Rev. bras. ortop. vol.51 número4

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

article

Measurement

of

quality

of

life

among

patient

undergoing

arthroplasty

of

the

thumb

to

treat

CMC

arthritis

夽

Marcio

Aurélio

Aita

∗

_,

_Rafael

_Saleme

_Alves,

_Luis

_Felipe

_Longuino,

Carlos

Henrique

Vieira

Ferreira,

Douglas

Hideki

Ikeuti,

Luciano

Muller

Reis

Rodrigues

FaculdadedeMedicinadoABC,DepartamentoClínico-CirúrgicoIV,DisciplinadeOrtopediaeTraumatologia,SantoAndré,SP,Brazil

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Articlehistory:

Received3August2015 Accepted5October2015 Availableonline6June2016

Keywords: Qualityoflife Trapeziumbone Arthroplasty Thumb

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Objective:Topresenttheclinicalandfunctionalresults,includingmeasurementofquality oflife,ofpatientsundergoingtrapeziometacarpalarthroplasty.

Method:Thiswasaprospectiveevaluationon45patients(53thumbs)withadiagnosisof idiopathicrhizarthrosiswhounderwentresectionarthroplastyandinterpositionofan unce-mentedAscension®_implant,_made_of_pyrocarbon._The_clinical_and_functional_results_were

analyzedthroughradiography,rangeofmotion(ROM)indegrees(◦_),_visual_analog_scale_(VAS)

forpainandthedisabilityofarm,shoulderandhand(DASH)questionnaireforqualityof life.Inthegroupanalyzed,38werewomenandsevenweremen,andtheirmeanagewas 63.17years(range:50–78).Eightpatientsweretreatedbilaterally.

Results:After42.08monthsoffollow-up(range:8–73),thesubjectivepainevaluation(VAS) scorewas1.37(range:1–4).ThecompleteROMofthethumbincreasedto95.75%(range: 75–100%)inrelationtothecontralateralside.ThemeanDASHquestionnairescorewas9.98 (range:1–18).Thecomplicationrate(negativeevents)was11.32%.Fivepatientspresented dislocationofthethumbprosthesis.Allofthemwerereoperatedbymeansofdorsal cap-suloplastyusingaportionoftheretinaculumoftheextensorsasagraft,andgoodclinical evolutionwasachievedinthesecases.Onepatientpresentedfracturingofthemetacarpal andwastreatedbymeansofosteosynthesisusingKirschnerwires.

Conclusion: Thismethodiseffectivefortreatingrhizarthrosis,accordingtothe measure-mentsmadeontheclinicalandfunctionalresults,evenaftertakingthecomplicationrate intoconsideration.Moreover,itprovidesanimprovementofqualityoflifeforthesepatients. ©2016PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedatHospitalMarioCovas,SantoAndré,SP,CentroHospitalarMunicipaldeSantoAndré,SP;andHospitaldeEnsino PadreAnchietadeSãoBernardodoCampo,SãoBernardodoCampo,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](M.A.Aita).

http://dx.doi.org/10.1016/j.rboe.2016.06.003

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Mensurac¸ão

da

qualidade

de

vida

dos

pacientes

submetidos

a

artroplastia

do

polegar

no

tratamento

da

rizartrose

Palavras-chave: Qualidadedevida Trapézio

Artroplastia Polegar

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e

s

u

m

o

Objetivo: Apresentarosresultadosclínico-funcionaiseamensurac¸ãodaqualidadedevida dospacientessubmetidosàartroplastiatrapézio-metacárpica.

Método: Avaliaçãoprospectivade45pacientese53polegaresacometidos,com diagnós-tico derizartroseidiopáticasubmetidosàartroplastiaderessecçãoeinterposição,com oimplanteAscension®_,_não_cimentado,_de_pirocarbono._Foram_analisados_os_resultados

clínico-funcionais:análiseradiográfica,oarcodemovimento(ADM)emgraus(◦_),_dor_(VAS:

visualanalogscore),qualidadedevida(Dash:disabilityshoulder,arm,andhandquestionnaire). Nogrupoanalisado,38sãomulheresesetesãohomenseaidademédiaéde63,17anos (50-78).Foramoperadosoitopacientescomacometimentobilateraldospolegares. Resultados: Após42,08meses(8-73)deseguimento,aavaliaçãosubjetivadador(VAS)foide 1,37(1-4).Oarcodomovimentocompletodopolegarteveumaumentode95,75%(75-100)do ladocontralateral.OquestionárioDashfoiemmédiade9,98(1-18).Ataxadecomplicações oueventosnegativosfoide11,32%.Observamoscincopacientescomluxaçõesdaspróteses depolegares.Todosforamreoperadosefez-seacapsuloplastiadorsal,comousocomo enxertodeumaporçãodaretináculadosextensores,obteve-seumaboaevoluçãoclínica nessescasos.Umpacienteapresentoufraturadometacarpoefoitratadocomosteossíntese comfiodeKirschner.

Conclusão:Ométodoéeficaznotratamentodarizartrosedeacordocomosvaloresapurados dosresultadosclínico-funcionais,mesmoconsiderando-seastaxasdecomplicac¸ões.Além disso,proporcionaamelhoriadaqualidadedevidadessespacientes.

Introduction

Rhizarthrosisisthemostcommondegenerativediseaseand theonethatmostrestrictsthethumbofmiddle-agedwomen, especiallyinthefifthandsixthdecadesoflife.Itcanalsobe observedinmenwithhistoryofrepetitivejointuseand in youngwomenwithligamentouslaxity.1

There are many recommended surgical techniques for the treatment of this disease: trapeziectomy; trapezio-metacarpal arthrodesis; ligament reconstruction; partialor totalarthroplasty;andarthroscopic resection,replacement, orinterposition.

Arthroscopic resectionand interpositionare well estab-lishedfor the treatmentof rhizarthrosisand present good results in 85% of patients. Currently, numerous partial or complete prostheses are being developed and improved to maintainaxial length ofthe first ray ofthe hand,shorten postoperativerecoverytime,2 _and_allow_for_a_total_recovery ofpinchstrength.However,resultsarenotwelldocumented.3 Thisstudyaimedtopresentclinicalandfunctionalresults and measurementin quality oflifeofpatients undergoing trapezio-metacarpalarthroplastywithuncemented pyrocar-bonAscension®_implant.

Material

and

methods

Thestudyassessed65patientswhoattendedapre-operative visitinthehandsurgeryoutpatientclinicoftheuniversity

hospitalslinkedtotheinstitution.Forty-fivepatientsand53 thumbswereselected.However,inthepostoperativeperiod, patients were followed-up in asingle outpatientclinic. All patientshadthediagnosisofprimaryrhizarthrosisstagesII

andIII_according_to_the_Eaton_and_Littler_{classification,}apud Martin-Ferreroetal.(Table1).2

Patients’ demographyconsistedof38femalesandseven males. Eight patients were surgically addressed for both hands.Thiswasaprospectivestudy,withmeanfollow-upof 42.08months(8–73).Meanagewas63.17years(50–78).

Patientswereassessedinapreoperativeevaluationandin thepostoperativeperiodthroughthefollowingmethods:

1. ApplicationoftheDASHquestionnairetoassessqualityof life;

Table1–EatonandLittlerclassificationapud Martin-Ferreroetal.2

Stage Radiologicalcriteria–EatonandLittler

I _Normal_joint_contours;_the_interlining_articulate_may_be

widenedsecondarytolaxityorjointeffusion

II _Slight_narrowing_of_the_interlining_articulate;_joint

debrisandosteophytes<2mm NormalSTjoint

III _Marked_degenerative_changes_with_no_interlining

articulate,geodes,osteophytes,andsclerosis>2mm; variabledegreesofsubluxation;normalSTjoint

IV _Similar_to_stageIII_but_with_degenerative_changes_of_the

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Figure1–Imagetocomparethepre-operativeplanning andradiographaspectspostoperative.

2. Measurement of the range of motion of the affected andunaffectedthumbswithaspecificgoniometer.Value expressed indicated the percentage of thumb range of motionrelativetotheunaffectedthumb;

3. Subjectiveanalysisofpainbyvisualanalogscale(VAS).

Surgicaltechniquewasthesameforallpatientsandwas appliedbythesamesurgeon(Fig.1):

1. Patientinstandard-fashionsupinepositionand prepara-tionunderlocalanesthesia;

2. Dorsalandlongitudinalapproachfortheaffectedthumb inthetrapezio-metacarpalregion;

3. Dissectionofthesensitivebranchofthedorsalnerveto thethumb;

4. Openingofthedorsalcapsuleandcarefuldissectionfor laterreinsertion;

5. Creationofthe proximalanddistalcomponentsofthe arthroplastywithresectionofmetacarpalandtrapezium osteophytes;

6. Creationofthemetacarpaltunnelwithspecificmills; 7. Placementofproofprosthesistoverifytheaccuratesize; 8. Creationofanorificeinthetrapezium,withspecificmills,

forperfectcongruencewiththedistalcomponentofthe prosthesis;

9. Placementofthepyrocarbonprosthesisonthemetacarpal in press-fit; performance of thumb bending, abduc-tion, and circumduction maneuvers to confirm stabil-ity of the prosthesis under direct visualization and fluoroscopy;

10. Soft-tissuebalancingwithdorsalcapsulesutureand ver-ificationofthestabilityofthearthroplasty;

11. Layerbylayerclosureandstitching;

12. Occlusivedressingandplacementofapreviouslymade functionalthumborthotics.

Patients in the postoperative follow-up returned every weektochangedressingsandundergocontrolX-rays.Thumb orthoticwasmaintainedforsixweeks;rehabilitationbegan inthesecondweekattheoccupationaltherapygroupofthe institution, with activities for analgesia, scarring manage-ment,andpassivemobilityofthethumb.

ThepresentedstudywasapprovedbytheResearchEthics CommitteeundertheprotocolNo.1,083,641andaninformed consentformwasprovidedforallparticipants,who volun-tarilyreadandsigned.

Results

Subjective assessmentofpain (VAS)was1.37 (1–4).Thumb rangeofmotionwas95.75%(75–100)oftheunaffectedside. MeanDASHquestionnairescorewas9.98(−18).

Complication rate was 11.32%, asthere were five dislo-cations; all thesepatients underwent reoperation with the dorsalcapsuloplastytechnique,usingadorsalwrist retinacu-lumgraft.Thesepatientspresentedagoodclinicaloutcome. Anotherpatienthad ametacarpal fractureandwastreated withinternalfixationwithKirschnerwires.Noneofthe oper-atedpatientshadfunctionalorposturalcomplaintsregarding there-operatedthumbs(Table2).

Regarding the pyrocarbon prosthesis, no patients pre-sentedimplantlooseningorfracture.

Discussion

There are numerous recommendedsurgical techniquesfor treatingrhizarthrosis.Theyallaimtoreducepainand defor-mity,increasingmobilityandthumbpinchstrength.

TheisolatedtrapeziectomydescribedbyGervisapud Ibsen-Sorensen3_or_associated_with_{interposition}_presents_excellent results,3–6_but_has_the_disadvantage_of_decreasing_the_length ofthefirstradiusandthedegreeofpinchstrength.7

Ligamentous reconstruction techniques associated with trapezoidal resection showed preservation of the radius length,andtheoretically,preservationofpinchstrength.2,4,8–11 However,theyrequireamultipleorwideaccessroute,using adjacentstructuresthatrequirealengthyscarringand reha-bilitationtime.

Searchingformorephysiologicalandlessinvasive proce-dures, aimingtopreservethe axial axisofmotionand the degreeofclampforce,aswellastoreducetheearlier post-operative recovery time, arthroscopy techniques12 _(with _or withoutinterpositionofstructures)andseveralpartialortotal replacementprosthesishavebeendeveloped.

In the present study, the partial uncemented pyrocar-bonAscension®_prosthesis13–15_was_implanted_with_a_dorsal accessroute,showinggoodfunctionalresultsandimproved qualityoflifeinpatientspostprocedure,despitethe compli-cationrateof11.32%.

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Table2–Epidemiologicalaspectsandclinicalandfunctionaloutcomesofpatientsundergoingthumbarthroplasty.

N Age(years) Sex Dominance Follow-up(months) DASH ROM(◦₎ _VAS _{Complications}

1 68 F ND 73 1 100 1

2 65 M ND 72 1 98 1

3 62 F D 69 6 91 2

4 63 F D 69 1 100 1

5 60 F D 68 1 95 2

6 65 F D 67 1 93 1 Dislocation

7 59 F D 65 18 88 3

8 70 F ND 64 1 100 1

9 59 F ND 62 1 100 1

10 75 F ND 62 6 85 2 Metacarpalfracture

11 64 M D 61 1 100 1

13 64 M D 56 1 100 1

14 62 F ND 56 12 83 2 Dislocation

15 56 M D 56 6 80 1 Dislocation

16 68 F D 55 1 100 1

17 70 F D 55 1 100 1

18 60 F D 55 1 100 1

19 67 F D 54 1 100 1

20 61 F ND 54 1 100 1

21 64 F D 54 1 100 1

22 58 M D 54 1 100 1

24 66 F D 48 1 100 1

25 64 F D 47 1 100 1

26 59 F ND 47 1 100 1

27 56 F D 43 1 100 1

28 69 F L 42 12 85 2

29 64 F ND 41 1 100 1

30 66 F D 39 1 100 1

31 59 F D 37 24 100 4

32 62 F ND 35 1 100 1

33 60 M D 34 1 100 1

34 60 F D 34 1 100 1

35 67 F D 31 1 100 1

36 61 F ND 28 1 100 1

37 57 F D 28 1 100 1

38 70 F D 27 1 100 1

39 62 F ND 26 1 100 1

40 50 M D 24 12 78 3

41 70 F D 18 1 100 1

42 63 F ND 17 1 100 1

43 58 F D 16 1 100 1

44 60 F D 14 1 100 1

45 78 F D 14 6 92 2

46 62 F D 13 18 75 3

47 59 M D 13 12 83 3

48 60 F D 12 18 80 3

49 62 F D 12 1 100 1

50 68 F D 36 18 88 2

51 64 F ND 25 1 100 1

52 59 F D 28 1 100 1

53 58 F ND 8 1 100 1

Source:SAME.

DASH,disabilitythearm,shoulder,andhand;ROM,rangeofmotion;VAS,visualanalogscore;kgf,kilogram-force;ND,non-dominant;D, dominant.

ComparingthepresentstudywiththatbyIbsen-Sorensen,3 which used a cemented metal-polyethylene total prosthe-sis, similar results were observed for pain improvement, complicationrate,andrangeofmotiongain.Inthepresent

study,therewerefivedislocationsin53operatedthumbsvs. fivedislocationsinthe54casesoperatedbyIbsen-Sorensen.

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reconstruction,4,9–11,16_with_patient_satisfaction_rates_close_to 90%.

Some comparative studies have shown the advantages of arthroplasty with interposition of pyrocarbon implants whencomparedtoligamentreconstructionwithoutimplant interposition.19

Althoughthe present study had a shortfollow-up time (42.08 months), the final results do not change much six monthsaftersurgery.

Prosthesis stability is due to several factors, including implant-trapezoidcongruenceand,moreover,healingofthe soft tissue envelope around the trapeziometacarpal joint, especiallythedorsalcapsule.

Pyrocarbon osseointegration was observed in all cases in the present study, without implant loosening or fracture, which is in agreement with the study by Beckenbaugh–Klawitter.14

The pyrocarbon prosthesis used in this technique has advantages over other implants. It preserves bone mass due to a basic minimal resection of the first metacarpal; trapezium resectionisnot necessary, andtherefore thumb height is maintained. As these are uncemented pros-theses that fixate to the metacarpal through press fit, and given that pyrocarbon has the same hardness as the bone, these prostheses allow for maximum grip with the metacarpal and do not generate debris or stress shielding. Furthermore, pyrocarbon has excellent biocompatibility.20

Complicationrateinthepresent studywas 11.32%.Five patientspresentedsingledislocations,whichwereresolved withdorsalcapsuloplasty.

ThestudybySzalayetal.,16_who_used_pyrocarbon interpo-sitionprosthesis,presentedahigherrateofcomplicationsand worsefunctionaloutcomeswhencomparedwiththepresent study.

Thepresentauthorsbelievethatreplacementarthroplasty of the base of the first metacarpal bone associated with interposition arthroplasty of the trapezium, using a single component,preservesthumblengthandrangeofmotion,as wellasqualityoflifeforthesepatients.Themobilityofthis joint,whichwaspreviouslysellar,becomessphericalwiththe useofthisprosthesis;thisdemonstratesthatthisprocedure iseffectiveintreatingrhizarthrosis.

Theauthorsnotethatpainimprovementisonlyobserved sixthmonthsaftertheprocedure;thereasonforthisisstill unknown, as pyrocarbon is a recent material in orthope-dics.

Thepresent study limited itself to presentingthe clini-calandfunctionalresultsandassessingthequalityoflifeof patientsafterthedescribedprocedure.

Conclusion

Thumb arthroplasty is effective in treating rhizarthrosis, according toclinical and functional outcomes and compli-cations rate, and provides better quality of life for these patients.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.Allmaterialwas provided by the company that owns the material, which allowed thestudy tobe conductedatno extra costto the BrazilianUnifiedHealthcareSystem.

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1.MartouG,VeltriK,ThomaA.Surgicaltreatmentof osteoarthritisofthecar-pometacarpaljointofthethumb:a systematicreview.PlastReconstrSurg.2004;114(2):421–32.

2.Martin-FerreroMH,VegaC,LomoJA.Long-termresults(more than10years)followupoftotaljointarthroplastyinthe treatmentofthumbcarpometacarpaljointosteoarthritis.J HandSurgEur.2011;361Suppl.:S46–7.

3.Ibsen-SorensenA.Theelektraprosthesisfortotal replacementofthefirstcmc-joint.Prospectivestudywith follow-upofonetosixyears.JHandSurgEur.2011;361 Suppl.:S50.

4.BurtonRI,PellegriniVDJr.Surgicalmanagementofbasaljoint arthritisofthethumb.PartII.Ligamentreconstructionwith tendoninterpositionarthroplasty.JHandSurgAm. 1986;11(3):324–32.

5.MurleyAH.Excisionofthetrapeziuminosteoarthritisofthe firstcarpometacarpaljoint.JBoneJointSurgAm.

1960;42:502–7.

6.DellPC,MunizRB.Interpositionarthroplastyofthe

trapeziometacarpaljointforosteoarthritis.ClinOrthopRelat Res.1987;(220):27–34.

7.EatonRG,LaneLB,LittlerJW,KeyserJJ.Ligament

reconstructionforthepainfulthumbcarpometacarpaljoint: along-termassessment.JHandSurgAm.1984;9(5): 692–9.

8.VermeulenGM,BrinkSM,SluiterJBA,EliasMGS,HoviusRES, MoojenTM.Ligamentreconstructionarthroplastyforprimary thumbcarpometacarpalosteoarthritis(WeilbyTechnique): prospectivecohortstudy.JHandSurgAm.2009;34: 1393–401.

9.DavisTR,BradyO,DiasJJ.Excisionofthetrapeziumfor osteoarthritisofthetrapeziometacarpaljoint:astudyofthe benefitofligamentreconstructionortendoninterposition.J HandSurgAm.2004;29(6):1069–77.

10.HartiganJB,SternPJ,KiefhaberTR.Thumbcarpometacarpal osteoarthritis:arthrodesiscomparedwithligament reconstructionandtendoninterposition.JBoneJointSurg Am.2001;83(10):1470–8.

11.TomainoMM.Ligamentreconstructiontendoninterposition arthroplastyforbasaljointarthritis.Rationale,current technique,andclinicaloutcome.HandClin.2001;17(2):207–21.

12.DaRinF,MathoulinC.Arthroscopictreatmentof osteoarthritisofscaphotrapezotrapezoidjoint.ChirMain. 2006;25Suppl1:S254–8.

13.ThompsonJS.Suspensionplasty.JOrthopSurgTech. 1989;4:1–13.

14.BeckenbaughRD,KlawitterJ,CookS.Osseointegrationand mechanicalstabilityofpyrocarbonandtitaniumhand implantsinaload-bearinginvivomodelforsmalljoint arthroplasty.JHandSurgAm.2006;31(7):1240–1.

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16.SzalayG,SchleicherI,AltV,PavlidisT,SchnettlerR.Operative treatmentofrhizarthritis:comparisonofligament

reconstructionaccordingtoEppingwithtrapezectomyand interpositionofpyrocarbonspacersasreplacementofthe trapezium.Orthopade.2011;40(3):237–46.

17.GervisWH.Excisionofthetrapeziuminosteoarthritisofthe trapezio-metacarpaljoint.JBoneJointSurgBr.

1949;31(4):537–9.

18.IyerKM.Theresultsofexcisionofthetrapezium.Hand. 1981;13(3):246–50.

19.Colegate-StoneTJ,GargS,SubramanianA,ManiGV.Outcome analysisoftrapezectomywithandwithoutpyrocarbon interpositiontotreatprimaryarthrosisofthe

trapeziometacarpaljoint.HandSurg.2011;16(1): 49–54.