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Costochondral Autograft as a Salvage Procedure After Failed Trapeziectomy in Trapeziometacarpal Osteoarthritis
Costochondral Autograft as a Salvage Procedure After Failed Trapeziectomy in Trapeziometacarpal Osteoarthritis Yann Glard, MD, André Gay, MD, David Valenti, MD, Christian Berwald, MD, Didier Guinard, MD, Régis Legré, MD From the Department of Plastic and Reconstructive Surgery, Hôpital de la Conception, Marseille, France.
Purpose: Osteoarthritis at the base of the thumb is a common problem, especially in women. Among the many surgical procedures aimed at restoring the function of the trapeziometacarpal joint, total trapeziectomy has been shown to provide good long-term results in most patients. But in some patients continued pain may lead the surgeon to consider a revision procedure. We report the use of costochondral autograft as an interposition material in revision of trapeziectomy in trapeziometacarpal osteoarthritis and to study its usefulness. Methods: The study design was retrospective. All of the patients had a costochondral autograft as a revision procedure after a failed trapeziectomy with ligament reconstruction. Patients were clinically assessed before and after surgery. The follow-up period was 24 months. Results were assessed as follows: good, complete relief of pain; fair, persistent mild pain and stiffness; poor, no relief of pain or any improvement with revision surgery. Results: Four patients were included; there were 2 good results, 2 fair results, and no poor result. Pain relief was obtained in all patients. Thumb opposition showed a slight improvement in 1 patient and no change in the other 3 patients. Pinch strength showed no change. One case of iatrogenic injury of the sensory branch of the radial nerve was noted. Conclusions: Costochondral autograft as a revision procedure after failed trapeziectomy is a reliable procedure. These preliminary outcomes showed that the result did not compare favorably with soft-tissue interposition. Nevertheless, in case of an iterative procedure, the lack of available soft-tissue material to interpose may lead the surgeon to consider a costochondral autograft. This procedure should be considered a salvage procedure. (J Hand Surg 2006;31A:1461–1467. Copyright © 2006 by the American Society for Surgery of the Hand.) Type of study/level of evidence: Retrospective therapeutic study/IV. Key words: Costochondral autograft, failed trapeziectomy, trapeziometacarpal joint.
steoarthritis at the base of the thumb is a common problem that might affect up to 10% of women between the ages of 45 and 70.1 A recent study showed that the radiographic prevalence of osteoarthritis at the base of the thumb is age related, and might be found in up to 30% of women aged 41 to 50 years.2 This radiographic prevalence could approach 100% in women older than 80 years.2 Many surgical procedures aimed at restoring the function of the trapeziometacarpal joint have
O
been described in the literature,1,3–7 all with differing results.1 Total trapeziectomy with ligament reconstruction has been shown to provide good long-term results in trapeziometacarpal osteoarthritis,7 but in some cases continued pain may lead the surgeon to consider a revision procedure.7 Many revision procedures after a primary trapeziectomy (with or without ligamentoplasty) have been described in the literature.8 –10 Costochondral graft has been successfully used as
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an autograft3 and as an allograft10 as primary procedures in trapeziometacarpal osteoarthritis. Our aim was to report the use of costochondral autograft as an interposition material in the revision of trapeziectomy in trapeziometacarpal osteoarthritis and to study its usefulness.
Materials and Methods The study design was retrospective. All of the patients at our institution who had a revision procedure using costochondral autograft after a failed trapeziectomy for base-of-thumb osteoarthritis were considered for inclusion. Criteria for inclusion were identified to minimize patient heterogeneity: a previous trapeziectomy without soft-tissue interposition and with ligament reconstruction (suspensionplasty using half of the abductor pollicis longus), a follow-up period of at least 24 months, and the absence of preoperative lesion of the radial nerve. Surgical Procedure First surgical step: articular release. The approach was made dorsally, between the abductor pollicis longus and the extensor pollicis longus (through the previous dorsal approach). The branches of the radial nerve and the radial artery were identified and protected. A capsule incision was made longitudinally. The fibrous material in the trapeziectomy defect was carefully removed using a gouge. The size of the defect to fill was measured. Second surgical step: costochondral autograft harvesting. The donor site was the distal end of the fifth or sixth rib. The incision line was placed in the inframammary fold (Fig. 1). The incision line was
Figure 1. Harvesting of the costochondral autograft. The incision is placed in the inframammary fold.
Figure 2. Harvesting of the costochondral autograft and protection of the pleura during the cartilage section.
4-cm long and was placed horizontally. The superficial aspect of the rib was exposed. The cartilaginous part of the rib was identified using a needle. The deep aspect of the rib was gently isolated from the surrounding soft tissues. An elevator was placed under the rib to protect the pleura when the cartilaginous rib was removed (Fig. 2). A 1.5-cm–long cylinder of cartilage was harvested (Fig. 3) and the skin was closed without drainage. Third surgical step: graft setting. The harvested cartilage was shaped in the required dimension (Fig. 4). The graft was placed into the trapeziectomy defect (Fig. 5) and stabilized using 2 stitches (Vicryl; Ethicon, Piscataway, NJ) (Fig. 6). No additional ligament reconstruction was performed. The capsule incision was closed, and the skin was closed without drainage. A cast was applied for 4 weeks.
Figure 3. A 1.5-cm cylinder of cartilage is harvested.
Glard et al / Costochondral Autograft After Failed Trapeziectomy
Figure 4. The harvested cartilage is shaped to the required dimension to fill the trapeziectomy defect.
Data Collection Before surgery, age, gender, side involved, dominant side, age at primary trapeziectomy, other surgical procedures before the trapeziectomy (type and date), reason of dissatisfaction with the primary trapeziectomy, and skin sensitivity in the radial nerve distribution were noted. Pain also was noted. It was assessed using a visual analogue scale from zero (no pain) to 100 (maximum pain) for stress and under resting conditions. The average of the 2 values was noted as the pain score. We also noted the key pinch strength (in kg), which was assessed using a dynamometer (Jamar pinch dynamometer; Preston Company, Jackson, MI); the ability to write without pain, which was assessed as possible, hardly possible, or impossible; the ability to use a contact key (to switch on a car engine), which was assessed as possible, hardly possible, or impossible. The range of motion
Figure 5. The graft is placed into the trapeziectomy defect.
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Figure 6. The graft is stabilized using 2 stitches (Vicryl).
in opposition also was noted. It was assessed using the Kapandji opposition score, ranging from 0 (no motion) to 10 (full range of motion).11 A clinical thoracic examination was performed and an anteroposterior view of the thorax were taken at 24 hours and at 1 week after surgery, respectively. The presence of a pneumothorax and/or hemothorax was noted. The following items were noted at 24 months after surgery (as previously defined): pain, key pinch, the ability to write, thumb range of motion (in opposition), and skin sensitivity in the radial nerve distribution. Patients also were asked if they experienced any thoracic pain at rest, under stress, or on palpation of the donor site, and if they were satisfied with the cosmetic result of the donor site. As defined by Conolly and Rath,9 based on the 24-month follow-up examination, the results were assessed as good if there was complete pain relief;, as fair if there was persistent mild pain and stiffness, or in case of difficulty performing work and hobbies as a result of grip weakness and limited range of motion; and as poor when no pain relief or improvement was obtained with revision surgery. Four joints in 4 patients were included; all 4 were women. The mean age at revision surgery was 52 years (range, 48 – 60 y). The right side was involved in 2 patients, and the left side was involved in the other 2 patients. All 4 patients were right handed and all had a trapeziectomy with ligament reconstruction a year before the revision arthroplasty using costochondral autograft. In 2 patients there was a previous surgery (De la Caffinière trapeziometacarpal prosthesis, Fixano, France). In these 2 patients the primary procedure was implanting the prosthesis, the second procedure was the prosthesis removal, followed by
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Table 1. Overall Results Age at costochondral graft, y Gender Side involved Dominant side Age at trapeziectomy, y Procedure prior to trapeziectomy Pain before surgery Pain after surgery Key pinch before surgery, kg Key pinch after surgery, kg Writing without pain before surgery Writing without pain after surgery Contact key before surgery Contact key after surgery Preoperative range of motion, °* Postoperative range of motion, °*
Patient 1
Patient 2
Patient 3
Patient 4
60 F L R 59 TM prosthesis 35 0 5 5 Possible Possible Impossible Possible 10 10
50 F R R 49 None 64 0 6 6 Impossible Hardly Impossible Hardly 8 10
53 F L R 52 None 39 0 5 5 Hardly Possible Hardly Possible 10 10
48 F R R 47 TM prosthesis 48 0 5 5 Hardly Hardly Hardly Possible 2 2
TM ⫽ trapeziometacarpal *Kapanji opposition score ranging from 0 (no motion) to 10 (full motion).
total trapeziectomy with ligament reconstruction (using half of the abductor pollicis longus), and the final procedure that was assessed in the present study was the costochondral autograft. In the 2 other patients the primary procedure was the trapeziectomy with ligament reconstruction (using half of the abductor pollicis longus) and the final procedure that was assessed in the present study was the costochondral autograft. In all patients the main reason for dissatisfaction with the primary procedure was continued pain.
Results The results of this study are shown in Table 1. Among the 4 patients, according to the grading system of Conolly and Rath,9 there were 2 good results and 2 fair results. Pain relief was obtained in all patients. Thumb opposition showed a slight improvement in 1 patient and no change in the other 3 patients. Pinch strength showed no change. One case of iatrogenic injury of the sensory branch of the radial nerve was noted. No case of postoperative intrathoracic complication (pneumothorax or hemothorax) was reported. At the 24-month follow-up evaluation, no chest pain was reported (at rest, under stress, or on palpation of the donor site), and all of the patients were satisfied with the appearance of the donor site. A preoperative and a postoperative (at 24 mo) x-ray of patient 1, who was classified as a good result, is shown in Figure 7. A preoperative and
Figure 7. (A) Preoperative and (B) postoperative x-rays of patient 1 (classified as a good result).
Glard et al / Costochondral Autograft After Failed Trapeziectomy
Figure 8. (A) Preoperative and (B) postoperative x-rays of patient 2 (classified as a fair result).
postoperative (at 24 mo) x-ray of patient 2, who was classified as a fair result, is shown in Figure 8.
Discussion Several techniques that aim to relieve pain in osteoarthritis of the base of the thumb have been described in the literature; satisfactory results have been obtained in most patients with most techniques.8 More specifically, total trapeziectomy with ligament reconstruction has been shown to provide good long-term results in many patients.7 In some patients (up to 30%), however, continued pain may lead the surgeon to consider a revision procedure.7 The classic procedures available for revision arthroplasty after total trapeziectomy are scaphoid-thumb metacarpal fusion,9 synthetic material interposition arthroplasty with or without ligament reconstruction,9 or biological soft-tissue interposition with or without ligament reconstruction.10 In many cases, multiple and iterative revision procedures are required to obtain satisfactory pain relief.8 Revision procedure outcomes have been poorly assessed in the literature. Series are small, and the follow-up time is short. In most reports8 –10 multiple procedures were assessed together, without clear separation between the different procedures used. Nevertheless, few things are now well known.
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Scaphoid-thumb metacarpal fusion is a difficult procedure with a high rate of nonunion and poor functional outcome.8 This procedure should be avoided. It also clearly has been assessed that synthetic-material interposition arthroplasty is a procedure with uncertain long-term effects, at least in primary procedures.6,12,13 One may think that the uncertain longterm outcome that is observed in primary procedures may be observed in revision procedures. Biologic soft-tissue interposition with or without ligament reconstruction as a revision procedure was partially assessed recently.10 Cooney et al10 published a series of 15 patients who had 17 revision procedures. The technique used was soft-tissue interposition alone or soft-tissue interposition with ligament reconstruction. The soft-tissue interposition materials consisted of 10 biologic tissues and 7 synthetic materials. The investigators assessed their outcome based on the evaluation method of Connolly and Rath,9 who used pain relief, motion, strength, and stability to provide a final score, as we did in the present study. The patients were not divided according to the material (biological or synthetic) used as an interposition device. They pointed out that, at 26 months after surgery, 13 hands showed good results, 2 hands showed fair results, and 2 hands showed poor results. They also compared preoperative and postoperative pain scores, which changed from 4.4 to 0.6; radial abduction, which changed from 35° to 40°; palmar abduction, which changed from 36° to 45°; thumb opposition flexion, which changed from 20 to 15 mm; grip strength, which changed from 16 to 20 kg; and pinch strength, which changed from 2.0 to 3.4 kg. These results are impressive and may lead one to think that the revision procedure that was reported by Cooney et al10 is the one to choose. Nevertheless, in case of iterative revision procedures, as described by Renfree and Dell,8 the problem of available biologic soft-tissue interposition material may occur, especially in young and middle-aged patients. Although Cooney et al10 used synthetic interposition material in 7 patients, we do not support this concept in young and middle-aged patients because it has been shown clearly that the long-term tolerance is poor.5,12,13 Therefore, we chose chondral autograft to relieve pain in these patients who required a revision procedure of a primary trapeziectomy. Chondrocostal autograft has been described many times in the literature for many indications, and the donor site morbidity has been well assessed.14 –18 Although immediate postoperative morbidity may occur (such as hemothorax and/or pneumothorax17),
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it has been shown that costochondral autograft presents less morbidity at the donor site than iliac crest harvesting, which is a common procedure in orthopedic surgery.18 We do not believe that costochondral autograft harvesting is more risky or more damaging than iterative tendon harvesting. Joint restoration using costochondral autograft is not new. It has been used for years in maxillofacial surgery,19 –21 and, more recently, it has been used in hand surgery. Hasegawa and Yamano22 published a series in which they used a costochondral autograft to restore the proximal interphalangeal joint. Sandow23 published a series in which he used a costochondral autograft to restore the proximal scaphoid. More specifically, it has been used in primary thumb trapeziometacarpal arthroplasty (for osteoarthritis), first as autograft,2 and then as allograft.4 The follow-up period was short (1 year for Tropet et al3 and 4 years for Trumble et al4), but this technique seems to provide satisfactory results. Our aim was to assess the outcome of costochondral autograft as a revision arthroplasty after trapeziectomy failure. Although allograft may be used to avoid the donor harvest, we chose autograft because allograft availability is poor in France. The outcome assessment was based on the evaluation method of Connolly and Rath,9 as it was performed in the series of Cooney et al.10 Criteria for inclusion were chosen to minimize patient heterogeneity. This is why we chose to include only patients who had a specific procedure: a trapeziectomy without soft-tissue interposition and with a suspensionplasty using half of the abductor pollicis longus. This does not mean that in our experience patients who had an interposition procedure in addition to the trapeziectomy never needed a salvage procedure. Similarly, in our experience, if a trapeziectomy with interposition failed, a revision procedure using costochondral autograft was possible without any additional difficulty. Another type of suspensionplasty (ie, extensor carpi radialis longus or flexor carpi radialis suspensionplasty) performed previously, or no ligament reconstruction at all, also would be acceptable for this procedure to be performed. Nevertheless, we chose to limit our study to a homogenous group of patients who had a salvage procedure using costochondral autograft after a failed trapeziectomy with ligament reconstruction using half of the abductor pollicis longus. Our results do not compare favorably with those published by Cooney et al.10 We reported 1 case of iatrogenic injury of the sensory branch of the radial nerve. This rate compares with the rate reported by Renfree and
Dell.8 In the technique we reported in the present study, no additional ligamentoplasty was performed because the ligament reconstruction was performed during the initial procedure. We reported no case of immediate postoperative intrathoracic complication (pneumothorax or hemothorax). Concerning the donor site, no pain (at rest, under stress, or on palpation) or dissatisfaction with the cosmetic result was noted in any patient at follow-up evaluation. The scar was not visible in the standing position because it was placed in the inframammary fold in all patients. Costochondral autograft as a revision procedure after failed trapeziectomy is a reliable procedure. These preliminary outcomes show that the result did not compare favorably with soft-tissue interposition with or without ligament reconstruction. Nevertheless, in case of an iterative procedure, the lack of available soft-tissue material to interpose may lead the surgeon to consider a costochondral autograft. This procedure should be considered as a salvage procedure. Received for publication March 5, 2006; accepted in revised form August 4, 2006. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Dr. Yann Glard, Department of Plastic and Reconstructive Surgery, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A09-0006$32.00/0 doi:10.1016/j.jhsa.2006.08.005
References 1. Taylor EJ, Desari K, D’Arcy JC, Bonnici AV. A comparison of fusion, trapeziectomy and silastic replacement for the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg 2005;30B:45– 49. 2. Sodha S, Ring D, Zurakowski D, Jupiter JB. Prevalence of osteoarthrosis of the trapeziometacarpal joint. J Bone Joint Surg 2005;87A:2614 –2618. 3. Tropet Y, Ridoux PE, Garbuio P, Vichard P. [Treatment of rhizomelic arthrosis of the thumb by partial resection of the trapezium and rib cartilage autograft. Preliminary results.] Chirurgie 1994;120:563–567. 4. Trumble TE, Rafijah G, Gilbert M, Allan CH, North E, McCallister WV. Thumb trapeziometacarpal joint arthritis: partial trapeziectomy with ligament reconstruction and interposition costochondral allograft. J Hand Surg 2000; 25A:61–76. 5. Nusem I, Goodwin DR. Excision of the trapezium and interposition arthroplasty with gelfoam for the treatment of trapeziometacarpal osteoarthritis. J Hand Surg 2003;28B: 242–245. 6. Minami A, Iwasaki N, Kutsumi K, Suenaga N, Yasuda K. A long-term follow-up of silicone-rubber interposition ar-
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7.
8.
9.
10.
11. 12.
13.
14.
throplasty for osteoarthritis of the thumb carpometacarpal joint. Hand Surg 2005;10:77– 82. Foucher G, Lanzetta M, Van Overstraeten L. [Comparison of treatment techniques of rhizarthrosis of the thumb. Apropos of a series of 98 cases.] Chirurgie 1993;119:586 –589. Renfree KJ, Dell PC. Functional outcome following salvage of failed trapeziometacarpal joint arthroplasty. J Hand Surg 2002;27B:96 –100. Conolly WB, Rath S. Revision procedures for complications of surgery for osteoarthritis of the carpometacarpal joint of the thumb. J Hand Surg 1993;18B:533–539. Cooney WP III, Leddy TP, Larson DR. Revision of thumb trapeziometacarpal arthroplasty. J Hand Surg 2006;31A: 219 –227. Kapandji A. [Proposal for a clinical score for flexion-extension of the long fingers.] Ann Chir Main 1987;6:288 –294. Chantelot C, Rtaimate M, Chantelot-Lahoude S, Migaud H, Fontaine C. Intracarpal synovitis related to Dacron interposition after trapeziectomy: a report of three cases. Chir Main 2004;23:208 –211. Martinet X, Belfkira F, Corcella D, Guinard D, Moutet F. [Foreign body reaction in osteoarthrosis of the trapeziometacarpal joint treated with trapezectomy and interposition of a Dacron “anchovy”. A series of 5 cases.] Chir Main 2004; 23:27–31. Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr Surg 1997;99:1030 –1036.
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15. Skouteris CA, Sotereanos GC. Donor site morbidity following harvesting of autogenous rib grafts. J Oral Maxillofac Surg 1989;47:808 – 812. 16. Tanzer RC. Microtia—a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61:161–166. 17. Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction: a long-term study. Plast Reconstr Surg 1995;95:961–968. 18. Laurie SW, Kaban LB, Mulliken JB, Murray JE. Donor-site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 1984;73:933–938. 19. Politis C, Fossion E, Bossuyt M. The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 1987;15:345–354. 20. Perrott DH, Umeda H, Kaban LB. Costochondral graft construction/reconstruction of the ramus/condyle unit: longterm follow-up. Int J Oral Maxillofac Surg 1994;23:321– 328. 21. Demir Z, Velidedeoglu H, Sahin U, Kurtay A, Coskunfirat OK. Preserved costal cartilage homograft application for the treatment of temporomandibular joint ankylosis. Plast Reconstr Surg 2001;108:44 –51. 22. Hasegawa T, Yamano Y. Arthroplasty of the proximal interphalangeal joint using costal cartilage grafts. J Hand Surg 1992;17B:583–585. 23. Sandow MJ. Proximal scaphoid costo-osteochondral replacement arthroplasty. J Hand Surg 1998;23B:201–208.
Purpose: Osteoarthritis at the base of the thumb is a common problem, especially in women. Among the many surgical procedures aimed at restoring the function of the trapeziometacarpal joint, total trapeziectomy has been shown to provide good long-term results in most patients. But in some patients continued pain may lead the surgeon to consider a revision procedure. We report the use of costochondral autograft as an interposition material in revision of trapeziectomy in trapeziometacarpal osteoarthritis and to study its usefulness. Methods: The study design was retrospective. All of the patients had a costochondral autograft as a revision procedure after a failed trapeziectomy with ligament reconstruction. Patients were clinically assessed before and after surgery. The follow-up period was 24 months. Results were assessed as follows: good, complete relief of pain; fair, persistent mild pain and stiffness; poor, no relief of pain or any improvement with revision surgery. Results: Four patients were included; there were 2 good results, 2 fair results, and no poor result. Pain relief was obtained in all patients. Thumb opposition showed a slight improvement in 1 patient and no change in the other 3 patients. Pinch strength showed no change. One case of iatrogenic injury of the sensory branch of the radial nerve was noted. Conclusions: Costochondral autograft as a revision procedure after failed trapeziectomy is a reliable procedure. These preliminary outcomes showed that the result did not compare favorably with soft-tissue interposition. Nevertheless, in case of an iterative procedure, the lack of available soft-tissue material to interpose may lead the surgeon to consider a costochondral autograft. This procedure should be considered a salvage procedure. (J Hand Surg 2006;31A:1461–1467. Copyright © 2006 by the American Society for Surgery of the Hand.) Type of study/level of evidence: Retrospective therapeutic study/IV. Key words: Costochondral autograft, failed trapeziectomy, trapeziometacarpal joint.
steoarthritis at the base of the thumb is a common problem that might affect up to 10% of women between the ages of 45 and 70.1 A recent study showed that the radiographic prevalence of osteoarthritis at the base of the thumb is age related, and might be found in up to 30% of women aged 41 to 50 years.2 This radiographic prevalence could approach 100% in women older than 80 years.2 Many surgical procedures aimed at restoring the function of the trapeziometacarpal joint have
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been described in the literature,1,3–7 all with differing results.1 Total trapeziectomy with ligament reconstruction has been shown to provide good long-term results in trapeziometacarpal osteoarthritis,7 but in some cases continued pain may lead the surgeon to consider a revision procedure.7 Many revision procedures after a primary trapeziectomy (with or without ligamentoplasty) have been described in the literature.8 –10 Costochondral graft has been successfully used as
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an autograft3 and as an allograft10 as primary procedures in trapeziometacarpal osteoarthritis. Our aim was to report the use of costochondral autograft as an interposition material in the revision of trapeziectomy in trapeziometacarpal osteoarthritis and to study its usefulness.
Materials and Methods The study design was retrospective. All of the patients at our institution who had a revision procedure using costochondral autograft after a failed trapeziectomy for base-of-thumb osteoarthritis were considered for inclusion. Criteria for inclusion were identified to minimize patient heterogeneity: a previous trapeziectomy without soft-tissue interposition and with ligament reconstruction (suspensionplasty using half of the abductor pollicis longus), a follow-up period of at least 24 months, and the absence of preoperative lesion of the radial nerve. Surgical Procedure First surgical step: articular release. The approach was made dorsally, between the abductor pollicis longus and the extensor pollicis longus (through the previous dorsal approach). The branches of the radial nerve and the radial artery were identified and protected. A capsule incision was made longitudinally. The fibrous material in the trapeziectomy defect was carefully removed using a gouge. The size of the defect to fill was measured. Second surgical step: costochondral autograft harvesting. The donor site was the distal end of the fifth or sixth rib. The incision line was placed in the inframammary fold (Fig. 1). The incision line was
Figure 1. Harvesting of the costochondral autograft. The incision is placed in the inframammary fold.
Figure 2. Harvesting of the costochondral autograft and protection of the pleura during the cartilage section.
4-cm long and was placed horizontally. The superficial aspect of the rib was exposed. The cartilaginous part of the rib was identified using a needle. The deep aspect of the rib was gently isolated from the surrounding soft tissues. An elevator was placed under the rib to protect the pleura when the cartilaginous rib was removed (Fig. 2). A 1.5-cm–long cylinder of cartilage was harvested (Fig. 3) and the skin was closed without drainage. Third surgical step: graft setting. The harvested cartilage was shaped in the required dimension (Fig. 4). The graft was placed into the trapeziectomy defect (Fig. 5) and stabilized using 2 stitches (Vicryl; Ethicon, Piscataway, NJ) (Fig. 6). No additional ligament reconstruction was performed. The capsule incision was closed, and the skin was closed without drainage. A cast was applied for 4 weeks.
Figure 3. A 1.5-cm cylinder of cartilage is harvested.
Glard et al / Costochondral Autograft After Failed Trapeziectomy
Figure 4. The harvested cartilage is shaped to the required dimension to fill the trapeziectomy defect.
Data Collection Before surgery, age, gender, side involved, dominant side, age at primary trapeziectomy, other surgical procedures before the trapeziectomy (type and date), reason of dissatisfaction with the primary trapeziectomy, and skin sensitivity in the radial nerve distribution were noted. Pain also was noted. It was assessed using a visual analogue scale from zero (no pain) to 100 (maximum pain) for stress and under resting conditions. The average of the 2 values was noted as the pain score. We also noted the key pinch strength (in kg), which was assessed using a dynamometer (Jamar pinch dynamometer; Preston Company, Jackson, MI); the ability to write without pain, which was assessed as possible, hardly possible, or impossible; the ability to use a contact key (to switch on a car engine), which was assessed as possible, hardly possible, or impossible. The range of motion
Figure 5. The graft is placed into the trapeziectomy defect.
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Figure 6. The graft is stabilized using 2 stitches (Vicryl).
in opposition also was noted. It was assessed using the Kapandji opposition score, ranging from 0 (no motion) to 10 (full range of motion).11 A clinical thoracic examination was performed and an anteroposterior view of the thorax were taken at 24 hours and at 1 week after surgery, respectively. The presence of a pneumothorax and/or hemothorax was noted. The following items were noted at 24 months after surgery (as previously defined): pain, key pinch, the ability to write, thumb range of motion (in opposition), and skin sensitivity in the radial nerve distribution. Patients also were asked if they experienced any thoracic pain at rest, under stress, or on palpation of the donor site, and if they were satisfied with the cosmetic result of the donor site. As defined by Conolly and Rath,9 based on the 24-month follow-up examination, the results were assessed as good if there was complete pain relief;, as fair if there was persistent mild pain and stiffness, or in case of difficulty performing work and hobbies as a result of grip weakness and limited range of motion; and as poor when no pain relief or improvement was obtained with revision surgery. Four joints in 4 patients were included; all 4 were women. The mean age at revision surgery was 52 years (range, 48 – 60 y). The right side was involved in 2 patients, and the left side was involved in the other 2 patients. All 4 patients were right handed and all had a trapeziectomy with ligament reconstruction a year before the revision arthroplasty using costochondral autograft. In 2 patients there was a previous surgery (De la Caffinière trapeziometacarpal prosthesis, Fixano, France). In these 2 patients the primary procedure was implanting the prosthesis, the second procedure was the prosthesis removal, followed by
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Table 1. Overall Results Age at costochondral graft, y Gender Side involved Dominant side Age at trapeziectomy, y Procedure prior to trapeziectomy Pain before surgery Pain after surgery Key pinch before surgery, kg Key pinch after surgery, kg Writing without pain before surgery Writing without pain after surgery Contact key before surgery Contact key after surgery Preoperative range of motion, °* Postoperative range of motion, °*
Patient 1
Patient 2
Patient 3
Patient 4
60 F L R 59 TM prosthesis 35 0 5 5 Possible Possible Impossible Possible 10 10
50 F R R 49 None 64 0 6 6 Impossible Hardly Impossible Hardly 8 10
53 F L R 52 None 39 0 5 5 Hardly Possible Hardly Possible 10 10
48 F R R 47 TM prosthesis 48 0 5 5 Hardly Hardly Hardly Possible 2 2
TM ⫽ trapeziometacarpal *Kapanji opposition score ranging from 0 (no motion) to 10 (full motion).
total trapeziectomy with ligament reconstruction (using half of the abductor pollicis longus), and the final procedure that was assessed in the present study was the costochondral autograft. In the 2 other patients the primary procedure was the trapeziectomy with ligament reconstruction (using half of the abductor pollicis longus) and the final procedure that was assessed in the present study was the costochondral autograft. In all patients the main reason for dissatisfaction with the primary procedure was continued pain.
Results The results of this study are shown in Table 1. Among the 4 patients, according to the grading system of Conolly and Rath,9 there were 2 good results and 2 fair results. Pain relief was obtained in all patients. Thumb opposition showed a slight improvement in 1 patient and no change in the other 3 patients. Pinch strength showed no change. One case of iatrogenic injury of the sensory branch of the radial nerve was noted. No case of postoperative intrathoracic complication (pneumothorax or hemothorax) was reported. At the 24-month follow-up evaluation, no chest pain was reported (at rest, under stress, or on palpation of the donor site), and all of the patients were satisfied with the appearance of the donor site. A preoperative and a postoperative (at 24 mo) x-ray of patient 1, who was classified as a good result, is shown in Figure 7. A preoperative and
Figure 7. (A) Preoperative and (B) postoperative x-rays of patient 1 (classified as a good result).
Glard et al / Costochondral Autograft After Failed Trapeziectomy
Figure 8. (A) Preoperative and (B) postoperative x-rays of patient 2 (classified as a fair result).
postoperative (at 24 mo) x-ray of patient 2, who was classified as a fair result, is shown in Figure 8.
Discussion Several techniques that aim to relieve pain in osteoarthritis of the base of the thumb have been described in the literature; satisfactory results have been obtained in most patients with most techniques.8 More specifically, total trapeziectomy with ligament reconstruction has been shown to provide good long-term results in many patients.7 In some patients (up to 30%), however, continued pain may lead the surgeon to consider a revision procedure.7 The classic procedures available for revision arthroplasty after total trapeziectomy are scaphoid-thumb metacarpal fusion,9 synthetic material interposition arthroplasty with or without ligament reconstruction,9 or biological soft-tissue interposition with or without ligament reconstruction.10 In many cases, multiple and iterative revision procedures are required to obtain satisfactory pain relief.8 Revision procedure outcomes have been poorly assessed in the literature. Series are small, and the follow-up time is short. In most reports8 –10 multiple procedures were assessed together, without clear separation between the different procedures used. Nevertheless, few things are now well known.
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Scaphoid-thumb metacarpal fusion is a difficult procedure with a high rate of nonunion and poor functional outcome.8 This procedure should be avoided. It also clearly has been assessed that synthetic-material interposition arthroplasty is a procedure with uncertain long-term effects, at least in primary procedures.6,12,13 One may think that the uncertain longterm outcome that is observed in primary procedures may be observed in revision procedures. Biologic soft-tissue interposition with or without ligament reconstruction as a revision procedure was partially assessed recently.10 Cooney et al10 published a series of 15 patients who had 17 revision procedures. The technique used was soft-tissue interposition alone or soft-tissue interposition with ligament reconstruction. The soft-tissue interposition materials consisted of 10 biologic tissues and 7 synthetic materials. The investigators assessed their outcome based on the evaluation method of Connolly and Rath,9 who used pain relief, motion, strength, and stability to provide a final score, as we did in the present study. The patients were not divided according to the material (biological or synthetic) used as an interposition device. They pointed out that, at 26 months after surgery, 13 hands showed good results, 2 hands showed fair results, and 2 hands showed poor results. They also compared preoperative and postoperative pain scores, which changed from 4.4 to 0.6; radial abduction, which changed from 35° to 40°; palmar abduction, which changed from 36° to 45°; thumb opposition flexion, which changed from 20 to 15 mm; grip strength, which changed from 16 to 20 kg; and pinch strength, which changed from 2.0 to 3.4 kg. These results are impressive and may lead one to think that the revision procedure that was reported by Cooney et al10 is the one to choose. Nevertheless, in case of iterative revision procedures, as described by Renfree and Dell,8 the problem of available biologic soft-tissue interposition material may occur, especially in young and middle-aged patients. Although Cooney et al10 used synthetic interposition material in 7 patients, we do not support this concept in young and middle-aged patients because it has been shown clearly that the long-term tolerance is poor.5,12,13 Therefore, we chose chondral autograft to relieve pain in these patients who required a revision procedure of a primary trapeziectomy. Chondrocostal autograft has been described many times in the literature for many indications, and the donor site morbidity has been well assessed.14 –18 Although immediate postoperative morbidity may occur (such as hemothorax and/or pneumothorax17),
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The Journal of Hand Surgery / Vol. 31A No. 9 November 2006
it has been shown that costochondral autograft presents less morbidity at the donor site than iliac crest harvesting, which is a common procedure in orthopedic surgery.18 We do not believe that costochondral autograft harvesting is more risky or more damaging than iterative tendon harvesting. Joint restoration using costochondral autograft is not new. It has been used for years in maxillofacial surgery,19 –21 and, more recently, it has been used in hand surgery. Hasegawa and Yamano22 published a series in which they used a costochondral autograft to restore the proximal interphalangeal joint. Sandow23 published a series in which he used a costochondral autograft to restore the proximal scaphoid. More specifically, it has been used in primary thumb trapeziometacarpal arthroplasty (for osteoarthritis), first as autograft,2 and then as allograft.4 The follow-up period was short (1 year for Tropet et al3 and 4 years for Trumble et al4), but this technique seems to provide satisfactory results. Our aim was to assess the outcome of costochondral autograft as a revision arthroplasty after trapeziectomy failure. Although allograft may be used to avoid the donor harvest, we chose autograft because allograft availability is poor in France. The outcome assessment was based on the evaluation method of Connolly and Rath,9 as it was performed in the series of Cooney et al.10 Criteria for inclusion were chosen to minimize patient heterogeneity. This is why we chose to include only patients who had a specific procedure: a trapeziectomy without soft-tissue interposition and with a suspensionplasty using half of the abductor pollicis longus. This does not mean that in our experience patients who had an interposition procedure in addition to the trapeziectomy never needed a salvage procedure. Similarly, in our experience, if a trapeziectomy with interposition failed, a revision procedure using costochondral autograft was possible without any additional difficulty. Another type of suspensionplasty (ie, extensor carpi radialis longus or flexor carpi radialis suspensionplasty) performed previously, or no ligament reconstruction at all, also would be acceptable for this procedure to be performed. Nevertheless, we chose to limit our study to a homogenous group of patients who had a salvage procedure using costochondral autograft after a failed trapeziectomy with ligament reconstruction using half of the abductor pollicis longus. Our results do not compare favorably with those published by Cooney et al.10 We reported 1 case of iatrogenic injury of the sensory branch of the radial nerve. This rate compares with the rate reported by Renfree and
Dell.8 In the technique we reported in the present study, no additional ligamentoplasty was performed because the ligament reconstruction was performed during the initial procedure. We reported no case of immediate postoperative intrathoracic complication (pneumothorax or hemothorax). Concerning the donor site, no pain (at rest, under stress, or on palpation) or dissatisfaction with the cosmetic result was noted in any patient at follow-up evaluation. The scar was not visible in the standing position because it was placed in the inframammary fold in all patients. Costochondral autograft as a revision procedure after failed trapeziectomy is a reliable procedure. These preliminary outcomes show that the result did not compare favorably with soft-tissue interposition with or without ligament reconstruction. Nevertheless, in case of an iterative procedure, the lack of available soft-tissue material to interpose may lead the surgeon to consider a costochondral autograft. This procedure should be considered as a salvage procedure. Received for publication March 5, 2006; accepted in revised form August 4, 2006. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Dr. Yann Glard, Department of Plastic and Reconstructive Surgery, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A09-0006$32.00/0 doi:10.1016/j.jhsa.2006.08.005
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