Pain free function of the thumb carpometacarpal (CMC) joint is essential for manual work. Osteoarthrithis of the thumb saddle joint is very common. Among different conservative and operative treatment options (ergotherapy, intraarticular infiltration, ligament reconstruction, resectionarthroplasty, arthrodesis, spacer), the implantation of a prosthesis is an alternative. This prospective study reports short time results of the uncemented hydroxilapatite coated Ivory prosthesis. The mean follow up time of the 21 patients was 12.1 months (range 6 to 18 months) and the mean age 57.2 years. The patients suffered from osteoarthritis of the thumb saddle joint stage II–III according to Eaton Littler. We evaluated the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS), clinical (abduction, flexion, strength) and radiological outcome. The clinical results showed excellent pain relief with an improvement of the VAS from 7.3 preoperative to 0.8 postoperative (p<
0.05) and a decline of the DASH score from 42.9 to 6.05 points (p<
0.5). We measured an abduction with a mean of 47.5° and a flexion with a mean of 43.2°. The power of the fist grip was in mean 31.3 kg, of the key grip 6.4 kg. Radiological there were no signs of implant loosening. As complications occurred one posttraumatic trapezium fracture with luxation and one tendovaginits De Quervain. The advantage of a total replacement of the CMC I joint, compared to the standard resection arthroplasty, is faster rehabilitation and preservation of the length of the thumb and so better strength. Our results are encouraging, but we have to wait for long time results mainly concerning implant loosening. In the case of the trapezium fracture with luxation we could remove the prosthesis and performed a resectionarthroplasty.
Bone marrow edema syndrome (BMES) is a common cause of severe bone and joint pain. Intra-articular migrating of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease. We reviewed 8 patients (4 female, 4 male) with unilateral BMES located in the knee. The patients were aged 39–56 years (mean 50.2). In all the patients bone marrow edema (BME) found in the primary magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice. The final MR investigation performed on average 8 months after baseline (range, 7–11 months) showed full resolution of BMES in 6 patients. One patient had small residual edematous bone areas. No quadrant was newly affected. Improvement of the MR imaging pattern was correlated with the clinical outcome in all patients. The severity of effort-induced pain (VAS) was reduced from 7.5 (2.0–10.0) at baseline to 5.9 (2.4–7.9) after 3 months and to 0.6 (0–0.9) after the final examination. Pain at rest (VAS) diminished from 3.9 (1.5–7.8) to 2.8 (1.4–6.0) after 3 months and to 0 at the final follow-up. All patients became asymptomatic after a mean of 9 months (6–11). Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended.
An unstable CMC I joint causes pain and dysfunction. Chronic subluxation can lead to cartilage damage and furthermore to rhizarthrosis. This study should evaluate the results of the Eaton Littler ligament reconstruction, in which a slip of the Flexor carpi radialis tendon (FCR) weaved through the basis of the first metacarpal and around the tendon of the Abductor pollicis longus and back to the FCR. Aftertreatment consists in 4 weeks cast, 4 weeks thermoplastic splint and physiotherapy, full opposition is allowed after 8 weeks. We performed 10 operations in 8 patients with a mean age of 35.9 years (6 female, 2 male). In 8 times the diagnosis was a rhizarthrosis Eaton Littler stadium I and in 2 times a posttraumatic instability. The mean follow up time was 15.4 months. We evaluated subjective satisfaction with the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS) and the patients were asked, if they would undergo the operation again. Furthermore the range of motion (ROM) was examined, the strengths (key and pin grip) were measured and radiographs were made. All patients would undergo the operation again. The mean DASH score was 17.4 points, the mean VAS in rest 0 and under stress 1.29. The mean pin grip strength was 3.98 kg and the mean key grip strength 7.14kg. The ROM was excellent with a mean anteposition of 39.5°, a mean abduction of 49.3°. The mean thumb opposition was Kapandji 9.9. Radiological there was no progression of the Eaton Littler stadium. As complications occurred 1 keloid and 1 hypaesthesia. Our experiences with the Eaton Littler procedure for stabilisation of the hypermobile thumb saddle joint were positive. Long time results will show, if the procedure can prevent cartilage damage and progression of rhizarthrosis.
Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES. The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES. Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months). The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease.
Bone marrow edema (BME) is frequently observed on MR images in patients presenting with severe joint pain and may be present in numerous bone and joint diseases. BME may be subdivided into ischemic (bone marrow edema syndrome, BMES), mechanical and reactive BME. Although bone marrow edema of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool. 70 patients (36 female, 34 male) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS). The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p<
0.0001) as well as the affected quadrant (p<
0.0001 for the medial femoral condyle and the medial femoral plateau). The probable mode of action is that high intramedullary pressure in the BME affected bone (normal values are less than 30 mmHg) is additionally raised for a short period of time by the impact of the hammer on the bone surface, causing intense local pain. The test is economical, easy to perform in a doctor’s office, and not time-consuming but the final and evidentiary dignosis of BME can only be made by MRI. The tapping test is a good screening instrument to diagnose BME in the knee.
