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

2. Pitfalls

3. Expectations

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

5. Expectations

6. 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

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

8. 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

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

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

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

12. Preferences Adaptive

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

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

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

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

17. Pitfalls - Injections

18. Cortisone vs. Placebo Pitfalls - Injections

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

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

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

23. Trapeziectomy vs. LRTI

24. Pitfalls - Joint Replacement

25. 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

26. Pitfalls - Snythetic Interposition

27. 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

28. Preferences

31. Preferences - Injections

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

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

34. Therapy Visits Post-op 1.No Therapy 2.1-4 visits 3.5-8 visits 4.9-12 visits 5.13-16 visits 6.17-20 visits 7.21-24 visits 8.Never stop

35. Duration of Rehab

36. The Need for Strength

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

38. CMC Arthroplasty - Outcomes

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

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