Artículos Médicos

Osteoartritis carpometacarpianas de pulgar asociada a hipotermia concomitante infrecuente que imita el síndrome del túnel carpiano irreversible

Introducción

The thumb carpometacarpal joint (CMCJ I) is the most common site of osteoarthritis (OA) in the hand with post-menopausal female predominance and it can be associated with concomitant carpal tunnel syndrome (CTS) in 25% of cases [1-3]. We present one case in which hypoproteinemia mimicking an advanced stage of CTS that required a CMCJ I arthrodesis.

Presentación del caso

A 57-year-old underweighted female (body height 1.55 m) presented with right advanced stage of symptomatic CMCJ I OA for many years (Figure 1A). She reported about loss of her body weight within the last 10 years from 60 kg (body mass index 25) to 43 kg (body mass index 17,9). The cause for the underweight was unknown by the patient, and she has ruled out a malnutrition. Additionally, she noted tingle at all fingertips of both hands. Clinical examination revealed a marked restriction of abduction/oppostion/circumduction of the thumb associated with an insufficient object grasp, and a pronounced thenar muscle atrophy (also left) (Figure 1B). Pain in visual analogue score (VAS, scale 0-10) was 9, Patient-rated wrist evaluation (PRWE, 0-100 points) 81, and grip strength (Jamar dynamometer) 28% to the opposite hand. Electroneurographic examination did not reveal peripheral nerve compression syndromes at her both hands nor a cervical spine disorder that led to the diagnosis by the neurologist of a polyneuropathy in the absence of any motor deficits with unknown etiology. The further diagnostic procedure yielded a hypoproteinemia with a pronounced decreased serum level of 55.7 g/l (normal range 65.0 – 85.0 g/l).
The arthrodesis of the CMCJ I was done utilizing an iliac crest corticocancellous bone graft to obtain the length of the thumb and a 3,0 mm cannulated titanium headless compression screw (DePuySynthes, USA) with the thumb in 50° abduction and 30° angled radially to the longitudinal axis of the second metacarpal bone after release of the adduction contracture with widening of the first web and resection of the corresponding articular surfaces (Figure 2A). Postoperatively, the right wrist with the thumb was immibilized in plaster splint for four weeks. At the 1-year follow-up we observed an uneventful bony healing and all functional tasks without a rotation failure of the thumb could be performed again. (Figure 2B-C). Pain and PRWE had improved to 9 and 32, and grip strength to 74% to the opposite hand. The patient was very satisfied with the outcome allowing performance of most activities in daily living again.

Discussion

Grip strength is one of the most relevant functional aspect to maintain independence and quality of life in humans. When decreased, it can have an impact on their functional capacity, but noted that it can decrease physiologically to 43% and more in healthy subjects starting with age of 60 years [4]. Muscle atrophy as one cause for decreased grip strength is a physiological age-related process as well, but it may arise (excluding central or peripheral nerve disorders) either by workrelated overuse, longstanding immobilization, malnutrition, chronic diseases of various internal organs, or by immune disorders [5]. With our patient, the symptoms of tingle at all fingertips and impaired opposition/circumduction of the thumb were similar to an advanced sensomotor CTS (i.e. distal median nerve palsy) [6]. However, the etiology of the hypoproteinemia that led to the pronounced thenar muscle atrophie associated with a highly restricted movement of the thumb (in combination with the longstanding painful CMCJ I OA) was unclear. Because of the longstanding anamnesis the muscle atrophy had to be considered as irreversible.

Treatment options for advanced stage of CMCJ I OA are the motion-preserving trapeziectomy (i.e. resection arthroplasty with or without ligamentous reconstruction, tendon interposition or suspension) and total CMCJ replacement that can be combined with other surgical wrist procedures, and the motion-restricting CMCJ I arthrodesis [7-10]. For treatment of irreversible peripheral motor nerve palsies a motion-enhancing procedure by a tendon transfer procedure is the method of choice, but detected only when a normal muscle activity of the donor muscle-tendon unit for the affected joint is present that was not given with our patient [11]. For thenar muscle atrophy caused by an irreversible CTS the Burkhalter opponensplasty (transfer of the extensor indicis proprius, motor innervated by the non-affected antagonistc radial nerve) is one option in order to improve opposition/ circumduction of the thumb (Figure 3A-B) [12,13]. Theoretically, the opponensplasty provides the option to combine it with a thumb motion- and length-preserving total CMCJ I replacement [2,14], but it was too risky for us because it had to be suspected with our patient that the muscle atrophy seemed to be generalized (involving possible donor muscle-tendon units). The combination of the opponensplasty with the motion-preserving trapeziectomy had to be considered critical as well because for the success of a tendon transfer procedure the physiological forces of the donor muscle-tendon unit should be preserved [11]. The problem of trapeziectomy is that this procedure does not obtain normal length of the thumb potentially leading to a painful impingement between the base of the first metacarpal and scaphoid or trapezoid bone (Figure 4A) associated with non-physiological muscle and tendon forces often resulting in a decreased stability in the adjacent metacarpaophalangeal joint, impaired grip strength and key pinch forces as compared to a total CMCJ I replacement [15-20]. Therefore, the CMCJ I arthrodesis was the only option of choice in order to improve the functionality of the entire affected hand with our patient. CMCJ I arthrodesis with or without bone grafting provides a stable and powerful thumb. It is recommended for younger patients with high claims in occupational work and leisure, but it should not be done in the presence of concomitant OA at the metacarpophalangeal joint potentially leading to an arthrodesis as well [2,7,21-24]. Noted that 80% of patients received a metacarpophalangeal joint arthrodesis in the presence of a well functioning CMCJ I reported difficulties such as slicing bread, using scissors, opening jars, handling small or heavy objects, writing, using a keyboard, or writing messages on a mobile phone [25]. Another indication is an irreducible Z - deformity of the thumb with closure of the first web and hyperextension in the metacarpophalangeal joint [26]. The outcome is reported to be controversial, patients satisfaction can be high but only 64% of patients would undergo the procedure again themselves depending on the postoperative pain relief [27]. No significant age-related differences in the patients satisfaction were found (55 years and younger vs. 65 years and older), however, due to its high complication rate it is not always recommended for women aged 40 years and older, and the patient's satisfaction is only high in 88% of cases when osseous fusion is obtained [28-31]. Nonunion is observed in up to 20% of cases especially if K-wires were used which underlines the need for a stable fixation such as recommended with the use of a cannulated compression screw [32,33]. Moreover, patients often compensate the loss of function after CMCJ I arthrodesis by developing increased non-physiological range of motion in the scaphotrapeziotrapezoidal and metacarpophalangeal joint potentially is observed in the metacarpophalangeal joint with a relative portion of 75% and followed by 25% in the scaphotrapeziotrapezoidal joint [35]. The incidence of scaphotrapeziotrapezoidal OA after CMCJ I arthrodesis is reported to be 16.2% radiographically; but noted that only 3.3% of them are symptomatically and for those cases the conversion to trapeziectomy is recommended [36]. For a failed CMCJ I arthrodesis in the absence of scaphotrapeziotrapezoidal OA the conversion to a motion-restoring total CMCJ I replacement that may decrease overuse-related disorders in the adjacent joints can improve the patients satisfaction in single cases as well [37]. Noted that for a failed trapeziectomy the thumb-index metacarpal arthrodesis with or without involvement of the trapezoid bone (Figure 4A-D) or an insertion of a joint prosthesis with the cup placed into the scaphoid bone (i.e. scaphometacarpal arthroplasty) is also to be considered as a salvage option of choice [38-40]. The limitation of a scaphometacarpal arthrodesis is that this procedure impairs the wrist biomechanics (i.e. restriction of mobility in the midcarpal joint), thus, it is recommended only if various previously performed procedures at the CMCJ I have been failed [41,42]. For specific cases which require excision of the entire trapez and first metacarpal bone the arthrodesis between the proximal phalanx of the thumb and the second metacarpal bone is described [43].

Declaration of conflicting interests

The author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

None.

Acknowledgements

The author would like to thank Dr. Tino Beylich (Klinikum Bad Salzungen GmbH, Germany), Dr. Ivo Nennstiel (SRH Klinikum Suhl, Germany), and Dr. Heiner Schmitz (Medical Centre Dr. Zollmann & Colleagues Jena, Germany) for their excellent support in treating our patients.

References

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