Update on Thumb Basal Joint Arthritis Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance. SUMMARY: Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

Severe camptodactyly: A systematic surgeon and therapist collaboration.

INTRODUCTION: Although common, the treatment of camptodactyly is controversial. PURPOSE: Our purpose is to delineate a logical stepwise treatment plan based on corresponding components of the pre-operative and intraoperative evaluation of camptodactyly. In addition, describe structure rehabilitation plan utilizing the same stepwise evaluation. METHODS: With the use of a retrospective cohort study design, we reviewed 18 consecutively operated digits in twelve patients with camptodactyly affecting the proximal interphalangeal (PIP) joint. There were five girls and eight boys, averaging eight years of age (range: 9 months to 15 years) at surgery. RESULTS: Surgery corrected flexion contractures with mean post-operative flexion contracture of 3° (range 0-25°) at mean follow-up of 11 months (range 3-32 months). 15 of 18 digits achieved full active PIP extension. DISCUSSION: By employing a detailed clinical assessment to guide surgical treatment followed by focused therapy, we have markedly improved flexion contractures in digits with moderate to severe camptodactyly. CONCLUSIONS: Hand therapy is essential to maintain and further surgical improvement of passive extension and to regain active extension following surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Basal joint osteoarthritis of the thumb: ligament reconstruction and tendon interposition versus hematoma distraction arthroplasty.

PURPOSE: Thumb basilar osteoarthritis is common. Several surgical options exist. Studies have evaluated outcomes in separate cohorts but have not compared methods. Our study compared the functional outcome of ligament reconstruction and tendon interposition (LRTI) suspension arthroplasty and hematoma distraction arthroplasty (HDA) by patient questionnaires, clinical measurements, and radiographic measurements to see whether there is validity in exclusively using either LRTI or HDA. METHODS: In this retrospective study, patients received LRTI (12 thumbs in 11 patients) or HDA (9 thumbs in 9 patients) according to the attending surgeon's preference, one exclusively performing LRTI and the other HDA. Patient perception was evaluated with a QuickDASH questionnaire and 10-point pain visual analog scale (VAS). Potential QuickDASH scores range from 0 to 100, with lower scores indicating better function. Clinical evaluation examined grip strength, tip pinch, and lateral pinch in kilograms-force, and range of motion. Measurements were compared with those from the contralateral hand and published normal values. Stressed and unstressed radiographs assessed metacarpal proximal and lateral migration and first web space. Chart review documented surgical times. RESULTS: The LRTI and HDA scored similarly on QuickDASH. Most reported excellent pain relief. Average grip, tip pinch, and lateral pinch were also similar in both groups. None achieved significance. Comparisons with contralateral hand and published normal results showed that LRTI and HDA were comparable. All except 2 could oppose to little finger base. With stress, additional proximal migration was similar. Web space was preserved with both procedures. LRTI took 54 minutes longer. CONCLUSIONS: The LRTI and HDA were comparable on all levels of objective and subjective measurements. Both groups satisfied the principal goals to provide a stable, mobile, pain-free thumb. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Functional outcome for children with thumb aplasia undergoing pollicization.

BACKGROUND: Hand function is difficult to evaluate in young patients. It is helpful to assess young children after surgery for trauma or congenital anomaly to see how they cope as they progress through their developmental milestones. METHODS: Functional outcome in 10 children (12 upper extremities) who had previous pollicization for a congenitally absent or severely hypoplastic thumb were evaluated by standard radiographs, thumb total active range of motion, grip and pinch strength, parent questionnaire, modified Jebsen functional testing, and a pegboard Functional Dexterity Test. RESULTS: Grip strength was significantly less (p = 0.008) in the hands that had been operated on (mean, 2 kg) compared with the hands that had not been operated on (mean, 5.6 kg). Pinch strength was also significantly less (p = 0.008) in the hands that had been operated on (mean, 1.0 kg) compared with those that had not been operated on (mean, 2.1 kg). In most, hands that had been operated on and those that had not been operated on tested outside the 2-SD range of age-matched normals for pinch and grip strength and also for the Functional Dexterity Test. In contrast, total Jebsen Hand Function Test time was not significantly different from hands that had not been operated on, except that some subtests were significantly different, such as checker stacking (p = 0.016; mean difference, 7.2 seconds) and page turning (p = 0.031; mean difference, -10 seconds). The total active range of motion in hands that had been operated on and those that had not been operated on was also not significantly different. All children used their reconstructed thumbs in a normal pattern. Parent questionnaires revealed satisfaction with appearance and good social interactions. Functional activities showed greatest difficulty handling small objects, especially when simultaneous pinch strength was required, such as fastening buttons and small snaps. CONCLUSIONS: This study demonstrates the importance of evaluating multiple aspects of functional outcome for congenital hand problems and of using comparative age-appropriate validated norms. Pollicization is a rewarding procedure for children with thumb aplasia.