Medium to Long-Term Follow-Up After Pyrocarbon Disc Interposition Arthroplasty for Treatment of CMC Thumb Joint Arthritis.

PURPOSE: Pyrocarbon disc interposition arthroplasty has been designed for the surgical treatment of Eaton-Glickel grade II/III carpometacarpal thumb joint arthritis. This study presents the results of this technique with a minimum 5-year follow up. METHODS: We assessed 4 questionnaires for patient-reported outcome measurements in a cross-sectional study: the Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand questionnaire, Michigan Hand Questionnaire, and questions about satisfaction at the 5-year follow up. We evaluated grip and pinch strength, range of motion, and the radiological position of the disc. Finally, a Kaplan-Meier survival analysis was performed. RESULTS: A total of 164 thumbs (in 137 patients) were available for follow-up varying from 5 to 12 years. Median Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand, and Michigan Hand Questionnaire scores were 17, 18, and 76, respectively. The satisfaction score was 9 (Likert scale of 1-10). Grip and pinch strength reached nearly 100% compared with the contralateral hand. Range of motion resulted in a Kapandji score of 10. Thumb height showed a marginal loss and the Kaplan-Meier survival curve showed a survival rate of 91%. CONCLUSIONS: Our study suggests that pyrocarbon disc interposition arthroplasty is a reliable and feasible treatment for carpometacarpal thumb joint arthritis at medium-term follow-up. It was associated with a high level of patient satisfaction; it maintained thumb height and the implant survived in 91% of patients. Strength and range of motion were comparable to the contralateral hand after a minimum follow-up of 5 years. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic versus Open Distal Hemitrapeziectomy without Interposition: 2-Year Results of a Randomized Controlled Trial.

BACKGROUND: Distal hemitrapeziectomy is suggested as an alternative for total trapeziectomy for carpometacarpal thumb joint osteoarthritis, when the scaphotrapeziotrapezoidal joint is unaffected. This can be performed as an arthroscopic or open procedure, with suggested advantages for the less invasive arthroscopic technique. To determine which technique has better outcome on subjective and objective measures, the authors performed a prospective, randomized, controlled trial. METHODS: The authors randomized 90 thumbs in the open ( n = 45) and arthroscopic ( n = 45) groups and evaluated results preoperatively and at 3-, 12- and 24-month follow-up. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) to assess pain and function. Also, the authors evaluated pinch, grip, and range of motion, together with return to work, satisfaction, and complications. RESULTS: Full follow-up was obtained in 62 thumbs (open group, n = 32; arthroscopic group, n = 30). For both groups, the PRWHE improved from preoperatively to 12- and 24-month follow-up. Also, grip power, key pinch, and tip pinch improved at final follow-up for both groups. Between groups, there were no clinically important differences between PRWHE, power of grip or pinch, and range of motion. Operation time was shorter for the open group; also, return to work was slightly shorter after open surgery. Satisfaction was comparable between groups. CONCLUSIONS: This study shows good functional improvement and pain reduction obtained with a hemitrapeziectomy. No arthroscopic benefits could be substantiated in the results. Because of shorter operation time for the open procedure, and because of equal outcomes compared to the arthroscopic technique, we prefer open hemitrapeziectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Long-term follow-up of patients treated with pyrocarbon disc implant for thumb carpometacarpal osteoarthritis: the effect of disc position on outcomes measures.

Pyrocarbon disc interposition arthroplasty is an effective treatment for thumb base osteoarthritis. However, as with all implant techniques, the disc can (sub)luxate over time. The relationship between disc position, the experienced pain, and the necessity for revision surgery is not known. This study evaluated the effect of radiographic pyrocarbon disc position on the Michigan Hand Questionnaire (MHQ) outcome measurement. In addition, the correlation between disc position and other factors, including pain intensity, thumb strength, and occupation, was assessed. In this retrospective study, we included 136 patients (161 thumbs) with a mean follow-up of 6.7 years (range 3.3-11). Radiographs were scored on disc position and classified as 'well aligned' (Grade 1) up to 'luxated' (Grade 4). A database used for outcome measures included MHQ scores, pain intensity, satisfaction, thumb strength, range of motion, occupation, and hand dominance. In bivariate analyses, we assessed any association between disc position and outcome measurements. Eighty of the 136 implants (59%) were well-positioned (not displaced), 41% were (slightly) displaced (grade 2-3). No relationship existed between the degree of disc displacement and MHQ scores. Manual labor occupation was the only factor that correlated with more severe disc displacement. We could not detect any association between disc position and other outcome variables including pain intensity, thumb strength, or hand dominance. In conclusion, our study suggests that radiographic disc displacement has little clinical consequences. Future studies must assess if there is a causality between heavy mechanical stress to the CMC1 joint and luxation of the pyrocarbon disc over time.Level of evidence: IV Therapeutic-Retrospective case series.

Stronger pinch strength at long-term follow-up after pyrocarbon disc interposition arthroplasty compared to trapeziectomy with ligament reconstruction and tendon interposition for CMC-1 osteoarthritis.

BACKGROUND/INTRODUCTION: In this study, we wanted to compare the pyrocarbon disc interposition arthroplasty (PDI) with trapeziectomy plus ligament reconstruction tendon interposition (LRTI). Primarily, we tested whether PDI resulted in a higher pinch strength. Secondarily, we compared the grip strength, range of motion (ROM), patient reported outcomes, satisfaction and complications. METHODS: Due to scarcity of preoperative hand measurements, we performed a descriptional cross-sectional cohort study of patients operated between 2006 and 2014, with a minimum of 5 years of follow-up. Patients were treated with PDI or LRTI. We determined key pinch strength as primary outcome, followed by tip- and tripod pinch, grip strength, palmar abduction and opposition; the Michigan Hand Outcome Questionnaire (MHQ), Patient Reported hand and Wrist evaluation (PRWHE), satisfaction and complications. Propensity score matching was used to match both study groups on demographic variables. A ratio of 2:1 was used resulting in inclusion of 62 (of 154) PDI and 31 (of 31) LRTI thumbs. RESULTS: The PDI-group patients showed stronger key and tip pinch strength than the LRTI group (p=0.027 and p=0.036 respectively). Tripod pinch, grip strength and ROM were equal for both groups. MHQ and PRWHE were comparable, with higher satisfaction for the PDI group. Eight PDI patients were converted to LRTI due to pain. CONCLUSION/DISCUSSION: This study confirmed our hypothesis that key and tip pinch strength is stronger after PDI compared to LRTI for CMC-1 joint osteoarthritis. Both techniques have comparable outcomes considering patient reported outcome (MHQ and PRWHE), ROM and complications.

Pyrocarbon Disc Interposition Arthroplasty (PyroDisk) for the Treatment of Carpometacarpal Thumb Joint Osteoarthritis.

In cases of isolated carpometacarpal (CMC) thumb joint osteoarthritis, a hemitrapeziectomy can be performed. To address the risk of subsidence of the first metacarpal, a pyrocarbon disc has been designed as an interposition prosthesis. The disc is made of pyrolytic carbon with the same elastic modulus as cortical bone, making it resistant to wear from surrounding bone. This property contributes to preservation of thumb length and prevents subsidence. The present video article shows the pyrocarbon disc interposition arthroplasty step by step. The procedure results in substantial pain reduction with good function and strength at long-term follow-up. The complication rate is comparable with that of other surgical tendinoplasties for CMC thumb joint osteoarthritis. The survival rate has been reported to be 91% at a minimum follow-up of 5 years1-3. CMC thumb joint osteoarthritis is a common pathology. If symptoms remain despite splinting and hand therapy, surgical treatment is often performed. The simple trapeziectomy is seen as the reference standard, with good results and fewer complications compared with other surgical procedures4-6. Despite this fact, many surgeons still prefer to combine trapeziectomy with a tendinoplasty in order to reduce the risk of proximal migration and impingement of the first metacarpal on the scaphoid7-9. However, the volume and stiffness of autologous tendons are far less than that of the trapezial bone. This might be one of the reasons that trapeziectomy with tendinoplasty does not lead to better results than simple trapeziectomy. To overcome the disadvantages of a tendinoplasty, the PyroDisk (Integra LifeSciences) was introduced for CMC thumb joint osteoarthritis to preserve thumb length and provide more stability than other traditional techniques. The disc is designed to be utilized after a distal hemitrapeziectomy for patients with CMC thumb joint osteoarthritis without involvement of the scaphotrapeziotrapezoid (STT) joint. Description: Preoperatively, review radiology images to confirm that the osteoarthritis is limited to the thumb CMC joint and that all appropriate tools for inserting the disc are available before beginning surgery. Next, the patient is placed with their arm on an arm rest. The CMC thumb joint is exposed via a dorsal longitudinal skin incision, sparing the dorsal radial nerve branches and the radial artery and accompanying venes. The capsule is opened with an H-incision. With 2 parallel cuts to the joint surface, the articular surfaces of the joint are removed. After resection of the articular joint surfaces, the residual width and height of the joint space after resection are measured. The central point in the joint surfaces is marked for the bone tunnels. With an awl, tunnels are created from the center of the joint surface to the proximal (trapezial bone) and distal (first metacarpal bone) and the dorsal side. The implant size is measured with the trial implants for correct size of the disc. A tendon strip of either APL (abductor pollicis longus) or FCR (flexor carpi radialis) tendon is harvested for use securing the disc. The disc is secured with the tendon strip from proximal through the trapezium, through the disc and distal through the first metacarpal, and is secured to itself at the trapezial bone. The position is checked under fluoroscopy. When the disc in the right position, the joint capsule and skin are closed and a plaster cast is applied with the thumb in abduction. Alternatives: Alternative treatments include hemitrapeziectomy without interposition; full trapeziectomy, with or without ligament reconstruction and/or tendon interposition; and joint resurfacing prostheses. Rationale: The advantage of pyrocarbon disc interposition arthroplasty over other treatment options is the preservation of the STT joint1. Therefore, the procedure is minimally harming the surrounding anatomy despite open surgery and has a high success rate in reducing pain while preserving function and strength. The risk of complications is comparable with that of other CMC joint arthroplasty techniques. A relatively high survival rate has been reported at a mean follow-up of 7 years (range, 5 to 12 years). In cases of recurrent pain, all other surgical options remain possible ("no bridges are burned"). The main disadvantage is the cost of the disc. Expected Outcomes: Our recent study of this technique showed good patient-reported outcomes, pain reduction, patient satisfaction, and preservation of strength and range of motion at a mean follow-up of 7 years1,2. The survival rate was 91%, with 3% failing as a result of disc dislocation. Other reasons of failure were STT osteoarthritis and pain without a specific cause. Important Tips: Preoperatively, make sure that only the CMC thumb joint has osteoarthritis and that the STT joint does not. In cases in which it is unclear whether the osteoarthritis is isolated to the CMC thumb joint, perform computed tomography to make certain10.Only a few millimeters of bone must be resected from the first metacarpal base and the distal trapezium. Both bone cuts must be made parallel to each other and perpendicular to the longitudinal axis of the first metacarpal bone.Bone tunnels must be exactly centered in the cut joint surfaces for proper implant positioning and to decrease the chance of subluxation.Size the implant properly and check movement and stability. Acronyms and Abbreviations: OR = operating roomFCR = flexor carpi radialisAPL = abductor pollicis longusPRWHE = Patient-Rated Wrist and Hand EvaluationDASH = Disabilities of the Arm, Shoulder and Hand QuestionnaireMHQ = Michigan Hand QuestionnaireROM = range of motionFU = follow-upCRPS = complex regional pain syndromeLRTI = ligament reconstruction and tendon interpositionMRI = magnetic resonance imagingCT = computed tomography.

Trapeziectomy and Alternative Suspension Technique in Thumb Carpometacarpal Arthritis: Patient-Reported Outcome Measures.

Purpose: For treatment of carpometacarpal thumb joint osteoarthritis, a trapeziectomy with an alternative suspension technique can be performed as the primary surgery or as the secondary after a failed primary surgery. This study evaluates the midterm follow-up (median, 54 months) for this technique using patient-reported outcome measures. Methods: After trapeziectomy, an alternative suspension technique is performed with a flexor carpi radialis tendon strip. Leaving the insertion intact, the strip is tunneled through a drill hole in the base of the first metacarpal and then through a drill hole in the second metacarpal neck and then sutured back onto itself. This suspends the first metacarpal to the shaft of the second metacarpal, creating a strong, V-shaped suspension. As the technique is performed in both the primary and secondary surgery, we analyzed both groups separately. As the primary outcome, we evaluated pain and function with the Patient-Rated Wrist and Hand Evaluation. Further, we evaluated the Disabilities of the Arm, Shoulder and Hand and Short Form 12 questionnaire scores from eligible patients. Finally, we correlated pain and function to quality of life. Results: The median Patient-Rated Wrist and Hand Evaluation score was 16.0 (interquartile range, 1.5-40.4) after the primary surgery and 46 (interquartile range, 34.0-75.5) after the secondary surgery. Patients after the primary surgery also scored better on the Disabilities of the Arm, Shoulder, and Hand questionnaire compared to patients after the secondary surgery. The Short Form 12 questionnaire physical scores were negatively correlated with the Disabilities of the Arm, Shoulder, and Hand questionnaire scores for the primary group (correlation coefficient, -0.468) and negatively correlated with the Patient-Rated Wrist and Hand Evaluation pain scores for the secondary group (correlation coefficient, -0.703). Conclusions: Trapeziectomy with this alternative suspension technique for treatment of carpometacarpal thumb joint osteoarthritis shows good patient-reported outcome measures for primary surgery and poor patient-reported outcome measures after the secondary surgery. Type of study/level of evidence: Therapeutic IV.

Arthrodesis of the Carpometacarpal Thumb Joint for Osteoarthritis; Long-Term Results Using Patient-Reported Outcome Measurements.

Background Results following carpometacarpal (CMC) arthrodesis of the thumb for osteoarthritis vary widely in literature. Data on long-term patient-reported outcome measurements (PROMs) after thumb CMC joint arthrodesis for osteoarthritis are scarce. Purpose We report the long-term outcomes of PROMs (function, pain, and satisfaction) after arthrodesis of the thumb CMC joint. We evaluated the correlation of function and pain with patient satisfaction. Methods Long-term PROMs after thumb CMC arthrodesis for osteoarthritis were evaluated using a retrospective cohort (1996-2015). Three different PROM questionnaires (Disabilities of the Arm, Shoulder, and Hand Questionnaire, Dutch Language version [DASH-DLV], the Patient-Related Wrist and Hand Questionnaire Dutch Language version [PRWHE-DLV], and a questionnaire concerning satisfaction) were sent to all patients. Results Twenty-five arthrodeses (21 patients) were available for long-term follow-up. The median follow-up time was 10.8 years (interquartile range [IQR]: 9.7-13.0). The median DASH score was 29.2 (IQR: 14.4-38.3), median PRWHE score was 25.0 (IQR: 12.5-44.3). The median satisfaction after the operation and satisfaction with outcome of the operation was 10 for both (on a Likert's scale with 1 worse and 10 excellent satisfaction). There was a statistically significant correlation between the PRWHE total score and PRWHE pain score and satisfaction with surgery and satisfaction with the result. There was no correlation between PRWHE function score and satisfaction or DASH and satisfaction. Results after hardware removal showed no significant differences compared with patients without hardware removal. Conclusion Patients who underwent arthrodesis for thumb CMC osteoarthritis showed high satisfaction at long-term follow-up, despite moderate results as measured using the DASH and PRWHE. The PRWHE total and PRWHE pain scores correlated significantly with satisfaction with surgery and satisfaction with the result, respectively, whereas no correlation was observed with the PRWHE function score or DASH and satisfaction. This therapeutic study reflects level of evidence IV.

[Treatment of osteoarthritis of the thumb basal joint]. / Behandeling van artrose van de duimbasis.

Osteoarthritis in the carpometacarpal joint of the thumb (CMC1) is described in three patients who were all restricted in their daily activities by the disease. CMC1 osteoarthritis is a common disease affecting mainly postmenopausal women and individuals who use the joint intensively. Two of our patients, a 52-year-old female teacher and a 45-year-old male dentist, were treated by resection of the articular surfaces and interposition of a tendon or a polycarbon disc into the joint. To achieve a strong, stable thumb a 58-year-old sculptress had arthrodesis of the left CMC1. In her right hand, resection of the trapezium and ligament reconstruction of the CMC1 joint was necessary. There is no evidence-based guideline for treatment of osteoarthritis of the carpometacarpal joint of the thumb. Many non-surgical and surgical treatment options for CMC1 osteoarthrosis have been described. Optimal treatment is chosen depending on radiological staging of the disease and on the wishes and expectations of the patient.