SYM10: Thumb Basal Joint Arthritis - Expert Surgeons

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SYM10: Thumb Basal Joint Arthritis -

Expert Surgeons Defend their Procedure

Moderator(s): Warren C. Hammert, MD

Faculty: Steven Z. Glickel, MD, Amy L. Ladd, MD, Jennifer Moriatis Wolf, MD, and

Jeffrey Yao, MD

Session Handouts

Saturday, October 03, 2020

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

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SYM10: Thumb Basil Joint ArthritisExpert Surgeons Defend Their

ProcedureModerator:

Warren C. Hammert, MD

Faculty: Steven Z. Glickel, MDAmy L. Ladd, MDJeffrey Yao, MD

Jennifer Moriatis Wolf, MD

Steven Z. Glickel, MD

Hematoma Distraction Arthroplasty

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Amy L. Ladd, MD

Trapeziectomy with Suture Suspension Arthroplasty

Jeffrey Yao, MD

Trapeziectomy with Suture Button Suspension Arthroplasty

Jennifer M. Wolf, MD

Ligament Reconstruction and Tendon Interposition Arthroplasty

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Thumb CMC Arthritis

Warren C. Hammert, MD

October 3, 2020

Disclosure

No relevant financial relationships with commercial interest to disclose

But, I live in Rochester, NY – Home of LRTI

Becker SJE, et al. Death, taxes, and trapeziometacarpal arthrosis hand. CORR. 2013Prevalence of thumb CMC arthritis increases with age, and radiographic changes consistent with the disease have been reported to be as high as 85% in individuals aged 71 to 80 years of age, and 100% in women aged 91 and older

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Anatomy and Biomechanics

Saddle joint – allows motion in 3 planesOpposition – flexion, abduction, pronation16 ligaments

Key stabilizers – AOL (beak ligament), DRL

Joint compression force 12-14X greater than force at tip of thumb and index during pinch

Imaging

Views of thumb rather than hand or wristRoberts, Bett’s, 300 stress view

Eaton Littler Classification most widely used• Stage 1-4

Imaging- Special Views

30 Degree stress view

Allows visualization of all trapezium articulations

Robert’s View

True AP

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Imaging

Pantrapezial Arthritis – Eaton Stage 4

Pantrapezial ArthritisMore likely to have carpal malalignment due to scaphoid shortening/ proximal row extension

May be exacerbated by trapezial excision and proximal trapezoid excision

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Nonoperative Treatment

BracingNSAIDSStrengtheningCorticosteroid injections

Orthotics

Strengthening

Adams JE et al. Radiographic Analysis of Simulated First Dorsal Interosseous and Opponens Pollicis Loading Upon Thumb CMC Joint Subluxation: A Cadaver Study. Hand 2018

McGee C et al. First Dorsal Interosseous Muscle Contraction Results in Radiographic Reduction of Healthy Thumb Carpometacarpal Joint. JHT 2015

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Surgical Treatment

• Eaton ligament reconstruction

• Metacarpal extension osteotomy

• Dorsal capsulodesis

• Implant arthroplasty

Trapezium Sparing Trapezial Excision• Excisional arthroplasty

• Trapeziectomy

• Trapeziectomy with interposition

• Trapeziectomy with ligament reconstruction

• Trapeziectomy with ligament reconstruction and tendon interposition

Outcomes

Most do well so becomes surgeon preference

What do we know?

• Authors' conclusions• We did not identify any studies that

compared surgery to sham surgery or to non‐operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

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Face off vs Cage Match

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DISCLOSURES

Steven Z. Glickel, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

HEMATOMA DISTRACTION ARTHROPLASTY

Steven Z. Glickel, M.D.OrthoManhattan

Clinical Professor of Orthopaedic SurgeryNYU Grossman School of Medicine

New York, N.Y.

EVIDENCE BASED

• Rationale for evidence based medicine is to base treatment upon available evidence

• For much of what we do there is little strong evidence but a lot of experience

• Treatment of basal joint disease is one of the few things in hand surgery for which there is compelling evidence

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EVIDENCE DAVIS• Trapeziectomy (T) 30, T+interposition 23, LRTI 23; Pinned 4 wks• Pain, ROM, stiffness, weakness, functional disability, key and tip pinch, grip, scaphoid-

thumb MC height• Results indistinguishable at 3 months and 1 year

Davis et al. JHS(B) 1997

• Trapeziectomy (T) 62, T+interposition 59, LRTI 62; Pinned 4 wks• Pain, ROM, stiffness, weakness, functional disability, key and tip pinch, grip, failure rate• Outcomes were very similar at 1 year F/U• “There appears to be no benefit to tendon interposition or ligament reconstruction”

Davis et al. JHS(Am) 2004

EVIDENCE DAVIS• Trapeziectomy 67, not pinned; LRTI 61 pinned 4 weeks• Pain, ROM, stiffness, weakness, key and tip pinch, grip, DASH• No significant differences at 3 month and 1 year f/u of trapeziectomy w/o pin and LRTI

with pinDavis, Pace JHS(E) 2009

• Trapeziectomy 52, trapeziectomy with PL interposition 46, LRTI 54; Pinned 4 weeks• Minimum 5 y f/u; mean 6 y; range 5-18 y• No difference in pain relief, grip, key and tip pinch

Gangopadhyay et al. J Hand Surg 2011

EVIDENCE COCHRANE 2005• 7 Studies 384 patients• Procedures

– Trapeziectomy– Trapeziectomy with interpositional arthroplasty– Trapeziectomy with ligament reconstruction – LRTI– Joint replacement

• No procedure superior re: pain, function, pt. global assessment, ROM or strength

• LRTI 11% more adverse events than other procedures

Wajon et al. Cochrane Database Syst Rev. 2005

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EVIDENCE COCHRANE 2009

• 9 studies 477 participants• Procedures

– Trapeziectomy– LRTI– Trapeziectomy with interpositional arthroplasty – Trapeziectomy with ligament reconstruction – Artelon– Arthrodesis– Joint replacement

• No procedure demonstrated superiority over another in terms of pain, physical function, patient global assessment or ROM


EVIDENCE COCHRANE 2015

• 11 studies 670 participants• Procedures

– Trapeziectomy– LRTI– Trapeziectomy with interpositional arthroplasty– Trapeziectomy with ligament reconstruction– Artelon– Arthrodesis– Swanson joint replacement

• No procedure demonstrated superiority in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or imaging


EVIDENCE BASED?

• Logic would suggest that if results are equivalent for several techniques it would make sense to do the simplest procedure that achieves that result

• That procedure is hematoma distraction arthroplasty

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HEMATOMA DISTRACTION

• I am not trying to convince you that HDA is the greatest thing since sliced bread

CRITERIA CMC ARTHROPLASTY

Important• Good results• Patient satisfaction• Low complication rate• Cost

Not Important• “Procedural chauvinism” • Devices and implants for the sake of

using devices and implants

HDA yields good results, high patient satisfaction, low complication rate and is most cost effective of procedures being discussed today


• HDA meets all of the criteria of what is important• Very underused based on its merits

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WHY NOT DO HDA

• Duration of immobilization (5-6 weeks)• Some patients do not like K-wires

• Duration of immobilization has no long term negative implication

Haase SC, Chung KC. Plast Reconstr Surg. 2011

• We use K-wires for dozens of indications; why is it problematic for HDA

PRE OP

PRE OP

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VOLAR CAPSULODESIS MP


ARTHROPLASTY SPACE

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POST OP

• 5-6 weeks in splint• Removable splint x 2 weeks• Therapy beginning when out of initial splint

– ROM for 1st month– ROM and strengthening thereafter

1 YEAR POST OP


• Trapeziectomy and pinning in abduction and extension for 6 weeks– 22 thumbs– F/U avg 6.5 years– 18 of 22 completely pain free– 21% increase in grip– 11% increase in key pinch– ROM nearly full– Arthritis Impact Measurement Scale: improvement in hand function

Gray, Meals. J Hand Surg. 2007

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LESS IS MORE

“There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of LRTI. This presents further evidence that potentially, “less is more” in the treatment of thumb CMC arthritis.”

Ladd and Yao, senior authorsPark et al. Hand, 2008

EVIDENCE BASED?

• We do what we have been taught and what we are comfortable doing that yields good results

• However, if an alternative exists that is as successful, more efficient and more cost effective, consideration might be given to trying that procedure

• The current trend seems to be in the opposite direction i.e. more devices, more implants, no demonstrably better results at greater cost

Thank you

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Amy L. Ladd, MD

Intellectual Property: Loci OrthopaedicsContracted Research: NIHOwnership Interests: Loci, Intuitive Surgical, Stryker

Amy L. Ladd MD

SYM10: Thumb Basal Joint Arthritis – Expert Surgeons Defend Their ProcedureASSH Annual Meeting 2020

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University of Rochester tradition LRTI

Richard I Burton MD

Vincent Pellegrini MD

Suture suspension arthroplasty 2009

Jeanne Delsignore MD

Ladd – volar

Weiss – dorsal

Distal insertion FCR & APL “nature’s anchors” 2019 JHS Weiss report 320 consecutive patients

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Anybody who hurts enough . . . And has failed the treatment ladder options

Special Considerations Pantrapezial collapse MP collapse

Relative contraindications Inflammatory arthritis Strength is critical

Volar (Wagner) approach Dorsal works fine, too

Ladd & Weiss Hand‐e Video AAOS and VuMedi, too

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Incision

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What all our procedures have in common

Pain‐free joint

Dexterity

Mobility

Strength

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Joint reaction force

Newton’s 3rd law of Motion

For every action, there is an equal and opposite reaction.

MP Arthrodesis Collapsible thumb > 30 degrees

Remember . . .

Trapeziectomy creates a marshmallow, not a drumhead!

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DISCLOSURES

Jeffrey Yao, MD

Royalty: Arthrex

Intellectual Property: Arthrex, Elevate Braces

Speakers Bureau: Depuy-Synthes, Trice/Segway, Exsomed

Ownership Interests: Elevate Braces, 3D Systems

Trapeziectomy with Suture Button Suspension: Allowing Early

Unprotected ROMJeffrey Yao, MD

ProfessorDepartment of Orthopaedic SurgeryStanford University Medical Center

Methods of Treatment for Thumb CMC Arthritis

• Trapeziectomy with hematoma distraction arthroplasty (HDA)• Gervis, 1949; Meals, 2004

• Ligament Reconstruction Tendon Interposition (LRTI)• Burton, Pelligrini 1986

• APL suspensionplasty• Thompson, 1989• Soejima, Hanamura, Kikuta, Iida, Naito, 2006

• Suture suspensionplasty• Delsignore, 2009

• Allograft rib interposition• Eaton, 1984, Trumble, 2000

• Implant arthroplasty -Not proven

• Unique Circumstances• Wilson metacarpal osteotomy – younger patients

• CMC arthrodesis – post-traumatic DJD in young laborers

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Patients Treated with All Techniques Do Well!

Evidence Based Medicine

• Conclusions from Cochrane Reviews 2005, 2009, 2015:

• Patients treated with all techniques do well• Treatment is largely based on surgeon preference• Trapeziectomy alone: lower complications• No need for ligament reconstruction!• No need for interposition!• Some secondary criteria may drive future trends• Operative time• Complications• Accelerated recovery

If you did this…

…you wouldn’t do this

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So if you did this…

…No need to do this!

Would You Want a Cast for 4 Weeks or More?

Or Would You Want THIS at 5 Days??

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Or this at 5 days?

Suture Button Suspension

Supporting Literature

Arthroscopy, 2010

Yao, JHS 2013Kakar, JHS 2014Mohan, J Orthop 2015Avant, Hand 2015Landes, Hand 2016

Desai, Hand 2016Hooke, JHS 2016Yao, JHS 2017Grasu, Hand 2019Hozack, Hand 2020

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Clinical Case – Eaton III

Clinical Case – Eaton III

Ballottment after Trapeziectomy

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Pearl: Use Targeting Jig for Precise Insertion of Guidewire

Pearl : Tensioning over a Clamp to Prevent Impingement

“Shenton’s Line of the Hand”

Final Result

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Post-Operative

• Thumb spica splint for 3-5 days

• Suture removal and scar massage

• Start ROM exercises at 3-5 days

• AROM for 4 weeks, advance to strengthening as tolerated

• Splint for comfort only

• Suture button postoperative therapy protocol has been developed

5 Days Post-Op

SIX WEEKS!

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Mid Term Clinical Experience

• 14 patients (16 thumbs)

• Mean followup 64 months (range 49 to 84)

• QuickDASH 8.7

• Radial abduction : 97%

• Palmar abduction : 105%

• Kapandji scores: either 9 or 10 in all patients

• Pinch strength: 107%

• Grip strength: 102%

• Trapezial space height: 71%

• 1 symptomatic hardware (removed), 2 transient DRSN neuropraxia

Yao, et al. (JHS 2017)

Conclusions for Thumb CMC DJD Treatment in 2020

• Ligament Reconstruction: Not Needed!

• Interposition: Not Needed!

• Suspension: Probably Needed!

• Suture Button? Not Needed… BUT:• Faster Rehabilitation• No need to wait to remove K-wire in 4 weeks

• No need to wait for anything to heal

• Splint for 3-5 days, then start aggressive hand therapy

If you did this…

…you wouldn’t do this

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So if you did this…

…No need to do this!

Wouldn’t You Want This for your Patients at 5 Days?

Thank You!

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DISCLOSURES

Jennifer Moriatis Wolf, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

The University of Chicago Medicine

Trapeziectomy/LRTI –Why Change What

Works?Jennifer Moriatis Wolf, MD

Professor, Orthopaedic Surgery

The University of Chicago


DISCLOSURES

• Salary – The Journal of Hand Surgery

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History

• Initial publication by Gervis on trapeziectomy only JBJS, 1944

• Eaton/Littler & Burton/Pellegrini discussed reconstruction of ligaments for stabilization of the first metacarpal base

• ‘the purpose of ligament reconstruction combined with arthroplasty is to restore strength by restabilizing the basal joint while providing pain relief’

• Eaton and Littler, JBJS, 1973• Burton and Pellegrini, J Hand Surg Am, 1983


How Best to Treat this 74 yo female?


Anatomy

• Saddle‐shaped joint• Two interlocking saddles

• Stabilized by ligaments to provide

• Mobility

• Stability

• Multiple ligaments described by Bettinger and Berger

JAAOS, 2010

Bettinger et al, J Hand Surg, 1999

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Key Ligaments

• Anterior oblique (AOL)

• Dorsoradial (DRL)

• Best current evidence• DRL thicker, stronger, tripartite

ligament Ladd, Hagert, JBJS, 2012

• Colman and Mass showed stability maintained at CMC except when DRL cut

J Hand Surg, 2007


Concept of Ligament Reconstruction using FCR strip

Littler & Eaton, JBJS 1973


Concept of Ligament Reconstruction using FCR strip

Littler & Eaton, JBJS 1973

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Trapeziectomy with Ligament Reconstruction and Tendon Interposition (LRTI)

• Classic ‘ligament reconstruction and tendon interposition’

• Uses half or all FCR to reconstruct ligaments and suspend metacarpal, with remainder placed into trapezial void

Burton and Pellegrini, J Hand Surg, 1985


Other Versions of Ligament Stabilization

• Weilby – FCR passed in figure‐of‐8 fashion around APL

• Weilby, J Hand Surg Br, 1988

• APL suspension – distally based slip used to suspend first metacarpal by passing it through a slit in FCR

• Sigfusson & Lundborg, Scand J Plast Recon Surg, 1991


So why add ligament reconstruction at all?

• Ligaments contribute to the balance of the trapeziometacarpal joint

• Lower risk of failure in hypermobile individuals after surgery

• Confers stability to the carpus

• Supporting evidence from outcomes

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• 163 volunteers aged 20-83y, 81 men and 82 womeno Average Beighton score of 2 (range, 0‐9) and stress ratio of 0.31 (range,

0.06‐0.58)

o Significant relationship between increased Beighton score and stress ratio p<0.001 J Hand Surg Am, 2011

• Garcia-Elias and Orsolini noted a significant correlation between thumb laxity and greater trapezial mobility Chir Main, 2011

• Hess et al noted that joint hypermobility was a source of failure of thumb CMC arthroplasty J Hand Surg Am, 2018

Hypermobility/Laxity and the Thumb


What is the Genesis and Impact of Joint Laxity?

• Not known in depth

• Hormones thought to have some influence

o Cooney and Lubahn – showed estrogen receptors in TM ligament (ASSH Annual Meeting presentation, 2014)

o Correlation between serum relaxin and radiographically measured laxity at TM jointWolf et al, J Hand Surg Am, 2013

o Shown a relationship between serum relaxin and MMP‐1 receptors in anterior oblique ligament in a study of 50 patients at surgery Wolf et al, CORR, 2015

Relaxinmolecular structure


Do the Ligaments Matter?

• Based on the theories of instability contributing to ultimate degenerative change – YES

o Burton and Pellegrini, J Hand Surg, 1988o Eaton, Glickel, Littler, J Hand Surg, 1985

• Based on evidence of hormonal impact on ligaments with possible hypermobility as an additional contributing factor –YES

• Should they be reconstructed?

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Carpal Stability

CORR, 2014

• Evaluated the stress radiographs of previous randomized trial comparing trapeziectomy to trapeziectomy + LRTI in 25 and 29 patients at mean 6 year followup

• 1/29 in LRTI group• 7/25 in trapeziectomy group • Radiographic findings did not correlate with outcomes

increased degenerative change at MC base and distal scaphoid


• Retrospective review of 33 patients undergoing trapeziectomy/suspensionplasty from 1999‐2006 with mean 10 mo followup• 6/22 (27%) wrists had DISI deformity preoperatively • 11/22 (50%) had DISI postoperatively• Significant decrease in carpal height ratio and radiolunate

angle• Significant relationship between clinical outcomes on

satisfaction questionnaire and radiolunate angle (P=0.041)

J Hand Surg, 2009


Outcomes of trapeziectomy/LRTI

• Mayo series of 57 hands included 18 undergoing LRTI with 15 year followup HAND, 2019

• 1 required revision

• Significant improvement in pain VAS and grip in majority

• Tomaino et al – LRTI with mean 9 year followup• 24 thumbs in 22 patients

• 21/22 had pain relief and satisfaction

• Demonstrated increased grip and pinch strength• J Bone Joint Surg Am, 1995

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Comparative studies• LRTI has better pain and functional outcomes and lower complication rates than arthrodesis

• Vermeulen et al, J Bone Joint Surg 2014

• LRTI demonstrated better preservation of trapezialspace ‐‐ correlated with pinch strength when compared to trapeziectomy alone

• De Smet et al, Hand Surg, 2004

• Trapeziectomy alone• is faster than LRTI ‐‐ Sandvall et al, J Hand Surg 2010• has lower complication rates than all other surgeries – Selleset al, Cochrane Rev, 2015


SUMMARY

• Trapeziectomy and LRTI (or ligament reconstruction in isolation) has demonstrated consistently good outcomes

• Importance of ligament reconstruction has not been definitively proven BUT evidence shows:

• Subtle carpal joint changes with trapeziectomy• Increased joint degeneration mitigated by LRTI• Increased subsidence with some correlation with decreased pinch


THANK YOU

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CASE DISCUSSIONS

“Failed” Surgery - Persistent Pain

Identify source• MCP joint• Radial sensory nerve• Subsidence/ impingement between metacarpal and scaphoid

• Residual osteophyte/ impingement between index and thumb metacarpal

Case Discussion54 y/o female

Dominant thumb

Two previous procedures

• APL-FCR suspension

• Persistent symptoms

• Revised to LRTI

• Persistent symptoms

Collapse with pinch, pain, weakness

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ECRL Transfer with MP Arthrodesis

Case

• 64 y/o female

• Pain non dominant thumb > 2 years

• Tried bracing, therapy/ strengthening exercises

• Remains symptomatic

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Case

Left Thumb – Eaton Stage 3

Discussion

What is your algorithm for management of MP joint?

Transfer/ tenotomy

Capsulodesis

Arthrodesis

How do you do it?

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SYM10: Thumb Basal Joint Arthritis - Expert Surgeons