Trapezial space height after trapeziectomy: mechanism of formation and benefits

Efficacy of Abductor Pollicis Longus Suspension Arthroplasty Combined With Mini TightRope for Osteoarthritis of Thumb Carpometacarpal Joint

BACKGROUND

We aimed to evaluate the efficacy of abductor pollicis longus (APL) suspension arthroplasty with trapeziectomy combined with first and second metacarpal fixation using suture button device.

METHODS

Thirteen patients (14 thumbs) who underwent APL suspension arthroplasty combined with suture button device for osteoarthritis of the carpometacarpal joint of the thumb (Eaton grade III: 6 and IV: 8 thumbs) at our institution between 2015 and 2019 and were followed up for more than 24 months were included in the study. Preoperative and postoperative range of motion (ROM) of radial and palmar abduction, grip and key pinch strength, visual analog scale (VAS) scores for pain, and the trapezial space ratio (TSR) on radiographic images before and after surgery were statistically examined.

RESULTS

The mean age of the patients was 59.6 ± 8.1 years, and the mean follow-up period was 45.4 ± 12.2 months. While grip and pinch strength did not significantly change between preoperative and final follow-up measurements, the ROM of radial and palmar abduction and the VAS score at the latest follow-up were significantly better than the preoperative values (P < .05). The mean TSR immediately after surgery and at the latest follow-up was 0.28 ± 0.089 and 0.22 ± 0.084, respectively, indicating a mean reduction rate of 23.3 ± 15.2%.

CONCLUSIONS

This surgical technique showed significant improvement in the ROM of radial and palmar abduction and the VAS score for pain, and the combined fixation of the first and second metacarpals with suture button device suppressed the subsidence of the first metacarpal.

A systematic review of management options for symptomatic scaphometacarpal impingement after trapeziectomy

Pain after trapeziectomy is a vexing problem, most commonly due to scaphometacarpal impingement. A number of treatment strategies have been described and are examined in this systematic review. In total, 27 studies describing revision surgery for unsatisfactory results after trapeziectomy were included. Results after soft tissue or synthetic suspensionplasties, arthrodesis procedures, implant arthroplasty and costochondral autografting were included. Most studies were heterogeneous in terms of patient selection and procedure performed, and the level of evidence and methodological quality were uniformly low. Autologous suspensionplasty procedures are the best studied and most rigorously reported techniques, with modest improvements in pain widely reported. Newer techniques using synthetic suture button suspension are encouraging with the benefit of earlier mobilization but require further study. Due to high incidences of complication and revision, the literature does not support the use of implant arthroplasty after trapeziectomy. Arthrodesis appears to be a reasonable last resort when attempts at suspension have failed.

Thumb basal joint arthritis in 2023

Thumb carpometacarpal or basal joint arthritis is the second most common location for osteoarthritis in the hand. It mainly affects women over 50years of age. Basal joint arthritis causes pain, loss of strength during pinch grips, and eventually stiffness and progressive deformity of the thumb column. Conservative treatment must be implemented first. It aims to spare the joint by using standardized methods. It must be initiated as soon as pain starts, not once the deformity has settled in. There is broad agreement that surgery is indicated when pain relief is not achieved after at least 6months of conservative treatment. The available surgical techniques can be classified as joint-sparing (extra-articular) and joint-sacrificing (intra-articular). The former consists of trapeziometacarpal stabilizing ligament reconstruction, subtraction osteotomy of the first metacarpal and thumb carpometacarpal denervation. The latter consists of trapeziometacarpal fusion, trapeziectomy (and its variants) and implant arthroplasty. Except in very specific cases, trapeziectomy and trapeziometacarpal implant arthroplasty with a total joint prosthesis or an interposition implant are the two main surgical techniques for treating basal joint arthritis. After reviewing the pathophysiology and the diagnosis of thumb basal joint arthritis, we will provide an overview of the available treatment options, with emphasis on the accepted surgical strategies in 2023. LEVEL OF EVIDENCE: III.

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.

First Carpometacarpal Joint Motion and Proximal Migration of the First Metacarpal After Tensioning of a Suture Device Suspensionplasty Compared With Trapeziectomy: A Biomechanical Cadaver Study

PURPOSE

The purpose of this cadaveric biomechanical experiment was to evaluate the effects of suture button suspensionplasty of the first carpometacarpal joint on thumb biomechanics and thumb position compared with an intact, arthritic specimen.

METHODS

Six tendons in 8 cadaver hands were loaded to simulate 6 activities of daily living and passively moved through a circumduction motion. Proximal migration of the base of the first metacarpal was measured using optical motion sensors in the intact hand, after trapeziectomy, and following insertion of a suture button suspensionplasty with nominal tightening (approximately 4.5 N) and with firm tightening (approximately 44.5 N).

RESULTS

Removal of the trapezium caused a significant increase in the proximal migration of the first metacarpal during a simulated jar grasp, opposition, flexion, extension, and abduction (average, 9.5 mm) compared with its location with the thumb in the intact, neutral position (average, 3.8 mm). Firm tightening of the tightrope caused a near elimination of the proximal migration of the first metacarpal (average, 0.7 mm). In all 6 static loading cases with the trapezium removed, firm tightening caused a significantly smaller migration than in the absence of tightening.

CONCLUSIONS

This biomechanical cadaver study supports the hypothesis that trapeziectomy results in proximal migration of the first metacarpal. Suture suspensionplasty mitigates against this migration while maintaining normal motion of the first metacarpal compared with the intact state. Firm tightening of the suture does not adversely affect the first metacarpal's mobility and further decreases proximal migration. However, firm tightening may cause impingement between the first and second metacarpals.

CLINICAL RELEVANCE

Suture button suspensionplasty can be used in addition to trapeziectomy in the treatment of basal joint arthritis, and may diminish the need for ligament reconstruction or temporary K-wire insertion.

Dual mobility prosthesis for trapeziometacarpal osteoarthritis: results from a prospective study of 55 prostheses

This prospective study evaluated outcomes after trapeziometacarpal joint replacement with a dual mobility prosthesis (Touch®) in 55 thumbs (52 patients) with a mean follow-up of 25 months (range 12-36). Pre- and postoperative assessments included pain, range of motion, the Kapandji index, pinch- and grip strength, as well as functional scores and radiological parameters. Mean preoperative metacarpophalangeal joint hyperextension of 19° (range 15°-28°) showed a significant correction after 1 year with a mean value of 2° (range 0°-5°). Mean Quick Disabilities of the Hand, Shoulder and Arm score was 14 (range 6-28), and Michigan Hand Questionnaire 82 (range 67-92). No revisions due to infection, loosening, dislocation or material failure occurred during follow-up. The dual mobility trapeziometacarpal joint prosthesis was a reliable treatment option to decrease pain, improve motion, strength and pre-existing metacarpophalangeal joint hyperextension at short-term follow-up.Level of evidence: IV.

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.

Natural History of Metacarpal Subsidence following Trapeziectomy and Its Relationship to Clinical Outcomes

METHODS

An institutional review board-approved retrospective review of patients who underwent trapeziectomy and ligament reconstruction and tendon interposition (LRTI) was conducted. Patient demographics, visual analogue scale pain scores, grip strength, pinch strengths, and radial and palmar abduction were collected. The trapezial space ratio (TSR) was measured by the scaphometacarpal distance divided by the length of the capitate. Subsidence [(postoperative TSR - preoperative TSR)/preoperative TSR] was measured and classified as severe (≥70%) or mild to moderate (<70%). Median rate of subsidence increase was calculated. Conolly-Rath scores were used to evaluate the proportion of good outcomes in each group.

RESULTS

A total of 141 trapeziectomies with LRTI were included. Subsidence increased 6.7% (5.4% to 23.0%) per week before 16 weeks and 0.3% (0.1% to 0.8%) per week thereafter. Visual analogue scale pain scores were not significantly different between patients with severe or mild to moderate subsidence ( P = 0.25) 16 weeks after thumb mobilization. The proportion of good outcomes was comparable between the two groups ( P = 0.12). There was no correlation between subsidence and pain (ρ = -0.20; P = 0.24), grip (ρ = -0.02; P = 0.93), key (ρ = -0.13; P = 0.62), tripod (ρ = 0.16; P = 0.71), or index tip pinch strengths (ρ = -0.28; P = 0.43) or radial (ρ = -0.03; P = 0.92) or palmar (ρ = -0.15; P = 0.61) abduction.

CONCLUSIONS

Subsidence occurs in all patients after trapeziectomy and LRTI, stabilizing 16 weeks after mobilization. Degree of subsidence does not correlate with postoperative outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Trapeziectomy with ligament reconstruction and tendon interposition arthroplasty continuously improves hand functions up to 5-year postoperatively

INTRODUCTION

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) arthroplasty is a reliable surgical procedure for the treatment of thumb carpometacarpal osteoarthritis, which provides good long-term outcomes. However, it remains unclear when the greatest benefit of this procedure can be obtained, and how long these benefits will continue. Therefore, we investigated the middle- to long-term advantages of this procedure by analysing the chronological changes in clinical outcomes by following the same patients from 1 year to a median 5 years after trapeziectomy with LRTI.

MATERIALS AND METHODS

Sixteen thumbs that completed consecutive clinical and radiographic evaluations preoperatively, 1 year, 2 years, 3 years, and median 5 years (range 4-8 years) after trapeziectomy with LRTI were included in this study. We investigated grip strength, pinch strength, range of motion (ROM) of the thumb, a visual analogue scale for pain, Disabilities of Arm, Shoulder and Hand (DASH) score, Hand20 questionnaire score, trapezial space height, and trapezial space ratio at every time point.

RESULTS

Hand strength (grip, pulp, and lateral pinch), palmar abduction, DASH score, and Hand20 questionnaire score were improved at 1 year postoperatively while the radial abduction showed significant improvement at the final follow-up. Moreover, pulp pinch strength, DASH score, and Hand20 questionnaire score continued to improve significantly from 1 year postoperatively to the final follow-up. Conversely, trapezial space height and ratio continuously decreased up to the final follow-up.

CONCLUSIONS

Trapeziectomy with LRTI consecutively improved the pinch strength, ROM of the thumb, DASH score, and Hand20 questionnaire score up to 5 years postoperatively. It also maintained the improvement of the other clinical outcomes up to 5 years postoperatively except for radiological findings.

Thumb-Basal Joint Arthroplasty Outcomes and Metacarpal Subsidence: A Prospective Cohort Analysis of Trapeziectomy With Suture Button Suspensionplasty Versus Ligament Reconstruction With Tendon Interposition

BACKGROUND

Thumb carpometacarpal (CMC) joint arthroplasty is a common procedure in the surgical management of symptomatic thumb basal joint arthritis. Following trapeziectomy, a number of suspensionplasty techniques are often used, but limited comparative evidence exists between these techniques. The central aim of this study was to prospectively compare the outcomes of 2 suspensionplasty techniques following trapeziectomy: suture button (TightRope) versus ligament reconstruction and tendon interposition (LRTI).

METHODS

Prospective data were collected on 112 consecutive patients with Eaton stage III-IV thumb CMC arthritis who underwent open trapeziectomy and suspensionplasty. There were 53 LRTI and 59 TightRope suspensionplasty procedures. Outcomes were measured using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Visual Analogue Scale (VAS) for pain, radiographic analysis, and lateral pinch strength. Patient demographic data and complications were also recorded.

RESULTS

Patients undergoing TightRope suspensionplasty had significantly higher trapeziometacarpal index and thus less subsidence than the LRTI group at 2 weeks (0.22 vs 0.17 [P < .0001]) and 3 months (0.17 vs 0.15 [P < .05]) postoperatively. TightRope suspensionplasty also had a significantly lower QuickDASH score at 2 weeks (64.7 vs 74.6 [P < .05]), 3 months (20.7 vs 32.5 [P < .05]), and 1 year postoperatively (7.57 vs 21.5 [P < .05]) compared with the LRTI group. However, there was no difference in VAS pain, lateral pinch strength, reoperation, or complications at any time point between groups.

CONCLUSIONS

Thumb CMC joint arthroplasty performed with a TightRope suspensionplasty versus LRTI yielded short-term improved resistance to subsidence, long-term greater improvement in clinical outcome by QuickDASH, and no difference in pain or complication rates.

A quantitative measurement of trapeziometacarpal joint pressure using a cadaveric model of lateral pinch

Trapeziectomy is performed for trapeziometacarpal (TMC) arthritis but decreased lateral pinch strength is a major source of discomfort after the surgery. The magnitude of the decrease is unclear, however, and how the pressure changes in the TMC joint is unknown. To investigate this relationship, we designed a cadaveric study to measure TMC joint pressure using a lateral pinch model, and quantitatively evaluated the effect of trapeziectomy on the pressure measurements. For 10 cadaveric forearms, physiologic forces were applied across the thumb TMC joint by loading five tendons, thereby simulating lateral pinch. Using pressure sensors, we measured the lateral pinch pressure and TMC joint pressure, which averaged 10.1 (range, 4.2-16.2) kg/cm² and 2.0 (range, 0.8-4.4) kg/cm² , respectively. A significant correlation between the measurements was found, with an average ratio of 19% (range, 10%-27%). After trapeziectomy and interposition of the tendon ball using flexor carpi radialis, the pressure measurements were repeated under the same conditions. Significant changes were found, which averaged 5.1 (range, 1.7-10.7) kg/cm² for lateral pinch pressure and 15.0 (range, 5.6-25.6) kg/cm² for TMC joint pressure. In conclusion, TMC joint pressure could be measured as the ratio relative to lateral pinch pressure using a cadaveric model. After trapeziectomy, the lateral pinch strength decreased, whereas the TMC joint pressure increased.

Differences between simple trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition for the treatment of trapeziometacarpal osteoarthritis: a systematic review and meta-analysis

BACKGROUND

The optimal management of trapeziometacarpal osteoarthritis remains controversial. This systematic review and meta-analysis assessed the subjective and objective outcomes and complications of simple trapeziectomy (T) versus trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI).

METHODS

The PubMed, Embase, Web of science, and Cochrane electronic databases were searched from inception to Aug 31, 2020. Key words included "osteoarthrosis", "carpometacarpal joint", and "trapeziectomy". Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) including patients treated for trapeziometacarpal osteoarthritis were included. The subjective outcomes (visual analog scale [VAS] and disabilities of the arm, shoulder, and hand questionnaire scores), objective outcomes (grip strength, tip, and key pinch strength) and complications were extracted. The methodological quality of each was assessed independently. Meta-analysis was performed for comparative trials. The protocol for this meta-analysis is available in PROSPERO (CRD42020195752).

RESULTS

From the 8 included studies (7 RCTs, 1 CCT), 656 cases were divided into T (n = 325) and T + LRTI (n = 331) groups. Compared with the T group, grip and tip pinch strength was better in the T + LRTI group (SMD = - 2.74, 95% confidence interval (CI) (- 3.46 to - 2.02), P < 0.00001) and (SMD = - 0.21, 95% CI (- 0.34 to - 0.08), P = 0.002), respectively, but there were significantly more complications 3 months after operation in the T + LRTI group (RR = 0.50, 95% CI (0.31 to 0.80), P = 0.004). The VAS score (SMD = 0.33, 95% CI (- 0.39 to 1.04), P = 0.37), DASH (SMD = - 1.86, 95% CI (- 7.59 to 3.87), P = 0.52), key pinch strength (SMD = - 0.13, 95% CI (- 0.28 to 0.01), P = 0.07), and incidence of complications 1 year after operation (RR = 0.83, 95% CI (0.53-1.29), P = 0.41) were not significantly different between the two groups.

CONCLUSION

While the T + LRTI group demonstrated a better effect in grip and tip pinch strength at the one-year follow-up, there was no statistical difference in key pinch strength, pain relief, and DASH. Furthermore, T + LRTI has more latrogenic injury, more short-term postoperative complications, and higher surgical costs. Considered comprehensively, if there is no special strength requirement, we recommend simple trapeziectomy.

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.

Total joint replacement for osteoarthritis of the carpometacarpal joint of the thumb: why and how?

Total joint replacement has certain advantages over other surgical treatment methods for osteoarthritis of the thumb carpometacarpal joint, including restoration of thumb length and alignment, good cosmetical result, fast recovery of hand function and prevention of iatrogenic complications at neighbouring joints. Disadvantages include the technical difficulty to perform this surgery and a possible higher complication rate. A meticulous surgical technique is mandatory. Combined with a cementless and modular ball-in-socket implant with a metal-on-polyethylene friction couple, a 10-year survival rate higher than 90% can be expected. Revision surgery is possible with implant exchange or conversion to trapeziectomy.

Revision Thumb Carpometacarpal Arthroplasty

Revision thumb carpometacarpal (CMC) arthroplasty alleviates persistent pain and instability after nonimplant or implant CMC arthroplasty. Metacarpal subsidence onto the scaphoid causing impingement, missed diagnosis such as scaphotrapezoid arthritis, and metacarpophalangeal hyperextension are common causes of failed CMC arthroplasty. Literature shows that revision CMC arthroplasty has satisfactory outcomes. Currently, the mantra of revision is to restore the metacarpal height and treat concomitant pathology, but no single operation is a universal solution. Revision CMC arthroplasty has a relatively high complication rate, lower patient satisfaction than primary CMC arthroplasty, and may result in the need for further operative intervention.

Surgical Treatment of Advanced Carpometacarpal Joint Arthritis: Trapeziectomy with Hematoma Arthroplasty

Osteoarthritis of the first carpometacarpal joint is common. When nonoperative measures fail, surgery may provide long-term pain relief. There are many surgical options in the management of carpometacarpal joint arthritis. Trapeziectomy with hematoma arthroplasty is technically simple, inexpensive, and has withstood the test of time. It is an excellent option for advanced carpometacarpal joint arthritis with multiple high-quality studies showing equivalent outcomes between this technique and ligament reconstruction tendon interposition techniques. This article reviews trapeziectomy with hematoma arthroplasty for treatment of carpometacarpal joint arthritis, including the indications for the procedure, the authors' preferred technique, and the current literature.

Combined Treatment of Trapeziometacarpal Joint Arthritis and Scapholunate Advanced Collapse Wrist

PURPOSE

The combined treatment of trapeziometacarpal joint arthritis and scapholunate advanced collapse (SLAC) wrist presents unique challenges. The consequences of the loss of radial column support caused by scaphoidectomy and trapeziectomy are not well known. The purpose of this study was to evaluate the outcomes of the simultaneous and staged treatment of trapeziometacarpal joint arthritis and SLAC wrist.

METHODS

A retrospective review of patients who underwent surgery for both trapeziometacarpal joint arthritis and SLAC wrist was performed. The wrist and thumb range of motion; grip and pinch strength; pain; quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; and radiographs were analyzed.

RESULTS

Twenty-four patients who underwent both trapeziectomy and 1 of 3 procedures for SLAC wrist (4-corner fusion [n = 10]), proximal row carpectomy [n = 9], and total wrist arthroplasty [n = 5]) in a single stage (n = 10) or in 2 stages (n = 14) were included. The median age was 63 years. The median follow-up period was 35 months. Twelve (50%) patients underwent complete scaphoidectomy, and 12 (50%) patients underwent partial scaphoidectomy. All 3 procedures resulted in an improvement in pain at rest, pain during activity, and quick Disabilities of the Arm, Shoulder and Hand scores. The final range of motion, grip and pinch strength, and complication rates were consistent with those reported in the literature for isolated procedures.

CONCLUSIONS

Trapeziometacarpal joint arthritis and SLAC wrist may be treated either simultaneously or in stages.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Comparison of 2 Postoperative Therapy Regimens After Trapeziectomy Due to Osteoarthritis: A Randomized, Controlled Trial

PURPOSE

The main aim of the present study was to evaluate whether early mobilization after trapeziectomy in the first carpometacarpal joint is noninferior to a postoperative regimen comprising the use of a rigid orthosis and mobilization after 6 weeks, with regards to patient-reported activity performance and the effect of surgery in patients with first carpometacarpal osteoarthritis.

METHODS

In this prospective, randomized, controlled noninferiority trial, participants were assessed at baseline (before group allocation) and at 3, 6, and 12 months after surgery. The primary outcomes were activity performance, measured using the Canadian Occupational Performance Measure (1-10, where 1 = unable to perform), and the patient-reported effect of surgery on a 6-point scale ranging from "much worse" to "completely recovered." A change of 2.0 points in the Canadian Occupational Performance Measure was used as a noninferiority margin. Secondary outcomes included hand function (patient-reported in the Measure of Activity Performance of the Hand questionnaire), pain on a numeric rating scale, grip and pinch strengths, and joint mobility. We performed both intention-to-treat and per-protocol analyses.

RESULTS

Of the 59 participants (88% women) with a mean age of 65 years, 55 (93%) completed all assessments. We found no differences between the groups in primary or secondary outcomes at any time point, except for more decreased pain at rest in the intervention group (n = 28) compared with the control group (n = 27) after 12 months. The per-protocol analyses did not change these results. Fifteen participants experienced 1 or more adverse events during the first 3 months, but the types and frequencies of adverse events were similar between the 2 groups.

CONCLUSIONS

A postoperative regimen with early mobilization after trapeziectomy is as safe and effective as a postoperative regimen with longer immobilization in patients with first carpometacarpal osteoarthritis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Effect of Tendon Strip (FCR vs APL) on Outcome of CMC Thumb Joint Arthroplasty With Pyrocarbon Disk Interposition

BACKGROUND

Pyrocarbon disk interposition for carpometacarpal (CMC) thumb joint osteoarthritis can be performed with a flexor carpi radialis (FCR) or abductor pollicis longus (APL) tendon strip. With the FCR technique, a ligament reconstruction is performed in addition to disk fixation, whereas with the APL technique the disk is simply secured in place. Our aim is to compare long-term postoperative outcomes between both techniques.

METHODS

In this observational study, we included 106 patients in 2 centers operated on between 2006 and 2011. We assigned patients to the FCR group or the APL group based on the respective tendon strip used. As a primary outcome, we analyzed postoperative key pinch. In addition, we analyzed postoperative tip pinch and tripod pinch, grip strength, range of motion, thumb height maintenance, and patient-reported outcome measures (PROMs).

RESULTS

The analysis showed clinically important stronger key pinch for the APL group (β = 1.28 kg). Tip pinch and grip strength showed higher outcome for the FCR group (β = 1.22 kg and 5.14 kg, respectively). Palmar abduction was in favor of the FCR group and opposition in favor of the APL group, but these were interpreted as not clinically relevant. Radiological thumb height maintenance and PROMs showed no clinical difference.

CONCLUSIONS

Pyrocarbon disk interposition arthroplasty for CMC thumb joint osteoarthritis can be secured with an APL or FCR tendon strip. At long-term follow-up, use of an APL tendon strip results in significantly higher key pinch and better opposition. Tip pinch, grip strength, and palmar abduction were better after use of the FCR tendon strip. The choice of the tendon strip can be based on outcomes considered most important for the individual patient.

Intraoperative Load Tolerance of the Thumb Carpometacarpal Joint After Resection-Suspension-Interposition Arthroplasty

Purpose

The objective was to measure the intraoperative load tolerance of the thumb carpometacarpal (CMC) joint after trapeziectomy, tendon suspension, and interposition.

Methods

In this single-center prospective study, preoperative pinch grip, thumb mobility, and hypermobility of the thumb CMC joint were determined by 2 hand surgeons. Patients completed the brief Michigan Hand Outcomes Questionnaire. During surgery and upon removal of the trapezium, the surgeon subjectively rated the degree of thumb CMC load tolerance as “stable,” “medium stable,” or “unstable.” A measurement system with an integrated force sensor was used to measure intraoperative thumb CMC load tolerance. The thumb ray was displaced manually by 10 mm toward the scaphoid, and the counteracting force was measured over the entire displacement. The objective load tolerance was determined as the maximal measured force after trapezium resection, tendon suspension, and interposition. Analysis of variance was used to test for the differences in load tolerance between the surgical steps. Spearman’s coefficient was used to find correlations between load tolerance and clinical or patient-reported variables.

Results

Twenty-nine patients with a mean age of 70 years (SD, 8.1 years) were available for analysis. The measured intraoperative load tolerance after trapeziectomy was 15.5 N (SD, 5.4 N) and significantly increased to 18.7 N (SD, 5.5 N) after suspension. Load tolerance only slightly increased after tendon interposition, increasing the force to 20.3 N (SD, 6.7 N). Neither the surgeon’s subjective stability rating nor the clinical or patient-reported variables correlated with the measured load tolerance after trapeziectomy.

Conclusions

Our results show that tendon suspension leads to the highest increase in thumb CMC load tolerance during resection-suspension-interposition arthroplasty.

Clinical relevance

Tendon suspension appears to be the most important step in stabilizing the metacarpal base after trapeziectomy, whereas tendon interposition does not seem to have a relevant additional effect regarding load tolerance, at least immediately after surgery.

Joint Distraction for Thumb Carpometacarpal Osteoarthritis: 2-Year Follow-up Results of 20 Patients

Background  Joint distraction is a fairly new treatment for patients with symptomatic thumb carpometacarpal osteoarthritis (CMC1 OA). A previous pilot study of five patients showed that CMC1 joint distraction is technically feasible. The current study presents the results of CMC1 joint distraction in 20 patients with a 2-year follow-up period. Purposes  The primary study aim was to assess if patients with CMC1 OA have better physical function and less pain 2 years after CMC1 joint distraction. Second, we assessed the number of patients who achieved a minimal clinically important difference (MCID) in patient-reported outcome measures at each follow-up time point. Furthermore, this study sought differences on magnetic resonance imaging (MRI) of the CMC1 joint before and after distraction. Adverse events were noted and reported. Methods  Twenty patients (median age of 54 years) with symptomatic CMC1 OA and an established indication for a trapeziectomy were enrolled. An external distractor device was placed over the CMC1 joint and left in situ for 8 weeks. Disabilities of the Arm, Shoulder, and Hand (DASH) score, Michigan Hand Outcome Questionnaire (MHQ), visual analogue scale (VAS), and grip strength were recorded preoperatively and at 3, 6, 12, and 24 months postoperatively. Results  Two years after joint distraction, physical function and pain scores had improved significantly compared with baseline: DASH from 48 to 17, MHQ from 56 to 83, and VAS for pain from 50 to 18 mm. Fourteen of 19 patients (74%) reached an MCID in DASH and MHQ scores. One patient was not satisfied with treatment outcome and chose to proceed with a trapeziectomy 14 months after initial distraction therapy. Conclusions  This study demonstrates that CMC1 joint distraction can postpone more invasive surgical interventions (e.g., trapeziectomy) for at least 2 years. Larger comparative studies are needed to assess the value of CMC1 joint distraction in the treatment of CMC1 OA. Level of Evidence  This is a Level IV, prospective case series study.

Trapeziometacarpal osteoarthritis: Arthroscopic hemitrapeziectomy using the Thenar Portal

BACKGROUND

Although the standard 1Radial and 1Ulnar portals allow for visualisation of most of the trapezium articular surface, the proximity of these two portals can often make arthroscopic triangulation and visualisation of the most lateral capsule and joint surface challenging. Despite its already reported advantages in improving visualisation, there is little literature reporting the clinical experience with the Thenar Portal. The purpose of this study is to describe potential complications and the short-term clinical-radiographic outcomes of arthroscopic hemitrapeziectomy using the Thenar Portal in order to determine its safety and efficacy as a standard working portal.

PATIENTS AND METHODS

A retrospective chart review was conducted for all patients diagnosed with first carpometacarpal (CMC) osteoarthritis who were treated surgically with an arthroscopic hemitrapeziectomy. Only patients with stage II or III osteoarthritis and a minimum of 1-year follow-up were included. Twenty-two patients (24 thumbs) with an average age of 62 years met the inclusion criteria. The average follow-up was 52 months. Intra-operative and post-surgical complications were recorded. Objective evaluation consisted of an assessment of range of motion (ROM), grip and pinch strength. Subjective evaluation consisted of a DASH questionnaire and the visual analog scale to score pain at rest, during activities, and function.

RESULTS

There were no intra- or post-surgical complications. In one case, pain persisted with a poor functional result, requiring a revision surgery. Average range of motion (compared with the contralateral) showed a statistically significant improvement in palmar abduction and radial abduction of the CMC joint: 50° vs. 55° (p=0.01235), and 50° vs. 55° (p=0.06009), respectively. There was no statistically significant improvement in thumb adduction, grip strength, or lateral and tip-pinch. All patients achieved retropulsion with their affected thumb. According to the VAS, average rest pain improved from 7.5 to 0 (p<0.001) and from 9 to 0 (p<0.001) during activity. The average final function and QuickDASH were 9 (VAS) and 8, respectively (p<0.001). The average radiographic proximal migration of the first metacarpal was 2.9mm (range: 0.7-5.8mm).

DISCUSSION

Arthroscopic hemitrapeziectomy using the Thenar portal: 1) improved visualisation of the trapeziometacarpal joint, 2) facilitated arthroscopic triangulation, and 3) represents a safe and effective alternative for the treatment of thumb osteoarthritis, with pain relief and function improvement in most patients without a higher risk of complications.

LEVEL OF EVIDENCE

IV.

What Are the Patient-reported Outcomes of Trapeziectomy and Tendon Suspension at Long-term Follow-up?

BACKGROUND

There are multiple options for the treatment of thumb carpometacarpal joint osteoarthritis (CMC1 OA), with evidence for pain relief and improved function. Although simple trapeziectomy has the lowest complication risk, tendon suspension of the first metacarpal and interposition is still the most commonly used surgical procedure in patients with CMC1 OA. Although there are several reports of good short-term results after trapeziectomy and tendon suspension-interposition arthroplasty, few studies have evaluated long-term outcomes. This study is one of the largest and longest follow-up evaluations of a cohort of patients with CMC1 OA who were treated with trapeziectomy and suspension-interposition arthroplasty, capturing 96% of the original cohort for evaluation.

QUESTIONS/PURPOSES

(1) After trapeziectomy and tendon suspension surgery, what are the long-term, patient-reported outcomes and clinical measurements (strength and ROM); and in unilateral procedures, how do these parameters compare with those of the contralateral hand that was not operated on? (2) What is the mean subsidence (unloaded trapezial space), and does pinch strength correlate with the amount of subsidence?

METHODS

From 1998 to 2005, 130 patients underwent trapeziectomy and abductor pollicis longus (APL) suspension-interposition arthroplasty for CMC1 OA at one orthopaedic department. During this period, 15 patients were treated with CMC1 arthrodesis and four were treated with implant arthroplasty, for a total of 149 patients. The surgeons used APL suspensionplasty for most patients, based on age and expected postoperative function; they also employed this procedure to avoid hardware or implant failure issues. The 100 living patients were asked to participate in this retrospective study, 96% (96) of whom were enrolled. The mean age at surgery was 58 ± 7 years. The patients completed a two-item thumb pain scale (modified from the SF-36 body pain scale), a hand pain VAS (average level of pain experienced over the week preceding measurement), and the 11-item QuickDASH. Patient-reported outcomes data were obtained from all 96 patients, and 83% (80) of patients underwent bilateral hand radiography and a physical examination at a mean follow-up of 17 ± 2.4 years. We calculated outcome data for each patient, and in 39 patients with unilateral surgery and intact contralateral CMC1 joint, we compared the operated side with the contralateral side. We compared our outcome data with that from the Swedish National Quality Registry for Hand Surgery (HAKIR), noting comparable outcomes for pain and QuickDASH scores.

RESULTS

At long-term follow-up after trapeziectomy and APL suspension surgery, the mean thumb pain score was 19 ± 26, hand pain VAS score 23 ± 25, and QuickDASH score 26 ± 21. In the patients with unilateral surgery and intact contralateral CMC1 joint, the thumb pain score for the operated side was lower than the contralateral side, specifically 19 ± 25 compared with 29 ± 30 (mean difference -9.8 [95% CI -19.5 to -0.2]; p = 0.045); hand pain VAS score was 24 ± 23 versus 30 ± 25 (mean difference -6.1 [95% CI -15.2 to 3.1]; p = 0.19), and the QuickDASH score was 27 ± 19. Grip strength showed no differences between the operated and contralateral sides (mean 16.7 ± 7.3 kg versus 16.6 ± 6.9 kg, mean difference 0.1 [95% CI -1.6 to 1.8]; p = 0.90), while pinch was different (4.4 ± 1.4 versus 5.0 ± 1.5 kg, mean difference -0.6 [95% CI -0.9 to -0.3]; p = 0.001). The mean trapezial space was 4.4 ± 2.2 mm, and there was no association between the trapezial space and pinch strength (0.07 kg [95% CI -0.04 to 0.18] per mm of space; p = 0.17).

CONCLUSION

The finding of comparable pain and function between operated and unoperated sides at long-term follow-up suggests that trapeziectomy and tendon suspension-interposition arthroplasty provides predictable outcomes, and surgeons can use these data to counsel patients that surgery can potentially return them to comparable use. However, as patients often have asymptomatic radiographic OA on the contralateral side, future studies are needed to examine the impact of asymptomatic disease on function.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Can we decrease the duration of basal thumb joint distraction for early osteoarthritis from 8 to 6 weeks? Study protocol for a non-inferiority randomized controlled trial

BACKGROUND

To our knowledge, to date, 52 patients with thumb carpometacarpal osteoarthritis (CMC1 OA) were treated with joint distraction. So far, most patients experienced improved physical function and less pain. After 2 years, only 1 patient proceeded to trapeziectomy. This study assesses if we can safely lower the distraction duration from 8 to 6 weeks for CMC1 joint distraction, maintaining the improvement in physical function and pain.

METHODS

This is a monocenter randomized controlled non-inferiority trial that includes patients younger than 65 years of age with ongoing symptoms of CMC1 OA and an established indication for surgery. All patients will be treated with CMC1 joint distraction. The primary outcome is to assess whether 6 weeks of joint distraction is not inferior to 8 weeks in terms of physical function at 1 year after surgery. Secondary outcomes will identify differences between groups at 1 year in pain intensity, patient satisfaction, hand health status, adverse event rates, treatment failure, differences in thumb strength and range of motion, and radiographic changes.

DISCUSSION

If safe, the duration of basal thumb joint distraction can be reduced to 6 weeks, reducing patient burden. Because this is a relatively new treatment, this trial will provide greater knowledge of potential adverse events. This knowledge allows for more informed decision making for patients considering CMC1 distraction treatment. Future studies can directly compare joint distraction to other treatments of CMC1 joint arthritis like splinting and trapeziectomy.

TRIAL REGISTRATION

Central Committee on Research Involving Human Subjects (CCMO), NL68225.100.18; registered on 9 August 2019. Medical Research Ethics Committees United (MEC-U), R19.003; registered on 9 August 2019. Netherlands Trial Register, NL8016 ; registered on 15 September 2019.

Does proximal migration of the first metacarpal correlate with remaining pain after trapeziectomy?

Proximal migration of the thumb metacarpal has been suggested as a possible cause of remaining pain after trapeziectomy for trapeziometacarpal joint osteoarthritis. The aim of this study was to investigate if proximal migration after trapeziectomy is associated with a poorer long-term outcome in terms of pain and objective physical variables. We retrospectively examined 91 thumbs in 65 patients after a mean of 10 years following trapeziectomy with or without ligament reconstruction and tendon interposition. Proximal migration of the thumb metacarpal was measured on plain lateral radiographs of the thumb and correlated to visual analogue pain scale (VAS), thumb range of motion and strength. Most thumbs had a severe proximal migration of the first metacarpal, the mean scaphoid metacarpal distance was 2.7 mm. Most patients reported no or little pain, median VAS was 0 at rest and 1 after load. There were no differences in reported VAS pain at rest or after load between patients with severe (<2 mm scaphoid metacarpal joint space) or less severe (≥2 mm metacarpal joint space) proximal migration. Patients that reported more pain (VAS >2) did not exhibit more migration than patients reporting less or no pain. Thumbs with severe migration had weaker key pinch (3.4 vs. 4.6 kg, p = 0.008) and grip strength (15 vs. 21 kg p = 0.002). We conclude that proximal migration most likely does not cause residual or recurrent pain after trapeziectomy.

Partial trapeziectomy for Eaton stage III thumb carpometacarpal arthritis: ligament reconstruction with tendon interposition using the entire flexor carpi radialis and interference screw fixation

BACKGROUND

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is currently the most popular technique for treating primary osteoarthritis of the thumb carpometacarpal joint. However, reduced trapezial height has sometimes been reported after LRTI. Longer immobilization and delayed rehabilitation times are also problematic. In this study, we evaluated the clinical and radiological outcomes of patients who underwent our modified LRTI procedure.

METHODS

Retrospective study included 26 thumbs in 24 cases with advanced stages. Our modified Burton's procedure was as follows: (1) trapeziectomy was limited to distal-half, (2) the entire flexor carpi radialis (FCR) was harvested from the forearm, and (3) half-slip of the FCR tendon was stabilized by interference screw in the first metacarpal bone tunnel.

RESULTS

Pain on the visual analogue scale (VAS), the quick Disabilities of the Arm Shoulder and Hand score, tip pinch strength significantly improved postoperatively. The preoperative height of the trapezial space was well-maintained at final follow-up. Magnetic resonance imaging at the one-year follow-up showed the existence of FCR tendon ball in 15 cases. Eighteen housewives resumed their daily activities after a mean period of 10 days postoperative, while another 6 patients returned to their original jobs after 3 weeks.

CONCLUSIONS

Our modified LRTI method involves distal-half trapeziectomy and entire FCR interposition. A sewn FCR tendon ball always provide enough volume to fill the trapeziectomy space, which helps to prevent sinking of the metacarpal bone. Our technique produced sufficient ligamentoplasty and allowed early mobilization after surgery.

The effect of remaining trapezial space on outcomes after trapeziectomy with ligament reconstruction tendon interposition for trapeziometacarpal osteoarthritis

Ligament reconstruction and tendon interposition (LRTI) procedures for trapeziometacarpal osteoarthritis aim to prevent proximal metacarpal migration to improve thumb function. We sought to evaluate the effect of the remaining trapezial space on outcomes after trapeziectomy with LRTI. Forty-seven patients were included in this study. Patients were evaluated clinically and radiologically. They were divided into two groups according to the remaining trapezial space at last follow-up. Postoperative to preoperative trapezial space ratio was >50% in group 1 and <50% in group 2. Mean follow-up was 30.8 months. Mean age, sex, dominant side, preoperative stage, and follow-up were similar in both groups. The mean QuickDASH scores were significantly better in group 1 than group 2. Mean tip and key pinch were significantly stronger in group 1, than group 2. Trapeziectomy with LRTI is the most used surgical technique and it produces satisfactory results. Improved clinical outcomes can be achieved when more than 50% of the preoperative trapezial space remains.

Failed Trapeziectomy Treated by Thumb Metacarpal Base Arthrodesis: A Case Series

Trapeziometacarpal joint arthritis is a prevalent condition with a preponderance to women. Most cases are asymptomatic, but typical symptoms are pain, reduced dexterity, and functional decline. Trapeziectomy is the most common surgical treatment in the United Kingdom for patients who remain significantly symptomatic despite nonoperative measures, and this generally produces acceptable outcomes; however, a proportion of patients remain significantly symptomatic. The authors present a case series of 4 patients who underwent successful thumb metacarpal base to index metacarpal base arthrodesis with either distal radial or iliac crest bone grafting. Three of these patients had persisting symptoms after a primary trapeziectomy and 1 patient had gross subluxation of the thumb related to rheumatoid arthritis. Technically, this is a simple procedure to perform. All patients had improved symptoms with satisfactory functional outcomes and an improved cosmetic appearance of the hand.

Simple trapeziectomy versus trapeziectomy with flexor carpi radialis suspension: a 17-year follow-up of a randomized blind trial

The purpose of this study was to investigate if there were any significant differences in the long-term outcomes of patients who participated in a randomized trial of trapeziectomy alone compared with trapeziectomy with ligament reconstruction and tendon interposition (LRTI). Sixty-five patients were invited for a follow-up visit at a mean of 17 years (range 15-20) postoperatively. Twenty-eight patients attended, who had 34 operations, 14 trapeziectomy alone and 20 with LRTI. There were no statistically significant differences between the two groups in terms of satisfaction with surgery or functional outcomes, with most measurements showing minimal or no differences in means between the two groups. There was no difference in the space between the metacarpal and scaphoid. Radial abduction was the only parameter that was significantly greater in the patients with simple trapeziectomy (median 79°) compared with trapeziectomy with LRTI (median 71°) (p = 0.04). Even at 17 years there is no significant benefit of LRTI over trapeziectomy alone for thumb carpometacarpal joint osteoarthritis.Level of evidence: I.

Trapeziometacarpal prostheses

In 1970, Jean-Yves de la Caffinière developed the first trapeziometacarpal (TMC) joint prosthesis, a ball-and-socket design based on hip replacement implants. From 1970 to 1990, the first generation of cemented prostheses was developed. At that time, trapeziectomy, with tendon interposition or suspension arthroplasty, and Swanson silastic spacers remained the most widely used surgical procedures for thumb basal joint arthritis. From 1990 to 2010, a second generation of cementless prostheses was developed. The third generation was introduced after 2010 and consisted of dual mobility prostheses. In 2020, TMC arthroplasty (simple or dual mobility) is a reliable option in thumb basal joint arthritis with an implant survival rate of 90% at 10 years of follow-up, while providing pain relief and restoring strength and mobility. Restoration of the thumb's length corrects most thumb Z-deformities, so the TMC joint prosthesis may be a viable alternative surgical solution to trapeziectomy, which remains the gold standard in English-speaking countries. Moreover, trapeziectomy after failed TMC arthroplasty provides outcomes equivalent to those of primary trapeziectomy.

Medium to Long-Term Follow-Up After Pyrocarbon Disc Interposition Arthroplasty for Treatment of CMC Thumb Joint Arthritis

PURPOSE

Pyrocarbon disc interposition arthroplasty has been designed for the surgical treatment of Eaton-Glickel grade II/III carpometacarpal thumb joint arthritis. This study presents the results of this technique with a minimum 5-year follow up.

METHODS

We assessed 4 questionnaires for patient-reported outcome measurements in a cross-sectional study: the Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand questionnaire, Michigan Hand Questionnaire, and questions about satisfaction at the 5-year follow up. We evaluated grip and pinch strength, range of motion, and the radiological position of the disc. Finally, a Kaplan-Meier survival analysis was performed.

RESULTS

A total of 164 thumbs (in 137 patients) were available for follow-up varying from 5 to 12 years. Median Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand, and Michigan Hand Questionnaire scores were 17, 18, and 76, respectively. The satisfaction score was 9 (Likert scale of 1-10). Grip and pinch strength reached nearly 100% compared with the contralateral hand. Range of motion resulted in a Kapandji score of 10. Thumb height showed a marginal loss and the Kaplan-Meier survival curve showed a survival rate of 91%.

CONCLUSIONS

Our study suggests that pyrocarbon disc interposition arthroplasty is a reliable and feasible treatment for carpometacarpal thumb joint arthritis at medium-term follow-up. It was associated with a high level of patient satisfaction; it maintained thumb height and the implant survived in 91% of patients. Strength and range of motion were comparable to the contralateral hand after a minimum follow-up of 5 years.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Revision procedures after trapeziometacarpal surgery

Surgical treatment of thumb basal joint arthritis generally yields good and excellent results. In case of failure, the surgeon will propose an appropriate solution to the patient, one that can be performed easily. Each technique has its own complications: shortening with trapeziometacarpal pain following trapeziectomy, loosening and instability following total arthroplasty, instability for some implants. There are also intolerances such as allergies to nickel, foreign body reactions to silicone and inflammatory reactions to some synthetic ligament implants. It is important to bear these complications in mind when determining the best possible surgical technique initially. The different surgical solutions are exposed here. Prosthetic replacement is preferred in case of loosening when it is technically possible in order to preserve the thumb's length. A conversion to trapeziectomy with or without interposition (implant or ligament reconstruction) will be carried out in the other cases. In case of trapeziectomy failure, solutions are more difficult to find. In the current state of things, it seems that implant or biological tissue interposition is the best solution.

Reporting Outcomes and Outcome Measures in Thumb Carpometacarpal Joint Osteoarthritis: A Systematic Review

PURPOSE

In the thumb carpometacarpal (CMC) joint osteoarthritis (OA) literature, there is substantial heterogeneity in outcome and outcome measure reporting. This could be rectified by a standardized core outcome set (COS). This study aimed to identify a comprehensive list of outcomes and outcome measures for thumb CMC joint OA, which represents the first step in developing a COS.

METHODS

A computerized search of MEDLINE, EMBASE, Cochrane, and CINAHL was performed to identify randomized controlled trials, as well as observational studies involving at least 50 participants aged greater than 18 years undergoing surgery for thumb CMC joint OA. Reported outcomes and outcome measures were extracted from these trials and summarized.

RESULTS

This search yielded 3,498 unique articles, 97 of which were used for analysis. A total of 33 unique outcomes and 25 unique outcome measures were identified. The most frequently used outcomes were complications (78), postoperative pain (73), radiologic outcomes (64), and grip strength (63). Within each reported outcome, there was substantial variation in how the outcome was measured. Of the 25 unique outcome measures, 10 were validated. Of the remaining 15, 12 were created ad hoc by the author. The Disabilities of the Arm, Shoulder, and Hand questionnaire was the most commonly reported outcome measure (34%).

CONCLUSIONS

There is a lack of consensus on critical outcomes after surgery for thumb CMC joint OA. A standardized COS created by stakeholder consensus would improve the consistency and therefore the quality of future research.

CLINICAL RELEVANCE

This systematic review of outcomes represents the first step in developing a core outcome set for thumb CMC joint OA.

Early to Mid-Term Results in Trapezio-metacarpal Joint Replacement using the ARPE Implant

Background:

Trapezio-Metacarpal Joint (TMJ) arthritis is a common cause of radial sided wrist pain. After conservative measures have been exhausted, the current mainstay of surgical treatment is trapeziectomy. Some surgeons combine this with additional ligament reconstruction and tendon or capsular interposition techniques to provide a more stable base for the thumb metacarpal.

Purpose:

In modern Orthopaedic practice, arthroplasty is the procedure of choice for many end-stage arthritic joints. However, due to the reliable and reproducible outcomes of trapeziectomy, this has yet to be widely adopted by hand surgeons in the management of TMJ arthritis. Recent series of arthroplasty implants have consistently shown good outcomes and trapezio-metacarpal joint replacement has been observed to provide excellent long-term function in the fit and active patient.

Methods:

We have performed a total of 52 TMJ arthroplasties in 46 patients in our institution for over 5 years (2011 to 2016). After excluding 3 cases, 43 available patients (49 implants) were subsequently asked to submit QuickDASH scores and a patient satisfaction survey.

Results:

Average QuickDASH score was 16.6, with high patient satisfaction postoperatively at 1 year. Complications included one intraoperative fracture, and five cases of post-operative instability/ dislocation. Dislocations were treated successfully with open reduction and revision.

Conclusion:

TMJ arthroplasty has shown good outcomes and patient satisfaction with a low revision rate and we recommend its use in active patients with well-preserved scapho-trapezio-trapezoid (STT) joints.

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.

Scaphometacarpal Space and Postoperative Outcomes: A Systematic Review

Background  A common notion is that more complex techniques for treating trapeziometacarpal arthritis such as ligament reconstruction and tendon interposition (LRTI) better preserve the scaphometacarpal (SMC) space compared to a simple trapeziectomy and that this leads to superior functional outcomes. Purpose  The purpose of this systematic review is to evaluate the relationship between scaphometacarpal space and objective outcomes such as grip and pinch strength as well as subjective patient-reported outcomes. Methods  A systematic review of the literature was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting SMC space and outcomes after surgery for carpometacarpal arthritis. The primary outcomes of these studies included any measure of postoperative scaphometacarpal space (trapezial height/trapezial index) as well as key pinch strength, grip strength, or lateral pinch strength. Studies that did not assess for association between SMC space and outcomes were excluded. Results  Fourteen studies were included in this systematic review. Three (21.4%) studies found a statistically significant correlation between postoperative SMC space and postoperative pinch or grip strength. The correlation was weakly positive in one study (key pinch vs. scaphometacarpal space, r  = 0.13), positive but unlisted in another (lateral pinch vs. trapezial ratio), and negative in the third study (key pinch vs. trapezial space ratio, r  = -0.47). Conclusion  Preservation of the SMC space postoperatively is not associated with postoperative outcomes. Further research is necessary to better characterize the importance of maintaining the SMC space in patients undergoing LRTI in order to substantiate claims by proponents of the procedure.

The Effect of Surgical Treatments for Trapeziometacarpal Osteoarthritis on Wrist Biomechanics: A Cadaver Study

PURPOSE

Studies have shown the effects of surgical treatments for trapeziometacarpal osteoarthritis on thumb biomechanics; however, the biomechanical effects on the wrist have not been reported. This study aimed to quantify alterations in wrist muscle forces following trapeziectomy with or without ligament reconstruction and replacement.

METHODS

A validated physiological wrist simulator replicated cyclic wrist motions in cadaveric specimens by applying tensile loads to 6 muscles. Muscle forces required to move the intact wrist were compared with those required after performing trapeziectomy, suture suspension arthroplasty, prosthetic replacement, and ligament reconstruction with tendon interposition (LRTI).

RESULTS

Trapeziectomy required higher abductor pollicis longus forces in flexion and higher flexor carpi radialis forces coupled with lower extensor carpi ulnaris forces in radial deviation. Of the 3 surgical reconstructions tested post-trapeziectomy, wrist muscle forces following LRTI were closest to those observed in the intact case throughout the range of all simulated motions.

CONCLUSIONS

This study shows that wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, LRTI most closely resembled the intact biomechanics in this cadaveric model.

CLINICAL RELEVANCE

Trapeziectomy, as a standalone procedure in the treatment of trapeziometacarpal osteoarthritis, may result in the formation of a potentially unfilled trapezial gap, leading to higher wrist muscle forces. This biomechanical alteration could be associated with clinically important outcomes, such as pain and/or joint instability.

Partial Versus Total Trapeziectomy With Interposition Arthroplasty for Trapeziometacarpal Osteoarthritis Grade II to III Eaton-Littler: A Clinical Trial

Purpose

Total trapeziectomy is the most widely used technique to treat isolated thumb trapeziometacarpal joint osteoarthritis. However, this technique has been associated with proximal migration of the thumb metacarpal, which has led some physicians to consider partial trapeziectomy as a valid alternative. The purpose of this study was to assess whether partial trapeziectomy improves final key pinch strength compared with total trapeziectomy.

Methods

We randomized 34 patients with basal thumb osteoarthritis into 2 groups to undergo partial or total trapeziectomy with interposition arthroplasty. Key pinch strength at 12 months was the primary outcome measure. Other variables measured included trapezial space height, range of motion, grip strength, change in key pinch strength, patient-reported outcome measures, and pain.

Results

No difference between groups was detected regarding final pinch strength, trapezial space height, grip strength, range of motion, change in pinch strength, patient-reported outcomes (Quick–Disabilities of the Arm, Shoulder, or Hand), or pain.

Conclusions

We cannot conclude that partial trapeziectomy provides an advantage over total trapeziectomy at 1 year after surgery. Although trapeziometacarpal space was substantially preserved in the partial trapeziectomy group at 12 months, this difference was not statistically or clinically significant.

Type of study/level of evidence

Diagnostic III.

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.

Unplanned Early Reoperation Rate Following Thumb Basal Joint Arthroplasty

Purpose

Thumb basal joint arthritis is a common degenerative condition of the hand that is often managed with thumb basal joint arthroplasty (BJA). This procedure generally results in a high level of patient satisfaction; however, the rate and cause of early unplanned reoperation after thumb BJA are not well-understood. Therefore, we performed a review to better understand the rate and cause of early reoperation.

Methods

A retrospective review of all thumb BJA cases performed at a single private academic center between 2014 and 2016 yielded 637 patients and 686 primary thumb BJAs with a minimum 1-year follow-up (mean, 2.4 years). Data collection included patient demographics, surgical technique and type of thumb BJA performed, time to reoperation, reason for early reoperation (within 2 years), and type of reoperation.

Results

Of 686 patients undergoing thumb BJAs, 10 had unplanned early reoperation (1.5%). Mean duration between the index procedure and reoperation was 5.2 months (range, 0.5–14.3 months). Of the 10 unplanned early reoperations, 4 thumbs in 4 patients required revision arthroplasties owing to persistent pain. Time to reoperation for revision arthroplasty was 9.6 months (range, 3.9–14.3 months). Three of 10 reoperations resulted from early infection, 2 from unplanned early removal of symptomatic K-wires, and one from radial sensory neuritis.

Conclusions

In this series of nearly 700 consecutive cases, we identified an unexpected early reoperation rate of 1.5%, with only a 0.6% reoperation rate specifically for painful subsidence requiring a revision arthroplasty. Mean time to revision was 9.6 months. These rates are lower than those published previously and should be considered by patients and surgeons when planning thumb BJA.

Type of study/level of evidence

Prognostic IV.

Trapeziectomy with Ligament Reconstruction and Interposition Arthroplasty Using the Palmaris Longus Tendon: An Average 5-Year Follow-up

Background

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with the flexor carpi radialis (FCR) tendon is one of the most common procedures for the treatment of trapeziometacarpal osteoarthritis. We modified the LRTI, using the palmaris longus (PL) tendon instead of the FCR tendon. The aim of this retrospective study was to evaluate the clinical outcomes of trapeziectomy with our modified LRTI procedure at a mean follow-up of 5 years.

Methods

Fourteen thumbs in 13 patients (12 women) with a mean age of 64 years (range, 50 to 77 years) were available for assessment for a mean duration of 62 months (range, 41 to 97 months). The patients were evaluated subjectively and objectively.

Results

The modified LRTI procedure provided good pain relief, motion, strength, and stability without any severe complications related to the PL tendon harvesting. Radiography showed that compared to the preoperative status, the trapezial space decreased by about 40% at the final follow-up.

Conclusions

The modified LRTI procedure provided significant subjective and objective improvements without severe complications particularly related to the harvesting of the PL tendon. This procedure is a valuable surgical option for trapeziometacarpal osteoarthritis and could be a useful salvage modality if the FCR tendon ruptures during the conventional LRTI procedure.

Long-term results of modified ligament reconstruction and tendon interposition for thumb basal joint arthritis

BACKGROUND

Thumb basal joint arthritis is a common, disabling condition of the hand. Ligament reconstruction and tendon interposition (LRTI) is one of the more common surgical solutions. We performed a retrospective study to evaluate long-term radiological and clinical outcomes of modified LRTI procedures in treating thumb basal joint arthritis.

METHODS

A total of 91 hands (84 patients) with full chart records were enrolled in this study. The average age was 65.4 years, and the mean follow-up was 11.7 years (range, 1-21.6 years). We evaluated pain, joint stability, power-grip and key pinch strength, and thumb radial abduction angle as the functional outcomes, and measured the height of the trapezial space as the radiographic result.

RESULTS

There were 66 and 23 hands with excellent and good results, respectively. The diminution of the trapezial space was 4.2 mm in the stage III group and 5.2 mm in the stage IV group. Power-grip and key pinch strength, and thumb radial abduction angle were better in those with stage III than in those with stage IV arthritis. Sixty-eight hands were followed up >5 years, and of them, 66 showed excellent or good results.

CONCLUSION

With good and durable surgical outcomes, the modified LRTI procedure could be a good treatment for thumb basal joint arthritis.

Trapeziectomy with LRTI or joint replacement for CMC1 arthritis, a randomised controlled trial

We compared an uncemented joint replacement (Elektra) with trapeziectomy (with ligament reconstruction and tendon interposition, LRTI) for the treatment of primary osteoarthritis in the first carpometacarpal joint (CMC1) in a randomised controlled trial. Forty patients were included (20 in each group) and followed for 2 years. The median age in the groups was 64 and 61, respectively, with 14 females in each. At final follow-up, there was no difference in the primary outcome measure (the quick disabilities of the arm, shoulder and hand score, QDASH), but the joint replacement group had significantly better motion and strength during the early rehabilitation period and significantly better range of thumb abduction and extension at the last follow-up. There were more complications in the joint replacement group with revision of prosthetic components in five cases, two of them due to cup loosening. Radiologically, lucency zones were seen around either cup or stem in 15 patients. Most were small, but two cases with major osteolysis resulted in revision. Shortening of the thumb ray was observed after trapeziectomy.

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.