thumb Metacarpal

Osteotomy

Pelligrini VD Jr. et al J Hand Surg,

1991;16A:967-974

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 1st metacarpal)

•Extension osteotomy of 1st metacarpal

- Palmar contact unloaded & contact pressure moved dorsally

- Indications: Eaton stage 1 disease

Pelligrini VD Jr. et al J Hand Surg, 1996;21A:16-

23

Pelligrini VD Jr. et al

6

•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

7

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

8

•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)

9

•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

10

•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”

•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

Suture Button Suspension

Arthroplasty for Thumb CMC Arthritis

Yao & Song 2012

Had experience with mini

Tightrope in revision cases

•55F 6 months post op (tx elsewhere)

11

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

12

58F CMC & STT jt involvement

•Work in plane between APL & EPB &

isolate and protect radial artery

13

•Remove trapezium with care not to injure

underlying FCR tendon!!!

•Inspect ST joint & debride if arthritic

14

•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

15

•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

16

•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 2-

4 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)

17

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

18

•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

2/11/2014

1

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

2/11/2014

2

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

2/11/2014

3

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

2/11/2014

4

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

2/11/2014

5

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

2/11/2014

6

THANK YOU