The Wisconsin Hand Experience 2016 CMC Pitfalls and
- Slides: 42
The Wisconsin Hand Experience 2016 CMC Pitfalls and Preferences Greg Watchmaker, MD Zion 2014
Pitfalls
Expectations
Expectations • Relieve pain 93% • Improve strength 93% • Restore basic tasks like opening a jar 93% • Prevent condtion from worsening 95%
Expectations
Prevalence • Radiographic 6: 1 female to male prevalence • 40% of women by 75 • Only 28% symptomatic Armstrong AL, Hunter JB, Davis TR. . J Hand Surg Br. 1994; 19: 340– 341
Growth of Thumb’s Importance Bipedalism and club weilding associated with thumb development
Thumb Strength Age 0 -5 Short web space, low muscle strength Age 6 – 12 Increasing muscle strength and thumb length Age >50 Back to being a toddler
Thumb Kinematics -Force increases exponentially from tip to base during pinch activities -120 kg force at CMC joint during pinch
CMC- Ligaments 3 – 16 Ligaments Anterior Oblique Ligament? Dorsal Deltoid Ligaments
CMC- Treatment Options - Adaptive techniques Neoprene/Custom Braces Warmth NSAIDs Cortisone Surgery
Preferences Adaptive
CMC Preferences Splinting 1. Neoprene prefabricated 2. Semi-rigid prefabricated 3. Custom thermal molded
Audience Preferences - Splinting 1. Neoprene prefabricated 2. Semi-rigid prefabricated 3. Custom thermal molded
Preferences- Splinting Randomized cross-over study Neoprene vs. custom thermal
Pitfalls - Injections Cortisone Culture expanded stem cells Hyaluronic acid Autologous fat
Pitfalls - Injections
Pitfalls - Injections Cortisone vs. Placebo
Surgical Options • Mini Tight. Rope • Hematoma Arthroplasty • Tendon Interposition • Joint or Hemi replacement • Synthentic Spacers • Arthroscopic Arthroplasties • Osteotomies
CMC Arthoplasty– Treatment - Trapezium Excision (1949) - Tendon Interposition (1970) - Ligament Reconstruction (1973) - Ligament Reconstruction and Trapeziectomy (1986) - Trapezium Excision (2007)
Interposition Material 1. Trapezium resection only (nothing) 2. Tendon Interposition (FCR, PL, APL) 3. Orthosphere 4. Artelon
Trapeziectomy vs. LRTI
Pitfalls - Joint Replacement
Pitfalls - Implants Artelon Fabric 12 of 32 (37%) revised for pain Pyrocarbon Implant (20% at 2 yrs) Silastic Implant Orthosphere 5 of 6 revised for pain
Pitfalls - Snythetic Interposition
Arthroscopic Arthroplasty • 26 patients with 20 month follow-up • Poly-L-lactic acid implant • Pain 6. 61 VAS 6. 03 • Quick. DASH 56 54 • Pinch 3. 7 kg 2. 2 kg
Preferences
Preferences
Preferences - Injections
Audience - Immobilization 1. 2. 3. 4. Cast 4 weeks or more Cast 2 -4 weeks Removable splint only No splint
Pinning the Joint 1. Never Pin 2. Sometimes Pin 3. Always Pin
Therapy Visits Post-op 1. 2. 3. 4. 5. 6. 7. 8. No Therapy 1 -4 visits 5 -8 visits 9 -12 visits 13 -16 visits 17 -20 visits 21 -24 visits Never stop
Duration of Rehab
The Need for Strength
Pitfalls - Ongoing Pain Incomplete bone resection Low-grade infection LABC and radial sensory nerve injury CRPS Scapho-trapezoidal arthrosis FCR tendinitis Adhesions
CMC Arthroplasty - Outcomes
CMC Arthroplasty - Outcomes
Take Home Messages More and more common Take time treating conservatively (adaptive devices, neoprene, injections) Any surgery with good technique is fine (with caveats)
Murren 2015 The Wisconsin Hand Experience CMC Pitfalls and Preferences Greg Watchmaker, MD
- Wisconsin hand experience
- Direct experience vs indirect experience
- Imprinting meaning psychology
- Early experience vs later experience debate
- C traps and pitfalls
- Nitcar
- Channel sharing and borrowing in cmc
- C-m-c m-c-m
- Cmc instrumentation and controls
- Time with hands
- The hour hand
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- Pitfalls of differentiation
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- What are two pitfalls (problems) of lock-based protocols
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- Forward elimination
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- The pitfalls of a differentiation strategy include
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- Circuit pitfalls in vlsi
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- Concurrency control mechanism
- Operational pitfalls aviation
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- Lack of social context cues theory
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