桡侧腕屈肌腱悬吊结合掌骨间韧带重建治疗第一腕掌关节骨关节炎

目的 评价大多角骨切除,桡侧腕屈肌腱悬吊结合掌骨基底间韧带重建治疗第一腕掌关节骨关节炎的疗效.方法 采用Schekker技术,应用大多角骨切除,桡侧半桡侧腕屈肌腱重建第一、二掌骨基底间韧带,并与剩余肌腱自身悬吊控制掌骨基底背侧半脱位,并形成肌腱填塞物内置大多角骨切除遗留空间控制掌骨下沉等手术步骤,治疗第一腕掌关节骨关节炎6例.术后手部功能评价指标包括握力(grip strength),捏力(key-pinch),第一腕掌关节直观模拟疼痛标尺法(visual analogue scales,VAS)及第一腕掌关节有效活动度评分(Kapandji score),术后12个月随访X线前后位片第一掌骨基底-舟骨远关节面间距,评价手术疗效.结果 术后随访时间为12～ 26个月,平均15个月.手术前后疼痛(VAS)平均分值为7.0/1.6;握力平均为11/22 kg;捏力平均为1.8/3.4 kg;Kapandji score 平均为6.0/8.7;12个月时测量X线前后位片第一掌骨基底-舟骨远关节面间距平均值为8.8mm.结论 大多角骨切除,桡侧腕屈肌腱动力性悬吊结合掌骨基底间韧带重建,最大程度地接近了该部位韧带解剖及生物力学方面的结构,可有效治疗第一腕掌关节骨关节炎.     

Interposition suspension arthroplasty according to Epping versus arthrodesis for trapeziometacarpal osteoarthritis

Summary BACKGROUND: Arthrodesis and trapezial excision with ligament reconstruction combined with tendon interposition according to Epping have proven to be highly effective techniques for treating primary osteoarthritis of the thumb carpometacarpal joint. To determine which of these two techniques gives better objective and subjective outcomes, the long-term results were compared in similar patients' groups. METHODS: 40 thumbs were prospectively randomized to undergo either carpometacarpal arthrodesis or trapezial excision with ligament reconstruction combined with tendon interposition. 20 cases treated with arthrodesis (group I) and 20 cases treated with arthroplasty (group II) were evaluated 6 months after the operation and then after a mean follow-up of 6.8 years. The outcomes were assessed with the Buck-Gramcko score. RESULTS: 6 months postoperatively, the mean total Buck-Gramcko score was rated significantly better in group I than in group II. But at the last follow-up control, no significant difference was found between both groups. Only group II had significantly better mean scores for palmar abduction and radial abduction. Other mean objective and subjective scores did not differ significantly between the groups. CONCLUSIONS: The after-treatment in patients undergoing arthroplasty lasted longer than in patients after the arthrodesis. It is caused by more complex surgery during Epping's procedure. But the outcomes become similar over a longer period. At the final follow-up control after arthroplasty only older patients subjectively appreciated better functional performance. After this experience we reserve the arthrodesis for younger active and arthroplasty for older patients.      

Effect of immobilization of metacarpophalangeal joint in thumb carpometacarpal osteoarthritis on pain and function. A quasi-experimental trial

Study Design

A quasi-experimental trial.

Arthroscopic hemiresection for stage II-III trapeziometacarpal osteoarthritis

Trapeziometacarpal osteoarthritis is a common problem, due to the anatomy of the first ray and the forces applied to the trapeziometacarpal joint throughout activities of daily living. Numerous treatment options exist, and continue to be developed, for this problem. The current goal is to eliminate pain and restore function and strength in a timely manner. New advances allow for earlier return to function with minimally invasive techniques. Arthroscopic hemitrapeziectomy combined with interposition arthroplasty and/or suspensionplasty is a treatment option for Stage II and III trapeziometacarpal arthritis that uses a minimally invasive technique and allows for earlier return of function.     

Carpometacarpal and metacarpophalangeal joint collapse is associated with increased pain but not functional impairment in persons with thumb carpometacarpal osteoarthritis

IntroductionDue to the complex shape of the carpometacarpal (CMC) joint, a fixed joint collapse deformity of the thumb CMC (CMC1) and metacarpophalangeal (MCP1) joint can present in advanced stages of CMC1 osteoarthritis (OA), resulting in adduction of the first metacarpal (MC1) and hyperextension of the MCP1.Purpose of the StudyTo determine whether joint collapse deformity is associated with worse pain and/or functional impairment.Study DesignCross-sectional.MethodsThis study used the baseline data from 140 patients enrolled in a longitudinal study of treatment for CMC1 OA. (efficacy of combined conservative therapies on clinical outcomes in patients with CMC1 OA). Joint collapse was determined at baseline using a pinch gauge. Pain was assessed on a visual analog scale (0-100) and function was assessed using the Functional Index for Hand Osteoarthritis questionnaire (0-30). Pain and function and the presence of joint collapse were entered in a univariate logistic regression. The final adjusted model for pain and joint collapse included age and sex. The final adjusted model for function and joint collapse included Kellgren Lawrence grade and grip strength.ResultsAbout 20% of participants demonstrated joint collapse on the tip-pinch test. The presence of joint collapse was associated with increased pain in the unadjusted [P = .047, OR = 2.45, 95% CI (1.01, 5.910)] and adjusted model [P = .049, OR = 2.45, 95% CI (1.00, 5.98)].ConclusionCMC1 patients with joint collapse reported increased pain compared with those without joint collapse. Future studies should determine the relationship between thumb hypermobility and joint collapse and how to manage these conditions effectively.     

Results of Abductor Pollicis Longus Suspension Ligamentoplasty for Treatment of Advanced First Carpometacarpal Arthritis

Background

Suspension ligamentoplasty using abductor pollicis longus (APL) tendon without bone tunneling, was introduced as one of the techniques for treatment of advanced first carpometacarpal (CMC) arthritis. The purpose of this study was to evaluate the radiologic and clinical results of APL suspension ligamentoplasty.

Methods

The medical records of 19 patients who underwent APL suspension ligamentoplasty for advanced first CMC arthritis between January 2008 and May 2012 were reviewed retrospectively. The study included 13 female and 6 male patients, whose mean age was 62 years (range, 43 to 82 years). For clinical evaluation, we assessed the grip and pinch power, radial and volar abduction angle, thumb adduction (modified Kapandji index), including visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Radiologic evaluation was performed using simple radiographs.

Results

The mean follow-up was 36 months (range, 19 to 73.7 months). Mean power improved from 18.3 to 27 kg for grip power, from 2.8 to 3.5 kg for tip pinch, and from 4.3 to 5.4 kg for power pinch. All patients showed decreased VAS from 7.2 to 1.7. Radial abduction improved from 71° preoperatively to 82° postoperatively. The modified Kapandji index showed improvement from 6 to 7.3, and mean DASH was improved from 41 to 17.8. The height of the space decreased from 10.8 to 7.1 mm. Only one case had a complication involving temporary sensory loss of the first dorsal web space, which resolved spontaneously.

Conclusions

The APL suspension ligamentoplasty for treatment of advanced first CMC arthritis yielded satisfactory functional results.     

Convergent validity and responsiveness of the Canadian Occupational Performance Measure for the evaluation of therapeutic outcomes for patients with carpometacarpal osteoarthritis

Study DesignThis is a longitudinal, observational, multicenter, cohort study.IntroductionThumb carpometacarpal (CMC) osteoarthritis (OA) is associated with more pain and restrictions than other hand OA. The use of patient-identified occupational performance goals to guide hand therapy treatment and to measure clinical outcomes is fundamental for a patient-centered intervention. The COPM enables subjects to identify goals for hand therapy and engage in a subject-specific therapeutic process.Purpose of the StudyThe purpose of this study is to evaluate the convergent validity and responsiveness of the COPM to evaluate the relationship between the patient’s self-perception and satisfaction of performance in everyday living and pain intensity, upper limb function, and manual ability.MethodsEligible participants to multiple hand therapy centers were recruited. Outcomes measures (VAS scale, QuickDASH, MAM-36, and the COPM questionnaire) were measured at the baseline and 3 months after.ResultsOne hundred forty-five (n = 145) consecutive patients for five different hand rehabilitation centers with symptomatic thumb CMC OA were screened for eligibility criteria. COPM-P and COPM-S were the most responsive instruments, with an area under the curve of 0.88 (95% CI 0.79-0.96) and 0.88 (95% CI 0.80-0.96), respectively.ConclusionsAlthough more investigation in this area is necessary to conclude that the COPM is the best option to evaluate the effectiveness of hand therapy interventions for thumb OA. The COPM focuses on function and occupation and, in comparison with others upper limb scales, does not require the use of another complementary scale for addressing both satisfaction and ADL status. COPM is an instrument with a good convergent validity and responsiveness to evaluate the relationship between the patient’s self-perception and satisfaction in thumb CMC OA.     

骨关节炎常用治疗药物的研究现状及展望

骨关节炎是老年人群中极其常见的疾病,目前尚无完全有效的治疗方法。药物治疗作为骨关节炎的一线治疗手段在改善临床症状,延缓疾病发展方面具有重要的作用。近年来随着临床医师对治疗药物的使用增多,对药物的疗效及副作用方面的理解也越来越多。本文就骨关节炎的药物治疗方面的研究进展及展望进行综述,以期对临床治疗提供参考。     

关节腔注射帕瑞昔布治疗早期膝骨关节炎的临床疗效分析

目的 :观察并评价早期膝骨关节炎患者进行关节腔注射帕瑞昔布的临床效果。方法 :自2016年9月至2017年8月治疗早期膝骨关节炎患者107例,男50例,女57例;年龄45～64(51.9±4.2)岁;分为基础治疗+口服氨基葡萄糖组(A组)36例,口服塞来昔布+基础治疗+口服氨基葡萄糖(B组)36例,关节腔注射帕瑞昔布+基础治疗+口服氨基葡萄糖组(C组)35例。3组患者治疗前性别、年龄、BMI、临床分期(Kellgren-Lawrence分级)比较差异无统计学意义。比较3组患者治疗前后VAS评分、HSS评分和患者满意度,并对3组患者治疗前后关节液中炎性细胞因子水平进行测定。结果:所有病例获得随访,时间(15.2±2.6)个月。每组患者治疗后VAS评分、HSS评分均较治疗前改善(P0.001)。3组患者治疗后的VAS评分、HSS评分,组间比较差异有统计学意义(P0.001),C组临床疗效优于A、B两组(P0.001),B组优于A组(P0.001);C组患者满意度最高(P0.001)。每组患者治疗后关节液中促炎因子TNF-α、IL-6浓度均较治疗前下降(P0.001),抑炎因子IL-10浓度较治疗前上升(P0.001)。3组患者治疗后关节液中TNF-α、IL-6、IL-10浓度,组间比较差异有统计学意义(P0.001)。结论:对于早期膝骨关节炎患者,通过关节腔注射帕瑞昔布可以显著改善临床症状,避免长期口服NSAIDs药物的不良反应,是一种有效治疗手段。     

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition

PURPOSE: To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improved the outcome of excision of the trapezium for the treatment of painful osteoarthritis of the trapeziometacarpal joint. METHODS: 183 thumbs with trapeziometacarpal osteoarthritis were randomized for treatment by either simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void during each of the 183 surgeries to hold the base of the thumb metacarpal at the level of the index carpometacarpal joint and was retained for 4 weeks in every case. All patients wore a thumb splint for 6 weeks. Each patient had subjective and objective assessments of thumb pain, stiffness, and strength before surgery and at 3 months and 1 year after surgery. RESULTS: The 3 treatment groups were well matched for age, dominance, and presence of associated conditions. Complications were distributed evenly among the 3 groups and no cases of subluxation/dislocation of the pseudarthrosis were observed. Of the 183 thumbs 82% achieved good pain relief and 68% regained sufficient strength to allow normal activities of daily living at the 1-year follow-up evaluation. Neither of these subjective outcomes nor the range of thumb movement was influenced by the type of surgery performed. Thumb key-pinch strength improved significantly from 3.5 kg before surgery to 4.6 kg at 1 year but the improvement in strength was not influenced by the type of surgery performed. CONCLUSIONS: The outcomes of these 3 variations of trapeziectomy were very similar at 1-year follow-up evaluation. In the short term at least there appears to be no benefit to tendon interposition or ligament reconstruction.     

Ultrasound-guided steroid injection for osteoarthritis of the trapeziometacarpal joint of the thumb

This contribution introduces an unreported technique of ultrasound-guided steroid injection, for osteoarthritis of the trapeziometacarpal joint.     

Dynamic suspension-sling arthroplasty with intermetacarpal ligament reconstruction for the treatment of trapeziometacarpal osteoarthritis

Our new dynamic suspension-sling arthroplasty of the trapeziometacarpal joint stabilizes the base of the first metacarpal after the removal of the trapezium in patients who have trapeziometacarpal joint osteoarthritis. Other techniques involving ligament reconstruction are accompanied by complications such as proximal migration, dorsal subluxation of the first metacarpal base, and impingement of the first and second carpometacarpal joints. In our technique, the first metacarpal is suspended by using a series of tendon loops derived from one-half of the flexor carpi radialis tendon and, therefore, anatomically reconstructs the intermetacarpal and palmar oblique ligaments. From 1988 to 2000, 197 patients (238 thumbs) underwent this procedure. Follow-up was an average of 1.92 years. After surgery, pain decreased, grip strength increased from 24 to 48.7 lb, key pinch increased from 4 to 7.6 lb, and Kapandji scores increased from 6 to 9.3 (averages). Our technique provides an interposition between the bases of the thumb and index metacarpals, resulting in decreased pain, greater strength, and increased flexibility of the trapeziometacarpal joint.