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

Suture Suspensionplasty Compared With Ligament Reconstruction and Tendon Interposition for Surgical Treatment of Thumb Carpometacarpal Arthritis

Purpose

Thumb carpometacarpal (CMC) arthritis is the most common arthritis of the hand, with most studies demonstrating little difference in outcomes between various surgical treatment techniques. However, trapeziectomy, followed by ligament reconstruction and tendon interposition (LRTI), remains the technique of choice among hand surgeons in the United States. In 2009, suture suspensionplasty (SS) was first described as a less invasive alternative to LRTI. The purpose of this study was to compare surgical details as well as patient-reported and radiographic outcomes between SS and LRTI for thumb CMC arthroplasty.

Methods

Following Institutional Review Board approval, 111 extremities were retrospectively identified in 104 patients who underwent carpometacarpal arthroplasty. Two age-matched cohorts were developed for patients having undergone LRTI (n = 58) or SS (n = 53) by one of three fellowship-trained hand surgeons. Tourniquet times were compared, and outcome measures included first metacarpal scaphoid space (FMSS) measured on 2-week postoperative radiographs, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score and pain score on a 10-point visual analog scale (VAS) from the preoperative visit as well as at 2 weeks, 6 weeks, and 3 months following surgery.

Results

There were no demographic differences between the two cohorts. There was no statistical difference between cohorts in VAS scores at any point in time. The SS cohort reported better QuickDASH scores at the 6-week postoperative visit; otherwise, QuickDASH scores did not differ between cohorts. The SS technique had shorter tourniquet times, and patients had less radiographic subsidence as evidenced by larger postoperative FMSS.

Conclusions

The SS arthroplasty technique demonstrated comparable early clinical results to LRTI. Furthermore, SS arthroplasty, which alleviates the need for tendon transfers and additional incisions with LRTI, had shorter tourniquet time, with less subsidence of the first metacarpal in the first 2 weeks.

Type of study/level of evidence

Therapeutic IV.

Biomechanical analysis of three techniques of suspensionplasty after trapeziectomy: a cadaveric study

The aim of the present cadaveric study was to assess resistance to first metacarpal subsidence of three techniques of suspensionplasty after trapeziectomy. In total, 18 forearms (mean age 60 years [range 20-89]) were used with six specimens per surgical technique: palmar oblique ligament reconstruction with tendon interposition (LRTI), abductor pollicis longus (APL) suspensionplasty, or suture suspensionplasty. There was no significant difference in mean trapezial space height after trapeziectomy and suspensionplasty compared to the preoperative trapezial height. However, after simulation of physiological lateral pinch, there was a significant (p < 0.05) difference in mean trapezial space height between the APL suspensionplasty and the suture suspensionplasty compared to the LRTI group. After axial loading, there was significantly greater metacarpal subsidence in the LRTI group compared to the APL and suture suspensionplasty groups but no statistically significant difference between the suture suspensionplasty and the APL suspensionplasty groups.Level of evidence: V.

Selective Denervation for the Thumb Carpometacarpal Joint: Clinical Outcome and Comparison Based on Eaton Stage

PURPOSE

Various operative treatment options for advanced thumb carpometacarpal (CMC) joint arthritis have been presented without a definite surgical guideline. Selective denervation is a less invasive method for thumb CMC arthritis. However, it is unclear whether the clinical outcome varies with the stage of thumb CMC arthritis. This study aimed to evaluate the effectiveness of selective denervation on CMC arthritis for pain relief and functional outcome and to determine whether selective denervation depends on the stage of thumb CMC arthritis.

METHODS

We evaluated 29 thumbs of 28 patients with thumb CMC arthritis treated with selective denervation. The disease stage was determined with the classification system described by Eaton. The denervation was performed in the articular branches of the palmar cutaneous branch of the median nerve, lateral antebrachial cutaneous nerve, and superficial branch of radial nerve. The clinical outcomes were evaluated using the visual analog scale (VAS) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores, along with evaluation of the improvement in both postoperative range of motion and strength recovery.

RESULTS

The mean duration of follow-up was 24 months (range, 18-48 months). The average VAS and DASH scores decreased from 6.1 to 1.3 and from 54.3 to 24.1, respectively. The range of motion during palmar abduction and opposition of the metacarpophalangeal joint improved with an increase in mean value from 44.1 to 53.7 degrees, and the Kapandji score increased from 7.2 to 9.2, respectively. The grip and key pinch strengths increased from mean preoperative values of 14.3 and 3.1 kg to 27.1 and 6.2 kg, respectively, as measured at the 12-month follow-up. The rate of change in the VAS and DASH scores was significantly higher in stages I to III than in stage IV ( P = 0.01, P < 0.01, respectively).

CONCLUSION

The selective denervation for thumb CMC arthritis was effective in pain relief and functional recovery with several advantages, including less invasive procedure, quick recovery time, and regaining of strength. The clinical outcomes were more effective in the early-stage group (Eaton stages I and II) compared with the advance-stage group (Eaton stages III and IV).

Arthroscopic Trapeziectomy

Several methods of resection arthroplasty for the thumb basal joint exist, yet one commonality of these procedures is the removal of the trapezium. My preference is to achieve total trapeziectomy through a less invasive approach and encourage immediate mobilization in order to expedite return to function. Herein I present a step by step method of arthroscopic total trapeziectomy without suspensionplasty.