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Summary Objective To investigate heterogeneous effects of a combination of conservative therapies compared with an education comparator for thumb base (TB) osteoarthritis (OA) according to clinically relevant characteristics. Methods Pre-planned subgroup analysis of the COMBO trial (n = 204) which compared a combination of education on self-management and ergonomic principles, a prefabricated neoprene splint, hand exercises, and diclofenac sodium gel, with education alone for radiographic and symptomatic TB OA. Primary outcomes were change in pain (visual analogue scale [VAS], 0–100 mm) and hand function (Functional Index for Hand Osteoarthritis questionnaire, 0–30) from baseline to week-6. Other outcomes were grip and tip-pinch strength and patient's global assessment (PGA) (VAS, 0–100 mm). Possible treatment effect modifiers were the presence of interphalangeal joint pain, erosive hand OA, radiographic thumb carpometacarpal joint subluxation (higher vs equal or lower than the sample mean), and baseline radiographic OA severity (Kellgren Lawrence grade). Linear regression models were fitted, adding interaction terms for each subgroup of interest. Results The treatment effects of the combined intervention at 6 weeks were greater in participants with lower joint subluxation compared with those with greater subluxation (pain −11.6 [95%CI −22.2, −9.9] and 2.6 [−5.5, 10.7], respectively, difference between the subluxation groups 14.2 units (95% CI 2.3, 26.1), p-value 0.02; and PGA −14.0 [−22.4, −5.5] and 1.5 [−6.2, 9.3), respectively, difference between the subluxation groups 15.5 units (95% CI 4.2, 26.8), p-value 0.03). There was no statistically significant heterogeneity for the other subgroups. Conclusion A combination of conservative therapies may provide greater benefits over 6 weeks in individuals with lower joint subluxation, although the clinical relevance is uncertain given the wide confidence intervals. Treatment strategies may need to be customized for those with greater joint subluxation. Trial registration number ACTRN 12616000353493.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance. SUMMARY Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

This study investigated revision surgery for the thumb after failed trapeziectomy with ligament reconstruction and tendon interposition and defined a revision concept. Twenty-four patients with 25 affected thumbs were examined at a mean of 5.5 years after their last revision operation. Pain during daily activities was 2.7 on a 0–10 numeric rating scale, pain at rest was 1.6 and the brief Michigan Hand Outcomes Questionnaire score was 63. Although 68% of patients indicated that their thumb was better than before primary surgery, the outcome after revision surgery was less favourable than that reported for primary trapeziectomy with ligament reconstruction and tendon interposition. We defined a revision algorithm to use as a guide for patients with residual symptoms after resection arthroplasty. The main reason for revision, symptomatic impingement of the thumb metacarpal, should be treated with resection of the metacarpal base and scaphotrapezoidal joint. An existing interposition should be revised, or a new interposition should be used, preferably with an autologous tendon or alternately with an allograft. Level of evidence: IV

Trapeziectomy is performed for trapeziometacarpal (TMC) arthritis but decreased lateral pinch strength is a major source of discomfort after the surgery. The magnitude of the decrease is unclear, however, and how the pressure changes in the TMC joint is unknown. To investigate this relationship, we designed a cadaveric study to measure TMC joint pressure using a lateral pinch model, and quantitatively evaluated the effect of trapeziectomy on the pressure measurements. For 10 cadaveric forearms, physiologic forces were applied across the thumb TMC joint by loading five tendons, thereby simulating lateral pinch. Using pressure sensors, we measured the lateral pinch pressure and TMC joint pressure, which averaged 10.1 (range, 4.2-16.2) kg/cm2 and 2.0 (range, 0.8-4.4) kg/cm2 , respectively. A significant correlation between the measurements was found, with an average ratio of 19% (range, 10%-27%). After trapeziectomy and interposition of the tendon ball using flexor carpi radialis, the pressure measurements were repeated under the same conditions. Significant changes were found, which averaged 5.1 (range, 1.7-10.7) kg/cm2 for lateral pinch pressure and 15.0 (range, 5.6-25.6) kg/cm2 for TMC joint pressure. In conclusion, TMC joint pressure could be measured as the ratio relative to lateral pinch pressure using a cadaveric model. After trapeziectomy, the lateral pinch strength decreased, whereas the TMC joint pressure increased.

Introduction Due to the complex shape of the carpometacarpal (CMC) joint, a fixed joint collapse deformity of the thumb CMC (CMC1) and metacarpophalangeal (MCP1) joint can present in advanced stages of CMC1 osteoarthritis (OA), resulting in adduction of the first metacarpal (MC1) and hyperextension of the MCP1. Purpose of the Study To determine whether joint collapse deformity is associated with worse pain and/or functional impairment. Study Design Cross-sectional. Methods This study used the baseline data from 140 patients enrolled in a longitudinal study of treatment for CMC1 OA. (efficacy of combined conservative therapies on clinical outcomes in patients with CMC1 OA). Joint collapse was determined at baseline using a pinch gauge. Pain was assessed on a visual analog scale (0-100) and function was assessed using the Functional Index for Hand Osteoarthritis questionnaire (0-30). Pain and function and the presence of joint collapse were entered in a univariate logistic regression. The final adjusted model for pain and joint collapse included age and sex. The final adjusted model for function and joint collapse included Kellgren Lawrence grade and grip strength. Results About 20% of participants demonstrated joint collapse on the tip-pinch test. The presence of joint collapse was associated with increased pain in the unadjusted [P = .047, OR = 2.45, 95% CI (1.01, 5.910)] and adjusted model [P = .049, OR = 2.45, 95% CI (1.00, 5.98)]. Conclusion CMC1 patients with joint collapse reported increased pain compared with those without joint collapse. Future studies should determine the relationship between thumb hypermobility and joint collapse and how to manage these conditions effectively.

Osteoarthritis of the first carpometacarpal joint is a frequent condition that hand surgeons have to deal with. When conservative measures such as physiotherapy, steroid injections, or splinting fail to alleviate symptoms, trapeziectomy is considered the gold standard for surgical treatment. In the present article, a novel technique is presented to denervate the joint capsule together with the periosteum and the endosteum to address sensory receptors located in these 2 extracapsular structures in the proximity of the first carpometacarpal joint area. Denervation with periosteal resection, apart from being a relatively easy and less aggressive technique compared with trapeziectomy, offers satisfactory pain relief with a faster recovery time.

Many surgical options have been proposed for the treatment of first carpometacarpal (CMC1) osteoarthritis. Conventional techniques are invasive, so we wanted to develop an arthroscopic technique. Partial trapeziectomy combined with various interpositions and ligament reconstruction is a long-standing intervention. As in total trapeziectomy, the combination with ligament reconstruction remains controversial. The aim of this study was to demonstrate the benefits of adding an abductor pollicis longus (APL) ligament reconstruction to partial trapeziectomy performed under arthroscopy. This study analyzes the results of two consecutive case series carried out by a single surgeon. Thirty-four patients underwent an isolated partial trapeziectomy and 49 patients underwent partial trapeziectomy with ligament reconstruction using the APL. The patients were reviewed with an average follow-up of 3.7 years (13 months to 8.6 years) by an independent observer. The assessment included the analysis of pain, thumb appearance, QuickDASH score, Nelson Hospital score, and measurements of mobility and strength. For all patients, there was a marked reduction in pain (7.13 preoperatively vs.1.37 postoperatively) with 71% of patients having a painless thumb, the Nelson (11.14) and QuickDASH (17.89) scores as well as a clinical improvement in mobility and grip strength (14.5 KgF preop vs. 19.6 KgF postop) and key pinch (4.4 KgF preop vs. 5.4 KgF postop). The mean recovery time was 18.8 weeks. Eighty-four percent of patients were satisfied with the procedure with 90% having a stable thumb. No CRPS was found. However, the results were better for patients who underwent ligament reconstruction. There was a significant gain in grip strength, better first web opening and a lower percentage of painful thumbs. The other items were also slightly improved, but not significantly (Nelson Hospital score, QuickDASH score, key grip strength, percentage of stable thumbs, subjective thumb value estimated by patients). This technique is a less aggressive treatment of CMC1 osteoarthritis, with simplified and rapid rehabilitation. The addition of ligament reconstruction using the APL appears useful. The advantages of arthroscopy are a less painful postoperative course, low morbidity, ligament conservation, along with better access to remove loose bodies, osteophytes and to perform synovectomy. Partial trapeziectomy, which is especially indicated when the scaphotrapeziotrapezoid joint is not symptomatic, is much less used than total trapeziectomy; however, it is an attractive surgical option for young patients with significant functional demands. Arthroscopic partial trapeziectomy is a safe and reliable procedure.

A 26-year-old patient with no prior medical history presented to the emergency department with pain in his right hand after getting into a fight with another person. Figure 1 shows the hand. The function was impaired by pain. Vascularisation of the hand and fingers was normal and there was no neurological deficit. An X-ray of the hand was taken (figure 2). Figure 1 Patient’s right hand. Figure 2 Posteroanterior X-ray of the right hand. What is the diagnosis? 1. Triquetral …

Our aim was to explore the different indications of the Mini TightRope® suture button whether during first-line treatment or secondary surgery of thumb carpometacarpal osteoarthritis (OA). The indications for this new device are presented and discussed based on our own small case series and published data. Twenty-one patients treated with the Mini TightRope® were included in a prospective study. One of them was operated on both sides. Fourteen devices were used in first intention for Eaton stage IV OA; the patients underwent trapeziectomy and suture button suspensioplasty only. Four cases consisted of revision surgery for painful proximalization of the first metacarpal after trapeziectomy and ligamentoplasty. Four cases consisted of secondary surgery after trapeziectomy and implant interposition (two silicone implants and two pyrocarbon implants). We captured the demographic data, follow-up time, pain level, pinch strength before and after surgery, range of motion, metacarpal subsidence, and postoperative complications. The average age of the patients was 60 years. There were 19 women and 2 men. The average follow-up time was 2.5 years (1–4). The average pain level, according to a visual analog scale (1–10) was 3.5 (2–5) preoperatively and 2 (1–4) postoperatively at rest and 7 (6–8) preoperatively and 4 (3–6) postoperatively with maximum load. The mean Kapandji score was 9 (7–10) and the retropulsion score was 3 (1–4). The average key pinch and tip pinch strengths were 80% and 78% of the contralateral side at the final follow-up. The trapeziectomy-suspensioplasty group had greater average trapezial space height compared to the revision surgery group (7.0 mm vs. 4.5 mm). There are several indications for the Mini TightRope® device in the treatment of severe thumb carpometacarpal OA: first metacarpal suspension during open or arthroscopic total or partial trapeziectomy and secondary surgery after failure of trapeziectomy with or without implant interposition. The advantage of this new device, which suspends the first metacarpal off the second metacarpal, is the very short immobilization period contrary to other suspensioplasty procedures.

Trapeziometacarpal joint ligament reconstruction is a surgical option in the early stages of thumb basal joint arthritis when the joint is painful and unstable without chondropathy. Arthroscopy is invaluable here to ensuring the joint surfaces are intact, which is often underestimated by radiography. The Eaton-Littler procedure using a distally pedicled flexor carpi radialis slip has been studied the most in this context. This reconstruction provides pain relief while slowing the rapid development of osteoarthritis.

Understanding the biomechanics of the trapeziometacarpal (TMC) or first carpometacarpal (CMC1) joint, the pathophysiology of basal thumb arthritis, the design and performance of surgical procedures require a solid anatomical basis. This review of literature summarizes the most recent data on the descriptive, functional, and comparative anatomy of healthy and arthritic TMC joints.

The two approaches most often used for placing implants and trapeziometacarpal prostheses are the laterodorsal approach and the lateropalmar approach. The advantages and disadvantages of these two approaches are set out. Each one allows optimal joint exposure while preserving or repairing the peritrapezial musculotendinous structures. They allow the insertion of partial or total trapeziometacarpal implants and modern coupled trapeziometacarpal prostheses. Each approach must be practiced and mastered on cadaver specimens before being used for trapeziometacarpal surgery.

Silicone implants for the treatment of basal thumb arthritis were first proposed in the 1970’s by Swanson. They became extremely popular and despite good functional results, the high rate of complications such as instability, material breakage and foreign body reactions led to them being progressively abandoned by most surgeons. Pyrocarbon implants were introduced at the beginning of the 2000’s. A large range of different implant models that can be used for either hemiarthroplasty or interposition arthroplasty. For some implants, a supplemental ligamentoplasty procedure is required to avoid instability. Miniaturization of some implants provides new options for minimally invasive surgery, which is relevant in low and medium grades of osteoarthritis, especially for young, active patients. Medium- and long-term follow-up have now been reached by some pyrocarbon interpositions. Their results confirm that these implants are a reliable alternative to other techniques. This paper focuses on the surgical techniques and outcomes of pyrocarbon implants for the treatment of basal thumb arthritis. It is based on published data and the author’s experience.

The treatment of trapeziometacarpal (TM) osteoarthritis is still debated, as many surgical options are available, and no technique has proven to be superior. Prosthetic treatment in this context has been described since the early 60s. Recently, the use of pyrolytic carbon-based prosthesis has revolutionized arthroplasty surgery in the hand. We performed a retrospective investigation of our surgical management of TM osteoarthritis since 2010 including the study only patients treated with partial trapeziectomy and Pyrodisk implant, with at least 5 years follow-up. After the application of inclusion criteria, 26 patients (6 males and 20 females) were retained. Despite the literature suggesting that implant TM surgery is well suited for older patients, in our experience, the procedure was mainly proposed to the young manual worker, with high demands in terms of thumb strength and stability (mean age of 53 years old, range 37-65). A statistically significant improvement in post-operative DASH, Kapandji and scores was observed. As well, strength measurements, particularly pinch strength and grip strength, increased significantly after the surgery. According to our findings, the Pyrodisk implant provides satisfactory results in terms of thumb strength and stability even in young and active patients and should therefore be considered as a valuable option in selected cases. Meticulous surgical procedure is mandatory in order to avoid complications and should therefore be executed by an expert surgeon. Abbreviation: IV: level of evidence.

Summary Background Carpometacarpal osteoarthritis of the thumb (CMC OA) is treated with various therapeutic approaches. However, the literature remains inconclusive regarding the ideal procedure for each disease stage. In this study, we assessed the international application of surgical treatment options including CMC I implants and non-surgical treatment options for CMC OA depending on the disease stage, with a strong focus on the detection of geographical disparities. Methods We conducted a large international online survey with members of hand surgical societies of the International Federation of Societies for Surgery of the Hand (IFSSH). The first part of the survey asked about general therapy options of CMC OA depending on the severity of the disease, whereas the second part specifically dealt with the use of prostheses. Results We could include 10 of 56 IFSSH member societies (6807 surgeons) and received answers from 1138 members (16.7%). Significant differences were detected in an increased use of corticosteroid injections in the USA, and a growing frequency of fat injections in Europe. Regarding use and frequency of the resection arthroplasty, we found similar results in all participating countries. Prosthetic implantation showed a significant difference between the USA and Europe, with far larger numbers stated by European hand surgeons. Conclusion CMC OA is treated differently in the participating countries depending on the stage of the disease. We give an insight into geographical differences in treatment paradigms, with corticosteroid injections being more prevalent in the USA, and prosthesis implantation being more frequently chosen in the selected European countries.

Background This study aimed to explore the clinical efficacy of treating a first metacarpal base fracture by closed reduction and percutaneous parallel K-wire interlocking fixation between the first and second metacarpals. Methods Twenty patients treated by the abovementioned modified technique (modified technique group) and ten patients treated by the traditional percutaneous K-wire fixation technique (traditional technique group) from October 2015 to November 2019 at our institution were retrospectively reviewed. The patients’ average age was 38 years (range, 16–61 years). The mean follow-up period was 13 months (range, 10–18 months). At the final follow-up, the functional recovery of the injured hand was assessed and compared between the modified and traditional technique groups. In addition, the functional recovery of the injured hand was compared with that of the uninjured hand within the modified technique group. Results All patients recovered well, with no cases of infection or nonunion. Compared with the traditional technique group, the modified technique group had a shorter operative time, lower postoperative visual analogue scale pain score, better effective range of motion score of the first carpometacarpal joint (Kapandji score), and had almost no need for auxiliary plaster fixation, enabling functional exercise to be started earlier. Within the modified technique group, the mean hand grip strength, pinch strength, and Kapandji score on the injured side did not significantly differ to the values on the uninjured side in both the extra-articular and intra-articular fracture subgroups. While the abduction and flexion–extension arcs of the thumb on the injured hand were significantly smaller than those on the uninjured hand in both the extra-articular and intra-articular fracture subgroups, the patients felt clinically well with respect to daily activities and strength. Conclusion The percutaneous parallel K-wire and interlocking fixation technique is simple, effective, and economical for first metacarpal base fractures.

Objective Complex base fractures of the fifth metacarpal bone and dislocation of the fifth carpometacarpal joint are more prone to internal rotation deformity of the little finger sequence after fixation with a transarticular plate. In the past, we have neglected that there is actually a certain angle of external rotation in the hamate surface of transarticular fixation. This study measured the inclination angle of the hamate surface relative to the fifth metacarpal surface for clinical reference. Methods In a prospective single‐center study, we investigated the tilt angle of 60 normal hamates. The study included thin‐layer computed tomography (CT) data from 60 patients from the orthopaedic clinic and inpatient unit from January 2017 to March 2020, including 34 men and 26 women who were 15~59 years old, average 35 years old. The CT data of 60 cases in Dicom format of the hand was input into Mimics and 3‐Matics software for three‐dimensional (3D) reconstruction and measuring the angle α between hamate surface and the fifth metacarpal surface. According to the possible placement of the transarticular plate on the fifth metacarpal surface, we measured the angle β between the hamate surface 1 and the fifth metacarpal surface and the angle γ between the hamate surface 2 and the fifth metacarpal surface. Results The average angle between the hamate surface and the fifth metacarpal surface was 11.66°. The hamate surfaces 1 and 2 have an external rotation angle of 7.30° and 7.51° on average with respect to the fifth metacarpal surface, respectively. There is no statistically significant difference in the angles between the two groups (P > 0.05). Conclusions The horizontal angle of the dorsal side of the hamate is different from the back of the fifth metacarpal surface, and the hamate has a certain external rotation angle with respect to the fifth metacarpal surface. No matter how the transarticular plate is placed, the plate always has a certain external rotation angle relative to the fifth metacarpal surface. When the fixation is across the fifth carpometacarpal joint, if the plate does not twist and shape, it will inevitably cause internal rotation of the fifth metacarpal, resulting in internal rotation deformity of the little finger sequence., When the fixation across the fifth carpometacarpal joint, if the plate does not twist and shape, it will inevitably cause internal rotation of the fifth metacarpal, resulting in internal rotation deformity of the little finger sequence.The left of Figure a shows that if the plate is pre‐bent, the normal position of the metacarpal bone can be guaranteed. The right of Figure a shows that if it is not pre‐bent, the internal rotation of the metacarpal bone will appear according to the original plane of the plate.Figure b shows the deformity of the internal rotation of the little finger.

Study Design This is a longitudinal, observational, multicenter, cohort study. Introduction Thumb carpometacarpal (CMC) osteoarthritis (OA) is associated with more pain and restrictions than other hand OA. The use of patient-identified occupational performance goals to guide hand therapy treatment and to measure clinical outcomes is fundamental for a patient-centered intervention. The COPM enables subjects to identify goals for hand therapy and engage in a subject-specific therapeutic process. Purpose of the Study The purpose of this study is to evaluate the convergent validity and responsiveness of the COPM to evaluate the relationship between the patient’s self-perception and satisfaction of performance in everyday living and pain intensity, upper limb function, and manual ability. Methods Eligible participants to multiple hand therapy centers were recruited. Outcomes measures (VAS scale, QuickDASH, MAM-36, and the COPM questionnaire) were measured at the baseline and 3 months after. Results One hundred forty-five (n = 145) consecutive patients for five different hand rehabilitation centers with symptomatic thumb CMC OA were screened for eligibility criteria. COPM-P and COPM-S were the most responsive instruments, with an area under the curve of 0.88 (95% CI 0.79-0.96) and 0.88 (95% CI 0.80-0.96), respectively. Conclusions Although more investigation in this area is necessary to conclude that the COPM is the best option to evaluate the effectiveness of hand therapy interventions for thumb OA. The COPM focuses on function and occupation and, in comparison with others upper limb scales, does not require the use of another complementary scale for addressing both satisfaction and ADL status. COPM is an instrument with a good convergent validity and responsiveness to evaluate the relationship between the patient’s self-perception and satisfaction in thumb CMC OA.

The authors aimed to explore patients' perioperative experience after trapeziectomy and ligament reconstruction tendon interposition through semistructured patient interviews to identify deficiencies in preoperative patient counseling.The authors conducted semistructured interviews with 14 patients who had undergone ligament reconstruction tendon interposition either 10 to 14 weeks or 9 to 12 months postoperatively at the time of their interview. The semistructured interview guide was developed by a fellowship-trained hand surgeon and a qualitative research specialist to discuss each patient's perioperative experience. Inductive and deductive qualitative coding strategies were used to develop a codebook. All transcripts were then double-coded and discussed to develop recurrent major themes from the patient interviews.The authors' interviews identified three major themes discussed consistently on the patient perioperative experience. First, despite specific counseling about a 3- to 6-month postoperative rehabilitation period, patients were still surprised at the length of the recovery process in regaining function, range of motion, and strength. Second, patients repeatedly outlined that surgery on the dominant hand imparted specific limitations that made the postoperative course difficult. Third, patients discussed the importance of hand therapy both in rehabilitation and in guiding patient postoperative expectations.Preoperative counseling is of vital importance to set patient expectations in terms of overall expected outcomes, but also regarding early limitations, expectations, and overall recovery length. These themes have influenced how we counsel our patients about recovery after thumb carpometacarpal surgery and may help other surgeons identify areas for improvement in their discussions with patients.

It has long been thought that the surgical treatment of osteoarthritis of the first carpometacarpal joint must replicate the normal anatomy. Common sense argues that biomechanical stability can be achieved by a simple ball-and-socket joint obviating complicated ligament reconstructions and trapezium replacements. Our argument is presented and the conclusions are based on the results of a very large series over a long period. A simple trapezium excision arthroplasty of the base of the thumb without ligamentous reconstructions is all that needs to be done to surgically solve painful osteoarthritis of the first carpometacarpal joint. Anything more is overoperating.

The aim of this study was to explore association between hypermobility and osteoarthritis (OA) at the first carpometacarpal (CMC) joint, using magnetic resonance imaging (MRI) to identify early change in women at high risk of developing OA but without yet established diagnoses.For this observational study, 33 women (aged 30-50 years) with self-reported history of maternal hand OA but without personal diagnoses of OA were recruited. Participants completed a 5-point hypermobility questionnaire. The 20 participants with 2 or more positive responses were categorized with "high hypermobility scores." The remaining 13 were categorized with "low hypermobility scores." Data collection included functional index, hand pain measure, parity, smoking status, and body mass index. Each participant underwent dominant hand radiographic and MRI examination. Imaging studies were interpreted by assessors blinded to hypermobility score categorization.No significant differences in age, body mass index, parity, functional index, or pain scores were observed between higher and lower hypermobility score groups. Similarly, there were no significant differences between groups for radiographic changes. However, significantly higher proportions of women with higher hypermobility scores were observed on MRI to have abnormalities of trapezium cartilage (75% vs. 38%), metacarpal cartilage (80% vs. 38%), and trapezium bone (70% vs. 31%); p0.05 for all.First CMC joint structural abnormalities were more frequently observed in women with higher hypermobility scores. Identification of early preradiographic changes in this group supports the concept that early-life joint laxity may contribute to future OA predisposition. Magnetic resonance imaging may be a preferred imaging test for detection of early cartilage changes in people at high risk of CMC joint OA.

Background: Trapeziometacarpal osteoarthritis is commonly treated with a trapeziectomy combined with a form of tendon plasty. The type of tendon plasty used is based on the surgeon's preference. The purpose of this observational study was to compare the outcomes of four different tendon plasties combined with trapeziectomy used to treat osteoarthritis of the trapeziometacarpal joint: the Weilby, Burton-Pellegrini, Zancolli, and anchovy plasty procedures. Methods: Patients treated with a trapeziectomy followed by a tendon plasty completed patient-reported outcome measures at baseline and 12 months postoperatively. The primary outcome was the Michigan Hand Outcomes Questionnaire pain subscale. Secondary outcomes were the minimal clinically important difference of Michigan Hand Outcomes Questionnaire pain scale score, Michigan Hand Outcomes Questionnaire hand function, satisfaction, and complication rate. Results: Seven hundred ninety-three patients underwent a trapeziectomy with a tendon plasty between November of 2013 and December of 2018. There was no difference in pain score after 12 months between the four tendon plasty techniques. Patients undergoing an anchovy plasty had a higher chance of reaching the minimal clinically important difference for Michigan Hand Outcomes Questionnaire pain score compared to the other techniques (OR, 2.3; 95 percent CI, 1.2 to 4.6). Overall, more than 80 percent of the patients were satisfied with the treatment outcome, independent of which technique was used. Complication rates of the different techniques were similar. Conclusions: Surgical treatment of osteoarthritis of the trapeziometacarpal joint reduced pain after 12 months, independent of which tendon plasty was used. Patients undergoing an anchovy plasty were more likely to experience a clinically relevant improvement in pain while having similar hand function, satisfaction, and complication rates. This suggests that anchovy plasty is the preferred tendon plasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background: The effectiveness of Manual Therapy (MT) in thumb carpometacarpal osteoarthritis (OA) is unclear.Objective: This study aimed to determine the effectiveness of MT for functional outcomes in patients with thumb carpometacarpal OA. Design: Systematic review and meta-analysis of randomized clinical trials. Methods: An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared MT versus other interventions in functional outcomes, such as thumb and/or hand function questionnaires, pinch and/or grip strength, thumb and/or hand range of motion, and pain intensity or pressure pain threshold in patients with thumb carpometacarpal OA. Results: Five clinical trials met the eligibility criteria; for the quantitative synthesis, four studies were included. The mean difference (MD) for grip strength was 0.87kg (95% CI = 0.29-1.44, p = .003), for pinch strength was 0.10kg (95% CI = -0.01-0.20, p = .06), and for the pressure pain threshold was 0.64kg/cm2 (95% CI = 0.07-1.20, p = .03). All differences were in favor of the MT group. Conclusions: In the short-term, there was moderate to high evidence, with statistically significant differences in the functional outcomes, in favor of MT versus sham interventions in patients with thumb carpometacarpal OA. However, these differences are not clinically important.

Osteoarthritis of the carpometacarpal (CMC)-1 joint is a common condition that can cause significant pain and functional problems. When nonoperative management fails, surgery may be indicated. Resection of the trapezium, often combined with soft tissue stabilization, is still considered the gold standard. But recovery time is often prolonged and a significant number of patients remain unsatisfied in the long term. Knowing that total endoprosthetic joint replacement is one of the most successful achievements of orthopedic surgery, many attempts have been made to produce a replacement for the CMC‑1 joint that provides a better outcome than trapeziectomy.Eaton-Glickel stage 2-3 CMC‑1 osteoarthritis.Symptomatic pan-trapezial osteoarthritis (Eaton-Glickel stage 4), infection, young manual worker, poor bone quality or insufficient trapezium size.A dorsoradial approach to the CMC‑1 joint is used. Minimal resection of the trapezial and metacarpal articular surfaces, including osteophytes and loose bodies. Reaming of the trapezium and broaching of the metacarpal stem with dedicated instruments. Implantation of the endoprosthetic components. Selection of the correct neck length to ensure a stable joint. Closure of the capsule and skin.Immobilization of thumb for 2 weeks in a splint. Followed by a removable thumb CMC brace for 4 weeks, starting with gentle mobilization exercises. No forceful gripping or pinching the first 6 weeks.A specific design-the uncemented, ball in socket, metal on polyethylene total joint replacement-has stood the test of time and successful long-term clinical and radiographic outcome results have been published. Recent comparative trials have shown better pinch strength, better pain relief and faster functional recovery, when compared to trapeziectomy with ligament reconstruction and tendon interposition. The incidence of complications such as dislocation, polyethylene wear and cup loosening is acceptable.OPERATIONSZIEL: Eine Arthrose des CMC(Karpometakarpal)-1-Gelenks ist eine häufige Erkrankung und kann erhebliche Schmerzen und Funktionsstörungen verursachen. Wenn konservative Behandlungsmaßnahmen keinen Erfolg zeigen, kann eine Operation indiziert sein. Als Goldstandard gilt nach wie vor die Trapeziumresektion, oft kombiniert mit einer Weichteilstabilisierung. Allerdings ist die Genesungszeit oft verlängert, und eine nicht unerhebliche Gruppe von Patienten bleibt auf Dauer unzufrieden. Angesichts der Tatsache, dass der vollständige endoprothetische Gelenkersatz eine der erfolgreichsten Entwicklungen in der orthopädischen Chirurgie darstellt, wurden viele Versuche unternommen, einen Ersatz für das CMC-1-Gelenk herzustellen, der ein günstigeres Ergebnis als die Trapezektomie bietet.Stadium 2‑3 nach Eaton und Glickel, CMC-1-Arthrose.Symptomatische pantrapeziale Arthrose (Stadium 4 nach Eaton und Glickel), Infektion, junge, körperlich arbeitende Personen, unzureichende Knochenqualität oder eine zu geringe Größe des Trapeziums.Der Zugang zum CMC-1-Gelenk erfolgt von dorsoradial. Minimale Resektion der Gelenkflächen des Trapeziums und des Mittelhandknochens, einschließlich Osteophyten und freier Gelenkkörper. Fräsen des Trapeziums und Aufrauen des Metakarpalschafts mit speziellen Instrumenten. Implantation der endoprothetischen Komponenten. Auswahl der richtigen Halslänge, um die Gelenkstabilität zu gewährleisten. Verschließen von Gelenkkapsel und Haut.Immobilisierung des Daumens für 2 Wochen mit einer Orthese. Anschließend abnehmbare Daumen-CMC-Schiene für 4 Wochen, Beginn der Mobilisierung mit sanften Übungen. Kein kraftvolles Greifen oder Zusammendrücken in den ersten 6 Wochen.Ein spezielles Design – eine zementfreie, Kugel-in-Pfanne‑, Metall-auf-Polyethylen-Totalendoprothese – hat sich über Jahre bewährt, Langzeitergebnisse zum erfolgreichen klinischen und radiologischen Verlauf wurden publiziert. Neuere vergleichende Studien haben gegenüber der Trapezektomie mit Bandrekonstruktion und Sehneninterponat eine höhere Pinch-Kraft, eine wesentlichere Schmerzlinderung und eine schnellere funktionelle Rekonvaleszenz gezeigt. Die Inzidenz von Komplikationen, wie Dislokationen, Polyethylenabrieb und Pfannenlockerung, liegt im akzeptablen Bereich.

Background To our knowledge, to date, 52 patients with thumb carpometacarpal osteoarthritis (CMC1 OA) were treated with joint distraction. So far, most patients experienced improved physical function and less pain. After 2 years, only 1 patient proceeded to trapeziectomy. This study assesses if we can safely lower the distraction duration from 8 to 6 weeks for CMC1 joint distraction, maintaining the improvement in physical function and pain. Methods This is a monocenter randomized controlled non-inferiority trial that includes patients younger than 65 years of age with ongoing symptoms of CMC1 OA and an established indication for surgery. All patients will be treated with CMC1 joint distraction. The primary outcome is to assess whether 6 weeks of joint distraction is not inferior to 8 weeks in terms of physical function at 1 year after surgery. Secondary outcomes will identify differences between groups at 1 year in pain intensity, patient satisfaction, hand health status, adverse event rates, treatment failure, differences in thumb strength and range of motion, and radiographic changes. Discussion If safe, the duration of basal thumb joint distraction can be reduced to 6 weeks, reducing patient burden. Because this is a relatively new treatment, this trial will provide greater knowledge of potential adverse events. This knowledge allows for more informed decision making for patients considering CMC1 distraction treatment. Future studies can directly compare joint distraction to other treatments of CMC1 joint arthritis like splinting and trapeziectomy. Trial registration Central Committee on Research Involving Human Subjects (CCMO), NL68225.100.18; registered on 9 August 2019. Medical Research Ethics Committees United (MEC-U), R19.003; registered on 9 August 2019. Netherlands Trial Register, NL8016; registered on 15 September 2019.

Excision of the trapezium is the common step in most arthroplasties for treating trapeziometacarpal arthritis. Trapeziectomy can be supplemented by several techniques intended to stabilize the first metacarpal but none of these has been proven superior. The aim of this study was to verify if a simplified suspension arthroplasty with the flexor carpi radialis (FCR) tendon, requiring only a single short surgical incision, no intraosseous tunnels and no interposition of prosthetic material, yields equal clinical outcomes to more complex techniques and if the clinical outcomes remain stable over the long term. A cohort of 299 patients was reviewed retrospectively at a follow-up ranging from 3 to 12 years (mean follow-up time 6 years) following total trapeziectomy and suspension arthroplasty using a half-tendon strip of FCR. At this long-term follow-up, the mean DASH score improved from 52 preoperatively to 20 postoperatively. Pain at follow-up was subjectively rated by patients as absent or improved in 92% cases. Thumb opposition assessed on the Kapandji scale was rated 9 or 10 in 144 (76%) hands, 7 or 8 in 30 (16%) hands and7 in 15 hands (8%). Mean palmar flexion and radial abduction were 45° and 42°, respectively. Mean key pinch and grip strength were 4.7 Kg and 23.5 kg, respectively. When treating trapeziometacarpal osteoarthritis, surgical techniques that do not require complex procedures, bone tunnels, K wire stabilization or interposition of prosthetic materials can be considered and maybe preferred. Our technique of trapeziectomy and suspension arthroplasty with the FCR tendon produces good long-term results.

Objective To evaluate the best option among orthoses for carpometacarpal (CMC) osteoarthritis (OA) of the thumb, using a network meta-analysis. Data Sources Medline, Embase, Cochrane, and ClinicalTrials.gov registry databases were used. PubMed, Embase, Cochrane Controlled Trials Register, Cochrane, and other databases were used without language restrictions. Study Selection We searched randomized controlled trials (RCTs) on adults with OA of the thumb by studying any orthosis from the beginning to March 10, 2020. Data Extraction Data were extracted and checked for accuracy and completeness by pairs of reviewers. Outcomes were pain and function. Comparative treatment effects were analyzed by random-effects model for direct pairwise comparisons and Bayesian network meta-analyses to integrate direct and indirect evidence. Data Synthesis Eleven RCTs involving 619 patients were included. We evaluated 5 groups, for 4 different orthoses: short thermoplastic CMC splint (rigid CMC) (n=5), long thermoplastic carpometacarpal-metacarpophalangeal splint (rigid CMC-MCP) (n=7), short neoprene CMC splint (soft CMC) (n=1), long neoprene CMC-MCP splint (soft CMC-MCP) (n=5), and one as a control group (n=5). Our results show that all splints were superior to placebo to reduce pain intensity and the top-ranked intervention was the rigid CMC-MCP (surface under the cumulative ranking curve analysis [SUCRA], score: 65.4). In function evaluation, we report a 71.6 SUCRA for rigid CMC. Conclusions Although the current evidence is unclear on the use of the splint in OA of the thumb, it is not known which orthosis is more effective and whether the orthosis is more effective than other interventions. The network meta-analysis shows that a long thermoplastic splint it is the best choice for pain relief and the short thermoplastic CMC splint is the best treatment to increase function. These results may suggest initial treatment with a long rigid orthosis and then a short rigid orthosis.

Objective Thumb carpometacarpal osteoarthritis (CMC1 OA) is typically understood as part of the disease entity of hand OA. However, CMC1 OA often occurs in isolation or is a primary source of symptoms and thus management can be improved by treatments that account for its unique characteristics. The aim of the current study was to explore the experiences of New Zealanders with CMC1 OA to better understand the unique impact of this condition, ascertain outcomes of importance, and identify treatment targets. Methods In this pragmatic qualitative study people who either reported a history suggestive of CMC1 OA or had been physician diagnosed were recruited from health and community settings in two centres in the South Island of New Zealand. Thirty participants (11 men and 19 women, mean age (SD) 65.4 (11.36) years) took part in individual face-to-face interviews and solicited diaries. The interviews were audio recorded and, along with the diaries, transcribed. Data were analysed by thematic analysis using a primarily inductive approach. The Health Impact Model was employed to aid interpretation of results. Results Five inter-related levels of health impact were identified: symptom status, functional limitations, restrictions in social activities and roles, negative thoughts and feelings, and an altered sense of self. Constant pain and pain at night were key symptoms which were associated with impact at the other levels. Conclusions Constant pain, pain at night, functional capacity, medication burden, emotional impact, and sense of self are important outcomes and treatment targets in people with CMC1 OA.

Trapeziometacarpal joint arthritis is a prevalent condition with a preponderance to women. Most cases are asymptomatic, but typical symptoms are pain, reduced dexterity, and functional decline. Trapeziectomy is the most common surgical treatment in the United Kingdom for patients who remain significantly symptomatic despite nonoperative measures, and this generally produces acceptable outcomes; however, a proportion of patients remain significantly symptomatic. The authors present a case series of 4 patients who underwent successful thumb metacarpal base to index metacarpal base arthrodesis with either distal radial or iliac crest bone grafting. Three of these patients had persisting symptoms after a primary trapeziectomy and 1 patient had gross subluxation of the thumb related to rheumatoid arthritis. Technically, this is a simple procedure to perform. All patients had improved symptoms with satisfactory functional outcomes and an improved cosmetic appearance of the hand.

Suture-button suspensionplasty has been popularized in the treatment of thumb carpometacarpal (CMC) arthritis in recent years. The surgical technique of this method was well defined previously. The most challenging and important part of this technique is the tensioning of the suture-button system to preserve first metacarpal height after trapeziectomy. In present study, we would like to present a technical trick about adjusting the tension while performing suspensionplasty using suture-button device in thumb CMC joint osteoarthritis. In the original technique, trapeziectomy is performed prior to fixation and tensioning of suture-button system. However, it is quite difficult to recreate the original trapezial space, since first metacarpal subsides after trapeziectomy. The trick in our technique is that trapezium remains in its anatomic position up to the end of the operation. Thus, we do not need to make effort to adjust the thumb ray height and use fluoroscopic imaging to ensure its position. In conclusion, we believe that our technique simplifies the most challenging part of the operation, shortens the operation time, preserves the original first ray height and diminishes the exposure of ionizing radiation as it reduces the need for fluoroscopy.Die Suture-button-Resektionssuspensionsarthroplastik für die Behandlung der Daumensattelgelenksarthrose erfreut sich seit ihrer Einführung einer gewissen Beliebtheit. Allerdings ist es schwierig die Spannung des Suture-button-Systems so einzustellen, dass eine Proximalisierung des ersten Mittelhandknochens sicher vermieden wird. Wir haben eine Technik entwickelt, die dies erleichtert. Dabei wird im Gegensatz zur Originaltechnik die Resektion des Trapeziums nicht zu Beginn der Operation durchgeführt, sondern erst nach Einbringen des Suture-button-Systems.

The aim of this retrospective study was to analyze the medium-term results of patients treated with a pyrocarbon interposition implant (Pyrocardan®, Wright Medical™) after failed trapeziectomy. Eight female patients with an average age of 63 years were included in this single-center study. The average follow-up was 54 months (28-85 months). The average time elapsed between the trapeziectomy and the revision surgery was 116 months. Trapeziectomy failures were due to a painful scaphometacarpal and/or metacarpotrapezoid impingement. Patients were assessed radiologically and clinically for range of motion, strength (pinch and grip), pain (visual analog scale - VAS) and function (QuickDASH and PRWE scores). We found pain reduction with the mean VAS decreasing from 6.3 preoperatively to 2.5 postoperatively. Function improved with the QuickDASH and PRWE scores going from 52.9 and 49.1 preoperatively to 30.7 and 31.0 at the last follow-up, respectively. Strength and range of motion did not change significantly. Seven patients were satisfied or very satisfied with the surgery, while one patient did not experience any improvement after surgery. There was no radiological evidence of dislocation or bone reaction around the implant. Revision of failed trapeziectomy with the Pyrocardan® implant in cases of severe and painful first metacarpal subsidence is an effective solution that improves pain and function in the medium term.