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 Copyright M.E.H. Boeckstyns, M.Crespi • 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.