Hand Arthritis

98 Pages·2006·3.44 MB·English

HAND ARTHRITIS
CONTENTS
Preface xi
Matthew M. Tomaino
Thumb by Metacarpal Extension Osteotomy: Rationale and Efficacy
for Eaton Stage I Disease 137
Matthew M. Tomaino
Thisarticledescribestherationaleandresultsofa‘‘biomechanical’’strategytorestoretra-
peziometacarpal(TM)stabilitywhensymptomaticEatonStageIdiseaseexists.Though
theauthorhasperformedTMarthroscopy,synovectomy,andcapsularshrinkageforsuch
casesin10patients,theauthorhasbeendissatisfiedwiththeoutcomes,particularlypain
relief.Theauthorcurrentlyreliesexclusivelyonextensionosteotomyastreatmentforthis
subsetofpatients.Thumbmetacarpalextensionosteotomyremainsaneffectivetreatment
alternativeforthehypermobileTMjointconsistentwithEatonStageIdisease.Thispro-
cedurealtersforces,shiftsloadawayfromthevolarcompartment,andfurtherengages
the dorsoradial ligament. Clinical outcomes are favorable, and no bridges are burned
shouldarthriticchangesdevelopinthefuture.
Ligament Reconstruction 143
Steven Z. Glickel and Salil Gupta
Volarligamentreconstructionuseshalfoftheflexorcarpiradialistendonpassedthrough
agougeholeinthebaseofthethumbmetacarpaltosubstituteforanacuteorchronically
lax anterioroblique ligament of the thumb carpometacarpal joint. The configuration of
thereconstructionfunctionallysubstitutesforthedorsoradialligamentaswell.Thetech-
niquehaschangedlittlesinceitsdescriptionin1973.Whentheprocedureisdoneforpa-
tientswhohaveStageIorearlyStageIIdisease,excellenttogoodresultscanbeexpected
in upwards of90% of patients.
Trapeziometacarpal Arthroscopy: A Classification and Treatment Algorithm 153
Alejandro Badia
Indicationsforarthroscopyofthetrapeziometacarpaljointofthethumbremainpoorly
understood. Arthroscopic assessment of the carpometacarpal joint allows direct visual-
izationofallcomponentsofthejoint,includingsynovium,articularsurfaces,ligaments,
andthejointcapsule.Italsoallowsfortheextentofjointpathologytobeevaluatedand
staged with intraoperative management decisions made based on this information. A
proposedarthroscopicclassificationforbasaljointosteoarthritisprovidesadditionalclin-
icalinformationandcandirectfurthertreatmentdependingonthestageofdisease.This
Æ Æ
VOLUME22 NUMBER2 MAY2006 v
articlereviewsthebriefhistoryoftrapeziometacarpalarthroscopyandprovidesinsight
astohowthistechniquecanbeaddedtothesurgeon’sarmamentariuminmanagingthis
common condition.
Trapeziectomy 165
John D. Mahoney and Roy A. Meals
Primary osteoarthritisofthecarpometacarpaljointofthethumbiscommon,especially
in women aged 60 or older. Patients usually present with activity-related pain at the
thumb base. First treatment may include activity modification, pain relieving medica-
tions,splinting,andpossiblycorticosteroidinjections.Whenthesemeasuresfailtopre-
serve or restore the patient’s quality of life, surgical intervention may be appropriate.
Many surgical alternatives are described for the treatment of thumb carpometacarpal
jointarthritis,andmostbeginwithatleastpartialtrapeziectomy.Hematoma-distraction
arthroplastyresultsinimprovedoutcomesascomparedwithhistoricalresultsfollowing
trapeziectomyalone.Temporarydistractionallowsthebody’shealingresponsetofillin
the trapezial void with scar tissue, obviating the need for ligament reconstruction or
tissue interposition.
Suspensionplasty for Basal Joint Arthritis: Why and How 171
Matthew M. Tomaino
Abductorpollicislongussuspensionplastyisasimple,effectivetreatmentalternativefor
basaljointarthritis.Useofasuspensionplastytechniqueacknowledgesourcurrentun-
derstandingofforcesinvolvedduringpinchandgrip,aswellastheroleofnormallig-
amentous anatomy. The primary rationale for performing suspensionplasty revolves
around resisting the sagittal plane collapse that will occur when the thumb is loaded
during pinch. In the absence of a volar-based suspension of the metacarpal, cantilever
bending forces and axial forcetransmission will result in the dissipation offorcealong
the thumb lever arm, and ultimately longitudinal collapse. Maximal grip and pinch
strengthrequiresuspensionplasty,whichcanbeperformedusingavarietyoftechniques.
The author’s currenttechnique for suspensionplasty isdescribed.
Rheumatoid Arthritis: Silicone Metacarpophalangeal Joint Arthroplasty
Indications, Technique, and Outcomes 177
Charles A. Goldfarb and Thomas T. Dovan
Silicone implantarthroplastyhas beenused formore than 40yearsfor severe rheuma-
toid disease at the metacarpophalangeal (MCP) joint. Multiple investigations have
shownthatsiliconearthroplastyplacestheMCPjointinamoreextendedposture,with
someimprovementinthetotalarcofmotion.Ulnardriftisalsoimproved,butstrength
and other objective measures have not demonstrated marked changes postoperatively.
Thelackofprospectivedataandmorecompleteoutcomeassessmenthasbeen,atleast
inpart,responsibleforthemarkeddifferenceinopinionsbetweenrheumatologistsand
hand surgeons on the effectiveness of MCP arthroplasty. Recent reports using patient-
centeredoutcomemeasureshaveshownthatearlyoutcomeisfavorable,withimprove-
ments in appearance, pain,and function.
Nonrheumatoid Metacarpophalangeal Joint Arthritis. Unconstrained
Pyrolytic Carbon Implants: Indications, Technique, and Outcomes 183
Wendy Parker, Steven L. Moran, Kirsten B. Hormel, Marco Rizzo,
and Robert D. Beckenbaugh
The metacarpophalangeal (MP) joint allows for a significant portion of hand function.
Osteoarthritis, although less prevalent than rheumatoid arthritis, is not uncommon
vi CONTENTS
andcanrendertheMPjointnonfunctional.WithunconstrainedMPjointimplants,sal-
vageofthisjointmaybeperformedreliablyinpatientswhohaveprimaryosteoarthritis
andpost-traumaticarthritis.Pyrolyticcarbonimplantsofferadvantagesoverpreviously
used implants. Pyrolytic carbon has an elastic modulus similar to cortical bone, which
aidsindampeningstressesattheboneprostheticinterfaceandenhancesbiologicalfix-
ation.Pyrolyticcarbonhasalsobeenfoundtohaveexcellentlong-termbiologicalcom-
patibility. This article provides an overview of the indications, technique, and early
outcomesforpatientsundergoingarthroplastyoftheMPjointusingapyrolyticcarbon
implant.
Finger Metacarpophalangeal Joint Disease: The Role of Resection
Arthroplasty and Arthrodesis 195
Matthew M. Tomaino and Michael Leit
Whenfingermetacarpophalangeal(MP)jointarthrosisexists,itisindeedinfrequentthat
implantarthroplastyisnotthemostoptimaltreatmentalternative.Inthesettingofpost-
traumaticorpostinfectiousdiseaseattheMPjoint,however,implantarthroplastyiscon-
traindicated;thusalternativetechniquesofrestoringpain-freefunctionbecomerelevant.
Despitethelimitedrolesofresectionarthroplastyandarthrodesis,thesetechniquescan
restore useful function. So long as the MP joint is pain free and relatively stable, most
patterns of functional prehension can be maintained. Indications and technical funda-
mentals ofresection arthroplastyand arthrodesis areaddressedin this article.
Prosthetic Replacement of the Proximal Interphalangeal Joint 201
Peter M. Murray
Thefirstproximalinterphalangealjoint(PIPJ)replacementswerehingeddevicesallow-
ingonlysingle-axismotion.NewerimplantarthroplastiesofthePIPJhaveanatomically
designedproximalphalangealandmiddlephalangealcomponents.Constraineddevices
havetypicallyleadtofailureatthehingemechanismortheprostheticboneinterface.A
need to create balanced forces across the joint was the rationale behind the semicon-
strainedPIPJprosthesis,whichusesananatomicdesign.LimitationsofthesiliconePIPJ
implantincludeitslackofresistancetovalgusloadingattheindexandlongdigitsdur-
ingthepinchmaneuver.ItisgenerallybelievedthataPIPJsurfacereplacementarthro-
plasty thatpreserves the collateral ligaments will achieve greater PIPJstability.
DistalInterphalangealJointArthrodesiswithScrewFixation:WhyandHow 207
Matthew M. Tomaino
Smalljointfusioncanbeperformedsuccessfullyusingavarietyoftechniques,andunion
rates are characteristically high if decortication, bony coaptation, and stability are ade-
quate.ThoughuseofKirschnerwires(K-wires)istime-honored,andallowsarthrodesis
inslightflexion,theuseofaheadlesscompressivescrewhastheadvantagesofeaseof
execution,fullyburiedhardware,andtheabilitytomobilizethefingeralmostimmedi-
ately.Inthisarticle,theauthorhighlightsthereasonsthathehasstoppedusingK-wires,
and describes his current technique fordistalinterphalangeal (DIP) jointarthrodesis.
Thumb Metacarpophalangeal Arthritis: Arthroplasty or Fusion? 211
Charles S. Day and Miguel A. Ramirez
The humanthumb assumes 50% ofthe workloadofthe humanhand, and istherefore
the most important digit. As such, the thumb has a propensity for the development of
CONTENTS vii
osteoarthritis.Moreover,thethumbisalsooftendiseased,inanywherefrom68%to80%
ofpatientswhohaverheumatoidarthritis.Muchattentionovertheyearshasbeengiven
tothecarpalmetacarpaljointofthethumb,whereasthemetacarpophalangeal(MP)joint
of the thumb remains largely unstudied. The purpose of this article is to review the
etiologyofthumbMPjointarthritis,anddiscussthedifferenttreatmentoptionsofthis
condition.
Degenerative and Post-Traumatic Arthritis Affecting the Carpometacarpal
Joints of the Fingers 221
Thomas R. Hunt, III
Patients presenting with symptomatic post-traumatic arthritis involving the finger car-
pometacarpal(CMC)jointsgenerallycomplainoflocalizedpainaggravatedbygripping,
shaking hands, and occupation or sports-specific activities. The majority of these
individualsexperienceepisodic,mildsymptomsandrespondtononoperativetreatment
measures.Asmallpercentagerequiresurgicalintervention,especiallyincasesofmissed
fracture/dislocationsandinstability.Reconstructionemphasizesstability,withaneyeto-
ward mobility for the ulnar column. Degenerative arthritis often manifests as a dorsal
bonyprominenceovertheintervalbetweenthesecondandthirdCMCjoints.Thisosteo-
phyticprojectioniscommonlyreferredtoasadorsalcarpometacarpalboss,andmaybe
surgicallyexciseddown tonormal articularcartilageif symptoms warrant.
Erratum 229
Index 231
viii CONTENTS
FORTHCOMING ISSUES
August2006
HandFractures andDislocations
Alan E. Freeland, MD,
and Sheila G. Lindley,MD, GuestEditors
November2006
Carpal Disorders
Steven K.Lee,MD, and
Michael Hausman,MD, GuestEditors
RECENT ISSUES
February2006
Pediatric Fractures,Dislocations,
andSequelae
Scott H. Kozin,MD, GuestEditor
November2005
Wrist Arthritis
Brian D.Adams,MD,Guest Editor
August2005
Distal RadiusFractures
David J.Slutsky,MD, FRCS(C),
and AndrewP. Gutow,MD, GuestEditors
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HandClin22(2006)xi
Preface
Hand Arthritis
MatthewM.Tomaino,MD,MBA
GuestEditor
Favorable management of the arthritic hand conscientious consideration, and perhaps im-
(basal, carpometacarpal, metacarpophalangeal, plementation, ofnewerdevelopments inthefield.
and interphalangeal joints) in some respects re- Wherepossible,outcomeshavebeenaddressedd
mains invariantdfundamental principles still aparticularlyimportantimperativeforeachofus
prevail, arguably, as the most critical aspect of in our clinical practices over the next decadedso
our care. Innovative surgeons continue to refine that we might create value for our patients, ex-
implant designs, surgical indications, and tech- ploring new developments when warranted, and
niques, however, and this issue of Hand Clinics relying ontime-honored solutions whennot.
addresses these incremental advances. Students
of history will agree that, absent an appreciation MatthewM.Tomaino, MD, MBA
thereof, historical blunders may be repeated. University of RochesterMedical Center
And yet, as is often the case, ‘‘the more things 601Elmwood Avenue, Box665
change, the more they stay the same.’’ In this Rochester,NY14642,USA
issue I am grateful for the expert contributions
E-mailaddress:
ofmycolleagueswhohavebeenchargedwithpro-
[email protected]
viding enough of a historical backdrop to enable
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HandClin22(2006)137–141
Thumb by Metacarpal Extension Osteotomy:
Rationale and Efficacy for Eaton Stage I Disease
Matthew M. Tomaino, MD, MBA
DepartmentofOrthopaedics,DivisionofHand,ShoulderandElbowSurgery,
UniversityofRochesterMedicalCenter,601ElmwoodAvenue,Box665,Rochester,NY14642,USA
The normal ligamentous anatomy of the DeQuervain’sdisease,flexorcarpiradialistendon-
thumbbasaljointprovidesextraordinarystability itis, and subsesamoid arthritis. Indeed, when the
withoutsacrificingmotion[1].Inprovidingafixed radiographisnormalandtendernessexistsonpal-
pivot point at the thumb trapeziometacarpal pationofthethenarmusclesattheleveloftheTM
(TM) joint, substantial cantilever bending forces joint,StageIdiseaseeffectivelybecomesadiagno-
are resisted, and large loads are accommodated sis ofexclusion [4,5].
during pinch and grip without subluxation or
pain[2,3].Whenligamentousrestraintiscompro- Pathomechanics
mised,however,functionalgripandpinchmayre-
Functional incompetence of the basal joint’s
sult in painful synovitis and hypermobility at the
palmar oblique ligament (POL) results in patho-
TMjointlongbeforethedevelopmentofcartilage
logic laxity, abnormal translation of the meta-
wearandarthritis [4].
carpal on the trapezium, and generation of
Thisarticledescribestherationaleandresultsof
excessive shear forces between the joint surfaces,
a‘‘biomechanical’’strategytorestoreTMstability
particularlywithinthepalmarportionofthejoint
when symptomatic Eaton Stage I disease exists.
during grip and pinch activity [6,7]. Histologic
Though the author has performed TM arthros-
study has shown that attritional changes in the
copy, synovectomy, and capsular shrinkage for
POL at its attachment to the palmar lip of the
such cases in 10 patients, I have been dissatisfied
metacarpal precede degeneration of cartilage [8].
with the outcomes, particularly pain relief, and
Cadavericinvestigationofacutedislocationof
currently rely exclusively on extension osteotomy
the thumb TM joint has shown that the primary
astreatmentforthissubsetofpatients.
restraintwas thedorsoradial (DRL)ligament [9].
ThusthePOLandDRLligamentarecriticalsta-
Clinicalpresentation
bilizers of the TM joint during lateral pinch, and
Radiographs are typically normal, or the TM when either or both are attenuated or incompe-
joint may appear widened, from synovitis. This tent, some degree of dorsal translation of the
stage reflects Stage I of the classic Eaton classifi- metacarpalmaycausesymptomsofpain.Indeed,
cation of basal joint arthritis. Physical examina- though Eaton and Littler [4] recommended liga-
tion may reveal only pain with TM stress and ment reconstruction in 1973 to restore thumb
tenderness to palpation beneath the thenar cone stabilityincasesofend-stageosteoarthritis,subse-
(Fig.1).Deformity,frankinstability,subluxation, quentreportshaveconfirmeditsefficacyforearly
orcrepitanceareunusual.Itiscriticaltoevaluate stage diseasedthe hypermobile TM jointdas
theentirehandforsignsandsymptomsofcarpal well [10,11].
tunnel syndrome, stenosing flexor tenosynovitis,
Rationale for osteotomy
E-mailaddress:[email protected]. Pellegrini and colleagues [12] were the first to
edu evaluate the biomechanical efficacy of extension
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doi:10.1016/j.hcl.2006.02.008 hand.theclinics.com
138 TOMAINO
simulated extension osteotomy reduced laxity in
alldirectionstested:dorsal-volar(40%reduction),
radial-ulnar(23%reduction),distraction(15%re-
duction), and pronation-supination (29% reduc-
tion). They hypothesized that the beneficial
clinicaleffectsofathumbmetacarpalextensionos-
teotomymaybepartiallycausedbytighteningof
theDRL,whichmightreducedorsal translation.
Clinical outcome
In lightof Pellegrini’s biomechanical data [12]
and the author’s own relative dissatisfaction
with Eaton ligament reconstruction for Stage I
disease, primarily related to what seemed to be
an 8- to 10-month recovery period and a fairly
stiff TM joint, I prospectively evaluated the effi-
cacy of a 30(cid:1) extension osteotomy in 12 patients
(12 thumbs) between 1995 and 1998 [5]. TM ar-
throtomy allowed accurate intra-articular assess-
ment and verified POL detachment from the
metacarpal rim in each case. Follow-up averaged
Fig.1. Thetrapeziometacarpalstresstest. 2.1 years and ranged between 6 and 46 months.
All osteotomies healed at an average of 7 weeks.
osteotomy (Fig. 2). Palmar contact area was un- Eleven patients were satisfied with outcome.
loaded with a concomitant shift in contact more Grip and pinch strength increased an average of
dorsally so long as arthrosis did not extend 8.5 and 3kg, respectively.
more dorsal than the midpoint of the trapezium. Since that study’s publication, the author has
Shrivastava and coworkers [13] studied the effect becomeevenmoreimpressedbytheefficacyofthe
of a simulated osteotomy on TM joint laxity by procedure and believe, as Shrivastava and col-
flexing the metacarpal base 30(cid:1), thus placing the leagues suggested [13], that osteotomy decreases
jointintherelationshipitwouldassumeifanex- laxity and shifts contact area more dorsally. It
tension osteotomy was performed (Fig. 3). The seems logical that the DRL participates in this
Fig.2. (A)Lateralradiographshowstheanticipatedwedgeofbonetoberesectedtoafforda30(cid:1)extensionosteotomy.
(B)Lateralradiographaftercompletionofextensionosteotomy.
THUMBBYMETACARPALEXTENSIONOSTEOTOMY 139
Fig.3. (A)Leftthumbinlateralpinchwithaplannedextensionosteotomydiagrammedontheskin.(B)Closureofthe
wedgecausesthemetacarpaltoextendawayfromtheindexfinger.(C)Toregainthelateralpinchposition,themeta-
carpalbasemustflexonthetrapeziumafterextensionosteotomy.(FromShrivastavaN,KoffMF,AbbottAE,etal.
Simulated extension osteotomy of the thumb metacarpal reduces carpometacarpal joint laxity in lateral pinch.
JHandSurg[Am]2003;28:735;withpermission.)
effect, and substantiates the contention that the a dorsally based 30(cid:1) wedge of bone (see Fig. 3).
DRLisanimportant stabilizer [9]. Amicrosagittalsawisusedtoscorethemetacarpal
The author’s surgical technique has changed 1cmdistaltoitsbasetransversely,butacomplete
little since the publication in 2000, except that I cut through the volar cortex is not made. A new
use staples now (OSStaple, Biomedical Enter- saw blade is left in that partial osteotomy site
prises, San Antonio, Texas) to avoid the use of and a second blade is used approximately 5 mm
a percutaneously placed Kirschner wire. Further, distal to the first cut at an angle of 30(cid:1), so that
if I am convinced that the joint surfaces are the two blades intersect at the volar cortex. The
essentially normal, which I usually assume if the wedge of bone is removed, the distal metacarpal
radiographisnormalandthereisnocrepitanceon is extended and compressed against the proximal
examination, Ido notperformanarthrotomy. fragment, and two 11 (cid:2) 8 staples are placed
(Fig. 4). Typically, the author maintains the re-
Surgicaltechnique duced position of the metacarpal while my assis-
tantpredrills,andthenplacesthestaples.
Regional, axillary block anesthesia is per- Alayeredclosureoftheperisoteumandskinis
formedandanonsteriletourniquetisplaced.After performed, and overlying thumb spica splint is
exsanguination with an Esmarch bandage and placed for 10 days. After that time sutures are
inflationofthetourniquetto250mmHg,adorsal removed and a thumb spica cast with the in-
incision is made from the base of the thumb terphalangealjointofthethumbleftfreeisplaced
metacarpal distally for approximately 3 cm. In foranadditional4weeks.Approximately6weeks
the subcutaneous tissue the sensory branches of following surgery, a forearm-based thumb spica
the radial and lateral antebrachial cutaneous orthoplast splint is placed, and the patient is
nervesare identified and protected.Subperiosteal instructed to begin gentle TM motion. Grip and
exposureisobtainedwithoutinjuringtheextensor pinch exercises are started at approximately 8
pollicislongus,andtheTMjointisidentifiedwith weeks after surgeryunlessunion isdelayed.
a25-gaugeneedle.OnecmdistaltotheTMjoint,
near circumferential access around the meta-
Discussion
carpalisobtainedinanticipationoftheosteotomy.
Thevolarextentofthemetacarpalisvisualizedat Although the cause of osteoarthritis of the
this location to facilitate accurate resection of TM joint is probably multifactorial, instability
140 TOMAINO
The precise role of thumb metacarpal exten-
sion osteotomy for the hypermobile TM joint is
no longer ill-defined. Biomechanical and clinical
data validate the rationale and favorable out-
come.Theprecisemechanismforpainreliefisnot
known, but it is probably a combination of load
transfer and diminishedlaxity. Because extension
osteotomy shifts mechanical loading at the TM
joint more dorsally and redirects force vectors,
fixed subluxation or multidirectional instability
contraindicatetheprocedure.Indeed,apreopera-
tive TM stress test is meant to provoke pain
related to POL incompetence only. More global
instability may reflect a greater degree of capsu-
loligamentous injury, and may necessitate liga-
ment reconstruction[4].
Insummary,pre-andpostoperativesubjective
andobjectiveassessmenthasallowedacomprehen-
siveanalysisofoutcomefollowinga30(cid:1)extension
osteotomyofthethumbmetacarpal[5].Excellent
pain relief and improved grip and pinch strength
comparefavorablywiththosepublishedfollowing
ligament reconstruction [10,11]. For Eaton Stage
I disease of the TM joint, this procedure appears
tobeanefficaciousalternativetoligamentrecon-
struction.Further,ithasbeentheauthor’spersonal
observationthatthisprocedureprovidesmorereli-
able pain relief than TM arthroscopy, synovec-
tomy,andcapsularshrinkage.
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