The Wisconsin Hand Experience 2016 CMC Pitfalls and Preferences Greg Watchmaker, MD Zion 2014

Pitfalls

Expectations

Relieve pain 93% Improve strength 93% Restore basic tasks like opening a jar 93% Prevent condtion from worsening 95%

Expectations

Prevalence Radiographic 6:1 female to male prevalence 40% of women by 75 Only 28% symptomatic Armstrong AL, Hunter JB, Davis TR.. J Hand Surg Br. 1994;19:340–341

Growth of Thumb’s Importance Bipedalism and club weilding associated with thumb development

Thumb Strength Age 0-5 Short web space, low muscle strength Age 6 – 12 Increasing muscle strength and thumb length Age >50 Back to being a toddler

Thumb Kinematics -Force increases exponentially from tip to base during pinch activities -120kg force at CMC joint during pinch

CMC- Ligaments 3 – 16 Ligaments Anterior Oblique Ligament? Dorsal Deltoid Ligaments

CMC- Treatment Options -Adaptive techniques -Neoprene/Custom Braces -Warmth -NSAIDs -Cortisone -Surgery

Preferences Adaptive

CMC Preferences Splinting 1.Neoprene prefabricated 2.Semi-rigid prefabricated 3.Custom thermal molded

Audience Preferences - Splinting 1.Neoprene prefabricated 2.Semi-rigid prefabricated 3.Custom thermal molded

Preferences- Splinting Randomized cross-over study Neoprene vs. custom thermal

Pitfalls - Injections Cortisone Culture expanded stem cells Hyaluronic acid Autologous fat

Pitfalls - Injections

Cortisone vs. Placebo Pitfalls - Injections

Surgical Options Mini TightRope Hematoma Arthroplasty Tendon Interposition Joint or Hemi replacement Synthentic Spacers Arthroscopic Arthroplasties Osteotomies

CMC Arthoplasty– Treatment -Trapezium Excision (1949) -Tendon Interposition (1970) - Ligament Reconstruction (1973) -Ligament Reconstruction and Trapeziectomy (1986) -Trapezium Excision (2007)

Interposition Material 1.Trapezium resection only (nothing) 2.Tendon Interposition (FCR, PL, APL) 3.Orthosphere 4.Artelon

Trapeziectomy vs. LRTI

Pitfalls - Joint Replacement

Pitfalls - Implants Pyrocarbon Implant (20% at 2 yrs) Silastic Implant Artelon Fabric 12 of 32 (37%) revised for pain Orthosphere 5 of 6 revised for pain

Pitfalls - Snythetic Interposition

Arthroscopic Arthroplasty 26 patients with 20 month follow-up Poly-L-lactic acid implant Pain 6.61 VAS  6.03 QuickDASH 56  54 Pinch 3.7kg  2.2kg

Preferences

Preferences - Injections

Audience - Immobilization 1.Cast 4 weeks or more 2.Cast 2-4 weeks 3.Removable splint only 4.No splint

Pinning the Joint 1.Never Pin 2.Sometimes Pin 3.Always Pin

Therapy Visits Post-op 1.No Therapy visits visits visits visits visits visits 8.Never stop

Duration of Rehab

The Need for Strength

Pitfalls - Ongoing Pain Incomplete bone resection Low-grade infection LABC and radial sensory nerve injury CRPS Scapho-trapezoidal arthrosis FCR tendinitis Adhesions

CMC Arthroplasty - Outcomes

Take Home Messages More and more common Take time treating conservatively (adaptive devices, neoprene, injections) Any surgery with good technique is fine (with caveats)

The Wisconsin Hand Experience Greg Watchmaker, MD CMC Pitfalls and Preferences Murren 2015