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.

Characterization of Trapezial Pommel in Relation to Radiographic and Wear Patterns in Carpometacarpal Osteoarthritis.

BACKGROUND: Trapezial pommel, or ulnar osteophyte positioned at the vertex of the saddle-shaped facet, is a consistent structural appearance in osteoarthritis (OA) of the first carpometacarpal. This study investigates its relation to radiographic measures (modified Eaton staging and thumb OA [ThOA] index) and wear patterns (trapezial surface morphology and cartilaginous eburnation). METHODS: In all, 137 whole trapezia were explanted from 116 patients and evaluated for Eaton staging, morphology (saddle, cirque, or dish), and eburnation (degree of cartilaginous effacement) of the articular surface of the trapezium. In total, 131 Robert's views and 126 stress views were reviewed by 2 blinded senior surgeons for ThOA index and pommel size. Statistical analyses included Spearman correlation and linear regression. RESULTS: Standardized pommel size achieved good intrarater reliability (correlation coefficient: 0.80-0.98) and moderate interrater reliability (correlation coefficient: 0.60-0.67). The ThOA index and pommel size were significantly correlated across Robert's (rs = 0.51) and stress views (rs = 0.64). The ThOA index better distinguished between stages compared with pommel size. All the radiographic measures inversely correlated with preserved cartilage and varied across morphologies. Pommel size differed significantly between dish and saddle, and the ThOA index was significantly different between all morphologies when using stress views. CONCLUSIONS: We reliably quantified the pommel feature and demonstrated significant correlations with other radiographic and topologic measures of arthritic disease. If future studies can demonstrate that the pommel is a pathogenic process in ThOA and its correction can curb disease progression, the identification of the pommel feature may help guide targeted intervention.

Osteonecrosis of the trapezium: a case report and review of the literature.

We describe the case of a 58-year-old woman with AVN of the left trapezium which was treated surgically. This paper aims to review the etiologies leading to the pathology and the different therapeutic options. Avascular necrosis (AVN) of the carpal bones most commonly involves the lunate and the scaphoid . AVN of the trapezium is extremely rare. To our knowledge only 3 cases have been published in the literature so far and they were all treated differently.

Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial.

Various systematic reviews have recently shown that intra-articular platelet-rich plasma (IA-PRP) can lead to symptomatic relief of knee osteoarthritis for up to 12 months. There exist limited data on its use in small joints, such as the trapeziometacarpal joint (TMJ) or carpometacarpal joint (CMCJ) of the thumb. A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the TMJ (grades: I-III according to the Eaton and Littler classification) was conducted. Group A patients (16 patients) received 2 ultrasound-guided IA-PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval. Patients were evaluated prior to and at 3 and 12 months after the second injection using the visual analogue scale (VAS) 100/100, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH), and patient's subjective satisfaction. No significant differences between the baseline clinical and demographic characteristics of the 2 groups were identified. After 12 months' follow-up, the IA-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of VAS score (P = 0.015), Q-DASH score (P = 0.025), and patients' satisfaction (P = 0.002). Corticosteroids offer short-term relief of symptoms, but IA-PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic TMJ arthritis.

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.

[Osteoarthrosis of the trapeziometacarpal joint].

Osteoarthrosis of the trapeziometacarpal joint is a common condition, especially in middle-aged women, and this review summarises the diagnosis and treatment modalities. Many patients have few symptoms and may be treated conservatively with orthoses, nonsteroidal anti-inflammatory drugs and intra-articular steroid injections. In patients with more persistent symptoms, surgical treatment has generally shown good results. Several surgical procedures have been described, but at present, trapeziectomy is the preferred treatment. Total joint arthroplasty is possible and may provide faster rehabilitation and a better grip strength but at the expense of a relatively high risk of implant failure.

Histopathological analysis of the synovium in trapeziometacarpal osteoarthritis.

Dorsoradial and anterior oblique ligaments were harvested during surgery in 13 patients with symptomatic trapeziometacarpal osteoarthritis, which had been graded preoperatively by a modified Eaton-Littler radiographic grading. Ligaments, including the periligamentous synovium, were stained with S100 protein, neurotrophic receptor p75, protein gene product 9.5, calcitonin gene related peptide, acetylcholine, substance P, neuropeptide Y, noradrenaline, N-methyl-D-aspartate-receptor and Met/Leu-enkephalin. The synovium was classified as showing no, low-grade or high-grade synovitis. Free nerve endings had higher immunoreactivity for substance P than for N-methyl-D-aspartate-receptor, enkephalin and noradrenaline. The synovial stroma had less immunoreactivity for N-methyl-D-aspartate-receptor than for noradrenaline, substance P and calcitonin gene related peptide. There was no relation between the grade of osteoarthritis and the visual pain analogue scale, synovitis score, immunoreactivity of all antibodies and quantity of free nerve endings or blood vessels. Synovium in trapeziometacarpal joint osteoarthritis produces several neuromediators causing a polymodal neurogenic inflammation and which may serve as biomarkers for osteoarthritis or therapeutic targets.

Cartilage wear patterns in severe osteoarthritis of the trapeziometacarpal joint: a quantitative analysis.

OBJECTIVE: The present quantitative study aimed to assess the three-dimensional (3-D) cartilage wear patterns of the first metacarpal and trapezium in the advanced stage of osteoarthritis (OA) and compare cartilage measurements with radiographic severity. DESIGN: Using 19 cadaveric trapeziometacarpal (TMC) joints, 3-D cartilage surface models of the first metacarpal and trapezium were created with a laser scanner, and 3-D bone surface model counterparts were similarly created after dissolving the cartilage. These two models were superimposed, and the interval distance on the articular surface as the cartilage thickness was measured. All measurements were obtained in categorized anatomic regions on the articular surface of the respective bone, and we analyzed the 3-D wear patterns on the entire cartilage surface. Furthermore, we compared measurements of cartilage thickness with radiographic OA severity according to the Eaton grading system using Pearson correlation coefficients (r). RESULTS: In the first metacarpal, the cartilage thickness declined volarly (the mean cartilage thickness of the volar region was 0.32 ± 0.16 mm, whereas that of the dorsal region was 0.53 ± 0.18 mm). Conversely, the cartilage evenly degenerated throughout the articular surface of the trapezium. Measurements of the categorized regions where cartilage thinning was remarkable exhibited statistical correlations with radiographic staging (r = -0.48 to -0.72). CONCLUSIONS: Our findings indicate that cartilage wear patterns differ between the first metacarpal and trapezium in the late stage of OA. There is a need for further studies on cartilage degeneration leading to symptomatic OA in the TMC joint.

Factors Associated With Radiographic Trapeziometacarpal Arthrosis in Patients Not Seeking Care for This Condition.

BACKGROUND: A common adage among hand surgeons is that the symptoms of trapeziometacarpal (TMC) arthrosis vary among patients independent of the radiographic severity. We studied factors associated with radiographic severity of TMC arthrosis, thumb pain, thumb-specific disability, pinch strength, and grip strength in patients not seeking care for TMC arthrosis. Our primary null hypothesis was that there are no factors independently associated with radiographic severity of TMC arthrosis according to the Eaton classification among patients not seeking care for TMC arthrosis. METHODS: We enrolled 59 adult patients not seeking care for TMC arthrosis. We graded patients' radiographic TMC arthrosis and asked all patients to complete a set of questionnaires: demographic survey, pain scale, TMC joint arthrosis-related symptoms and disability questionnaire (TASD), and a depression questionnaire. Metacarpophalangeal hyperextension and pinch and grip strength were measured, and the grind test and shoulder sign were performed. RESULTS: Older age was the only factor associated with more advanced radiographic pathophysiology of TMC arthrosis. One in 5 patients not seeking care for TMC arthrosis experienced thumb pain; no factors were independently associated with having pain or limitations related to TMC arthrosis. Youth and male sex were associated with stronger pinch and grip strength. CONCLUSIONS: There are a large number of patients with relatively asymptomatic TMC arthrosis. Metacarpophalangeal hyperextension and female sex may have a relationship with symptoms, but further study is needed. Our data support the concept that TMC arthrosis does not correlate with radiographic arthrosis.

Artroplastia de fijación con hemibandeleta del palmar mayor en el tratamiento de la rizartrosis: Resultados preliminaries / Fixing arthroplasty with a slip of major palmar in the treatment of the trapeziometacarpal arthrosis: preliminary results

Objetivo: Evaluar los primeros resultados tras la realización de una artroplastia de fijación e interposición utilizando una bandeleta cubital del tendón palmar mayor en el tratamiento de la rizartrosis. Material y método: Desde abril de 2014 hasta enero de 2017, 16 pacientes con rizartrosis en estadio 3 y 4 de Eaton fueron intervenidos con hemitrapeziectomia y reconstrucción ligamentosa utilizando una plaslos pacientes fue de 64,3 (DS 7,4) años. El seguimiento medio postquirúrgico fue de 20,7 (DS 10,6) meses. Resultados: Los resultados funcionales según la clasificación Green y O'Brien fueron excelentes en 4 pacientes (25%), buenos en 10 pacientes (62,5%) y regulares en 2 pacientes (12,5%). La escala Quick-Dash preoperatoria pasó de 74,8 (DS 10,6) puntos a 10,8 (DS 9,9) puntos al final del seguimiento. De acuerdo a la escala Mayo, la muestra tenía una media de 85,4 (DS 14,6) puntos. Radiográficamente, no encontramos colapso articular trapecio-metacarpiano al final del seguimiento. Conclusiones: Esta técnica permite reproducir la función de los ligamentos trapeciometacarpianos y al realizar una plastia de fijación de la base del primer metacarpiano, lo estabiliza y evita el colapso articular, consiguiendo una articulación indolora y estable, con un buen arco de movilidad del pulgar. Los resultados clínicos y radiológicos al final del seguimiento son buenos y esperanzadores pero se necesita un mayor número de pacientes y mayor seguimiento para obtener conclusiones más definitivas

Purpose: To evaluate the early results after the fixing and interposition artroplasty using a cubital slip of the flexor carpi radialis for the treatment of ostheoarthritis of the thumb. Methods: From April 2014, to January 2017, 16 patients with ostheoarthritis of the thumb in stage 3 and 4 of Eaton underwent reconstruction with hemitrapeziectomy and ligaments reconstruction using a plasty of the palmar major. Mean patient age at surgery was 64, 3 (DS 7, 4) years. The minimum follow-up was 20, 7 (DS 10, 6) months. Results: The functional outcome according to Green and O’Brien score was excellent in 4 patients (25%) good in 10 patients (62, 5%) and satisfactory in 2 patients (12, 5%). The mean according Quick-Dash score was 74, 8 (DS 10, 6) points before the surgery to 10.8 (DS 9, 9) points at the end of the follow-up and according modified Mayo score, the result was 85, 4 (DS 14, 6) points. On the X-rays, there isn't collapse postoperative and the end of the follow-up. Conclusions: This technique enables to simulate the function of carpometacarpal ligaments and to perform a fixing arthroplasty of the base of the first metacarpal to stabilizes it and avoids the collapse of the joint, getting a painless and stable joint, with a good range motion of the thumb. The clinical and radiographic findings at follow-up were good and encouraging but more patients and longer follow-up is needed to reach definitive conclusions

Dubious space for Artelon joint resurfacing for basal thumb (trapeziometacarpal joint) osteoarthritis. A systematic review.

Introduction: Trapeziometacarpal arthritis is a common and disabling condition. There is no evidence in the literature of superiority of one surgical procedure over others. Several prosthetic implants have been introduced to preserve joint mobility. Sourced of data: We searched the on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'artelon', 'thumb', 'carpometacarpal', 'trapeziometacarpal' and 'rhizoarthrosis'; 11 studies were identified. Areas of agreement: The use of Artelon implant is not recommended because of its high revision rate and worse outcomes compared to conventional techniques. Areas of controversy: Inert materials subjected to compressive and shearing forces could produce debris and subsequent inflammatory response. There is debate in the published scientific literature regarding the role of preoperative antibiotic profilaxis and post-surgery inflammatory response. Growing points: Standard techniques such as trapeziectomy alone or combined with interposition or suspensionplasty offer effective treatment for thumb basal joint arthritis. Areas timely for developing research: Several prosthetic implants show promising results in terms of pain relief and functional request, but there is a need of long-term randomized controlled trials to demonstrate their equivalence, and eventually superiority, compared to standard techniques.

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.

A comparative study of diagnostic and imaging techniques for osteoarthritis of the trapezium.

OBJECTIVES: The aims of this study were to determine whether micro-CT is a reliable investigation method to evaluate the severity of OA in the trapezium and to develop a novel micro-CT scoring system based on a quantitative assessment of the subchondral bone thickness in order to better assess OA through an objective parameter. METHODS: We compared different diagnostic and imaging techniques performed consecutively on each sample: X-ray, visual analysis, micro-CT and histology. OA and healthy trapezia were subjected to semi-quantitative and quantitative analyses to be classified in four degrees of severity in OA (control, OA-2, OA-3 and OA-4). Specifically, samples were analysed using Dell's score for X-ray, Brown's score for visual analysis and Mankin's score for histology. Micro-CT was scored using a novel quantitative scoring system based on subchondral bone thickness measurements. Results obtained with each technique were then compared and correlated. RESULTS: X-ray analysis showed a higher frequency of OA-2 (27%) and OA-3 (32%) compared with OA-4 (5%), whereas visual analysis, micro-CT and histology showed a lower percentage for OA-2 (18%, 18% and 14%) and OA-3 (23%) and increased frequency for OA-4 (45%, 32% and 40%). Only the micro-CT score of subchondral bone thickness correlated significantly with all the other techniques (P < 0.05). CONCLUSION: This is the first comparison of techniques proposing a novel scoring system based on objective and quantitative micro-CT data that can be applied as a useful diagnostic tool for OA, providing a deeper comprehension of the pathophysiology of OA in trapezium.

Anatomical study of the ligamentous attachments and articular surfaces of the trapeziometacarpal joint. Consequences on surgical management of its osteoarthrosis.

In the goal to optimize conservative surgical techniques of the trapeziometacarpal joint in cases of moderate osteoarthritis, we have defined the relationships between the ligamentous attachments and the articular surfaces onto the trapezium and the first metacarpal bone on the one hand, and the dorsovolar and the transverse diameters of the articular surfaces on the other hand. Thirty-six trapeziometacarpal joints (from 18 fresh cadavers) were studied. They were separated into two groups depending on the macroscopic assessment of chondral disease. Group A included stages I to III (no osteoarthritis or moderate osteoarthritis), group B included stages IV (major cartilage destruction). The dorsovolar and transverse sizes of the articular surfaces were measured. Dorsoradial ligament (DRL), posterior oblique ligament (POL), intermetacarpal ligament (IML), ulnar collateral ligament (UCL) and anterior oblique ligament (AOL) were dissected and the distance between their attachments and the articular surfaces were measured. Group A included 17 joints (71% males) and group B included 19 joints (95% females). For the first metacarpal bone, the average ratio between the dorsovolar diameter and the transverse diameter of metacarpal articular surfaces was significantly higher in group B and the average distance between the ligamentous attachments and the articular surface was more than two millimeters, except for the DRL in group B. For the trapezium, only the posterior ligaments (DRL and POL) of group A were inserted at a mean distance more than two millimeters from the articular surfaces. Dorsovolar length of the metacarpal articular surface was higher for osteoarthritis cases. This difference can be explained by the existence of a palmar osteophyte that was always found in stage IV. Describing a map of the ligamentous attachment distance from the articular surface could help surgeons to avoid the ligamentous injury during minimal osteochondral resection.

Addition-subtraction osteotomy without ligamentoplasty for symptomatic trapezial dysplasia with metacarpal instability.

Trapeziometacarpal joint pain is often associated with a dynamic adduction deformity of the thumb metacarpal, combined with radial subluxation at the base of the thumb metacarpal, due to trapeziometacarpal dysplasia. Addition-subtraction osteotomy is a surgical option to correct the bony deformity when conservative treatment fails. Eight patients who underwent surgery with this technique were prospectively evaluated. All patients were female and mean age was 42 (range 27-59) years. Mean follow-up period was 23 (range 10-42) months postoperatively. Seven patients (87.5%) were very satisfied. Joint mobility and strength of the operated thumb was restored to a degree comparable to the contralateral thumb. Overall function according to the Quick-DASH score improved by 75.5% and pain according to the Visual Analogue Scale decreased by 65%. Radiological evaluation showed a decrease of the trapezial slope. Mean angle between the articular surface of the trapezium and the long axis of the second metacarpal measured 1420 preoperatively 1290 and postoperatively. In the present study results of addition-subtraction osteotomy without ligamentoplasty were promising, especially for function and pain. The technique may be a valuable treatment option for trapeziometacarpal dysplasia with metacarpal instability.

Acrometastasis showing an occult lung cancer.

The purpose of this paper was to present a case of an occult lung cancer diagnosed by the presenceof a carpal bone metastatic lesion.

[Isis(®) trapeziometacarpal prosthesis in basal thumb osteoarthritis: 30 months follow-up in 30 cases]. / La prothèse trapézométacarpienne Isis(®) dans la rhizarthrose : à propos de 30 cas à 30 mois de recul moyen.

OBJECTIVES: The goal of our work was to evaluate the results of the Isis(®) trapeziometacarpal prosthesis. METHODS: Our retrospective study included 26 patients, 30 prosthesis. The mean follow-up was 30 months. Preoperatively, the pain was 8.1 out of 10, the QuickDASH was 68.5 and the average Kapandji score was 7.8. The Dell's stage was 2.3. The prosthesis used was hybrid: the trapezial cup was cemented in 90% of cases, and the metacarpal stem was cementless. RESULTS: Eighty-seven percent of patients were satisfied or very satisfied. At last follow-up, the pain was 3.4 out of 10, the QuickDASH was 37.8, and the average Kapandji score 9.1. The range of motion in flexion-extension and abduction-adduction were respectively 30.5° and 31.7±11°. The strength of the key-pinch, pulp-pinch and grasp averaged 75% of the contralateral side. On radiologic review, the rate of radiolucent lines was 20%, and the loosening or non-osteointegration rate 10%. No dislocation was noted. One surgical revision was necessary for symptomatic metacarpal non-osteointegration. The survival rate of the prosthesis was 93% at 42 months. DISCUSSION: Clinical results are good. However, the rate of abnormal radiographic images (30%) at 30 months follow-up must incite caution. Although these prosthetic loosenings seem to be less symptomatic, a longer follow-up is necessary to assess the sustainability of clinical results and the future of these periprosthetic radiolucent lines. This led us to change our practice to using noncemented prostheses from now on.

Trapezial metastasis as the first indication of primary non-small cell carcinoma of the lung.

Metastasis to the bones of the hand and wrist is not common, and its discovery may reveal an advanced primary tumor located centrally. Clinically, hand metastasis is hard to differentiate from other more common hand pathologies. Its rarity, coupled with a lack of unique clinical manifestations, makes hand and wrist metastasis difficult to diagnose. However, its diagnosis is critical to initiate an appropriate course of treatment. We present a patient in whom lung carcinoma metastasis to the trapezium was definitively diagnosed upon surgical management of symptoms that were consistent with thumb carpometacarpal arthritis.

Carpal tunnel syndrome secondary to an osteophyte of the trapezium.

We report a 42-year-old man with a rare carpal tunnel syndrome (CTS) secondary to an osteophyte of the trapezium. The patient presented with a 3-year history of CTS, consisting of progressive pain and paresthesias in his right hand, positive Tinel and Phalen signs, and an electrodiagnostic study demonstrating median nerve compression at the wrist. The procedure was an open carpal tunnel release. Intraoperatively, a bony protuberance was found beneath the transverse carpal ligament (TCL), resulting in compression of the median nerve. The median nerve was decompressed and the patient's symptoms resolved postoperatively. Surgical pathology revealed bony fragments, and a postoperative CT scan was supportive of an osteophytic remnant protruding from the trapezium. Carpal bone osteophytes are rarely reported causes of CTS.

The usefulness of magnetic resonance imaging of the hand and wrist in very early rheumatoid arthritis.

INTRODUCTION: Magnetic resonance imaging (MRI) was used to study the hand and wrist in very early rheumatoid arthritis (RA), and the results were compared with early and established disease. METHODS: Fifty-seven patients fulfilling the new American College of Rheumatology criteria for RA, 26 with very early RA (VERA), 18 with early RA (ERA), and 13 with established RA (ESTRA), (disease duration < 3 months, < 12 months, and > 12 months, respectively) were enrolled in the study. MRI of the dominant hand and wrist was performed by using fat-suppressed T2-weighted and plain and contrast-enhanced T1-weighted sequences. Evaluation of bone marrow edema, synovitis, and bone erosions was performed with the OMERACT RA MRI scoring system. RESULTS: Edema, erosions, and synovitis were present in VERA, and the prevalence was 100%, 96.15%, and 92.3%, respectively. Significant differences in edema and erosions were found between VERA and ESTRA (P < 0.05). No significant difference was found in synovitis. CONCLUSIONS: Edema, erosions, and synovitis are findings of very early RA. MRI, by detecting these lesions, may play an important role in the management of these patients.