Facts Around the Saddle Joint (CMC1 Joint) Instructional Course SGH 17.09.2020

Facts around the saddle joint (CMC1 joint) Instructional Course SGH 17.09.2020

Esther Vögelin, MD, Prof

Hand Surgery and Surgery of Peripheral Nerves Anatomy • Thumb • STT and midcarpal joints • CMC joint • MCP joint • IP joint Anatomy

• How many trapezial articulations?

• Two more important joints: 2 - Scaphotrapezoidal joint (5) 3 - MCP joint 1 5 4

• Skeletal Radiol 2015;44:165-77 Anatomy

• Two opposing saddles à wide range of motion

• Skeletal Radiol 2015;44:165-77 Anatomy

• Stability à 3 main ligament complexes

• Palmar (anterior)[2]: • AOL („beak“), ulnar collateral • Dorsal (posterior)[3]: • POL, DRL • Intermetacarpal [2]

• Skeletal Radiol 2015;44:165-77 Radiology • Robert‘s view (pa), oblique, lateral Staging Stages Radiological disease change 1 Slight widening of joint space, < 1/3 subluxation of joint 2 <2mm osteophytes present, 1/3 subluxation of joint

3 >2mm osteophytes present, > 1/3 subluxation of joint, joint space narrowing

4 Erosion of scaphotrapezial joint, significant joint space narrowing, major subluxation of joint Early stage treatment • Stabilization of CMC joint • Synovectomy • CMC joint alignement

• CMC joint arthroscopy à debridement, synovectomy, electrothermal shrinkage of ligaments - Normal radiographs, - Restricted painful mobility

• J AM Acad Orthop Surg 2008;16(3):140-51 Early stage treatment • Ligament reconstruction for stabilization of the CMC joint - Littler Eaton procedure: ½ FCR à AOL, intermetacarpal, dorsoradial ligaments J Bone Joint Surg Am 1973;55(8):1655-66 J Hand Surg Am 2000;25(2):297-304 - Brunelli procedure: APL Tendon à 1st and 2nd MC J Hand Surg Br Vol 1989;14B:209-212 - Pechlaner technique: ECRL strip through 1st MC and trapezium Pechlaner S. et al. Operationsatlas Handch. 1997 - Dorsal re-enforcement of the capsule and ligament complex FESSH Congress 2017; oral presentation, Langer MF Oper Orthop Traumatol 2015 Early stage treatment • Addition-substraction osteotomy with ligamentoplasty

• Chir Main 2007;26:26-30 • J Hand Surg Eur Vol 2009;34E(2):264-7 • J Hand Surg Eur Vol 2011;37E(2):138-44 Late stage treatment • Partial resection arthroplasty (stage I-II) • With tendon interposition • With Pyrocarbon • With Artelon (biocompatible polyurethaneurea--> high rate of explantation)

• Chir Main 2009;28:230-38 • J Hand Surg 2012;37:1125-9 • J Plast Surg Hand Surg 2016;50:35-9 • Int Orthop 2016:40(7):1465-71 Late stage treatment • Resection arthroplasty • Hematoma distraction arthroplasty

• J Hand Surg E 2019;44(2):146-50 • J Hand Surg E 2019;44(2):129-37 Late stage treatment • Resection arthroplasty • with tendon interposition • with LRTI and suspension FCR, ECRL, APL • Tight rope suspension

• J Hand Surg E 2019;44(2):146-50 • J Hand Surg Am 2013;38(9):1806-11 Late stage treatment • Resection arthroplasty • with LRTI and suspension FCR and APL

• J Hand Surg E 2019;44(2):146-50 • J Hand Surg Am 2013;38(9):1806-11 Late stage treatment • Evaluate ST and MCP joint

• Skeletal Radiol 2015;44:165-77 • J Hand Surg Am 2013;38(9):1806-11 What happens after RSI with time? 20 years after RSI Late stage treatment • Resection arthroplasty with suspension • Tight rope suspension

• Skeletal Radiol 2015;44:165-77 • J Hand Surg Am 2013;38(9):1806-11 Late stage treatment • Resection arthroplasty with implant • Pyrocardan

• HANSUR 2017 http://dx.doi.org/10.1016/j.hansur.2017.01.003 Late stage treatment • Resection arthroplasty with implant • Ivory arthroplasty, Rubis II, Roseland, ARPE, Touch® • Survival rates in 10-16 years 71-92%

• J Hand Surg E 2019;44(2):138-45 Late stage treatment • Arthrodesis (systemic joint laxity, high demand occupation) à no difference in outcome but high non union rate (39%)

• Chir Main 2005;24(5):222-4 Isolated STT Arthritis • Without CMC arthritisà STT arthrodesis if there is midcarpal instability • Check dorsal displacement of capitato-lunate joint

• J Hand Surg 2011;36A:516-20 STT arthritis • Arthroplasty à tendon or pyrocarbon spacer

• J Hand Surg 2011;36A:516-20 • Hand Surg Rehabil 2017;36(2):113-21 STT Arthritis with CMC arthritis • With CMC arthritisà resection arthroplasty or double burger

• J Hand Surg 2019;44(9):887-97 Summary • Complex joint, don‘t forget neighbour joints • Early stages of CMC arthritis (I-II): - Arthroscopy, synovectomy, thermal shrinking - Ligament reconstruction - Extension-osteotomy of MC and augmentation-osteotomy of trapezium - Partial resection of CMC I (Tendon, pyrocarbon interposition) • Late stages CMC arthritis (II-IV): - Trapezectomy alone, with ligament suspension- /interposition-arthroplasty, MCP capsulodesis > 30° hyperextension - Partial resection of CMC I and STT joint (if good bone stock) • Isolated STT arthritis: - Check the midcarpal joint • J Hand Surg 2017;42(2):104-112