Thumb Basal Joint Arthroplasty Research Articles

The Effect of Preoperative Benzodiazepine Usage on Postoperative Opioid Consumption After Hand Surgery: A Multicenter Analysis.

Background Prescription rates of opioids and benzodiazepines have steadily increased in the last decadewith the percentage of prescription opioid overdose deaths involving benzodiazepines more than doubling during that time. Orthopaedic surgery is one of the highest-volume opioid prescribing medical specialties, but the effects of benzodiazepine use on orthopaedic surgery patient outcomes are not well understood. The purpose of the study was to utilize the state Prescription Drug Monitoring Program (PDMP) database to investigate if perioperative benzodiazepine use predisposes patients to prolonged opioid use following hand and upper extremity orthopaedic surgery. Methods This study was retrospective and conducted at three urban academic institutions. All patients who underwent carpal tunnel release, thumb basal joint arthroplasty, and distal radius fracture open reduction internal fixation performed by 14 board-certified, fellowship-trained orthopaedic hand and upper extremity surgeons between April 2018 and August 2019, were collected via a database query. All opioid and benzodiazepine prescriptions were collected from three months preoperatively to six months postoperatively. Results In this study, 634 patients met the inclusion criteria presented to one of the three institutions during the 18-month study period. Patients consisted of 276 carpal tunnel releases, 217 distal radius fracture open reduction internal fixations, and 141 thumb basal joint arthroplasties. Benzodiazepine users were 14.6% more likely to fill an additional opioid prescription (p<0.005) and were 10.8% more likely to experience prolonged three to six-month postoperative opioid use (p<0.005). Conclusion This study found that patients who use benzodiazepines are at a higher risk of filling additional opioid prescriptions and prolonged opioid use following hand and upper extremity surgery. Prescribers should take this into account when prescribing opioids after upper extremity orthopaedic surgery.

Optimal Position of the Bone Anchor for the Internal Brace Suspensionplasty Technique for Thumb Basal Joint Arthroplasty

Ligament reconstruction and tendon interposition is a common technique for thumb basal joint arthroplasty. Recently, a variation of this technique, a suture suspensionplasty, has been introduced. The goal of our study was to assess the optimal position of the bone anchor in the thumb metacarpal. We hypothesized that an anchor placed in the radial aspect of the thumb metacarpal base would provide improved stability and resist subsidence more effectively than an ulnar-based thumb anchor. Eight fresh-frozen cadaver arms were imaged fluoroscopically in anteroposterior and lateral views centered over the thumb carpometacarpal joint before and after trapeziectomy and after the placement of radial-based and ulnar-based bone anchors. The intermetacarpal angle between the thumb and index metacarpals was measured on all images after the application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, and adduction were measured. Subsidence was calculated as the percentage loss of the trapezial space. Both radially and ulnarly placed internal brace constructs allowed more radial abduction, opposition, and palmar abduction than the pretrapeziectomy constructs. They both also reduced subsidence by approximately 20% to 29% compared with the posttrapeziectomy constructs. Comparing radial to ulnar constructs, motion and subsidence were similar. There was immediate stability of the thumb with respect to axial load and subsidence after anchor placement, and this was independent of the anchor position. The position of the bone anchor in the thumb metacarpal base did not affect the range of motion. Although the device can limit subsidence, it does not appear to restrict any range of motion of the thumb, irrespective of anchor position. This cadaver study can help hand surgeons understand the effect of positioning of bone anchors when performing a specific suture suspensionplasty technique.

Preoperative Opioid Use Results in Greater Postoperative Opioid Consumption After Thumb Basal Joint Arthroplasty

PurposeThumb basal joint arthroplasty surgery is a common hand surgery after which patients often require opioids. To better understand safe opioid consumption patterns, this study sought to identify risk factors for filling a second prescription and/or prolonged opioid use (prescription over 6 months after the surgery). Preoperative opioid use was hypothesized to show an association with greater postoperative opioid use.MethodsA retrospective review of consecutive patients who underwent primary thumb basal joint arthroplasty was conducted, yielding 110 patients for analysis. Demographic and clinical data were collected. Opioid prescription data were extracted from 6 months before the surgery to 9 months after the surgery using a state prescription drug monitoring program. Bivariate and multivariate analyses were performed for filling a second opioid prescription or filling an opioid prescription over 6 months after the surgery.ResultsAll the patients filled their initial postoperative prescription. Of the 110 patients, 26.4% filled an opioid prescription before the surgery, 42% filled a second postoperative prescription, and 14.5% were still consuming opioids over 6 months after the surgery. Patients using preoperative opioids had 7-fold higher odds of filling a second opioid prescription and 37-fold higher odds of prolonged use. No other demographic or clinical factors, including the type of procedure or number of initial opioids prescribed, were associated with increased use of postoperative opioids. Of all the opioid prescriptions filled after the initial postoperative prescription, only 9.3% were prescribed by a surgeon’s office.ConclusionsPatients who undergo thumb basal joint arthroplasty with preoperative opioid use have much greater odds of filling a second opioid prescription and prolonged use after the surgery. Low initial surgeon-provided opioid dosages did not correlate to filling a second prescription, indicating that lower initial doses are feasible. Finally, nearly all opioid-naïve patients who filled a second opioid prescription received them from providers other than a surgeon, indicating the need for greater communication with nonsurgical providers simultaneously caring for patients in the perioperative period.Type of study/level of evidenceTherapeutic III.

Unplanned Early Reoperation Rate Following Thumb Basal Joint Arthroplasty

PurposeThumb basal joint arthritis is a common degenerative condition of the hand that is often managed with thumb basal joint arthroplasty (BJA). This procedure generally results in a high level of patient satisfaction; however, the rate and cause of early unplanned reoperation after thumb BJA are not well-understood. Therefore, we performed a review to better understand the rate and cause of early reoperation.MethodsA retrospective review of all thumb BJA cases performed at a single private academic center between 2014 and 2016 yielded 637 patients and 686 primary thumb BJAs with a minimum 1-year follow-up (mean, 2.4 years). Data collection included patient demographics, surgical technique and type of thumb BJA performed, time to reoperation, reason for early reoperation (within 2 years), and type of reoperation.ResultsOf 686 patients undergoing thumb BJAs, 10 had unplanned early reoperation (1.5%). Mean duration between the index procedure and reoperation was 5.2 months (range, 0.5–14.3 months). Of the 10 unplanned early reoperations, 4 thumbs in 4 patients required revision arthroplasties owing to persistent pain. Time to reoperation for revision arthroplasty was 9.6 months (range, 3.9–14.3 months). Three of 10 reoperations resulted from early infection, 2 from unplanned early removal of symptomatic K-wires, and one from radial sensory neuritis.ConclusionsIn this series of nearly 700 consecutive cases, we identified an unexpected early reoperation rate of 1.5%, with only a 0.6% reoperation rate specifically for painful subsidence requiring a revision arthroplasty. Mean time to revision was 9.6 months. These rates are lower than those published previously and should be considered by patients and surgeons when planning thumb BJA.Type of study/level of evidencePrognostic IV.

Radiographic Outcomes in Treatment of Thumb Basal Joint Arthritis: Does Interposition of Acellular Dermal Allograft Prevent Metacarpal Settling?

Background Osteoarthritis at the thumb carpometacarpal joint can have a profound impact on quality of life. Here, we evaluate radiographic outcomes in patients who have had open complete trapeziectomy, ligament reconstruction with tendon interposition, and acellular dermal matrix (GraftJacket) interposition—Group A, and compare them with those without GraftJacket interposition—Group B.Materials and Methods Thirty patients who had undergone operative treatment for thumb basal joint arthritis by a single surgeon from 2009 to 2016 were identified, and charts were retrospectively reviewed for demographic data, surgical and radiographic outcomes, and complications.Results There was no significant difference in pre- and postoperative radial abduction or pre- and postoperative palmar abduction. The difference in intraoperative joint space was significant (p = 0.006), but the difference in postoperative joint space was not (p = 0.310). The average amount of metacarpal settling was 6.9 versus 3.7 mm (p = 0.035) (Groups A and B, respectively). Three patients in Group A developed an inflammatory reaction to the GraftJacket, and one required reoperation for allograft removal.Conclusion This study suggests that thumb basal joint arthroplasty with GraftJacket interposition does not lead to more favorable radiographic outcomes at long-term follow-up. The increased costs associated with GraftJacket use may not be justified in light of these outcomes.

Preemptive Analgesia in Thumb Basal Joint Arthroplasty: Immediate Postoperative Pain with Preincision versus Postincision Local Anesthesia

Purpose Currently no guidelines exist for the timing of the injection of anesthetics in surgeries performed under general anesthesia to minimize postoperative pain. To better understand the role of timing of the injection of local anesthesia in hand surgery performed under general anesthesia, we evaluated the effect of pre- versus postincisional local analgesic injection on immediate postoperative pain experience. We hypothesize that the preincisional (preemptive) injection will result in decreased immediate postoperative pain experience and analgesic use when compared with postincisional injection. Methods Consecutive cases of thumb basal joint arthroplasty performed over a 4-year period were retrospectively reviewed. During the first half of the study period, the surgical site was infiltrated with 0.5% bupivacaine at the completion of surgery following closure. During the second half of the study period, the surgical site was infiltrated with 0.5% bupivacaine prior to skin incision. Data collected included patient demographics, immediate postoperative recovery room (PACU) pain scores, and postoperative opioid consumption in morphine equivalents. Results Two-tailed t -test identified no significant difference between the pre- and postincision cohorts relative to PACU entrance pain scores and time spent in the PACU. PACU exit pain scores were significantly lower in the preincision cohort. The mean PACU pain score was also significantly lower in the preincision cohort. PACU opioid consumption, converted into morphine equivalents, was found to be 211 mg in the preincision versus 299 mg in the postincision cohort. Conclusion The preincisional (preemptive) injection of local anesthesia was found to result in lower pain scores during and upon exit of the PACU as compared with the postclosure group. In addition, the preincision cohort also trended toward lower opioid consumption while in the PACU. Consideration should be given to the routine use of preincision injection of local anesthesia to maximize pain relief in a multimodal pain strategy in hand surgical patients. Level of Evidence Therapeutic level III.

Thumb Basal Joint Arthroplasty: Prospective Comparison of Perioperative Analgesia and Opioid Consumption: Level 2 Evidence

There is no financial information to disclose. Trapeziectomy alone or in combination with a suspensionoplasty technique is a common surgical treatment for symptomatic basal joint arthritis, but is considered one of the more painful procedures of the hand. Various modalities for perioperative pain control are employed in the endeavor to manage postoperative pain, including peripheral nerve blocks and the infiltration of local anesthetics into the surgical site. We undertook a prospective comparative study with the hypothesis that peripheral nerve blocks would provide better pain control than local anesthesia with Marcaine or Exparel with respect to pain scores and opioid pill consumption. All consecutive patients undergoing thumb basilar joint arthroplasty were prospectively enrolled and allocated to one of three perioperative anesthesia groups: (1) peripheral nerve block, (2) local anesthesia with Marcaine and (3) local anesthesia with Exparel. Total opioid pill consumption and visual analog scale (VAS) pain scores were reported and collected for the first 5 postoperative days (POD). Seventy-eight patients were enrolled in the study with 27, 23, and 28 patients assigned to the peripheral nerve block (Group 1), Marcaine (Group 2) and Exparel (Group 3) groups, respectively. All groups experienced an increase in both opioid pill consumption and VAS scores from POD 0 to POD 1 (P < 0.05). Postoperative VAS was lowest in Group 3 from POD 0 to 2, although not statistically significant. During the same period, except for POD 0, average VAS scores were highest in Group 1 (Peripheral block). However, after POD 2, VAS scores normalized between all Groups and decreased uniformly thereafter. Total opioid consumption was lowest in Group 3 (11 pills) compared to Group 1 (17 pills) and Group 2 (19 pills), (P = 0.06). •There was a trend in all groups towards increase postoperative pain and opioid consumption between POD 0 and 1. After POD 2, pain decreased uniformly in all groups.•Total opioid consumption was found to be least in Group 3 (Exparel). Similarly, there was a trend towards better postoperative VAS in the Exparel group, but the trend was not statistically significant and did not continue beyond POD 2.•Peripheral nerve blocks were not found to be superior in terms of postoperative pain beyond POD 0. Moreover, peripheral nerve blocks and Marcaine alone had higher pain scores and opioid consumption after POD 0.•The effectiveness of each modality, as well as their potential risks and costs, should be considered when determining the optimal strategy.

Basal joint arthroplasty decreases carpal tunnel pressure.

There is a well-documented association between carpal tunnel syndrome (CTS) and thumb carpometacarpal (CMC) arthritis, and these conditions commonly coexist. We have observed that patients who have previously undergone thumb basal joint arthroplasty (BJA) seem rarely to present subsequently with CTS. Our hypothesis is that BJA decreases the pressure within the carpal tunnel. Twenty-eight patients (6 with coexistent CTS) undergoing BJA were enrolled in the study. The pressure within the carpal tunnel immediately before and after BJA was measured using a commercially available pressure monitor device (Stryker STIC; Kalamazoo, MI). In patients with concomitant CTS undergoing both BJA and carpal tunnel release (CTR), the pressure was measured after BJA but prior to release of the transverse carpal ligament. The pressure within the carpal tunnel decreased after BJA in all patients. There were 3 patients with stage II arthritis, 15 patients with stage III arthritis, and 10 patients with stage IV arthritis. The mean pressure prior to BJA among all patients was 23.9mmHg and decreased to 11.0mmHg after BJA. Patients with concomitant CTS had a mean pre-BJA pressure of 26.5mmHg, which decreased to 7.3mmHg after BJA. BJA decompresses the carpal tunnel and decreases the pressure within. In patients with concomitant CTS, the BJA alone (without additional release of the transverse carpal ligament) decreases the carpal tunnel pressure. Further study is warranted to determine the need for discrete release of the transverse carpal ligament in patients with CTS who are undergoing BJA. Level II, diagnostic.

Description and Outcomes of a New Technique for Thumb Basal Joint Arthroplasty

Many surgeries have been described for thumb basal joint arthroplasty, but none is clearly superior to the others. The purposes of this study were to describe a simple technique for trapeziectomy and ligament reconstruction, and to determine its objective and subjective outcomes. The surgical technique involves trapeziectomy, interposition of tissue, and abductor pollicis longus ligament reconstruction around the extensor carpi radialis longus tendon through a single incision. A retrospective chart review was performed on 48 patients who had undergone this surgery over an 11-year period by a single surgeon. At a minimum of 8 months' follow-up, grip had improved from 71% of contralateral strength to 93% of contralateral strength (p = .02), an increase of 32%. Appositional pinch had improved from 66% of contralateral strength to 98% of contralateral strength (p = .03), an increase of 49%. Radial abduction did not change to a statistically significant degree. Trapezial space ratio measured 0.44 preoperatively and 0.31 postoperatively (p < .01), a decrease of 30%. Of 42 patients, 27 had little or no pain and an additional 11 had improved pain postoperatively. Of 41 patients, 26 were very or extremely satisfied and 13 were satisfied with the outcome of the surgery. The described technique for trapeziectomy and ligament reconstruction is easy to perform, has a number of potential advantages over other arthroplasty techniques, and has similar short-term outcomes compared with ligament reconstruction and tendon interposition.

Suture Anchor Suspension and Fascia Lata Interposition Arthroplasty for Basal Joint Arthritis of the Thumb

Although the ideal treatment of thumb basal joint osteoarthritis is debated, most surgeons advocate trapeziectomy with ligament reconstruction tendon interposition arthroplasty. However, harvesting and weaving autologous tendon creates scarring, alters wrist kinetics, may prolong recovery, and is time consuming. In this article, the authors propose a new method of arthroplasty using suture anchor suspensionplasty and cadaveric fascia lata interposition. Thirty-eight consecutive patients who underwent 46 thumb carpometacarpal joint arthroplasties were analyzed retrospectively. All patients were treated by the senior author (J.U.) at one institution over 6 years. Total (n = 17) or partial (n = 29) trapeziectomy was performed followed by Mitek suture anchor suspension of the first to the second metacarpal and cadaveric fascia lata interposition. Preoperative and postoperative evaluations of pain, satisfaction, and strength were undertaken in the short term (3 months) and long term (last follow-up). Follow-up averaged 4 years. Thirty-one women and seven men were treated, all with advanced osteoarthritis (Eaton stage III and IV). In the short term, 93 percent of thumbs had excellent pain relief, whereas in the long term, pain relief increased to 96 percent. In the short term, 87 percent of cases showed high satisfaction, but this increased to 93 percent in the long term. Average key pinch and tip pinch improvements were 1.5 kg (76 percent improvement, p < 0.001) and 2.0 kg (81 percent improvement, p < 0.001), respectively. Three patients had minor complications. Thumb basal joint arthroplasty using suture anchor suspension and fascia lata interposition is a reliable, effective, and expeditious technique. It obviates the need for tendon harvest and manipulation while treating the underlying pathomechanics of the disorder.