Radiographic assessment of the trapezial space before and after ligament reconstruction and tendon interposition arthroplasty

Long-term outcomes of trapeziectomy with Gore-Tex® ligament reconstruction for trapezio-metacarpal osteoarthritis

BACKGROUND

Trapezio-metacarpal osteoarthritis is a common condition for which the reference standard treatment after failure of non-operative measures is trapeziectomy. Several techniques have been devised to avoid proximal migration of the first metacarpal bone (M1) with impingement on the scaphoid bone. We have developed a Gore-Tex® ligament reconstruction technique that avoids potential complications of tendon harvesting. The objective of this study was to assess the long-term outcomes of this technique.

HYPOTHESIS

Trapeziectomy with Gore-Tex® ligament reconstruction is a reliable option for providing lasting pain relief in patients with trapezio-metacarpal osteoarthritis.

MATERIALS AND METHODS

We conducted an observational, single-centre, single-surgeon, retrospective cohort study in consecutive patients managed by primary trapeziectomy. We excluded patients with revision trapeziectomy or less than 10 years' follow-up. The primary outcome was event-free survival, defined as absence of revision surgery and of a numerical rating scale score for pain above 3/10. The secondary criteria were clinical tolerance of the Gore-Tex® implant and radiological changes. The patients were assessed at last follow-up either in person or during a teleconsultation.

RESULTS

Of 78 included joints, 54 were assessed during patient visits and 24 by teleconsultation. At 10 years, the event-free survival rate was 91.3%, and 60.3% of patients were free of pain. Evidence of osteolysis was visible in 24% of patients. No patient experienced clinical intolerance of the Gore-Tex® implant. The mean Disabilities of Arm, Shoulder and Hand score was 25.5. Metacarpo-phalangeal hyperextension was significantly increased, to 30.6°, and the mean trapezial space ratio was significantly decreased, to 39.1% of the baseline value.

CONCLUSION

Long-term event-free survival was high. Functional outcomes and pain were similar to previous reports. Trapeziectomy with Gore-Tex® ligament reconstruction obviates the need for tendon harvesting. Osteolysis developed in some patients but did not correlate with clinical intolerance. Long-term clinical and radiological monitoring is in order after Gore-Tex® implantation.

LEVEL OF EVIDENCE

IV, Observational, single-centre, single-surgeon, retrospective cohort study.

Complications of prosthesis versus trapeziectomy in trapeziometacarpal joint arthritis: A systematic review

OBJECTIVE

Thumb osteoarthritis is a frequent pathology, mainly affecting the elderly. The surgical treatment initially described and having proved its worth is total trapeziectomy. Since the advent of trapeziometacarpal prostheses, several studies showed the non-inferiority of this technique on clinical criteria, with superiority in bone sparing, although neither technique demonstrated overall superiority. We therefore examined the specific complications of each surgical technique by analyzing their nature and prevalence through a review of the literature to compare them on these new parameters.

METHODS

Seventy-four of the 320 articles reviewed were included, 38 of which concerned trapeziectomy, and 36 concerned prostheses, for a total of 4,865 patients. They were original studies, involving adults undergoing trapeziometacarpal arthroplasty or trapeziectomy, published after 2015, reporting at least one well-described complication.

RESULTS

6.13% of trapeziectomies presented severe complications (in particular thumb collapse and metacarpophalangeal hyperextension), 3.31% moderate complications and 1.90% minor complications, leading to a 2.0% revision rate. 23.88% of prostheses had severe complications (loosening, dislocation and wear), 5.06% moderate complications and 1.36% minor complications, leading to a 12.8% revision rate. In addition, we analyzed more recent prosthesis designs separately, and found lower prevalence of severe complications (16.56%) and revision surgery (4.3%).

CONCLUSION

Revision surgery for trapeziometacarpal prostheses is usually only a standard trapeziectomy with the same follow-up as first-line trapeziectomy, whereas revision surgery for trapeziectomies is much more complex and the results are uncertain. For this reason, we would reserve total trapeziectomy for revision surgeries and patients with low functional demand for whom a second surgery is not desirable. Further studies could confirm this attitude, especially focusing on the latest generation of dual mobility implants.

LEVEL OF EVIDENCE: 1

Biomechanical Comparison of FiberLock Suspensionplasty and Flexor Carpi Radialis Ligament Reconstruction for Treatment of Thumb Carpometacarpal Osteoarthritis

BACKGROUND

The purpose of this study was to compare the cyclic and load to failure characteristics of post-trapeziectomy suspensionplasty with the FiberLock Suspension System (FLSS; Arthrex Inc., Naples, Florida) to flexor carpi radialis ligament reconstruction (FCRLR). We hypothesized that the FLSS will have increased stiffness, yield, and ultimate load compared with FCRLR.

METHODS

Ten matched pairs of cadaveric hands were used. One side of each pair was randomly assigned to receive the FCRLR or FLSS and the contralateral side received the other suspensionplasty. A complete trapeziectomy was performed followed by FLSS or FCRLR. Cyclic and load to failure characteristics were measured with loading in the distal to proximal direction. A preload of 1 N with 30 cycles of 1 N to 10 N was applied, followed by load to failure. A paired t test was used for statistical analysis (P < .05).

RESULTS

The FLSS had significantly decreased nonrecoverable deformation and deformation at peak load during cyclic loading (P < .04). The FLSS also had significantly increased stiffness, yield load, ultimate load, and load and energy absorbed at 10 mm displacement compared with FCRLR (P < .04). All 10 FCRLR specimens failed with suture tearing through the tendon. Nine FLSS specimens failed due to suture slipping from the SwiveLock anchor (Arthrex Inc., Naples, Florida) and 1 failed due to the FiberTak anchor (Arthrex Inc., Naples, Florida) pulling through the index metacarpal.

CONCLUSION

Suspensionplasty with the FLSS demonstrated greater structural integrity compared with FCRLR following trapeziectomy. The FLSS procedure may result in decreased thumb subsidence and decreased construct failure.

Suspension arthroplasty using the palmaris longus tendon with a suture button for thumb trapeziometacarpal arthritis: a retrospective observational study

BACKGROUND

This study was performed to assess the clinical and radiographic results at a minimum of 2 years after ligament reconstruction suspension arthroplasty (LRSA) that comprised full trapeziectomy and suspensionplasty using the palmaris longus tendon and the Mini TightRope (Arthrex, Naples, FL) for advanced thumb carpometacarpal arthritis.

METHODS

We clinically and radiographically evaluated 26 thumbs in 26 patients who had undergone LRSA at least 2 years previously. The mean follow-up period was 35.9 months. We evaluated the subjective clinical outcomes (visual analogue scale and Quick Disabilities of the Arm, Shoulder, and Hand scores) and objective clinical outcomes (range of motion, pinch strength, grip strength, and trapezial space height ratio).

RESULTS

At the final follow-up evaluation, the mean visual analogue scale score was 11.1 (standard deviation (SD) 13.4) and the mean Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 9.39 (SD 10.1). The mean palmar and radial abduction were 62.3° (SD 11.8°) and 63.8° (SD 9.09°), respectively. The mean key pinch and grip strength were 3.92 (SD 1.07) kg and 19.7 (SD 7.77) kg, respectively. The mean trapezial space ratio was 0.21 (SD 0.10). The subjective clinical outcomes, range of motion, and pinch strength were significantly improved compared with preoperatively.

CONCLUSIONS

LRSA for advanced-stage thumb carpometacarpal osteoarthritis relieves pain, improves range of motion and strength, and obtains favourable subjective patient-reported clinical outcomes.

Modification of Burton and Pellegrini trapeziectomy technique: Medium-term comparative analysis

INTRODUCTION

Ligament reconstruction and tendon interposition (LRTI) arthroplasty is the procedure of choice of most hand surgeons in the treatment of basal joint arthritis of the thumb. Progressive and natural collapse after trapeziectomy is a common problem.

DESCRIPTION OF TECHNIQUE

We performed LRTI with flexor carpi radialis (FCR) hemitendon technique, then proceeded to block the hemitendon plasty with a bone fragment at the base of the metacarpal. This technique allows us to maintain tension and to obtain immediate stability.

PATIENTS AND METHODS

We conducted a single-center retrospective longitudinal observational study including 51 patients with diagnosis of symptomatic osteoarthritis of the trapeziometacarpal joint. Group A consisted of 24 thumbs treated with trapeziectomy with LRTI with FCR hemitendon using the Burton-Pellegrini technique. Group B included 27 thumbs treated using the modified technique. The postoperative height of the Scaphometacarpal (SM) space was analyzed. Clinical outcome, opposition, retroversion, patient satisfaction and surgical timing were studied.

RESULTS

The difference of the SM space, after applying correction factor, at one and six months postoperative is significantly less in the modified technique group (P = .033 and P = .001, respectively). The average height loss of the SM space from one to six months postoperative measurement was smaller in the study group, showing greater stability of the plasty.

CONCLUSIONS

The use of a bone fragment to block the FCR plasty improves the results at one and six months postoperatively, showing a diminished height loss of the SM space, improved thumb opposition and without prolonging surgical timing in our series.

Modification of Burton and Pellegrini trapeziectomy technique: Medium-term comparative analysis

INTRODUCTION

Ligament reconstruction and tendon interposition (LRTI) arthroplasty is the procedure of choice of most hand surgeons in the treatment of basal joint arthritis of the thumb. Progressive and natural collapse after trapeziectomy is a common problem.

DESCRIPTION OF TECHNIQUE

We performed LRTI with flexor carpi radialis (FCR) hemitendon technique, then proceeded to block the hemitendon plasty with a bone fragment at the base of the metacarpal. This technique allows us to maintain tension and to obtain immediate stability.

PATIENTS AND METHODS

We conducted a single-center retrospective longitudinal observational study including 51 patients with diagnosis of symptomatic osteoarthritis of the trapeziometacarpal joint. Group A consisted of 24 thumbs treated with trapeziectomy with LRTI with FCR hemitendon using the Burton-Pellegrini technique. Group B included 27 thumbs treated using the modified technique. The postoperative height of the Scaphometacarpal (SM) space was analyzed. Clinical outcome, opposition, retroversion, patient satisfaction and surgical timing were studied.

RESULTS

The difference of the SM space, after applying correction factor, at one and six months postoperative is significantly less in the modified technique group (p=0.033 and p=0.001 respectively). The average height loss of the SM space from one to six months postoperative measurement was smaller in the study group, showing greater stability of the plasty.

CONCLUSIONS

The use of a bone fragment to block the FCR plasty improves the results at one and six months postoperatively, showing a diminished height loss of the SM space, improved thumb opposition and without prolonging surgical timing in our series.

Radiological imaging of the trapeziometacarpal joint: a historical and clinical perspective

The opposable thumb provides both stability and mobility and is needed to accomplish different prehensile tasks. The trapezium is a complex bone, with a distal articular surface that is convex in the sagittal plane of the thumb and concave in the coronal plane of the thumb. The numerous additional articulations with the carpus and the oblique orientation to the main plane of the hand makes it difficult to evaluate the trapeziometacarpal joint using standard hand or wrist radiographic views. This review gives an overview of the different radiological views that have been described for the thumb with an emphasis on their historical origin and positioning during radiography. We also describe different measurements and classifications that can be obtained using different thumb radiographs.

Trapeziectomy with Ligament Reconstruction and Tendon Interposition versus Trapeziometacarpal Joint Replacement for Thumb Carpometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis

Background  The trapeziometacarpal articulation in the thumb is a joint that is second-most commonly affected by osteoarthritis, and this can lead to considerable hand pain and disability. Currently, there is a multiplicity of surgical options available to address this problem, yet none has proven to be significantly superior to the others. Objective  This study aims to compare the outcome of trapeziectomy with ligament reconstruction and tendon interposition versus trapeziometacarpal joint replacement for thumb carpometacarpal osteoarthritis. Materials and Methods  A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. The NICE Healthcare Databases Advanced Search (HDAS) tool was used to search articles. One randomized controlled trial (RCT), one prospective cohort study and two retrospective cohort studies were identified. Results  Our results demonstrate a significant difference in the Quick Disabilities of the Arm Shoulder and Hand (QDASH) score between the trapeziectomy with ligament reconstruction and tendon interposition (LRTI) and Joint Replacement groups with the joint replacement group exhibiting better QDASH scores than the LRTI group. We also found that those who had a joint replacement had a significantly better thumb opposition than those in the LRTI group, as demonstrated by a superior Kapandji score. However, the complication rate of joint replacement appears to be higher. Conclusion  Our study reveals that while both treatment options are valid, the limited body of evidence currently available shows that joint replacement carries more risks and thus should not replace the current standard treatment of trapeziectomy with LRTI. This study highlights the need for more trials to be performed to more accurately compare the two treatment modalities. For the time being, we advocate that joint replacement is only performed by surgeons who perform this procedure regularly to reduce the risk of complications.

Prognostic factors and clinical features in metacarpophalangeal joint hyperextension after ligament reconstruction with trapeziectomy: A retrospective cohort study

BACKGROUND

Management of metacarpophalangeal (MCP) hyperextension deformity in thumb carpometacarpal (CMC) joint arthritis is challenging. It remains unclear how the preoperative MCP joint angle affects the outcomes. The present study aimed to clarify the associations between postoperative MCP hyperextension deformity and outcomes, and to determine the preoperative MCP joint angle that can predict poor outcomes.

METHODS

We investigated the functional outcomes of patients who underwent surgery for CMC arthritis at two institutions from 2016 to 2020. All patients received a modified Thompson technique, ligament reconstruction suspension arthroplasty, and had no additional treatment for MCP hyperextension. The patients were divided into three groups according to their postoperative MCP joint angles: Group A, <10°; Group B, 10°-20°; Group C, >20°. Evaluations included preoperative and postoperative VAS, Quick DASH, range of motion (ROM), grip power, pinch strength, first web space angle, and postoperative trapezial space ratio (TSR).

RESULTS

Overall, 66 eligible patients (72 thumbs) were identified and received follow-up for a mean of 25.2 months. The 72 thumbs were assigned to Group A (n = 38), Group B (n = 16), and Group C (n = 18). Group C had significantly lower preoperative MCP joint angle and postoperative grip power, pinch strength, and TSR compared with the Group A (P < 0.05). However, there were no significant differences in VAS, Quick DASH, ROM, and first web space angle (P > 0.05). The preoperative risk factor for highly residual MCP hyperextension was preoperative MCP joint angle (OR = 1.078; P = 0.001), with a cut-off value of 21.5° (AUC = 0.79; sensitivity = 0.813; specificity = 0.821).

CONCLUSIONS

Postoperative MCP hyperextension of >20° after ligament reconstruction with trapeziectomy has adverse effects on functional outcomes. In cases with preoperative MCP joint angle of >21.5°, additional treatment for MCP hyperextension should be considered.

A Modified Suture Suspension Arthroplasty Technique for the Treatment of Basal Joint Arthritis: Short- to Intermediate-Term Outcomes

Background: To present a retrospective study on the outcomes of a modified version of suture suspension arthroplasty with trapeziectomy on patients with thumb basal joint arthritis and to evaluate the relationship between the degree of subsidence and functional outcome. Methods: We performed a chart review on 67 patients (75 thumbs) who were surgically treated for thumb carpometacarpal osteoarthritis with trapeziectomy and suture suspension arthroplasty from May 2010 to May 2016. Outcome measures included Disabilities of the Arm, Shoulder and Hand (DASH), grip strength, lateral/precision pinch strength, range of motion, and return to work/resumption of usual activities. Radiographic images were used to measure first metacarpal subsidence into the trapezial space. Results: Clinical outcomes were satisfactory, showing an initial postoperative DASH score of 45.94, which decreased to 27.93 at 6 months postoperatively and to 19.69 at 1 year postoperatively. Radiographic images revealed a mean first metacarpal subsidence of 39% compared with the preoperative images. Grip and pinch strengths showed steady improvement from initial postoperative to final follow-up visits, resulting in 90% recovery of gross grasp, 77% recovery of lateral pinch, and 79% recovery of precision pinch compared with the contralateral side. Conclusions: Our study has found that suture suspension arthroplasty with trapeziectomy is an effective treatment for thumb basal joint arthritis. Suture suspension arthroplasty allows for short immobilization time, avoids tendon sacrifice, avoids anchor use, and leaves a cosmetically appealing scar. Furthermore, a relationship of any significance between postoperative first metacarpal subsidence and functional outcomes does not appear.

Trapeziectomy with suture-button suspensionplasty versus ligament reconstruction and tendon interposition: a randomized controlled trial

The purpose of the present study was to compare the results of patients operated with trapeziectomy and ligament reconstruction and tendon interposition (LRTI) using flexor carpi radialis tendon versus trapeziectomy followed by suspension of the first metacarpal to the second metacarpal using a Mini TightRope® suture button (suture button suspension: SBS). A single-center prospective randomized controlled trial was performed, comparing 37 patients with SBS and 39 with LRTI. All surgeries were performed by the same fellowship-trained hand surgeon. Patients were assessed by an independent observer at 40 months' follow-up. Pre- and postoperative strength, trapezial space ratio (TSR), range of motion, QuickDASH and visual analogue pain score were recorded. Both procedures improved functional parameters of pain, key strength, tip strength and grip strength while maintaining range of motion, without significant differences. In the SBS group, TSR decreased by 17%, compared to 28% in the LRTI group. The mean operative time was shorter in SBS (63 vs 91 minutes; p < 0.0001), as was immobilization time (2 vs 6 weeks; p < 0.0001), and patients resumed normal activity sooner (10 vs 12 week; p = 0.0138) and required less physical therapy (19.3 vs 13.1 weeks; p < 0.0001). We believe that our results are related to the hypothesis suggested by biomechanical studies that revealed better initial load bearing profile and maintenance of trapezial space following serial loading in cadaver models.

The influence of K-wire transfixation on proximalization of the first metacarpal after resection suspension interposition arthroplasty

INTRODUCTION

Osteoarthritis of the first carpometacarpal joint is a common degenerative disease and surgical treatment includes resection suspension interposition arthroplasty (RSIA) with or without temporary transfixation of the first metacarpal. One major drawback includes proximalization of the first metacarpal during the postoperative course. Specific data comparing different transfixation techniques in this context is sparse.

MATERIALS AND METHODS

In this retrospective study, we measured the trapezial space ratio (TSR) in 53 hands before and after RSIA to determine the proximalization of the first metacarpal depending on the type of Kirschner (K)-wire transfixation. We, therefore, compared transfixation of the first metacarpal to the scaphoid with one K-wire (1K) to transfixation of the first metacarpal with two K-wires (2K), either to the carpus (2Ka), or to the second metacarpal (2Kb), or to both second metacarpal and carpus (2Kc).

RESULTS

While preoperative TSR did not differ between group 1K and 2K (p = 0.507), postoperative TSR was significantly higher in group 2K compared to 1K (p = 0.003). Comparing subgroups, postoperative TSR was significantly higher in group 2Kc than 1K (p = 0.046), while we found no significant difference comparing either group 2Ka or 2Kb to 1K (p = 0.098; p = 0.159). Neither did we find a significant difference within 2K subgroups, comparing group 2Ka and 2Kb (p = 0.834), 2Ka and 2Kc (p = 0.615), or 2Kb and 2Kc (p = 0.555).

CONCLUSIONS

The results of our study suggest that transfixation with two K-wires should be preferred to transfixation with one K-wire after RSIA. Specifically, transfixation from first to second metacarpal and from first metacarpal to carpus resulted in least proximalization of the first metacarpal postoperatively.

Total trapeziectomy for osteoarthritis of the trapeziometacarpal joint: Clinical and radiological outcomes in 21 cases with minimum 10-year follow-up

INTRODUCTION

Trapeziectomy is a technique of choice for osteoarthritis of the trapeziometacarpal joint, but few studies have assessed long-term radiological and clinical outcome in total trapeziectomy, mean follow-up being rather between 2 and 6 years in most cases. The main aim of the present study was to assess loss of trapezial space height at a minimum 10 years' follow-up. Secondary endpoints comprised functional outcome at the same follow-up.

HYPOTHESIS

There is systematic loss of trapezial space height, with discrepancy between radiological and clinical results, beyond 10 years' follow-up.

MATERIAL AND METHODS

Sixteen patients were retrospectively reassessed at a mean 13.8 years' follow-up (range, 10-17.8 years), for 21 total trapeziectomies. Criteria for the main endpoint comprised trapezial space height (TSH) and trapezial space ratio (TSR=TSH/thumb P1 phalanx length). Secondary endpoint criteria comprised pain, Kapandji opposition and retropulsion scores, active abduction, dynamometric parameters (key-pinch, tip-pinch and grip strength compared to the contralateral side), QuickDASH and satisfaction.

RESULTS

Mean TSH and TSR were respectively 3.7mm (range, 0.5-6.1) and 0.14 (0.02-0.25) at last follow-up. Ranges of motion were conserved, with mean Kapandji score of 9.3 (6-10), Kapandji retropulsion score of 2.8 (1-4) and active abduction of 43° (30-45°). Strength measurements were comparable to contralateral values except for key-pinch, which was significantly weaker on the operated side (4.8kg (1.5-8.5kg) versus 5.5kg (1.5-8kg); p=0.041). Mean QuickDASH was 23.5 (0-68.2), and overall satisfaction on VAS was 9.5/10 (6-10). Statistical testing confirmed the absence of correlation between radiological and clinical criteria.

DISCUSSION

Despite systematic trapezial space height loss, functional results were satisfactory and stable at a mean follow-up of 13.8 years. There was no correlation between radiological and clinical criteria in the long term.

LEVEL OF EVIDENCE

IV, single-center retrospective study.

Effect of Partial and Complete Trapezoid Excision on Radiographic and Functional Results After Abductor Pollicis Longus Suspensionplasty

PURPOSE

We hypothesized that adding complete or partial trapezoid excision is associated with greater radiographic carpal collapse and worse functional outcomes compared with a simple trapeziectomy and abductor pollicis longus suspensionplasty.

METHODS

A total of 69 patients had abductor pollicis longus suspensionplasty (79 hands), 87% of whom were female, mean age 64 years. Scaphotrapezium-trapezoid arthritis noted at surgery was treated with an additional proximal trapezoid excision (PT) in 21 (27%) or complete trapezoid resection (CT) in 22 hands (28%). No trapezoid was excised in 36 hands. The primary outcome was final radiolunate (RL) extension of 15° or greater on lateral radiographs. Logistic regression (for change in RL angle) and linear regression (for continuous variables) with robust variance estimate to account for within-subject correlation (generalized estimating equation method) were used to investigate whether the trapezoid excision groups had an effect on the outcomes of interest. Models were adjusted for age and sex.

RESULTS

Median follow-up was 92 months. Complete trapezoid resection had the most increase in RL angle, but PT had a higher incidence (29% vs 26%) of final RL angle of 15° or greater compared with CT. When stratified into groups with a final RL greater than or less than 15°, the former group had worse total function (Patient-Rated Wrist Evaluation) and Quick-Disabilities of the Arm, Shoulder, and Hand scores. Symptomatic index metacarpal migration was seen in 4 CT and 2 PT wrists (18% and 10%, respectively) and was considered to indicate failure.

CONCLUSIONS

Compared with no trapezoid excised, both PT and CT had a greater incidence of lunate extension of 15° or greater, consistent with radiographic nondissociative-dorsal intercalated carpal instability, which was associated with inferior functional scores. Symptomatic proximal collapse of the index metacarpal was seen in both CT and PT. Further studies should evaluate whether routine excision of the proximal trapezoid is necessary for scaphotrapezoid arthritis, because any disruption of the scaphotrapezoid ligament complex appears to increase risk for developing carpal instability nondissociative-dorsal intercalated carpal instability over time and may be associated with inferior functional results. Complete trapezoid excision is not recommended.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Arthroscopic ligamentoplasty for osteoarthritis of the thumb carpometacarpal joints: Clinical and radiological outcomes with a minimum 2-year follow-up

BACKGROUND

We reported a new technique for arthroscopic ligamentoplasty for the thumb carpometacarpal osteoarthritis (CMC-OA) along with a minimum of 2 years of results.

METHODS

Twenty-nine thumbs with CMC-OA in stages II and III according to the Eaton and Glickel classification, were treated by arthroscopic ligamentoplasty. The procedure included partial trapeziectomy followed by ligamentoplasty similar to the Thompson technique. We evaluated pain VAS; DASH; grip and pinch strength; thumb abduction range of motion, and radiographic examination preoperatively and every 3 months until 1 year after surgery, and every 6 months thereafter. The mean duration of the follow-up was 3.2 years with a range of 2.0-6.0 years.

RESULTS

Pain, VAS, and DASH were significantly improved at 3 months after surgery than those preoperatively. Further, the strength of grip, tip, and key pinch significantly increased at 9, 9, and 12 months after surgery, respectively. Additionally, these improvements were maintained until the final follow-up. The range of motion tended to decrease in both palmar and radial abduction, although the differences were not significant. Radiographic examination after surgery showed that the ratio of trapezial space was significantly reduced because of surgical excision of the trapezium. However, there were no significant differences in the results between each follow-up time and the final follow-up. Moreover, the ratio of subluxation on the plain X-ray was significantly improved and maintained until the final follow-up. The parameters of clinical and radiographic outcomes, except motion, were significantly improved, even in patients with including those in stage III and with greater than 1/3 subluxation of the 1st metacarpal base on plain radiography.

CONCLUSION

Arthroscopic ligamentoplasty was effective for pain relief and improvement of grip and pinch strength for the patients with symptomatic CMC-OA.

LEVEL OF EVIDENCE

Therapeutic study/Level IV.

Novel Modification of Abductor Pollicis Longus Suspension Arthroplasty with Trapeziectomy for Thumb Carpometacarpal Osteoarthritis

BACKGROUND

We compared the clinical results of a newly modified abductor pollicis longus (APL) suspension arthroplasty with trapeziectomy procedure (modified Thompson procedure) with those of the original APL suspension arthroplasty with trapeziectomy procedure (original Thompson procedure) for treatment of advanced osteoarthritis of the thumb carpometacarpal (CMC) joint and assessed the effectiveness of the modified Thompson procedure for thumb CMC osteoarthritis.

METHODS

Ten hands of 10 patients (Group 1) were treated with the original Thompson procedure. Twenty hands of 16 patients (Group 2) were treated with the modified Thompson procedure, in which the bone tunnel positions were rearranged for a more dorsoradial passage of the transferred APL.

RESULTS

Significant differences between values before and after surgery were noted in thumb palmar and radial abduction angles, pinch power, grip strength, Quick Disability of Arm, Shoulder, and Hand questionnaire (Quick DASH) score, and visual analog scale (VAS) score. There was no statistically significant difference in thumb palmar abduction angle, pinch power, grip strength, Quick DASH score, or VAS score between Groups 1 and 2. However, range of motion of radial abduction in the thumb was significantly better for patients in Group 2 than for those in Group 1.

CONCLUSIONS

The modified Thompson procedure is a simple, effective technique that results in greater improvement in thumb radial abduction angle, as compared with the original technique, in patients with advanced thumb CMC osteoarthritis. Additionally, the modified technique is as useful as the original procedure for early restoration of thumb function and pain relief.

Suture Suspensionplasty Using Abductor Pollicis Longus and Flexor Carpi Radialis for Advanced Thumb Carpometacarpal Joint Arthritis

PURPOSE

Current operative treatment for advanced thumb carpometacarpal (CMC) joint arthritis mainly constitutes complete trapeziectomy with or without additional stabilizing procedures. However, it is unclear whether the additional procedures influence overall clinical outcomes. Therefore, the purpose of this study was to evaluate the effectiveness of our posttrapeziectomy suture suspensionplasty technique, performed using the abductor pollicis longus and flexor carpi radialis tendons, in patients with advanced thumb CMC arthritis.

MATERIALS AND METHODS

We evaluated 36 thumbs of 35 patients with advanced thumb CMC arthritis treated with combined operative excision of trapezium followed by a suture suspensionplasty using flexor carpi radialis and abductor pollicis longus tendons. We used a minimal volar approach to create a sling construct with a nonabsorbable suture material, which could support the thumb metacarpal base without pin fixation or tendon transfer. For radiographic evaluation, we used the ratio of the radial metacarpal subluxation to metacarpal articular width, estimated from the bilateral stress-view radiographic images of the thumb, and calculated the trapezial space ratio by dividing the trapezial space height by the proximal phalangeal length. The clinical outcomes were evaluated using the visual analog scale and disabilities of the arm, shoulder, and hand scores, along with evaluation of the improvement in both postoperative range of motion and strength recovery.

RESULTS

The mean duration of follow-up was 26 months (range, 18-60 months). The average visual analog scale and disabilities of the arm, shoulder, and hand scores decreased from 5.9 to 0.4 and from 51.6 to 27.0, respectively. The range of motion during palmar abduction and opposition of the metacarpophalangeal joint improved with an increase in mean value from 49.1 degrees to 54.1 degrees, and from 7.8 to 9.3 Kapandji score, respectively. The grip and key pinch strengths showed no significant changes from mean preoperative values of 13.3 kg and 3.8 kg to 13.2 kg and 3.2 kg, respectively, as measured at the 18-month follow-up.

CONCLUSIONS

Our suture suspensionplasty technique has several advantages including minimal invasive approach, short operative time, cost-effectiveness, and early mobilization. We suggest that it can be used as an effective, alternative stabilization method after a complete trapeziectomy.

Outcomes of Surgical Management for Thumb Basilar Arthritis in Patients 55 Years of Age and Younger

Background: Trapeziectomy with ligament reconstruction tendon interposition (LRTI) or suspensionplasty is an effective treatment in older patients with end-stage thumb basilar arthritis. However, the survivability of this procedure is unknown in younger patients who may impart more stress on their thumbs. Methods: A retrospective review was performed on all patients who underwent trapeziectomy and LRTI or suspensionplasty at 55 years of age or younger from 1992 to 2008. Objective clinical outcome measures included preoperative to postoperative changes in thumb range of motion, grip and pinch strength, a study-specific thumb function score, and the Buck-Gramcko subjective outcome score. Progressive metacarpal subsidence was evaluated on radiographs. Survivorship free from revision surgery was calculated with a Kaplan-Meier analysis. Results: A total of 57 wrists underwent trapeziectomy and LRTI (n = 18) or suspensionplasty (n = 39). The mean patient age at the time of surgery was 49.6 years (range: 38-55 years). Mean clinical and radiographic follow-up were 10.2 and 6.4 years, respectively. Overall, there were significant improvements in pain and grip strength despite progressive and metacarpal subsidence. Survivorship was 100% and 86% free from revision surgery at 10 and 15 years, respectively (n = 2 failures). Conclusions: Trapeziectomy and LRTI or suspensionplasty in patients less than or equal to 55 years of age can result in considerable improvements in pain and grip strength with a 10-year survivorship free from revision.

Outcomes of Revisions for Failed Trapeziometacarpal Joint Arthritis Surgery

PURPOSE

We compare outcomes of revision surgery for trapeziometacarpal (TM) arthritis with outcomes for both primary and revision surgery for TM arthritis reported in the literature. We hypothesized that patients undergoing revision surgery for TM arthritis would demonstrate pain and functional outcome scores that were worse than those of patients undergoing primary TM surgery.

METHODS

A retrospective analysis of all patients undergoing revision TM surgery at a single institution from 1995 to 2015 was performed. Eighty-three patients (86 hands) met the inclusion criteria. Of these, 25 patients (27 hands) were available for follow-up via phone survey or clinical examination; 58 patients (59 hands) were available for chart review only. Patients available for phone survey or clinical examination were evaluated with the visual analog scale, Disabilities of the Arm, Shoulder, and Hand score, and the Conolly-Rath evaluation method. Patients available for clinical examination were also evaluated with grip strength, pinch strength, and radiographs.

RESULTS

Median follow-up was 8.5 years (range, 2.0-21.2 years). Twenty percent of patients experienced postoperative complications, most commonly pin problems (7%). Of the 27 hands available for interview or clinical examination, 15 were dominant and 12 were nondominant. The average visual analog scale was 28.2 (SD, 29.7). Disabilities of the Arm, Shoulder, and Hand scores averaged 32.0 (SD, 20.8). According to the Conolly and Rath criteria, 10 patients had a good outcome, 7 were fair, and 10 were poor. For the group of 13 patients who underwent physical examination, average adduction was 42° in the affected side versus 51° in the nonaffected side. Radial abduction was 58° in the affected side versus 65° in the nonaffected side. Palmar abduction was 53° versus 85° in each group, respectively. Tip finger pinch was 3.4 kg for the affected hand versus 4.0 kg for the nonaffected side. Key pinch was 4.7 and 5.5 kg, respectively. Grip strength was measured as 22.1 kg in the affected side versus 27.6 kg in the contralateral side when adjusted for dominance.

CONCLUSIONS

In our study group, revision surgery for unsuccessful primary TM surgery demonstrated results inferior to those previously reported for primary surgery for TM arthritis but similar to prior studies of revision TM surgery. Revision surgery, however, can result in satisfactory long-term outcomes particularly when metacarpophalangeal joint pathology is addressed and complications are avoided.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Early Results of the ARPE Arthroplasty Versus Trapeziectomy for the Treatment of Thumb Carpometacarpal Joint Osteoarthritis

BACKGROUND

Thumb carpometacarpal joint arthroplasty for osteoarthritis may hold advantages over trapeziectomy by preserving range of motion, whilst providing stability and preventing thumb shortening.

METHODS

We compare functional and satisfaction outcomes scores, radiological shortening and complication rates between patients treated with trapeziectomy and those receiving the ARPE thumb CMCJ arthroplasty.

RESULTS

Seventy-five trapeziectomies and one hundred and ten ARPE arthroplasties were performed over the study period. Both treatments resulted in significant improvements in functional scores. When matching patients according to pre-operative function, patients receiving the ARPE arthroplasty had better post-operative function (Quick DASH: trapeziectomy = 25.1, ARPE = 16.8). More patients receiving the ARPE arthroplasty were satisfied with their treatment (trapeziectomy = 7.8/10, ARPE = 8.7/10) and would have the same treatment again (trapeziectomy = 76%, ARPE = 89%). The ARPE also resulted in less thumb shortening. However the ARPE arthroplasty is associated with a higher complication rate, with 14% of patients requiring further surgery at a mean of 2 years follow up (95% implant survival).

CONCLUSIONS

Both trapeziectomy and the ARPE CMCJ arthroplasty are effective treatment options for thumb CMCJ osteoarthritis. Arthroplasty may offer potential advantages in terms of post-operative function and patient satisfaction. However the risk of complications and requirement for further surgery is greater and must be carefully considered during patient selection and pre-operative counselling.

Basilar Thumb Arthritis: The Utility of Suture-Button Suspensionplasty

BACKGROUND

We sought to compare the functional outcomes, radiographic outcomes, and complications of trapeziectomy and flexor carpi radialis (FCR) to abductor pollicis longus (APL) side-to-side tendon transfer with or without suture-button suspensionplasty for thumb basilar joint arthritis.

METHODS

Patients treated with and without suture-button suspensionplasty were compared over a 6-year period. Data were reviewed for complications and functional outcomes, including grip and pinch strength, range of motion, and visual analog scale (VAS) pain scores. Plain radiographs were independently reviewed at initial presentation and at final follow-up, including proximal phalanx length, trapezial space height, and trapezial height ratio.

RESULTS

Seventy thumb arthroplasties were performed in 70 patients. Trapeziectomy with FCR-APL side-to-side tendon transfer was performed in 39 patients, and trapeziectomy with FCR-APL side-to-side tendon transfer with suture-button suspensionplasty was performed in 31 patients. Mean length of follow-up was 28.4 ± 3.9 and 23.8 ± 2.6 months, respectively. Postoperative grip, oppositional and appositional pinch strength, and VAS pain scores improved compared with preoperative values, but were not significantly different based on suture-button suspensionplasty. Percentage decline in trapezial space ratio was significantly different between groups at 36.7% and 20.4% for procedures with and without suture-button suspensionplasty, respectively indicating that the trapezial space was better maintained within the suture suspension cohort. The incidence of postoperative complications, including surgical site infection, paresthesias, reoperation, complex regional pain syndrome, and symptomatic subsidence, was not significantly different between groups.

CONCLUSIONS

Trapeziectomy with FCR to APL side-to-side tendon transfer with and without suture-button suspensionplasty results in comparable improvement in pain, grip strength, and functional parameters. Suture-button suspensionplasty results in significantly greater preservation of trapezial space.

Reliability of Metacarpal Subsidence Measurements after Thumb Carpometacarpal Joint Arthroplasty

Background

Thumb metacarpal subsidence after trapeziectomy can affect clinical function over time. Methods for measuring subsidence after trapeziectomy have been described, and they rely on an intact thumb metacarpal or proximal phalanx for measurement. The authors evaluated the reliability and reproducibility of measuring the trapezial space ratio, using previously described methods. In addition, the authors evaluated a new method that measures trapezial space on a posteroanterior (PA) hand/wrist radiograph that does not rely on an intact thumb metacarpal or proximal phalanx for measurement, which can often be altered by degenerative changes or in cases in which metacarpophalangeal arthrodesis is performed during carpometacarpal (CMC) joint arthroplasty to correct excessive hyperextension. The authors hypothesized that a new method of calculating trapezial space would have comparable reliability and reproducibility to previously proposed methods.

Methods

Thirty-seven PA hand/wrist radiographs from patients who had trapeziectomy with ligament reconstruction and tendon interposition were evaluated. Trapezial space was measured using PACS (Picture Archiving and Communication System) digital tools as the distance perpendicular to the tangents of the scaphoid and first metacarpal joint surfaces. All X-rays were evaluated individually by five fellowship-trained hand surgeons, twice, 4 weeks apart. The reviewers calculated trapezial space ratios, using three different methods, two previously described and a novel one: (1) trapezial space relative to first metacarpal length (classic 1); (2) trapezial space relative to proximal phalanx length (classic 2); and (3) trapezial space relative to capitate height (novel). Inter- and intraobserver reliabilities were measured using intraclass correlation coefficients (ICC) and limits of agreement for each method.

Results

The authors identified excellent agreement between the classic 1, classic 2, and novel methods with an ICC greater than 0.8, indicating excellent agreement. The average trapezial space ratios for the thumb proximal phalanx, thumb metacarpal, and capitate methods were measured as 0.19, 0.12, and 0.24, respectively. The upper and lower limits of the 95% confidence intervals for both the inter- and intraobserver agreements of the aforementioned trapezial space ratios were (0.17-0.26), (0.11-0.17), and (0.21-0.34) for the interobserver rates and (0.11-0.25), (0.06-0.16), and (0.12-0.33) for the intraobserver rates, respectively.

Conclusion

Measuring trapezial space is an important diagnostic tool to assess postoperative changes in thumb length. The trapezial space indexed to the capitate height method (novel) provides a simple and similarly reliable method for calculating the trapezial space ratio on a PA radiograph of the hand/wrist when other measurement techniques are unavailable and when the thumb metacarpal or proximal phalanx is not intact. The authors found a high degree of reproducibility and inter- and intraobserver reliability as measured by the ICC and the 95% limits of agreement that compare with previous agreements in the literature.

Radiographic Optimization of the Eaton Classification

Thumb basal arthritis is evaluated using the Eaton classification. However, the shape and orientation of the trapezium do not allow easy visualization of this bone. The purpose of this study was to determine if the intra- and interobserver reliability of the Eaton classification could be improved using a combination of X-rays. Six hand surgeons independently evaluated 40 sets of X-rays. First, the X-rays were staged using the posterior–anterior and lateral views of the wrist, and then using just the Bett’s (Gedda’s) view. Subsequently, all three views were evaluated together. The process was repeated at least 1 week later. Intra- and interobserver reliability was measured using kappa statistics. Results show a trend toward increased reliability when the three views are used. Agreement between the stages using the posterior–anterior and lateral X-rays and the Bett’s view was only fair. With three views, intraobserver reproducibility is good while interobserver reliability is moderate.

The "Pillow" Technique for Thumb Carpometacarpal Joint Arthritis: Cohort Study With 10- to 15-Year Follow-Up

PURPOSE

Arthritis of the carpometacarpal joint of the thumb is common, and there are many studies regarding its treatment. We investigated the long-term outcome of interposition arthroplasty with a fascia lata allograft (pillow technique), without ligament reconstruction, to treat thumb carpometacarpal arthritis. The technique consisted of complete trapeziectomy, use of alloplastic tensor fascia lata, and K-wire immobilization for 5 weeks.

METHODS

The outcomes of 31 thumbs in 24 female patients were measured at a mean follow-up of 12.5 years (range, 10-15 years).

RESULTS

Grip strength, key pinch, pulp-to-pulp pinch, tripod pinch, and range of motion were all improved. The Disabilities of the Arm, Shoulder, and Hand median score, which was only measured postoperatively, was an average of 5 (range, 0-52.6). No extrusion of the graft material was noted, and no revisions were performed.

CONCLUSIONS

Our results indicate that a fascia lata allograft can be used as an interposition material in thumb carpometacarpal arthroplasty. This technique provides pain relief and satisfactory function at an average of 12.5 years after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Mini Tightrope Fixation Versus Ligament Reconstruction - Tendon Interposition for Maintenance of Post-trapeziectomy Space Height: A Biomechanical Study

PURPOSE

To test the biomechanical stability of ligament reconstruction and tendon interposition (LRTI) compared with Mini TightRope fixation for thumb metacarpal subsidence after trapeziectomy.

METHODS

Fifteen fresh human cadaveric hands underwent trapeziectomy and were divided into 3 treatment groups: LRTI using a biotenodesis screw and single versus dual Mini TightRope fixation. The thumb and index fingers were removed distal to the metacarpal; the distal ends of the metacarpals and proximal radius were potted in urethane resin and mounted onto a servohydraulic testing machine. A cyclic axial load was applied to stress the trapezial cavity. We recorded displacement of the first metacarpal via the position of the actuator head and computed the size of the trapezial space as the difference of the initial size and first metacarpal displacement. Each specimen underwent cyclical loading until the first metacarpal had collapsed completely onto the scaphoid (failure of the repair) or until 6 hours of testing had been completed. The number of cycles to failure, change in the size of the trapezium cavity, and relative change in size of the trapezium cavity were determined.

RESULTS

The trapezial space had completely closed before 6 hours of testing were completed in all biotenodesis screw-augmented LRTI specimens and remained present in all single and dual Mini TightRope specimens. Absolute (and normalized) changes in the size of the trapezial cavity in the single and dual Mini TightRope specimens were 11 ± 2 and 10 ± 2 mm, respectively.

CONCLUSIONS

Dual Mini TightRope fixation provided superior load bearing and maintenance of trapezial space height compared with single Mini TightRope or LRTI biotenodesis screw procedures.

CLINICAL RELEVANCE

This study demonstrates that patients who undergo suture suspension arthroplasty may be able to move earlier because of the immediate stability the construct affords.

SURGICAL TREATMENT OF RHIZARTHROSIS: TRAPEZIECTOMY WITH OR WITHOUT LIGAMENTOPLASTY VERSUS TOTAL PROSTHESIS

Objective: The aim of this study was to review cases that underwent surgical treatment using two techniques: trapeziectomy with or without ligamentoplasty and arthroplasty with implant. Methods: Fifty-two hands that were surgically treated for rhizarthrosis between 1995 and 2008 were evaluated: 32 cases of trapeziectomy with or without ligamentoplasty (group A) and 20 with implant arthroplasty (group B). The mean follow-up for group A was 72 months and for group B, 23 months. There were no significantly different results with regard to pain, activities of daily living, mobility or strength. In the radiographic evaluation, it was found that the scaphometacarpal height was better preserved in group B. The mean time taken to achieve recovery was 10 weeks in group A and 4.5 in group B. Four cases with complications were recorded: one case of algoneurodystrophy in group A and two cases of dislocation and one case of fracture of the trapezium in group B. Results: The results from prostheses were better than the results from the traditional treatment for rhizarthrosis using trapeziectomy with or without ligamentoplasty because of the rapid recovery that prostheses provide. Conclusion: However, prostheses should be applied carefully, because there is a potential for complications relating to the implants.

Meniscal allograft arthroplasty for the treatment of trapeziometacarpal arthritis of the thumb

BACKGROUND

Arthritis at the trapeziometacarpal joint of the thumb is common. Several surgical options exist showing favorable results. We report the outcomes after interposition of allograft knee meniscus for thumb trapeziometacarpal arthritis.

METHODS

Twenty-three patients (25 thumbs) had surgery for thumb trapeziometacarpal arthritis using knee meniscal allograft tissue. Eleven thumbs had a minimum follow-up of 24 months, 2 thumbs had a minimum of 12 months, and 12 thumbs had less than 6 months. Disabilities of arm, shoulder, and hand (DASH) questionnaire scores, pain levels, grip strength, pinch strength, range of motion, and radiographic measurements were performed.

RESULTS

Between the preoperative and 24-month follow-up measurements, patient pain levels were reduced. There was a significant improvement in DASH scores. Comparisons between preoperative and postoperative strength measurements showed increase in grip strength and key pinch strength. Trapeziometacarpal subsidence was 5.5 %, and subluxation index measurements decreased 3.9 %. There was no clinical or radiographic evidence of foreign body reaction and no other complications occurred.

CONCLUSIONS

The results of meniscal allograft arthroplasty are comparable to other surgical techniques for trapeziometacarpal arthritis with respect to pain, outcomes, strength, oppositional motion, complications, surgical time, cost, and return to work. The results suggest that meniscal allograft arthroplasty is a viable option in the surgical management of stages II and III arthritis of the TM joint. Further follow-up and clinical studies are warranted.

Dual mini TightRope suspensionplasty for thumb basilar joint arthritis: a case series

PURPOSE

To evaluate the efficacy of the technique of dual Mini TightRope suspensionplasty for treatment of trapeziometacarpal joint arthritis.

METHODS

We conducted a retrospective study investigating the use of a dual Mini TightRope suspensionplasty technique from 2010 to 2013 at a single institution. We identified 11 patients (12 thumbs). Grip and pinch strength, thumb range of motion, and complications were reviewed. The trapezial space ratio was measured from the preoperative, postoperative, and follow-up radiographs. All patients completed the Disabilities of Arm, Shoulder, and Hand survey, Patient-Rated Wrist Evaluation, and the Michigan Hand Outcome Questionnaire at the latest follow-up.

RESULTS

Dual Mini TightRope suspensionplasty resulted in reduced pain levels, increased grip and pinch strength, and preserved range of motion. Radiographs demonstrated maintenance of trapezial space height at an average of 17 months (range, 10-26 mo). There were no cases of impingement or fracture of the first and second metacarpal bases.

CONCLUSIONS

Dual Mini TightRope suspensionplasty for the management of trapeziometacarpal joint arthritis yielded satisfactory results with improvement in strength and function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Trapezium excision and suture suspensionplasty (TESS) for the treatment of thumb carpometacarpal arthritis

Basilar thumb arthritis, or first carpometacarpal arthritis, is a common condition affecting older women and some men. It is estimated that as many as one third of postmenopausal woman are affected. Surgical treatment of this condition includes options ranging from arthrodesis to prosthetic arthroplasty. Intermediate options include complete or partial trapezial excision with or without interposition of a cushioning/stabilizing material (auto source, allo source, synthetic source). A multitude of methods appear to offer similar end results, although some methods definitely involve more surgical work and perhaps greater patient risk. Through retrospective evaluation of a cohort of patients who underwent suture suspensionplasty, we determined the postoperative effect on strength, motion, patient satisfaction, complications, and radiographic maintenance of the scaphoid-metacarpal distance. This review shows the method to be clinically effective and, by comparison with a more traditional ligament reconstruction trapezial interposition arthroplasty, the method does not require use of autograft or allograft tendon and has fewer surgical steps. Forty-four patients were included in this retrospective study. The results showed that 91% of patients were satisfied with the procedure. Pinch and grip strength remained the same preoperatively and postoperatively. A Disabilities of the Arm, Shoulder, and Hand patient-reported outcome instrument (DASH) scores averaged 30 at final follow-up. Three patients developed a late complication requiring further surgical intervention. In summary, this technique appears to be technically reproducible, requires no additional tendon material, and achieves objectively and subjectively similar results to other reported procedures used to manage first CMC Arthritis.

Evidence-based medicine: thumb carpometacarpal arthroplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Recount the epidemiology of basilar joint arthritis. 2. Understand how the anatomy and kinematics of this joint contribute to the development of the disease process. 3. Combine patient history, clinical examination, and radiographic findings to formulate a diagnosis and staging of the arthritis. 4. Incorporate conservative management into the patient treatment plan to aid in determining a patient's surgical candidacy. 5. Comprehend the basic principles of available surgical options, potential complications, and evidence pertaining to surgical outcome.

SUMMARY

This article has been prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured for physicians to comparatively evaluate their care of a patient with arthritis of the thumb carpometacarpal joint.

Thumb carpometacarpal arthroplasty with ligament reconstruction and interposition costochondral arthroplasty

Background Thumb arthritis at the carpometacarpal (CMC) joint is one of the most common sites of arthritis, especially in women. Thumb arthroplasty is an effective method of relieving pain and improving function. Materials and Methods Qualitative and quantitative outcomes were assessed clinically and radiographically in 58 patients (66 thumbs) with thumb basal joint arthritis limited to the trapeziometacarpal joint, treated with hemiresection arthroplasty of the trapezium, flexor carpi radialis (FCR) ligament reconstruction, and allograft costochondral interposition graft. Description of Technique The thumb CMC joint arthroplasty is performed using an FCR tendon for ligament reconstruction combined with removal of the distal half of the trapezium, which is replaced with a life preserver-shaped spacer that is carved out of allograft cartilage. Results Results of the validated Disability of Arm, Shoulder, and Hand (DASH) questionnaire at a mean follow-up time of 56 months (range, 24-103 months) revealed that 90% of the patients had a high level of function with minimal symptoms. Important improvements in web space with increased palmar and radial abduction and grip and pinch strength measurements were observed. The trapeziometacarpal space had decreased 21% after surgery, while trapeziometacarpal subluxation was 14% compared with 21% before surgery. There was an inverse correlation between the loss of trapezial height and subluxation and clinical outcome. Conclusions The results of this study demonstrate that, although the preoperative trapezial height was not maintained, the reconstructed thumbs remained stable, with little subluxation and improved clinical outcomes. Level of Evidence IV, retrospective case series.

[Clinical and radiologic evaluation of a polylactic acid interposition arthroplasty after trapezectomy]

Surgical management of trapeziometacarpal osteoarthritis does not obey to strict rules. The use of interposition implants made of different materials leads to enrichment of surgeon's resources. This prospective study reports the radiological and clinical results of 45 patients treated by total trapeziectomy with polylactic acid interposition implant, with an average follow-up of 31 months. Thirty-seven surgical treatments were carried out after ineffective medical treatment. According to Dell classification, there were five stages II, 30 stages III and two stages IV. Mean age was 66 years. Dominant side was involved in 60%. Thumbs were pain free at 5 months in average and 81% of the patients reported good results (Alnot stages 0 and 1). The average opposition was 9.1/10, the average M1M2 angle was 40°, and the average key pinch strength was 4.4 kg. Six patients suffered from sympathetic dystrophy but neither infection nor local inflammatory reaction was observed. Collapse of the trapezium space was constant and the trapezium space ratio was 76% at the follow-up. Seventy-five per cent of patients returned back to their occupation. The satisfaction rate was 89%. The radioclinical results were very good in our series. The interposition of polylactic acid implant permits to avoid the presumed complications of tendon harvesting, and those of other types of material used in the same indication. Its safety seems excellent.

Trapeziometacarpal joint arthritis

Trapeziometacarpal (TM) joint arthritis is a common cause of radial-sided wrist pain that preferentially affects women. It is diagnosed by a thorough history, physical examination, and radiographic evaluation. While radiographs are used to determine the stage of disease, treatment is dependent on symptom severity. Nonoperative treatment frequently consists of activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), splinting, and corticosteroid injections. After failure of conservative treatment, various surgical options exist depending on the stage of disease. This article reviews the literature supporting the various surgical treatment options. Special consideration is given to the comparison of trapeziectomy with and without tendon interposition and ligament reconstruction.

Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition

PURPOSE

To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improve the outcome of trapezial excision for the treatment of basal joint arthritis after a minimum follow-up of 5 years.

METHODS

We randomized 174 thumbs with trapeziometacarpal osteoarthritis into 3 groups to undergo simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void and retained for 4 weeks, and a thumb spica was used for 6 weeks in all 3 groups. We reviewed 153 thumbs after a minimum of 5 years (median, 6 y; range, 5-18 y) after surgery with subjective and objective assessments of thumb pain, function, and strength.

RESULTS

There was no difference in the pain relief achieved in the 3 treatment groups, with good results in 120 (78%) patients. Grip strength and key and tip pinch strengths did not differ among the 3 groups and range of movement of the thumb was similar. Few complications persisted after 5 years, and these were distributed evenly among the 3 groups. Compared with the results at 1 year in the same group of patients, the good pain relief achieved was maintained in the longer term, irrespective of the type of surgery. While improvements in grip strength achieved at 1 year after surgery were preserved, the key and tip pinch strengths deteriorated with time, but the type of surgery did not influence this.

CONCLUSIONS

The outcomes of these 3 variations of trapeziectomy were similar after a minimum follow-up of 5 years. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term.

TREATMENT OF BASAL JOINT ARTHRITIS OF THE THUMB: TRAPEZIECTOMY WITH OR WITHOUT TENDON INTERPOSITION/LIGAMENT RECONSTRUCTION

This prospective study compared the outcome — subjective, objective and radiographic — of two surgical techniques for treating basal joint arthritis of the thumb: a "simple" trapeziectomy (group I) and a ligament reconstruction/tendon (group II) interposition technique. There were respectively 22 patients in group I and 34 in group II, all women with primary osteoarthritis.

Both techniques gave favourable results and there were no significant differences for pain relief, patient satisfaction, mobility, DASH-score, key pinch force and gripping force. However in group II, the trapezial height was better preserved indicating that the proximal migration of the thumb was prevented or limited. There was also a significant correlation between the remaining trapezial space and key pinch force.

Comparison of trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition: a systematic literature review

BACKGROUND

Trapeziectomy with ligament reconstruction and tendon interposition is currently the most popular technique for operative treatment of trapeziometacarpal osteoarthritis. Based on the evidence, however, it is uncertain whether the addition of ligament reconstruction and tendon interposition to trapeziectomy confers any advantage. The aim of this study was to systematically review the literature and determine which procedure, trapeziectomy or trapeziectomy with ligament reconstruction and tendon interposition, offers the best results to patients.

METHODS

A literature search was undertaken of the following electronic databases: Cochrane, AMED, EMBASE, HaPI, HealthSTAR, MEDLINE, TRIP, and Proceedings First (2002 to 2009). Studies were selected by two independent assessors if (1) the study population included patients with trapeziometacarpal osteoarthritis and (2) the study was a randomized controlled trial or systematic review comparing the two procedures. Objective (i.e., range of motion, grip strength, pinch strength, health cost, and postoperative complications) and subjective (i.e., pain relief, hand function, overall satisfaction, and quality of life) outcomes were extracted. Statistical pooling and power analyses were performed with available data.

RESULTS

Two systematic reviews and four randomized controlled trials were identified and included. There were no statistically significant differences in postoperative grip strength (p = 0.77); tip pinch strength (p = 0.72); key pinch strength (p = 0.90); pain visual analogue scale score (p = 0.34); Disabilities of the Arm, Shoulder and Hand score (p = 0.75); and number of adverse events (p = 0.13). No studies reported health costs or quality of life.

CONCLUSION

Neither procedure produced greater benefit in terms of outcomes investigated.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.(Figure is included in full-text article.).

Morphometric and biomechanical comparison of tendons used for interposition arthroplasty in carpometacarpal arthritis of the thumb

PURPOSE

To identify the wrist tendon most effectively maintaining the trapezial space in interpositional arthroplasty in osteoarthritis of the carpometacarpal joint of the thumb.

METHODS

The morphometrics of the os trapezium and the tendons of the flexor carpi radialis, extensor carpi radialis longus, and abductor pollicis longus were determined. The stiffness and compressive loading characteristics of the rolled-up tendons were compared to the os trapezium.

RESULTS

No significant morphometric differences between the three tendons were found. The mass and volume of the trapezium was significantly larger when compared to the tendon balls. No significant differences in the compressive loading resistance were found between the tendons, but the mean stiffness was 85% lower when compared to the os trapezium.

CONCLUSIONS

Neither tendon material approached the volume nor the stiffness provided by the os trapezium. Any tendon is considered to insufficiently maintain the trapezial space following trapeziectomy.

Revision surgery after trapeziometacarpal arthroplasty

BACKGROUND

The majority of patients with trapeziometacarpal joint (TMJ) arthritis can be successfully treated with some form of arthroplasty. Residual pain therefore is rather uncommon, but particularly difficult to treat. The aims of this study were to determine the number of patients in need of additional surgery; to identify the most common causes for persistent pain and to establish a treatment algorithm.

PATIENTS

Twelve patients (11 females, 1 male) who had undergone secondary surgery after TMJ arthroplasty were retrospectively analyzed at a mean time of 32 months after the primary procedure. Parameters included the indication for secondary surgery, the type of procedure, the ultimate range of motion, residual pain levels, upper extremity function assessed by the DASH score and the distance from the first metacarpal bone to the scaphoid.

RESULTS

The overall results were assessed according to the Conolly score. The revision rate after primary arthroplasty at our institution was 2.9%. Most common problems for secondary surgery included mechanical pain due to crepitation of the base of the first metacarpal bone, neuropathy of the superficial branch of the radial nerve and concomitant scaphotrapezial arthritis. A total of 19 procedures were performed resulting in two good, five fair and five poor results. A treatment algorithm is presented.

Basal joint osteoarthritis of the thumb: ligament reconstruction and tendon interposition versus hematoma distraction arthroplasty

PURPOSE

Thumb basilar osteoarthritis is common. Several surgical options exist. Studies have evaluated outcomes in separate cohorts but have not compared methods. Our study compared the functional outcome of ligament reconstruction and tendon interposition (LRTI) suspension arthroplasty and hematoma distraction arthroplasty (HDA) by patient questionnaires, clinical measurements, and radiographic measurements to see whether there is validity in exclusively using either LRTI or HDA.

METHODS

In this retrospective study, patients received LRTI (12 thumbs in 11 patients) or HDA (9 thumbs in 9 patients) according to the attending surgeon's preference, one exclusively performing LRTI and the other HDA. Patient perception was evaluated with a QuickDASH questionnaire and 10-point pain visual analog scale (VAS). Potential QuickDASH scores range from 0 to 100, with lower scores indicating better function. Clinical evaluation examined grip strength, tip pinch, and lateral pinch in kilograms-force, and range of motion. Measurements were compared with those from the contralateral hand and published normal values. Stressed and unstressed radiographs assessed metacarpal proximal and lateral migration and first web space. Chart review documented surgical times.

RESULTS

The LRTI and HDA scored similarly on QuickDASH. Most reported excellent pain relief. Average grip, tip pinch, and lateral pinch were also similar in both groups. None achieved significance. Comparisons with contralateral hand and published normal results showed that LRTI and HDA were comparable. All except 2 could oppose to little finger base. With stress, additional proximal migration was similar. Web space was preserved with both procedures. LRTI took 54 minutes longer.

CONCLUSIONS

The LRTI and HDA were comparable on all levels of objective and subjective measurements. Both groups satisfied the principal goals to provide a stable, mobile, pain-free thumb.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Suture anchor suspension and fascia lata interposition arthroplasty for Basal joint arthritis of the thumb

BACKGROUND

Although the ideal treatment of thumb basal joint osteoarthritis is debated, most surgeons advocate trapeziectomy with ligament reconstruction tendon interposition arthroplasty. However, harvesting and weaving autologous tendon creates scarring, alters wrist kinetics, may prolong recovery, and is time consuming. In this article, the authors propose a new method of arthroplasty using suture anchor suspensionplasty and cadaveric fascia lata interposition.

METHODS

Thirty-eight consecutive patients who underwent 46 thumb carpometacarpal joint arthroplasties were analyzed retrospectively. All patients were treated by the senior author (J.U.) at one institution over 6 years. Total (n = 17) or partial (n = 29) trapeziectomy was performed followed by Mitek suture anchor suspension of the first to the second metacarpal and cadaveric fascia lata interposition. Preoperative and postoperative evaluations of pain, satisfaction, and strength were undertaken in the short term (3 months) and long term (last follow-up). Follow-up averaged 4 years.

RESULTS

Thirty-one women and seven men were treated, all with advanced osteoarthritis (Eaton stage III and IV). In the short term, 93 percent of thumbs had excellent pain relief, whereas in the long term, pain relief increased to 96 percent. In the short term, 87 percent of cases showed high satisfaction, but this increased to 93 percent in the long term. Average key pinch and tip pinch improvements were 1.5 kg (76 percent improvement, p < 0.001) and 2.0 kg (81 percent improvement, p < 0.001), respectively. Three patients had minor complications.

CONCLUSIONS

Thumb basal joint arthroplasty using suture anchor suspension and fascia lata interposition is a reliable, effective, and expeditious technique. It obviates the need for tendon harvest and manipulation while treating the underlying pathomechanics of the disorder.

Description and outcomes of a new technique for thumb Basal joint arthroplasty

PURPOSE

Many surgeries have been described for thumb basal joint arthroplasty, but none is clearly superior to the others. The purposes of this study were to describe a simple technique for trapeziectomy and ligament reconstruction, and to determine its objective and subjective outcomes.

METHODS

The surgical technique involves trapeziectomy, interposition of tissue, and abductor pollicis longus ligament reconstruction around the extensor carpi radialis longus tendon through a single incision. A retrospective chart review was performed on 48 patients who had undergone this surgery over an 11-year period by a single surgeon.

RESULTS

At a minimum of 8 months' follow-up, grip had improved from 71% of contralateral strength to 93% of contralateral strength (p = .02), an increase of 32%. Appositional pinch had improved from 66% of contralateral strength to 98% of contralateral strength (p = .03), an increase of 49%. Radial abduction did not change to a statistically significant degree. Trapezial space ratio measured 0.44 preoperatively and 0.31 postoperatively (p < .01), a decrease of 30%. Of 42 patients, 27 had little or no pain and an additional 11 had improved pain postoperatively. Of 41 patients, 26 were very or extremely satisfied and 13 were satisfied with the outcome of the surgery.

CONCLUSIONS

The described technique for trapeziectomy and ligament reconstruction is easy to perform, has a number of potential advantages over other arthroplasty techniques, and has similar short-term outcomes compared with ligament reconstruction and tendon interposition.

Prognostic factors for the recovery of hand function following trapeziectomy with ligamentoplasty stabilisation

INTRODUCTION

Numerous procedures are in use to treat trapeziometacarpal osteoarthritis. Most of these techniques impair hand function. In a series of trapeziectomies stabilized by ligament reconstruction with tendon suspension, we investigated whether eventual parameters influenced hand function and dexterity.

HYPOTHESIS

Some parameters influence hand function recovery following trapeziectomy combined to ligamento-tendinous stabilization.

MATERIALS AND METHODS

This is a continuous, retrospective, single surgeon series; 60 cases of thumb trapeziometacarpal osteoarthritis were treated with trapeziectomy and ligament reconstruction (40 palmaris longus, and 20 half flexor carpi radialis) with no additional metacarpophalangeal (MCP) joint surgery. Besides assessing classical clinical outcome criteria (pain, mobility, force), we analyzed hand function: this was obtained with a questionnaire about different everyday movements. Five types of grip were included in this analysis: spherical, pinch grasp, key pinch, power grip, and precision pinch.

RESULTS

Fifty-one trapeziectomies (85%) were evaluated at an average follow-up of 7.5 years (5-11.5). Ninety-four percent of patients had good results for pain. The average Kapandji score for mobility was 9.6 (6-10) with a mean web angle at 36.5 degrees. Hyperextension of the MCP joint occurred in 36 cases and measured an average of 26 degrees (5 degrees-50 degrees). Compared to the contralateral side average strength was 97% with the Jamar dynamometer and 88% for the key pinch. The rate of satisfaction was 96%. Collapse of trapezial height was constant, and at last follow-up, the trapezial index was 50% of its preoperative initial value. The results relative to hand function assessment were good in 58% of patients. The spherical grip was the most difficult to restore. The analysis of the 42% of patients with average or poor hand function showed five prognostic factors for a poor outcome: young age at surgery, persisting postoperative pain, postoperative hyperextension of the MCP joint, reduced postoperative web angle and trapezial space collapse.

LEVEL OF EVIDENCE

Level IV. Therapeutic study.

Long-term follow-up of basal joint resection arthroplasty of the thumb with transfer of the abductor pollicis brevis origin to the flexor carpi radialis tendon

PURPOSE

To investigate the long-term functional and clinical outcomes of a tendon transfer during basal joint interposition arthroplasty for osteoarthritis of the basal joint of the thumb, in which the origin of the abductor pollicis brevis (APB) and opponens pollicis is transferred to the flexor carpi radialis tendon, in order to increase the abduction moment arm of the thumb and provide dynamic stabilization of the base of the first metacarpal.

METHODS

We observed 22 patients, who received basal joint interposition arthroplasty with APB and opponens pollicis tendon transfer, over an average of 9 years (range, 3-20 years). Subjective outcome measures included patient satisfaction scores, visual analog scale scores for pain, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Clinical evaluations included thumb range of motion, grip strength, and pinch strength.

RESULTS

At an average follow-up of 9 years, 95% of patients (21 out of 22) subjectively scored the procedure as good or excellent and reported improvement in activities of daily living. Mean visual analog scale pain score was 4.4 at rest and 7.8 with activity (out of 100), and mean DASH score was 13.3 (out of 100). Average grip strength of the operated hand was equal to that of the contralateral hand, and lateral and tip pinch strengths were 79% and 93%, respectively, of the contralateral hand. No intraoperative or early postoperative complications were reported, although 1 patient whose procedure was performed as treatment for failed silastic arthroplasty reported metacarpal instability at 9-year follow-up (DASH score of 22).

CONCLUSIONS

Basal joint arthroplasty with APB and opponens pollicis tendon transfers provides excellent long-term results for carpometacarpal thumb osteoarthritis. The procedure is safe, with a low complication rate. Its success has long-term durability as measured by patient satisfaction, functional outcome measures, range of motion, and strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treatment of Idiopathic Postmenopausal Osteoarthrosis of the Trapeziometacarpal Joint With the Epping Resection Arthroplasty Technique

Surgical treatment of idiopathic postmenopausal osteoarthrosis of the trapeziometacarpal joint with the Epping resection arthroplasty was performed in 57 cases in 49 women. Data show good pain relief (between 58% and 76%), very good subjective results with 89% patient satisfaction and Disability of Arm, Shoulder, Hand (DASH) scores in the lower third of the scale after 35 months' follow-up. Good functional results with respect to radial abduction (51 degrees) and palmar flexion (45 degrees), as well as improvement in strength measurements, could be achieved. Some patients (13%) reported remaining problems with occasional pain during performance of activities of daily life and work. A significant proximal metacarpal migration (31%) without correlation to objective or subjective outcome was found. The Epping procedure has proven to be a valuable alternative procedure to treat idiopathic postmenopausal trapeziometacarpal arthrosis after a midterm follow-up period. Still, careful patient selection is important and sufficient preoperative information necessary.