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Home / LWW Techniques FLA, SF, LTE and Case Study & Review

LWW Techniques FLA, SF, LTE and Case Study & Review

Posted on May 29, 2010 by Badia Hand to Shoulder Center

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Treatment of Early Basal Joint Arthritis Using a Combined Arthroscopic Debridement and Metacarpal Osteotomy

ABSTRACT
Osteoarthritis of the thumb basal joint is a common and disabling condition, and early stages of which are often seen in middle-aged women. Arthroscopic assessment of the first carpometacarpal joint allows easy identification and classification of joint pathology with minimal morbidity. This allows the condition to be managed either arthroscopically or converted to an open procedure as indicated. Different procedures have been described to treat different stages of this disease. The senior author has recently described an arthroscopic staging system to determine treatment for basal joint osteoarthritis. We now present our surgical technique and early clinical experience with arthroscopic synovectomy, debridement, and corrective osteotomy for arthroscopic stage II of thumb basal joint arthritis. Forty-three patients (38 women and 5 men) were arthroscopically diagnosed as having stage II basal joint osteoarthritis of the thumb between 1998 and 2001, and they were the focus of the present study. In all the patients, there was no improvement after a period of 6 to 12 weeks of conservative treatment. All the procedures were performed by the senior author. The surgical procedure included arthroscopic synovectomy, debridement, and occasional thermal capsulorraphy, followed by an extension-abduction closing wedge osteotomy in all the cases. A 0.045-in Kirschner wire provided stability to the osteotomy. By performing an osteotomy that redirects the axial loads in this joint, we have obtained satisfactory results in terms of pain relief, stability, and pinch strength. Arthroscopy allows us to not only determine the optimum indication for this osteotomy, but also to debride the joint and minimize the inflammatory response. Hence, we recommend arthroscopic synovectomy, debridement with or without a thermal capsulorraphy, and a dorsoradial closing wedge osteotomy for the treatment of arthroscopic stage II of thumb carpometacarpal joint osteoarthritis. Keywords: thumb, carpometacarpal, osteoarthritis, arthroscopy, osteotomy.

HISTORICAL PERSPECTIVE
The trapeziometacarpal (TMC) joint displays an exclu- sive anatomic design that allows arc of motion in three different planes to place the thumb for axial loads. For this reason, it is not uncommon for this joint to develop osteoarthritis even when other small joints in the vicinity stay unchanged.1 It has been demonstrated that there is a strong correlation between extreme basal joint laxity, specifically volar ligament instability, and evolvement of the early degenerative changes.1Y8 These alterations are common causes of pain, weakness, and adduction deformity.9 Different procedures have been proposed for the treatment of first carpometacarpal (CMC) joint arthritis.1,3Y5,9Y32 Clinical and radiographic assessments have constituted the basic tools for evalu- ation of the first CMC joint during the last several decades.1,5,29Y31 Eaton and Glickel5 proposed a staging system for thumb CMC arthritis, which has been extensively used not just to categorize the disease, but also to provide a treatment rationale. Bettinger et al30 introduced the trapezial tilt as a parameter to predict further progression of the disease. They found that in advanced stages (Eaton III and IV), the trapezial tilt was high (50- T 4-; normal, 42- T 4-). Barron et al1 concluded that there appeared to be no indication for magnetic resonance imaging (MRI), tomography, or ultrasonography in the routine evaluation of basal joint disease. Despite the importance of a radiographic classification to understand the progression of the disease, our experience has showed us that there are instances when it is very difficult to make an accurate diagnosis of the disease stage, based solely on radio- graphic studies. Clinical symptoms are often much more pronounced than plain radiographs would suggest.

Recent advances in arthroscopic technology have allowed complete examination of smaller joints throughout the body with minimal morbidity.33 More- over, arthroscopy has already been proved to be reliable for direct evaluation of the first CMC joint.32 This technique is often used initially for diagnostic purposes and, once established, can be incorporated into our treatment plan. Arthroscopy of the thumb basal joint allows us to look within a joint that is commonly affected by both traumatic and chronic conditions, providing clear visualization of the articular surfaces and assessment of ligamentous integrity, and hence permitting confirmation of the preoperative radiograph- ic staging in all the cases. The senior author recently described an arthroscopic classification for thumb CMC osteoarthritis29 (Table 1).

The benefits of basal joint arthroscopy are evident in early stages of the disease. For instance, in arthroscopic stage I, it is very common to have normal radiographic studies in the presence of painful limitation of the thumb. In our experience, we have found that this group of patients displayed mild to moderate synovitis that could benefit from a thorough joint debridement/ synovectomy, combined with thermal shrinkage of the ligaments to enhance the stability if necessary. Tom- aino24,25 concluded that Eaton stage I disease is a good indication for thumb metacarpal extension osteotomy. A more reliable indication might be when there is only focal articular cartilage loss and the joint is, therefore, worth preserving. First metacarpal osteotomy has been advocated to modify the mechanical stress areas of the joint.9,23Y29 Based on the arthroscopic changes found in stage II, we support the fact that it may be feasible to modify the joint by an osteotomy and preserve the trapezium. Moreover, the metaphyseal osteotomy leads to decompression and reactive hyperemia that may help in arresting the progression of the arthritis.34,35 Menon described a technique demonstrating arthroscopic de- bridement of the trapezial articular surface and interposition of autogenous tendon, fascia lata, or Gore-Tex patch into the CMC joint in patients with stage II and III.31 The main goal of the present study is to present the surgical technique and results of our arthroscopic stage II patients treated with an arthroscopic basal joint debridement with capsulorraphy and a closing wedge extension-abduction metacarpal osteotomy.

INDICATIONS AND CONTRAINDICATIONS
Stage II arthroscopic CMC joint arthritis is our indication for the extension abduction metacarpal osteotomy coupled with a thorough arthroscopic syno- vectomy and capsulorraphy. The joint findings that we have previously described for arthroscopic stage II of the disease warrants a modification of the joint by changing the load vector on both the articular surfaces through an osteotomy. Arthroscopy not only allows staging of the arthritis but the joint can also be effectively debrided, and capsulorraphy can be done. However, this procedure should be avoided in advanced basal joint arthritis or when scaphotrapezial-trapezoid joint is arthritic, wherein a more aggressive procedure is warranted. Eaton stage I might be amenable to a simple synovectomy/debridement, reserving the osteotomy for more advanced arthroscopic findings. On the other hand, if the arthroscopic evaluation depicts complete articular cartilage loss, the next logical step is to perform partial trapezium excision with tendon interpo- sition arthroplasty.

| ARTHROSCOPIC AND RADIOGRAPHIC CORRELATION
Arthroscopic stage I universally correlate well with that of radiographic stage I. Arthroscopic stage II usually corresponds to radiographic stage II changes, but some radiographic stage I patients may display focal loss of articular cartilage consistent with arthroscopic stage II. Herein lays one of the great advantages of this technology. Only the rare case demonstrates less cartilage wear than expected on the plain radiograph. Consequently, radiographic stage III rarely is considered arthroscopic stage II, but that does greatly influence and diversify the treatment options. More advanced radio- graph findings will usually reveal widespread cartilage loss when arthroscopy is performed. Hence, later stages are not necessarily a panacea as related to the use of arthroscopy.

Surgical Technique
The procedure was performed under wrist block regional anesthesia with tourniquet control. A single Chinese finger trap was used on the thumb with 5 to 8 lb of ongitudinal traction. The arm was held down with wide tape around the tourniquet securing it to the hand table to serve as countertraction. A shoulder holder, rather than a traction tower, was used to facilitate fluoroscopic intervention more easily. The Trapeziometacarpal joint was detected by palpation. Joint distension was achieved by injecting 1 to 3 mL of normal saline (Fig. 1). It is important to distally direct the needle approximately 20 degrees to clear the dorsal flare of the metacarpal base and enter the joint capsule. This course should be reproduced upon entering with arthroscopic sleeve/ trocar assembly to minimize iatrogenic cartilage injury. Fluid distention is important to facilitate this. The incision for the 1-R (radial) portal, used for proper assessment of the dorsoradial ligament, posterior oblique ligament, and ulnar collateral ligament, was placed just volar to the abductor pollicis longus tendon. The incision for the 1-U (ulnar) portal, for better evaluation of the anterior oblique ligament and ulnar collateral ligament, was made just ulnar to the extensor pollicis brevis tendon. A short-barrel, 1.9-mm, 30- degree inclination arthroscope was used for complete visualization of the CMC joint surfaces, capsule, and ligaments, and then appropriate management was done, as dictated by the stage of the arthritis detected (Fig. 2A). A full-radius mechanical shaver with suction was used in all the cases, particularly for initial debridement and visualization. Most of the cases were augmented with radiofrequency ablation to perform a thorough synovectomy and radiofrequency was also used to perform chondroplasty in the cases with focal articular cartilage wear or fibrillation. Chondroplasty refers to thedebridement of the fibrillated cartilage to improve vascularity of the cartilage and enhance the growth of fibrocartilage. Ligamentous laxity and capsular attenu- ation were treated with thermal capsulorraphy using a radiofrequency shrinkage probe. We were careful to avoid thermal necrosis; hence, a striping technique was used to tighten the capsule of the lax joints. The striping technique refers to thermal shrinkage performed in longitudinal stripes on the lax capsule, so as to leave vascular zones between the stripes; hence, thermal necrosis is prevented. Arthroscopic stage I disease was characterized by synovitis without any cartilage wear, wherein a synovectomy coupled with thermal capsulor- raphy as described was performed.

Arthroscopic stage II patients were characterized by focal wear of the articular surface (Fig. 2B) that required a joint modifying procedure, to alter the vector forces across the joint. After synovectomy, debridement, and occasional loose body removal, the joint was reassessed to determine the extent of instability and capsular attenuation. A shrinkage capsulorraphy was performed in many of the cases, with chondroplasty done to anneal the cartilage borders. The arthroscope was then removed, and the ulnar portal extended distally to expose the metacarpal base. Mini Hohmann retractors were placed around the base allowing good access for the oscillating saw (Fig. 3A). A dorsoradial closing wedge osteotomy was then performed to place the thumb in a more extended and abducted position (Fig. 3B and C), which minimized the tendency of subluxation and changed the contact points of worn articular cartilage. This wedge of bone is usually 3 mm wide dorsally and should also be wider on the radial side. This places the thumb in the requisite dorsal and radially abducted position. The osteotomy was fixed by a single oblique 0.045-inch Kirschner wire placed across the first CMC joint in a reduced position (Fig. 4A and B). This not only allowed for healing of the osteotomy in the desired position but also corrected the metacarpal subluxation, so often seen in this stage (Fig. 5A and B). As the metaphysis heals, the volar capsule also tightens minimizing the chance of recurrent subluxation. A thumb spica cast was given for protection, and the wire was removed at approximately 4 to 5 postoperative weeks. After the wire removal, the patient is subjected to an intense rehabilitation protocol for about 4 to 6 weeks to gain maximum motion and strength.

COMPLICATIONS
In the present series, one of the patients developed constant pain later owing to the progression of osteoar- thritis after the procedure. She did not respond to steroid injections and physical therapy. Eventually, she had to undergo an arthroscopic assisted hemitrapezectomy, with a good result. The second complication encoun- tered in our series was complex regional pain syndrome (type I) in one patient, who developed it after the pin removal. This patient was managed with continuous physical therapy, stellate brachial plexus blockades, and neurontin.

SUMMARY
As arthroscopy becomes validated as a technique, we might see a day where less intra-articular injections are given and more joint preservation, rather than palliation, is sought. Arthroscopic assessment of the CMC joint allows direct visualization of all components of the joint including synovium, articular surfaces, ligaments, and the joint capsule. Hence, it allows the evaluation and staging of the joint pathology. Furthermore, the most suitable intraoperative management decision can be made based on this information. We recommend closing wedge extension-abduction osteotomy of the first metacarpal combined with synovectomy and capsulor- raphy for the arthroscopic stage II patients. By preserv- ing the joint, we have ”burned no bridges,^ and a more aggressive procedure, either arthroscopic or open, can be done in the future if symptoms warrant. Hence, arthroscopic visualization allows for the least aggressive procedure to be performed as dictated by the intra- operative findings. According to the arthroscopic clas- sification proposed, we recommend arthroscopic synovectomy and thermal capsulorraphy in patients with stage I, whereas in patients with stage II disease, we combine the synovectomy and capsulorraphy with dorsoradial osteotomy of the first metacarpal.

 

 

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Jamee Wilson
19:01 15 Jul 21
We brought our 17 year old son to Dr. Badia for a hand injury suffered playing baseball. From the moment we walked in... to the office, everyone was kind and attentive. He ended up needing surgery and the entire process was extremely smooth and again, everyone we came in contact with was amazing. The office and surgery center are in the same building so it is very convenient. We had been to other doctors for this same injury several years ago and the injury kept getting misdiagnosed so it was great that Dr. Badia diagnosed the problem and took care it so my son doesn’t have to deal with it anymore.read more
Willy G.
Willy G.
15:19 12 Jul 21
I had a really severe thumb break into 3 PCs. My Finger was in the shape of a Z. I remembered OthroNow and went to Dr... Badia. Was best decision I could make, had surgery next day and was successful. My thumb looks great and doing great. Their staff is amazing from full service of urgent care, to his doctor office staff, surgery center, and their therapy staff is amazing. I would highly recommend them especially for full service from beginning to end.read more
Lia L
Lia L
18:00 25 Jan 21
Not good for pediatric patients . Long wait time, so had a lot of ppl waiting. Would not let me wait on chaira... outside of xray room but rather in the outside waiting room even though my child was only 10. Don’t take pediatric patients if you can’t properly accommodate one guardian.read more
Maria Santos
Maria Santos
01:45 06 Nov 20
I am really satisfy with my hand surgery that was done by Dr. Alejandro Badia, and I want to thanks all the... professional personal and staff that always are very kind. I highly recommended!read more
Najlaa Bayram
Najlaa Bayram
03:45 02 Nov 20
Dr. Badia is an outstanding Dr and surgeon. I first sought his expertise, in late 2013, after a misdiagnosis and a... botched surgery by another Dr that left me with unbearable pain and unable to move my right hand for months.After doing some research online, looking for some excellent hand surgeons, a lot of articles came up praising Dr. Badia's expertise and competence. I sent him an email explaining what happened, how the pain started and asked for his opinion. To my surprise,I received a thorough response the same day with detailed information.I right then decided to drive 4hours to go see him; I must say it was the best decision I made. From the 1st visit, Dr. Badia performed surgery to fix the initial issue and later did another surgery to correct the botched one; I couldn't be happier with the results.Earlier this year, I slipped and injured my left wrist. I made another trip to Miami and once again Dr. Badia came to the rescue. He did surgery on my left wrist after the conservative treatment didn't fully help and at the same time did a cubital nerve release on my right elbow that instantly stopped the pain I've been having.I HIGHLY recommend Dr. Badia; he's a true expert and an outstanding surgeon. His staff is very kind, professional, friendly and truly cares.read more
danadenni
danadenni
21:18 17 Oct 20
My husband and I contacted Dr Badia for my hand issues. I had researched approximately five hand specialists in... Florida and one in New York city before I found Dr Badia about an hour away from us.My husband and I went to Doral, Florida and the minute I met Dr Badia I knew he was going to do my surgery.He has personality plus !!! and loves what he does. He is kind, patient and listens to his patients. He respects your hands !Dr Badia was highly recommended and I am so glad that we found him. He did the surgery on my hand and with a bit of rehab it healed better than I expected and my pain was gone !Dr Badias office personnel are wonderful ! It is quite obvious that they love working there with him and that they love their jobs. My husband and I have never experienced an office with so many helpful and caring people.We both recommend Dr Badia. We still drive to his office for anything to do with hand issues and he takes care of whatever it is. We both trust our hands ONLY to him ! He is a gem.read more
Yohann Dessureault
Yohann Dessureault
02:25 01 Oct 20
I first contacted Dr. Badia's clinic after I injured my hamate bone. I needed a surgery and someone in my family that... knew Dr. Badia convinced me that he was one of the best if not the best hand surgeon in the world. I am a high level Baseball player so I needed treatments in order to get back on the field as soon as possible. I have been able to book an appointment the next week which was great. I'm Canadian which made it tougher with my insurance company, but Dr. Badia's team has been really helpful with that, they sent numerous emails and even made some calls with the company to make sure I would not have any fees related to the consultation and surgery. The surgery went really well, without any complication and I don't think it would have been as quick and easy with anyone else than Dr. Badia and his team. I would definitively recomand Badia Hand to Shoulder Center to anyone in the need of treatments.read more
David Carvallo
David Carvallo
15:29 31 Aug 20
I injured my shoulder right as we entered into a lockdown due to a pandemic. It was next to impossible to get anyone to... see me and assess my injury. Dr. Badia and his team, following carefully laid out safety protocols, were able to bring me in, have x-rays, MRI and thorough review of the findings all in ONE visit!!! I was given an interim treatment plan to bridge the gap as surgeries were restricted due to COVID-19. As soon as surgeries resumed, I was scheduled for my procedure. To say that both Dr. Badia and his team are amazing is an understatement.They helped me handle a difficult insurance approval process to ensure I had the best surgeon treating me and my procedure at The Surgery Center at Doral and communication with my PCP and Cardiologist was excellent.Everyone made me feel very safe and confident that I was in the best possible setting where I wouldn’t be exposed to needless risk in a traditional hospital. The results of my surgery so far have been amazing. I’ve had next to no pain post-op and my recovery is coming along at lightning speed thanks Dr. B’s amazing talent and the dream team he has at OrthoNow where I have been undergoing physical therapy. I couldn’t say enough good things about him and the team. His expertise and dedication to providing the best possible care using cutting edge technology make for patient centered care and well being vs. insurance driven red tape so often seen today. Highly recommend Dr. Badia!read more
Ruth Rheaume
Ruth Rheaume
22:34 11 Aug 20
I went to Dr. Badia with a bad infection in my nail. He is so good at what he does and took care of me with such... concern. Gigi is the sweetest, cutest thing ever, who also made sure that I was comfortable and helped so I would not be nervous. The whole staff makes you feel like family. Thank you everyone from the bottom of my heart and I would recommend Dr. Badia's expertise and his office to anyone. So, if you have an injury or a problem, please go see him.read more
Mark Ferry
Mark Ferry
20:51 05 Aug 20
Tele-med conference with Dr. Badia and staff regarding "golfer's elbow"
Richard Chung
Richard Chung
11:49 23 Jul 20
Staff was very welcoming and accommodating.. Dr. B. was very professional and caring.He seems to be a driving... innovator and in improving the lives of patients in the South Florida area.read more
julio hernandez
julio hernandez
17:05 15 Jul 20
Dr Badia is the best orthopedic surgeon in Miami hands down. I need surgery because of a multiple fracture in my left... forearm. Went to other doctors (UM, mount Sinai) and they didn’t promise me I would recover 100% of my injuries and told me I would not be able to do sports again.Dr Badia did tell me I would heal 100% and it’s true. I did a much simpler surgery and fixed me in no time.Would recommend to anyone. Two thumbs upread more
Deb Duro
Deb Duro
17:19 07 Jul 20
Wonderful practice very welcoming staff and amazing service with top notch technology. I was a patient and I am a... colleague of Dr Badia and had the best treatment for my hand injury got diagnosed in the spot with a 3D Ultrason super modern technology and treated at the same moment. Really superb experience being a physician I absolutely recommended Dr Badia Hand and Shoulder Center at OrthoNOW!read more
Leonard Wolfson
Leonard Wolfson
19:42 04 Nov 19
Excellent visit. I injured my finger yesterday and was seen today by Dr. Badia. The staff was friendly and very... efficient and the doctor spent more than enough time explaining what was going on and explaining my options. Truly a great experience.read more
Luisa Alfonso
Luisa Alfonso
16:25 06 Sep 19
The Dr and staff are professional and friendly. I’m happy I came here and I received the attention and answers I... needed. I had injured my hand and I left the office feeling better. Thank you all for everything!!!read more
Robledo Aybar
Robledo Aybar
16:30 09 Aug 19
Due to a fall, I fractured my wrist in late Nov. 2018. Dr Badia and his team helped me overcome this issue and today... I’m working, and back on my bike and running. The best service and experience!read more
Ellen Westbrook
Ellen Westbrook
23:08 29 Jul 19
Staff displayed professionalism and caring. Dr. Badia was as enthusiastic as I was about this surgery to improve the... function of my hand. The surgical day process was smooth; I was kept informed every step of the way. I felt comfortable and safe.read more
victor mendelsohn
victor mendelsohn
02:37 30 May 19
From the first call I made to Dr. Badia‘s office I was impressed by the professionalism of the person who answered the... phone. When I arrived at the office for my appointment I was once again greeted in a professional manner. This professionalism radiated through all of the team. I hadn’t seen Dr. Badia for over 10 years and he greeted me as if we’ve been in contact with each other for years.read more
Alexander Aguiar
Alexander Aguiar
18:19 24 Apr 19
From my first visit the staff as well as the Dr. Badia have been exceptionally professional and caring. I had an injury... to my pinky finger, the required a placement of a rod in order to align. The surgery went well and was scheduled right away. The office staff has been amazing with scheduling and confirming appointments. Overall I am very happy with the care i received as well as the results. My finger healed and my range of motion has also gotten much better. Thank you Dr. Badiaread more
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305 227-HAND (4263)

3650 NW 82nd Ave. Suite 103
Doral, Florida 33166
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Badia Hand to Shoulder Center
Complete Care of the Hand, Wrist, Elbow and Shoulder in one Medical Facility Dr. Alejandro Badia, M.D, F.A.C.S. Past President ISSPORTH (2011-2013)
Our Office Hours:
3650 NW 82nd Ave, Doral, FL 33166, USA - Badia Hand to Shoulder Center
Monday 8:30 AM – 5:00 PM
Tuesday 8:30 AM – 5:00 PM
Wednesday 8:30 AM – 5:00 PM
Thursday 8:30 AM – 5:00 PM
Friday 8:30 AM – 5:00 PM
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305 227-HAND (4263)

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