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A Long-term Multi-center Outcomes Study of Silicone Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis
SUMMARY
HYPOTHESIS
In severe CTS with impairment of thumb opposition, function may be reconstructed with an opponensplasty. If recovery of thumb opposition is predicted, we can determine whether opponensplasty should be applied or not at the time of carpal tunnel release. In this study, the duration of disease did not correlate with the recovery of thumb opposition, but there was some correlation with age. Good recovery of thumb opposition can be expected in patients under 50 years of age. However, recovery was still unpredictable in patients 50 years of age and older. Further studies, such as second lumbrical CMAP, may be required to better predict the recovery of thumb opposition in severe CTS.
Rheumatoid arthritis often results in deformities at the metacarpophalangeal (MCP) joint. Patients with severe deformities that interfere with everyday activities can be treated by silicone metacarpophalangeal joint arthroplasty (SMPA). High level evidence for the long-term effectiveness of this procedure is unavailable. The purpose of this paper is to prospectively compare long-term outcomes for a surgical and a non-surgical cohort of rheumatoid arthritis patients.
REFERENCES 1. Capasso M, Manzoli C, Uncini A. Management of extreme carpal tunnel syndrome: evidence from a long-term follow-up study. Muscle Nerve. 2009;40:86-93. 2. Nobuta S, Sato K, Komatsu T, Miyasaka Y, Hatori M. Clinical results in severe carpal tunnel syndrome and motor nerve conduction studies. J Orthop Sci. 2005;10:22-6. 3. Mondelli M, Reale F, Padua R, Aprile I, Padua L. Clinical and neurophysiological outcome of surgery in extreme carpal tunnel syndrome. Clin Neurophysiol. 2001 Jul;112:1237-42.
METHODS This is a multi-center prospective NIH funded cohort study of rheumatoid arthritis patients enrolled from 2004 to 2008. Patients could elect to undergo SMPA and medical therapy or medical therapy alone. A total of 67 surgical and 95 nonsurgical patients with severe subluxation and/or ulnar drift of the fingers at the MCP joints were recruited. The patients were followed prospectively for three years. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales (AIMS2), grip/pinch strength, Jebson-Taylor test and ulnar deviation, extensor lag and arc of motion measurements at the MCP joints.
RESULTS There was no significant difference in the mean age (surgical mean=60, nonsurgical mean=62), race, education, and income at baseline between the two groups. Surgical subjects had worse MHQ function and functional measurements at baseline. At 3 years, the mean overall MHQ score and the MHQ function, activities of daily living, aesthetics and satisfaction scores showed significant improvement in the surgical group compared to the non-surgical group. Ulnar deviation, extensor lag and arc of motion in the MCP and proximal interphalangeal (PIP) joints also improved significantly in the surgical group. There was no improvement in the mean AIMS2 scores and grip/pinch strength. Complications were minimal with a prosthesis fracture rate of 9.5%.
SUMMARY POINTS ∙ Figure 1. A 55-year-old woman had extensive thenar muscle atrophy (arrow) and was unable to perform a pulp pinch. Figure 2. Eighteen months after surgery, the thenar muscle atrophy had disappeared and she was able to perform a pulp pinch.
∙
The results from extended follow-up of this cohort have shown that the benefits of SMPA continue through 3 years after surgery. RA patients with poor baseline functioning show long term improvement in hand function and appearance following treatment with SMPA compared to non-surgical controls.
PAPER 03 5IVSTEBZ 4FQUFNCFS to1. #FTU1BQFST
A Long-term Multi-center Outcomes Study of Silicone Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis Level 2 Evidence
t Jennifer F. Waljee, MD, MS 1BUSJDJB##VSOT .1) )ZVOHKJO.,JN 4D% 'SBOL%#VSLF .% &'4IBX8JMHJT .% ,FWJO$$IVOH .% .4
♦ Speaker has nothing of financial value to disclose
Figure 1. Means and 95% confidence intervals from baseline to 3 years for select MHQ scores: Surgical vs. non-surgical subjects
3
METHODS
Table 1. Mean Scores for Surgical (SMPA) vs. Non-Surgical Subjects Preoperative
1-Year Postoperative 2-Year Postoperative 3-Year Postoperative
MHQ Scales1
SMPA
Non-SMPA
SMPA
Non-SMPA
SMPA
Non-SMPA
SMPA
Non-SMPA
Function
37 (22) 58 (19)**
62 (23)
59 (24)
62 (19)
58 (22)
59 (19)
58 (21)
ADL
34 (26) 59 (24)**
55 (30)
60 (26)
58 (29)
61 (25)
55 (27)
61 (27)
Work
41 (22) 59 (23)**
47 (29)
61 (26)
54 (27)
61 (26)
51 (28)
61 (27)
Pain
49 (26)
36 (25)*
34 (25)
36 (26)
36 (25)
32 (25)
38 (26)
31 (24)
Aesthetics
33 (22) 47 (24)**
68 (23)
52 (23)
66 (23)
53 (21)
60 (21)
54 (20)
Satisfaction
27 (20) 47 (25)**
64 (26)
48 (27)
61 (27)
51 (25)
55 (25)
53 (25)
Overall Score
37 (17) 56 (19)**
60 (22)
57 (21)
61 (21)
59 (20)
57 (20)
59 (21)
AIMS2 Scales2 Physical
4.0 (2.4) 2.5 (1.9)** 3.4 (2.4) 2.4 (1.9) 3.3 (2.2) 2.5 (2.0) 3.4 (2.3) 2.6 (2.2)
Affect
4.2 (1.9) 3.1 (1.8)** 3.6 (1.9) 2.8 (1.6) 3.7 (1.8) 2.9 (1.7) 3.7 (2.3) 2.7 (1.6)
Symptom
5.7 (2.8) 4.3 (2.4)* 4.9 (2.7) 4.0 (2.5) 4.6 (2.4) 3.9 (2.3) 5.0 (2.3) 4.0 (2.5)
Social interaction 4.1 (2.0) 3.6 (1.4)* 3.9 (2.0) 3.6 (1.4) 4.1 (2.1) 3.7 (1.3) 4.1 (2.1) 3.5 (1.6) Objective Measurements Grip Strength (kg) Key (lateral) pinch (kg) 2-point (tip) pinch (kg) Three-jaw (palmar) pinch (kg) Jebson-Taylor (s)3
5.4 (5.2) 8.6 (7.4)* 6.1 (4.5) 10.3 (7.8) 6.1 (4.4) 10.6 (7.5) 6.0 (4.2) 9.7 (5.9) 3.5 (2.2) 4.0 (1.8)
3.1 (1.8) 4.1 (2.0) 3.2 (1.9) 3.7 (1.9) 3.0 (2.0) 3.4 (1.8)
2.5 (1.6) 3.1 (1.5)* 2.6 (1.6) 3.1 (1.7) 2.4 (1.5) 2.9 (1.5) 2.2 (1.4) 2.7 (1.3) 2.5 (1.5) 3.2 (1.4)* 2.6 (1.5) 3.2 (1.4) 2.5 (1.4) 3.2 (1.5) 2.4 (1.5) 2.7 (1.2)
Thirty-nine Lewis rats were randomized into three groups. In all groups, the tibial nerve was transected and repaired in one of three ways. Group 1 was repaired with a 10 mm autograft (representing a partial injury) complemented by a SETS nerve transfer using the peroneal nerve. Group 2 was repaired with a 10 mm autograft only (partial injury only). Group 3 was repaired with SETS peroneal nerve transfer alone and the tibial stumps were capped to prevent regeneration across the gap, serving as control. Nerve histomorphometry, retrograde labeling, muscle mass analysis, and muscle force testing were performed. Data was analyzed by NewmanKeuls testing and significance was determined as p<0.05.
RESULTS Nerve histomorphometry of the distal tibial nerve showed significantly (p<0.03) increased myelinated axonal counts in Group 1 (5659±3803) as compared to Group 2 (2904±1752) and Group 3 (2400±850) at 5 and 8 weeks. Retrograde labeling at 8 weeks confirmed increased motor reinnervation in the distal tibial stump. Functional recovery was evaluated with muscle force testing at 8 weeks, which revealed a significant increase in force (p<0.05) in the “Supercharge” group (Group 1) in comparison to the partial injury group (Group 2).
SUMMARY POINTS ∙
55 (27) 43 (12)**
44 (15)
41 (12)
Ulnar Drift3
37 (15)
13 (11)
Extensor Lag3 MCP Arc of Motion PIP Arc of Motion
65 (23) 47 (18)**
28 (15)
20 (15) 37 (18)** 56 (27) 70 (22)**
35 (15)
43 (11)
39 (10)
44 (13)
40 (12)
34 (15)
14 (9)
33 (16)
14 (11)
34 (17)
49 (21)
25 (14)
48 (23)
29 (15)
53 (21)
30 (16)
33 (19)
33 (17)
33 (20)
30 (14)
29 (16)
67 (24)
71 (19)
66 (25)
67 (22)
64 (26)
67 (21)
Abbreviations: AIMS2, Arthritis Impact Measurement Scales 2, ADL, activities of daily living; SMPA, Silicone Metacarpophalangeal Joint Arthroplasty. Cell values are means (SD). 1 Higher scores correspond to better outcomes, except for pain where higher scores correspond to greater pain. 2 For all AIMS2 subscales, higher scores correspond to worse outcome. 3 Higher values correspond to worse outcome. * P < 0.05 and ** P < 0.001 for between group difference at baseline.
∙ ∙
Complementing a regenerating partially injured nerve with a SETS nerve transfer resulted in superior myelinated axonal regeneration as determined by histomorphometry. SETS enhanced motor recovery in the partial injury model as evidenced by a significant increase in muscle force measurements. Our findings may have a significant clinical application particularly in cases where prolonged regeneration across long distances is anticipated and may yield suboptimal recovery.
t(SBOUSFDFJWFE3"3
PAPER 04 5IVSTEBZ 4FQUFNCFS to1. #FTU1BQFST
“Supercharge” Nerve Transfer to Enhance Motor Recovery
Figure 1. Experimental groups
Not a clinical study ♦ Scott J. Farber, MD 4JNPOF(MBVT .% :JOH:BO .% 1I% %BOJFM)VOUFS 3" 1IJMJQ++PIOTPO 1I% 4VTBO&.BDLJOOPO .%
HYPOTHESIS The use of a “Supercharge” end-to-side nerve transfer (SETS) will enhance functional recovery in situations of an incomplete nerve injury. SETS nerve transfer provides additional axons for early reinnervation of target muscle to prevent atrophy and fibrosis while axons from the injured nerve continue to regenerate.
4
Figure 2. Myelinated Fiber Counts at 5 and 8 weeks
♦ Speaker has nothing of financial value to disclose
HYPOTHESIS
In severe CTS with impairment of thumb opposition, function may be reconstructed with an opponensplasty. If recovery of thumb opposition is predicted, we can determine whether opponensplasty should be applied or not at the time of carpal tunnel release. In this study, the duration of disease did not correlate with the recovery of thumb opposition, but there was some correlation with age. Good recovery of thumb opposition can be expected in patients under 50 years of age. However, recovery was still unpredictable in patients 50 years of age and older. Further studies, such as second lumbrical CMAP, may be required to better predict the recovery of thumb opposition in severe CTS.
Rheumatoid arthritis often results in deformities at the metacarpophalangeal (MCP) joint. Patients with severe deformities that interfere with everyday activities can be treated by silicone metacarpophalangeal joint arthroplasty (SMPA). High level evidence for the long-term effectiveness of this procedure is unavailable. The purpose of this paper is to prospectively compare long-term outcomes for a surgical and a non-surgical cohort of rheumatoid arthritis patients.
REFERENCES 1. Capasso M, Manzoli C, Uncini A. Management of extreme carpal tunnel syndrome: evidence from a long-term follow-up study. Muscle Nerve. 2009;40:86-93. 2. Nobuta S, Sato K, Komatsu T, Miyasaka Y, Hatori M. Clinical results in severe carpal tunnel syndrome and motor nerve conduction studies. J Orthop Sci. 2005;10:22-6. 3. Mondelli M, Reale F, Padua R, Aprile I, Padua L. Clinical and neurophysiological outcome of surgery in extreme carpal tunnel syndrome. Clin Neurophysiol. 2001 Jul;112:1237-42.
METHODS This is a multi-center prospective NIH funded cohort study of rheumatoid arthritis patients enrolled from 2004 to 2008. Patients could elect to undergo SMPA and medical therapy or medical therapy alone. A total of 67 surgical and 95 nonsurgical patients with severe subluxation and/or ulnar drift of the fingers at the MCP joints were recruited. The patients were followed prospectively for three years. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales (AIMS2), grip/pinch strength, Jebson-Taylor test and ulnar deviation, extensor lag and arc of motion measurements at the MCP joints.
RESULTS There was no significant difference in the mean age (surgical mean=60, nonsurgical mean=62), race, education, and income at baseline between the two groups. Surgical subjects had worse MHQ function and functional measurements at baseline. At 3 years, the mean overall MHQ score and the MHQ function, activities of daily living, aesthetics and satisfaction scores showed significant improvement in the surgical group compared to the non-surgical group. Ulnar deviation, extensor lag and arc of motion in the MCP and proximal interphalangeal (PIP) joints also improved significantly in the surgical group. There was no improvement in the mean AIMS2 scores and grip/pinch strength. Complications were minimal with a prosthesis fracture rate of 9.5%.
SUMMARY POINTS ∙ Figure 1. A 55-year-old woman had extensive thenar muscle atrophy (arrow) and was unable to perform a pulp pinch. Figure 2. Eighteen months after surgery, the thenar muscle atrophy had disappeared and she was able to perform a pulp pinch.
∙
The results from extended follow-up of this cohort have shown that the benefits of SMPA continue through 3 years after surgery. RA patients with poor baseline functioning show long term improvement in hand function and appearance following treatment with SMPA compared to non-surgical controls.
PAPER 03 5IVSTEBZ 4FQUFNCFS to1. #FTU1BQFST
A Long-term Multi-center Outcomes Study of Silicone Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis Level 2 Evidence
t Jennifer F. Waljee, MD, MS 1BUSJDJB##VSOT .1) )ZVOHKJO.,JN 4D% 'SBOL%#VSLF .% &'4IBX8JMHJT .% ,FWJO$$IVOH .% .4
♦ Speaker has nothing of financial value to disclose
Figure 1. Means and 95% confidence intervals from baseline to 3 years for select MHQ scores: Surgical vs. non-surgical subjects
3
METHODS
Table 1. Mean Scores for Surgical (SMPA) vs. Non-Surgical Subjects Preoperative
1-Year Postoperative 2-Year Postoperative 3-Year Postoperative
MHQ Scales1
SMPA
Non-SMPA
SMPA
Non-SMPA
SMPA
Non-SMPA
SMPA
Non-SMPA
Function
37 (22) 58 (19)**
62 (23)
59 (24)
62 (19)
58 (22)
59 (19)
58 (21)
ADL
34 (26) 59 (24)**
55 (30)
60 (26)
58 (29)
61 (25)
55 (27)
61 (27)
Work
41 (22) 59 (23)**
47 (29)
61 (26)
54 (27)
61 (26)
51 (28)
61 (27)
Pain
49 (26)
36 (25)*
34 (25)
36 (26)
36 (25)
32 (25)
38 (26)
31 (24)
Aesthetics
33 (22) 47 (24)**
68 (23)
52 (23)
66 (23)
53 (21)
60 (21)
54 (20)
Satisfaction
27 (20) 47 (25)**
64 (26)
48 (27)
61 (27)
51 (25)
55 (25)
53 (25)
Overall Score
37 (17) 56 (19)**
60 (22)
57 (21)
61 (21)
59 (20)
57 (20)
59 (21)
AIMS2 Scales2 Physical
4.0 (2.4) 2.5 (1.9)** 3.4 (2.4) 2.4 (1.9) 3.3 (2.2) 2.5 (2.0) 3.4 (2.3) 2.6 (2.2)
Affect
4.2 (1.9) 3.1 (1.8)** 3.6 (1.9) 2.8 (1.6) 3.7 (1.8) 2.9 (1.7) 3.7 (2.3) 2.7 (1.6)
Symptom
5.7 (2.8) 4.3 (2.4)* 4.9 (2.7) 4.0 (2.5) 4.6 (2.4) 3.9 (2.3) 5.0 (2.3) 4.0 (2.5)
Social interaction 4.1 (2.0) 3.6 (1.4)* 3.9 (2.0) 3.6 (1.4) 4.1 (2.1) 3.7 (1.3) 4.1 (2.1) 3.5 (1.6) Objective Measurements Grip Strength (kg) Key (lateral) pinch (kg) 2-point (tip) pinch (kg) Three-jaw (palmar) pinch (kg) Jebson-Taylor (s)3
5.4 (5.2) 8.6 (7.4)* 6.1 (4.5) 10.3 (7.8) 6.1 (4.4) 10.6 (7.5) 6.0 (4.2) 9.7 (5.9) 3.5 (2.2) 4.0 (1.8)
3.1 (1.8) 4.1 (2.0) 3.2 (1.9) 3.7 (1.9) 3.0 (2.0) 3.4 (1.8)
2.5 (1.6) 3.1 (1.5)* 2.6 (1.6) 3.1 (1.7) 2.4 (1.5) 2.9 (1.5) 2.2 (1.4) 2.7 (1.3) 2.5 (1.5) 3.2 (1.4)* 2.6 (1.5) 3.2 (1.4) 2.5 (1.4) 3.2 (1.5) 2.4 (1.5) 2.7 (1.2)
Thirty-nine Lewis rats were randomized into three groups. In all groups, the tibial nerve was transected and repaired in one of three ways. Group 1 was repaired with a 10 mm autograft (representing a partial injury) complemented by a SETS nerve transfer using the peroneal nerve. Group 2 was repaired with a 10 mm autograft only (partial injury only). Group 3 was repaired with SETS peroneal nerve transfer alone and the tibial stumps were capped to prevent regeneration across the gap, serving as control. Nerve histomorphometry, retrograde labeling, muscle mass analysis, and muscle force testing were performed. Data was analyzed by NewmanKeuls testing and significance was determined as p<0.05.
RESULTS Nerve histomorphometry of the distal tibial nerve showed significantly (p<0.03) increased myelinated axonal counts in Group 1 (5659±3803) as compared to Group 2 (2904±1752) and Group 3 (2400±850) at 5 and 8 weeks. Retrograde labeling at 8 weeks confirmed increased motor reinnervation in the distal tibial stump. Functional recovery was evaluated with muscle force testing at 8 weeks, which revealed a significant increase in force (p<0.05) in the “Supercharge” group (Group 1) in comparison to the partial injury group (Group 2).
SUMMARY POINTS ∙
55 (27) 43 (12)**
44 (15)
41 (12)
Ulnar Drift3
37 (15)
13 (11)
Extensor Lag3 MCP Arc of Motion PIP Arc of Motion
65 (23) 47 (18)**
28 (15)
20 (15) 37 (18)** 56 (27) 70 (22)**
35 (15)
43 (11)
39 (10)
44 (13)
40 (12)
34 (15)
14 (9)
33 (16)
14 (11)
34 (17)
49 (21)
25 (14)
48 (23)
29 (15)
53 (21)
30 (16)
33 (19)
33 (17)
33 (20)
30 (14)
29 (16)
67 (24)
71 (19)
66 (25)
67 (22)
64 (26)
67 (21)
Abbreviations: AIMS2, Arthritis Impact Measurement Scales 2, ADL, activities of daily living; SMPA, Silicone Metacarpophalangeal Joint Arthroplasty. Cell values are means (SD). 1 Higher scores correspond to better outcomes, except for pain where higher scores correspond to greater pain. 2 For all AIMS2 subscales, higher scores correspond to worse outcome. 3 Higher values correspond to worse outcome. * P < 0.05 and ** P < 0.001 for between group difference at baseline.
∙ ∙
Complementing a regenerating partially injured nerve with a SETS nerve transfer resulted in superior myelinated axonal regeneration as determined by histomorphometry. SETS enhanced motor recovery in the partial injury model as evidenced by a significant increase in muscle force measurements. Our findings may have a significant clinical application particularly in cases where prolonged regeneration across long distances is anticipated and may yield suboptimal recovery.
t(SBOUSFDFJWFE3"3
PAPER 04 5IVSTEBZ 4FQUFNCFS to1. #FTU1BQFST
“Supercharge” Nerve Transfer to Enhance Motor Recovery
Figure 1. Experimental groups
Not a clinical study ♦ Scott J. Farber, MD 4JNPOF(MBVT .% :JOH:BO .% 1I% %BOJFM)VOUFS 3" 1IJMJQ++PIOTPO 1I% 4VTBO&.BDLJOOPO .%
HYPOTHESIS The use of a “Supercharge” end-to-side nerve transfer (SETS) will enhance functional recovery in situations of an incomplete nerve injury. SETS nerve transfer provides additional axons for early reinnervation of target muscle to prevent atrophy and fibrosis while axons from the injured nerve continue to regenerate.
4
Figure 2. Myelinated Fiber Counts at 5 and 8 weeks
♦ Speaker has nothing of financial value to disclose