Carpal-metacarpal Joint Research Articles

Arthroscopy-assisted partial trapeziectomy combined with ligament reconstruction for thumb carpometacarpal joint osteoarthritis: A different technique.

There is no consensus on the best surgery option for thumb carpometacarpal osteoarthritis (CMC OA). The traditional method has the risk of large trauma, obvious metacarpal subsidence, and decreased stability. The aim of this study is to introduce a different technique to restore the function and stability of the first carpal metacarpal joint with minimal trauma, rapid pain relief, reduced complications, and the clinical outcomes in the long-term follow-up was evaluated and statistically analyzed. This was a retrospective study of 10 patients with a mean age of 51.8 years. The surgery consisted of removing partial trapezium through arthroscopy, reconstructing the stability with flexor carpi radialis suspension and tendon interposition. The subjective assessment included visual analog scale (VAS) of pain, quick disabilities of the arm, shoulder, and hand (Quick-DASH) score, and patient satisfaction. The range of motion, grip strength, pinch strength, and radiographic assessment, which can reflect stability of the thumb, were objectively evaluated and statistically analyzed. Ten patients were monitored at a mean follow-up of 6.8 years. The mean grip strength improved significantly from 16.64 to 22.57 kg after surgery. Pinch strength improved significantly from 3.72 to 5.71 kg on average. The Kapandji score improved significantly from 5.7 to 8.6 on average. 80% (8/10) of the patients were satisfied with this surgery. On objective indicators, the VAS score decreased significantly from 6.4 to 1.3 on average. The mean Quick-DASH score improved significantly from 6.1 to 28.9. Postoperative x-ray showed slight subsidence and dislocation of the first metacarpal in two patients and did not affect the function by measurement. Arthroscopy-assisted partial trapezium resection combined with ligament reconstruction could be a workable and promising surgical technique in patients with thumb CMC OA. It can offer the advantages of minimizing surgical injury by preserving the first carpal metacarpal joint capsule to protect its stability, with a rapid pain relief, function improvement, and satisfactory results in patients' clinical measurements.

Luxación inestable traumática trapecio-metacarpiana.

Isolated dislocation of the carpal-metacarpal joint of the thumb or Trapezio-metacarpal (TMC) is a rare but challenging lesion, and represents 1% of all fractures of the hand. There is still controversy about the best treatment for this pathology. Acute TMC joint dislocation is usually managed by three treatment modalities: closed reduction and immobilization with a cast, closed or open reduction with Kirschner wires fixation, and reconstruction or repair of ligaments and capsulorrhaphy. Suture anchor repair is currently being used as the primary treatment for unstable dislocations. The aim of the present work is to review two cases of carpo-metacarpal dislocation of the thumb treated by reduction and Kirschner wires fixation, and show their evolution.

Osteocondrosis en el toro de lidia y evaluación de su efecto sobre la movilidad del animal

La osteocondrosis es un proceso degenerativo de las superficies articulares. Es una enfermedad descrita ampliamente en el caballo, con escasas referencias bibliográficas en bovino y prácticamente inexistentes en la raza de lidia. El objetivo de este trabajo fue informar sobre la prevalencia de osteocondrosis en toros y novillos, estudiar sus posibles causas y analizar la repercusión de esta patología en la movilidad del animal durante la lidia. Para ello se han estudiado 120 animales de la raza bovina de lidia, de 3, 4 y 5 años, lidiados en diferentes plazas de toros. Durante el faenado de las reses posterior a la lidia se realizó un estudio macroscópico de las articulaciones carpo-metacarpianas, estudiándose la presencia de lesión en las caras articulares implicadas y su grado de gravedad. Paralelamente se grabó la lidia de cada animal para el análisis de su movilidad y evaluación del síndrome de caída. Los resultados reflejan una lesión del cartílago articular en mayor o menor grado en aproximadamente el 80 % de los animales estudiados, apareciendo en el 63 % de los casos sobre la cara medial de la articulación y mayoritariamente de forma bilateral. Se observa una influencia negativa en la tasa de caídas manifestadas por el toro durante la lidia, lo que hace necesario nuevas investigaciones y estudios dirigidos a determinar sus posibles causas: factores genéticos, nutricionales y los inadecuados protocolos de entrenamiento entre otras.

Novel isometric exercises for the dynamic stability programs for thumb carpal metacarpal joint instability

Novel isometric exercises for the dynamic stability programs for thumb carpal metacarpal joint instability

Hematoma Evacuation to Improve Closed Reduction of Bennett Fracture

Dear Sir, The Bennett fracture is an intra-articular fracture of the base of the thumb and is the most common first metacarpal fracture [1, 2]. The mechanism of injury is axially-directed force through the partially flexed first metacarpal which causes an intra-articular fracture with a single volar ulnar fragment. Closed reduction and casting, closed reduction and percutaneous pinning, and open reduction and internal fixation are described as the possible treatment options. The goal of the reduction is to achieve less than a 1 mm gap at the articular surface of the first metacarpal [1, 3]. The technique of the closed reduction is described as first metacarpal extension and protonation while applying longitudinal traction and manual pressure to the base of the metacarpal in order to reduce the fracture. If adequate reduction cannot be achieved with a closed reduction, open reduction and fixation can be considered [3]. Before resorting to open reduction, however, hematoma evacuation may help with a closed reduction by decreasing the intra-articular pressure and allowing for better reduction in acute cases. A 61-year-old male sustained a right Bennett fracture after a fall. Closed/open reduction and percutaneous pinning/internal fixation for the right Bennett fracture was indicated. Despite several attempts of a closed reduction, congruent joint surface could not be achieved. Before moving to an open reduction, an 18-gauge needle was inserted into the first carpal metacarpal joint (Fig. 1). Less than 1 cc hematoma was evacuated. The needle was removed and closed reduction was performed according to previously described technique [3] . After hematoma evacuation, anatomic closed reduction was successfully achieved (Fig. 2). Two 1.2 mm K-wires were used for fracture fixation. The bone healed and patient recovered without complications. Fig. 1 Intraoperative fluoroscopy image of right first metacarpal. Please note that the 18-gauge needle was inserted to drain hematoma Fig. 2 Post-reduction fluoroscopy image of right first metacarpal fracture. Successful closed reduction was achieved Hematoma evacuation and bone reduction has previously been described [4], however, according to our best knowledge, it has not been described for the closed reduction of Bennett fracture. We believe that intra-articular hematoma could be a possible barrier to a successful closed reduction. Because of joint distraction caused by the intra-articular hematoma, an 18-gauge needle is relatively easy to insert in the joint and has shown to be successful in evacuating the hematoma.

Distinguishing erosive osteoarthritis and calcium pyrophosphate deposition disease

Erosive osteoarthritis is a term utilized to describe a specific inflammatory condition of the interphalangeal and first carpal metacarpal joints of the hands. The term has become a part of medical philosophical semantics and paradigms, but the issue is actually more complicated. Even the term osteoarthritis (non-erosive) has been controversial, with some suggesting osteoarthrosis to be more appropriate in view of the perspective that it is a non-inflammatory process undeserving of the "itis" suffix. The term "erosion" has also been a source of confusion in osteoarthritis, as it has been used to describe cartilage, not bone lesions. Inflammation in individuals with osteoarthritis actually appears to be related to complicating phenomena, such as calcium pyrophosphate and hydroxyapatite crystal deposition producing arthritis. Erosive osteoarthritis is the contentious term. It is used to describe a specific form of joint damage to specific joints. The damage has been termed erosions and the distribution of the damage is to the interphalangeal joints of the hand and first carpal metacarpal joint. Inflammation is recognized by joint redness and warmth, while X-rays reveal alteration of the articular surfaces, producing a smudged appearance. This ill-defined, joint damage has a crumbling appearance and is quite distinct from the sharply defined erosions of rheumatoid arthritis and spondyloarthropathy. The appearance is identical to those found with calcium pyrophosphate deposition disease, both in character and their unique responsiveness to hydroxychloroquine treatment. Low doses of the latter often resolve symptoms within weeks, in contrast to higher doses and the months required for response in other forms of inflammatory arthritis. Reconsidering erosive osteoarthritis as a form of calcium pyrophosphate deposition disease guides physicians to more effective therapeutic intervention.

Trapeziectomy made simpler (and quicker)

BACKGROUND Trapeziectomy for thumb carpal-metacarpal joint arthritis yields good results in terms of improvement of pain and physical function.1 Traditional piecemeal trapeziectomy can be time-consuming. We describe a quick and simple way to remove the trapezium in one piece. TECHNIQUE A standard approach to the trapezium is made with protection of the radial nerve, the trapezium being exposed with a longitudinal incision in the carpometacarpal ligament.2 A 2.5mm drill is used to drill across the bulk of the trapezium (Fig. 1). A cortical 3.5mm tap is then inserted and used for leverage and retraction (Fig. 2) while soft tissue is dissected from around the bone using a scalpel, allowing delivery of the complete trapezium attached to the tap (Fig. 3). DISCUSSION We have found this method for excision of the trapezium to be slick and effective and to have good results. We have seen a time saving of around 15 minutes per procedure. We cannot claim credit for this technique, it being shown to us by one of the authors who learnt it in the US.

Interposition Arthoplasty of the First Carpal-Metacarpal Joint Using Suture Anchor and Polydioxanone Ribbon

Osteoarthritis of the first carpal-metacarpal joint is common, and there are a number of procedures described to deal with it. We describe a technique used in our practice and evaluate the outcomes.

Carpal Boss: Effect of Wedge Excision Depth on Third Carpometacarpal Joint Stability

We hypothesize that carpal-metacarpal (CMC) instability after carpal boss wedge excision is not caused only by damage to the dorsal ligament but mainly depends on the depth of the bony resection. To test our hypothesis, this study analyzes the effect of wedge excisions with different depths (0, 15%, 35%, 55% of the third CMC joint) and the effect of different forces (0, 50, 100 N.m) on the stability (measured as the passive flexion) of the third CMC joint using 12 fresh-frozen human cadaver wrists. The passive flexion is defined as the increase in angular motion of the third CMC joint and represents change in stability during flexion of the joint. The results show that the mean passive flexion measured in the wedge excisions of 15% and 35% of the joint did not differ from that of neutral controls. Joints analyzed after a 55% wedge excision showed a significant increase in angular motion (increased passive flexion). This relates to the 50 N.m as well as the 100 N.m loaded test position. This study shows that a wedge excision of clinically applicable depth of 35% does not create instability during flexion of the third CMC joint when loaded with physiologically relevant forces. Yet an extended and hardly clinically relevant 55% wedge excision results in a change in stability of the joint. To prevent instability when performing a wedge excision for symptomatic carpal boss, care must be taken to avoid excisions that exceed 35% of the third CMC joint.

First Carpal-Metacarpal Joint Dislocation and Trapezial Fracture Treated With External Fixation in an Adolescent

The intrinsic joint stability of the first carpal-metacarpal joint (CMC) makes dislocation a rare injury with fewer than 40 cases described. The degree to which supporting ligaments have been disrupted is reflected clinically by a spectrum of joint stability. Close review of radiographs and an attentive physical examination are necessary to make the diagnosis. Acute treatment has consisted of closed or open reduction with K-wires for stabilization or casting with failures leading to chronic joint instability and the need for soft tissue tendon suspension to maintain joint alignment. We present the case of a 12-year-old boy with a complete first CMC dislocation and trapezial fracture treated with closed reduction and external fixation. At a 3-year follow-up, our patient demonstrates excellent range of motion, strength, and no joint instability without functional limitations. We suggest that external fixation be added to the armamentarium for managing these difficult injuries especially in the pediatric population where interference with growth plates is not ideal.

Percutaneous Pinning of Fifth Carpal–Metacarpal Fracture–Dislocations: An Alternative Pin Trajectory

Traditional management of unstable fourth and fifth carpal-metacarpal (CMC) fracture-dislocations (fx-dislocs) of the hand includes closed reduction and percutaneous pinning (CRPP) versus open reduction internal fixation (ORIF). Traditional trajectory of pin placement is toward the base of the hook of the hamate. Our case series of CMC fx-dislocs treated with this trajectory led to the development of ulnar deep motor branch symptoms (sxs). We attempt to propose an alternative trajectory that could lower the chance of iatrogenic injury. Five fresh frozen cadaveric specimens underwent percutaneous pinning of the fifth CMC joint using fluoroscopic guidance. Each cadaver was dissected, and the proximity of the deep motor branch of the ulnar nerve was measured in relation to a pin that penetrated the volar cortex. Our results confirm the close proximity of the deep motor branch of the ulnar nerve to the volar cortex of the hamate and demonstrate the potential for iatrogenic injury during CRPP of the fifth CMC fx-dislocs, especially with penetration of the volar cortex. By demonstrating the close proximity of the deep motor branch to the volar cortex of the hamate in cadavers, we highlight the potential for iatrogenic injury with CRPP of CMC fx-dislocs as seen in our case series. We recommend a more midaxial starting point on the proximal metacarpal with a trajectory aimed at the midbody of the hamate to prevent penetration of the hamate volar cortex and limit the chances of iatrogenic injury.

Thumb Metacarpophalangeal Arthritis: Arthroplasty or Fusion?

The human thumb assumes 50% of the workload of the human hand, and is therefore the most important digit. As such, the thumb has a propensity for the development of osteoarthritis. Moreover, the thumb is also often diseased, in anywhere from 68% to 80%of patients who have rheumatoid arthritis. Much attention over the years has been given to the carpalmetacarpal joint of the thumb, whereas the metacarpophalangeal (MP) joint of the thumb remains largely unstudied. The purpose of this article is to review the etiology of thumb MP joint arthritis, and discuss the different treatment options of this condition.

Total joint replacement in osteoarthritis

Surgical approaches have been developed for most of the sites of osteoarthritis, including the carpal metacarpal and first metatarsal phalangeal joint, the hips, knees, shoulders, ankles and elbows. This chapter will address surgical options for advanced osteoarthritis of the hips and knees and will focus primarily on total hip and knee replacement.

TRAPEZIO-METACARPAL ARTHRITIS

For trapeziometacarpal arthritis, trapezium excision and ligament reconstruction that is distinct from the ligament reconstruction tendon interposition (LRTI) arthroplasty has a distinct role. Emphasis is placed on the use of the abductor pollicis longus for tendon interposition and "suspensionplasty" for the arthritic thumb carpal metacarpal joint. The advantages of the abductor pollicis longus techniques as originally advocated by Thompson, and modified by Diao, are reviewed. The surgical technique for this procedure, clinical results and biomechanical cadaver analysis comparing abductor pollicis longus suspensionplasty done with two techniques, as they compare to the LRTI procedure, are included. The abductor pollicis longus suspensionplasty is an excellent treatment choice both for index procedures for carpometacarpal (CMC) thumb arthritis, and for salvage of the failed thumb CMC arthroplasty.

Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis

A series of 19 consecutive patients who underwent scaphoid-trapezium-trapezoid arthrodesis for chronic scapholunate instability or isolated arthrosis was reviewed. The average follow-up of 14 patients was 62 months. Eight of these 14 patients had significant residual symptoms and/or functional limitations at follow-up, and 11 had complications, including radiocarpal arthrosis (six patients), trapeziometacarpal arthrosis (four patients), and nonunion (three patients). Fusion without reduction of the scaphoid to a normal orientation was predictive of a poor result, but normal scaphoid positioning did not preclude development of arthrosis. Development of a painful degenerative thumb carpal-metacarpal joint may occur as an isolated phenomenon after scaphoid-trapezium-trapezoid arthrodesis.

Tendon Interposition Arthroplasty of Carpometacarpal Joint of the Thumb

Osteoarthritis of the thumb carpal metacarpal joint is effectively managed by complete excision of the trapezium or excision of the distal half of the trapezium with maintenance of the space by insertion of interposition tendinous material from palmaris longus or flexor carpi radialis. The more recent modification of partial trapezium excision has improved pinch strength and maintenance of thumb length and so has enhanced the final results. Carpal metacarpal ligament reconstruction is demonstrated because it is occasionally necessary.

Complete Dislocation of a Little Finger Metacarpal Phalangeal Joint Treated by Closed Technique

Complete dorsal dislocation of the metacarpal phalangeal joint almost always requires an open reduction. This case report presents an unusual set of circumstances allowing a closed reduction to be performed. The metacarpal-phalangeal joint of the patients' little finger was reduced before the carpal-metacarpal joint, followed by placement of percutaneous Kirschner wires.

Osteoarthritis of the carpometacarpal joint of the thumb

Osteoarthritis of the carpal-metacarpal joint of the thumb is not rare and can severely disable the use of the hand because of pain. It is more common in women and frequently bilateral. The various operative technics are presented in detail.