SYM10: Thumb Basal Joint Arthritis - Expert Surgeons ...
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SYM10: Thumb Basal Joint Arthritis -
Expert Surgeons Defend their Procedure
Moderator(s): Warren C. Hammert, MD
Faculty: Steven Z. Glickel, MD, Amy L. Ladd, MD, Jennifer Moriatis Wolf, MD, and
Jeffrey Yao, MD
Session Handouts
Saturday, October 03, 2020
75TH VIRTUAL ANNUAL MEETING OF THE ASSH
OCTOBER 1-3, 2020
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
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SYM10: Thumb Basil Joint ArthritisExpert Surgeons Defend Their
ProcedureModerator:
Warren C. Hammert, MD
Faculty: Steven Z. Glickel, MDAmy L. Ladd, MDJeffrey Yao, MD
Jennifer Moriatis Wolf, MD
Steven Z. Glickel, MD
Hematoma Distraction Arthroplasty
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Amy L. Ladd, MD
Trapeziectomy with Suture Suspension Arthroplasty
Jeffrey Yao, MD
Trapeziectomy with Suture Button Suspension Arthroplasty
Jennifer M. Wolf, MD
Ligament Reconstruction and Tendon Interposition Arthroplasty
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Thumb CMC Arthritis
Warren C. Hammert, MD
October 3, 2020
Disclosure
No relevant financial relationships with commercial interest to disclose
But, I live in Rochester, NY – Home of LRTI
Becker SJE, et al. Death, taxes, and trapeziometacarpal arthrosis hand. CORR. 2013Prevalence of thumb CMC arthritis increases with age, and radiographic changes consistent with the disease have been reported to be as high as 85% in individuals aged 71 to 80 years of age, and 100% in women aged 91 and older
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Anatomy and Biomechanics
Saddle joint – allows motion in 3 planesOpposition – flexion, abduction, pronation16 ligaments
Key stabilizers – AOL (beak ligament), DRL
Joint compression force 12-14X greater than force at tip of thumb and index during pinch
Imaging
Views of thumb rather than hand or wristRoberts, Bett’s, 300 stress view
Eaton Littler Classification most widely used• Stage 1-4
Imaging- Special Views
30 Degree stress view
Allows visualization of all trapezium articulations
Robert’s View
True AP
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Imaging
Pantrapezial Arthritis – Eaton Stage 4
Pantrapezial ArthritisMore likely to have carpal malalignment due to scaphoid shortening/ proximal row extension
May be exacerbated by trapezial excision and proximal trapezoid excision
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Nonoperative Treatment
BracingNSAIDSStrengtheningCorticosteroid injections
Orthotics
Strengthening
Adams JE et al. Radiographic Analysis of Simulated First Dorsal Interosseous and Opponens Pollicis Loading Upon Thumb CMC Joint Subluxation: A Cadaver Study. Hand 2018
McGee C et al. First Dorsal Interosseous Muscle Contraction Results in Radiographic Reduction of Healthy Thumb Carpometacarpal Joint. JHT 2015
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Surgical Treatment
• Eaton ligament reconstruction
• Metacarpal extension osteotomy
• Dorsal capsulodesis
• Implant arthroplasty
Trapezium Sparing Trapezial Excision• Excisional arthroplasty
• Trapeziectomy
• Trapeziectomy with interposition
• Trapeziectomy with ligament reconstruction
• Trapeziectomy with ligament reconstruction and tendon interposition
Outcomes
Most do well so becomes surgeon preference
What do we know?
• Authors' conclusions• We did not identify any studies that
compared surgery to sham surgery or to non‐operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.
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DISCLOSURES
Steven Z. Glickel, MD
Speaker has no relevant financial relationships with commercial interest to disclose.
HEMATOMA DISTRACTION ARTHROPLASTY
Steven Z. Glickel, M.D.OrthoManhattan
Clinical Professor of Orthopaedic SurgeryNYU Grossman School of Medicine
New York, N.Y.
EVIDENCE BASED
• Rationale for evidence based medicine is to base treatment upon available evidence
• For much of what we do there is little strong evidence but a lot of experience
• Treatment of basal joint disease is one of the few things in hand surgery for which there is compelling evidence
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EVIDENCE DAVIS• Trapeziectomy (T) 30, T+interposition 23, LRTI 23; Pinned 4 wks• Pain, ROM, stiffness, weakness, functional disability, key and tip pinch, grip, scaphoid-
thumb MC height• Results indistinguishable at 3 months and 1 year
Davis et al. JHS(B) 1997
• Trapeziectomy (T) 62, T+interposition 59, LRTI 62; Pinned 4 wks• Pain, ROM, stiffness, weakness, functional disability, key and tip pinch, grip, failure rate• Outcomes were very similar at 1 year F/U• “There appears to be no benefit to tendon interposition or ligament reconstruction”
Davis et al. JHS(Am) 2004
EVIDENCE DAVIS• Trapeziectomy 67, not pinned; LRTI 61 pinned 4 weeks• Pain, ROM, stiffness, weakness, key and tip pinch, grip, DASH• No significant differences at 3 month and 1 year f/u of trapeziectomy w/o pin and LRTI
with pinDavis, Pace JHS(E) 2009
• Trapeziectomy 52, trapeziectomy with PL interposition 46, LRTI 54; Pinned 4 weeks• Minimum 5 y f/u; mean 6 y; range 5-18 y• No difference in pain relief, grip, key and tip pinch
Gangopadhyay et al. J Hand Surg 2011
EVIDENCE COCHRANE 2005• 7 Studies 384 patients• Procedures
– Trapeziectomy– Trapeziectomy with interpositional arthroplasty– Trapeziectomy with ligament reconstruction – LRTI– Joint replacement
• No procedure superior re: pain, function, pt. global assessment, ROM or strength
• LRTI 11% more adverse events than other procedures
Wajon et al. Cochrane Database Syst Rev. 2005
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EVIDENCE COCHRANE 2009
• 9 studies 477 participants• Procedures
– Trapeziectomy– LRTI– Trapeziectomy with interpositional arthroplasty – Trapeziectomy with ligament reconstruction – Artelon– Arthrodesis– Joint replacement
• No procedure demonstrated superiority over another in terms of pain, physical function, patient global assessment or ROM
Wajon et al. Cochrane Database Syst Rev. 2009
EVIDENCE COCHRANE 2015
• 11 studies 670 participants• Procedures
– Trapeziectomy– LRTI– Trapeziectomy with interpositional arthroplasty– Trapeziectomy with ligament reconstruction– Artelon– Arthrodesis– Swanson joint replacement
• No procedure demonstrated superiority in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or imaging
Wajon et al. Cochrane Database Syst Rev. 2015
EVIDENCE BASED?
• Logic would suggest that if results are equivalent for several techniques it would make sense to do the simplest procedure that achieves that result
• That procedure is hematoma distraction arthroplasty
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HEMATOMA DISTRACTION
• I am not trying to convince you that HDA is the greatest thing since sliced bread
CRITERIA CMC ARTHROPLASTY
Important• Good results• Patient satisfaction• Low complication rate• Cost
Not Important• “Procedural chauvinism” • Devices and implants for the sake of
using devices and implants
HDA yields good results, high patient satisfaction, low complication rate and is most cost effective of procedures being discussed today
HEMATOMA DISTRACTION
• HDA meets all of the criteria of what is important• Very underused based on its merits
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WHY NOT DO HDA
• Duration of immobilization (5-6 weeks)• Some patients do not like K-wires
• Duration of immobilization has no long term negative implication
Haase SC, Chung KC. Plast Reconstr Surg. 2011
• We use K-wires for dozens of indications; why is it problematic for HDA
PRE OP
PRE OP
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POST OP
• 5-6 weeks in splint• Removable splint x 2 weeks• Therapy beginning when out of initial splint
– ROM for 1st month– ROM and strengthening thereafter
1 YEAR POST OP
HEMATOMA DISTRACTION
• Trapeziectomy and pinning in abduction and extension for 6 weeks– 22 thumbs– F/U avg 6.5 years– 18 of 22 completely pain free– 21% increase in grip– 11% increase in key pinch– ROM nearly full– Arthritis Impact Measurement Scale: improvement in hand function
Gray, Meals. J Hand Surg. 2007
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LESS IS MORE
“There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of LRTI. This presents further evidence that potentially, “less is more” in the treatment of thumb CMC arthritis.”
Ladd and Yao, senior authorsPark et al. Hand, 2008
EVIDENCE BASED?
• We do what we have been taught and what we are comfortable doing that yields good results
• However, if an alternative exists that is as successful, more efficient and more cost effective, consideration might be given to trying that procedure
• The current trend seems to be in the opposite direction i.e. more devices, more implants, no demonstrably better results at greater cost
Thank you
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Amy L. Ladd, MD
Intellectual Property: Loci OrthopaedicsContracted Research: NIHOwnership Interests: Loci, Intuitive Surgical, Stryker
Amy L. Ladd MD
SYM10: Thumb Basal Joint Arthritis – Expert Surgeons Defend Their ProcedureASSH Annual Meeting 2020
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University of Rochester tradition LRTI
Richard I Burton MD
Vincent Pellegrini MD
Suture suspension arthroplasty 2009
Jeanne Delsignore MD
Ladd – volar
Weiss – dorsal
Distal insertion FCR & APL “nature’s anchors” 2019 JHS Weiss report 320 consecutive patients
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Anybody who hurts enough . . . And has failed the treatment ladder options
Special Considerations Pantrapezial collapse MP collapse
Relative contraindications Inflammatory arthritis Strength is critical
Volar (Wagner) approach Dorsal works fine, too
Ladd & Weiss Hand‐e Video AAOS and VuMedi, too
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What all our procedures have in common
Pain‐free joint
Dexterity
Mobility
Strength
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Joint reaction force
Newton’s 3rd law of Motion
For every action, there is an equal and opposite reaction.
MP Arthrodesis Collapsible thumb > 30 degrees
Remember . . .
Trapeziectomy creates a marshmallow, not a drumhead!
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DISCLOSURES
Jeffrey Yao, MD
Royalty: Arthrex
Intellectual Property: Arthrex, Elevate Braces
Speakers Bureau: Depuy-Synthes, Trice/Segway, Exsomed
Ownership Interests: Elevate Braces, 3D Systems
Trapeziectomy with Suture Button Suspension: Allowing Early
Unprotected ROMJeffrey Yao, MD
ProfessorDepartment of Orthopaedic SurgeryStanford University Medical Center
Methods of Treatment for Thumb CMC Arthritis
• Trapeziectomy with hematoma distraction arthroplasty (HDA)• Gervis, 1949; Meals, 2004
• Ligament Reconstruction Tendon Interposition (LRTI)• Burton, Pelligrini 1986
• APL suspensionplasty• Thompson, 1989• Soejima, Hanamura, Kikuta, Iida, Naito, 2006
• Suture suspensionplasty• Delsignore, 2009
• Allograft rib interposition• Eaton, 1984, Trumble, 2000
• Implant arthroplasty -Not proven
• Unique Circumstances• Wilson metacarpal osteotomy – younger patients
• CMC arthrodesis – post-traumatic DJD in young laborers
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Patients Treated with All Techniques Do Well!
Evidence Based Medicine
• Conclusions from Cochrane Reviews 2005, 2009, 2015:
• Patients treated with all techniques do well• Treatment is largely based on surgeon preference• Trapeziectomy alone: lower complications• No need for ligament reconstruction!• No need for interposition!• Some secondary criteria may drive future trends• Operative time• Complications• Accelerated recovery
If you did this…
…you wouldn’t do this
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So if you did this…
…No need to do this!
Would You Want a Cast for 4 Weeks or More?
Or Would You Want THIS at 5 Days??
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Or this at 5 days?
Suture Button Suspension
Supporting Literature
Arthroscopy, 2010
Yao, JHS 2013Kakar, JHS 2014Mohan, J Orthop 2015Avant, Hand 2015Landes, Hand 2016
Desai, Hand 2016Hooke, JHS 2016Yao, JHS 2017Grasu, Hand 2019Hozack, Hand 2020
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Clinical Case – Eaton III
Clinical Case – Eaton III
Ballottment after Trapeziectomy
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Pearl: Use Targeting Jig for Precise Insertion of Guidewire
Pearl : Tensioning over a Clamp to Prevent Impingement
“Shenton’s Line of the Hand”
Final Result
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Post-Operative
• Thumb spica splint for 3-5 days
• Suture removal and scar massage
• Start ROM exercises at 3-5 days
• AROM for 4 weeks, advance to strengthening as tolerated
• Splint for comfort only
• Suture button postoperative therapy protocol has been developed
5 Days Post-Op
SIX WEEKS!
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Mid Term Clinical Experience
• 14 patients (16 thumbs)
• Mean followup 64 months (range 49 to 84)
• QuickDASH 8.7
• Radial abduction : 97%
• Palmar abduction : 105%
• Kapandji scores: either 9 or 10 in all patients
• Pinch strength: 107%
• Grip strength: 102%
• Trapezial space height: 71%
• 1 symptomatic hardware (removed), 2 transient DRSN neuropraxia
Yao, et al. (JHS 2017)
Conclusions for Thumb CMC DJD Treatment in 2020
• Ligament Reconstruction: Not Needed!
• Interposition: Not Needed!
• Suspension: Probably Needed!
• Suture Button? Not Needed… BUT:• Faster Rehabilitation• No need to wait to remove K-wire in 4 weeks
• No need to wait for anything to heal
• Splint for 3-5 days, then start aggressive hand therapy
If you did this…
…you wouldn’t do this
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So if you did this…
…No need to do this!
Wouldn’t You Want This for your Patients at 5 Days?
Thank You!
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DISCLOSURES
Jennifer Moriatis Wolf, MD
Speaker has no relevant financial relationships with commercial interest to disclose.
The University of Chicago Medicine
Trapeziectomy/LRTI –Why Change What
Works?Jennifer Moriatis Wolf, MD
Professor, Orthopaedic Surgery
The University of Chicago
The University of Chicago Medicine
DISCLOSURES
• Salary – The Journal of Hand Surgery
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The University of Chicago Medicine
History
• Initial publication by Gervis on trapeziectomy only JBJS, 1944
• Eaton/Littler & Burton/Pellegrini discussed reconstruction of ligaments for stabilization of the first metacarpal base
• ‘the purpose of ligament reconstruction combined with arthroplasty is to restore strength by restabilizing the basal joint while providing pain relief’
• Eaton and Littler, JBJS, 1973• Burton and Pellegrini, J Hand Surg Am, 1983
The University of Chicago Medicine
How Best to Treat this 74 yo female?
The University of Chicago Medicine
Anatomy
• Saddle‐shaped joint• Two interlocking saddles
• Stabilized by ligaments to provide
• Mobility
• Stability
• Multiple ligaments described by Bettinger and Berger
JAAOS, 2010
Bettinger et al, J Hand Surg, 1999
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The University of Chicago Medicine
Key Ligaments
• Anterior oblique (AOL)
• Dorsoradial (DRL)
• Best current evidence• DRL thicker, stronger, tripartite
ligament Ladd, Hagert, JBJS, 2012
• Colman and Mass showed stability maintained at CMC except when DRL cut
J Hand Surg, 2007
The University of Chicago Medicine
Concept of Ligament Reconstruction using FCR strip
Littler & Eaton, JBJS 1973
The University of Chicago Medicine
Concept of Ligament Reconstruction using FCR strip
Littler & Eaton, JBJS 1973
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The University of Chicago Medicine
Trapeziectomy with Ligament Reconstruction and Tendon Interposition (LRTI)
• Classic ‘ligament reconstruction and tendon interposition’
• Uses half or all FCR to reconstruct ligaments and suspend metacarpal, with remainder placed into trapezial void
Burton and Pellegrini, J Hand Surg, 1985
The University of Chicago Medicine
Other Versions of Ligament Stabilization
• Weilby – FCR passed in figure‐of‐8 fashion around APL
• Weilby, J Hand Surg Br, 1988
• APL suspension – distally based slip used to suspend first metacarpal by passing it through a slit in FCR
• Sigfusson & Lundborg, Scand J Plast Recon Surg, 1991
The University of Chicago Medicine
So why add ligament reconstruction at all?
• Ligaments contribute to the balance of the trapeziometacarpal joint
• Lower risk of failure in hypermobile individuals after surgery
• Confers stability to the carpus
• Supporting evidence from outcomes
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The University of Chicago Medicine
• 163 volunteers aged 20-83y, 81 men and 82 womeno Average Beighton score of 2 (range, 0‐9) and stress ratio of 0.31 (range,
0.06‐0.58)
o Significant relationship between increased Beighton score and stress ratio p<0.001 J Hand Surg Am, 2011
• Garcia-Elias and Orsolini noted a significant correlation between thumb laxity and greater trapezial mobility Chir Main, 2011
• Hess et al noted that joint hypermobility was a source of failure of thumb CMC arthroplasty J Hand Surg Am, 2018
Hypermobility/Laxity and the Thumb
The University of Chicago Medicine
What is the Genesis and Impact of Joint Laxity?
• Not known in depth
• Hormones thought to have some influence
o Cooney and Lubahn – showed estrogen receptors in TM ligament (ASSH Annual Meeting presentation, 2014)
o Correlation between serum relaxin and radiographically measured laxity at TM jointWolf et al, J Hand Surg Am, 2013
o Shown a relationship between serum relaxin and MMP‐1 receptors in anterior oblique ligament in a study of 50 patients at surgery Wolf et al, CORR, 2015
Relaxinmolecular structure
The University of Chicago Medicine
Do the Ligaments Matter?
• Based on the theories of instability contributing to ultimate degenerative change – YES
o Burton and Pellegrini, J Hand Surg, 1988o Eaton, Glickel, Littler, J Hand Surg, 1985
• Based on evidence of hormonal impact on ligaments with possible hypermobility as an additional contributing factor –YES
• Should they be reconstructed?
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The University of Chicago Medicine
Carpal Stability
CORR, 2014
• Evaluated the stress radiographs of previous randomized trial comparing trapeziectomy to trapeziectomy + LRTI in 25 and 29 patients at mean 6 year followup
• 1/29 in LRTI group• 7/25 in trapeziectomy group • Radiographic findings did not correlate with outcomes
increased degenerative change at MC base and distal scaphoid
The University of Chicago Medicine
• Retrospective review of 33 patients undergoing trapeziectomy/suspensionplasty from 1999‐2006 with mean 10 mo followup• 6/22 (27%) wrists had DISI deformity preoperatively • 11/22 (50%) had DISI postoperatively• Significant decrease in carpal height ratio and radiolunate
angle• Significant relationship between clinical outcomes on
satisfaction questionnaire and radiolunate angle (P=0.041)
J Hand Surg, 2009
The University of Chicago Medicine
Outcomes of trapeziectomy/LRTI
• Mayo series of 57 hands included 18 undergoing LRTI with 15 year followup HAND, 2019
• 1 required revision
• Significant improvement in pain VAS and grip in majority
• Tomaino et al – LRTI with mean 9 year followup• 24 thumbs in 22 patients
• 21/22 had pain relief and satisfaction
• Demonstrated increased grip and pinch strength• J Bone Joint Surg Am, 1995
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The University of Chicago Medicine
Comparative studies• LRTI has better pain and functional outcomes and lower complication rates than arthrodesis
• Vermeulen et al, J Bone Joint Surg 2014
• LRTI demonstrated better preservation of trapezialspace ‐‐ correlated with pinch strength when compared to trapeziectomy alone
• De Smet et al, Hand Surg, 2004
• Trapeziectomy alone• is faster than LRTI ‐‐ Sandvall et al, J Hand Surg 2010• has lower complication rates than all other surgeries – Selleset al, Cochrane Rev, 2015
The University of Chicago Medicine
SUMMARY
• Trapeziectomy and LRTI (or ligament reconstruction in isolation) has demonstrated consistently good outcomes
• Importance of ligament reconstruction has not been definitively proven BUT evidence shows:
• Subtle carpal joint changes with trapeziectomy• Increased joint degeneration mitigated by LRTI• Increased subsidence with some correlation with decreased pinch
The University of Chicago Medicine
THANK YOU
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CASE DISCUSSIONS
“Failed” Surgery - Persistent Pain
Identify source• MCP joint• Radial sensory nerve• Subsidence/ impingement between metacarpal and scaphoid
• Residual osteophyte/ impingement between index and thumb metacarpal
Case Discussion54 y/o female
Dominant thumb
Two previous procedures
• APL-FCR suspension
• Persistent symptoms
• Revised to LRTI
• Persistent symptoms
Collapse with pinch, pain, weakness
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ECRL Transfer with MP Arthrodesis
Case
• 64 y/o female
• Pain non dominant thumb > 2 years
• Tried bracing, therapy/ strengthening exercises
• Remains symptomatic
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Case
Left Thumb – Eaton Stage 3
Discussion
What is your algorithm for management of MP joint?
Transfer/ tenotomy
Capsulodesis
Arthrodesis
How do you do it?
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