Conservative There is moderate quality evidence that manual therapy and therapeutic exercise improves pain in patients with thumb CMC OA at both short- and intermediate-term follow-up, and low to moderate quality evidence that magneto therapy improves pain and function at short-term follow-up. There is moderate evidence that orthoses (splints) can improve hand function at long-term follow-up. There is very low to low-quality evidence that other conservative interventions provide no significant improvement in pain and in function at short- and long-term follow-up. Some of the commonly performed conservative interventions performed in therapy have evidence to support their use to improve hand function and decrease hand pain in patients with CMC OA. Patients with CMC OA of the thumb should initially be treated conservatively. Conservative treatment is equal to any non-surgical treatment and includes splinting, manual therapy, therapeutic exercises, magneto therapy, laser, NSAID medication and injections with corticosteroids. Manual therapy Manual therapy is another commonly used treatment modality in which the joints or muscles of patients are manipulated with the intention of restoring the range of motion of the joint or increasing the flexibility of the muscles around the joint. Intervention techniques: * Kaltenborn Mobilization Technique * Maitland's Mobilization * Neurodynamic Techniques Kaltenborn mobilization technique The specific Kaltenborn mobilization of posterior-anterior gliding with distraction in grade 3 of the CMC joint; the Convex/Concave Rule was applied in each case. In brief, Kaltenborn described these mechanics in terms of the convex-concave rule; the direction of decreased joint gliding in a hypomobile joint and, thus, the appropriate treatment can be deduced by this rule. With movement of a concave joint partner, the glide occurs in the same direction. The form of the joint surface has been considered to induce its gliding/sliding movement; a female (concave) joint surface glides in the same direction as the bone movement, whereas a male (convex) surface glides in the opposite direction of the bone movement. Traction is the technique that distracts 1 articular surface perpendicular to the other, and the glide technique describes the translational gliding of 1 articular surface parallel to the other. Traction in grade 3 has been defined as an additional force, which is applied in the parallel axis. This results in surrounding soft tissues and joint stretching, separating the joint surfaces. Neural mobilization technique Nerve mobilization aims to glide a nerve by alternating moving at least two joints to increase in nerve strain due to nerve bed elongation at one joint (e.g., wrist extension) is simultaneously counterbalanced by a decrease in nerve bed length at an adjacent joint (e.g., elbow flexion). The nerve mobilization technique for the median nerve consists of alternating the combination of elbow extension (which increases tension on the median nerve) and wrist flexion (which decreases tension on the median nerve) movement with the combination of elbow flexion (decreasing tension) and wrist extension (increasing tension) movement. The radial nerve mobilization involves alternating the following 2 movements: shoulder depression applied simultaneously with elbow flexion and wrist flexion and ulnar deviation wrist extension; and shoulder elevation simultaneously with elbow extension, wrist extension. These movements can be alternated at a rate of approximately 2 seconds per cycle (1 second into extension and 1 second into flexion). Speed and amplitude of movement is adjusted to ensure that no pain was produced. At each session, the technique can be applied 3 times for 3 min separated by 1-min rest periods. Surgery If conservative treatment does not reduce the complaints of patients, surgical treatment is indicated. This might be the case when pain persists or when functional disability remains present after conservative treatment. There are several surgical options to treat CMC OA of the thumb. The aim of the treatment is not to cure the disease but to minimize the complaints and symptoms of patients. Because many different expert opinions about the surgical treatment exist, there are many varieties of surgery, even within one type of surgery. However, there are four types of surgical techniques that are most commonly used. These techniques can be categorized as follows: * Trapeziectomy * Arthrodesis * Joint replacement * Metacarpal osteotomy Throughout the years many clinical trials have been carried out, investigating which surgical technique is superior. The levels of evidence of these studies vary from case reports up to randomized controlled trials and systematic reviews. Most studies focused on levels of pain, strength of the thumb, thumb mobility, satisfaction and complications. No significant evidence has been found to claim that one of the four treatments is superior to one of the others in both short- and long-term effect. Further investigation is needed, but until new evidence is found, investigators advice to carry out the most simple treatment with the least amount of complications. This means that the trapeziectomy is the most recommended surgical procedure for now. Showing the forces after trapeziectomy Types of trapeziectomy The principle of this procedure is the removal of the trapezium bone. It was originally described by Gervis in 1949 24. Because half of the carpometacarpal joint is removed, the complaints of patients caused by OA are usually gone. Four main varieties within this procedure are performed: ::::::::::* Trapeziectomy ::::::::::* Trapeziectomy with tendon interposition (TI) ::::::::::* Trapeziectomy with ligament reconstruction (LR) ::::::::::* Trapeziectomy with a combination of ligament reconstruction and tendon interposition (LRTI) Claims have been made that one of these procedures is superior to the others, but there is no scientific evidence to support these statements. When pain, grip strength and key and tip pinch strengths were examined, investigators could not find a significant difference between the different procedures. Investigators suggest that the trapeziectomy without any interposition or reconstruction is preferred. It is a simpler procedure then the trapeziectomy with TI or LR and it tends to have fewer complications than the trapeziectomy with LRTI. Trapeziectomy is considered a good surgical option to treat stage II to IV of CMC OA of the thumb. Trapeziectomy The most simple form out of the four variations is the trapeziectomy alone, also referred as the simple trapeziectomy. During this procedure, the trapezium bone is removed without any further surgical adjustments.The trapezium bone will be removed through an approximately three centimeter long incision along the lateral side of the thumb. To preserve surrounding structures, the trapezium bone will be removed through fragmentation of the bone (the bone will therefore be broken into pieces). An empty gap is left by the trapeziectomy and the wound is closed with sutures. Despite this gap, no significant changes in function of the thumb are reported. After the surgery, the thumb will be immobilized with a cast. Trapeziectomy with TI Some physicians still believe that it is better to fill the gap left by the trapeziectomy. They assume that filling the gap with a part of a tendon is preferable in terms of function, stability and position of the thumb. They are afraid that leaving a gap might result in complications such as shortening or subluxation of the thumb. During trapeziectomy with TI, a tendon interposition is performed. A longitudinal strip of the palmaris longus tendon is separated. If this tendon is absent (which is the case in 13% of the population), half of the flexor carpi radialis tendon (FCR) can be used. The tendon is then formed into a circular shape and placed in the gap, where it will be stabilized by sutures. Trapeziectomy with LR Another technique used to assumable restore stability of the thumb, is a ligament reconstruction after a trapeziectomy is performed. The thought is that ligament reconstruction provides more stability to the thumb after removal of the trapezium bone. During this procedure the anterior oblique ligament is reconstructed using the FCR tendon. There is a wide variety in techniques to perform this LR, but they all have a similar goal. Arthrodesis of the thumb Trapeziectomy with LRTI Some physicians suppose that combining LR with TI results in an even better stabilised thumb. Like the name already suggests, this procedure includes a combination of a trapeziectomy with a LR as well as a TI. Arthrodesis Arthrodesis of the CMC1 joint is a surgical procedure in which the trapezium bone and the metacarpal bone of the thumb are secured together. Because the joint is fixed, and therefore can not be moved, the complaints of the patient are mainly gone.During the surgery the two bones will be fixated using K-wires. The use of plates and screws has also been described. The thumb will be positioned in a way it can still perform a pinch grip. Because of the fixation, the two bones will fuse together. This will occur usually within four to six weeks. However, this technique has some disadvantages. The palm of the hand is unable to be flattened, making it difficult to wear gloves or put your hand in a pocket. Because the stress on the CMC1 joint is now divided over the other joints, those joints are more likely to be damaged. Nevertheless, this procedure can be used in patients with stage II and III CMC OA as well as
Trapeziometacarpal osteoarthritis
Median rhomboid glossitis
Carpal coalition
Olecranon bursitis
Metatarsophalangeal joint sprain
Back strain
Tarsal tunnel syndrome
Retrocalcaneal bursitis