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Running head: POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE Postoperative Outcomes of the Tenotomy or TightRope Procedure for Carpometacarpal Joint Osteoarthritis Katie Aho, Zach Kilpatrick, Britlyn Long, Katie Lozon, Josie Miller, Kirk Anderson, Jeanine Beasley, Brittany Krenselewski, and Nancy Plekker Grand Valley State University POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 1 Postoperative Outcomes of the Tenotomy or TightRope Procedure for Carpometacarpal Joint Osteoarthritis Abstract Background:​ Osteoarthritis (OA) of the carpometacarpal (CMC) joint is one of the most prevalent issues of the hand, resulting in significant functional ramifications in relation to pinch strength, mobility, and pain. When surgical intervention is required, the standard method is through a partial or complete trapeziectomy with ligament reconstruction and tendon interposition (LRTI). This study reports the postoperative Occupational Therapy (OT) interventions and outcomes following a less common surgery, the Mini TightRope arthroplasty. The Mini TightRope arthroplasty consists of suspending the first metacarpal to the second by means of a thick suture material allowing earlier initiation of range of motion (ROM) as an OT intervention. Research has shown that the use of orthoses, exercises, range of motion (ROM), and specific modalities following a CMC surgery can be effective to increase function and decrease pain. Although there are brief protocols reported in the literature for this surgery, actual OT occupation-based interventions are complex and vary to meet the individual needs of patients. These variations include the timing of CMC AROM, type of orthosis, length of time in the orthosis, and when to return to occupation-based and functional use of the hand. ​Methods: This study reports the actual postoperative course and outcomes based on a retrospective chart review. Outcome measures included the Quick DASH, grip strength, pinch strength, range of motion, and the numeric pain rating scale. The purpose of the study is to report the outcomes and postoperative OT following CMC joint Mini TightRope arthroplasty. This retrospective chart review may help to advance the profession of OT by providing occupation-based guidelines based on actual cases. ​Results: ​Statistical significance of ​p =​ .019 was found between gender and initial QuickDASH score. Males had a superior average initial QuickDASH score of 49.18 compared to 57.30 for females. There was a minimally clinically significant improvement from initial QuickDASH score to the final reported QuickDASH score of 15.96 points. ​Conclusion: Of the participants, 12% are diagnosed with diabetes which is representative of the prevalence of diabetes in the overall population in the United States. Some of the findings that are not statistically significant showed to be clinically significant, such as the recorded pain reduction for individuals with more than two therapy visits and the 15.96 point improvement in QuickDASH score. From the results, certain factors such as edema and smoking have less of an effect on the rehabilitation potential than expected. Keywords: ​osteoarthritis, QuickDASH, Mini TightRope arthroplasty, orthosis, orthoses, pain. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 2 Osteoarthritis (OA) of the carpometacarpal (CMC) joint is one of the most prevalent issues of the hand (Valdes & Marik, 2010). OA can be characterized by degeneration of articular cartilage at a joint and the underlying bone which can be attributed to mechanical influences, the effects of aging, and genetic factors (Goldberg & Goldberg, 2007). OA of the CMC joint can result in significant functional ramifications in relation to pinch strength, mobility, and pain (Valdes & Marik, 2010). CMC OA occurs more frequently in women and it has been found that 75% of women between the ages of 60 and 70 suffer from this condition (Valdes & Marik, 2010). This gender-related skew is thought to be tied to the postmenopausal induced laxity of joints (Neumann & Bielefeld, 2003). Previous research has shown that the use of orthoses, home exercises, range of motion (ROM), and specific exercises following CMC Mini TightRope surgery can provide beneficial outcomes for patients (​Roberts, Jabaley & Nick, 2001; Wouters, Tsehaie, Hovius, Dilek, & Selles, 2018)​. Details about postoperative interventions based on a retrospective chart review has not been reported. The purpose of the study is to determine the outcomes following CMC joint Mini TightRope arthroplasty when combined with an OT early mobilization protocol. ​The research question is; what are the patient outcomes following a CMC joint Mini TightRope arthroplasty with an early mobilization post-operative protocol? Conservative Management Modalities and Orthotics Conservative management is often attempted prior to a surgical intervention. A popular method of conservative management for CMC OA is use of an orthosis (​Boustedt, Nordenskiöld, & Nilsson, 2009​; Kjeken et al., 2016). The European League Against Rheumatism (EULAR) recommends an orthosis to prevent deformities (Kjeken et al., 2016). Having CMC OA can POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 3 cause pain, physical deformities, reduced hand strength and mobility, as well as decreased participation in activities of daily living (ADLs). Typically a short and more pliable orthosis is used during the day, to allow for hand function while still providing stability, whereas a more rigid orthosis is recommended during the night (​Bani et al., 2013​; Kjeken et al., 2016; Neumann & Bielefeld, 2003). Another popular form of conservative management is the use of ​nonsteroidal anti-inflammatory drugs and cortisol injections at the CMC joint (Gillis et al., 2011). A research article by Kwasniewski (2005) stated that corticosteroid injection, with the use of a thumb spica orthosis, provided long-term relief to those in the early stages of CMC joint OA. However, multiple injections can lead to laxity and weakening of the CMC joint, so caution must be taken (Kwasniewski, 2005). Preparatory techniques used in the treatment of this condition can include: heat (paraffin baths, and hot packs) (​Cantero-Téllez et al., 2018; Boustedt et al., 2009; ​Valdes & von der Heyde, 2012), injections (​Jahangiri & Najafi, 2014; Monfort et al., 2015​; ​Salini, De Amicis, Abate, Natale, Di Iorio​, 2009), iontophoresis (Spaans et al., 2015; Jain et al., 2010) electrotherapy (Davenport BJ., 2009), and low level laser therapy (O’Brien & McGaha, 2014; Valdes & Marik, 2010; ​Brosseau et al., 2005; Medina-Porqueres & Cantero-Tellez, 2018)​. One of the most common treatment modalities, based on a survey of 524 therapists, is the use of paraffin baths (O’Brien & McGaha, 2014). Assistive Technology (AT), such as built up handles, adaptive equipment, joint protection and patient education have also been found to be effective methods used to demonstrate significant improvement scores based on the Canadian Occupational Performance Measure (COPM) (​Boustedt et al., 2009​; Kjeken, Darre, Smedslund, POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 4 Hagen & Nossum, 2011; ​Ataker et al.​, 2012; Kjeken et al., 2016; ​Bani, et al., 2013; Shankland & Nedelec, 2018)​. Exercise The CMC joint requires dynamic stability from the osseous, musculature, and ligamentous systems for mobility and strength (O'Brien & Giveans, 2013). Research has shown that dynamic stability exercises can increase function and decrease pain for patients through strengthening the intrinsic musculature (O'Brien & Giveans, 2013). The first dorsal interosseous (FDI) plays a key role in thumb CMC stability (McGee, O'Brien, Van Nortwick, Adams, & Van Heest, 2015). One study determined that contraction of the FDI, along with thumb stabilizing muscles, led to a reduction of thumb CMC radial subluxation as demonstrated in hands with normal function (McGee et al., 2015).​ ​Studies that include both exercise and orthoses have resulted in functional improvement and pain reduction (O'Brien & Giveans, 2013). Surgical Management When conservative management treatment options are no longer effective and the pain is disabling, surgery is typically offered as the next option (Neumann & Bielefeld, 2003). The most common surgical procedure chosen by 93% of surgeons (Yuan, Aliu, Chung, & Mahmoudi, 2017)) is a partial or complete trapeziectomy with ligament reconstruction and tendon interposition (LRTI) (Chuang, Huang, Lu, & Shih, 2015). A newer surgical procedure, the Mini TightRope arthroplasty (see Figure 1), has been developed to provide CMC stability using 2 strands of #2 FiberWire®​ ​that are fixed with 2 oblong stainless steel buttons for cortical fixation. The Mini TightRope arthroplasty consists of complete trapezium excision which is then POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 5 supported by the Mini TightRope implant that maintains the proper positioning of the thumb metacarpal to the index metacarpal. This internal suspension reduces the need for lengthy postoperative immobilization, which can result in joint stiffness (Hooke et al., 2016). A study found that 39% of patients experienced mild to moderate stiffness a year after an LRTI procedure (Parry & Kakar, 2015). A study by Hooke et al. (2016) using the Mini TightRope arthroplasty demonstrated increased strength, decreased pain, and allowed mobilization as early as 10 days following the operation. Occupational Therapy (Post-Op protocol) Although there is research to support the Mini TightRope surgical procedure, there is little research done on the specific post-operative protocol. A study by Ataker (2012), reported a protocol after a suspension surgical arthroplasty that involved wearing a forearm based thumb spica orthosis. Active range of motion (AROM) to the CMC was delayed in this protocol until four weeks postoperatively, only allowing tendon gliding exercises for digits 2-5 (Ataker ​et al., 2012​). After four weeks, orthotic wear gradually decreased and was discontinued by twelve weeks (Ataker et al., 2012). Similarly, another study by Roberts et al. (2001), utilized a forearm based thumb spica orthosis. The thumb spica orthosis is then discontinued at 3 weeks and AROM exercises are initiated 3-4 times a day for the wrist and thumb. Scar massage and modalities were also used as needed. An additional study by (​Tsehaie​ et al., 2019) utilized a progression of 3 orthoses and investigated shorter versus longer immobilization lengths. The study concluded that shorter immobilization is equivalent to longer immobilization for pain and hand function outcomes (​Tsehaie​ et al., 2019). The Mini TightRope procedure allows earlier mobilization of the thumb CMC joint, due to the stability provided by the tightrope. Our study, POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 6 using a retrospective design reviewed the postoperative course and therapeutic interventions based on a retrospective chart review. Protocol for CMC TightRope Arthroplasty Protocols are individualized to meet the specific needs of each patient and vary based on a variety of factors. The therapists at Orthopedic Associates of Michigan (OAM) had an initial guiding protocol that included the following. Patients were placed in a bulky dressing that provides wrist and thumb support. Patients were then permitted to start gentle AROM of wrist and thumb upon the removal of stitches 10 to 14 days after surgery. AROM included palmar abduction (PABD) and radial abduction (RABD) along with opposition of the thumb to fourth and fifth digits. A forearm IP free thumb spica orthosis is also fabricated at this time (see Figure 2). Additional treatment included mobilization of the scar, continued AROM, management of edema, and OT services to monitor functional motion and progress. After six weeks post-operation, patients progress to wearing a short opponens orthosis or neoprene thumb orthosis as needed (see Figure 3). At 8 weeks post-operation, light pinch and grip exercises are incorporated as tolerated. Patients may begin activities that are comfortable without restrictions at 10 to 12 weeks after surgery. At that time, education regarding assistive devices and joint protection are implemented (​Orthopaedic Associates of Michigan, n.d.).​ A home exercise program was also given to each patient (see Appendix B). Outcome Measures This study involved a retrospective chart review that includes data extraction and analysis from office charts of one hand surgeon as well as the postoperative therapy charts. Multiple therapists were involved in the post-operative care of these patients but they all worked at the POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 7 same office and were guided by the same early mobilization protocol. A variety of outcome measures were analyzed and include the following. Quick Dash The Quick Disabilities of the Hand, Arm, and Shoulder questionnaire, also known as the QuickDASH, is used to address upper-extremity musculoskeletal disorders. The Questionnaire is 11 questions long and it is often used to address musculoskeletal disorders (​Gummesson, Ward, & Atroshi, 2006). A study by Franchignoni et al. (2014), reported that a score change of 15.91 points, between upper and lower bounds, is needed to determine a minimal clinically significant difference. Grip Strength Grip strength testing was performed using a Jamar dynamometer abiding by the American Society of Hand Therapists (ASHT) positioning guidelines ​(MacDermid, Solomon, & Valdes, 2015)​. A study by Kim, Park, and Shin (2014) reported that the minimally clinically important difference is a change of 6.5 kg (19.5%) for grip strength. Pinch Strength Standard pinch strength measures include key, tip, and palmar pinch (Mathiowetz et al., 1985; Valdes & Marik, 2010). Data gathered from this study include key and palmar pinch strength. To collect pinch strength results, therapists used the gold standard B&L pinch gauge and the recommended ASHT positioning guidelines (Mathiowetz et al., 1985). Range of Motion This study included postoperative AROM measurements of the involved CMC, MP, and IP joints of the thumb. A study by Ataker (2012), showed the average postoperative palmar POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 8 abduction was 45 degrees and the average radial abduction was 40 degrees, 12 weeks following CMC arthroplasty. Average final follow up measurements were 50 degrees for palmar abduction and 55 degrees for radial abduction (Ataker et al., 2012). Pain The numeric pain rating scale (NPRS) is a verbal scale that describes a patient’s current pain to evaluate a response to an intervention 0-10, with 0 meaning no pain, and 10 being the worst pain they have ever experienced (Walten, 2018). A two point reduction rating of pain presents as a clinically important difference (Farrar, Young, Lamoreaux, Werth, & Poole, 2001). Methods The study is a retrospective cohort chart review.​ ​This study was approved for human subjects by the Grand Valley State University review board. Participants include patients with OA of the CMC joint who received a trapeziectomy with Mini TightRope arthroplasty from 1/9/2015 through 12/28/2018 and postoperative occupational therapy. There were 196 patients ​ 62.67). (Female= 141, Male=53); average age at the date of surgery was 62 years old (​M= Inclusion criteria required participants to have had a Mini TightRope arthroplasty in the last four years. Patient charts for those meeting the inclusion criteria were identified by a research assistant at OAM including ICD 10 codes for primary OA, unspecified M19.049, right hand M18.11, left hand M18.12, and OA, unspecified ICD 9 is 715.94. Exclusion criteria for this study are individuals under the age of 18, individuals who had an additional surgical procedure on the same hand, and individuals who received therapy at a different location. A secure workplace was given to researchers at OAM to extract the data. Each patient chart that met the criteria was given a number to de-identify the information. The code linking this data to a POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 9 specific patient is kept at OAM. All de-identified data was stored in BitLocker, a secure program for analysis throughout the duration of this study. The researchers reviewed each chart to obtain the following information: demographics, comorbidities (diabetes, etc.), therapeutic interventions (including type of orthosis, length of time orthosis was worn), time before initiation of thumb AROM, modalities, and outcome measures (QuickDASH, grip strength, pinch strength, AROM, and NPRS) (see Appendix A for complete list). All therapeutic interventions and measurements from therapy sessions were recorded. Collected data was transferred into the ​Statistical Package for the Social Sciences (SPSS) program version 22.​ Analysis was done by determining the ​type and combinations of therapeutic interventions at each therapy session and how this may have affected the outcome measures. Also, demographic and patient specific data were analyzed to determine trends such as the onset of the CMC OA and potential differences between genders. Specific analysis included comparing means, running independent sample T-tests, conducting Mann-Whitney U, and comparing box-plots. A statistician was consulted to assist in directing the researchers to determine the possible correlations as they relate to the purpose of the study and the research question. The research question is; following a CMC joint Mini TightRope arthroplasty is pain decreased and hand function increased with an early mobilization post-operative protocol? The purpose of the study is to determine the outcomes following CMC joint Mini TightRope arthroplasty when combined with an occupational therapy early mobilization protocol. Results Data were collected from 196 patient charts. AROM was initiated between 6 and 17 days post op. For a complete list of frequencies see Table 1. ​Age was not found to have a significant POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 10 effect on initial QuickDASH score, initial pain, or number of therapy visits. Data revealed that there was no significant findings in regards to the comorbidity of diabetes or smoking.​ However, statistical significance of ​p =​ .019 was found between gender and initial QuickDASH score. Males had a superior average initial QuickDASH score of 49.18 compared to 57.30 for females. As expected, a statistically significant correlation was found between individuals’ reported pain and QuickDASH scores. As an individuals’ pain increased, their score on the QuickDASH also increased (​p​ < .01). At the initial visit, 186 patients were given a forearm based IP free thumb spica orthosis, nine patients were issued a hand based IP free thumb spica orthosis, and one patient refused the orthosis and received a neoprene thumb support instead. Common wearing schedules included wear as needed for pain, remove for bathing only, remove for exercise, wear at work for heavy activities, and wear at night. Common physical agent modalities that were used in the first visit include hot pack, iontophoresis, and ultrasound (see Table 2); of the 118 patients with only one therapy visit, 20% had edema management. AROM was initiated at the initial visit with nearly all patients. Initial AROM ranged from 6-17 days post surgery. ​Changes to a prescribed orthosis are listed in Table 3, modalities used in additional visits are listed in Table 2, and wearing schedules for patient remained constant throughout all additional visits. The Mann Whitney test indicated that individuals who have diabetes had an average length of therapy of 2.78 days as compared to 1.39 days (​p =​ .152). Of the patients that had two or more therapy visits, there was a minimally clinically significant difference (Franchignoni et al., 2014) in improvements from initial QuickDASH score to the final reported QuickDASH score with a difference of 15.96 points. ​No significant or clinical differences were found POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 11 between pain but patients reported the pain to be on average 1.22 points lower between their first and last reported score. AROM measurements are only being reported for those requiring only two therapy visits due to lack of initial and final data for more than two visits. Final changes in AROM for those who only received two visits are (Mean) PABD (↑10.5º Range​), RABD (​↑​6º), metacarpophalangeal (MP)​ extension (​↑​4.17º), MP flexion (​↑​12.94º), wrist extension (​↑​8.09º), wrist flexion (​↑​1.63º), ulnar deviation (​↑​13.14º), radial deviation (​↑​3.33º), interphalangeal (IP) extension (​↑​7.21º), and IP flexion (​↑​12.77º). Of the initial 196 patients, ​78​ required a second therapy visit. On the second visit, two patients were given a hand based thumb spica orthosis, 28 were given a neoprene thumb support, and​ 48​ patients were provided with an orthosis adjustment for their initial orthosis (see Table 2). The wearing instructions for the orthoses did not change. Discussion This is the first study that we are aware of that describes the actual post-operative patient therapeutic intervention details of the CMC Mini TightRope based on a retrospective data set. Although participants in this study all received surgical intervention and skilled therapy at a specific location in west Michigan, the sample appears to be representative based on the percentage that had diabetes (11%), the ratio of men to women (53:141), and the average age at the date of surgery (62 yrs). The results of the study are statistically significant and have implications for the field of OT. The statistically important difference occurred between diabetes and therapy length, QuickDASH score and Gender, and as expected pain and QuickDASH score. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 12 Although some of the findings are not statistically significant, some showed to be clinically significant, such as the recorded pain reduction for individuals with more than three therapy visits (↓2) and improvements in QuickDASH score for two or more visits (↓15.96). Additionally, certain factors such as diabetes, edema, and smoking have less of an effect on the rehabilitation potential than expected. The most important takeaway from this study is that skilled therapeutic intervention statistically and clinically improved QuickDASH scores among individuals receiving more than one therapy visit. Early mobilization led to an increase in the hand function of the patients they treated. This is supported by the work of Tsehaie et al. (2019) that showed equivalent outcomes with a shorter immobilization. Most of the patients required only one therapy visit in our study but patients with diabetes typically had more than one visit. By showing that diabetes is associated with an increased amount of therapy, therapists can expect that patients with diabetes will on average require more skilled therapeutic intervention. ​Although diabetes may affect the length of therapy, it did not have an impact on the other outcome measures in this study such as ROM, pain, or QuickDASH. Other demographic factors such as age or smoking status did not have an impact on pain or function. An intuitive notion that as someone's pain increases, so does their QuickDASH score, was supported by the research. It is important to note that this is not impacted by the early or late mobilization of a patient. There was no statistical or clinical difference between the date skilled hand therapy was started and the outcomes of pain and function. Studies by ​Horlock and Belcher (2002) and ​Tsehaie et. al. (2019) support that when patients were mobilized earlier this did not POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 13 decrease their function or increase their pain even after a one year follow up. However, these studies interviewed patients and found that even though pain and function did not increase, patient satisfaction and productivity were improved due to the fact that they were able to engage in desired occupations earlier in the recovery process. With that being said there was a minimally clinically important difference among patients receiving three therapy visits and also a decreased average pain score among those receiving two or more skilled therapy visits. Additional research is needed to determine if patients that had 2-3 visits instead of just one would have long term outcomes. Due to the fact that on average men had a better QuickDASH than women, it may impact therapeutic intervention. For example, higher QuickDASH (or decreased function) scores may require more modalities and conservative treatment. Another change that could be made to accommodate for the difference in QuickDASH scores is the type of orthosis a patient is prescribed. The most common sequence of prescribed orthosis for this study was a forearm based thumb spica orthosis followed by a hand based thumb spica or a neoprene thumb support. A study by Prosser et al. (2014) showed no significant difference between the type of orthosis (rigid or semi-rigid) and outcomes of pain and function at a one-year follow-up. Additional research is needed to determine if there are improved outcomes with a hand based thumb spica or or neoprene orthosis that could be used instead of the forearm based thumb spica at the initial therapy visit. The limitations of this study include being a retrospective chart review, the lack of a control group, lack of a pre-test or baseline measure, only one surgeon and clinic in West Michigan, and most patients only had one postoperative therapy visit. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 14 A study by Horlock and Belcher (2002) revealed that patient outcomes following trapezium excision were no different when individuals were placed in long mobilization (2 weeks in a cast) or early mobilization (1 week in a cast), followed by a custom forearm based thumb spica. Each group improved in subjective and objective movement with the early mobilization group reporting more satisfaction following the procedure as a result of the convenience it provided. Shorter periods of immobilization show the same functional outcomes while providing a more convenient therapy treatment experience for patients (Tsehaie et. al., 2019). The CMC Mini TightRope applies a considerably shorter immobilization at 8-13 days following the surgical procedure. Patients are able to start recovery faster and may be able to quickly return to work and daily activities. Additional research is needed to determine if AROM provides even better outcomes when started earlier than in our study. This study reported the outcomes and post-operative occupational therapy following CMC joint Mini TightRope arthroplasty. It is our hope that this retrospective chart review will help therapists to more clearly understand the early mobilization intervention, determine the appropriate orthosis, and understand the factors that require individualized adaptation to the protocol based on actual cases. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 15 References Ataker, Y., Gudemez, E., Ece, S. C., Canbulat, N., & Gulgonen, A. (2012). Rehabilitation Protocol after Suspension Arthroplasty of Thumb Carpometacarpal Joint Osteoarthritis. 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H., & van den POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 19 Hout, W. B. (2015). Healthcare costs and loss of productivity in patients with trapeziometacarpal osteoarthritis. ​Journal of Hand Surgery (European Volume),​ ​40(​ 9), 927–934. doi: 10.1177/1753193414568293 Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., & Rogers, S. (1985). Grip and pinch strength: Normative data for adults.​,OTS Occupational Therapy Program, University of Wisconsin-Milwaukee​. McGee, C., O'Brien, V., Van Nortwick, S., Adams, J., & Van Heest, A. (2015). First dorsal interosseous muscle contraction results in radiographic reduction of healthy thumb carpometacarpal joint. ​Journal of Hand Therapy​, ​28​(4), 375-381. Retrieved from ProQuest database. Medina-Porqueres, I., & Cantero-Tellez, R. (2018). Class IV laser therapy for trapeziometacarpal joint osteoarthritis: Study protocol for a randomized placebo-controlled trial. Physiotherapy Research International, 23​(2). doi:10.1002/pri.1706 Monfort, J., Rotés-Sala, D., Segalés, N., Montañes, F., Orellana, C., Llorente-Onaindia, J., . . . Benito, P. (2015). Comparative efficacy of intra-articular hyaluronic acid and corticoid injections in osteoarthritis of the first carpometacarpal joint: Results of a 6-month single-masked randomized study. ​Joint Bone Spine, 82(​ 2), 116-121. doi:10.1016/j.jbspin.2014.08.008 Neumann, D. A., & Bielefeld, T. (2003). The carpometacarpal joint of the thumb: Stability, deformity, and therapeutic intervention. ​Journal of Orthopaedic & Sports Physical Therapy, 33​(7), 386-399. doi:10.2519/jospt.2003.33.7.386 POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 20 O'Brien, V. H., & Giveans, M. R. (2013). Effects of a dynamic stability approach in conservative intervention of the carpometacarpal joint of the thumb: A retrospective study. ​Journal of Hand Therapy​, ​26​, 44-52. https://doi.org/10.1016/j.jht.2012.10.005 O’Brien, V. H., & McGaha, J. L. (2014). Current practice patterns in conservative thumb CMC joint care: Survey results. ​Journal of Hand Therapy, 27​(1), 14-22. doi:10.1016/j.jht.2013.09.001 Orthopaedic Associates of Michigan. (n.d.). Arthritis of the Hand, Thumb & Wrist. Retrieved from https://www.oamichigan.com/hand-upper-extremity/hand-upper-extremity-conditions/art hritis-hand-thumb-wrist/ Orthopaedic Associates of Michigan. (n.d.). Thumb CMC arthroplasty [Pamphlet]. Parry, J. A., & Kakar, S. (2015). Dual Mini TightRope suspensionplasty for thumb basilar joint arthritis: a case series. ​The Journal of Hand Surgery,​ ​40​(2), 297-302. doi:10.1016/j.jhsa.2010.02.013 Prosser, R., Hancock, M., Nicholson, L., Merry, C., Thorley, F., & Wheen, D. (2014). Rigid versus semi-rigid orthotic use following TMC arthroplasty: A randomized controlled trial. ​Journal of Hand Therapy, 27(​ 4), 265-271. doi:10.1016/j.jht.2014.06.002 Roberts, R. A., Jabaley, M. E., & Nick, T. G. (2001). Results Following Trapeziometacarpal Arthroplasty of the Thumb. ​Journal of Hand Therapy, 14​(3), 202-207. Salini, V., De Amicis, D., Abate, M., Natale, M., & Di Iorio, A. (2009). Ultrasound-Guided POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 21 Hyaluronic Acid Injection in Carpometacarpal Osteoarthritis: Short-Term Results. International Journal of Immunopathology and Pharmacology,​ 455–460. https://doi.org/​10.1177/03946320090220022 Shankland, B., & Nedelec, B. (2018). A client-centered approach for thumb carpometacarpal joint osteoarthritis pain: Two case studies.​ Journal of Hand Therapy, 31​(2), 265-270. doi:http://dx.doi.org.ezproxy.gvsu.edu/10.1016/j.jht.2018.01.005 Spaans, A. J., Van Minnen, P., Kon, M., Schuurman, A. H., Schreuders, A., & Vermeulen, G. M. (2015). Conservative Treatment of Thumb Base Osteoarthritis: A Systematic Review. The Journal of Hand Surgery, 40(​ 1), 16-21 The Arthrex Mini TightRope® Implant. (n.d.). Retrieved from https://www.arthrex.com/resources/video/zjVzzFW31ECuVgFH-QvDJA/the-arthrex-min i-tightrope-implant Tsehaie, J., Wouters, R. M., Feitz, R., Slijer, H. P., Hovius, S. E.R., Selles, R. W., & Hand Wrist Study Group. (2019). Shorter vs longer immobilization after surgery for thumb carpometacarpal osteoarthritis: A propensity score-matched study. ​Archives of Physical Medicine and Rehabilitation. Valdes, K., & Marik, T. (2010). A systematic review of conservative interventions for osteoarthritis of the hand. ​Journal of Hand Therapy,​ 334-351. Valdes, K., & von der Heyde, R. (2012). An Exercise Program for Carpometacarpal Osteoarthritis Based on Biomechanical Principles. ​Journal of Hand Therapy, 25​(3), 251-263. Wouters, R. M., Tsehaie, J., Hovius, S. E., Dilek, B., & Selles, R. W. (2018). Postoperative POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 22 Rehabilitation Following Thumb Base Surgery: A Systematic Review of the Literature. Archives of Physical Medicine and Rehabilitation, 99​(6). doi:10.1016/j.apmr.2017.09.114 Yuan, F., Aliu, O., Chung, K. C., & Mahmoudi, E. (2017). Evidence-based practice in the surgical treatment of thumb carpometacarpal joint arthritis. ​The Journal of Hand Surgery, 42​(2). doi:10.1016/j.jhsa.2016.11.029 POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 23 Table 1 Frequency of days post-op that AROM was initiated Day of AROM initiation Frequency 6 1 7 7 8 80 9 6 10 11 11 51 12 6 13 17 15 2 17 1 Note.​ Day AROM was not found in 14 patient charts Table 2 Types of modalities used at therapy visits - n​ umber of patient receiving intervention ?? Modalities First Therapy Second Third Therapy Four or More Visit Therapy Visit Visit Therapy Visits Edema Management 15 1 1 0 E-stim 0 1 2 8 Ice 1 0 0 0 Iontophoresis 0 1 1 5 Fluidotherapy 0 2 1 3 Moist Hot pack 9 16 11 35 Paraffin 0 1 0 0 Ultrasound 0 6 3 18 Scar Mobilization 163 27 14 30 POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 24 Table 3 Initiation Dates for Orthoses Visit Orthosis Type Number of Patients Issued 1 Forearm based IP free thumb spica 186 1 Hand based IP free thumb spica 9 1 Neoprene thumb support 1 2 Neoprene thumb support 28 2 Hand based IP free thumb spica 2 3 Neoprene thumb support 10 3 Hand based IP free thumb spica 1 4 Neoprene thumb support 2 4 Hand based IP free thumb spica 0 5 Neoprene thumb support 2 5 Hand based IP free thumb spica 0 6 Neoprene thumb support 0 6 Hand based IP free thumb spica 0 7 Neoprene thumb support 1 7 Hand based IP free thumb spica 0 Note.​ One patient refused the forearm based IP free thumb spica but accepted a neoprene thumb support instead on first visit. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 25 Figure 1.​ Arthrex Mini TightRope implant in the CMC joint arthroplasty. Illustration from​ Arthrex, Inc. and used with permission. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 26 ​ orearm based thumb spica IP free orthosis. Figure 2. F POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 27 ​ eoprene thumb orthosis. Used with permission from Nancy Plekker and Brittany Figure 3. N Krenselewski. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 28 ​ edian number of therapy visits for people with or without diabetes. Figure 4. M POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 29 ​ edian number of Initial QuickDASH scores for Females and Males. Figure 5. M POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 30 Appendix A CMC Research Code Book Code Meaning of Code Description Subject # Subject Number The number given to the de-identified patient Gender Gender Gender of patient Age Age Age of patient at date of surgery Surg Date Surgery Date Date of Surgery Condition Condition ICD-10 and ICD-9 codes of patients with carpometacarpal joint osteoarthritis (OA) DomHand Dominant Hand The dominant hand of the patient Height (in) Height (in) Patient height (in inches) at the date of surgery Weight Weight (in) Patient weight (in pounds) at the date of surgery (lbs) BMI Body Mass Index Patient body mass index at the date of surgery SMK Smoker Yes, no, or former smoker Diabetes Diabetes If the patient has diabetes (yes or no) EDM Edema Amount of edema present Affected Affected Hand The hand that was operated on Hand I Wearing Initial Wearing Schedule The initial wearing schedule for the orthosis Schedule Orthosis Orthosis Type of orthosis given Length OI Length of orthosis Length of time the orthosis was worn for intervention POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 31 DAY # Days Post- Op AROM The number of days after surgery when AROM AROM EX exercises began Length Th Length of therapy How many times/weeks was the patient seen Minutes 1 Minutes seen by an OT How long did the therapy session last during session 1 Minutes 2 Minutes seen by an OT How long did the therapy session last during session 2 Minutes 3 Minutes seen by an OT How long did the therapy session last during session 3 Comp Tip I Comp Tip Index Comp tip measurement of Index finger of affected hand Comp Tip Comp Tip Middle Composite tip measurement of middle finger of M affected hand Comp Tip Comp Tip Ring Composite tip measurement of ring finger of R affected hand Comp Tip Compt Tip S small Composite tip measurement of small finger of S affected hand I PABD Initial Palmar Abduction Initial palmar abduction measurement I RABD Initial Radial Abduction Initial radial abduction measurement I GS Initial Grip Strength What grip strength was recorded during that treatment session. I PS Initial Pinch Strength What pinch strength was recorded during that treatment session. I CMC OPP Initial CMC Opposition What active range of motion of opposition at the AROM Active Range of Motion CMC joint was recorded during that treatment session. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 32 I MP F/E Initial MP What active range of motion of flexion and AROM Flexion/Extension Active extension at the metacarpophalangeal joint was Range of Motion recorded during that treatment session. I IP F/E Initial IP What active range of motion of flexion and AROM Flexion/Extension Active extension at the interphalangeal joint was recorded Range of Motion during that treatment session. I Initial Unaffected Wrist The initial measurement of extension and flexion Unaffected Extension/Flexion Active active range of motion at the wrist joint of the Wrist E/F Range of Motion unaffected hand. AROM I Affected Initial Affected Wrist The initial measurement of extension and flexion Wrist E/F Extension/Flexion Active active range of motion at the wrist joint of the AROM Range of Motion affected hand. I Initial Unaffected Wrist The initial measurement of ulnar and radial Unaffected Ulnar/Radial Deviation deviation active range of motion at the wrist joint of Wrist U/R Active Range of Motion the unaffected hand. Dev AROM I Affected Initial Affected Wrist The initial measurement of ulnar and radial Wrist U/R Ulnar/Radial Deviation deviation active range of motion at the wrist joint of Dev AROM Active Range of Motion the affected hand. I QDASH Initial Quick Dash What QuickDASH questionnaire score was recorded during that treatment session. I NPRS Initial Numeric Pain What numeric pain rating scale score was recorded Rating Scale during that treatment session. V1 Visit 1 Modalities Modalities during the first therapy visit Modalities I Scar Initial Scar Mobilization If scar mobilization occurred at the initial post-op Mobilizatio visit (yes or no) n POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 33 Other OM Other Outcome Any other outcome measured that were recorded at Measures the conclusion of treatment. Education Patient Education Did the patient receive education and what education was given Other Other Services Did the patient receive other services besides OT Services V2 Comp Visit 2 Comp Tip Index Comp tip measurement of Index finger of affected Tip I hand V2 Comp Visit 2 Comp Tip Middle Composite tip measurement of middle finger of Tip M affected hand second visit V2 Comp Visit 2 Comp Tip Ring Composite tip measurement of ring finger of Tip R affected hand second visit V2 Comp Visit 2 Compt Tip S Composite tip measurement of small finger of Tip S small affected hand second visit V2 Wearing Visit 2 Wearing The orthosis wearing schedule given at the second therapy visit second visit V2 Orthosis Visit 2 Orthosis Type of orthosis given at the second therapy visit V2 CMC Visit Number 2 CMC What active range of motion of opposition at the OPP Opposition CMC joint was recorded during that treatment AROM Active Range of Motion session. V2 RABD Visit Number 2 CMC Measurement of active range of motion of radial radial abduction abduction at the CMC joint was recorded during the treatment session. V2 PABD Visit Number 2 CMC Measurement of active range of motion of palmar palmar abduction abduction at the CMC joint was recorded during the treatment session. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 34 V2 MP F/E Visit Number 2 MP What active range of motion of flexion and AROM Flexion/Extension Active extension at the metacarpophalangeal joint was Range of Motion recorded during that treatment session. V2 Unaff Visit Number 2 The measurement of extension and flexion active Wrist F/E Unaffected Wrist range of motion at the wrist joint of the unaffected AROM Extension/Flexion Active hand. Range of Motion V2 Aff Visit Number 2 Affected The measurement of extension and flexion active Wrist F/E Wrist Extension/Flexion range of motion at the wrist joint of the affected Active Range of Motion hand. V2 Unaff Visit number 2 The measurement of ulnar and radial deviation R/U Dev Unaffected Wrist active range of motion at the wrist joint of the Ulnar/Radial Deviation unaffected hand. Active Range of Motion V2 Aff R/U Visit Number 2 Affected The measurement of ulnar and radial deviation Dev Wrist Ulnar/Radial active range of motion at the wrist joint of the Deviation Active Range affected hand. of Motion V2 IP F/E Visit Number 2 IP What active range of motion of flexion and AROM Flexion/Extension Active extension at the interphalangeal joint was recorded Range of Motion during that treatment session. V2 QDASH Visit Number 2 Quick What QuickDASH questionnaire score was Dash recorded during that treatment session. V2 NPRS Visit Number 2 Numeric What numeric pain rating scale score was recorded Pain Rating Scale during that treatment session. V2 Visit 2 Modalities Modalities during the therapy visit Modalities V2 Scar Initial Scar Mobilization If scar mobilization occurred at the initial post-op Mobilizatio visit (yes or no) n POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 35 V3 GS Visit Number 3 Grip What grip strength was recorded during that Strength treatment session. V3 3PP Visit Number 3 Palmar What palmar pinch strength was recorded during Pinch Strength that treatment session. V3 LPS Visit Number 3 Lateral What lateral pinch strength was recorded during that Pinch Strength treatment session V3 CMC Visit Number 3 CMC What active range of motion of radial and palmar R/P AROM radial and palmar abduction at the CMC joint was recorded during that abduction treatment session. Active Range of Motion V3 MP F/E Visit Number 3 MP What active range of motion of flexion and AROM Flexion/Extension Active extension at the metacarpophalangeal joint was Range of Motion recorded during that treatment session. V3 IP F/E Visit Number 3 IP What active range of motion of flexion and AROM Flexion/Extension Active extension at the interphalangeal joint was recorded Range of Motion during that treatment session. V3 QDASH Visit Number 3 Quick What QuickDASH questionnaire score was Dash recorded during that treatment session. V3 NPRS Visit Number 3 Numeric What numeric pain rating scale score was recorded Pain Rating Scale during that treatment session. V3 Visit 2 Modalities Modalities during the therapy visit Modalities V3 Aff R/U Visit number 3 The measurement of ulnar and radial deviation Dev Unaffected Wrist active range of motion at the wrist joint of the Ulnar/Radial Deviation unaffected hand. Active Range of Motion V3 Unaff Visit Number 3 Affected The measurement of ulnar and radial deviation Wrist R/U Wrist Ulnar/Radial active range of motion at the wrist joint of the Deviation Active Range affected hand. of Motion POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 36 V3 Aff Visit Number 3 Affected The measurement of extension and flexion active Wrist F/E Wrist Extension/Flexion range of motion at the wrist joint of the unaffected Active Range of Motion hand. V3 Unaff Visit Number 3 The measurement of extension and flexion active Wrist F/E Unaffected Wrist range of motion at the wrist joint of the affected Extension/Flexion Active hand. Range of Motion V3 Scar Visit Number 3 Scar If scar mobilization occurred at the post-op visit Mobilizatio Mobilization (yes or no) n V3 Orthosis Visit 3 Orthosis Type of orthosis given at the therapy visit V3 Wearing Visit 3 Wearing The orthosis wearing schedule given at the therapy Schedule visit second visit V4 GS Visit Number 4 Grip What grip strength was recorded during that Strength treatment session. V4 LPS Visit Number 4 Lateral What lateral pinch strength was recorded during that Pinch Strength treatment session. V4 3PP Visit Number 4 Palmer What palmer pinch strength was recorded during Pinch Strength that treatment session V4 RABD Visit Number 4 CMC Measurement of active range of motion of radial radial abduction abduction at the CMC joint was recorded during the treatment session. V4 PABD Visit Number 4 CMC Measurement of active range of motion of palmar palmar abduction abduction at the CMC joint was recorded during the treatment session. V4 MP F/E Visit Number 4 MP What active range of motion of flexion and Flexion/Extension Active extension at the metacarpophalangeal joint was Range of Motion recorded during that treatment session. POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 37 V4 IP F/E Visit Number 4 IP What active range of motion of flexion and Flexion/Extension Active extension at the interphalangeal joint was recorded Range of Motion during that treatment session. V4 QDASH Visit Number 4 Quick What QuickDASH questionnaire score was Dash recorded during that treatment session. V4 NPRS Visit Number 4 Numeric What numeric pain rating scale score was recorded Pain Rating Scale during that treatment session. V4 Visit 4 Modalities Modalities during the therapy visit Modalities V4 Aff Visit number 5 Affected The measurement of ulnar and radial deviation Wrist R/U Wrist Ulnar/Radial active range of motion at the wrist joint of the Dev Deviation Active Range unaffected hand. of Motion V4 Wrist Visit Number 5 The measurement of ulnar and radial deviation Unaff R/U Unaffected Wrist active range of motion at the wrist joint of the Dev Ulnar/Radial Deviation affected hand. Active Range of Motion V4 Aff Visit Number 4 Affected The measurement of extension and flexion active Wrist F/E Wrist Extension/Flexion range of motion at the wrist joint of the unaffected Active Range of Motion hand. V4 Unaff Visit Number 4 The measurement of extension and flexion active Wrist F/E Unaffected Wrist range of motion at the wrist joint of the affected Extension/Flexion Active hand. Range of Motion V4 Scar Visit Number 4 Scar If scar mobilization occurred at the post-op visit Mobilizatio Mobilization (yes or no) n V4 Orthosis Visit 4 Orthosis Type of orthosis given at the therapy visit POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 38 V4 Wearing Visit 4 Wearing The orthosis wearing schedule given at the therapy Schedule visit second visit V4 CMC Visit Number 4 CMC What active range of motion of opposition at the OPP Opposition CMC joint was recorded during that treatment AROM Active Range of Motion session. V5 GS Visit Number 5 Grip What grip strength was recorded during that Strength treatment session. V5 LPS Visit Number 5 Lateral What lateral pinch strength was recorded during that Pinch Strength treatment session. V5 3PP Visit Number 5 Palmer What palmer pinch strength was recorded during Pinch Strength that treatment session V5 RABD Visit Number 5 CMC Measurement of active range of motion of radial radial abduction abduction at the CMC joint was recorded during the treatment session. V5 PABD Visit Number 5 CMC Measurement of active range of motion of palmar palmar abduction abduction at the CMC joint was recorded during the treatment session. V5 MP F/E Visit Number 5 MP What active range of motion of flexion and Flexion/Extension Active extension at the metacarpophalangeal joint was Range of Motion recorded during that treatment session. V5 IP F/E Visit Number 5 IP What active range of motion of flexion and Flexion/Extension Active extension at the interphalangeal joint was recorded Range of Motion during that treatment session. V5 QDASH Visit Number 5 Quick What QuickDASH questionnaire score was Dash recorded during that treatment session. V5 NPRS Visit Number 5 Numeric What numeric pain rating scale score was recorded Pain Rating Scale during that treatment session. V5 Visit 5 Modalities Modalities during the therapy visit Modalities POSTOPERATIVE OUTCOMES OF TENOTOMY OR TIGHTROPE 39 V5 Aff Visit number 5 Affected The measurement of ulnar and radial deviation Wrist R/U Wrist Ulnar/Radial active range of motion at the wrist joint of the Dev Deviation Active Range unaffected hand. of Motion V5 Unaff Visit Number 5 The measurement of ulnar and radial deviation Wrist R/U Unaffected Wrist active range of motion at the wrist joint of the Dev Ulnar/Radial Deviation affected hand. Active Range of Motion V5 Aff Visit Number 5 Affected The measurement of extension and flexion active Wrist F/E Wrist Extension/Flexion range of motion at the wrist joint of the unaffected Active Range of Motion hand. V5 Unaff Visit Number 5 The measurement of extension and flexion active Wrist F/E Unaffected Wrist range of motion at the wrist joint of the affected Extension/Flexion Active hand. Range of Motion V5 Scar Visit Number 5 Scar If scar mobilization occurred at the post-op visit Mobilizatio Mobilization (yes or no) n V5 Orthosis Visit 5 Orthosis Type of orthosis given at the therapy visit V5 Wearing Visit 5 Wearing The orthosis wearing schedule given at the therapy Schedule visit second visit V5 CMC Visit Number 5 CMC What active range of motion of opposition at the OPP Opposition CMC joint was recorded during that treatment AROM Active Range of Motion session. V6 GS Visit Number 6 Grip What grip strength was recorded during that Strength treatment session. V6 LPS Visit Number 6 Lateral What lateral pinch strength was recorded during that Pinch Strength treatment session.