Excision of the trapezium for osteoarthritis at the base of the thumb

Arthroscopic Partial Trapeziectomy for Thumb Carpometacarpal Joint Osteoarthritis: 5-Year Follow-up

Osteoarthritis of the thumb carpometacarpal (CMC) joint is the most common type of arthritis of the hand. The goal of the study was to evaluate clinical results and radiographic changes after arthroscopic partial trapeziectomy combined with ligament shrinkage and K-wire fixation to treat thumb CMC joint arthritis. From February 2013 to March 2014, 24 patients with thumb CMC joint arthritis received this arthroscopic procedure. We investigated the preoperative and postoperative Modified Mayo Wrist Score (MMWS); Disabilities of the Arm, Shoulder and Hand (DASH) score; radiographic changes; and associated complications. Sixteen patients completed 5 years of functional score and radiographic follow-up. Comparison of preoperative and postoperative MMWS and DASH scores showed significant improvement after the arthroscopic procedure. Pre-operative and postoperative evaluation of radiographic changes showed significant differences in the CMC joint distance, scaphoid-metacarpal distance, trapezium-metacarpal distance, and metacarpal prominence distance. This arthroscopic procedure is an effective and less invasive method for the treatment of CMC joint arthritis. This procedure can improve clinical function, preserve the mechanical height of the trapezium, and increase CMC joint space. We report our surgical technique and some pitfalls that required attention during the arthroscopic procedure. [Orthopedics. 2022;45(3):e140-e147.].

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.

Efficacy of Abductor Pollicis Longus Suspensionplasty Compared to Ligament Reconstruction and Tendon Interposition

Background: Multiple surgical techniques are described for basal joint osteoarthritis. This study compares clinical outcomes and patient satisfaction with trapeziectomy and abductor pollicis longus (APL) suspensionplasty compared to trapeziectomy with ligament reconstruction and tendon interposition (LRTI) when performed by 2 fellowship-trained hand surgeons. Methods: A retrospective review of 51 consecutive patients undergoing APL suspensionplasty (53 hands) was performed. With this technique, a distally based APL slip is brought through and sewn to the flexor carpi radialis (FCR). The remaining APL is placed in the trapeziectomy void. This technique was compared to 151 patients (166 hands) who underwent LRTI using the FCR tendon. Outcomes assessed included postoperative pain relief, grip and pinch strength, complications, and need for reoperation. Two-tailed, Fisher's exact test was used for data analysis. Results: APL suspensionplasty resulted in postoperative pain relief in 92.5% (n = 49) compared to 94.0% (n = 156) with LRTI (P = .758). Mean postoperative grip and pinch strengths with APL suspensionplasty were 41.2 and 10.4 kg, respectively. With LRTI, average grip strength was 42.0 kg, and pinch was 10.1 kg. Both techniques were well tolerated with minimal complications. In the APL group, 1 patient had a postoperative infection requiring drainage. Among the LRTI cases, 1 wound dehiscence required closure, and 2 minor postoperative wound infections resolved with oral antibiotics. Mean follow-up time among APL suspensionplasty patients was 3.3 months compared to 8.4 months following LRTI. Conclusions: APL suspensionplasty is a safe, effective procedure which provides similar pain relief and functional outcomes compared to LRTI.

Arthroplasty of the trapeziometacarpal joint with or without bioabsorbable polylactide scaffold (RegJoint™) interposition

The RegJoint™, a bioabsorbable polylactide scaffold, was introduced in 2011 for scaphometacarpal interposition following trapeziectomy for osteoarthritis. As previous clinical trials provided controversial results, we aimed to prove the non-inferiority of RegJoint™ interposition. In this retrospective study, first metacarpal suspension arthroplasty alone (SA) was compared to suspension with RegJoint™ interposition (RJ). Thirty-four patients with 37 treated thumbs (SA: 14; RJ: 23) were assessed clinically and radiologically at a mean follow-up of 5.3 ± 2.6 years (SA: 7.96; RJ: 3.73). Patient-reported outcomes were measured on three questionnaires (DASH, PRWE and PEM) and a visual analogue pain scale; there were no significant differences between the 2 groups. Clinical assessment comprised range of motion, opposition, pain, first-ray length, hand span, prominence, instability, force and sensitivity to touch. The RJ group showed significantly better palmar abduction (p = 0.026); the other outcome parameters were comparable in the 2 groups. Follow-up radiographs showed osteolysis in 2 SA hands and 3 RJ hands (p = 0.551). First-ray length had decreased by a mean 4.7 ± 2.7 mm at follow-up (SA: -3.8; RJ: -5.2; p = 0.056). No signs of adverse tissue reactions were observed. We conclude that RegJoint™ spacers do not produce more complications than suspension alone but provide no added benefit.

Thumb Carpometacarpal Arthritis Surgery: The Patient Experience

BACKGROUND

Patients with symptomatic recalcitrant thumb carpometacarpal arthritis often undergo surgery. Although most surgical patients do well, the authors anticipated that a substantial portion of their thumb carpometacarpal surgery patients would have unsatisfactory experiences and express unmet expectations, dissatisfaction, and regret, regardless of surgical procedure performed. The authors hypothesized those experiences would correlate with patient-reported outcomes scores.

METHODS

The authors identified patients who had undergone trapeziectomy alone or with ligament reconstruction 1 to 4 years previously for primary thumb carpometacarpal arthritis. One hundred twelve patients completed Quick Disabilities of the Arm, Shoulder and Hand and visual analogue scale pain, expectations, satisfaction, and regret questionnaires.

RESULTS

More than 40 percent of patients expected to "return to normal" after surgery for pain, strength, and/or function. Including all patients, 7, 19, and 11 percent had unmet expectations for improvement in pain, strength, and function, respectively. Twelve percent expressed dissatisfaction with their outcome. Although just 4 percent regretted undergoing surgery, 13 percent would likely not recommend the procedure to someone they care about. There were no statistically significant differences for any patient-reported outcomes between trapeziectomy-alone (n = 20) and trapeziectomy with ligament reconstruction (n = 92). Visual analogue scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores were both moderately correlated with expectations being met for pain, strength, and function and for satisfaction with surgical outcome.

CONCLUSIONS

Patients' thumb carpometacarpal surgical experiences vary considerably. Many express dissatisfaction or a lack of expectations met with the two most common procedures. A thorough understanding and review of expectations preoperatively may be uniquely pertinent for these patients. Further research should determine predictors and potentially modifiable factors for unsatisfactory outcomes.

F. Brunelli Ligamentoplasty as Treatment in Thumb Basal Joint Arthritis: Up to 9 Years Follow-up

Thumb basal joint arthritis treatment with biological arthroplasty is a widely used procedure in hand surgery centers. The several described techniques are based on the use of different tendons of the wrist, implying frequently a tenoplasty around flexor carpi radialis or transosseous tunnels to stabilize the articulation. The authors have been using, for many years, the technique conceived by F. Brunelli that relies on the anchorage of the volar band of the abductor pollicis longus tendon to the first intermetacarpal ligament, to obtain a suspension arthroplasty. Technical details are discussed. Sixty-seven patients in Eaton-Littler stage 2 or 3 with >4 years follow-up after surgery were evaluated. Each patient expressed a subjective evaluation relating to pain, functionality, strength, esthetic aspect, and general satisfaction. The following parameters have been considered as objective data: the angle of the first web space, the abduction and opposition of the first digit, the pinch, and the strength. X-rays were also performed to verify the distance between the scaphoid and the first metacarpal. In 84% of cases, a significant improvement was found in the considered parameters. Joint space was maintained in 76% of cases at radiologic follow-up. No patient needed surgical revision. The tenoplasty conceived by F. Brunelli presents several advantages, including the simple and reproducible execution, short surgical time, and comfortable postoperative course for the patient. After mid-term follow-up, authors believe this procedure is particularly respectful of the anatomy and physiology of the first ray and gives optimal results in most of the cases, but, in patients with severe subluxation of the 1st metacarpal (identifiable as Eaton-Littler stage 3), it is less reliable, because of the degeneration of the intermetacarpal ligament.

Comparison of arthrodesis and arthroplasty of Chinese thumb carpometacarpal osteoarthritis

Background

The thumb carpometacarpal (CMC) osteoarthritis is very common. Multiple methods are used to treat progressive thumb CMC osteoarthritis, among which trapeziometacarpal arthrodesis and trapezial excision with ligament reconstruction and tendon interposition (LRTI) are the most common. These two surgical treatment methods have received mixed reviews in previous studies in the west patients. This retrospective study studied the effects, advantages, and disadvantages of arthrodesis and arthroplasty for treating thumb carpometacarpal osteoarthritis in Chinese patients.

Methods

Between February 2012 and September 2017, 39 Chinese patients with stage II or III thumb carpometacarpal osteoarthritis underwent surgery (trapeziometacarpal arthrodesis in 22, trapezial excision with ligament reconstruction and tendon interposition in 17). Postoperative objective and subjective evaluations were performed. The objective evaluation involved grip strength, pinch strength, thumb abduction degree (palmar and radial), and Kapandji opposition scores. The subjective evaluation involved visual analog scale (VAS) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores.

Results

Intergroup differences in pinch strength, thumb abduction degrees (palmar and radial), and Kapandji opposition scores were obvious, whereas those in grip strength, VAS score, and DASH score were not.

Conclusion

In Chinese patients, both techniques relieved pain and improve grip strength. Arthrodesis displayed better pinch strength, while arthroplasty displayed better motor function. Patients were satisfied with the effects of both techniques.

Minimum 10-year clinical and radiological follow-up of trapeziectomy with interposition or suspensionplasty for basal thumb arthritis

HYPOTHESIS

The aim of this article is to analyze clinical and radiological outcomes of trapeziectomy performed for basal thumb arthritis after a minimum follow-up of 10 years to gain further insight from shorter and medium-term studies reporting satisfactory evolution.

METHODS

We reviewed 67 trapeziectomies, operated on by the same senior surgeon after a minimum follow-up of 10 years. The sample included 16 cases of suspensionplasty and 51 interpositions. Clinical outcome evaluated strength, pain, joint amplitude, Kapandji opposition score, Disabilities of the Arm, Shoulder and Hand score, complications and revision surgery. Radiological evaluation criteria included osteoarthritis and collapse of the trapezial void.

RESULTS

After a 10-year follow-up, clinical results remained stable despite radiological degradations. Long-term clinical outcomes of trapeziectomy for basal thumb arthritis are very positive, with interpositioning as an isolated procedure appearing, clinically, to be the preferred treatment despite greater radiological degradation when compared to suspensionplasty.

CONCLUSION

In addition to offering insight into minimum 10-year follow-up, this study also pinpoints this paradoxical dissociation of clinical-radiological outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Thumb Metacarpal Subsidence After Partial Trapeziectomy With Capsular Interposition Arthroplasty: A Biomechanical Study

Background: In a cadaveric model, we evaluated thumb metacarpal subsidence, indicated by a decreased metacarpal-to-scaphoid distance, after 2 surgical procedures used to treat thumb carpometacarpal (CMC) osteoarthritis (OA): partial trapeziectomy with capsular interposition (PTCI), which involves removal of 2 mm of both the distal trapezium and base of the metacarpal; and total trapeziectomy with capsular interposition (TTCI). Methods: Nine matched pairs of cadaveric hands were randomly assigned to undergo either PTCI or TTCI. Preoperatively, physiologic forces were applied across the thumb CMC joint by loading 6 tendons, simulating lateral pinch. Anteroposterior radiographs were obtained, and the metacarpal-to-scaphoid distance on each image was estimated independently by 3 separate readers using customized software. A hand surgeon then performed the PTCI and TTCI procedures, and the measurements under loading were repeated. The results were assessed for interrater reliability. Mean values for metacarpal-to-scaphoid distance before and after the surgical procedures were compared. Results: Preoperatively, the metacarpal-to-scaphoid distance in the PTCI and TTCI groups was not significantly different. Postoperatively, metacarpal subsidence was significantly less in the PTCI group (17% compared with 34% for TTCI; P = .05). Conclusions: Metacarpal subsidence occurred after both PTCI and TTCI, but significantly less subsidence was observed after PTCI; thus, thumb length was better preserved. Previous research has shown an inverse correlation between maintenance of thumb length and overall Disabilities of the Arm, Shoulder, and Hand (DASH) score. A procedure for treating thumb CMC OA that preserves thumb length and minimizes disruption of stabilizing joint tissue may provide enhanced maintenance of thumb stability and improved patient outcomes.

Interposition Arthroplasty Versus Hematoma and Distraction for the Treatment of Osteoarthritis of the Trapeziometacarpal Joint

Background: Various surgical techniques were reported with excellent result for the treatment of trapeziometacarpal joint arthritis. However, the best treatment option was not defined yet.

Methods: This randomized prospective study compared the result of two surgical techniques: tendon interposition arthroplasty (64 patients) and K. wire distraction (56 patients) after trapeziectomy for stage 3 or 4 osteoarthritis of the trapeziometacarpal joint.

Results: After a mean follow-up period of 6.8 (range, 3-10) years it was possible to observe a higher rate of pain relief following trapeziectomy with K. wire suspension, but no significant differences in strength, range of motion and DASH score between the two groups. On lateral unloaded radiographs the height of the space between the base of the thumb metacarpal and the scaphoid showed a mean value of 6.5 mm for both groups; the average distance between the metacarpal base and the trapezium was not statistically significant in the two groups. Complications were observed only in patients treated with trapeziectomy and interposition arthroplasty and were represented by tendinitis of the FCR in 15% of cases.

Conclusions: We demonstrate that the trapezium excision and bone space distraction technique requires a smaller incision, a shorter surgical time, an easier surgical technique, and a less painful recovery, maintaining overlapping levels of functional restore.

Simple Trapeziectomy for Arthrosis of the Basal Joint of the Thumb: 49 Thumbs Reviewed After Two Years

Background: Many different surgical strategies for arthrosis of the carpometacarpal joint of the thumb are described in the literature. In 2010 we changed our routine procedure from an interposition arthroplasty using the abductor pollicis longus (APL) tendon to simple trapeziectomy without suspension or interposition. The purpose of this study was to review the clinical outcome after trapeziectomy and to compare it to those we had achieved with the APL procedure.

Methods: We examined 49 hands operated with simple trapeziectomy during 2011-2012. Time between operation and review was 26 (15-26) months. Subjective estimation of pain before and after surgery and satisfaction with the general results were evaluated with visual analogue scales. The ability to participate in various activities of daily living before and after the operation were noted and patients completed the Quick-DASH and the PRWHE questionnaires. The mobility of the thumb and wrist were recorded and grip and key pinch strength were measured. The distance between the base of the first metacarpal and the scaphoid was noted on radiographs.

Results: There were no significant differences between the present results and those we had achieved with the APL procedure regarding subjective estimation of pain and satisfaction, activities of daily living, mobility, strength and radiographic carpometacarpal distance. For many outcome parameters there was a non-significant trend for better results among the trapeziectomy patients, but increased clumsiness was reported by 20 of them.

Conclusions: We conclude that our results with simple trapeziectomy are at least as good as with the APL procedure. However, the considerable number of patients complaining of clumsiness is worrying.

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.

Partial trapeziectomy with capsular interposition arthroplasty (PTCI): a novel technique for thumb basal joint arthritis

INTRODUCTION

Osteoarthritis of the thumb trapeziometacarpal (basal) joint is a very common problem facing the hand and upper extremity surgeon. Many surgical procedures have been described with varied results. We present the surgical technique--partial trapeziectomy with capsular interposition arthroplasty--used by the senior author over the last 10 years. The essential steps of the procedure are: bony resection of the base of the first metacarpal and the distal trapezium; interposition of a proximally based joint capsule flap; and reefing of periosteal flaps elevated from the first metacarpal and including the abductor pollicis longus tendon. This procedure utilizes capsular tissue as an interposition without ligament reconstruction, eliminating the need for tendon harvest and the morbidity associated with the harvest. The postoperative rehabilitation is simple and can be done at home. An illustrative case is presented.

LEVEL OF EVIDENCE

Level V.

Management of osteoarthrosis of the thumb joints

We present current concepts and evidence to optimize diagnosis and management of osteoarthritis in the thumb joints. Numerous options and controversies exist for surgical treatment of carpometacarpal joint arthritis. Fewer options exist for metacarpophalangeal joint arthritis. Surgical treatment for interphalangeal arthritis is mainly arthrodesis.

Surgical treatment of trapeziometacarpal joint arthritis: a historical perspective

BACKGROUND

The trapeziometacarpal (TMC) joint's unique anatomy and biomechanics render it susceptible to degeneration. For 60 years, treatment of the painful joint has been surgical when nonoperative modalities have failed. Dozens of different operations have been proposed, including total or subtotal resection of the trapezium or resection and implant arthroplasty. Proponents initially report high levels of patient satisfaction, but longer-term reports sometimes fail to support initial good results. To date, no one procedure has been shown to be superior to another.

QUESTIONS/PURPOSES

This review sought to identify factors responsible for the development of many different procedures to treat the same pathology and factors influencing whether procedures remain in the armamentarium or are abandoned.

METHODS

I performed a nonsystematic historical review of English-language surgical journals using the key words "carpometacarpal arthritis", or "trapeziometacarpal arthritis", and "surgery" in combination with "history" using the PubMed database. In addition, bibliographies of pertinent articles were reviewed.

RESULTS

The factors that led to many surgical innovations appear to be primarily theoretical concerns about the shortcomings of previously described procedures, especially about proximal migration of the thumb metacarpal after trapezial resection. Longevity of a particular procedure seems to be related to simplicity of design, especially for prosthetic arthroplasty. The evolution of surgery for TMC joint arthritis both parallels and diverges from that in other joints. For example, for most degenerated joints (even many in the hand), treatment evolved from resection arthroplasty to implant arthroplasty. In contrast, for the TMC joint, the 60-year-old procedure of trapezial resection continues to be performed by a majority of surgeons; many modifications of that procedure have been offered, but none have shown better pain reduction or increased function over the original procedure. In parallel, many differently designed prosthetic total or hemijoint arthroplasties have been proposed and performed, again with as yet unconvincing evidence that this technology improves results over those obtained by simple resection arthroplasty.

CONCLUSIONS

Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. In the absence of evidence for the superiority of any one procedure, surgeons should consider using established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissue-engineered solutions are an important area of current research but have not yet reached the clinical trial stage.

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.

Preserving the posttrapeziectomy space with a human acellular dermal matrix spacer: a pilot case series of patients with thumb carpometacarpal joint arthritis

Supplemental Digital Content is available in the text.

Background:

Advanced thumb carpometacarpal arthritis is widely treated with trapeziectomy and tendon interposition despite donor-site morbidities. Trapeziectomy alone leaves a postresection space, leading to proximal metacarpal migration and scaphoid/trapezoid impingement. Prosthetic implants have been unsuccessful due to particulate debris, silicone synovitis, osteolysis, and migration. Recent studies have shown successful use of allograft for interposition material in the posttrapeziectomy space both in animal and human models. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using a spacer constructed from human acellular dermal matrix (HADM).

Methods:

Sixteen patients with Eaton stage III–IV thumb carpometacarpal osteoarthritis received the above procedure from the 2 senior authors. HADM was imbricated to fill the posttrapeziectomy space and secured to the volar capsule and metacarpal base. Pre- and postoperative trapezial space on radiograph, pain scores, and grip strength were recorded.

Results:

Six months postoperatively, radiographs showed an average joint space loss of 11%. Heights postoperatively were not significantly different from immediate postoperative heights (P ≥ 0.01). At 6 months, patients had improved pain and grip strength (P ≤ 0.01). No infections, foreign body reactions, or other complications occurred.

Conclusions:

HADM has been used extensively in other forms of reconstruction and has been shown to incorporate into surrounding tissues through neovascularization. Our early results illustrate that HADM can safely fill the dead space left by trapeziectomy.

Salvage options for flexor carpi radialis tendon disruption during ligament reconstruction and tendon interposition or suspension arthroplasty of the trapeziometacarpal joint

Several techniques of thumb basilar joint arthroplasty depend on an intact flexor carpi radialis (FCR) tendon. There are situations, however, when the FCR tendon may be attenuated or iatrogenically injured, which make these techniques difficult or unfeasible. Familiarity with intraoperative salvage techniques in this setting is imperative. We present techniques for stabilizing the base of the thumb metacarpal when the FCR is deficient or injured.

Patient-reported outcomes after Silastic replacement of the trapezium for osteoarthritis

This retrospective study evaluated 69 Swanson trapezium replacements performed between 1990 and 2009 for trapeziometacarpal osteoarthritis in 58 patients. Pain and function were assessed using the Michigan Hand Questionnaire and the Disability of the Arm, Shoulder and Hand questionnaire. Patients had a mean age of 62 years at the time of surgery, with a mean time of 7.7 years (range 9 months to 19 years) from surgery to follow-up interview. There was no association between outcome scores and the length of follow-up, suggesting that the results are maintained over time (Spearman's rank correlation test < ±0.2). Scores for activities of daily living and work-related activities were higher when surgery was on the dominant hand (p < 0.05). Silicone trapezium replacement remains a good option for patients with painful trapeziometacarpal osteoarthritis that has not responded to nonoperative management.

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.

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.).

Thumb basal joint arthroplasty using abductor pollicis longus tendon: an average 5.5-year follow-up

PURPOSE

The goal of this study was to evaluate the 4-year minimum (5.5-y average) results of trapeziectomy and ligament reconstruction using a modified Thompson technique with the abductor pollicis longus tendon for the primary treatment of advanced-stage basal joint arthritis (Eaton stages III and IV).

METHODS

We evaluated 25 thumbs in 18 patients after ligament reconstruction arthroplasty for surgical treatment of advanced thumb basal joint arthritis. Treatment consisted of piecemeal excision of the entire trapezium, ligament reconstruction and interposition using the abductor pollicis longus tendon, and 8 weeks of K-wire immobilization of the thumb metacarpal. We evaluated range of motion, lateral pinch, tip pinch, grip strength, and outcomes questionnaires including the Arthritis Impact Measurement Scales 2 Short Form before and at an average of 5.5 years after surgery.

RESULTS

Seventeen of 18 patients reported excellent or good relief of pain and were satisfied with their operation, and all of the patients would have the operation again. Of the 25 thumbs, 24 adducted fully into the plane of the palm and opposed to the fifth metacarpal head. Preoperative and postoperative strength comparisons demonstrated an average increase in grip, key pinch, and tip pinch strength of 14%, 12%, and 6%, respectively. The outcomes data demonstrated noteworthy improvement in writing, buttoning a shirt, turning a key/lock, and arthritis pain categories.

CONCLUSIONS

This technique restored a stable, pain-free thumb that yielded excellent strength and motion at an average of 5.5 years after the procedure. Compared with published reports of techniques that use hematoma distraction or harvest of all or part of the flexor carpi radialis tendon, this modified Thompson technique has similar pain relief, satisfaction, and motion but had less improvement in strength, which might have resulted from differences in the studied samples.

Arthroscopic total trapeziectomy

Trapeziometacarpal osteoarthritis is a common pathology resulting in severe impairments in daily living activities. Many procedures have been described in the treatment of stages Eaton II, III and IV. Bibliographical research evidences that other techniques could not improve the results of the simple trapeziectomy. A surgical technique with an arthroscopically assisted total resection of the trapezium is described. This technique is carried out with a 2.7-mm arthroscope, using the conventional portals (1R and 1U) and a fluoroscan. Surgery ends with soft dressings and rehabilitation begins immediately. In the last 9 years, we treated more than 70 patients. Video-assisted total trapeziectomy offers a simple technique with sufficient postoperative comfort that allows an early return to the daily living activities.

Outcomes of trapeziectomy with a modified abductor pollicis longus suspension arthroplasty for the treatment of thumb carpometacarpal joint osteoarthritis

PURPOSE

Various arthroplasty procedures have been described for the treatment of thumb carpometacarpal joint osteoarthritis. The purpose of this study was to determine the outcomes of patients treated with trapeziectomy and a variation of abductor pollicis longus suspension arthroplasty.

METHODS

Eighteen consecutive patients were treated by a single surgeon (K.C.C.) with trapeziectomy and abductor pollicis longus suspension arthroplasty (21 thumbs). Prospective outcomes data were collected before the operation and at 3, 6, and 12 months after surgery. Outcomes were assessed with x-rays, grip/key pinch strength, the Jebsen-Taylor test, and the Michigan Hand Outcomes Questionnaire.

RESULTS

Immediately after surgery, a 32 percent loss in carpometacarpal joint height was observed and an additional 11 percent proximal metacarpal migration was observed at 1 year. The mean grip strength was 11.1 kg preoperatively and 7.7, 14.3, and 16.7 kg at 3 months, 6 months, and 1 year postoperatively, respectively. Michigan Hand Outcomes Questionnaire results demonstrated improvements in all domains. Statistically significant improvements were noted in the domains of overall score, from 41 to 67 (p = 0.03); activities of daily living, from 43 to 66 (p = 0.01); work, from 41 to 65 (p = 0.05); patient satisfaction, from 25 to 68 (p = 0.01); and pain, which decreased from 73 to 30 (p < 0.01).

CONCLUSIONS

Abductor pollicis longus suspension arthroplasty is a faster and technically easier technique that avoids any additional deficit by using an accessory tendon. This procedure gives acceptable patient-rated outcomes, especially in pain relief and satisfaction.

A cemented surface replacement prosthesis in the basal thumb joint

PURPOSE

The purpose of this study was to evaluate a cemented prosthesis (Avanta SR TMC prosthesis; Avanta Orthopaedics, San Diego, CA) of the basal thumb joint on the outcomes of range of motion, strength, pain, function, and loosening.

METHODS

Between July 2004 and December 2007, a total of 15 prostheses in 13 patients were implanted, with an average follow-up period of 36 months (range, 21-63 mo). Before and during the follow-up, the following scores were recorded: Kapandji-score (range of opposition), strength (hand dynamometer and pinch meter), pain (sequential occupational dexterity assessment [SODA], and Michigan Hand Outcomes Questionnaire [MHQ]) and function (9-hole peg test, SODA and MHQ). Radiographs taken before and after surgery were reviewed.

RESULTS

The measurements of range of opposition and strength did not show any significant postoperative improvement. Pain during activities (SODA) decreased significantly, and the function with both hands (SODA and MHQ) improved significantly after surgery. The review of pre- and postoperative radiographs did not show any signs of implant loosening after surgery. One failure and one nerve injury occurred.

CONCLUSIONS

In this group of patients, the Avanta SR TMC prosthesis provided statistically significant improvements in function with both hands and in pain during activity, but no significant change in range of motion, strength, or in function of the operated hand used alone. Prosthesis loosening was not detected.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

This is an update of a Cochrane Review first published in 2005. Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To compare the effect of different surgical techniques in reducing pain and improving physical function, patient global assessment, range of motion and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, to investigate whether there was any improvement or deterioration in outcomes between the 12-month review and five year follow up.

SEARCH STRATEGY

We searched:(CENTRAL) (The Cochrane Library 2008, issue 1), MEDLINE (1950 to Dec 2008), CINAHL (1982 to Dec 2008), AMED (1985 to Dec 2008) and EMBASE (1974 to Dec 2008), and performed handsearching of conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Randomised or quasi-randomised trials where the intervention was surgery and pain, physical function, patient global assessment, range of motion or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse effects. We contacted trial authors for missing information.

MAIN RESULTS

We included nine studies involving 477 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint resurfacing, arthrodesis and joint replacement). Studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement for pain and physical function. The majority of studies included in this review had an unclear risk of bias which raises some doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment or range of motion. Of participants who underwent trapeziectomy with ligament reconstruction and tendon interposition, 22% had adverse effects (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1)) compared to 10% who underwent trapeziectomy. Trapeziectomy with ligament reconstruction and tendon interposition is therefore associated with 12% more adverse effects (RR = 2.21, 95% CI 1.18 to 4.15).

AUTHORS' CONCLUSIONS

Although it appears that no one procedure produces greater benefit in terms of pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy has fewer complications than trapeziectomy with LRTI.

Ligament reconstruction arthroplasty for primary thumb carpometacarpal osteoarthritis (weilby technique): prospective cohort study

PURPOSE

The Weilby procedure is one of several accepted methods to treat primary thumb carpometacarpal osteoarthritis. We found no previous studies that included preoperative and postoperative subjective outcomes using validated questionnaires or preoperative and postoperative objective outcomes such as specific strength and range-of-motion measurements. Therefore, we performed a prospective cohort study in which we analyzed preoperative and postoperative objective and subjective outcomes after Weilby interposition tendoplasty.

METHODS

Nineteen patients (20 thumbs) with primary thumb carpometacarpal osteoarthritis were treated with Weilby interposition tendoplasty. For subjective assessment, the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome data collection instrument was used to evaluate preoperative and postoperative outcomes at 0, 3, 6, and 12 months. Furthermore, patients completed a specific personal questionnaire at 12 months of follow-up. Objective assessments included interphalangeal joint flexion/extension; metacarpophalangeal joint flexion/extension; and carpometacarpal joint palmar abduction, opposition, and extension. Tip pinch, key pinch, 3-point pinch, and overall grip strengths were also measured. The measurements were performed preoperatively and at 3, 6, and 12 months after surgery. All complications were registered.

RESULTS

The DASH score was significantly improved, and 17 of 19 patients were satisfied with the procedure. The interphalangeal joint flexion/extension, metacarpophalangeal joint flexion/extension, and carpometacarpal joint extension did not significantly change. Carpometacarpal joint palmar abduction and opposition were significantly improved at 12 months. The tip pinch and key pinch strengths were increased but not significantly. The 3-point pinch and overall grip strengths were significantly improved at 12 months.

CONCLUSIONS

The Weilby procedure is a reliable alternative to treat primary thumb carpometacarpal osteoarthritis without requiring bone tunnel creation. It achieves pain relief, stability, mobility, and strength. The objective and subjective outcomes of this study compare favorably with those of earlier reports of the Weilby procedure and are similar to the published results of the more commonly performed Burton-Pellegrini technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Comparative study between trapezium resection and tendon interposition with and without ligamentplasty in the management of carpometacarpal arthrosis of the thumb

PURPOSE

Treating arthrosis in the base of the thumb has been a highly controverted subject. Many surgeries have been described, such as the isolated trapezium resection; resection with interposition with and without ligament plasty; arthrodesis, and arthroplasties. The purpose of this paper is to compare the two techniques which are currently the most used in this treatment.

METHODS

A prospective study has been made to compare the surgical results between the trapezium resection with tendon interposition (tenoarthroplasty) - 22 cases - and tenoarthroplasty associated to ligament plasty-24 cases. Objective evaluation was done by measuring opponence, movements of the metacarpophalangeal joint, pinch and grasp strength, radiographic measurement of the distance between the base of first metacarpal and the scaphoid, and measurement of the angle between the first and the second metacarpals. Subjective evaluation was done with a DASH questionnaire, visual analog scale to evaluate pain and patient satisfaction.

RESULTS AND CONCLUSION

After application of the criteria described and using Student 't' tests for statistical analysis, the authors concluded that the ligament reconstruction has no advantage over the simple resection and tendon interposition in carpometacarpal arthrosis of the thumb.

Trapeziectomy for trapeziometacarpal joint osteoarthritis: is ligament reconstruction and temporary stabilisation of the pseudarthrosis with a Kirschner wire important?

This randomised prospective study compared two operations for trapeziometacarpal joint osteoarthritis: trapeziectomy with Flexor carpi radialis ligament reconstruction, tendon interposition and Kirschner wire insertion followed by splintage for 6 weeks (T+LRTI) and excision of the trapezium with no Kirschner wire and immobilisation of the thumb in a soft bandage for only 3 weeks (T). Sixty-seven thumbs with trapeziectomy (T) and 61 with trapeziectomy and ligament reconstruction and tendon interposition (T+LRTI) were assessed preoperatively and at 3-months and 1-year after surgery. Forty-seven percent and 73% of patients reported no pain or only aching after use at 3-months and 1-year respectively and the DASH and Patient Evaluation Measure (PEM) outcome scores reduced postoperatively indicating improved function. However the pain, DASH and PEM scores, and also key and tip thumb pinch and all the other clinical outcome measures, did not differ significantly between the two groups at either 3-months or 1-year after surgery.

Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995-2005

There are numerous techniques for the surgical management of thumb carpometacarpal (CMC) joint arthritis. The four senior authors of this study employ three such techniques: trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition (LRTI). This study examines the three commonly utilized procedures at a single institution. This study examines the 10-year experience from 1995-2005 with a minimum 3-month follow-up. Disabilities of the arm, shoulder, and hand (DASH) scores, pre-and postoperative pinch strength, and operative time were examined. After approval from the institutional review board of our institution was obtained, all patients treated surgically by three of the senior authors were contacted via mail and phone. Each patient was asked to complete and return a DASH questionnaire. Of the 115 patients treated during that period, 60 participated in this study. Each patient's final postoperative pinch measurement was obtained from occupational therapy and clinic records. This pinch strength was compared to the preoperative pinch and contralateral pinch strength. Lastly, the total operative time for each procedure was obtained from the operative record. The only significant finding in this study was a shorter mean operative time with the trapeziectomy group (76.90 min) and osteochondral allograft group (90.45 min) when compared to the LRTI group (139.00 min; p = 0.001 and p = 0.001, respectively). We found no significant difference between groups in terms of DASH score and pinch strength. There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of the LRTI. This presents further evidence that potentially, "less is more" in the treatment of thumb CMC arthritis. We used a retrospective study design to evaluate potential differences between the three surgical techniques described above, therapeutic, levels III-IV.

Treatment of advanced carpometacarpal joint disease: trapeziectomy and hematoma arthroplasty

Some surgical treatment options of painful basal joint arthritis do not require complex arthroplasty or suspensionplasty techniques. Simple trapeziectomy with temporary pinning of a slightly overdistracted thumb metacarpal can provide reliable pain relief, good motion, and functional stability. Recent literature supports alternative options when compared with formal ligament reconstruction or suspensionplasty procedures. Simple trapeziectomy is associated with less morbidity due to shorter operative times and the lack of need for graft harvest and ligament reconstruction.

Treatment of advanced CMC joint disease: trapeziectomy and implant arthroplasty (silastic-metal-synthetic allograft)

Osteoarthritis of the basal joint of the thumb is a common and frequently debilitating condition, most often affecting middle-aged women. Nonoperative treatment with activity modification, splinting, oral anti-inflammatory medication, and intraarticular steroid injection frequently leads to acceptable control of symptoms. If nonoperative treatment fails, many surgical techniques have been described for management of symptomatic advanced degenerative joint changes. This article reviews the literature related to various arthroplasty options for advanced disease. Treatment decisions must clearly be tempered by the surgeon's experience, the patient's goals and expectations, and the extent of degenerative disease.

Abductor pollicis longus "hammock" ligamentoplasty for treatment of first carpometacarpal arthritis

The association of trapeziectomy with ligamentoplasty is a simple treatment for osteoarthritis at the base of the thumb. Here we present the long-term results of a technique that creates a "hammock" under the first metacarpal bone using the Abductor Pollicis Longus tendon. This paper reports the results of treatment by this operation of 60 thumbs in 50 patients, including 13 men and 37 women of average age 60 (46-75) years. Thirty thumbs presented with severe pain and 30 with moderate pain. At final follow-up, 47 thumbs (78%) had experienced dramatic relief of pain following the procedure, 12 (20%) thumbs still had mild pain and one (2%) thumb had severe pain. No patients needed revision.

To suspend or not to suspend: a randomised single blind trial of simple trapeziectomy versus trapeziectomy and flexor carpi radialis suspension

The thumb carpometacarpal joint is the second most common site of osteoarthritis in humans. There are numerous operations for the condition but, perhaps, the commonest is trapeziectomy, sometimes supplemented by a suspension procedure, most commonly using part of the flexor carpi radialis tendon. In order to determine whether there is an advantage to a suspension procedure, or not, 65 patients with Eaton and Glickel Grade III or IV arthritis of the carpometacarpal joint of their thumbs were randomised into either undergoing trapeziectomy alone (with no wiring) or a trapeziectomy with flexor carpi radialis suspension. Patient satisfaction from both operations was similar. There was increased range of movement in the trapeziectomy alone group, but there was no difference in grip or pinch strength. Measurement of the gap on X-ray left by the trapeziectomy was less when trapeziectomy alone was performed.

Treatment of early basal joint arthritis using a combined arthroscopic debridement and metacarpal osteotomy

Osteoarthritis of the thumb basal joint is a common and disabling condition, and early stages of which are often seen in middle-aged women. Arthroscopic assessment of the first carpometacarpal joint allows easy identification and classification of joint pathology with minimal morbidity. This allows the condition to be managed either arthroscopically or converted to an open procedure as indicated. Different procedures have been described to treat different stages of this disease. The senior author has recently described an arthroscopic staging system to determine treatment for basal joint osteoarthritis. We now present our surgical technique and early clinical experience with arthroscopic synovectomy, debridement, and corrective osteotomy for arthroscopic stage II of thumb basal joint arthritis. Forty-three patients (38 women and 5 men) were arthroscopically diagnosed as having stage II basal joint osteoarthritis of the thumb between 1998 and 2001, and they were the focus of the present study. In all the patients, there was no improvement after a period of 6 to 12 weeks of conservative treatment. All the procedures were performed by the senior author. The surgical procedure included arthroscopic synovectomy, debridement, and occasional thermal capsulorraphy, followed by an extension-abduction closing wedge osteotomy in all the cases. A 0.045-in Kirschner wire provided stability to the osteotomy. By performing an osteotomy that redirects the axial loads in this joint, we have obtained satisfactory results in terms of pain relief, stability, and pinch strength. Arthroscopy allows us to not only determine the optimum indication for this osteotomy, but also to debride the joint and minimize the inflammatory response. Hence, we recommend arthroscopic synovectomy, debridement with or without a thermal capsulorraphy, and a dorsoradial closing wedge osteotomy for the treatment of arthroscopic stage II of thumb carpometacarpal joint osteoarthritis.

A new abductor pollicis longus suspension arthroplasty

PURPOSE

Surgical treatment of osteoarthritis of the first carpometacarpal joint aims to achieve complete pain relief with restoration of thumb strength and stability. The aim of this study was to introduce a variation of the abductor pollicis longus (APL) sling arthroplasty and to determine its efficacy in comparison with other tendon sling arthroplasty procedures.

METHODS

Between January 1999 and December 2003, 104 trapeziectomies in 74 consecutive patients (30 bilateral cases) were performed using a new APL sling arthroplasty. Patients were evaluated at 6 and 12 months after surgery. The outcomes were analyzed subjectively by questionnaire and objectively by clinical and radiographic evaluation.

RESULTS

After 6 months, excellent results in terms of pain relief were achieved in 95 thumbs (91%) of 65 patients. The remaining 9 thumbs had ongoing pain and had a secondary surgery performed between 6 and 12 months after the initial surgery. Pain relief was achieved in 1 thumb by scaphotrapezoid arthrodesis and in the other 8 thumbs by excision of the osteophyte on the ulnar-volar surface of the base of the first metacarpal, which was impinging on the base of the second metacarpal or the trapezoid. The gap was filled with a palmaris tendon anchovy. After 12 months, the 65 patients with successful trapeziectomies and APL sling remained pain-free. In these patients tip pinch, key pinch, and power grip strength increased by 46%, 19%, and 41%, respectively, from the preoperative values. In the 35 unilateral cases, tip pinch, key pinch, and power grip strength increased from 53%, 77%, and 65% of the contralateral hand strength before surgery to 82%, 89%, and 90%, respectively.

CONCLUSIONS

This modified APL sling arthroplasty is a new and effective way of creating a suspension sling with the APL tendon after trapeziectomy, with results comparable or better than other published methods, for the treatment of osteoarthritis of the first carpometacarpal joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Total joint arthroplasty in the treatment of advanced stages of thumb carpometacarpal joint osteoarthritis

PURPOSE

Osteoarthritis of the thumb basal joint is a very common and disabling condition that frequently affects middle-aged women. Many different surgical techniques have been proposed for extensive degenerative arthritis of the first carpometacarpal (CMC) joint. Joint replacement has been an effective treatment of this condition. The purpose of this article is to present the outcome of a total cemented trapeziometacarpal implant in the treatment of more advanced stages of this disease.

METHODS

Total joint arthroplasty of the trapeziometacarpal joint was performed on 26 thumbs in 25 patients to treat advanced osteoarthritis (Eaton and Littler stages III and IV) between 1998 and 2003. Indications for surgery after failure of conservative treatment were severe pain, loss of pinch strength, and diminished thumb motion that limited activities of daily living. A trapeziometacarpal joint prosthesis was the implant used in this series. The average follow-up time was 59 months.

RESULTS

At the final follow-up evaluation, thumb abduction averaged 60 degrees and thumb opposition to the base of the small finger was present. The average pinch strength was 5.5 kg (85% of nonaffected side). One patient had posttraumatic loosening, which was revised with satisfactory results. Radiographic studies at the final follow-up evaluations did not show signs of atraumatic implant loosening. One patient complained of minimal pain, and the remaining 24 patients were pain free.

CONCLUSIONS

In our series, total joint arthroplasty of the thumb CMC joint has proven to be efficacious with improved motion, strength, and pain relief. We currently recommend this technique for the treatment of stage III and early stage IV osteoarthritis of the CMC joint in older patients with low activity demands.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Thumb trapeziometacarpal arthritis: treatment with ligament reconstruction tendon interposition arthroplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the pathomechanical and biochemical basis for thumb trapeziometacarpal joint degeneration. 2. Diagnose and grade trapeziometacarpal joint disease based on presentation, physical examination (including provocative testing), and radiographic evidence. 3. Understand the principles of ligament reconstruction and tendon arthroplasty procedures. 4. Describe the surgical technique for ligament reconstruction tendon interposition arthroplasty and its variants.

BACKGROUND

Osteoarthritis of the trapeziometacarpal joint is the second most common site of degenerative joint disease in the hand, and mostly affects postmenopausal women. Degenerative arthritis of the thumb trapeziometacarpal joint is associated with a lack of bony constraints and laxity of the supporting ligaments, particularly the anterior oblique ("beak") ligament, which is consistently implicated in disease progression. Resultant increases in joint stress loads leads eventually to metacarpal and trapezial articular destruction, thumb instability, and pain.

METHODS

In this article, the authors review the diagnosis and treatment modalities available to the surgeon in the treatment of patients with trapeziometacarpal osteoarthritis. The technique of ligament reconstruction tendon interposition arthroplasty is discussed in detail.

RESULTS

Ligament reconstruction tendon interposition arthroplasty procedures center on three common principles: (1) excision of the diseased trapezium; (2) reconstruction of the beak ligament; and (3) interposition of a tissue substance to maintain metacarpal position.

CONCLUSIONS

Both conservative and surgical management can be effective in the treatment of trapeziometacarpal arthritis, when properly selected. The success of ligament reconstruction tendon interposition arthroplasty in treating trapeziometacarpal arthritis has withstood the test of time.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To investigate the effect of surgery in reducing pain and improving physical function, patient global assessment, range of motion, and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, it was the reviewers intention to investigate whether there was any improvement or deterioration in outcomes between the 12 months review and a 5 year follow-up.

SEARCH STRATEGY

We searched the the following databases in the Cochrane Library 2004, Issue 4: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE) as well as MEDLINE (1966-Dec 2004), CINAHL (1982-Dec 2004), AMED (1985-Dec 2004), and EMBASE (1974-Dec 2004). Database searches were supplemented by hand searching conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Studies were included if they were: randomised, quasi-randomised or controlled trials; intervention was surgery; and pain, physical function, patient global assessment, range of motion, or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two independent reviewers examined the identified studies according to the inclusion criteria. Included studies were assessed for methodological quality and then data, including adverse effects, was extracted and cross-checked. Authors were contacted to provide missing information.

MAIN RESULTS

Seven studies involving 384 participants were included. Studies of five surgical procedures were identified (trapeziectomy, trapeziectomy with interpositional arthroplasty, trapeziectomy with ligament reconstruction, trapeziectomy with ligament reconstruction and tendon interposition (LRTI), and joint replacement). All studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement across all stages of 27 to 57 mm on a 0-100 VAS scale for pain and 18-24 mm on a 0-100 VAS scale for physical function. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment, range of motion or strength. However, participants who underwent trapeziectomy had 16% fewer adverse effects (p=0<.001) than the other commonly-used procedures studied in this review; conversely, those who underwent trapeziectomy with ligament reconstruction and tendon interposition had 11% more (p=0.03) (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1).

AUTHORS' CONCLUSIONS

No one procedure produced greater strength than any other. Although this also appears to be the case for pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy is safer and has fewer complications than the other procedures studied in this review, and conversely trapeziectomy with LRTI has more.

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

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

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition

PURPOSE

To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improved the outcome of excision of the trapezium for the treatment of painful osteoarthritis of the trapeziometacarpal joint.

METHODS

183 thumbs with trapeziometacarpal osteoarthritis were randomized for treatment by either 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 during each of the 183 surgeries to hold the base of the thumb metacarpal at the level of the index carpometacarpal joint and was retained for 4 weeks in every case. All patients wore a thumb splint for 6 weeks. Each patient had subjective and objective assessments of thumb pain, stiffness, and strength before surgery and at 3 months and 1 year after surgery.

RESULTS

The 3 treatment groups were well matched for age, dominance, and presence of associated conditions. Complications were distributed evenly among the 3 groups and no cases of subluxation/dislocation of the pseudarthrosis were observed. Of the 183 thumbs 82% achieved good pain relief and 68% regained sufficient strength to allow normal activities of daily living at the 1-year follow-up evaluation. Neither of these subjective outcomes nor the range of thumb movement was influenced by the type of surgery performed. Thumb key-pinch strength improved significantly from 3.5 kg before surgery to 4.6 kg at 1 year but the improvement in strength was not influenced by the type of surgery performed.

CONCLUSIONS

The outcomes of these 3 variations of trapeziectomy were very similar at 1-year follow-up evaluation. In the short term at least there appears to be no benefit to tendon interposition or ligament reconstruction.

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

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

Excision of the trapezium and interposition arthroplasty with gelfoam for the treatment of trapeziometacarpal osteoarthritis

Excision of the trapezium with Gelfoam interposition was performed in 35 thumbs, 34 of which were evaluated after an average 5 years. Twenty-four patients had unilateral procedures. The follow-up examination included a standardized questionnaire and clinical and radiological examinations. Pain relief was achieved in all cases. The patients considered that 32 of their operated hands had improved function, while two had not improved. All patients were satisfied with the final postoperative result. Adduction of the thumb to the index finger, and opposition to the tip of the little finger was possible in all cases. Weakness, in comparison to the other thumb, of lateral pinch (71%; P=0.0001), tip pinch (74%; P=0.007), and grip strength (85%; P=0.006) were observed. The first web span was preserved in all hands. Calculation of the trapezial space ratio demonstrated only slight, insignificant shortening (7%; P=0.06) of the thumb ray. No significant correlations between the postoperative trapezial space ratio and lateral pinch strength, tip pinch strength, and grip strength were observed. We conclude that excision of the trapezium and Gelfoam interposition has no specific complications and is a reliable surgical treatment for osteoarthritis of the trapeziometacarpal joint.

Swanson versus APL arthroplasty in the treatment of osteoarthritis of the trapeziometacarpal joint: a prospective and randomized study in 26 patients

Twenty-six patients were operated because of osteo-arthritis of the trapeziometacarpal joint. After excision of the trapezium, they were randomized to receive either a Swanson silicone trapezium implant or a tendon interposition arthroplasty using a strip of the abductor pollicis longus tendon (APL). No infection or clinical silicone synovitis occurred and no major radiographic cyst formation was found. Two endoprostheses dislocated early. All 13 patients in the Swanson group and 11 of the 13 in the APL group were subjectively satisfied at 2-5 year (mean, 43 months) follow-up. All patients were free of pain at rest and at light work, but half of the patients in each group still experienced pain with heavy work. Thumb pinch strength and range of motion were not significantly different in the two groups. The trapezial space decreased both with load and length of follow-up in both groups. Five endoprostheses subluxed during stressed pinch. In conclusion, both methods gave good, but not complete, pain relief and neither produced better results than the other in the short term.

Silicone arthroplasty for trapeziometacarpal arthritis

Twenty-three patients who had undergone trapeziectomy and Helal silicone rubber ball interposition for trapeziometacarpal arthritis were reviewed. The average age at operation was 63 (range 48-84) years and the mean follow-up was 59 (range 12-138) months. Of the 23 patients reviewed, two had pain at rest and four had some discomfort on exertion. Mean post-operative thumb extension was 37 degrees whilst mean palmar abduction was 40 degrees. Mean post-operative grip strength was 19 kg and thumb-pinch strength was 4.0 kg, 77% and 78% of the age- and sex-matched normal values. There were no cases of prosthetic dislocation, prosthetic fracture or silicone synovitis.

Trapezial space height after trapeziectomy: mechanism of formation and benefits

Seventy-three thumbs in 67 women with osteoarthritis of the trapeziometacarpal joint were assessed prospectively. The patients were randomly allocated for treatment by either trapeziectomy alone (n = 26) or trapeziectomy with tendon interposition (n = 23) or ligament reconstruction (n = 24). A K-wire was passed through the thumb metacarpal base and across the trapezial space into the distal pole of the scaphoid in all procedures; this held the base of the metacarpal away from the scaphoid for 4 weeks. Standard thumb radiographs were used to calculate the trapezial space ratio before surgery and at 1-year follow-up examination. The trapezial space ratio decreased significantly from a preoperative mean of 0.40 (range, 0.20-0.56) to a mean of 0.18 (range, 0.08-0.30) after trapeziectomy, 0.16 (range, 0.07-0.30) after trapeziectomy with tendon interposition, and 0.20 (range, 0.00-0.33) after trapeziectomy with ligament reconstruction. There was no significant difference between these 1-year follow-up trapezial space ratios, suggesting that the placement of a K-wire across the trapezial void is as effective as tendon interposition or ligament reconstruction in creating a trapezial space in the short term at least. However, the need to create a trapezial space and maintain thumb length is questioned because the trapezial space height did not correlate with thumb strength at 1-year follow-up examination.