Trapeziometacarpal subluxation predisposes to incident trapeziometacarpal osteoarthritis (OA): the Framingham Study

OBJECTIVE: Osteoarthritis (OA) of the thumb carpo-metacarpal joint is a common condition that can lead to substantial pain, instability, deformity, and loss of motion. It has been hypothesized that instability of the trapeziometacarpal joint combined with strenuous use can potentially lead to OA. However, as yet there have been no longitudinal evaluations to determine if this hypothesis is true. We examined the relation of radial subluxation to the risk of radiographic OA at trapeziometacarpal joint. METHODS: We conducted a nested case-control study. We restricted our evaluation of cases to subjects with no radiographic trapeziometacarpal OA at baseline (1967). We defined incident trapeziometacarpal OA as the development of a modified Kellgren and Lawrence grade>or=2 in that joint at a later examination (1992-1993). Radial subluxation of the base of the first metacarpal off the trapezium and the amount of the base of the first metacarpal covering the articulating surface of the trapezium were measured using a digital calculation caliper. We examined the relation of gender-specific quartile groups of radial subluxation to the risk of trapeziometacarpal OA using a conditional logistic regression model. RESULTS: We assessed 203 men and 431 women. After adjusting for age, handedness, number of other joints with OA, and grip strength, the odds ratios for the risk of trapeziometacarpal OA in men were 1.0, 1.8, 2.7, and 3.1 from the lowest quartile of radial subluxation to the highest quartile, respectively (P for trend=0.015). There was no significant relationship between radial subluxation quartiles and incident trapeziometacarpal OA in women. CONCLUSION: This study provides evidence that radial subluxation predisposes to subsequent OA of the trapeziometacarpal joint in men.     

Long-term follow-up of trapeziometacarpal arthroplasty with coexisting scaphotrapezial disease.

Visualization of the scaphotrapezial joint during basal joint arthroplasty has been recommended to establish the stage of degeneration. This study attempts to clarify that recommendation and evaluate whether moderate wear of the joint precludes a good result of trapeziometacarpal hemiarthroplasty. To assess the need for inspection of the scaphotrapezial joint, x-ray films, tomograms, and operative findings in 23 cases of basal joint arthroplasty were reviewed. X-ray findings agreed with operative findings at the scaphotrapezial joint in only 76% of the cases. We also evaluated 18 thumbs in 15 patients who underwent interposition arthroplasty of the trapeziometacarpal joint and at surgery had moderate degenerative changes of the scaphotrapezial joint. The scaphotrapezial joints were left intact and the trapeziometacarpal joints were reconstructed. Follow-up averaged 8 years. In no case was there x-ray or symptomatic progression of the disease at the scaphotrapezial joint. Clinically, 78% were rated excellent, 17% good, and 5% fair.     

Templates of the cartilage layers of the patellofemoral joint and their use in the assessment of osteoarthritic cartilage damage

OBJECTIVE: To develop a methodology for generating templates that represent the normal human patellofemoral joint (PFJ) topography and cartilage thickness, based on a statistical average of healthy joints. Also, to determine the cartilage thickness in the PFJs of patients with osteoarthritis (OA) and develop a methodology for comparing an individual patient's thickness maps to the normal templates in order to identify regions that are most likely to represent loss of cartilage thickness. DESIGN: The patella and femur surfaces of 14 non-arthritic human knee joints were quantified using either stereophotogrammetry or magnetic resonance imaging. The surfaces were aligned, scaled, and averaged to create articular topography templates. Cartilage thicknesses were measured across the surfaces and averaged to create maps of normal cartilage thickness distribution. In vivo thickness maps of articular layers from 33 joints with OA were also generated, and difference maps were created depicting discrepancies between the patients' cartilage thickness maps and the normative template. RESULTS: In the normative template, the surface-wide mean+/-SD (maximum) of the cartilage thickness was 2.2+/-0.4mm (3.7mm) and 3.3+/-0.6mm (4.6mm) for the femur and patella, respectively. It was demonstrated that difference maps could be used to identify regions of thinner-than-normal cartilage in patients with OA. Patients were shown to have statistically greater regions of thin cartilage over their articular layers than the normal joints. On average, patients showed deficits in cartilage thickness in the lateral facet of the patella, in the anterior medial and lateral condyles, and in the lateral trochlea of the femur. CONCLUSIONS: This technique can be useful for in vivo clinical evaluation of cartilage thinning in the osteoarthritic patellofemoral joint.     

Sequential wear patterns of the articular cartilage of the thumb carpometacarpal joint in osteoarthritis

PURPOSE: The thumb carpometacarpal (CMC) joint is a primary location for osteoarthritis (OA) in the body; however, articular cartilage thickness distribution during progression of OA in the joint has not been reported previously. Determining the cartilage wear patterns within the joint is important in understanding the etiology and treatment of thumb CMC joint OA. This study used cadaveric specimens to investigate the wear patters of the articular surfaces of the trapezium and thumb metacarpal. METHODS: A total of 104 fresh-frozen thumb CMC joints were radiographed, disarticulated, and visually staged for OA. Cartilage thickness maps of the trapezium and metacarpal were determined for each joint by using stereophotogrammetry. Average cartilage thickness maps for the trapezium and metacarpal were generated from all specimens for each of 4 stages of OA, showing the progression of cartilage thickness changes with disease. RESULTS: In normal joints, the surface-wide mean thickness of the articular layers is 0.8 +/- 0.2 mm for the trapezium and 0.7 +/- 0.2 mm for the metacarpal. The average thickness maps were analyzed by anatomic quadrant (dorsal-radial, dorsal-ulnar, volar-radial, volar-ulnar) within the 4 stages of OA. Corresponding quadrants also were compared across the increasing stages of OA. Results show that cartilage degradation is initiated in the radial quadrants of the metacarpal and progresses to the volar quadrants of the articular surface, while significant wear is seen on the dorsal-radial quadrant of the trapezium and progresses to the volar quadrants in late-stage osteoarthritis. CONCLUSIONS: These quantitative results on cartilage thinning agree with previous investigators' reports of high load bearing and low load bearing areas in the CMC joint during functional pinch and grasp positions. Understanding the progression of OA in the thumb CMC joint may aid in the surgical treatment of this disease.     

Basal joint arthroplasty using the Roosevelt Hospital techniques

Many reconstructive procedures have been developed to treat osteoarthritis of the basal joint of the thumb. The current article describes techniques used at the Hand Surgery Center at Roosevelt Hospital in New York City. A tonometry applanation radiographic staging system is outlined; it serves as a rationale for selecting which form of arthroplasty is appropriate for a particular patient and is predicated on the extent of involvement of the trapezial articulations. Stage 1 disease implies symptomatic laxity of the trapeziometacarpal joint with normal articular surfaces and is most appropriately treated with volar ligament reconstruction. Stage 2 is an intermediate category and amenable to either volar ligament reconstruction or interpositional arthroplasty of the trapeziometacarpal joint, based on the condition of the articular cartilage at surgery. In stage 3 disease there are significant degenerative changes of the trapeziometacarpal joint with preservation of the articular surfaces of the scaphotrapezial joint. Two variations on ligament reconstruction with interpositional arthroplasty of the trapeziometacarpal joint are described; they have consistently good results. Finally, stage 4 is characterized by pantrapezial degenerative disease and necessitates trapezial resection. Reconstruction may be by silicone rubber implant arthroplasty using a stemmed trapezial implant stabilized by an abductor pollicis longus tenodesis. The alternative is a procedure in which the thumb metacarpal is tethered to the index metacarpal by a ligament reconstruction.     

Scaphotrapezial dislocation: a case report

Traumatic dislocation of either trapezium or trapezoid is rare. We found less than 20 cases of each reported in the literature. We describe a case of traumatic dislocation of the scaphotrapezial joint associated with subluxation of the scaphotrapezoidal joint, which to our knowledge has not been reported.     

In vivo kinematics of the thumb during flexion and adduction motion: Evidence for a screw‐home mechanism

The thumb plays a crucial role in basic hand function. However, the kinematics of its entire articular chain have not yet been quantified. Such investigation is essential to improve our understanding of thumb function and to develop better strategies to treat thumb joint pathologies. The primary objective of this study is to quantify the in vivo kinematics of the trapeziometacarpal (TMC) and scaphotrapezial (ST) joints during flexion and adduction of the thumb. In addition, we want to evaluate the potential coupling between the TMC and ST joints during these tasks. The hand of 16 asymptomatic women without signs of thumb osteoarthritis were CT scanned in positions of maximal thumb extension, flexion, abduction, and adduction. The CT images were segmented and three‐dimensional surface models of the radius, scaphoid, trapezium, and the first metacarpal were created for each thumb motion. The corresponding rotations angles, translations, and helical axes were calculated for each sequence. The analysis shows that flexion and adduction of the thumb result in a three‐dimensional rotation and translation of the entire articular chain, including the trapezium and scaphoid. A wider range of motion is observed for the first metacarpal, which displays a clear axial rotation. The coupling of axial rotation of the first metacarpal with flexion and abduction during thumb flexion supports the existence of a screw‐home mechanism in the TMC joint. In addition, our results point to a potential motion coupling between the TMC and ST joints and underline the complexity of thumb kinematics. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1556–1564, 2017.

     

Scaphotrapezial joint arthroscopy: a palmar portal

PURPOSE: Arthroscopy of the scaphotrapezial trapezoid (STT) joint is performed traditionally through a dorsal radial midcarpal portal. This portal allows visualization of the dorsal rim of the STT joint but is difficult to approach owing to lack of surface landmarks and it passes close to the radial artery and nerve. The purpose of this study was to assess the safety, ease of access, and visualization of the STT joint through a palmar portal. METHODS: Five cadaveric wrists were dissected initially to identify the anatomy around the palmar aspect of the STT joint and to identify a safe route for an arthroscopic portal. A further 5 cadaveric wrists then were used to confirm the efficacy of the portal. RESULTS: A palmar portal to the STT joint can be established 3 mm ulnar to the abductor pollicis longus tendon, 6 mm radial to the scaphoid tubercle, and midway between the radial styloid and base of the first metacarpal. CONCLUSIONS: A palmar arthroscopic portal to the STT joint can be identified readily because of the palpable surface landmarks, improves the visualization of its articular surface compared with a dorsal portal because of the orientation of the joint, is safe, and provides a second portal through which therapeutic interventions may be considered.     

Preliminary study on diffraction enhanced radiographic imaging for a canine model of cartilage damage

OBJECTIVE: To demonstrate the ability of a novel radiographic technique, Diffraction Enhanced Radiographic Imaging (DEI), to render high contrast images of canine knee joints for identification of cartilage lesions in situ. METHODS: DEI was carried out at the X-15A beamline at Brookhaven National Laboratory on intact canine knee joints with varying levels of cartilage damage. Two independent observers graded the DE images for lesions and these grades were correlated to the gross morphological grade. RESULTS: The correlation of gross visual grades with DEI grades for the 18 canine knee joints as determined by observer 1 (r2 = 0.8856, P = 0.001) and observer 2 (r2 = 0.8818, P = 0.001) was high. The overall weighted kappa value for inter-observer agreement was 0.93, thus considered high agreement. CONCLUSION: The present study is the first study for the efficacy of DEI for cartilage lesions in an animal joint, from very early signs through erosion down to subchondral bone, representing the spectrum of cartilage changes occurring in human osteoarthritis (OA). Here we show that DEI allows the visualization of cartilage lesions in intact canine knee joints with good accuracy. Hence, DEI may be applicable for following joint degeneration in animal models of OA.     

Histopathology of the palmar beak ligament in trapeziometacarpal osteoarthritis.

Eighteen cadaver hands were studied to investigate the relationship between degeneration of the palmar beak ligament and articular disease of the trapeziometacarpal joint. Eight of 18 joints had chondromalacia alone; 10 contained areas of eburnation in the palmar aspect of the joint. Beak ligament degeneration correlated closely with the presence of articular degeneration; all joints with eburnation demonstrated frank detachment of the ligament from its metacarpal insertion site. Histologically, the collagen fibers of the beak ligament were disorganized at the metacarpal attachment. The normal insertional zone of fibrocartilage was often unrecognizable on the metacarpal side and, in more degenerative specimens, an intervening synovial recess appeared at the palmar beak of the metacarpal. The trapezial insertion of the beak ligament showed no degenerative change. Increasingly severe cartilage disease was associated with progressive and selective degeneration of the collagen framework of the beak ligament at its insertion onto the thumb metacarpal. These localized histopathologic findings further support the existence of an anatomically distinct intra-articular beak ligament essential to the normal function of the trapeziometacarpal joint and suggest an etiologic relationship to osteoarthritic disease.     

The relationship between articular cartilage degeneration and bone changes of the first metatarsophalangeal joint.

Plain-film radiography is commonly used in the assessment of joints affected by osteoarthritis. It has been shown that the condition of articular cartilage in the knee, when grossly assessed, does not always correlate well to the radiographic evaluation of the joint. The aim of this study was to determine whether a relationship existed between the radiographic appearance of the subchondral bone and the morphological condition of the articular cartilage surfaces of the first metatarsophalangeal joint. Forty-nine pairs of cadaveric metatarsals and their respective proximal phalanges were studied in order to determine the correlation between articular cartilage degeneration and radiographic grade using a modified Kellgren-Lawrence scale. The relationship between cartilage degeneration and age, gender, osteophytes, metatarsal length, and measured angles (proximal articular set angle, distal articular set angle, intermetatarsal angle) was also investigated. It was found that there was a significant correlation between radiographic grade and cartilage degeneration on both the metatarsal head and the base of the proximal phalange (r2 = .2038 and .1733, respectively). However, while useful in the clinical setting, bony changes of the first metatarsophalangeal joint, as seen radiographically, fail to provide a full representation of the level of cartilage degeneration on the articular surfaces of this joint.     

Definition and classification of basal joint osteoarthritis. A critical analysis and proposals. Treatment options

Several definitions and classifications of basal joint osteoarthritis exist. Each of them can be criticized. The authors propose to define basal thumb osteoarthritis as osteoarthritis of the trapezometacarpal joint associated or not with lesions of scapho-trapezio-trapezoid and/or metacarpophalangeal joints. The proposed classification is derived from the Eaton-Littler classification. Stage O is identical to stage I of the Eaton-Littler classification: trapeziometacarpal instability without cartilage lesions. Stage I is osteoarthritis of the trapeziometacarpal joint only, without metacarpophalangeal deformity. Stage II is trapeziometacarpal osteoarthrites combined with reductible hyperextension deformity of the metacarpophalangeal joint. Stage III is trapeziometacarpal osteoarthrites combined with irreductible metacarpophalangeal deformity. Stage IV is identical to stage IV of the Eaton-Littler classification: combined trapeziometacarpal and scapho-trapezio-trapezoid osteoarthritis. The advantage of the proposed classification is that basal joint osteoarthritis is not only defined as real or potential (stage O) osteoarthritis of the trapeziometacarpal joint, but also includes precise evaluation of two other joints at the base of the thumb. This classification can be a guide for treatment options.     

The nerve supply of the trapeziometacarpal joint

Ten forearm and hand specimens from fresh cadavers were dissected and examined under magnification for articular branches to the trapeziometacarpal joint arising from the thenar and palmar cutaneous branches of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm. In all but one specimen the thenar branch of the median nerve sent an articular branch to the trapeziometacarpal joint. Multiple branches from the palmar cutaneous branch of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm were also found. All these branches need to be divided during a "complete" denervation of the trapeziometacarpal joint.     

Osteoarthritis of the trapeziometacarpal joint: the pathophysiology of articular cartilage degeneration. II. Articular wear patterns in the osteoarthritic joint.

An anatomic and radiographic study of the osteoarthritic trapeziometacarpal joint was conducted on 27 surgical specimens harvested during basal joint arthroplasty. Surface wear patterns were analyzed by hyaline cartilage staining, and relative involvement of trapezium and metacarpal was calculated as the trapezium/metacarpal eburnation ratio. Eburnation occurred only on facing trapeziometacarpal surfaces in contact areas of the palmar compartment. Metacarpal degeneration began at the palmar joint margin adjacent to the beak ligament and extended dorsally, while trapezial degeneration originated on the central palmar slope and spread centrifugally with more advanced disease. Eburnation consistently involved a greater surface area on the trapezium than on the metacarpal in a ratio of nearly 3:1. A decreasing trapezium/metacarpal eburnation ratio correlated closely with worsening radiographic stage. These observations suggest translation of metacarpal on trapezium in the production of arthritic surface lesions and support a hypothesis of pathologic joint instability as the cause of trapeziometacarpal osteoarthritis.     

Prevalence and involvement patterns of radiographic hand osteoarthritis in Japanese women: the Hizen–Oshima Study

The prevalence and pattern of joint involvement in radiographic hand osteoarthritis (OA) have been reported in Western populations, but similar data are lacking for Japanese. We examined this issue in 551 Japanese women aged ≥40 years. Radiographs were obtained of both hands and graded according to the Kellgren–Lawrence (K-L) criteria. OA was defined as K-L grade 2 or higher. The prevalence of radiographic OA in the IP, MCP, and CMC joints was distributed similarly in both hands. The most frequent locations of radiographic OA were the distal IP joints of the index finger, the IP joint of the thumb, and the distal IP joints of the middle finger, in this order. The prevalence of radiographic OA in each joint group increased significantly with age, and that in Japanese women was lower in the thumb CMC joint and higher in the thumb IP joint compared to those in Caucasian women reported previously. The strongest predictor for the presence of radiographic OA in a particular joint was the disease status in the same joint of the opposite hand (OR = 18.5; 95% CI; 15.2–22.7), followed by the joints in the same row of the same hand (OR = 15.5; 95% CI, 11.9–20.1), and then by the joints in the same ray of the same hand (OR = 1.3; 95% CI, 1.0–1.6). Although the prevalence of hand OA is likely to show site-specific differences between Japanese and Caucasian women, our results indicate that both groups show similar involvement pattern symmetrically and in the same row of the same hand.     

Results of a five-year series of 44 trapeziectomies associated with ligamentoplasty and interposition arthroplasty

BACKGROUND: Surgical management of trapeziometacarpal joint osteoarthritis remains controversial. There have been few long term studies of trapeziectomy combined with ligamentoplasty and interposition arthroplasty (TLIA). Our results are based on a five year minimum follow-up study. METHODS: We carried out a study of 44 TLIA in 39 consecutive patients. A physical and radiological assessment was undertaken after on average of 6.9 years by a independent observer. RESULTS: A durable physical improvement was obtained in 18 cases in less than six months and in five cases after more than one year. Thereafter there was no secondary deterioration. A standard pain measurement gave an average result of 1.4 on a ten point scale. Pain was independent of displacement of the first metacarpal bone but had a tendency to be greater where associated with scaphotrapezoidal joint osteoarthritis. Strength was improved in 36 cases. The patients were satisfied and considered their grip to be normal in 41 cases. These variables did not change over time. DISCUSSION: TLIA give an excellent result in more than 90% of cases. This remains unchanged seven years after surgery. As opposed to prostheses, there is no secondary deterioration once healing is achieved. Algodystrophy is the main drawback. CONCLUSION: In our opinion, TLIA remains the best available surgical treatment of trapeziometacarpal joint osteoarthristis.     

Joint-specific prevalence of osteoarthritis of the hand

PURPOSE: To quantify the prevalence of radiographic hand osteoarthritis (OA) among a group of community-dwelling individuals. Joint-specific prevalence rates/100 of radiographic OA of the hand were quantified and reported by age, gender, and dominant hand. METHODS: Data from a community-based, longitudinal study designed to follow the natural history of OA were used. Participants were ambulatory men and women, ages 40 years and older, with and without radiographic hand OA (N = 3327). Bilateral hand OA was examined at three joints: second distal interphalangeal joints (DIP), third proximal interphalangeal joints (PIP), and first carpometacarpal joint of the thumb (CMC). The ordinal scale of Kellgren and Lawrence (0-4) was used to determine OA status (grades 2+). RESULTS: Radiographic hand OA status was determined for all persons in the study group comprised of 2302 women (69%) and 1025 men (31%). The sample sizes for the age groups (years) were 532 (40-49), 905 (50-59), 998 (60-69), 749 (70-79), and 143 (80+). Overall, the DIP joint demonstrated the highest OA prevalence, while the PIP joint showed the lowest prevalence. Joint-specific hand OA prevalence rates for second DIP, third PIP, and first CMC were 35%, 18%, and 21%, respectively. Expectedly, hand OA prevalence for all joints increased with age. With exceptions, women demonstrated higher hand OA prevalence rates for the three sites examined. However, among men aged 40-49, the second DIP joint OA rate was higher (13%) compared with women (8%). Additionally, men in that age group demonstrated an elevated first CMC joint OA rate (9%) compared with women (5%). Gender-specific hand dominance analyses demonstrated that the majority of individuals with unilateral second DIP or third PIP OA presented in their dominant hand. However, among those with unilateral first CMC OA, both genders displayed a tendency to present in their nondominant hand. CONCLUSION: These findings suggest the need for further investigation of the role gender can play in the development of hand OA in populations under 60 years of age. Additional epidemiological studies addressing hand OA will serve to bridge the gap between the current levels of knowledge about the knee and the hand. The disease burden of hand OA affects a large percentage of the population. Research efforts that more exhaustively characterize the prevalence of hand OA may contribute toward interventions that, ultimately, impact a rapidly growing segment of our population.     

The association of radiographic foot osteoarthritis and radiographic osteoarthritis at other sites

OBJECTIVE: To quantify the association between radiographic foot osteoarthritis (OA) and radiographic OA at four joints: second distal interphalangeal (DIP), third proximal interphalangeal (PIP), first carpometacarpal (CMC), and the knee. METHODS: Data collected for the Clearwater Osteoarthritis Study (COS) were analyzed (N=3436). The study outcome was first metatarso-phalangeal joint (first MTP) OA status. The predictor variables were second DIP, third PIP, first CMC, and knee OA. The Kellgren and Lawrence scale determined OA status. The strength of the association between foot OA and other sites was further explored by unilateral and bilateral categories. RESULTS: For both genders, we found a significant, positive relationship between grade 2+ foot OA and second DIP, third PIP, first CMC, and knee OA. This relationship maintained its significance after adjustment for age, body mass index, and occupational history. Adjusted odds ratios ranged from 3.2 for the second DIP joint (P<0.0001) to 3.7 for the knee joint (P<0.0001). Relative to unilateral joint disease, co-existing bilateral disease yielded a significantly elevated risk for foot OA for all joints examined. While other studies have not specifically examined co-occurrence with foot OA, our findings are consistent with results from related studies. CONCLUSIONS: There is a dearth of studies exploring foot OA. Our findings support the theory of a systemic etiology involved in the development of OA. Future epidemiological studies that further distinguish the relationship between OA at differing sites will provide an enhanced ability to describe the respective influences of mechanical and systemic factors in the development of this disease.     

Characterization of lesions of the talus and description of tram-track lesions

BACKGROUND: The ankle joint, although not prone to primary osteoarthritis (OA), is known to be susceptible to secondary OA as a result of sports injuries and other trauma. Unlike the knee joint, a thorough investigation of talar cartilage lesions has not been previously reported. METHODS: One hundred and five human tali from 67 donors were used to determine the type and location of the most common lesions through gross examination, radiography, diffraction enhanced imaging, and histology. "tram-track lesions" also are described. RESULTS: The most anterior and posterior regions of the talar dome, along with the medial and lateral borders of the dome were most affected by cartilage degeneration. These are regions that appear to be most subjected to frictional forces from their articulating counterparts during high stress activities that move articulating surfaces slightly out of congruence with each other. One particularly striking cartilage degeneration pattern that, to our knowledge, has not been described histologically, is the tram-track lesion. These lesions displayed a longitudinally oriented groove in the cartilage, running from anterior to posterior, in which the deepest portion of the groove was located in the middle of the anterior-posterior axis of the talus. Several of these cartilage grooves had a bony ridge beneath, mirroring the cartilage groove whereas others did not. This suggests that the cartilage groove develops before the interruption of the tidemark (border between the calcified and uncalcified cartilage). In specimens for which the articulating tibial articular surface was available, (17) it was found that the tibia displayed small osteophytes on the anterior articular margin that exactly corresponded to their articulation with the talar cartilage grooves as the ankle articulated through plantar flexion and dorsiflexion. CONCLUSION: This study provides an in-depth histologic and gross anatomic look at the most common lesions of the talus of the ankle joint. In particular, the "tram-track" lesion was shown to be a consequence of its tibial articulation and to include both subchondral bone and articular cartilage changes.