Ligamentous stability of the base of the thumb

Trapeziometacarpal Dislocations in Pediatric Age, Is There a Better Treatment? Series of Cases and a Systematic Review

(1) Background: Dislocations of the trapeziometacarpal joint (TMC) are uncommon in children and adolescents. Only a few isolated cases are reported in the literature. Therapeutic guidance is minimal and inconclusive. (2) Methods: The authors present four patients treated for this unusual lesion. We evaluated the evolution according to treatment, age, patient activity, and quickDASH. Despite the clear limitation of the small number of patients, it is relevant to try to better understand this lesion and its evolution. A systematic review of the literature was also conducted. (3) Results: This is the largest published series of TMC dislocations in children and adolescents. Patients included a 12-year-old girl treated conservatively with a poor quickDASH; a 9-year-old girl treated surgically with the Eaton-Littler technique for a new dislocation with a partially modified quickDASH; a 13-year-old boy with two necessary closed reductions for a new dislocation and a very good final quickDASH; and a 12-year-old boy treated with closed reduction and percutaneous fixation with excellent final results with quickDASH. (4) Conclusions: In the absence of scientific evidence, conservative treatment and ligament reconstruction did not provide good functionality. In contrast, closed reduction with percutaneous fixation provided excellent results. Therefore, the authors would recommend closed reduction and percutaneous needle fixation as an elective method to treat TMC dislocations in pediatric and adolescent patients.

Isolated Trapeziometacarpal Joint Dislocation With Five Years of Follow-up: A Case Report and Review of the Literature

Isolated trapezio-metacarpal joint dislocation is a rare injury. Despite being simple to reduce, there is not yet a consensus regarding how to secure the reduction, the type of immobilization, and the postoperative protocol. Herein, we present a rare case of pure trapezio-metacarpal joint dislocation without any associated fractures that was treated with closed reduction and intermetacarpal fixation, six weeks of immobilization, and an early rehabilitation protocol.

Anatomical study for elucidating the stabilization mechanism in the trapeziometacarpal joint

To determine the pathogenesis of trapeziometacarpal (TMC) joint instability, which leads to osteoarthritis, we investigated the anatomical relationships among the surrounding ligaments, muscles (first dorsal interosseous [FDI] and opponens pollicis [OPP]), and joint capsule. We examined the bone morphology and cortical bone thickening in 25 cadaveric thumbs using micro-computed tomography and performed macroscopic and histological analyses. The dorsal trapezium had a tubercle with cortical bone thickening, corresponding to the attachment of the FDI aponeurosis intermingled with the joint capsule. Radially, the thin joint capsule was observed to underlie the muscular part of the OPP. Therefore, the dorsal ligaments, which have been previously considered static stabilizers, could be interpreted as parts of the capsuloaponeurotic complex consisting of the FDI aponeurosis and joint capsule. In the radial aspect, muscular OPP activation may be essential for TMC joint stabilization. Our findings may contribute to the appropriate management of TMC osteoarthritis.

Anatomical 3 Ligaments Reconstruction for Symptomatic Thumb Carpometacarpal Joint Instability

Thumb carpometacarpal (CMC) joint instability is thought to be a debilitating disorder and, if left untreated, develops joint persistent synovitis and osteoarthritis. In this study, we report a novel surgical technique reconstructing the anterior oblique ligament, the dorsoradial ligament, and the intermetacarpal ligament simultaneously using both the transverse carpal ligament, and the palmaris longus tendon. Six patients with a mean age of 44 years showing no osteoarthritic changes by the radiographical examination underwent our anatomical three ligaments reconstruction for persistent painful thumb CMC joint instability. Clinical results with the mean follow-up of 20 months demonstrated that the pain was subjectively improved in all patients, both the grip and the pinch strength were increased significantly and good functional motion of the thumb could be observed after the operation. These findings indicated that our surgical procedure could be one option of treatment of the symptomatic CMC joint instability in early-stage arthritis.

Influence of differences in bone morphology on the distribution patterns of subchondral bone density across the trapeziometacarpal joint

We aimed to clarify the effects of morphological patterns of the trapezium and first metacarpal on the distribution of subchondral bone density across the articular surface of the trapeziometacarpal (TMC) joint using computed tomography osteoabsorptiometry. Thirty-three patients with normal TMC joints were evaluated. The percentages of the high-density areas in the radial-dorsal and ulnar-volar regions of the trapezium were significantly higher than that in the ulnar-dorsal region, and that of the ulnar-dorsal region of the first metacarpal was significantly lower than in the other three regions. The percentage of the high-density area of the radial-dorsal region of the trapezium and trapezial inclination (TI) showed a significant positive correlation, and the percentages of the high-density areas in the ulnar-dorsal and ulnar-volar regions had significant negative correlations with TI at the articular surface of the first metacarpal. These results indicate that bony morphologic differences in the trapezium affect the distribution pattern of subchondral bone density through the TMC joint.

Ligamentous constraint of the first carpometacarpal joint

To examine the role of the ligaments in maintaining stability of the first carpometacarpal (CMC) joint, a sequential ligament sectioning study of sixteen specimens was performed. While a small compressive force was maintained, loads were applied to displace each specimen in four directions - volar, dorsal, radial, and ulnar. Translations of the specimen in both dorsal-volar and radial-ulnar axes were measured. Initially, the tests were conducted with the specimen intact. These tests were then repeated following sectioning of the CMC anterior oblique ligament (AOL), ulnar collateral ligament (UCL), intermetacarpal ligament (IML) and dorsal radial ligament (DRL). The first CMC joint translation was increased in the absence of IML and DRL (p < 0.05). Both IML and DRL were important in constraining the first CMC joint translation against external applied loads. Potential applications of these findings include the treatment of joint hypermobility and the reduction or delay of onset or progression of first CMC joint osteoarthritis.

Traumatic Isolated Thumb Carpometacarpal Joint Dislocation - Report of Two Clinical Cases

Isolated thumb carpometacarpal joint dislocation is a rare lesion that accounts for less than 1% of all hand lesions.

The authors present two cases of traumatic isolated thumb carpometacarpal joint dislocation. One of them was treated with closed reduction and cast immobilization, and the other was treated with closed reduction, Kirschner-wires pinning, and cast immobilization.

The first patient had a good functional outcome and showed no signs of thumb carpometacarpal instability. The patient treated with Kirschner wires presented signs of clinical instability and radiological subluxation.

Isolated thumb carpometacarpal dislocation is a rare lesion that can cause joint instability, which interferes with the normal function of the hand and can lead to articular degenerative changes.

The best management of this lesion is still controversial, since there is lack of evidence in the literature showing superiority of one treatment over the other.

Chronic Carpometacarpal Dislocation of the Thumb: A Case Report and Review of the Literature

CASE

We report a case of a chronic, irreducible carpometacarpal (CMC) dislocation of the thumb, which was managed with a trapeziometacarpal arthrodesis.

CONCLUSION

This case demonstrates that arthrodesis is a suitable salvage procedure for chronic, irreducible CMC dislocations of the thumb.

[Biomechanical evaluation of the first carpometacarpal joint stability by using different reconstruction methods]

Objective

To study the biomechanical differences of the first carpometacarpal joint stability by using different reconstruction methods so as to provide theoretical basis for the clinical choice of reconstruction method.

Methods

The upper limb specimens were selected from 12 fresh adult cadavers, which had no fracture, bone disease, dislocation of wrist joint, deformity, degeneration, or ligament injury on the anteroposterior and lateral X-ray films. The specimens were randomly divided into 5 groups: normal group, injury group, palmar carpometacarpal ligaments reconstruction group, dorsal carpometacarpal ligaments reconstruction group, and palmar and dorsal carpometacarpal ligaments reconstruction group. Three normal specimens were used as normal group, and then were made of the first carpometacarpal joint dislocation models (injury group); after the first carpometacarpal joint dislocation was established in the other 9 specimens; the volar ligament, dorsal ligament, and volar-dorsal ligaments were reconstructed with Eaton-Little method, Yin Weitian method, and the above two methods in 3 construction groups. The biomechanical test was done to obtain the load-displacement curve and to calculate the elastic modulus.

Results

During biomechanical test, ligament rupture and loosening of Kirschner wire occurred in 1 case of injury group and palmar carpometacarpal ligaments reconstruction group; no slipping was observed. The elastic modulus values were (11.61±0.20), (5.39±0.12), (6.33±0.10), (7.12±0.08), and (8.30±0.10) MPa in normal group, injury group, palmar carpometacarpal ligaments reconstruction group, dorsal carpometacarpal ligaments reconstruction group, and palmar and dorsal carpometacarpal ligaments reconstruction group respectively, showing significant differences among groups ( P<0.05).

Conclusion

Volar ligament reconstruction, dorsal ligament reconstruction, and volar-dorsal ligament reconstruction all can greatly improve the stability of the first carpometacarpal joint. And the effect of volar-dorsal ligament reconstruction is the best, but the stability can not restore to normal.

Stabilisation of the Trapezio-Metacarpal Joint

A new technique of trapezio-metacarpal stabilisation is described which uses the abductor pollicis longus tendon passed through the bases of the first and second metacarpals to fasten the base of the thumb. A biomechanical rationale is presented, as well as the surgical technique and 12 results at follow-up one to six years later.

MR Imaging of Thumb Carpometacarpal Joint Ligament Injuries

This study describes the MR imaging appearances of the supporting ligaments of the thumb carpometacarpal joint in asymptomatic volunteers and in a group of patients following joint injury. Fourteen patients with 11 acute and three chronic injuries underwent MR imaging. The anterior oblique ligament was the most commonly injured ligament, usually on the metacarpal side where it was disrupted, or allowed dislocation because of subperiosted stripping from the base of the thumb metacarpal. The dorsal radial ligament was occasionally avulsed or partially torn from the trapezoid. Following chronic injury, MR imaging can evaluate ligamentous laxity, ganglion cyst formation or osteoarthritis. Accurate evaluation of ligament injury may identify patients who would benefit from surgery.

Comparison of clinical outcome with radiological findings after trapeziectomy with ligament reconstruction and tendon interposition

The aim of our study was to investigate if pre- and postoperative radiographic thumb carpometacarpal position is correlated with clinical and subjective outcomes. Radiographs of 105 patients undergoing trapeziectomy with ligament reconstruction and tendon interposition were analysed before, as well as 1 year after, surgery for dorsal subluxation and proximal migration of the thumb metacarpal bone. Furthermore, key pinch strength was measured and patients completed the Michigan Hand Outcomes Questionnaire. Baseline dorsal subluxation and scaphometacarpal distances significantly decreased from 8.2 mm and 11.0 mm to 5.2 mm and 5.1 mm at 1 year, respectively. There was no correlation between the amount of subluxation or proximal migration and the Michigan Hand Outcomes Questionnaire score or key pinch strength. These results suggest that postoperative position of the metacarpal base of the thumb does not affect clinical or subjective outcomes after trapeziectomy with ligament reconstruction and tendon reposition of the thumb carpometacarpal joint.

LEVEL OF EVIDENCE

Level 3.

[Ligament reconstruction for trapeziometacarpal joint instability]

OBJECTIVE

Restoring stability and preventing subluxation/dislocation of the trapeziometacarpal (first carpometacarpal = CMC-I) joint while preserving mobility.

INDICATIONS

Posttraumatic, acquired or congenital instability of the CMC-I joint.

CONTRAINDICATIONS

Existence of osteoarthritis of the CMC-I joint. Neurogenic or muscular origin dysfunction of thenar muscles and other contractures the CMC-I area. Infections.

SURGICAL TECHNIQUE

Radiopalmar approach to the CMC-I joint, reduction, and transosseous ligament reconstruction with a distally pedicled tendon strip from the abductor pollicis longus muscle.

POSTOPERATIVE MANAGEMENT

Splint immobilization for 5 weeks.

RESULTS

This procedure generally results in good or very good outcomes. Of 24 patients, only one patient experienced rupture of the ligament reconstruction. Ligament reconstruction for the carpometacarpal joint of the thumb relieves pain and restores stability while preserving functional range of motion in patients with chronic instability.

A novel use for suture button suspension: reconstruction of the dorsal ulnar ligament to treat thumb metacarpal dislocation

There are numerous treatment algorithms that have been developed to treat thumb carpometacarpal (CMC) arthritis. A newer treatment option for these patients is CMC stabilization using suture button suspensionplasty. The authors of this case report have extensive experience with the suture-button suspensionplasty using the Mini TightRope CMC technique (Arthrex). We present a novel usage of the suture-button suspensionplasty to reconstruct the dorsal ulnar ligament (in contrast to the usual reconstruction of the volar beak ligament) to treat a patient with persistent thumb metacarpal dislocation at the CMC joint. Two separate patients are presented. One patient demonstrates volar beak ligament instability, and the other demonstrates dorsal ulnar ligament instability. Both patients' demographics and operative indications are described. The operative technique for the novel usage of the suture-button suspensionplasty is described. Operative results of the dorsal ulnar ligament reconstruction are reviewed. After suture-button suspension of the thumb metacarpal to the trapezium, the dorsal ulnar ligament has been reconstructed. The patient demonstrated stability of the thumb CMC joint without dorsal or radial dislocation. The authors of this case report present a novel usage of the suture-button suspensionplasty to treat a patient with proximal thumb metacarpal dislocation at the trapezial-metacarpal interface. This method, in contrast to the referenced method of volar beak ligament reconstruction, allows reconstruction of the dorsal ulnar ligament. This allows stabilization of the joint by preventing dorsal and radial dislocation of the metacarpal.

Primary repair of capsuloligamentous structures of trapeziometacarpal joint: A preliminary study

BACKGROUND

Isolated trapezio-metacarpal joint dislocation is uncommon and challenging since controversy still exists regarding its management.

DESCRIPTION

We present a short case series in which direct repair of trapezio-metacarpal ligaments was done in three patients who had isolated, unstable dislocation of the thumb carpometacarpal joint. All of them were engaged in tasks where no compromise in hand functions and grip strength was affordable. The dislocation was addressed primarily by repair of volar oblique and dorsoradial ligaments with suture anchors. The joint was immobilised in a cast for 4 weeks followed by gradual mobilisation.

RESULTS

At an average follow up of 15 months, all the three patients have no restriction in the range of motion. There are no symptoms and signs of instability. In two patients, there is no pain at all; while one patient has occasional pain which is mild and does not interfere with the hand function. Radiographic examination showed normal joint alignment and no signs of subluxation or early osteoarthritis.

CONCLUSION

Repair of the capsuloligamentous complex with suture anchors may be considered as a treatment option in unstable trapezio-metacarpal joint dislocations in high demand patients.

Trapeziometacarpal joint stability: the evolving importance of the dorsal ligaments

BACKGROUND

Trapeziometacarpal (TMC) arthritis of the thumb is a common source of hand pain and disability. TMC ligamentous instability may play a role in TMC degeneration. However, the relative importance of the TMC ligaments in the etiology of degeneration and the use of surgery to treat instability in early-stage arthritis are unclear.

QUESTIONS/PURPOSES

In this review, we addressed several questions: (1) What are the primary ligamentous stabilizers of the thumb TMC joint? (2) What is the evidence for ligament reconstruction or ligament imbrication in the treatment of thumb TMC joint osteoarthritis? And (3) what is the evidence for thumb metacarpal osteotomy in the treatment of thumb TMC joint osteoarthritis?

METHODS

We performed a systematic review of the literature using PubMed (MEDLINE(®)) and Scopus(®) (EMBASE(®)) for peer-reviewed articles published until November 2012. Fifty-two studies fit the inclusion criteria. Twenty-four studies were anatomic, biomechanical, or histopathologic studies on TMC joint ligamentous anatomy, 16 studies were clinical studies concerning ligament reconstruction, and 12 studies were clinical studies on thumb metacarpal osteotomy.

RESULTS

Over the past two decades, increasing evidence suggests the dorsoradial ligament is the most important stabilizer of the TMC joint. Other ligaments consistently identified are the superficial anterior oblique, deep anterior oblique, intermetacarpal, ulnar collateral, and posterior oblique ligaments. Ligament reconstruction and metacarpal osteotomy relieve pain and improve grip strength based on Level IV studies.

CONCLUSIONS

The dorsal ligaments are the primary stabilizers of the TMC joint. Ligament reconstruction and metacarpal osteotomy ameliorate ligamentous laxity and relieve pain based on Level IV studies.

Carpometacarpal dislocation of the thumb associated with fracture of the trapezium

Carpometacarpal dislocation (CMC) of the thumb associated with fracture of trapezium is an extremely rare injury, with only 12 cases that sustained similar injuries reported in the literature. In this article, another patient with this rare injury was reported, and all previously published cases were extensively reviewed. The presented case and all previously published cases had a longitudinally oriented trapezium fracture, which is naturally unstable and almost always associated with dislocation of the CMC joint. In contrast to previous descriptions, we believe that CMC joint dislocation and trapezium fracture are not two distinct pathologies that occur simultaneously by chance but share cause and consequence.

The carpometacarpal joint of the thumb: MR appearance in asymptomatic volunteers

PURPOSE

To prospectively characterize the MR appearance of the carpometacarpal (CMC) joint of the thumb in asymptomatic volunteers.

MATERIALS AND METHODS

Thirty-four asymptomatic volunteers (17 women, 17 men, mean age, 33.9 ± 9.2 years) underwent MR imaging of the thumb after approval by the local ethical committee. Two musculoskeletal radiologists independently classified visibility and signal intensity (SI) characteristics of the anterior oblique (AOL/beak ligament), the posterior oblique (POL), the intermetacarpal (IML), and the dorsoradial ligaments (DRL) on a three-point Likert scale. The thickness of all ligaments, cartilage integrity, and presence of joint fluid were assessed. The alignment of the first metacarpal base with the trapezium was quantified on sagittal and coronal planes.

RESULTS

The ligaments of the CMC joint were constantly visible in all volunteers for the POL and IML, and in all but one for the AOL and DRL. On intermediate-weighted fat-saturated images the POL (65 %/74 % reader 1/reader 2) and DRL (58 %/64 %) were commonly of increased SI, while the IML had a striated appearance in 91 %/76 % of subjects. The AOL showed a variable SI (36 %/42 % low, 27 %/27 % increased, 36 %/30 % striated). The IML was the thickest ligament with a mean of 2.9 mm/3.1 mm and the DRL the thinnest (1.2 mm/1.4 mm). There was a mean dorsal subluxation of 1.8 mm/2.0 mm and radial subluxation of 2.8 mm/3.4 mm of the metacarpal base. The AOL was significantly thicker in men (1.7 mm) than in women (1.2 mm; p = 0.02). Radial subluxation was significantly larger in men (3.4 mm) than in women (2.2 mm; p = 0.02). No subluxation in palmar or ulnar direction was seen.

CONCLUSIONS

Radial and dorsal subluxation of the CMC joint can be a normal finding in a resting position at MR imaging. The CMC ligaments showed a considerable variability of signal intensity with a typically striated IML; thickness of the AOL is typically less than 2.2 mm, of the POL typically less than 2.9 mm.

Macroscopic and microscopic analysis of the thumb carpometacarpal ligaments: a cadaveric study of ligament anatomy and histology

BACKGROUND

Stability and mobility represent the paradoxical demands of the human thumb carpometacarpal joint, yet the structural origin of each functional demand is poorly defined. As many as sixteen and as few as four ligaments have been described as primary stabilizers, but controversy exists as to which ligaments are most important. We hypothesized that a comparative macroscopic and microscopic analysis of the ligaments of the thumb carpometacarpal joint would further define their role in joint stability.

METHODS

Thirty cadaveric hands (ten fresh-frozen and twenty embalmed) from nineteen cadavers (eight female and eleven male; average age at the time of death, seventy-six years) were dissected, and the supporting ligaments of the thumb carpometacarpal joint were identified. Ligament width, length, and thickness were recorded for morphometric analysis and were compared with use of the Student t test. The dorsal and volar ligaments were excised from the fresh-frozen specimens and were stained with use of a triple-staining immunofluorescent technique and underwent semiquantitative analysis of sensory innervation; half of these specimens were additionally analyzed for histomorphometric data. Mixed-effects linear regression was used to estimate differences between ligaments.

RESULTS

Seven principal ligaments of the thumb carpometacarpal joint were identified: three dorsal deltoid-shaped ligaments (dorsal radial, dorsal central, posterior oblique), two volar ligaments (anterior oblique and ulnar collateral), and two ulnar ligaments (dorsal trapeziometacarpal and intermetacarpal). The dorsal ligaments were significantly thicker (p < 0.001) than the volar ligaments, with a significantly greater cellularity and greater sensory innervation compared with the anterior oblique ligament (p < 0.001). The anterior oblique ligament was consistently a thin structure with a histologic appearance of capsular tissue with low cellularity.

CONCLUSIONS

The dorsal deltoid ligament complex is uniformly stout and robust; this ligament complex is the thickest morphometrically, has the highest cellularity histologically, and shows the greatest degree of sensory nerve endings. The hypocellular anterior oblique ligament is thin, is variable in its location, and is more structurally consistent with a capsular structure than a proper ligament.

LIGAMENT LENGTH DURING CIRCUMDUCTION OF THE TRAPEZIOMETACARPAL JOINT AFTER LIGAMENT SECTIONING

Thumb motion and stability were examined after sequential division of support ligaments of the trapeziometacarpal (TMC) to simulate the pathologic condition of ligament laxity. The motion obtained with passive circumduction was measured with a magnetic tracking system. The lengths of the TMC joint ligaments were approximated by measuring the distance between origin and insertion of each ligament. The change in this apparent interorigin distance of the ligaments was measured before and after ligament sectioning. The anterior oblique ligament (AOL) and the ulnar collateral ligament (UCL) had the greatest effect on TMC joint stability during circumduction of the thumb. Division of the first intermetacarpal ligament (IML) did not produce a change in apparent length of other ligaments. We conclude that small changes in ligament length affect thumb stability and alter the path of circumduction. Neither the IML or posterior oblique ligaments were major stabilizers of the TMC joint during circumduction, prehensile grasp, or tip pinch. Reconstruction of the AOL and UCL ligaments should be considered for treatment of the initial stages of TMC instability.

First carpal-metacarpal joint dislocation and trapezial fracture treated with external fixation in an adolescent

The intrinsic joint stability of the first carpal-metacarpal joint (CMC) makes dislocation a rare injury with fewer than 40 cases described. The degree to which supporting ligaments have been disrupted is reflected clinically by a spectrum of joint stability. Close review of radiographs and an attentive physical examination are necessary to make the diagnosis. Acute treatment has consisted of closed or open reduction with K-wires for stabilization or casting with failures leading to chronic joint instability and the need for soft tissue tendon suspension to maintain joint alignment. We present the case of a 12-year-old boy with a complete first CMC dislocation and trapezial fracture treated with closed reduction and external fixation. At a 3-year follow-up, our patient demonstrates excellent range of motion, strength, and no joint instability without functional limitations. We suggest that external fixation be added to the armamentarium for managing these difficult injuries especially in the pediatric population where interference with growth plates is not ideal.

Treatment of advanced carpometacarpal joint disease: carpometacarpal arthroplasty with ligament interposition

Basal joint arthritis is a common condition, primarily affecting postmenopausal women. Persistent pain and functional impairment despite conservative treatment are indications for operative intervention. Ligament reconstruction and tendon interposition (LRTI) arthroplasty is one of the most popular and time-tested operations to treat metacarpal instability and basal joint arthritis. LRTI incorporates three fundamental principles that address the underlying anatomic pathology: (1) trapezium excision, either partial or complete, to eliminate eburnated bone and the source of pain; (2) anterior oblique ligament reconstruction for carpometacarpal joint stability; and (3) tendon interposition to minimize axial shortening and prevent bony impingement.

Anatomy and pathomechanics of the thumb

The prehensile thumb provides the human mind an outlet for coordinated activity through its fine motions of prehension, opposition, and circumduction. A comprehensive understanding of the anatomy and biomechanics of the thumb provides a foundation on which functional disorders may be recognized and effectively treated.

Traumatic thumb carpometacarpal joint dislocations

Isolated traumatic dislocation of the thumb carpometacarpal joint, also called the trapeziometacarpal joint, is a rare injury. Controversy still exists concerning which ligaments are the true key stabilizers for the joint and therefore need to be damaged to result in dislocation, and optimal treatment strategies for thumb carpometacarpal joint dislocations are the subject of continuing debate. We give a review of the literature concerning traumatic dislocations of the carpometacarpal joint of the thumb and propose a treatment algorithm.

Three-dimensional imaging of the carpal ligaments

This article provides a new perspective and detailed anatomic description of the attachments of the carpometacarpal (CMC) ligaments, intercarpal ligaments, and radiocarpal ligaments, which are described and illustrated using a unique combination of detailed dissection, CT imaging, and three-dimensional digitization. Detailed information is also provided about the ligamentous attachments of the CMC joints, carpal bones, and distal radius. This information advances the current knowledge and understanding of the normal anatomy and its impact on the mechanics of the radiocarpal intercarpal ligaments and the CMC joints, and should help surgeons to assess and treat injuries and degenerative changes seen in the wrist and CMC joints. Furthermore, this additional knowledge of the ligaments will help to further understand wrist kinematics and, more precisely, the function of the individual ligaments and their roles in joint motion and stability and injuries.

A new surgical technique for the ligament reconstruction of the trapeziometacarpal joint

Isolated traumatic dislocation of the trapeziometacarpal joint is rare compared with fracture-dislocation of the joint. The mechanism of injury is usually axial loading on a flexed thumb metacarpal, leading to dorsal dislocation of the joint. Closed reduction with immobilization is an acceptable method of treatment if the joint is stable after the reduction. Otherwise, early ligamentous reconstruction is recommended to reduce the likelihood of secondary arthritis. Various surgical techniques have been used to reestablish the ligamentous integrity of the joint; however, these techniques usually reconstruct only 1 or 2 ligaments around the joint. The current technique is aimed to reconstruct all 4 ligaments of the trapeziometacarpal joint using a half strip of extensor carpi radialis brevis tendon.

Three-dimensional analysis of the ligamentous attachments of the first carpometacarpal joint

PURPOSE

To show the ligamentous locations and attachments of the first carpometacarpal (CMC) joint on a 3-dimensional (3-D) surface model.

METHODS

Ten fresh-frozen cadaver wrists were used to dissect and identify the first CMC ligaments. Their ligamentous attachments and whole bone surfaces were digitized 3-dimensionally and their areas were calculated. The attachments of each ligament were represented in a model combining 3-D computed tomography surfaces overlaid by a digitized 3-D surface and also were shown visually by a specific color on 3-D bone images. The superimposed outlines of the ligamentous attachments on both the radial and ulnar base of the first metacarpal (MC) also are described.

RESULTS

Seven ligaments of the first CMC joint were identified: the dorsoradial ligament, the posterior oblique ligament, the superficial anterior oblique ligament, the deep anterior oblique ligament, the ulnar collateral ligament, the dorsal first MC ulnar base-second MC radial base intermetacarpal ligament, and the volar first MC ulnar base-second MC radial base intermetacarpal ligament. The detailed locations and areas of the ligamentous attachments of the first CMC joint were determined. The average locations of the centroid of the ligamentous attachments of the ulnar collateral and the dorsoradial ligaments were located ulnovolar and dorsoradial on the first MC base, respectively.

CONCLUSIONS

The anatomic 3-D attachment sites of the first CMC ligaments were shown qualitatively and their areas were quantified. The results of this study improve the knowledge and understanding of the normal anatomy and its impact on the mechanics of the first CMC joint. This should help in making an accurate assessment of radiographic images and treating injuries and degenerative changes in the first CMC joint by ligament reconstruction, repair, and arthroscopy.

The ABJS 2005 Nicolas Andry Award: osteoarthritis and injury at the base of the human thumb: survival of the fittest?

The basal joint complex, consisting of four trapezial articulations providing a foundation for the thumb, defines our anatomic evolution from a Simian ancestry by providing an opposable member. Ironically, the trapeziometacarpal joint also is responsible for the most common malady leading to operative reconstruction in the upper limb for arthritic disease. The paradoxic relationship between these two facts has stimulated investigation that has defined the scientific basis for common surgical procedures and provided a foundation for the development of novel treatments for conditions at the base of the thumb. Patterns of articular surface degeneration are determined by areas of contact loading in the joint. Ligament reconstruction, metacarpophalangeal joint flexion splinting, and extension metacarpal osteotomy for early disease resulting from instability all have biomechanical justification for their clinical application. Likewise, percutaneous pinning of Bennett's fracture dislocation is predicated on reestablishing functional continuity of the beak ligament and unloading the palmar joint surfaces. For advanced disease, ligament reconstruction has become the cornerstone of arthroplasty. Perhaps most importantly, the trapeziometacarpal joint as an instability model can provide insight into the interplay of mechanical and biological factors in producing the primary lesion associated with osteoarthritis.

Anatomie et physiologie de l’articulation trapézométacarpienne humaine

Biomechanics of the trapeziometacarpal joint (TMJ) are controversial, because of differences between its normal anatomical description and theories of its pathophysiology. The aim of this article is to explain the mechanisms underlying trapeziometacarpal osteoarthritis by means of the anatomy and physiology of the TM joint. Having described the main ligaments and their roles in the physiology of the joint, it is then difficult to understand why trapezectomy usually improves patients with TMO, when the ligaments are destroyed or only partially repaired by tendinoplasty. Different explanations of TMO are detailed but it seems, according to the literature, that TMO can be explained more by genetic considerations than anatomic dysfunction. The theory of Zancolli is not verified by facts, and other concepts such as ligament theory, and dysplasia of the caudal aspect of the trapezial bone are not sufficient to understand this disease. The same discussion is engaged with regard to explaining the automatic rotation of the thumb in the TM joint. The cantilever bending principle is described as proposed by Bettinger and al.

Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review

In most cases of basal joint osteoarthritis, surgery becomes an option at stages II, III, and IV, as classified by Eaton. Controversy exists regarding which technique achieves the best outcome. This systematic review was undertaken to address the question of which technique, if any, offers the best outcome to patients with osteoarthritis of the first carpometacarpal joint greater than stage II. A thorough search of the electronic databases Cochrane, Cinahl, Healthstar, and MEDLINE/PubMed was undertaken to identify reviews and articles on primary comparative studies of the different surgical options. The methodological quality of the retrieved articles was assessed on the basis of specific criteria. Inclusion criteria were applied to 44 of 254 possibly relevant articles. Eight reviews and 18 comparative studies met the criteria and were reviewed. Each of the techniques, arthrodesis, trapeziectomy with or without biological/synthetic interposition, osteotomy, and joint replacement, was associated with unique benefits and risks. There was great variability in outcome measurements. The majority of retrieved review articles claim that ligamentous reconstruction and tendon interposition may represent the best option; however, validity assessment of these studies revealed methodological flaws. Furthermore, results from the articles on comparative studies indicate that ligamentous reconstruction and tendon interposition may provide no additional benefit when compared with arthrodesis and trapeziectomy alone or with tendon interposition. There is no consensus as to which clinical outcomes are most important in thumb basal joint surgery and how these should be measured. This renders the appraisal and comparison of such studies a challenging task. Until large randomized controlled trials that compare techniques in similar populations with respect to staging and prognostic factors are undertaken and the clinical outcomes are clearly defined, surgeons will continue to claim superiority of one technique over another without supporting evidence.

Rebalancing of Forces as an Adjunct to Resection Suspension Arthroplasty for Trapezial Osteoarthritis

The carpometacarpal (CM) joint of the thumb is commonly affected by osteoarthritis. The strength required for a first CM ligament reconstruction depends on the forces across the joint. If these forces are rebalanced to reduce the requirements necessary to prevent subluxation, reconstructive requirements are lowered and surgical dissections reduced. A method to achieve this goal based on Landsmeer's zig-zag compression concept is presented. Fifteen consecutive patients (11 women; mean age, 63 years) with pantrapezial osteoarthritis were selected over a 2-year period to undergo this novel procedure. After standard trapezial resection, trapezoidal hemiresection was performed, allowing for medial movement of the first metacarpal base. Following the zig-zag concept, the first metacarpophalangeal joint reciprocally fell into flexion, decreasing forces causing subluxation of the first metacarpal base. A saddle-like suspension under the metacarpal base was created using the trapezial capsule. All 15 patients had excellent outcomes with elimination of pain, early recovery of mobility and power, and no recurrent subluxations. The durability of the procedure was confirmed clinically and radiologically. The medial relocation of the first metacarpal base rebalances and attenuates the normal deforming forces thereby eliminating the need for a strong CM ligament reconstruction.

The carpometacarpal joint of the thumb: stability, deformity, and therapeutic intervention

The carpometacarpal (CMC) of the thumb is a saddle joint that permits a wide range of motion and is largely responsible for the characteristic dexterity of human prehension. This joint, located at the very base of the thumb, is subject to large physical stresses throughout life. Osteoarthritis (posttraumatic or idiopathic), rheumatoid arthritis, and postmenopausal laxity of the capsular ligaments can predispose structural instability and impairment of this important joint. The instability is characterized by varying and often progressive dislocation of the joint surfaces, resulting in a displaced axis of rotation and abnormal actions of thumb muscles. The main consequence of the instability is most often pain and weakness, most notably during pinch and grasping actions. This paper is conceptually divided into 2 sections. The first section describes the anatomic structures that maintain stability in the normal CMC joint of the thumb and how disease or trauma can cause instability and ultimate deformity. The second section describes both nonsurgical and surgical interventions that are most often used to treat an unstable CMC joint. This paper is intended primarily as an overview for the physical therapist who does not specialize in the treatment of the hand, although desires basic information on this important topic.

Trapezial tilt: a radiographic correlation with advanced trapeziometacarpal joint arthritis

Trapeziometacarpal (TMC) joint arthritis is a common and debilitating condition of the hand. We defined a radiographic measure of trapezial inclination (trapezial tilt) and found a positive correlation between an increased trapezial tilt and severity of TMC joint arthritis. Radiographs (Robert's views) were obtained from 50 pairs of normal hands to evaluate the trapezial tilt to assess radial inclination of the trapezium with respect to the second metacarpal. The trapezial tilt was also measured in 65 hands from 43 patients with various stages of TMC joint arthritis and compared with the normal value. The trapezial tilt for hands without arthritis was 42 degrees +/- 4 degrees, Eaton stages I and II was 42 degrees +/- 4 degrees, and Eaton stages III and IV was 50 degrees +/- 4 degrees. Trapezial tilt angles from the Eaton III and IV group were significantly greater than those of the normal and Eaton I and II groups. Advanced TMC joint arthritis (Eaton III and IV) is associated with an increased trapezial tilt. Mild TMC joint arthritis with an increased trapezial tilt may be treated surgically. We speculate that a trapezio-trapezoid and trapezio-II metacarpal arthrodesis, or an opening wedge osteotomy of the trapezium might arrest the progression of TMC joint arthritis by resetting the slope of the trapezium and decreasing the shear stress within the TMC joint.

Material properties of the trapezial and trapeziometacarpal ligaments

Destabilization of the trapezium from its normal orientation with respect to the trapezoid, second metacarpal, and thumb metacarpal leads to incongruity at the trapeziometacarpal (TMC) joint. Abnormal shear forces may eventually result in TMC joint arthritis. By determining the relative stiffness and strength of the ligaments that stabilize this joint, one may infer their role in providing stability to the TMC joint. This study addresses the material properties of the ligaments stabilizing the trapezium and TMC joint to better understand the mechanics and kinematics of this joint. Fresh-frozen cadaveric hands (10 males and 10 females) were used to obtain bone-ligament-bone complexes from the dorsal and volar trapeziotrapezoid ligaments, dorsal and volar trapezio-second metacarpal ligaments, anterior oblique ligament, dorsoradial ligament, and trapezio-third metacarpal (T-III MC) ligament. The following material properties were derived from our data: ultimate load, ultimate stress (normalized failure load), ultimate strain (percent elongation), stiffness, toughness (energy to failure), and hysteresis. The dorsoradial ligament demonstrated the greatest ultimate load and toughness (energy to failure). The T-III MC ligament demonstrated the greatest ultimate stress (normalized failure load) and stiffness. The anterior oblique ligament demonstrated the least stiffness and the greatest hysteresis. The material properties of capsuloligamentous structures may be a good indicator of their importance to joint stability. Using these criteria we conclude that the T-III MC and dorsoradial ligaments are important stabilizers of the trapezium and TMC joint, respectively. These two ligaments were found to be the strongest, stiffest, and toughest ligaments, while the anterior oblique ligament was relatively weak and compliant. The dorsal trapezio-second metacarpal, volar trapezio-second metacarpal, and T-III MC ligaments were all relatively strong and are anatomically aligned to function as tension bands to restrain the trapezium against cantilever bending forces applied to it by the thumb during key or tip pinch.

Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment

Predisposing factors contributing to the development of first carpometacarpal (CMC) osteoarthritis include an inherent laxity or incongruency of this joint, a shallow trapezium saddle, and heavy stresses placed on the joint with pinching and grasping. Splinting is a common mode of conservative treatment for CMC osteoarthritis. This study assessed the objective and subjective responses of patients with CMC osteoarthritis who wore short and long opponens splints, as well as radiographic changes associated with wearing of the splints. The study evaluated 26 hands. Each patient was assigned at random to wear the long or the short splint first. Patients wore the splints for one week. They then documented function in their splints (on 22 activities of daily living) and rated splint satisfaction and pain levels on visual analog scales. One week after application of the first splint, the second splint was applied and worn for one week, and all measures were repeated. On the final visit, tip pinches were evaluated and x-rays were taken to assess subluxation. One-way repeated-measure analysis and paired comparison were used to analyze the pinch, pain, radiographic, and splint-rating measures. Descriptive statistics were used to assess activity-of-daily-living function and splint preference. Both splints appear to reduce subluxation at the first CMC joint in patients with grades 1 and 2 osteoarthritis. The majority of the patients picked the short splint when asked at the end of the study which splint they preferred. The splints do not appear to increase pinch strength or affect pain levels associated with the performance of pinch strength measurements. This study supports anecdotal evidence that patients with CMC osteoarthritis get pain relief with splinting.

Basal joint arthroplasty using an allograft tendon interposition versus no interposition: a radiographic, vascular, and histologic study

To assess the role of a tendon spacer that fills the trapezial void, the trapeziums were excised and anterior oblique ligaments were reconstructed in 25 monkeys. In addition to the ligament reconstruction, 20 of the monkeys had the trapezial void filled with a tendon allograft. The trapezial space was investigated at 0, 3, 6, 15, and 40 weeks using routine histologic staining, arterial perfusion (Spalteholz), and standardized radiographs. There was a statistically greater decline in trapezial height in the animals without tendon interposition allografts. The tendon grafts became progressively neovascularized and populated with fibroblasts. By 40 weeks, the allograft was no longer a folded tendon but a homogeneous mass of collagen, fibroblasts, and capillaries. The specimens without an interpositional tendon graft had loose fibroadipose tissue filling the carpal void. Polarized light microscopy showed fibers crossing the subchondral bone and moving into the adjacent fibrous spacer in the specimens implanted with a tendon graft. The results indicate that filling the trapezial void with an interposition tendon spacer may aid in maintaining normal wrist anatomy.

Arthritis of the thumb basal joint complex

Osteoarthritis at the base of the thumb is a common and extremely disabling condition that severely compromises function of the entire hand. Successful treatment is based on an understanding of the specific anatomy and the unique functional attributes of the human hand and thumb. Preservation of the web space is a priority in nonsurgical care and splinting as well as a principal goal of surgical reconstruction. Exercise regimens are designed to emphasize thenar strengthening to encourage preservation of the web space. Activity analysis and modification are focused on joint protection and the avoidance of positions that will accentuate the pathologic condition of trapeziometacarpal subluxation accompanying the retropulsion of the thumb that occurs with contracture of the web space. Surgical treatment is directed toward restoring the thumb-index web space and stabilizing the newly fabricated basal joint by reconstructing the beak ligament and providing a suitable interposition material. After-care likewise emphasizes restoration of the thumb web space, joint mobilization, and strengthening of the supporting thenar musculature. A well-integrated surgical and therapy team will produce uniformly good functional results in the treatment of this disabling condition at the base of the thumb that differentiates us from our simian ancestors.

Trapeziometacarpal joint instability affects the moment arms of thumb motor tendons

This study measured the changes in moment arm length of thumb motor tendons after simulated ligamentous instability and subsequent reconstruction of the trapeziometacarpal joint. Excursions of thumb motor tendons were measured simultaneously with the trapeziometacarpal joint angulation during flexion to extension and abduction to adduction motion. Tendon moment arms were calculated based on joint and tendon displacement techniques in the intact joint, after sequential sectionings of the capsuloligamentous restraints, and after the reconstruction procedure of Eaton and Littler. The results showed that moment arms of the abductor pollicis longus and extensor pollicis brevis tendons increased significantly as compared with those for normal joints during flexion to extension motion after sectioning the palmar capsuloligamentous components. After the ulnopalmar structures were cut, the moment arm of the extensor pollicis longus tendon had a statistically significant increase during abduction to adduction motion, and those of the extensor and flexor pollicis longus tendons decreased significantly during flexion to extension motion. Changed moment arms were restored to a normal level after the ligamentous reconstruction. These results indicate that ligamentous disruptions alter the mechanical balance of thumb motor tendons, which may contribute to joint deformities observed in trapeziometacarpal joint arthritis. Restoring joint stability is important to correct mechanical imbalance of the tendons.

Long-term results of volar ligament reconstruction for symptomatic basal joint laxity

It has been hypothesized that instability of the thumb trapeziometacarpal joint is a major factor in the etiology of degenerative disease. Theoretically, surgically stabilized joints should be subject to less shear force and, hence, will be less likely to develop degenerative changes. The long-term results of volar ligament reconstruction were assessed in 19 patients (24 thumbs). The average age at surgery was 33 years (range, 18-55 years). Twenty-three thumbs were radiographic stage I; a preoperative x-ray was not available in 1. The follow-up period averaged 15 years (range, 10-23 years). At the final follow-up visit 15 thumbs were stage I, 7 were stage II, and 2 were stage III. Fifteen patients were at least 90% satisfied with the results of the surgery. Only 8% of thumbs advanced to radiographic arthritic disease, which compares favorably with the 17% to 33% reported incidence of stage III/IV basal joint arthritis in the general population.

An anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint

We provide a detailed and comprehensive anatomic description of the ligaments stabilizing the trapezium and trapeziometacarpal joint. Sixteen ligaments were identified. Fourteen ligaments inserted onto the trapezium and 2 others attached independently to the thumb metacarpal. The ligaments inserting onto the trapezium were the superficial anterior oblique, deep anterior oblique (beak ligament), dorsoradial, posterior oblique, ulnar collateral, dorsal trapezio-trapezoid, volar trapezio-trapezoid, dorsal trapezio-second metacarpal, volar trapezio-second metacarpal, trapezio-third metacarpal, volar scaphotrapezial, radial scaphotrapezial, transverse carpal, and trapezio-capitate ligaments. The remaining 2 ligaments attach onto the thumb metacarpal and are the proper intermetacarpal and the dorsal intermetacarpal. The dorsoradial and deep anterior oblique ligaments play a substantial role in stabilizing the trapeziometacarpal joint, and the deep anterior oblique ligament may function as a pivot for the first metacarpal during palmar abduction to allow rotation (pronation). The dorsal trapezio-second metacarpal, volar trapezio-second metacarpal, and trapezio-third metacarpal ligaments function as tension bands and are required to prevent instability from cantilever bending forces on the trapezium.

Histopathology of the palmar beak ligament in trapeziometacarpal osteoarthritis

Eighteen cadaver hands were studied to investigate the relationship between degeneration of the palmar beak ligament and articular disease of the trapeziometacarpal joint. Eight of 18 joints had chondromalacia alone; 10 contained areas of eburnation in the palmar aspect of the joint. Beak ligament degeneration correlated closely with the presence of articular degeneration; all joints with eburnation demonstrated frank detachment of the ligament from its metacarpal insertion site. Histologically, the collagen fibers of the beak ligament were disorganized at the metacarpal attachment. The normal insertional zone of fibrocartilage was often unrecognizable on the metacarpal side and, in more degenerative specimens, an intervening synovial recess appeared at the palmar beak of the metacarpal. The trapezial insertion of the beak ligament showed no degenerative change. Increasingly severe cartilage disease was associated with progressive and selective degeneration of the collagen framework of the beak ligament at its insertion onto the thumb metacarpal. These localized histopathologic findings further support the existence of an anatomically distinct intra-articular beak ligament essential to the normal function of the trapeziometacarpal joint and suggest an etiologic relationship to osteoarthritic disease.

Acute dislocation of the trapeziometacarpal joint in a child

An acute dorsal dislocation of the trapeziometacarpal joint in a child is presented. The mechanisms of injury and controversies of treatment are discussed. The achievement of a stable reduction acutely is emphasized. After healing, joint stability is confirmed by obtaining stress radiographs to identify whether joint subluxation is present before degenerative changes occur.

Joint injuries of the hand in athletes

The variety of injuries that occur in the joints of the hand range from skin abrasions to displaced intra-articular fractures. This article discusses serious injuries involving ligaments, volar plate, and bones at specific anatomic regions of the joints of the hand.

[Peri-trapezial arthrotic lesions]

The usual concept of arthrosis of the base of the thumb as a carpometacarpal arthrosis has been replaced by the concept of its being a pantrapezial arthrosis involving all of the peritrapezial joint spaces. In the pathogenesis of pantrapezial arthrosis, the static role of the shaft of the thumb, and the strains from pinching movements between the thumb and fingers are of predominant importance. The lack of satisfactory radiographic technique up to now has made the evaluation of this joint difficult, but the possibility of trapezometacarpal dysplasias favoring arthrosis should be considered. The treatment of an arthrosis of the basal joint of the thumb is surgical when medical treatment has not been successful. The various techniques, which currently are numerous, are given in detail. Carpo-metacarpal arthrodesis has still some precise indications. Arthroplasties have superseded the usual trapezectomy which, nevertheless, seemed to give satisfactory results. The various techniques of arthroplasty and their respective indications according to individual patients, and the anatomic type of the arthrosis of the base of the thumb are discussed.

Anatomical and biomechanical studies of the pathogenesis of trapeziometacarpal degenerative arthritis

An anatomical and biomechanical study of the stabilizing ligaments of the thumb trapeziometacarpal joint was conducted on 32 hand specimens. Five main ligamentous structures could be identified. The mechanical properties (in particular, strength) of the five ligaments using a strain-rate failure test were determined and evaluated quantitatively. The maximum tensile strength of each ligament was correlated with the condition of the trapeziometacarpal articular cartilage. In studying the anterior oblique ligament, maximum strength decreased from Grade 0 to Grade 1 by 51%. With the first intermetacarpal ligament, the drop from Grade 1 to Grade 2 was 53%. With the posterior oblique ligament, the decrease was closely related to the grade of the deterioration of the trapeziometacarpal articular surface. These three ligaments also significantly decreased in strength with age. Our results may suggest that the anterior oblique ligament, intermetacarpal ligament and posterior oblique ligament play a large role in stabilizing the trapeziometacarpal joint and that the decrease in their strength is related to the pathogenesis of trapeziometacarpal osteoarthritis.