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Minimally Invasive Thumb Carpometacarpal Joint Arthrodesis With Headless Screws and Arthroscopic Assistance

      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.

      Key words

      Thumb carpometacarpal (CMC) joint osteoarthritis (OA) is the most common form of OA affecting the hand.
      • 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.
      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).
      • Kapoutsis D.V.
      • Dardas A.
      • Day C.S.
      Carpometacarpal and scaphotrapeziotrapezoid arthritis: arthroscopy, arthroplasty, and arthrodesis.
      Figure thumbnail gr1
      Figure 1A 47-year-old man sustained thumb CMC joint OA. A Lateral view radiograph. B Computed tomographic imaging.
      Eaton and Glickel
      • Eaton R.G.
      • Glickel S.Z.
      Trapeziometacarpal osteoarthritis: staging as a rationale for treatment.
      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.
      • Klenner A.F.
      • Towfigh A.H.
      • Klenner K.
      [Injuries and posttraumatic osteoarthritis of the first carpometacarpal joint].
      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.
      • Harenberg P.S.
      • Jakubietz M.G.
      • Jakubietz R.G.
      • Schmidt K.
      • Meffert R.H.
      Treatment of osteoarthritis of the first carpometacarpal joint by resection-suspension-interposition arthoplasty using the split abductor pollicis longus tendon.
      • Desmoineaux P.
      • Delaroche C.
      • Beaufils P.
      Partial arthroscopic trapeziectomy with ligament reconstruction to treat primary thumb basal joint osteoarthritis.
      • Abbas K.
      • Hashmi P.
      • Raza H.
      Short term results of ligament reconstruction and tendon interposition resection arthroplasty for basal joint arthritis.
      • Yao J.
      • Song Y.
      Suture-button suspensionplasty for thumb carpometacarpal arthritis: a minimum 2-year follow-up.
      • Choa R.M.
      • Parvizi N.
      • Giele H.P.
      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.
      • Hammer P.E.
      • Shiri R.
      • Kryger A.I.
      • Kirkeskov L.
      • Bonde J.P.
      Associations of work activities requiring pinch or hand grip or exposure to hand-arm vibration with finger and wrist osteoarthritis: a meta-analysis.
      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.
      • Martou G.
      • Veltri K.
      • Thoma A.
      Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review.
      Arthrodesis results in a stable and pain-free CMC joint.
      • Vermeulen G.M.
      • Slijper H.
      • Feitz R.
      • Hovius S.E.
      • Moojen T.M.
      • Selles R.W.
      Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review.
      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.
      • Eaton R.G.
      • Lane L.B.
      • Littler J.W.
      Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment.
      • Freedman D.M.
      • Eaton R.G.
      • Glickel S.Z.
      Long-term results of volar ligament reconstruction for symptomatic basal joint laxity.
      • Froimson A.I.
      Tendon arthroplasty of the trapeziometacarpal joint.
      • Kuhns C.A.
      • Emerson E.T.
      • Meals R.A.
      Hematoma and distraction arthroplasty for thumb basal joint arthritis: a prospective, single-surgeon study including outcomes measures.
      The main complication of arthrodesis is nonunion. Reported nonunion rates are between 17% and 50%.
      • Kenniston J.A.
      • Bozentka D.J.
      Treatment of advanced carpometacarpal joint disease: arthrodesis.
      • De Smet
      • Vaes F.
      • Van Den Broecke J.
      Arthrodesis of the trapeziometacarpal joint for basal joint osteoarthritis of the thumb: the importance of obtaining osseous union.
      • Hartigan B.J.
      • Stern P.J.
      • Kiefhaber T.R.
      Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition.
      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 thumbnail gr2
      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 thumbnail gr3
      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.
      • Zdráhal M.
      Arthrodesis of the carpometacarpal joint of the thumb using a cannulated screw.
      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 thumbnail gr4
      Figure 4Arthrodesis is completed using 2 cross Herbert screws. A Lateral view. B Oblique view. C Anteroposterior view. D Incisions are closed.

      Pearls and Pitfalls

      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.
      • van der Westhuizen J.
      • Mennen U.
      A working classification for the management of scapho-trapezium-trapezoidosteo-arthritis.
      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.
      • Da Rin F.
      • Mathoulin C.
      Arthroscopic treatment of osteoarthritis of scaphotrapezotrapezoid joint.

      Postoperative Management

      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,
      • Martou G.
      • Veltri K.
      • Thoma A.
      Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review.
      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),
      • Kapandji A.I.
      Clinical evaluation of the thumb’s opposition.
      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
      • Williams R.M.
      • Kiefhaber T.R.
      • Sommerkamp T.G.
      • Stern P.J.
      Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft.
      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
      CaseAge, ySideStageThumb Abduction (degrees)Kapandji Opposition ScoreStrength, kgPain, cmDASH Questionnaire Score
      PalmarRadialGripPinch
      138RIV51556437.1542
      244RII67708386.3438
      3
      Case 3 showing in the figures.
      47LIII66697355.2540
      452RIII62597416.8349
      550RII61647314.5446
      646RIV60576386.8742
      741LIII63687356.3437
      853LII68738334.2336
      964RIII65677375.7533
      1043RII72759426.1430
      1149LII65648405.7633
      Mean4864667385.9539
      DASH, Disabilities of the Arm, Shoulder, and Hand.
      Case 3 showing in the figures.
      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,
      • Hudak P.L.
      • Amadio P.C.
      • Bombardier C.
      Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). The Upper Extremity Collaborative Group (UECG).
      we obtained an average score of 86 (range, 75–95), which corresponded to 6 excellent, 3 good, and 2 fair results (Table 2) (Fig. 6A–D).
      Figure thumbnail gr5
      Figure 5Radiographs 45 months after surgery. A Lateral view. B Oblique view. C Anteroposterior view.
      Table 2Outcomes at Final Follow-Up
      CaseThumb Abduction (degrees)Kapandji Opposition ScoreStrength, kgPain, cmDASH Questionnaire ScoreSmith and Cooney
      PalmarRadialGripPinchScoreGrade
      158636548.50280Good
      263627467.90190Excellent
      3
      Case showing in the figures.
      62657407.41390Excellent
      458586487.60285Good
      567607396.81490Excellent
      652636457.50290Excellent
      755626528.52175Fair
      870657467.70390Excellent
      965697548.11575Fair
      1067688477.80685Good
      1165647457.40295Excellent
      Mean6263.546.73477.70386
      DASH, Disabilities of the Arm, Shoulder, and Hand.
      Case showing in the figures.
      Figure thumbnail gr6
      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.

      Complications

      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.

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        Arthroscopic treatment of osteoarthritis of scaphotrapezotrapezoid joint.
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