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The Wisconsin Hand Experience 2016

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.

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The Wisconsin Hand Experience 2016

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  1. The Wisconsin Hand Experience2016 CMC Pitfalls and Preferences Greg Watchmaker, MD Zion 2014

  2. Pitfalls

  3. Expectations

  4. Expectations • Relieve pain 93% • Improve strength 93% • Restore basic tasks like opening a jar 93% • Prevent condtion from worsening 95%

  5. Expectations

  6. 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

  7. Growth of Thumb’s Importance Bipedalism and club weilding associated with thumb development

  8. 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

  9. Thumb Kinematics -Force increases exponentially from tip to base during pinch activities -120kg force at CMC joint during pinch

  10. CMC- Ligaments 3 – 16 Ligaments Anterior Oblique Ligament? Dorsal Deltoid Ligaments

  11. CMC- Treatment Options • Adaptive techniques • Neoprene/Custom Braces • Warmth • NSAIDs • Cortisone • Surgery

  12. Preferences Adaptive

  13. CMC Preferences Splinting • Neoprene prefabricated • Semi-rigid prefabricated • Custom thermal molded

  14. Audience Preferences - Splinting • Neoprene prefabricated • Semi-rigid prefabricated • Custom thermal molded

  15. Preferences- Splinting Randomized cross-over study Neoprene vs. custom thermal

  16. Pitfalls - Injections Cortisone Culture expanded stem cells Hyaluronic acid Autologous fat

  17. Pitfalls - Injections

  18. Pitfalls - Injections Cortisone vs. Placebo

  19. Surgical Options • Mini TightRope • Hematoma Arthroplasty • Tendon Interposition • Joint or Hemi replacement • Synthentic Spacers • Arthroscopic Arthroplasties • Osteotomies

  20. CMC Arthoplasty– Treatment - Trapezium Excision (1949) • Tendon Interposition (1970) • Ligament Reconstruction (1973) • Ligament Reconstruction and Trapeziectomy (1986) • Trapezium Excision (2007)

  21. Interposition Material • Trapezium resection only (nothing) • Tendon Interposition (FCR, PL, APL) • Orthosphere • Artelon

  22. Trapeziectomy vs. LRTI

  23. Pitfalls - Joint Replacement

  24. 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

  25. Pitfalls - Snythetic Interposition

  26. Arthroscopic Arthroplasty • 26 patients with 20 month follow-up • Poly-L-lactic acid implant • Pain 6.61 VAS  6.03 • QuickDASH 56  54 • Pinch 3.7kg 2.2kg

  27. Preferences

  28. Preferences

  29. Preferences - Injections

  30. Audience - Immobilization • Cast 4 weeks or more • Cast 2-4 weeks • Removable splint only • No splint

  31. Pinning the Joint • Never Pin • Sometimes Pin • Always Pin

  32. Therapy Visits Post-op • No Therapy • 1-4 visits • 5-8 visits • 9-12 visits • 13-16 visits • 17-20 visits • 21-24 visits • Never stop

  33. Duration of Rehab

  34. The Need for Strength

  35. Pitfalls - Ongoing Pain Incomplete bone resection Low-grade infection LABC and radial sensory nerve injury CRPS Scapho-trapezoidal arthrosis FCR tendinitis Adhesions

  36. CMC Arthroplasty - Outcomes

  37. CMC Arthroplasty - Outcomes

  38. Take Home Messages More and more common Take time treating conservatively (adaptive devices, neoprene, injections) Any surgery with good technique is fine (with caveats)

  39. The Wisconsin Hand Experience Murren 2015 CMC Pitfalls and Preferences Greg Watchmaker, MD

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