If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
We describe a minimally invasive arthrodesis technique using an arthroscope and fixation with headless screws. From February 2007 to March 2010, we treated 11 thumbs in 11 patients with posttraumatic carpometacarpal joint osteoarthritis. All patients reported pain at the thumb carpometacarpal joint. Preoperatively, mean grip and pinch strength was 38 and 5.9 kg, respectively. At a mean time of 9 weeks, all patients achieved complete union at the fusion site. Mean follow-up was 46 months. At the final follow-up, mean grip and pinch strength was 47 and 7.7 kg, respectively. Based on the Kapandji opposition score (full scored = 10), the mean thumb opposition score was 7. All patients had pain relief. There were 6 excellent, 3 good, and 2 fair results.
The main presenting problem of the disorder is pain in the joint. A clinical diagnosis is confirmed by radiological evidence of joint subluxation, diminished joint space, osteophytes, and sclerosis of the joint surfaces (Fig. 1A, B).
classified OA into stages I through IV based on these degenerative changes. Rest, use of orthoses, and injections may alleviate the pain but are temporary solutions.
When nonsurgical treatments no longer provide satisfactory relief from pain, surgery is indicated. Surgical options include ligament reconstruction, interposition (tendon, bone graft, or spacer), trapeziectomy, metacarpal osteotomy, arthroplasty, prosthetic replacement, and arthrodesis.
Treatment of osteoarthritis of the first carpometacarpal joint by resection-suspension-interposition arthoplasty using the split abductor pollicis longus tendon.
A prospective case-control study to compare the sensitivity and specificity of the grind and traction-shift (subluxation-relocation) clinical tests in osteoarthritis of the thumb carpometacarpal joint.
Because each is associated with unique benefits and risks, the best option is still controversial. A decision regarding which procedure should be performed is often based on patient and hand surgeon preferences with consideration also given to patient age, employment, and hobbies.
Arthrodesis is often indicated for a young active male or manual worker who needs a strong pinch more than fine motion of the thumb, especially for stage II to IV and posttraumatic OA.
Carpometacarpal arthrodesis is often approached through the Wagner, longitudinal dorsoradial, curved dorsoradial, or transverse incisions, usually 3 to 5 cm long. Fixation implants include Kirschner wires, plates and screws, and cannulated screw.
This report introduces a minimally invasive procedure for CMC joint arthrodesis using headless screws and arthroscopic guidance. We also present the long-term results of patients after using the technique.
Indications and Contraindications
The best indication of our technique is a thumb CMC joint with posttraumatic, symptomatic OA (stage II–IV) involving the presence of osteophytes or one-third or more subluxation of the joint, with or without joint space narrowing. Patients with arthritis caused by other reasons, such as congenital disorders, rheumatoid and diabetes arthritis, or ligamentous deterioration, may also be candidates. However, the technique is designed as an alternative for traditional open arthrodesis rather than trapeziectomy or ligament reconstruction trapezial interposition arthroplasty.
Surgical Technique
The patient is positioned supine under general anesthesia or regional block with the arm abducted on an operating table. A forearm tourniquet is applied to provide a bloodless field. The thumb CMC joint is identified by palpation and fluoroscopy. The portal is planned over the CMC joint at the junction of glabrous and non-glabrous skin (Fig. 2A). This portal is used both as the viewing portal and the working portal. A 5-mm longitudinal skin incision is made. Tenotomy scissors are used to spread the soft tissue and pierce the capsule. An assistant provides traction along the first ray to open up the articular working space. A blunt trocar with cannula is introduced and then a 2.7-mm, 30° angled arthroscope is inserted. Degenerative changes of the articular surfaces are assessed. Under fluoroscopic observation, a 3-mm burr is inserted to remove articular cartilage on both sides of the joint (Fig. 2B). During this procedure, the assistant then applies axial compression force onto the thumb base to assess bony apposition (Fig. 2C). The joint is irrigated with saline to remove debris and the extent of burring is next assessed by direct arthroscopic viewing (Fig. 2D, E). Burring and arthroscopic assessment are repeated until articular cartilage has been removed with exposure of underlying cancellous bone (Fig. 3A, B). If there are any remaining bony prominences in the space, they may be easily removed through the portal using a hemostat.
Figure 2A A 5-mm-long incision is made. B A 3.5-mm-diameter burr is inserted into the joint though a cannula. C While applying axial compression force onto the joint, the articular surfaces of both sides are removed (arrow). D Irrigation. E Inspection with arthroscope.
Figure 3A The joint space is assessed arthroscopically. B Articular cartilage on both sides is removed until underlying cancellous bone is exposed. C A 1-mm-diameter guidewire is placed across the arthrodesis site. D Compression (arrows) is attained by implanting the first screw over the guidewire.
After preparation, the space is filled with small allogeneic bone graft chips inserted through the portal. The thumb metacarpal and trapezium are temporarily stabilized with a 1-mm guidewire under fluoroscopic guidance (Fig. 3C). The insertion point of the guidewire is placed at the junction of the glabrous and non-glabrous skin. Care is taken to place the thumb tip at level of the middle phalanx of the index finger to achieve the optimal functional position.
After pre-drilling with a 2.5-mm cannulated drill bit, a compressing cannulated, 3-mm, self-tapping screw is placed over the guidewire through the small skin incision made at the wire insertion. Thus, compression is achieved at the arthrodesis site (Fig. 3D). A second guidewire is inserted to cross the first guidewire and a second screw is implanted in the same manner. Correct positioning of the screws is confirmed by intraoperative fluoroscopy. The guidewires are removed and all incisions closed (Fig. 4A–D).
Figure 4Arthrodesis is completed using 2 cross Herbert screws. A Lateral view. B Oblique view. C Anteroposterior view. D Incisions are closed.
During removal of the articular cartilage, care is taken to avoid iatrogenic injuries to the soft tissues surrounding the joint. To improve bone healing, bone grafts are used to fill the void produced by burring, but not necessarily attempting to restore the length of the first ray. To achieve compression at the interface between the thumb metacarpal and trapezium, one screw is implanted initially, followed by the second guidewire and screw. Use of longer screws may cause hardware irritation, which should be avoided. Damage to the scaphotrapeziotrapezoid joint may occur in stage IV patients. However, in many instances if scaphotrapeziotrapezoid OA is asymptomatic or only mildly symptomatic, one may try conservative treatment at this latter joint before resorting to surgery.
If surgery becomes warranted, available options for pain at this joint include resection of the distal pole of the scaphoid and ligament reconstruction trapezial interposition arthroplasty.
After surgery, we used a plaster hand orthosis to protect the arthrodesis. The metacarpophalangeal joint and interphalangeal joint are left free. Six weeks later, the orthosis is replaced with a removable brace allowing wrist exercises. Radiography is performed every 3 weeks until bone union has occurred. The patient is then released for full use of the hand thereafter.
Clinical Cases
From February 2007 to March 2010, 11 patients with thumb CMC joint OA were treated. All patients had a history of injury to the joint. Mean interval between the injury and thumb arthrodesis was 5 years (range, 3–8 y). Mean age at surgery was 48 years (range, 38–64 y). All patients were male. Osteoarthritis developed in the right (dominant) hand in 7 patients and in the left (nondominant) hand in 4. According to Eaton–Littler classification,
there were 5 patients with stage II OA, 4 with stage III, and 2 with stage IV. Mean total palmar abduction and radial abduction of the joint was 64° (range, 51° to 72°) and 66° (range, 55° to 75°), respectively. Based on the Kapandji opposition score (best score = 10),
the mean thumb opposition score was 7 (range, 6–9). Mean grip and pinch strength of the hand was 38 kg (31–43 kg) and 5.9 kg (4.2–7.1 kg), respectively. Thumb CMC joint pain averaged 5 (range, 3–6) based on visual analog scale
using a 10-cm-long line (0 = no pain and 10 = worst pain). Based on DASH questionnaire score, the mean score of the series was 39 (range, 33–49) (Table 1).
Table 1Patient Demographics and Preoperative Measurements
Postoperatively, wound infection did not occur. All patients achieved complete radiographic union at the arthrodesis site within a mean time of 9 weeks (range, 6–12 wk). Patient follow-up extended from 42 to 50 months with a mean of 46 months (Fig. 5A–C). At the final follow-up, the mean total palmar abduction and radial abduction of the thumb CMC joint was 62° (range 52° to 70°) and 64° (range, 58° to 69°), respectively. Mean thumb opposition score was 7 (range, 6–8). Mean grip and pinch strength of the hand was 47 kg (range, 39–54 kg) and 7.7 kg (range, 6.8–8.5 kg), respectively. Mean pain score at the arthrodesis site was 0 (range, 0–2). No patient required further surgical intervention. Mean DASH questionnaire score was 3 (range, 1–6). Based on the Smith and Cooney score,
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). The Upper Extremity Collaborative Group (UECG).
Figure 6Range of motion of the thumb 45 months after surgery. A Extension. B Thumb pulp to the pulp of the little finger. The thumb can maximally reach the base of the little finger. C Abduction. D Flexion.
The complication we found in the series included slight loss of length of the first ray. Other complications that occur in a large series could include nonunion, malunion, fixation failure, implant breakage, infection, and persistent pain. Pain owing to screw irritation may also occur when too long a screw is implanted.
References
Armstrong A.L.
Hunter J.B.
Davis T.R.C.
The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women.
Treatment of osteoarthritis of the first carpometacarpal joint by resection-suspension-interposition arthoplasty using the split abductor pollicis longus tendon.
A prospective case-control study to compare the sensitivity and specificity of the grind and traction-shift (subluxation-relocation) clinical tests in osteoarthritis of the thumb carpometacarpal joint.
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). The Upper Extremity Collaborative Group (UECG).
01447-6&id=gr1.jpg){kind=link}
01447-6&id=gr2.jpg){kind=link}
01447-6&id=gr3.jpg){kind=link}
01447-6&id=gr4.jpg){kind=link}
01447-6&id=gr5.jpg){kind=link}
01447-6&id=gr6.jpg){kind=link}