Prospective Clinical Trial Comparing Trapezial Denervation With Trapeziectomy for the Surgical Treatment of Arthritis at the Base of the Thumb.

BACKGROUND: Trapeziectomy is considered to be the "gold standard" procedure for first carpometacarpal joint (first CMCJ) osteoarthritis. First CMCJ denervation offers the potential benefit of a shorter procedure with bone and joint preservation and swift postoperative rehabilitation. This trial aimed to compare functional outcomes, patient satisfaction, quality of life, and cost effectiveness following these treatments. METHODS: This study was a prospective clinical trial commencing December 2005 to November 2013. A range of functional outcomes assessments were used preoperatively at 6 and 12 mo and 5 y after surgery. These included measurements of strength/motion, visual analogue score, Michigan Hand Outcomes and the European Quality of Life-5 Dimensions questionnaires. Data were analyzed using a two-sample t-test and Mann-Whitney test. RESULTS: A total of 45 patients were studied of 55 recruited. Age ranged from 41 to 72 (mean = 59). Thirty-five patients underwent denervation and 10 initially had trapeziectomy. Nine patients were converted to trapeziectomy within an average of 6 to 12 mo. There was no significant difference in the functional outcomes at different points of follow-ups. Similarly, there was no significant difference in the time of return to work or cost effectiveness. Denervation achieved a success rate of just above 70%, whereas no revisions were required for the trapeziectomy group. CONCLUSIONS: There was no difference between the two treatments. First CMCJ denervation does not appear to be superior to trapeziectomy. However, the advantage of rapid rehabilitation makes it more favored by patients but at the expense of 30% reoperation rate. LEVEL OF EVIDENCE: Level II.

Study to Assess Outcome After Open and Closed Carpal Tunnel Decompression.

Carpal tunnel decompression (CTD) is the most commonly performed surgical procedure within a hand unit. We have analyzed data on outcomes after carpal decompression performed by both open and closed techniques to assess whether outcomes differed between the 2 procedures. Data were jointly gathered from 2 units. The aim was to assess the outcome after CTD. Completed data were gathered from 621 CTD procedures performed on 484 patients. Of the procedures, 358 were performed via a standard open CTD technique and 263 procedures were performed via a closed single-port Agee technique. Assessments were performed by means of the Levine-Katz questionnaire, Semmes-Weinstein monofilament testing, grip strength, and pinch-grip strength testing. Assessments were performed both preoperatively and 6 months postoperatively. A randomly selected 10% of patients were also assessed at 12 months. The results were statistically better after closed CTD at the 6-month postoperative stage. However, the difference became less marked by 12-month postoperative stage. Our results show that CTD whether performed by an open or closed technique resulted in a similar outcome at the 12-month postoperative stage. However, those procedures performed by a closed technique offered a more rapid recovery in the first 6 months postoperative than by an open technique.

Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition.

PURPOSE: To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improve the outcome of trapezial excision for the treatment of basal joint arthritis after a minimum follow-up of 5 years. METHODS: We randomized 174 thumbs with trapeziometacarpal osteoarthritis into 3 groups to undergo simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void and retained for 4 weeks, and a thumb spica was used for 6 weeks in all 3 groups. We reviewed 153 thumbs after a minimum of 5 years (median, 6 y; range, 5-18 y) after surgery with subjective and objective assessments of thumb pain, function, and strength. RESULTS: There was no difference in the pain relief achieved in the 3 treatment groups, with good results in 120 (78%) patients. Grip strength and key and tip pinch strengths did not differ among the 3 groups and range of movement of the thumb was similar. Few complications persisted after 5 years, and these were distributed evenly among the 3 groups. Compared with the results at 1 year in the same group of patients, the good pain relief achieved was maintained in the longer term, irrespective of the type of surgery. While improvements in grip strength achieved at 1 year after surgery were preserved, the key and tip pinch strengths deteriorated with time, but the type of surgery did not influence this. CONCLUSIONS: The outcomes of these 3 variations of trapeziectomy were similar after a minimum follow-up of 5 years. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term.

A randomized controlled trial of real versus sham acupuncture for basal thumb joint arthritis.

We report a single-blinded randomized controlled trial comparing acupuncture to sham (non-penetrating) needling for relief of symptoms of basal thumb joint arthritis. Seventy acupuncture naive patients with basal thumb joint arthritis were randomized to receive true acupuncture or sham needling with 35 patients in each arm. Blinded baseline and post-treatment assessments included visual analogue pain scores for different grips and movement. Function was assessed using the Nelson questionnaire. Both groups showed statistically and clinically significant improvements in pain at week one post-treatment compared with baseline, but there was no difference between the treatment groups. The pain relief was comparable with published data for some standard treatments. Acupuncture did not perform better than sham needling in this study, indicating that pain relief may have been achieved through non-specific mechanisms. Level of evidence: I.

Metacarpal osteotomy for correction of acquired phalangeal rotational deformity.

Symptomatic phalangeal rotation deformities require corrective osteotomy. Surgery at the phalangeal level is technically demanding and has a higher complication rate. We describe the surgical technique of metacarpal base osteotomy for rotation correction of the digit. This technique is simple, allows early rehabilitation, and has a lower complication rate.

Outcomes of silicone arthroplasty for rheumatoid metacarpophalangeal joints stratified by fingers.

PURPOSE: Previous studies have demonstrated that outcomes for the ulnar digits appear to be worse than those of the radial digits after silicone metacarpophalangeal joint arthroplasty (SMPA) for the rheumatoid hand. This study examines various components of hand deformities in an effort to understand SMPA outcomes in terms of metacarpophalangeal (MCP) joint range of motion and alignment. We hypothesize that the ulnar fingers will have less improvement, marked by greater ulnar drift, extension lag, and less MCP joint arc of motion than the radial fingers. METHODS: Sixty-eight surgical patients were recruited from 3 sites in this multicenter, international prospective cohort study. All patients had a diagnosis of rheumatoid arthritis, were between the ages of 18 and 80, and were eligible to have SMPA based on measured hand deformities (extensor lag and ulnar drift). Ulnar drift, extension lag, and arc of motion for the MCP joint of each finger were measured at baseline (before surgery) and 1 year after SMPA. RESULTS: All fingers showed an improvement in ulnar drift from baseline to 1 year after surgery. The smallest improvement was in the index finger, and the largest improvement was in the little finger. Similarly, the largest improvement in extension lag was seen in the little finger, and the smallest improvement was seen in the index finger. In terms of MCP joint arc of motion, all fingers moved to a more extended posture and gained an improved arc of motion, but the biggest improvement was observed in the 2 ulnar fingers and less in the 2 radial fingers. CONCLUSIONS: Our hypothesis that the ulnar fingers would have worse outcomes than the radial fingers was not proven by this study. Although experiences have indicated that it is more difficult to maintain posture for the ring and little fingers after SMPA owing to the deforming forces, sufficient correction of the deformities in the ulnar fingers is possible, if adequate bone resection and realigning of the extensor mechanism are carefully performed during the procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

A multicenter clinical trial in rheumatoid arthritis comparing silicone metacarpophalangeal joint arthroplasty with medical treatment.

PURPOSE: Metacarpophalangeal (MCP) joint deformities caused by rheumatoid arthritis can be treated using silicone metacarpophalangeal joint arthroplasty (SMPA). There is no consensus as to whether this surgical procedure is beneficial. The purpose of the study was to prospectively compare outcomes for a surgical and a nonsurgical cohort of rheumatoid arthritis patients. METHODS: The prospective study was conducted from January 2004 to May 2008 at 3 referral centers in the United States and England. Over a 3-year period, 70 surgical and 93 nonsurgical patients were recruited. One year data are available for 45 cases and 72 controls. All patients had severe ulnar drift and/or extensor lag of the fingers at the MCP joints. The patients all had 1-year follow-up evaluations. Patients could elect to have SMPA and medical therapy or medical therapy alone. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales, grip and pinch strength, Jebson-Taylor test, and ulnar deviation and extensor lag measurements at the MCP joints. RESULTS: There was no difference in the mean age for the surgical group (60) when compared to the nonsurgical group (62). There was also no significant difference in race, education, and income between the 2 groups. At 1-year follow-up, the mean overall MHQ score showed significant improvement in the surgical group but no change in the nonsurgical group, despite worse MHQ function at baseline in the surgical group. Ulnar deviation and extensor lag improved significantly in the surgical group, but the mean Arthritis Impact Measurement Scales scores and grip and pinch strength showed no significant improvement. CONCLUSIONS: This prospective study demonstrated significant improvement for RA patients with poor baseline functioning treated with SMPA. The nonsurgical group had better MHQ scores at baseline, and their function did not deteriorate during the 1-year follow-up interval.

Diagnosis and treatment of swellings in the hand.

Patients commonly present to their general practitioner with swellings of the hand. These include a variety of diagnoses with certain lesions (for example, ganglion) being more common than others. Some may even be familiar as they are often site specific. For those that are not routinely seen, or for those that look suspicious, referral to a hand surgeon is usually customary. This article aims to provide general practitioners with clear and concise information and terms of reference on the common hand swellings that they may encounter.

Basal thumb arthritis.

Basal thumb arthritis is a common condition seen in hand clinics across the United Kingdom and is often associated with other pathological conditions such as carpal tunnel syndrome and scaphotrapezial arthritis. Typically, patients complain of pain localised to the base of the thumb. This pain is often activity related, particularly after excessive use involving forceful pinch. A detailed history and examination is normally all that is needed to make the diagnosis. Provocative manoeuvres may be helpful in localising symptoms to the basal joint with degenerative changes or synovitis. Radiographs are useful for confirming the diagnosis and staging the disease in order to plan for surgery. The mainstay of initial treatment of basal thumb arthritis of any stage is activity modifications, rest, nonsteroidal anti-inflammatory drugs, exercises and splinting. A variety of surgical procedures are available to treat the condition when conservative measures have failed, in order to control symptoms and improve function. We review the current literature and discuss the clinical aspects of this condition, staging, and treatment options available, and the difficulties treating this group of patients.

Primary care management of patients with carpal tunnel syndrome referred to surgeons: are non-operative interventions effectively utilised?

AIM: To investigate the non-operative primary care management (splintage, task modification advice, steroid injections and oral medications) of carpal tunnel syndrome before patients were referred to a hand surgeon for decompression. DESIGN AND SETTING: Preoperative data were obtained on age, gender, body mass index, employment, symptom duration, and preoperative clinical stage for patients undergoing carpal tunnel decompression (263 in the USA, 227 in the UK). RESULTS: Primary care physicians made relatively poor use of beneficial treatment options with the exception of splintage in the US (73% of cases compared with 22.8% in the UK). Steroid injections were used in only 22.6% (US) and 9.8% (UK) of cases. Task modification advice was almost never given. Oral medication was employed in 18.8% of US cases and 8.9% of UK cases. CONCLUSIONS: This study analyses the non-operative modalities available and suggests that there is scope for more effective use of non-operative treatment before referral for carpal tunnel decompression.

Seven-Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study.

OBJECTIVE: Rheumatoid arthritis (RA) causes destruction of the metacarpophalangeal (MCP) joints, leading to hand deformities, pain, and loss of function. This study prospectively assessed long-term functional and health-related quality-of-life outcomes in RA patients with severe deformity at the MCP joints. METHODS: RA patients between ages 18 to 80 years with severe deformity at the MCP joints were referred to 1 of the 3 study sites. Subjects who elected to undergo silicone metacarpophalangeal joint arthroplasty (SMPA) while continuing with medical management were followed in the SMPA cohort. Subjects who elected to continue with medical management alone without surgery were followed in the non-SMPA cohort. Objective measurements included grip and pinch strength as well as arc of motion, ulnar drift, and extensor lag of the MCP joints. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Radiographs of SMPA implants were assessed and graded as intact, deformed, or fractured. RESULTS: MHQ scores showed large improvements post-SMPA, and baseline-adjusted expected outcomes in the SMPA group were significantly better at year 7 in function, aesthetics, satisfaction, and overall score compared to non-SMPA. SMPA subjects did not improve in grip or pinch strength, but achieved significant improvement and maintained the improvement long term in ulnar drift and extensor lag. CONCLUSION: Benefits of the SMPA procedure are maintained over 7 years with low rates of implant fracture or deformity. Non-SMPA patients remained stable in their hand function over the 7-year study duration.

Carpal tunnel syndrome, the search for a cost-effective surgical intervention: a randomised controlled trial.

OBJECTIVE: There is insufficient evidence regarding the clinical and cost-effectiveness of surgical interventions for carpal tunnel syndrome. This study evaluates the cost, effectiveness and cost-effectiveness of minimally invasive surgery compared with conventional open surgery. PATIENTS AND METHODS: 194 sufferers (208 hands) of carpal tunnel syndrome were randomly assigned to each treatment option. A self-administered questionnaire assessed the severity of patients' symptoms and functional status pre- and postoperatively. Treatment costs were estimated from resource use and hospital financial data. RESULTS: Minimally invasive carpal tunnel decompression is marginally more effective than open surgery in terms of functional status, but not significantly so. Little improvement in symptom severity was recorded for either intervention. Minimally invasive surgery was found to be significantly more costly than open surgery. The incremental cost effectiveness ratio for functional status was estimated to be 197 UK pounds, such that a one percentage point improvement in functioning costs 197 UK pounds when using the minimally invasive technique. CONCLUSIONS: Minimally invasive carpal tunnel decompression appears to be more effective but more costly. Initial analysis suggests that the additional expense for such a small improvement in function and no improvement in symptoms would not be regarded as value-for-money, such that minimally invasive carpal tunnel release is unlikely to be considered a cost-effective alternative to the traditional open surgery procedure.

Patient expectations and long-term outcomes in rheumatoid arthritis patients: results from the SARA (Silicone Arthroplasty in Rheumatoid Arthritis) study.

Little evidence exists to understand the influence of patient expectations on outcomes for silicone metacarpophalangeal arthroplasty (SMPA). The purpose of this paper is to compare long-term treatment outcome experiences regarding hand function/appearance for a surgical and nonsurgical cohort of rheumatoid arthritis (RA) patients and contrast them to expectations at baseline. This sample is part of a larger multicenter prospective cohort study of RA patients enrolled from 2004 to 2008. A total of 169 RA patients with severe deformities at the metacarpophalangeal (MCP) joints were recruited in the original study. Expectations for SMPA were collected at enrollment. A follow-up patient-reported questionnaire was completed at long-term follow-up. Baseline expectation questionnaires were collected from 137 patients, and follow-up data from 84 patients (average 6.7 years follow-up). At baseline, a significantly higher percent of patients who chose surgery expected to do "Anything I want" or "More activities than I do now" 1 year from enrollment than those who chose nonsurgical treatment. At follow-up, surgical patients remained more likely to indicate that they were currently able to do "Anything" or "More activities" than nonsurgical patients. A higher percentage of surgical patients were "very satisfied" or "quite satisfied" with their treatment compared to nonsurgical patients. RA subjects who chose SMPA reported greater expectations for surgery prior to surgery and also greater levels of hand function and satisfaction at long-term follow-up.

The effect of swan neck and boutonniere deformities on the outcome of silicone metacarpophalangeal joint arthroplasty in rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis patients with swan neck deformities are postulated to have greater metacarpophalangeal joint arc of motion because of their need to flex the joint to make a fist, whereas the boutonniere deformity places the fingers into the flexed position, creating less demand on the joint for grip. This study analyzes the effect of these deformities on the joint's arc of motion and hand function. METHODS: The authors measured the metacarpophalangeal joint arc of motion in 73 surgical patients. Data were allocated into groups by finger and hand deformity. Linear regression models were used to analyze the effect of the deformity on the joint's arc of motion. Functional outcomes were measured by the Michigan Hand Outcomes Questionnaire and the Jebson-Taylor Test. RESULTS: Nineteen fingers had boutonniere deformity, 95 had swan neck deformities, and 178 had no deformity. The no-deformity group had the least arc of motion at baseline (16 degrees) compared with the boutonniere (26 degrees) and swan neck (26 degrees) groups. Mean arc of motion in the no-deformity group compared with the boutonniere group at baseline was statistically significant, but all groups had similar arc of motion at long-term follow-up. Only mean Jebson-Taylor Test scores at baseline between the boutonniere and no-deformity groups were significantly different. CONCLUSIONS: The results did not support the hypothesis that swan neck deformities have better arc of motion compared with boutonniere deformity. Boutonniere deformity has worse function at baseline, but there was no difference in function among groups at long-term follow-up.

Long-term followup for rheumatoid arthritis patients in a multicenter outcomes study of silicone metacarpophalangeal joint arthroplasty.

OBJECTIVE: Rheumatoid arthritis (RA) often results in deformities at the metacarpophalangeal (MCP) joints. Patients with severe deformities can be treated by silicone metacarpophalangeal joint arthroplasty (SMPA). The objective of the study is to prospectively compare long-term outcomes for an SMPA surgical and a nonsurgical cohort of RA patients. METHODS: A total of 67 surgical and 95 nonsurgical patients with severe subluxation and/or ulnar drift of the fingers at the MCP joints were recruited from 2004-2008 in this multicenter prospective cohort study. Patients could elect to undergo SMPA or not. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales 2 (AIMS2), grip/pinch strength, Jebsen-Taylor Test, ulnar deviation, extensor lag, and arc of motion measurements at the MCP joints. RESULTS: There was no significant difference in the mean age, race, education, and income at baseline between the 2 groups. Surgical subjects had worse MHQ function and functional measurements at baseline. At 3 years, the mean overall MHQ score and the MHQ function, activities of daily living, aesthetics, and satisfaction scores showed significant improvement in the surgical group compared to the nonsurgical group. Ulnar deviation, extensor lag, and arc of motion in the MCP and proximal interphalangeal joints also improved significantly in the surgical group. No improvement was seen in the mean AIMS2 scores and grip/pinch strength. Complications were minimal with a fracture rate of 9.5%. CONCLUSION: RA patients with poor baseline functioning showed long-term improvement in hand function and appearance following treatment with SMPA compared to nonsurgical controls.

The rheumatoid metacarpophalangeal joint.

Rheumatoid metacarpophalangeal joint deformities remain an important cause of disability. Surgical intervention in carefully selected patients improves function and prolongs independence. This article discusses the commonly used reconstructive techniques and their benefits. Case selection through a combined clinic with rheumatologists and hand therapists is recommended.

Properties of the International Classification for Functioning, Disability and Health in assessing hand outcomes in patients with rheumatoid arthritis.

OBJECTIVES: Variables from a study of patients with rheumatoid arthritis were linked to the International Classification of Functioning, Disability and Health (ICF) Core Set for rheumatoid arthritis. The purpose of this analysis was to evaluate the ICF Core Sets for rheumatoid arthritis for assessing the functional outcomes of the rheumatoid hand. DESIGN: Prospective cohort. SUBJECTS: A total of 142 subjects with rheumatoid arthritis. METHODS: Patients who elected to have or not have arthroplasty were linked with the ICF Core Sets. Study variables were assigned into one of the Core Set blocks that compose the ICF model. The blocks were then entered into multiple regression models to determine the contribution of each block in explaining the variation in hand outcome at enrollment, as well as the change in hand outcome after one year. RESULTS: Seventy percent of the reported hand outcome at enrollment was explained by the ICF Core Set blocks. For change in hand outcome at one year, the ICF Core Set blocks measured at enrollment explained 18% of the variance. CONCLUSION: The components of the ICF Core Set for rheumatoid arthritis explained much of the variation in hand functioning for patients with rheumatoid arthritis, but were not predictive of the change in hand functioning after one year.

Differences between the United States and the United Kingdom in the treatment of rheumatoid arthritis: analyses from a hand arthroplasty trial.

Previous studies have found differences in rheumatoid hand surgical practice around the world. The specific aim of this study is to compare baseline characteristics of rheumatoid arthritis (RA) patients in the United States (US) and the United Kingdom (UK) that may be influenced by the two different health-care systems. Patients were recruited from three sites (two in the US and one in England) as part of a National Institutes of Health funded study to examine outcomes of silicone metacarpophalangeal joint (MCPJ) arthroplasty in RA patients. Outcomes measurements included biomechanical assessments (grip strength, pinch strength, and mean ulnar drift and extensor lag at the MCPJs of all four fingers), a health-related quality of life questionnaire (the Michigan Hand Outcomes Questionnaire), and a medication assessment. American patients have a significantly higher income level (p<0.001) and have completed higher levels of education (p<0.001) than British patients. There were no significant differences in terms of self-reported disease severity or deformity at the MCPJs. RA patients in the US are more likely to take biologic medications (p<0.001), steroids (p=0.02), and Cox-2 inhibitors (p=0.02). Patients in the UK are significantly more likely (p<0.001) to take nonsteroidal anti-inflammatory drugs. There are differences in the demographic characteristics and medication use of RA patients with hand deformities in the US and UK. These differences may be influenced by the private versus socialized health-care systems. However, the perception of hand disease severity in participants in this study appears to be comparable between these countries.