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Thumb CMC Arthritis: Fellowship Virtual Debate Series
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Thumb CMC Arthritis: Fellowship Virtual Debate Series
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Language: EN.
Segment:0 .
WARREN HAMMERT: So welcome to our hand fellowship virtual debate. This is Week 4 and we're going to talk about thumb CMC arthritis tonight. So as a moderator, I have nothing to disclose financially related to this presentation or this program. But as you know, I live in Rochester, new York, which is the home of the LRTI.
WARREN HAMMERT: In spite of that, I'm going to be optimistic and not have bias throughout this presentation and give everybody an equal chance. And so as you can see, I'm in Las Vegas right now. This is a big event and I'm happy to have participants that are going to make this huge. And so said, you know, Las Vegas is probably the place to host this. That's where all the big events are hosted. And so we're going to begin with the Indiana Hand to Shoulder Center.
SHANNON FITZPATRICK: Dr. Kristin Buterbaugh is going to present on the LRTI with Dr. Tom Kaplan in her corner. Next, we will have the group from Stanford discussing the Suture Button Suspension. Dr. Jill Putnam is going to present and Dr. Jeff Yao will be in her corner. Then we will move on to the East Coast and our Brown group will present on the APL-FCR Suspension Arthroplasty with a little bit of a twist.
WARREN HAMMERT: Dr. Shannon Fitzpatrick is going to discuss this and Dr. Peter Weiss will be in her corner. And finally, we're going to talk about Thumb CMC Arthrodesis. This will be presented by Dr. Jeff Stepan, and Ryan Calfee will be in his corner. This was the initial logo I found from Wash U, but I didn't feel like they could defend things adequately with this, so I did find something a little bit more robust for them to use on their their logo.
WARREN HAMMERT: So this is the case we're going to talk about. A 64-year-old, pain in her non-dominant left thumb. For over two years, she's tried bracing therapy, exercises to protect the thumb CMC joint, but she's symptomatic enough that she wants to proceed with surgery. So these are the clinical pictures. You can see her thumb metacarpal, adduction contracture, you can see MP joint hyperextension, but pretty good mobility of the thumb.
WARREN HAMMERT: She can oppose it to the base of the small finger. Here you can see her radiographs, which again demonstrate the metacarpal contracted and the thumb MP joint hyperextended. You can see some subluxation and that the trapezium is somewhat eroded. So why do we want to talk about this? There's not a lot of level one studies in hand surgery, but this is actually a pretty good study by Tim Davis and his group in England.
WARREN HAMMERT: So 5 to 18 year follow up of a prospective randomized trial on thumb CMC surgical treatment. So they compared simple trapeziectomy, trapeziectomy with palmaris longus interposition or one of the early versions of the LRTI as described by Dr. Burton with 50% of the FCR tendon. And their conclusion was that there's really no benefit to tendon interposition or ligament reconstruction
WARREN HAMMERT: and so then the question becomes, well, why do we need to really have this debate and talk about it if that's the case? But I would say, in the words of Lee Corso. [VOICEOVER] "Corso. Not so fast." There's more there's more to it than that. So let's look at this just a little bit further as we start our debate.
WARREN HAMMERT: So if you look at the Cochrane Reviews, there have been several. And so go back to 2005, 2009, 2015, 2017. The summation of these is all fairly similar. We're unable to demonstrate any technique confers one benefit over another technique in terms of pain or physical function. And so that's the idea behind the debate tonight. We're going to discuss these various options and at the end, hopefully someone will convince us that one is the best option.
WARREN HAMMERT: [VOICEOVER] Oh, for the thousands in attendance and the millions watching around the world on HBO Pay-Per-View ladies and gentlemen, from Mandalay Bay, Las Vegas. Uh, let's get ready to rumble. OK. So I am going to end my show and we'll turn it over to the group from Indianapolis
WARREN HAMMERT: and we will start the debate with the LRTI by Dr. Buterbaugh. So you should be able to take control and share your screen now.
KRISTIN BUTERBAUGH: OK OK.
KRISTIN BUTERBAUGH: Everybody can see it? Yep. Good Evening. I will be speaking on LRTI, the gold standard. Thank you to Dr. Kaplan and to Dr. Fisher for helping me with my presentation. Again, here's the case that Dr. Hammert just showed us. A 64-year-old woman with stage three thumb CMC OA. As we all know, the CMC joint of the thumb has liberal range of motion due to its lack of bony confinement and reliance on ligamentous stability.
KRISTIN BUTERBAUGH: 8 to 13% of men and 25 to 36% of women ages 50 years and older develop CMC arthritis and of these, 20% of affected people require some form of treatment in their lifetime. So here's the challenge. How do we best manage CMC arthritis surgically? The answer remains controversial. I will show you why trapeziectomy with ligament reconstruction and tendon interposition a.k.a. the LRTI remains the gold standard in comparison to the other treatments discussed today, including mini tightrope suspension, suture suspension plasty and thumb CMC fusion.
KRISTIN BUTERBAUGH: The origins of LRTI began with trapeziectomy, introduced by Jervis in 1949, and it is notable to state that trapeziectomy with distraction haematoma formation continues to demonstrate excellent functional outcomes with resolution of pain. However, trapeziectomy alone does not treat ligamentous degeneration and instability and dorsal subluxation has been noted following simple trapeziectomy.
KRISTIN BUTERBAUGH: Additionally, trapeziectomy with distraction arthroplasty commonly requires k-wires which can be cumbersome for patients and lead to pin tract infections post-op. Burton and Pellegrini described trapeziectomy with LRTI as shown on this schematic in 1986. In order to address thumb metacarpal proximal migration and impingement after trapeziectomy. Now, for the top five reasons why LRTI is the gold standard. Number one is long standing good results.
KRISTIN BUTERBAUGH: While newer techniques like the tight ropes and suture suspension plasty show promise in intermediate follow up, no other technique demonstrates such a consistent track record and for good results. Additionally, wouldn't you rather take those extra 15 to 20 minutes in the OR for a good long term result rather than try to perform the quickest surgery possible sacrificing biologic support for abrasive suture?
KRISTIN BUTERBAUGH: Burton and Pellegrini looked at 24 thumbs following LRTI with an average of a nine year follow up. 95% had excellent pain relief and were satisfied with their outcome. The average grip strength reflected a 93% improvement. Average tip, pinch tip, pinch strength and key pinch strength also improved. Radiographs showed an average loss of height of the arthroplasty space of 13% at nine years.
KRISTIN BUTERBAUGH: Gangopadhyay et al performed a prospective randomized study of 174 thumbs comparing trapeziectomy distraction arthroplasty, tendon interposition and LRTI. Average follow up was six years with a range from 5 to 18 years. All demonstrated long term results of excellent pain relief, improved grip strength and equal complication rates.
KRISTIN BUTERBAUGH: To quote Dr. Hammert regarding his reasoning for LRTI, although there are theoretical advantages to the newer procedures, we have a time tested procedure with consistent results which have been replicated by many surgeons. In addition, this procedure is still widely used for revision surgery when other procedures have not provided acceptable results. As a testament to this statement.
KRISTIN BUTERBAUGH: Look at all these other new procedures, to name a few that showed so much promise and led to early failure. The number two reason for LRTI is widespread use. LRTI is the most widely used surgical technique among hand surgeons in the US. Recently, Yuan et al looked at Medicare data for the most commonly performed procedures for CMC arthritis and 3530 patients from 2001 to 2010.
KRISTIN BUTERBAUGH: 89% of surgeons performed tendon interposition with or without ligament reconstruction, and this demonstrated a consistent upward trend over time. Additionally, a 2010 ASSH survey by Brunton and Wilgus found that 68% of hand surgeons preferred trapeziectomy with LRTI. This speaks to the reliability and reproducibility of the procedure.
KRISTIN BUTERBAUGH: Number three is patient satisfaction. LRTI continues to be successful in providing patient satisfaction and quantifiable improvement in patient reported outcomes. Linz et al performed LRTI on 30 thumbs, and their outcome analysis revealed that 89% of patients were satisfied with their pain relief. 87% would undergo the surgery again. More recently, Vermeulen et al performed a randomized controlled trial comparing arthrodesis with LRTI in 43 patients.
KRISTIN BUTERBAUGH: They found that 86% in the LRTI group would have their procedure again, while only 53% in the arthrodesis group would. Of note this study was prematurely halted due to the increased complication rate in arthrodesis group, which was 71% compared with 29% in LRTI. Who wouldn't be dissatisfied with such a high risk of complications and loss of motion at the CMC joint?
KRISTIN BUTERBAUGH: Which leads us to reason number four. Low failure rate, particularly in comparison to arthrodesis. A recent systematic review found that LRTI had the lowest failure rate of 0.24 per 100 procedure years. The authors of this study propose twice the failure rate of LRTI to be the benchmark for comparison. Of note the failure rate of arthrodesis was 0.52 per 100 procedure years, which is greater than twice the failure rate of LRTI.
KRISTIN BUTERBAUGH: Hippensteel et al compared functional outcome of arthrodesis with LRTI in 50 patients. While they found similar outcomes at one year, the arthrodesis group had a 26% nonunion rate and a higher rate of secondary operations compared with LRTI. Number five is LRTI's low cost in comparison to other procedures such as tightrope suspension plasty, arthrodesis and suture suspension, plasty
KRISTIN BUTERBAUGH: when a speed spiral implant is used. Studies have noted the concern of additional cost of tightrope arthroplasty in particular, in some cases up to $500 for the implant. This is despite the lack of evidence supporting its advantage over trapeziectomy. This is an extra cost on top of other complications such as inadvertent overtightening of the thumb metacarpal to index finger, foreign body reaction and second metacarpal fracture.
KRISTIN BUTERBAUGH: And finally, a bonus reason to choose LRTI. In comparison with suture suspension plasty, LRTI may better manage preoperative and post-operative tendonitis. Lowe and Hales found a high incidence of FCR tendonitis following trapeziectomy with APL suspension plasty. In their study of 81 thumb,. 25% developed tendonitis post-op at a mean of 4.7 months. They postulated that FCR may be may be tensioned and constricted by the APL tendon that loops around it.
KRISTIN BUTERBAUGH: Suture could do the same. In summary, why LRTI remains the gold standard. Long standing, excellent results, widespread use, high patient satisfaction, low failure rate and low cost. Listen to Dr. Hammert. Choose a procedure that provides patients with a thumb that maintains a more natural appearance and excellent function 15 to 20 years post-op. Thank you.
KRISTIN BUTERBAUGH:
WARREN HAMMERT: Very nice presentation that sets the stage, that sets the bar pretty high. So we will move on to Dr. Putnam from Stanford to try to convince us that the suture button suspension, albeit much more costly, is a better operation.
JILL PUTNAM: All right.
JILL PUTNAM: Do you see that in presenter mode? Uh, that looks good. [WARREN HAMMERT] OK, great. Thank you for the introduction. And thank you, Dr. Yao, for mentoring me in this debate. I should disclose that Dr. Yao is an Arthrex consultant. So these are the radiographs that Dr. Hammert gave us and my job is to prove to all of you that the tightrope is superior to the LRTI, the arthrodesis and the suture suspension plasty.
JILL PUTNAM: And I'd like to begin by telling you why those last three are not the right options. So we'll start with LRTI. This was introduced by a lot of noteworthy names in hand surgery, but when you really look at the results of LRTI, they're really not that impressive. There have been plenty of RCTS and systematic reviews showing us that there's a higher complication rate with LRTI compared with trapeziectomy and that in the end, in the long term there's no benefit to tendon, interposition or ligament reconstruction.
JILL PUTNAM: And LRTI can take quite a lot longer, even double the time of a trapeziectomy, so why tie all of those knots and all of those anchovies if it really makes no difference? And no offense to our colleagues at Indiana, but I'm not convinced. How about arthrodesis? Well, I think we can all agree that they're pretty narrow indications for this procedure.
JILL PUTNAM: Our average senior patient is not a great candidate for an arthrodesis. Time to union, it's going to take more time for mobilization, which patients don't love and then that complication rate that Kristen already mentioned, including a potentially high nonunion rate and a rate of secondary surgery, those are concerning and then reduced range of motion again, like Kristen mentioned, especially with difficulty flattening their hand on the table,
JILL PUTNAM: patients do not like that. Now, the suture suspension sounds like a great idea, but again, you have to consider all that time for mobilization and loss of productivity for an average return to work of about nine weeks. Kristen also mentioned a relatively high rate of FCR tendinitis or even a rupture that merits consideration, and then recently I've been hearing that the suture suspension can or should be augmented with the speed spiral
JILL PUTNAM: and I have to wonder why even use the suture suspension plasty if you have to augment it with this overpriced fruit roll up. And I'm not sure I'm hoping that our colleagues from Brown can can kind of give us a little bit more information on that. So with these last three techniques, you're going to get five weeks post op in a cast at least, but with the tight rope, you could have this at five days.
JILL PUTNAM: And we're able to get patients moving that quickly and have that excellent result because this is biomechanically the superior implant. This biomechanical study showed that the tightrope better maintains trapezius space compared to the LRTI, and this study showed that the tightrope was equivalent biomechanically to a k-wire, at least an initial load to failure. And those results have been borne out clinically as well.
JILL PUTNAM: This is a study from Mayo last year where they looked at FCL-APL side to side tendon transfer with and without the tightrope, and they found that the tightrope better maintained trapezial space without any increased rate of complication. So again, the biomechanics of the implant are why we're able to get patients moving so much earlier. at 3 to 5 days, they can start range of motion exercises and patients love that.
JILL PUTNAM: So here's a patient at six weeks post op with excellent range of motion. She had no pain, and these are her preoperative and post-operative radiographs. She was very happy. And we have midterm outcomes as well. I'd like to highlight excellent range of motion and excellent pinch strength. Pinch strength and grip strength with this procedure at about five years out.
JILL PUTNAM: There are a few pearls to this technique. One of them is that the incision over the second metacarpal should be made over the ulnar aspect, respecting a nerve branch that is frequently crossing there. And then we recommend use of this targeting guide, which helps line up the pin into the second metacarpal just where you want it and that should be exiting on the ulnar border of that second metacarpal
JILL PUTNAM: and you can see this transition in the wire here where it transitions to a 1.1mm k-wire for entrance into the second metacarpal. And here you can see careful placement of the suture button again into the ulnar aspect of the second metacarpal to prevent any dorsal prominence or irritation from that suture button. And here's intraoperative loading. again, showing excellent maintenance of the trapezial height.
JILL PUTNAM: So I think I've proven that the tightrope wins out. It resists metacarpal subsidence. You don't have to use any k-wires or wait for anything to heal, and it allows for a faster rehab ultimately. I think I've proven that it's the superior implant. But wait, there's more. What about this patient who needs a revision CNC arthroplasty after she's failed, say, an LRTI, or a suture suspension plasty and has symptomatic subsidence of the first metacarpal?
JILL PUTNAM: There have been a couple of studies that show that the implant of choice may be the tightrope in revision CNC arthroplasty. The studies out of UVA couple of years ago and at ASSH last year, there was a study from Duke with similar opinions. And if it's all about the money, the tightrope may not be as bad as it seems. Tightrope at our institution runs about $400 versus if your LRTI needs to be backed up with an interference screw, that'll be even more expensive.
JILL PUTNAM: If you happen to be using an implant with your suture suspension, that can be quite expensive. If you need extra time in the OR for that LRTI, that's going to be quite a bit more expensive. But we all know that in the end, the cost of a happy patient on post-op day five, no, that's priceless. So it comes down to would you want this cast for five weeks or more?
JILL PUTNAM: Or would you want this excellent result at five days? And that's all I've got. Thank you.
JEFFREY YAO: Great job.
WARREN HAMMERT: OK very nice presentation. Pretty convincing. Let's hear from our next group from Brown.
WARREN HAMMERT: Dr. Fitzpatrick is going to discuss her preferred technique.
SHANNON FITZPATRICK: Can you hear and see me? Yes. My name is Shannon Fitzpatrick. I'm one of the current Brown Fellows. Dr. Weiss and I have been charged with defending the suture suspension. And not only will we talk about that, but we'll also talk about he suture suspension
SHANNON FITZPATRICK: with a bit of a twist. Of note, Dr. Weiss has interests in Arthrosurface, Incorporated and this will be important for the end of this discussion. This is a typical patient presented in this conference. She's a 58-year-old female with four years of thumb pain, secondary to basal thumb arthritis. On x rays, she is in Eaton stage three thumb arthritis. She does not have any MCP hyperextension. Of note in our practice,
SHANNON FITZPATRICK: we do not treat patients with thumb MCP hyperextension any differently than those that do not unless they are symptomatic after a basal thumb arthroplasty. This patient is a neonatologist, so her thumbs are very, very important for her vocation as she cares for and examines infants. She has failed extensive non-operative management with splints and cortisone injections, and she has elected to pursue operative intervention.
SHANNON FITZPATRICK: In our practice, we traditionally use a suture suspension arthroplasty to address basal thumb arthritis. This concept was originally described by Delsignore in 2009. Our practice is modified and the original inscription and this modification was published in JHS in 2018. As you can see in the left hand photo, we use a traditional Wagner approach.
SHANNON FITZPATRICK: Once the trapezium is excised, in this center photo, you can see that we take a number two ortho code suture. It's placed through the APL at its insertion on the base of the thumb metacarpal. The suture is passed through the FCR tendon distally near its insertion on the second metacarpal. The suture is then woven back through the APL and the FCR tendons. The two ends of the suture are then tied together in a snug fashion, but not so tightly as to tether the EPL and FCR together tethering of these tendons can result in discomfort and decreased function of the thumb.
SHANNON FITZPATRICK: The idea really here is to create a suture hammock for the thumb metacarpal base to rest upon. This suspends it from the distal scaphoid articular surface. Once the suspension is completed, the thumb metacarpal is finally tested for longitudinal stability. Here in the right hand side of the screen, you can see the final construct. It's very important to note that no tendon graft or k-wire is used during this procedure.
SHANNON FITZPATRICK: The pros of this procedure include that it doesn't require a second incision to harvest a tendon. Since a tendon is not harvested, there is no alteration in wrist kinematics. The k-wire is not used in the post-operative period to provide stability. This avoids neuroma formation, tendon adhesion, scar tenderness and even potentially complex regional pain syndrome.
SHANNON FITZPATRICK: And this technique, immediate stability is achieved because one is not relying on soft tissue scar formation or maturation. This allows us to not be forced to cast patients in the post-operative period. Moreover, this is a cost effective procedure because there is no cost associated with any implants. It was also time efficient, given its simple and elegant technique.
SHANNON FITZPATRICK: Our average operative times at our institution are 23.4 minutes. When you compare this to LRTI, it is almost 40 minutes in the literature, so twice as long. How many patients initially have a quicker recovery with higher CRWE scores? In long term, these initial higher scores even out, they are about the same for all techniques. The cons of this procedure are that we have had a few patients with distal FCR ruptures at the 3 to 4 month mark.
SHANNON FITZPATRICK: When this occurs, there is no intervention required. Initially, it's painful, but this resolves. You may have a bump in their forearm, which can be cosmetically displeasing to your particularly young lady. More recently, we've added a twist to our suture suspension, particularly in patients with EMCP hyperextension or in revisions. In addition to our suture suspension, we use the tails of the suture and we pass them through a piece of rolled human collagen.
SHANNON FITZPATRICK: This provides a harder fulcrum for the thumb and is a piece of a vest for the suture suspension. On the left hand side of the slide, you can see a radiograph with this new twist. You can appreciate the well maintained height of the metacarpal. On the right side of the slide you can see a graph representing biomechanical testing of the ability of various basal thumb arthroplasties, including LRTI, suture suspension alone, trapeziectomy alone, and our rolled human collagen versus the strength of intact bone.
SHANNON FITZPATRICK: You can appreciate that the role of collagen has characteristics that most closely mirror that of intact bone when compared to the other techniques. We think that this aids in maintaining the height of the metacarpal and that it reduces the amount of play in the MCP joint. We do suspect that the collagen softens over time. The pros of this new twist are that it provides increased stability of the joint and it improves maintenance of metacarpal height, particularly in challenging patients to care for initially or in revisions.
SHANNON FITZPATRICK: The cons are that the implant costs $1,500, but you can use this different CPT code to recoup those costs. The other disadvantage is that this does take longer when using this technique than just the suture suspension alone. These are preferred techniques when operatively addressing basal thumb arthritis for the reasons I have discussed. We feel that this is a highly favorable operative technique. Thank you for your time.
WARREN HAMMERT: OK I'm not sure we're any closer than we were when we started this, because another very convincing presentation. Let's see if the group from Wash U can convince us that thumb CMC arthrodesis is the way to go. So we'll let Dr. Stepan present here.
JEFFREY STEPAN: All right. Fantastic can everyone hear me OK?
JEFFREY STEPAN: Good? All right. So I'm going to go ahead and present on CMC arthrodesis. Thank you to Dr. Calfee for helping with this presentation and being a mentor for over almost 10 years now. So to proceed, I'm not going to say that CMC arthrodesis should be done in every patient, but I'd like to maybe dispel some of the myths that have been reported by previous presenters here. So to just frame the discussion a little bit, I'll start us off with a case from earlier in my fellowship year.
JEFFREY STEPAN: So this is a 39-year-old female with five years of thumb CMC pain who failed non-operative management. Ligamentously lax with a Beighton score of seven, considerable laxity of the CMC joints as well as pain there. You can see the subluxation on x-rays and maybe some of the beginning of osteophytes here at the ulnar border of the trapezium. So, given a global ligamentous laxity, laxity, ligament, reconstruction and osteotomy, probably not advisable.
JEFFREY STEPAN: So really here in the US, the treatment options become trapeziectomy and as we've just heard, doesn't really matter. Whatever tendon, suture or device you want to add or even not add to it versus arthrodesis. So what are some of the classic indications that younger active patients, as we all know. Paper we've lost your audio.
JEFFREY STEPAN: You could say that symptomatic arthritis or. Oh, can you hear me now? Yeah, we can hear you now but we lost you for a moment. Oh, I'm sorry. Can yeah. Go back to the beginning of that slide. This slide here? OK sorry about that.
JEFFREY STEPAN: Um, classic indication for arthrodesis, as we all know, are the younger, active patients with any sort of manual labor. Um, putting extreme force to the joint and any patient with significant ligamentous laxity contraindications would be STT arthritis or poor bone quality. But we've just heard all about trapeziectomies and how great there are, They are
JEFFREY STEPAN: so why do CMC arthrodesis instead? So there is the possibility of improved pinch strength once it's fused, there's no worry about longevity, there are still salvage options available. And when you fix the metacarpal out of the adducted position, it gets rid of the MP hyperextension, kind of obviating the need for any intervention at the MP joint. Most detractors would say range of motion, high nonunion rates and maybe hardware issues as major negatives.
JEFFREY STEPAN: So let's take a look at the literature that previous people have looked at to say why arthrodesis was bad. So the highest level of evidence was against arthrodesis. This is a randomized control trial out of the Netherlands that was stopped early. But when you take a little bit closer look at the study itself, they're all females, they're all over 59,
JEFFREY STEPAN: that's the average age, far cry from the typical arthrodesis patient. They used no bone graft and they started moving their arthrodesis patients at about four weeks. I think everyone would agree that's too early. So how did they arrive at this high complication rate? They took scar tenderness and minor complications like that, not necessarily associated with the surgery performed.
JEFFREY STEPAN: We also don't know if their symptons, their delayed unions were actually symptomatic and they didn't provide any definitions for nonunions. Despite this, they went on to provide outcome assessment. They weren't able to provide outcome assessments due to being underpowered, but they went ahead and re-evaluated the their same cohort of patients about five years later, with even fewer patients to compensate for this, over a third of their data ended up being statistically modeled.
JEFFREY STEPAN: And they actually showed the arthrodesis patients got worse over four years. Needless to say, this is not consistent with any of the previous comparative studies which we'll go over now. So the largest of these studies was this retrospective cohort out of Cincinnati and showed equal satisfaction between groups, equal improvement in pain, stronger pinch strength with arthrodesis.
JEFFREY STEPAN: About a third of patients were unable to flatten their hand on the table. Although overall nonunion rates were a bit high, only three were symptomatic, and there was only one nonunion in the locked plate group. For this prospective comparative study out of year is another study showing similar patient rated outcomes and overall complications between LRTI and arthrodesis patients.
JEFFREY STEPAN: In this study, when looking at range of motion, there was no difference in the ability to flatten the hand in contrast to the study at Cincinnati. There were, however, high rate revision early in the treatment process and similar symptomatic nonunion rates. So when you ask what about long term results after arthrodesis that we weren't able to provide with the tight rope, for example.
JEFFREY STEPAN: But with this study out of Mayo, we can see all patients are satisfied, almost all patients were satisfied with low pain scores. They had similar symptomatic nonunion rates, about 7%, STT arthritis long term developed, and only about 6% of patients only have, one of which required revision surgery about 18 years after a successful arthrodesis. In terms of the approach usually just do a standard dorsal approach here after meticulous preparation of the bone and Ronjeur with,
JEFFREY STEPAN: sorry, Ronjeur and burr to cancellous bone which can be seen on the left. The excision can be extended proximally, here another incision can be dorsally for some distal radius bone graft, which you can see here. And goal of fusion is for the thumb pulp to rest on the middle phalanx of the index finger with the wrist and slight extension as shown here. So there are plenty of hardware options.
JEFFREY STEPAN: In this case, the CMC fusion plate was used. Here are some examples of use of a headless compression screw as well with final x-rays on the right. So now that we have an overview of CMC arthrodesis in the literature, I kind of want to bring it back to the case that I showed at the beginning of the presentation. Question marks surrounding trapeziectomy are really about longevity and such a young patient with no true salvage options.
JEFFREY STEPAN: Is it really going to last 30 to 40 years for this ligamentous laxed patient, so using the literature I just presented, we can see CMC arthrodesis can provide better strength, equal range of motion and outcomes while still preserving the ability to perform revision surgery in the future if necessary. This all must be balanced, however, against an increased upfront risk of revision surgery, so I'm sure it's no surprise we performed a CMC arthrodesis for this patient.
JEFFREY STEPAN: Fortunately, no follow up x-rays due to Covid but that being said, she had a prior successful fusion on the contralateral side that's currently without pain and back to full activity. So in conclusion, as with everything in hand surgery, it's about patient selection but when deciding between trapeziectomy and arthrodesis, we really must decide if potential benefits of arthrodesis that we discussed are worth the upfront increased risks of revision surgery.
JEFFREY STEPAN: Thank you.
WARREN HAMMERT: So another excellent presentation. And that's one of the things about this technique or this condition that makes it interesting is there's a lot of good ways to approach this, and there's not one that's clearly right and a bunch of others that are clearly wrong. So what I want to do now is go through some stuff with the mentors of the groups and just kind of get their thoughts on a couple of things.
WARREN HAMMERT: So I'm going to try to share my screen and hopefully do a better job this time. Can everybody see the full screen now? Yes, yep.
WARREN HAMMERT: OK, so let's let's go through from the mentors and we've got a good idea about the CMC joint, how to manage that but I want to talk about the MP joint a little bit because that's one of the things that I think can cause failure or cause a unsuccessful or a less than optimal result is not looking at that MP joint. So we'll start with Tom Kaplan. Give us your thoughts on how you would manage the joint.
WARREN HAMMERT: Do you address these with tendon transfers, tenotomies, capsulodesis, arthrodesis, kind of, what's your algorithm?
THOMAS KAPLAN: Sure thanks. So first, thanks to all the Fellows. Great presentations and thanks to great moderation there Warren, and Jerry for getting this organized. I think the MP joint is like most things with the CMC joint as well,
THOMAS KAPLAN: it kind of depends. You know, not every amount of hyperextension needs to be treated and there'll be there's no kind of hard cutoff. I think one thing that we look at is and you know, kudos to one of our past Fellows last year who kind of started looking at this is, you know, is not only is there what the passive MP hyperextension is, but what is the dynamic MP hyperextension or the ability to maintain or to prevent an active collapse deformity.
THOMAS KAPLAN: So in patients with MP hyperextension, I also ask them to do a pinch test and see whether or not they compensate for that hyperextension or not, because I think it's mainly in those patients who have active collapse, not just passive hyperextension, that you have to then address the MP joint. So if a patient has more than 30, 40 degrees of hyperextension and they have active collapse, then usually that's someone that we're going to do an additional procedure on.
THOMAS KAPLAN: You look at their MP joint, obviously preoperatively, if there's any arthrosis that's going to go to effusion. Patients, many patients have very limited, limited mobility in their |MP joint. They may be better off with fusion as well, but if they have good motion of their MP joint, no arthrosis, then oftentimes we'll treat those patients with active collapse with a capsulodesis and the only other pearl I'll throw out there is when, if you're doing a dorsal approach to the CMC joint, doing a transverse capsulotomy can help you because on the way out you can imbricate the dorsal capsule of the CMC joint helping to extend that first metacarpal and that can help with the MP compensatory hyperextension that's developed.
WARREN HAMMERT: So in 30 seconds, tell us how you do your capsulodesis. There's a bunch of different approaches to this, and I don't have one that I think is the best. I've tried things and I move around. How do you do your capsulodesis?
THOMAS KAPLAN: Yeah, mine is. I go through a Bruner incision volar approach to the MP joint. I release the volar plate along the radial margin, along the sesamoid, and then proximally, mobilizing the volar plate, roughing up the metacarpal neck.
THOMAS KAPLAN: And I use a suture anchor in the metacarpal neck and then pass that through the volar plate to tighten it up. And I try to place it in about 20 to 30 degrees of flexion, you know, have it tight at about 20 to 30 degrees because these always stretch out to some degree.
WARREN HAMMERT: Yeah OK, great. That's a very good synopsis of this. Jeff Yao? Other thoughts or do you approach the MP joint any differently?
JEFFREY YAO: No, I think that was great. I mirror what Tom says. I do a from 30 to 50 degrees. I do prefer a capsulodesis. I like the dynamic pinch testing, the dynamic active collapses. And so I do a capsulodesis, very similar to what he described.
JEFFREY YAO: I learned recently from Scott Wolfe that just if you used to do a distally based releasing the volar plate discipline, advancing distally, I learned that from Dick Berger but sometimes that could be a little bit challenging because you have the sesamoids there so I learned from Scott that you can remove the the radial sesamoid, give yourself a little bit extra space and advance it distally.
JEFFREY YAO: But I've found now that just advancing proximally is a lot easier. And then for greater than 50 degrees, or if there's any evidence of arthritis, I do a arthrodesis.
WARREN HAMMERT: OK and one other thing that neither one of you mentioned, but it's probably obvious if there's valgus or varus instability that's better treated with an arthrodesis, I think as well if it's unstable. But just the isolated hyperextension is what we're kind of talking about.
WARREN HAMMERT: But occasionally you will see patients that have ulnar collateral ligament insufficiency as well. So Peter Weiss do you have anything different? It was mentioned in your presentation that it sounds like your implant does a lot to take care of the MP joint hyperextension. Any other pearls that you can share with us?
PETER WEISS: Well, first of all, with regard to your x ray, I actually think the biggest problem is there's substantial adduction deformity that's probably fixed.
PETER WEISS: And, you know, the metacarpals slid off the trapezium and it's in a fixed position, that's a little different than what we usually see. A lot of these, the hard part is actually not the MCP joints, but is getting the thumb metacarpal out away from the index metacarpal in a more functional position. I think a lot of this particular like your X-ray will require some resection of the MCP, the sorry, the metacarpal shaft proximally in order to get enough space.
PETER WEISS: I don't think you can usually get this completely released by soft tissue means. So sometimes I'll saw a half a centimeter or a centimeter of the metacarpal base just to be able to get it in ad sorry abducted position so that at least your arthroplasty at the CMC joint has a chance to work. I think the biggest part of failure in this procedure is not the MCP, but is actually an incomplete reconstruction of the normal anatomy of the MCP or the MC thumb versus the rest of the hand.
PETER WEISS: That being said, you know, I've been at this for 30 years and I trained where Tom was. And, you know, you had eight different guys doing eight different things for the MCP joint. I, I used to do taken out, you know, a portion of the volar plate and sewn it up tight, which is what I learned Steichen did. I did fusions, which was which Strickland and Kleiman kind of did.
PETER WEISS: And then I did nothing, which is what most of the rest of the guys did. My kind of approach to this now is I don't do anything primarily unless there's substantial pain at the MCP, regardless of the amount of hyperextension. And I find if you can reconstitute the height of the thumb metacarpal and keep it stable and you know, regardless of the technique you use, a lot of times the MCP will re kind of balance itself.
PETER WEISS: It's a little bit like, shortening, you know, doing an ulnar shortening osteotomy for TFCC tears, you kind of tighten up all the ulnar structures and it kind of makes the, the overall structure more stable. I think that happens to the MCP joint if you reconstitute the height of the thumb metacarpal and I think there's some biomechanical data that's going to be coming out and presented in the near future that will document that.
PETER WEISS: So I, I tend to just treat that if it's really symptomatic. Otherwise, I would tell the patient, look, you've got some hyperextension, I'm going to try to fix your CMC joint, there's a chance that you may need another procedure for the joint, but I think it's going to be on the lower side of 50% and I'd rather do that as a secondary procedure if it's required.
WARREN HAMMERT: Now, those are some good pearls. I think getting the metacarpal into extension and out of flexion as it is here will often help improve that joint quite a bit. So for the last couple of minutes, I just want to go through a case for the faculty to discuss and not just the mentors, but anybody else that has thoughts on this. Be happy to hear their opinions.
WARREN HAMMERT: 54-year-old lady, this is her dominant thumbs had two previous procedures. The first was an FCR suspension. She continued to be symptomatic and then was converted to an LRTI using the entire FCR. She presents to me with impingement of the metacarpal base on the scaphoid with pinch metacarpal adduction contracture to some degree and MP joint hyperextension.
WARREN HAMMERT: So open up to any of the people on the panel. How would you approach this problem? Two previous surgeries? What would you do at this point in time? Do you fuse the metacarpal of the thumb to the metacarpal of the index, or is there something else that you can do? Oh, wait. Before we go on to this, I want to go back. I neglected to ask Ryan Calfee his approach to MP joint. I apologize Ryan, tell me what your approach is, if anything different.
RYAN CALFEE: Don't have much different. I do what Tom does, look for active collapse and think I treat it very rarely. And if the patient really has a lot of collapse on active pinch, I'll use it. Otherwise, the folks in the Midwest are pretty tolerant of it.
WARREN HAMMERT: So if the CMC joint has been fused, would you would you fuse the MP joint as well?
RYAN CALFEE: No, but I've never had that problem with the CMC fuse. The MP no longer hyperextends. It just doesn't happen.
WARREN HAMMERT: So problem solved by fusing it. OK. So now then to this case. Two previous surgeries. How would you approach this? Ryan, do you want to start and anybody else can join in?
RYAN CALFEE: Sure so I'll start by just saying that I think if somebody has failed these two surgeries and as everyone's presentation pointed out, just about everything works in the thumb. So I think you got to figure out why did it fail? What's wrong with the patient or was there something truly wrong with the surgeries that were done? Um, and and I would be very humble about doing more surgery because we've looked at our results on revision and they're fairly miserable at Wash U at least in terms of making people that have pain after these procedures better with more of the same procedures.
RYAN CALFEE: Um, so I would be very hesitant to do anything unless any of my other mentors on this line have other options that are great. I'll send them to you. Um, but I think that if everything really seemed reasonable and maybe one problem is are soft tissues. I have done the occasional revision, then going to something artificial, whether it's a suture suspension tightrope or internal brace or any other type of suture as opposed to soft tissues.
RYAN CALFEE: But but I'm concerned that unless there's a really, really convincing mechanical reason for pain and a really good reason that these others failed, that this person is still going to have pain.
JEFFREY STEPAN: Warren, if I may, I agree with Ryan. I think it's for someone to fail to procedures. It's you have to wonder if there's something else going on.
JEFFREY STEPAN: But in the absence of that, I like to sort of group the potential causes of failure, which are thankfully rare into a few different categories. And I think the major causes of failure of any of these procedures are potential subsidence, which looks like there may be some, but it's hard to tell from these radiographs. Impingement of the thumb metacarpal into the second metacarpal with whatever technique you use, if it's done too tightly, that can occur.
JEFFREY STEPAN: Appreciated or underappreciated scaphoid trapezoid, arthritis could be a cause, and then MCP joint could be a cause. So you really have to try to identify from those four things I find which are the most common, which it could be. And I find selective lidocaine injections would be very effective for that. I like to inject into the areas where the patient seems to have the most pain, and that can help me sort of identify between those.
JEFFREY STEPAN: But that being said, you know, obviously I'm biased, but I think, you know, if the patient's there aren't any other secondary issues or potential secondary gain issues with the patient, I think a failure of two biologic type procedures as we're done here, I think is a is a clear indication for use of the suture button suspension and I think the folks from Duke have published some work on that.
WARREN HAMMERT: So share your tips on how you extend the metacarpal with the suture button suspension.
WARREN HAMMERT: I've played around with it in the lab and I've done it a few times, but I have trouble getting the metacarpal to come away from the palm. It still wants to collapse when I do it. So share with everybody how you get that metacarpal to extend.
JEFFREY STEPAN: Yeah thankfully you don't always have to. It depends on the indication of course, but I'll use a lot of soft tissue balancing.
JEFFREY STEPAN: Particularly I'd use a dorsal capsulotomy to gain access to my joint in the first place and then when I put my implant in, I put it in from dorsal radial over to the second metacarpal and I think the key maneuver is and I basically put it in, I have the second button just at the level of the insertion. And then I think the key move is then I imbricate the dorsal capsule, so that it helps when you imbricate the dorsal capsule helps draw the the base of the metacarpal in a little bit.
JEFFREY STEPAN: And so that that seems to work well for me.
WARREN HAMMERT: Peter, is this a case where you would consider your implant?
PETER WEISS: So first, I think, I don't know what kind of FCR/APL suspension, if it was an APL transfer, you know, like a tendon based transfer or a suture based transfer. So the difference, I think the problem you got to think about with tendons, they have a high elastin content. They stretch.
PETER WEISS: It's not a rigid structure. So if you're going to use a tendon, whether it's LRTI or APL transfer or whatever you want to call it, there is an element of stretch that can occur. Uh, I hate to even give Jeff a, you know, a, any any, any benefit for this. Uh, Jeff, by the way, congratulations on becoming a professor. That's great for you.
PETER WEISS: Um, you know, but I do think one of the things that the tightrope and the suture suspension with ortho core do, they're basically, they use rigid sutures that don't have any elastic component. So they're are a stabilized structure. In this particular case, I think there's always a benefit for having some type of tissue interposed between the base of the thumb and the distal scaphoid and maybe also between the base of the thumb and the trapezoid index metacarpal base.
PETER WEISS: So for me, today, if I do a revision, which I see quite a few from the Boston area, um, I would put a, a speed spiral human collagen implant here. Before I use the speed spiral. The way this, you know, I think I saw Greenberg was on the call today. The way this all started was this is nothing new, this. Jim Strickland used rolled up gore-tex when I was a fellow in 1990 and '91.
PETER WEISS: And those patients did awesome structurally, but at three years they all went to shit because the gore-tex delaminated and it caused a foreign body reaction just like PLA or PGA do today. And so what we learned was that the technique was actually valid, the material was not valid and that's a little bit like Jill's comment on the, the ardalan spacer. But I started using Durgan, which was bovine collagen used for rotator cuff repairs.
PETER WEISS: I basically cut Durgan into strips, rolled it up just like Strickland taught me, put some suture through it and stuck it in patients thumbs. And this was 20 years ago and we have 20 year data on those patients and they are doing fabulously. It's biologic, it has structure to it. It gets remodeled by the bone's own natural fibroblasts. So the only reason that that wasn't commercialized was because the FDA would not allow bovine collagen to be used in a ectopic location outside of the shoulder.
PETER WEISS: And Integra had made a whole machine to make the stuff and basically the FDA said no. So when human collagen became available about two years ago. Uh, I jumped on it with this company and I said, you got to get the license for this, because basically we're talking about the same structure as what I used 20 years ago that worked quite well. And so that's why the FDA now has cleared this, even though it's really there's nothing new about this.
PETER WEISS: It's, it's 20-year-old technology. And so I like the idea of having something that's interposed there, plus a stabilizing structure on top of it, whether you use even if you use a tightrope and a speed spiral or some something that's non-elastic and then something that provides both an immediate probably not long term, but immediate stability, plus an interposition biologics material that probably within one month is has got soft tissue ingrowth.
PETER WEISS: The other option, I think, to Ryan's point is you could do, you know if you just want really a one and done no risk whatsoever you could you could fuse this thumb and be done with it. But you know I do one fusion every 6 to 8 years and you know, I mean, that was a nice presentation, but I think it was Jeff but you know, if you operate on normal looking thumbs on x-rays with fusions, you know you're going to get good results, right?
JEFFREY STEPAN: Oh, boy. I just got to get you, Ryan, because you were a resident here. You can't. Good we got you.
WARREN HAMMERT: Tom, anything that you would add or.
THOMAS KAPLAN: Um, I mean, all great points. I mean, I think Ryan had a good point of saying, hey, you got to think about, you know, I think the hard part with these are why they failed, right?
THOMAS KAPLAN: I mean, so I think you really have to kind of diagnostically kind of figure it out, whether it's instability, is it impingement, is it neurologic, is there nerve issues going on there as well that hasn't been recognized? And then you have to obviously treat you know, you have to tailor what you're going to do to why you think the patient is still hurting. I mean, I guess the only other thing I would think about and it kind of similar to what Peter was saying about putting something biologic in there, I think, you know, potentially on the patient, if you think that this patient has problems with instability, proximal migration and hyperextension and you're trying to achieve stability and there's not a neurologic problem or something else, I mean, I'd probably I mean, I know hate, you know, Peter, I know Brown might be a little bit different, but we still have a surgery center that we work in and cost matters.
THOMAS KAPLAN: And, you know, you can get free college from the patient, don't have to have a special machine or anything like that. So I mean, I think going to a you know, you've already burned the AP and the APL and the FCR but you can certainly go to the ECRL and that makes a great salvage for this where you have plenty of tendon to to do another ligament reconstruction and tendon interposition and put in some biology that's actually compatible with the patient.
THOMAS KAPLAN: So I think potentially you would try one more time. And I think that I think you mentioned also first metacarpal, second metacarpal fusion. I know Dr. Greenberg has done one of these in the not too distant past and in the right patient. I think that's a good procedure. You know, high complication rate, really careful on non-unions there, but certainly provides a stable thumb and is if you're looking for the one and done, that's probably the route I'd go for an instability problem.
PETER WEISS: So let me just make two comments on what Tom said. One is any biologic tissue you get from the body. Now, autograft is going to be non structural. it's going to be squishy. You ever try to use graft jacket like Dean Satriani talks about or palmaris longus tendon that's squishy and you try to sew it together. It's basically smush. It's like putting wet spaghetti in there as opposed to something where you can stick it between your fingers and you cannot compress it.
PETER WEISS: That's one comment. And second is, even though this is probably not the right forum, it's 2.5445, not 25447 If you use an implant and the facility fee is higher for that and covers the cost of the implant. Now that's, don't ever mention that I said that on this call, but that's actually true. Indiana should certainly know that. That, that is fair. Um, yeah.
WARREN HAMMERT: So I think those are all very good points of discussion and I think, you know, the problem is there's not one clear right or wrong answer for anything that we really talked about tonight, which is what makes this a great topic for debate. This lady was actually unstable at her MP joint as well as her CMC joint. And I think we all know there are some patients you take the trapezium out and it feels like it's pretty stable without doing anything.
WARREN HAMMERT: It just kind of sits where it's supposed to sit and you feel like this isn't going to collapse and there's others. You take the trapezium out and you feel like the thumb is going to impinge against the radius. It's just globally unstable in every direction and I really wanted to do the first to second metacarpal arthrodesis in this lady because I thought that was going to be the most predictable, but she didn't want a fusion.
WARREN HAMMERT: And so we did exactly what Tom mentioned. I took the ECRL and then you drill a hole in the metacarpal base from dorsal to volar, bring it through, and now it's right where your FCR would have started and so now you've got the option essentially to do the same type of a procedure as you would with the standard LRTI, with the full FCR. And so that's what I ended up doing with her. And she actually did, did well, here's the x-rays and fused the MP joint at the same time.
WARREN HAMMERT: And then she came back and she had her other side done a couple years later and I just did a standard LRTI on that side. But I think we've approached an hour now. I think there were excellent presentations by all of the Fellows and learned a lot from listening to the presentations as well as the mentors. So I will turn it back over to Jerry for some final words
WARREN HAMMERT: but I thank everybody for their presentations and for their contributions.
JEFFREY YAO: All right. Thank you, Warren. I want to thank all the faculty and Fellows for excellent presentations and discussions. Always fun to see the playful banter and little jabs at each other, but hopefully this has been a good educational experience for everybody.
JEFFREY YAO: Thank you for everybody who responded to the surveys, but we really want to try and continue this forward perhaps on every other week basis until the end of the academic year and perhaps go into monthly as everybody gets busier. But please send me any feedback or anything you could think of to make it a kind of a better forum for Fellows and faculty. But this has been awesome from everybody
JEFFREY YAO: so I really do appreciate it. If I could ask the faculty, I kind of made a screw up on the schedule for next week. So we are looking at changing topics. If anybody has suggestions or they want to participate for something they can get together pretty quickly with their Fellows, please let me know. But we will be doing a little bit of a revision to the schedule coming up.
JEFFREY YAO: I really appreciate everybody again, excellent discussions again. Awesome thanks, Jerry. Great job, everybody. Thanks, everybody. Everybody stay safe. Thanks for tuning in. Thanks, Warren. Warren, great moderation.
JEFFREY YAO: Thanks
Segment:0 .
WARREN HAMMERT: So welcome to our hand fellowship virtual debate. This is Week 4 and we're going to talk about thumb CMC arthritis tonight. So as a moderator, I have nothing to disclose financially related to this presentation or this program. But as you know, I live in Rochester, new York, which is the home of the LRTI.
WARREN HAMMERT: In spite of that, I'm going to be optimistic and not have bias throughout this presentation and give everybody an equal chance. And so as you can see, I'm in Las Vegas right now. This is a big event and I'm happy to have participants that are going to make this huge. And so said, you know, Las Vegas is probably the place to host this. That's where all the big events are hosted. And so we're going to begin with the Indiana Hand to Shoulder Center.
SHANNON FITZPATRICK: Dr. Kristin Buterbaugh is going to present on the LRTI with Dr. Tom Kaplan in her corner. Next, we will have the group from Stanford discussing the Suture Button Suspension. Dr. Jill Putnam is going to present and Dr. Jeff Yao will be in her corner. Then we will move on to the East Coast and our Brown group will present on the APL-FCR Suspension Arthroplasty with a little bit of a twist.
WARREN HAMMERT: Dr. Shannon Fitzpatrick is going to discuss this and Dr. Peter Weiss will be in her corner. And finally, we're going to talk about Thumb CMC Arthrodesis. This will be presented by Dr. Jeff Stepan, and Ryan Calfee will be in his corner. This was the initial logo I found from Wash U, but I didn't feel like they could defend things adequately with this, so I did find something a little bit more robust for them to use on their their logo.
WARREN HAMMERT: So this is the case we're going to talk about. A 64-year-old, pain in her non-dominant left thumb. For over two years, she's tried bracing therapy, exercises to protect the thumb CMC joint, but she's symptomatic enough that she wants to proceed with surgery. So these are the clinical pictures. You can see her thumb metacarpal, adduction contracture, you can see MP joint hyperextension, but pretty good mobility of the thumb.
WARREN HAMMERT: She can oppose it to the base of the small finger. Here you can see her radiographs, which again demonstrate the metacarpal contracted and the thumb MP joint hyperextended. You can see some subluxation and that the trapezium is somewhat eroded. So why do we want to talk about this? There's not a lot of level one studies in hand surgery, but this is actually a pretty good study by Tim Davis and his group in England.
WARREN HAMMERT: So 5 to 18 year follow up of a prospective randomized trial on thumb CMC surgical treatment. So they compared simple trapeziectomy, trapeziectomy with palmaris longus interposition or one of the early versions of the LRTI as described by Dr. Burton with 50% of the FCR tendon. And their conclusion was that there's really no benefit to tendon interposition or ligament reconstruction
WARREN HAMMERT: and so then the question becomes, well, why do we need to really have this debate and talk about it if that's the case? But I would say, in the words of Lee Corso. [VOICEOVER] "Corso. Not so fast." There's more there's more to it than that. So let's look at this just a little bit further as we start our debate.
WARREN HAMMERT: So if you look at the Cochrane Reviews, there have been several. And so go back to 2005, 2009, 2015, 2017. The summation of these is all fairly similar. We're unable to demonstrate any technique confers one benefit over another technique in terms of pain or physical function. And so that's the idea behind the debate tonight. We're going to discuss these various options and at the end, hopefully someone will convince us that one is the best option.
WARREN HAMMERT: [VOICEOVER] Oh, for the thousands in attendance and the millions watching around the world on HBO Pay-Per-View ladies and gentlemen, from Mandalay Bay, Las Vegas. Uh, let's get ready to rumble. OK. So I am going to end my show and we'll turn it over to the group from Indianapolis
WARREN HAMMERT: and we will start the debate with the LRTI by Dr. Buterbaugh. So you should be able to take control and share your screen now.
KRISTIN BUTERBAUGH: OK OK.
KRISTIN BUTERBAUGH: Everybody can see it? Yep. Good Evening. I will be speaking on LRTI, the gold standard. Thank you to Dr. Kaplan and to Dr. Fisher for helping me with my presentation. Again, here's the case that Dr. Hammert just showed us. A 64-year-old woman with stage three thumb CMC OA. As we all know, the CMC joint of the thumb has liberal range of motion due to its lack of bony confinement and reliance on ligamentous stability.
KRISTIN BUTERBAUGH: 8 to 13% of men and 25 to 36% of women ages 50 years and older develop CMC arthritis and of these, 20% of affected people require some form of treatment in their lifetime. So here's the challenge. How do we best manage CMC arthritis surgically? The answer remains controversial. I will show you why trapeziectomy with ligament reconstruction and tendon interposition a.k.a. the LRTI remains the gold standard in comparison to the other treatments discussed today, including mini tightrope suspension, suture suspension plasty and thumb CMC fusion.
KRISTIN BUTERBAUGH: The origins of LRTI began with trapeziectomy, introduced by Jervis in 1949, and it is notable to state that trapeziectomy with distraction haematoma formation continues to demonstrate excellent functional outcomes with resolution of pain. However, trapeziectomy alone does not treat ligamentous degeneration and instability and dorsal subluxation has been noted following simple trapeziectomy.
KRISTIN BUTERBAUGH: Additionally, trapeziectomy with distraction arthroplasty commonly requires k-wires which can be cumbersome for patients and lead to pin tract infections post-op. Burton and Pellegrini described trapeziectomy with LRTI as shown on this schematic in 1986. In order to address thumb metacarpal proximal migration and impingement after trapeziectomy. Now, for the top five reasons why LRTI is the gold standard. Number one is long standing good results.
KRISTIN BUTERBAUGH: While newer techniques like the tight ropes and suture suspension plasty show promise in intermediate follow up, no other technique demonstrates such a consistent track record and for good results. Additionally, wouldn't you rather take those extra 15 to 20 minutes in the OR for a good long term result rather than try to perform the quickest surgery possible sacrificing biologic support for abrasive suture?
KRISTIN BUTERBAUGH: Burton and Pellegrini looked at 24 thumbs following LRTI with an average of a nine year follow up. 95% had excellent pain relief and were satisfied with their outcome. The average grip strength reflected a 93% improvement. Average tip, pinch tip, pinch strength and key pinch strength also improved. Radiographs showed an average loss of height of the arthroplasty space of 13% at nine years.
KRISTIN BUTERBAUGH: Gangopadhyay et al performed a prospective randomized study of 174 thumbs comparing trapeziectomy distraction arthroplasty, tendon interposition and LRTI. Average follow up was six years with a range from 5 to 18 years. All demonstrated long term results of excellent pain relief, improved grip strength and equal complication rates.
KRISTIN BUTERBAUGH: To quote Dr. Hammert regarding his reasoning for LRTI, although there are theoretical advantages to the newer procedures, we have a time tested procedure with consistent results which have been replicated by many surgeons. In addition, this procedure is still widely used for revision surgery when other procedures have not provided acceptable results. As a testament to this statement.
KRISTIN BUTERBAUGH: Look at all these other new procedures, to name a few that showed so much promise and led to early failure. The number two reason for LRTI is widespread use. LRTI is the most widely used surgical technique among hand surgeons in the US. Recently, Yuan et al looked at Medicare data for the most commonly performed procedures for CMC arthritis and 3530 patients from 2001 to 2010.
KRISTIN BUTERBAUGH: 89% of surgeons performed tendon interposition with or without ligament reconstruction, and this demonstrated a consistent upward trend over time. Additionally, a 2010 ASSH survey by Brunton and Wilgus found that 68% of hand surgeons preferred trapeziectomy with LRTI. This speaks to the reliability and reproducibility of the procedure.
KRISTIN BUTERBAUGH: Number three is patient satisfaction. LRTI continues to be successful in providing patient satisfaction and quantifiable improvement in patient reported outcomes. Linz et al performed LRTI on 30 thumbs, and their outcome analysis revealed that 89% of patients were satisfied with their pain relief. 87% would undergo the surgery again. More recently, Vermeulen et al performed a randomized controlled trial comparing arthrodesis with LRTI in 43 patients.
KRISTIN BUTERBAUGH: They found that 86% in the LRTI group would have their procedure again, while only 53% in the arthrodesis group would. Of note this study was prematurely halted due to the increased complication rate in arthrodesis group, which was 71% compared with 29% in LRTI. Who wouldn't be dissatisfied with such a high risk of complications and loss of motion at the CMC joint?
KRISTIN BUTERBAUGH: Which leads us to reason number four. Low failure rate, particularly in comparison to arthrodesis. A recent systematic review found that LRTI had the lowest failure rate of 0.24 per 100 procedure years. The authors of this study propose twice the failure rate of LRTI to be the benchmark for comparison. Of note the failure rate of arthrodesis was 0.52 per 100 procedure years, which is greater than twice the failure rate of LRTI.
KRISTIN BUTERBAUGH: Hippensteel et al compared functional outcome of arthrodesis with LRTI in 50 patients. While they found similar outcomes at one year, the arthrodesis group had a 26% nonunion rate and a higher rate of secondary operations compared with LRTI. Number five is LRTI's low cost in comparison to other procedures such as tightrope suspension plasty, arthrodesis and suture suspension, plasty
KRISTIN BUTERBAUGH: when a speed spiral implant is used. Studies have noted the concern of additional cost of tightrope arthroplasty in particular, in some cases up to $500 for the implant. This is despite the lack of evidence supporting its advantage over trapeziectomy. This is an extra cost on top of other complications such as inadvertent overtightening of the thumb metacarpal to index finger, foreign body reaction and second metacarpal fracture.
KRISTIN BUTERBAUGH: And finally, a bonus reason to choose LRTI. In comparison with suture suspension plasty, LRTI may better manage preoperative and post-operative tendonitis. Lowe and Hales found a high incidence of FCR tendonitis following trapeziectomy with APL suspension plasty. In their study of 81 thumb,. 25% developed tendonitis post-op at a mean of 4.7 months. They postulated that FCR may be may be tensioned and constricted by the APL tendon that loops around it.
KRISTIN BUTERBAUGH: Suture could do the same. In summary, why LRTI remains the gold standard. Long standing, excellent results, widespread use, high patient satisfaction, low failure rate and low cost. Listen to Dr. Hammert. Choose a procedure that provides patients with a thumb that maintains a more natural appearance and excellent function 15 to 20 years post-op. Thank you.
KRISTIN BUTERBAUGH:
WARREN HAMMERT: Very nice presentation that sets the stage, that sets the bar pretty high. So we will move on to Dr. Putnam from Stanford to try to convince us that the suture button suspension, albeit much more costly, is a better operation.
JILL PUTNAM: All right.
JILL PUTNAM: Do you see that in presenter mode? Uh, that looks good. [WARREN HAMMERT] OK, great. Thank you for the introduction. And thank you, Dr. Yao, for mentoring me in this debate. I should disclose that Dr. Yao is an Arthrex consultant. So these are the radiographs that Dr. Hammert gave us and my job is to prove to all of you that the tightrope is superior to the LRTI, the arthrodesis and the suture suspension plasty.
JILL PUTNAM: And I'd like to begin by telling you why those last three are not the right options. So we'll start with LRTI. This was introduced by a lot of noteworthy names in hand surgery, but when you really look at the results of LRTI, they're really not that impressive. There have been plenty of RCTS and systematic reviews showing us that there's a higher complication rate with LRTI compared with trapeziectomy and that in the end, in the long term there's no benefit to tendon, interposition or ligament reconstruction.
JILL PUTNAM: And LRTI can take quite a lot longer, even double the time of a trapeziectomy, so why tie all of those knots and all of those anchovies if it really makes no difference? And no offense to our colleagues at Indiana, but I'm not convinced. How about arthrodesis? Well, I think we can all agree that they're pretty narrow indications for this procedure.
JILL PUTNAM: Our average senior patient is not a great candidate for an arthrodesis. Time to union, it's going to take more time for mobilization, which patients don't love and then that complication rate that Kristen already mentioned, including a potentially high nonunion rate and a rate of secondary surgery, those are concerning and then reduced range of motion again, like Kristen mentioned, especially with difficulty flattening their hand on the table,
JILL PUTNAM: patients do not like that. Now, the suture suspension sounds like a great idea, but again, you have to consider all that time for mobilization and loss of productivity for an average return to work of about nine weeks. Kristen also mentioned a relatively high rate of FCR tendinitis or even a rupture that merits consideration, and then recently I've been hearing that the suture suspension can or should be augmented with the speed spiral
JILL PUTNAM: and I have to wonder why even use the suture suspension plasty if you have to augment it with this overpriced fruit roll up. And I'm not sure I'm hoping that our colleagues from Brown can can kind of give us a little bit more information on that. So with these last three techniques, you're going to get five weeks post op in a cast at least, but with the tight rope, you could have this at five days.
JILL PUTNAM: And we're able to get patients moving that quickly and have that excellent result because this is biomechanically the superior implant. This biomechanical study showed that the tightrope better maintains trapezius space compared to the LRTI, and this study showed that the tightrope was equivalent biomechanically to a k-wire, at least an initial load to failure. And those results have been borne out clinically as well.
JILL PUTNAM: This is a study from Mayo last year where they looked at FCL-APL side to side tendon transfer with and without the tightrope, and they found that the tightrope better maintained trapezial space without any increased rate of complication. So again, the biomechanics of the implant are why we're able to get patients moving so much earlier. at 3 to 5 days, they can start range of motion exercises and patients love that.
JILL PUTNAM: So here's a patient at six weeks post op with excellent range of motion. She had no pain, and these are her preoperative and post-operative radiographs. She was very happy. And we have midterm outcomes as well. I'd like to highlight excellent range of motion and excellent pinch strength. Pinch strength and grip strength with this procedure at about five years out.
JILL PUTNAM: There are a few pearls to this technique. One of them is that the incision over the second metacarpal should be made over the ulnar aspect, respecting a nerve branch that is frequently crossing there. And then we recommend use of this targeting guide, which helps line up the pin into the second metacarpal just where you want it and that should be exiting on the ulnar border of that second metacarpal
JILL PUTNAM: and you can see this transition in the wire here where it transitions to a 1.1mm k-wire for entrance into the second metacarpal. And here you can see careful placement of the suture button again into the ulnar aspect of the second metacarpal to prevent any dorsal prominence or irritation from that suture button. And here's intraoperative loading. again, showing excellent maintenance of the trapezial height.
JILL PUTNAM: So I think I've proven that the tightrope wins out. It resists metacarpal subsidence. You don't have to use any k-wires or wait for anything to heal, and it allows for a faster rehab ultimately. I think I've proven that it's the superior implant. But wait, there's more. What about this patient who needs a revision CNC arthroplasty after she's failed, say, an LRTI, or a suture suspension plasty and has symptomatic subsidence of the first metacarpal?
JILL PUTNAM: There have been a couple of studies that show that the implant of choice may be the tightrope in revision CNC arthroplasty. The studies out of UVA couple of years ago and at ASSH last year, there was a study from Duke with similar opinions. And if it's all about the money, the tightrope may not be as bad as it seems. Tightrope at our institution runs about $400 versus if your LRTI needs to be backed up with an interference screw, that'll be even more expensive.
JILL PUTNAM: If you happen to be using an implant with your suture suspension, that can be quite expensive. If you need extra time in the OR for that LRTI, that's going to be quite a bit more expensive. But we all know that in the end, the cost of a happy patient on post-op day five, no, that's priceless. So it comes down to would you want this cast for five weeks or more?
JILL PUTNAM: Or would you want this excellent result at five days? And that's all I've got. Thank you.
JEFFREY YAO: Great job.
WARREN HAMMERT: OK very nice presentation. Pretty convincing. Let's hear from our next group from Brown.
WARREN HAMMERT: Dr. Fitzpatrick is going to discuss her preferred technique.
SHANNON FITZPATRICK: Can you hear and see me? Yes. My name is Shannon Fitzpatrick. I'm one of the current Brown Fellows. Dr. Weiss and I have been charged with defending the suture suspension. And not only will we talk about that, but we'll also talk about he suture suspension
SHANNON FITZPATRICK: with a bit of a twist. Of note, Dr. Weiss has interests in Arthrosurface, Incorporated and this will be important for the end of this discussion. This is a typical patient presented in this conference. She's a 58-year-old female with four years of thumb pain, secondary to basal thumb arthritis. On x rays, she is in Eaton stage three thumb arthritis. She does not have any MCP hyperextension. Of note in our practice,
SHANNON FITZPATRICK: we do not treat patients with thumb MCP hyperextension any differently than those that do not unless they are symptomatic after a basal thumb arthroplasty. This patient is a neonatologist, so her thumbs are very, very important for her vocation as she cares for and examines infants. She has failed extensive non-operative management with splints and cortisone injections, and she has elected to pursue operative intervention.
SHANNON FITZPATRICK: In our practice, we traditionally use a suture suspension arthroplasty to address basal thumb arthritis. This concept was originally described by Delsignore in 2009. Our practice is modified and the original inscription and this modification was published in JHS in 2018. As you can see in the left hand photo, we use a traditional Wagner approach.
SHANNON FITZPATRICK: Once the trapezium is excised, in this center photo, you can see that we take a number two ortho code suture. It's placed through the APL at its insertion on the base of the thumb metacarpal. The suture is passed through the FCR tendon distally near its insertion on the second metacarpal. The suture is then woven back through the APL and the FCR tendons. The two ends of the suture are then tied together in a snug fashion, but not so tightly as to tether the EPL and FCR together tethering of these tendons can result in discomfort and decreased function of the thumb.
SHANNON FITZPATRICK: The idea really here is to create a suture hammock for the thumb metacarpal base to rest upon. This suspends it from the distal scaphoid articular surface. Once the suspension is completed, the thumb metacarpal is finally tested for longitudinal stability. Here in the right hand side of the screen, you can see the final construct. It's very important to note that no tendon graft or k-wire is used during this procedure.
SHANNON FITZPATRICK: The pros of this procedure include that it doesn't require a second incision to harvest a tendon. Since a tendon is not harvested, there is no alteration in wrist kinematics. The k-wire is not used in the post-operative period to provide stability. This avoids neuroma formation, tendon adhesion, scar tenderness and even potentially complex regional pain syndrome.
SHANNON FITZPATRICK: And this technique, immediate stability is achieved because one is not relying on soft tissue scar formation or maturation. This allows us to not be forced to cast patients in the post-operative period. Moreover, this is a cost effective procedure because there is no cost associated with any implants. It was also time efficient, given its simple and elegant technique.
SHANNON FITZPATRICK: Our average operative times at our institution are 23.4 minutes. When you compare this to LRTI, it is almost 40 minutes in the literature, so twice as long. How many patients initially have a quicker recovery with higher CRWE scores? In long term, these initial higher scores even out, they are about the same for all techniques. The cons of this procedure are that we have had a few patients with distal FCR ruptures at the 3 to 4 month mark.
SHANNON FITZPATRICK: When this occurs, there is no intervention required. Initially, it's painful, but this resolves. You may have a bump in their forearm, which can be cosmetically displeasing to your particularly young lady. More recently, we've added a twist to our suture suspension, particularly in patients with EMCP hyperextension or in revisions. In addition to our suture suspension, we use the tails of the suture and we pass them through a piece of rolled human collagen.
SHANNON FITZPATRICK: This provides a harder fulcrum for the thumb and is a piece of a vest for the suture suspension. On the left hand side of the slide, you can see a radiograph with this new twist. You can appreciate the well maintained height of the metacarpal. On the right side of the slide you can see a graph representing biomechanical testing of the ability of various basal thumb arthroplasties, including LRTI, suture suspension alone, trapeziectomy alone, and our rolled human collagen versus the strength of intact bone.
SHANNON FITZPATRICK: You can appreciate that the role of collagen has characteristics that most closely mirror that of intact bone when compared to the other techniques. We think that this aids in maintaining the height of the metacarpal and that it reduces the amount of play in the MCP joint. We do suspect that the collagen softens over time. The pros of this new twist are that it provides increased stability of the joint and it improves maintenance of metacarpal height, particularly in challenging patients to care for initially or in revisions.
SHANNON FITZPATRICK: The cons are that the implant costs $1,500, but you can use this different CPT code to recoup those costs. The other disadvantage is that this does take longer when using this technique than just the suture suspension alone. These are preferred techniques when operatively addressing basal thumb arthritis for the reasons I have discussed. We feel that this is a highly favorable operative technique. Thank you for your time.
WARREN HAMMERT: OK I'm not sure we're any closer than we were when we started this, because another very convincing presentation. Let's see if the group from Wash U can convince us that thumb CMC arthrodesis is the way to go. So we'll let Dr. Stepan present here.
JEFFREY STEPAN: All right. Fantastic can everyone hear me OK?
JEFFREY STEPAN: Good? All right. So I'm going to go ahead and present on CMC arthrodesis. Thank you to Dr. Calfee for helping with this presentation and being a mentor for over almost 10 years now. So to proceed, I'm not going to say that CMC arthrodesis should be done in every patient, but I'd like to maybe dispel some of the myths that have been reported by previous presenters here. So to just frame the discussion a little bit, I'll start us off with a case from earlier in my fellowship year.
JEFFREY STEPAN: So this is a 39-year-old female with five years of thumb CMC pain who failed non-operative management. Ligamentously lax with a Beighton score of seven, considerable laxity of the CMC joints as well as pain there. You can see the subluxation on x-rays and maybe some of the beginning of osteophytes here at the ulnar border of the trapezium. So, given a global ligamentous laxity, laxity, ligament, reconstruction and osteotomy, probably not advisable.
JEFFREY STEPAN: So really here in the US, the treatment options become trapeziectomy and as we've just heard, doesn't really matter. Whatever tendon, suture or device you want to add or even not add to it versus arthrodesis. So what are some of the classic indications that younger active patients, as we all know. Paper we've lost your audio.
JEFFREY STEPAN: You could say that symptomatic arthritis or. Oh, can you hear me now? Yeah, we can hear you now but we lost you for a moment. Oh, I'm sorry. Can yeah. Go back to the beginning of that slide. This slide here? OK sorry about that.
JEFFREY STEPAN: Um, classic indication for arthrodesis, as we all know, are the younger, active patients with any sort of manual labor. Um, putting extreme force to the joint and any patient with significant ligamentous laxity contraindications would be STT arthritis or poor bone quality. But we've just heard all about trapeziectomies and how great there are, They are
JEFFREY STEPAN: so why do CMC arthrodesis instead? So there is the possibility of improved pinch strength once it's fused, there's no worry about longevity, there are still salvage options available. And when you fix the metacarpal out of the adducted position, it gets rid of the MP hyperextension, kind of obviating the need for any intervention at the MP joint. Most detractors would say range of motion, high nonunion rates and maybe hardware issues as major negatives.
JEFFREY STEPAN: So let's take a look at the literature that previous people have looked at to say why arthrodesis was bad. So the highest level of evidence was against arthrodesis. This is a randomized control trial out of the Netherlands that was stopped early. But when you take a little bit closer look at the study itself, they're all females, they're all over 59,
JEFFREY STEPAN: that's the average age, far cry from the typical arthrodesis patient. They used no bone graft and they started moving their arthrodesis patients at about four weeks. I think everyone would agree that's too early. So how did they arrive at this high complication rate? They took scar tenderness and minor complications like that, not necessarily associated with the surgery performed.
JEFFREY STEPAN: We also don't know if their symptons, their delayed unions were actually symptomatic and they didn't provide any definitions for nonunions. Despite this, they went on to provide outcome assessment. They weren't able to provide outcome assessments due to being underpowered, but they went ahead and re-evaluated the their same cohort of patients about five years later, with even fewer patients to compensate for this, over a third of their data ended up being statistically modeled.
JEFFREY STEPAN: And they actually showed the arthrodesis patients got worse over four years. Needless to say, this is not consistent with any of the previous comparative studies which we'll go over now. So the largest of these studies was this retrospective cohort out of Cincinnati and showed equal satisfaction between groups, equal improvement in pain, stronger pinch strength with arthrodesis.
JEFFREY STEPAN: About a third of patients were unable to flatten their hand on the table. Although overall nonunion rates were a bit high, only three were symptomatic, and there was only one nonunion in the locked plate group. For this prospective comparative study out of year is another study showing similar patient rated outcomes and overall complications between LRTI and arthrodesis patients.
JEFFREY STEPAN: In this study, when looking at range of motion, there was no difference in the ability to flatten the hand in contrast to the study at Cincinnati. There were, however, high rate revision early in the treatment process and similar symptomatic nonunion rates. So when you ask what about long term results after arthrodesis that we weren't able to provide with the tight rope, for example.
JEFFREY STEPAN: But with this study out of Mayo, we can see all patients are satisfied, almost all patients were satisfied with low pain scores. They had similar symptomatic nonunion rates, about 7%, STT arthritis long term developed, and only about 6% of patients only have, one of which required revision surgery about 18 years after a successful arthrodesis. In terms of the approach usually just do a standard dorsal approach here after meticulous preparation of the bone and Ronjeur with,
JEFFREY STEPAN: sorry, Ronjeur and burr to cancellous bone which can be seen on the left. The excision can be extended proximally, here another incision can be dorsally for some distal radius bone graft, which you can see here. And goal of fusion is for the thumb pulp to rest on the middle phalanx of the index finger with the wrist and slight extension as shown here. So there are plenty of hardware options.
JEFFREY STEPAN: In this case, the CMC fusion plate was used. Here are some examples of use of a headless compression screw as well with final x-rays on the right. So now that we have an overview of CMC arthrodesis in the literature, I kind of want to bring it back to the case that I showed at the beginning of the presentation. Question marks surrounding trapeziectomy are really about longevity and such a young patient with no true salvage options.
JEFFREY STEPAN: Is it really going to last 30 to 40 years for this ligamentous laxed patient, so using the literature I just presented, we can see CMC arthrodesis can provide better strength, equal range of motion and outcomes while still preserving the ability to perform revision surgery in the future if necessary. This all must be balanced, however, against an increased upfront risk of revision surgery, so I'm sure it's no surprise we performed a CMC arthrodesis for this patient.
JEFFREY STEPAN: Fortunately, no follow up x-rays due to Covid but that being said, she had a prior successful fusion on the contralateral side that's currently without pain and back to full activity. So in conclusion, as with everything in hand surgery, it's about patient selection but when deciding between trapeziectomy and arthrodesis, we really must decide if potential benefits of arthrodesis that we discussed are worth the upfront increased risks of revision surgery.
JEFFREY STEPAN: Thank you.
WARREN HAMMERT: So another excellent presentation. And that's one of the things about this technique or this condition that makes it interesting is there's a lot of good ways to approach this, and there's not one that's clearly right and a bunch of others that are clearly wrong. So what I want to do now is go through some stuff with the mentors of the groups and just kind of get their thoughts on a couple of things.
WARREN HAMMERT: So I'm going to try to share my screen and hopefully do a better job this time. Can everybody see the full screen now? Yes, yep.
WARREN HAMMERT: OK, so let's let's go through from the mentors and we've got a good idea about the CMC joint, how to manage that but I want to talk about the MP joint a little bit because that's one of the things that I think can cause failure or cause a unsuccessful or a less than optimal result is not looking at that MP joint. So we'll start with Tom Kaplan. Give us your thoughts on how you would manage the joint.
WARREN HAMMERT: Do you address these with tendon transfers, tenotomies, capsulodesis, arthrodesis, kind of, what's your algorithm?
THOMAS KAPLAN: Sure thanks. So first, thanks to all the Fellows. Great presentations and thanks to great moderation there Warren, and Jerry for getting this organized. I think the MP joint is like most things with the CMC joint as well,
THOMAS KAPLAN: it kind of depends. You know, not every amount of hyperextension needs to be treated and there'll be there's no kind of hard cutoff. I think one thing that we look at is and you know, kudos to one of our past Fellows last year who kind of started looking at this is, you know, is not only is there what the passive MP hyperextension is, but what is the dynamic MP hyperextension or the ability to maintain or to prevent an active collapse deformity.
THOMAS KAPLAN: So in patients with MP hyperextension, I also ask them to do a pinch test and see whether or not they compensate for that hyperextension or not, because I think it's mainly in those patients who have active collapse, not just passive hyperextension, that you have to then address the MP joint. So if a patient has more than 30, 40 degrees of hyperextension and they have active collapse, then usually that's someone that we're going to do an additional procedure on.
THOMAS KAPLAN: You look at their MP joint, obviously preoperatively, if there's any arthrosis that's going to go to effusion. Patients, many patients have very limited, limited mobility in their |MP joint. They may be better off with fusion as well, but if they have good motion of their MP joint, no arthrosis, then oftentimes we'll treat those patients with active collapse with a capsulodesis and the only other pearl I'll throw out there is when, if you're doing a dorsal approach to the CMC joint, doing a transverse capsulotomy can help you because on the way out you can imbricate the dorsal capsule of the CMC joint helping to extend that first metacarpal and that can help with the MP compensatory hyperextension that's developed.
WARREN HAMMERT: So in 30 seconds, tell us how you do your capsulodesis. There's a bunch of different approaches to this, and I don't have one that I think is the best. I've tried things and I move around. How do you do your capsulodesis?
THOMAS KAPLAN: Yeah, mine is. I go through a Bruner incision volar approach to the MP joint. I release the volar plate along the radial margin, along the sesamoid, and then proximally, mobilizing the volar plate, roughing up the metacarpal neck.
THOMAS KAPLAN: And I use a suture anchor in the metacarpal neck and then pass that through the volar plate to tighten it up. And I try to place it in about 20 to 30 degrees of flexion, you know, have it tight at about 20 to 30 degrees because these always stretch out to some degree.
WARREN HAMMERT: Yeah OK, great. That's a very good synopsis of this. Jeff Yao? Other thoughts or do you approach the MP joint any differently?
JEFFREY YAO: No, I think that was great. I mirror what Tom says. I do a from 30 to 50 degrees. I do prefer a capsulodesis. I like the dynamic pinch testing, the dynamic active collapses. And so I do a capsulodesis, very similar to what he described.
JEFFREY YAO: I learned recently from Scott Wolfe that just if you used to do a distally based releasing the volar plate discipline, advancing distally, I learned that from Dick Berger but sometimes that could be a little bit challenging because you have the sesamoids there so I learned from Scott that you can remove the the radial sesamoid, give yourself a little bit extra space and advance it distally.
JEFFREY YAO: But I've found now that just advancing proximally is a lot easier. And then for greater than 50 degrees, or if there's any evidence of arthritis, I do a arthrodesis.
WARREN HAMMERT: OK and one other thing that neither one of you mentioned, but it's probably obvious if there's valgus or varus instability that's better treated with an arthrodesis, I think as well if it's unstable. But just the isolated hyperextension is what we're kind of talking about.
WARREN HAMMERT: But occasionally you will see patients that have ulnar collateral ligament insufficiency as well. So Peter Weiss do you have anything different? It was mentioned in your presentation that it sounds like your implant does a lot to take care of the MP joint hyperextension. Any other pearls that you can share with us?
PETER WEISS: Well, first of all, with regard to your x ray, I actually think the biggest problem is there's substantial adduction deformity that's probably fixed.
PETER WEISS: And, you know, the metacarpals slid off the trapezium and it's in a fixed position, that's a little different than what we usually see. A lot of these, the hard part is actually not the MCP joints, but is getting the thumb metacarpal out away from the index metacarpal in a more functional position. I think a lot of this particular like your X-ray will require some resection of the MCP, the sorry, the metacarpal shaft proximally in order to get enough space.
PETER WEISS: I don't think you can usually get this completely released by soft tissue means. So sometimes I'll saw a half a centimeter or a centimeter of the metacarpal base just to be able to get it in ad sorry abducted position so that at least your arthroplasty at the CMC joint has a chance to work. I think the biggest part of failure in this procedure is not the MCP, but is actually an incomplete reconstruction of the normal anatomy of the MCP or the MC thumb versus the rest of the hand.
PETER WEISS: That being said, you know, I've been at this for 30 years and I trained where Tom was. And, you know, you had eight different guys doing eight different things for the MCP joint. I, I used to do taken out, you know, a portion of the volar plate and sewn it up tight, which is what I learned Steichen did. I did fusions, which was which Strickland and Kleiman kind of did.
PETER WEISS: And then I did nothing, which is what most of the rest of the guys did. My kind of approach to this now is I don't do anything primarily unless there's substantial pain at the MCP, regardless of the amount of hyperextension. And I find if you can reconstitute the height of the thumb metacarpal and keep it stable and you know, regardless of the technique you use, a lot of times the MCP will re kind of balance itself.
PETER WEISS: It's a little bit like, shortening, you know, doing an ulnar shortening osteotomy for TFCC tears, you kind of tighten up all the ulnar structures and it kind of makes the, the overall structure more stable. I think that happens to the MCP joint if you reconstitute the height of the thumb metacarpal and I think there's some biomechanical data that's going to be coming out and presented in the near future that will document that.
PETER WEISS: So I, I tend to just treat that if it's really symptomatic. Otherwise, I would tell the patient, look, you've got some hyperextension, I'm going to try to fix your CMC joint, there's a chance that you may need another procedure for the joint, but I think it's going to be on the lower side of 50% and I'd rather do that as a secondary procedure if it's required.
WARREN HAMMERT: Now, those are some good pearls. I think getting the metacarpal into extension and out of flexion as it is here will often help improve that joint quite a bit. So for the last couple of minutes, I just want to go through a case for the faculty to discuss and not just the mentors, but anybody else that has thoughts on this. Be happy to hear their opinions.
WARREN HAMMERT: 54-year-old lady, this is her dominant thumbs had two previous procedures. The first was an FCR suspension. She continued to be symptomatic and then was converted to an LRTI using the entire FCR. She presents to me with impingement of the metacarpal base on the scaphoid with pinch metacarpal adduction contracture to some degree and MP joint hyperextension.
WARREN HAMMERT: So open up to any of the people on the panel. How would you approach this problem? Two previous surgeries? What would you do at this point in time? Do you fuse the metacarpal of the thumb to the metacarpal of the index, or is there something else that you can do? Oh, wait. Before we go on to this, I want to go back. I neglected to ask Ryan Calfee his approach to MP joint. I apologize Ryan, tell me what your approach is, if anything different.
RYAN CALFEE: Don't have much different. I do what Tom does, look for active collapse and think I treat it very rarely. And if the patient really has a lot of collapse on active pinch, I'll use it. Otherwise, the folks in the Midwest are pretty tolerant of it.
WARREN HAMMERT: So if the CMC joint has been fused, would you would you fuse the MP joint as well?
RYAN CALFEE: No, but I've never had that problem with the CMC fuse. The MP no longer hyperextends. It just doesn't happen.
WARREN HAMMERT: So problem solved by fusing it. OK. So now then to this case. Two previous surgeries. How would you approach this? Ryan, do you want to start and anybody else can join in?
RYAN CALFEE: Sure so I'll start by just saying that I think if somebody has failed these two surgeries and as everyone's presentation pointed out, just about everything works in the thumb. So I think you got to figure out why did it fail? What's wrong with the patient or was there something truly wrong with the surgeries that were done? Um, and and I would be very humble about doing more surgery because we've looked at our results on revision and they're fairly miserable at Wash U at least in terms of making people that have pain after these procedures better with more of the same procedures.
RYAN CALFEE: Um, so I would be very hesitant to do anything unless any of my other mentors on this line have other options that are great. I'll send them to you. Um, but I think that if everything really seemed reasonable and maybe one problem is are soft tissues. I have done the occasional revision, then going to something artificial, whether it's a suture suspension tightrope or internal brace or any other type of suture as opposed to soft tissues.
RYAN CALFEE: But but I'm concerned that unless there's a really, really convincing mechanical reason for pain and a really good reason that these others failed, that this person is still going to have pain.
JEFFREY STEPAN: Warren, if I may, I agree with Ryan. I think it's for someone to fail to procedures. It's you have to wonder if there's something else going on.
JEFFREY STEPAN: But in the absence of that, I like to sort of group the potential causes of failure, which are thankfully rare into a few different categories. And I think the major causes of failure of any of these procedures are potential subsidence, which looks like there may be some, but it's hard to tell from these radiographs. Impingement of the thumb metacarpal into the second metacarpal with whatever technique you use, if it's done too tightly, that can occur.
JEFFREY STEPAN: Appreciated or underappreciated scaphoid trapezoid, arthritis could be a cause, and then MCP joint could be a cause. So you really have to try to identify from those four things I find which are the most common, which it could be. And I find selective lidocaine injections would be very effective for that. I like to inject into the areas where the patient seems to have the most pain, and that can help me sort of identify between those.
JEFFREY STEPAN: But that being said, you know, obviously I'm biased, but I think, you know, if the patient's there aren't any other secondary issues or potential secondary gain issues with the patient, I think a failure of two biologic type procedures as we're done here, I think is a is a clear indication for use of the suture button suspension and I think the folks from Duke have published some work on that.
WARREN HAMMERT: So share your tips on how you extend the metacarpal with the suture button suspension.
WARREN HAMMERT: I've played around with it in the lab and I've done it a few times, but I have trouble getting the metacarpal to come away from the palm. It still wants to collapse when I do it. So share with everybody how you get that metacarpal to extend.
JEFFREY STEPAN: Yeah thankfully you don't always have to. It depends on the indication of course, but I'll use a lot of soft tissue balancing.
JEFFREY STEPAN: Particularly I'd use a dorsal capsulotomy to gain access to my joint in the first place and then when I put my implant in, I put it in from dorsal radial over to the second metacarpal and I think the key maneuver is and I basically put it in, I have the second button just at the level of the insertion. And then I think the key move is then I imbricate the dorsal capsule, so that it helps when you imbricate the dorsal capsule helps draw the the base of the metacarpal in a little bit.
JEFFREY STEPAN: And so that that seems to work well for me.
WARREN HAMMERT: Peter, is this a case where you would consider your implant?
PETER WEISS: So first, I think, I don't know what kind of FCR/APL suspension, if it was an APL transfer, you know, like a tendon based transfer or a suture based transfer. So the difference, I think the problem you got to think about with tendons, they have a high elastin content. They stretch.
PETER WEISS: It's not a rigid structure. So if you're going to use a tendon, whether it's LRTI or APL transfer or whatever you want to call it, there is an element of stretch that can occur. Uh, I hate to even give Jeff a, you know, a, any any, any benefit for this. Uh, Jeff, by the way, congratulations on becoming a professor. That's great for you.
PETER WEISS: Um, you know, but I do think one of the things that the tightrope and the suture suspension with ortho core do, they're basically, they use rigid sutures that don't have any elastic component. So they're are a stabilized structure. In this particular case, I think there's always a benefit for having some type of tissue interposed between the base of the thumb and the distal scaphoid and maybe also between the base of the thumb and the trapezoid index metacarpal base.
PETER WEISS: So for me, today, if I do a revision, which I see quite a few from the Boston area, um, I would put a, a speed spiral human collagen implant here. Before I use the speed spiral. The way this, you know, I think I saw Greenberg was on the call today. The way this all started was this is nothing new, this. Jim Strickland used rolled up gore-tex when I was a fellow in 1990 and '91.
PETER WEISS: And those patients did awesome structurally, but at three years they all went to shit because the gore-tex delaminated and it caused a foreign body reaction just like PLA or PGA do today. And so what we learned was that the technique was actually valid, the material was not valid and that's a little bit like Jill's comment on the, the ardalan spacer. But I started using Durgan, which was bovine collagen used for rotator cuff repairs.
PETER WEISS: I basically cut Durgan into strips, rolled it up just like Strickland taught me, put some suture through it and stuck it in patients thumbs. And this was 20 years ago and we have 20 year data on those patients and they are doing fabulously. It's biologic, it has structure to it. It gets remodeled by the bone's own natural fibroblasts. So the only reason that that wasn't commercialized was because the FDA would not allow bovine collagen to be used in a ectopic location outside of the shoulder.
PETER WEISS: And Integra had made a whole machine to make the stuff and basically the FDA said no. So when human collagen became available about two years ago. Uh, I jumped on it with this company and I said, you got to get the license for this, because basically we're talking about the same structure as what I used 20 years ago that worked quite well. And so that's why the FDA now has cleared this, even though it's really there's nothing new about this.
PETER WEISS: It's, it's 20-year-old technology. And so I like the idea of having something that's interposed there, plus a stabilizing structure on top of it, whether you use even if you use a tightrope and a speed spiral or some something that's non-elastic and then something that provides both an immediate probably not long term, but immediate stability, plus an interposition biologics material that probably within one month is has got soft tissue ingrowth.
PETER WEISS: The other option, I think, to Ryan's point is you could do, you know if you just want really a one and done no risk whatsoever you could you could fuse this thumb and be done with it. But you know I do one fusion every 6 to 8 years and you know, I mean, that was a nice presentation, but I think it was Jeff but you know, if you operate on normal looking thumbs on x-rays with fusions, you know you're going to get good results, right?
JEFFREY STEPAN: Oh, boy. I just got to get you, Ryan, because you were a resident here. You can't. Good we got you.
WARREN HAMMERT: Tom, anything that you would add or.
THOMAS KAPLAN: Um, I mean, all great points. I mean, I think Ryan had a good point of saying, hey, you got to think about, you know, I think the hard part with these are why they failed, right?
THOMAS KAPLAN: I mean, so I think you really have to kind of diagnostically kind of figure it out, whether it's instability, is it impingement, is it neurologic, is there nerve issues going on there as well that hasn't been recognized? And then you have to obviously treat you know, you have to tailor what you're going to do to why you think the patient is still hurting. I mean, I guess the only other thing I would think about and it kind of similar to what Peter was saying about putting something biologic in there, I think, you know, potentially on the patient, if you think that this patient has problems with instability, proximal migration and hyperextension and you're trying to achieve stability and there's not a neurologic problem or something else, I mean, I'd probably I mean, I know hate, you know, Peter, I know Brown might be a little bit different, but we still have a surgery center that we work in and cost matters.
THOMAS KAPLAN: And, you know, you can get free college from the patient, don't have to have a special machine or anything like that. So I mean, I think going to a you know, you've already burned the AP and the APL and the FCR but you can certainly go to the ECRL and that makes a great salvage for this where you have plenty of tendon to to do another ligament reconstruction and tendon interposition and put in some biology that's actually compatible with the patient.
THOMAS KAPLAN: So I think potentially you would try one more time. And I think that I think you mentioned also first metacarpal, second metacarpal fusion. I know Dr. Greenberg has done one of these in the not too distant past and in the right patient. I think that's a good procedure. You know, high complication rate, really careful on non-unions there, but certainly provides a stable thumb and is if you're looking for the one and done, that's probably the route I'd go for an instability problem.
PETER WEISS: So let me just make two comments on what Tom said. One is any biologic tissue you get from the body. Now, autograft is going to be non structural. it's going to be squishy. You ever try to use graft jacket like Dean Satriani talks about or palmaris longus tendon that's squishy and you try to sew it together. It's basically smush. It's like putting wet spaghetti in there as opposed to something where you can stick it between your fingers and you cannot compress it.
PETER WEISS: That's one comment. And second is, even though this is probably not the right forum, it's 2.5445, not 25447 If you use an implant and the facility fee is higher for that and covers the cost of the implant. Now that's, don't ever mention that I said that on this call, but that's actually true. Indiana should certainly know that. That, that is fair. Um, yeah.
WARREN HAMMERT: So I think those are all very good points of discussion and I think, you know, the problem is there's not one clear right or wrong answer for anything that we really talked about tonight, which is what makes this a great topic for debate. This lady was actually unstable at her MP joint as well as her CMC joint. And I think we all know there are some patients you take the trapezium out and it feels like it's pretty stable without doing anything.
WARREN HAMMERT: It just kind of sits where it's supposed to sit and you feel like this isn't going to collapse and there's others. You take the trapezium out and you feel like the thumb is going to impinge against the radius. It's just globally unstable in every direction and I really wanted to do the first to second metacarpal arthrodesis in this lady because I thought that was going to be the most predictable, but she didn't want a fusion.
WARREN HAMMERT: And so we did exactly what Tom mentioned. I took the ECRL and then you drill a hole in the metacarpal base from dorsal to volar, bring it through, and now it's right where your FCR would have started and so now you've got the option essentially to do the same type of a procedure as you would with the standard LRTI, with the full FCR. And so that's what I ended up doing with her. And she actually did, did well, here's the x-rays and fused the MP joint at the same time.
WARREN HAMMERT: And then she came back and she had her other side done a couple years later and I just did a standard LRTI on that side. But I think we've approached an hour now. I think there were excellent presentations by all of the Fellows and learned a lot from listening to the presentations as well as the mentors. So I will turn it back over to Jerry for some final words
WARREN HAMMERT: but I thank everybody for their presentations and for their contributions.
JEFFREY YAO: All right. Thank you, Warren. I want to thank all the faculty and Fellows for excellent presentations and discussions. Always fun to see the playful banter and little jabs at each other, but hopefully this has been a good educational experience for everybody.
JEFFREY YAO: Thank you for everybody who responded to the surveys, but we really want to try and continue this forward perhaps on every other week basis until the end of the academic year and perhaps go into monthly as everybody gets busier. But please send me any feedback or anything you could think of to make it a kind of a better forum for Fellows and faculty. But this has been awesome from everybody
JEFFREY YAO: so I really do appreciate it. If I could ask the faculty, I kind of made a screw up on the schedule for next week. So we are looking at changing topics. If anybody has suggestions or they want to participate for something they can get together pretty quickly with their Fellows, please let me know. But we will be doing a little bit of a revision to the schedule coming up.
JEFFREY YAO: I really appreciate everybody again, excellent discussions again. Awesome thanks, Jerry. Great job, everybody. Thanks, everybody. Everybody stay safe. Thanks for tuning in. Thanks, Warren. Warren, great moderation.
JEFFREY YAO: Thanks
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