Bilateral osteoarthritis of the trapeziometacarpal joint treated by bilateral tendon interposition arthroplasty

B I L A T E R A L O S T E O A R T H R I T I S OF T H E T R A P E Z I O M E T A C A R P A L J O I N T T R E A T E D BY B I L A T E R A L TENDON INTERPOSITION ARTHROPLASTY A. DAMEN, B. VAN DER LEI and P. H. ROBINSON

From the Departments of Plastic, Reconstructive and Hand Surgery, University Hospital, Groningen and the Medical Centre, Leeuwarden, The Netherlands Twenty-four flexor carpi radialis (FCR) tendon interposition arthroplasties of the trapezium for bilateral trapeziometacarpal osteoarthritis were reviewed. Pain was reduced in all cases. Function was improved in all right hands and in 92% of the left hands. FCR tendon interposition arthroplasty for bilateral trapeziometacarpal osteoarthritis yields satisfactory long-term results on both sides. Journal of Hand Surgery (British and European Volume, 1997) 22B: 1 : 96-99

Osteoarthritis of the trapeziometacarpal joint (TMJ) is usually of idiopathic origin, although it can also be caused by rheumatoid arthritis and other connective tissue diseases. It usually affects both hands. Trauma can also cause trapeziometacarpal osteoarthritis and then usually one side is affected. Many surgical procedures have been described for this condition including: ligament reconstruction (Slocum, 1943); arthrodesis (Maller, 1949); excision of the trapezium (Gervis, 1949); resection arthroplasty of the trapezium with either biological (Dell and Muniz, 1987; Froimson, 1970; Robinson et al, 1991) or synthetic material (Creighton et al, 1991; Swanson, 1972); resurfacing arthroplasty for either the metacarpal or trapezium articular surface with biological (Patterson, 1933) or synthetic material (Kessler and Axer, 1971); joint replacement arthroplasty (de la Caffinibre and Aucouturier, 1979; Ferrari and Steffee, 1986); ligament reconstruction and tendon interposition (Burton and Pelligrini, 1986); tendon suspension sling arthroplasty (Kleinman and Eckenrode, 1991; Necking and Eiken, 1986; Sigfusson and Lundborg, 1991); stabilized resection arthroplasty (Uriburu et al, 1992); and other techniques (Harrison, 1976; Wilson, 1973). Most authors use the same surgical technique for osteoarthritis of the TMJ for either the dominant or non-dominant hand. However, it is questionable if the same operation is indicated for both hands. Stark et al (1977) stated that if both thumbs were involved and needed surgery, they often fused the TMJ of the dominant thumb and performed an interposition arthroplasty of the TMJ of the other thumb. This combination would result in a strong and stable thumb in the dominant hand and one with good mobility in the non-dominant hand. However, we have always treated bilateral trapeziometacarpal osteoarthritis with bilateral FCR tendon interposition arthroplasty. It was the purpose of this study to evaluate our long-term results in bilateral FCR tendon interposition arthroplasties of the trapezium.

of persistent pain of both trapeziometacarpal joints despite conservative therapy in 12 patients. There were 11 women and one man, all right-handed (see Table 1). Seven were housewives. The mean duration of preoperative complaints in the first hand was 82 months (range 9-240). The preoperative treatment consisted of injections with corticosteroids, analgesics and physiotherapy. The average age at the time of the first operation was 58 years (range 46-67). Ten patients already had bilateral complaints at first consultation and the mean interval between the two operations was 22 months (range 2-81). The diagnosis was primary osteoarthritis in 11 patients and rheumatoid arthritis in one patient (patient 12, Table 1). The mean follow-up after the first operation was 105 months (range 24 213) and the mean follow-up after the second operation was 83 months (range 15-211). Postoperative evaluation comprised both subjective and objective criteria including pain level, the ability to perform activities of daily living, the patient's opinion about cosmetic appearance and overall satisfaction with the surgical procedure. Palmar abduction, radial abduction, opposition, tip pinch, lateral pinch and grip strength were measured. Pinch strengths were recorded with a Preston pinch meter and grip strength with a Jamar dynamometer according to the protocol described by Mathiowetz et al (1984). The mean value of three measurements of each hand was recorded. The handle position was adapted to the most suitable for the subject. X-rays were taken to measure the distance between the scaphoid and base of the first metacarpal bone. Surgical technique

A modification of the procedure as originally described by Froimson (1970) was used. A straight incision is made in the anatomical snuffbox with an extension towards the radial side of the base of the first metacarpal. Care is taken not to damage branches of the radial nerve and the radial artery. The capsule is incised longitudinally and reflected by sharp dissection from the base of the first metacarpal. After exposure, the trapezium is excised in pieces or en bloc, dissecting close to the bone to prevent damage

PATIENT AND M E T H O D S

In the period of 1974 to 1991 we have carried out bilateral FCR tendon interposition arthroplasty because 96

TENDON ARTHROPLASTYFOR BILATERALTMJ OA

97

Table 1--Patient details Patient

Occupation

1 2 3 4 5 6 7 8 9 10 11 12

Housewife Housewife Hairdresser Clerk Seamstress Housewife Nurse Housewife Nurse Housewife Housewife Housewife

Hand operated frst

Duration of preoperative complaints (months)

Left Right Right Right Left Right Left Right Right Left Left Right

72 48 24 48 12 120 9 48 24 240 60 67

to the F C R t e n d o n which is l o c a t e d in the g r o o v e o f the t r a p e z i u m . O n e has to m a k e sure t h a t the w h o l e t r a p e z i u m a n d all o s t e o p h y t e s a r e r e m o v e d . A distally b a s e d l o n g i t u d i n a l slip o f the F C R t e n d o n , 10 to 12 c m in length is then taken, rolled into a ball, fixed with r e s o r b a b l e suture a n d is then inserted into the space o f the excised t r a p e z i u m (the so-called " a n c h o v y o p e r a t i o n " ) . The p r o c e d u r e is c o m p l e t e d b y deep soft tissue closure with a b s o r b a b l e sutures a n d skin closure with nylon. T h e o p e r a t i o n takes on average a b o u t 40 to 45 min. T h e t h u m b is i m m o b i l i z e d in p l a s t e r o f P a r i s in a b d u c t i o n a n d o p p o s i t i o n for a p e r i o d o f 6 weeks. T h e n the p a t i e n t starts active excercises b u t still wears a n i g h t splint for the next 6 weeks.

Fig 1

Age at first operation (years)

Follow-up after first operation (months)

Interval (months)

213 158 145 134 128 118 90 86 79 43 40 24

2 28 24 15 13 81 18 6 2 7 6 9

58 46 52, 58 j 55 57 54 62 62 66 54 67

RESULTS

Subjective opinion (Table 2) Pain C o m p a r e d with the p r e o p e r a t i v e s i t u a t i o n all patients c o n s i d e r e d t h a t the p a i n was r e d u c e d after the o p e r a t i o n on b o t h hands. H o w e v e r , in seven o f the 24 h a n d s some residual p a i n was felt.

Function A l l patients went b a c k to their f o r m e r activities.

X-ray of patient 6. She considered the overall result of her right hand to be unsatisfactory because pain recurred 9 years after operation.

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T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 1 FEBRUARY 1997

Appearance All hands were considered to have a good cosmetic appearance.

Overall result The results in 17 hands were very satisfactory. Only one patient (number 6) considered the overall result of her right hand to be unsatisfactory, ten years after operation. At first she was very content with the result but after 9 years the pain had recurred (Fig 1). None of the patients had noticed a reduction in the length of the thumb. All would be prepared to undergo the same surgical procedure again and would advise others to do so. The overall end result was reached after an average period of 10 months (range 3-60).

Objectivefindings (Table 3)

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to% t¢'5 t'M

All could adduct the thumb against the second metacarpal and in all but two hands it was possible to oppose the top of the thumb to the head of the fifth metacarpal bone. The range of movements and grip strengths are given in Table 3. All patients could lay their hands flat on a table. None of them had hypertrophic scarring or symptoms suggestive of a neuroma. X-rays showed that the distance between the scaphoid and the base of the first metacarpal bone averaged 5.5 mm (range 4-9 mm) on the right side and 5.7 mm (range 4-8 mm) on the other side. Bony contact was never observed.

Complications There were two cases of sympathetic reflex dystrophy and both were successfully treated. In one case the dorsal branch of the radial artery was accidentally divided and ligated without any sequelae. DISCUSSION

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I

The present study of patients with bilateral ostcoarthritis of the TMJ demonstrates that resection of the trapezium and FCR tendon interposition arthroplasty in both hands yields satisfactory results independent of hand dominance. Stark et al (1977) stated that fusion of the TMJ is especially suited for persons who want a strong and painless thumb. If both thumbs are to be operated on because of osteoarthritis of the TMJ, they recommended a fusion of the dominant thumb and an interpositional arthroplasty for the non-dominant side in active patients. They noted that in less demanding patients an interpositional arthroplasty on both sides could be sufficient. We have performed bilateral interposition arthroplasties in all cases with satisfactory results. Comparing the dominant right hand with the left one

TENDON ARTHROPLASTY FOR BILATERAL TMJ OA

99

Table 3--Overall objective results (range)

Hand

Palmarabduction

Radialabduction

Tip pinch (kg)

Lateralpinch (kg)

Gripstrength (kg)

Distancebetween scaphoid and metacarpal (mm)

40 ( 2 8 - 5 5 ) ° 43 ( 2 6 - 5 5 ) °

42 ( 3 0 - 6 0 ) ° 41 ( 3 0 - 6 0 ) °

3.5 (1.8 5.1) 2.9 ( 1 . 0 - 4 . 9 )

4.6 (3.1 5.8) 4.3 ( 1 . 6 - 6 . 5 )

23 ( 1 4 - 3 2 ) 21 ( 8 - 3 5 )

5.5 ( 4 - 9 ) 5.7 ( 4 - 8 )

R L

the subjective results (Table 2) in both hands are comparable, except that in the right hand there was some residual pain. This could be associated with more strenuous activities using the dominant hand. Comparing the objective results of both hands (Table 3), there is no essential difference in mobility. Comparing the strength of both hands with the normative data established by Mathiowetz et al (1985) in healthy individuals, it is quite clear that the pinch strength was reduced. The grip strength was less affected by the operation in our patients. References Burton R, Pelligrini VD (1986). Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty. Journal of Hand Surgery, 11A: 324-332. Caffini~re de la JY, Aucouturier P (1979). Trapeziometacarpal arthrop|asty by total prosthesis. The Hand, 11 : 41 46. Creighton J J, Steichen JB, Strickland JW ( 1991 ). Long-term evaluation of silastic trapezial arthroplasty in patients with osteoarthritis. Journal of Hand Surgery, 16A: 510-519. Dell PC, Muniz RB (1987). Interposition arthroplasty of the trapeziometacarpal joint for osteoarthritis. Clinical Orthopaedics and Related Research, 220: 27-34. Ferrari B, Steffee AD (1986). Trapeziometacarpal total joint replacement using the Steffee prosthesis. Journal of Bone and Joint Surgery, 68A: 1177 1184. Froimson AI (1970). Tendon arthroplasty of the trapeziometacarpal joint. Clinical Orthopaedics and Related Research, 70: 191-199. Gervis WH (l 949). Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint. Journal of Bone and Joint Surgery, 31B: 537-539. Harrison SH (1976). The bypass operation for arthritis at the first carpometacarpal joint. The Hand, 8: 145-149. Kessler I, Axer A (1971). Arthroplasty of the first carpometacarpal joint with a silicone implant. Plastic and Reconstructive Surgery, 47 : 252-257. Kleinman WB, Eckenrode JF (1991). Tendon suspension sling arthroplasty

for thumb ~rapeziometacarpal arthritis. Journal of Hand Surgery, 16A: 983-991. Mathiowetz V, Weber K, Volland G, Kashman N (1984). Reliability and validity of grip and pinch strength evaluations. Journal of Hand Surgery, 9A: 222 226. Mathiowetz V, Kashman N, Volland G, Weber K, Dowe M, Rogers S (1985). Grip and pinch strength : Normative data for adults. Archives of Physical Medicine and Rehabilitation, 66: 69-74. M011er GM (1949). Arthrodesis of the trapeziometacarpal joint for osteoarthritis. Journal of Bone and Joint Surgery, 31B: 540 542. Necking LE, Eiken O (I986). ECRL-strip plasty for metacarpal base fixation after excision of the trapezium. Scandinavian Journal of Plastic, Reconstructive and Hand Surgery, 20 : 229-234. Patterson R (1933). Carpometacarpal arthroplasty of the thumb. Journal of Bone and Joint Surgery, 15: 240-241. Robinson D, Aghasi M, Halperin N (1991). Abductor pollicis longus tendon arthroplasty of the trapeziometacarpal joint : Surgical technique and results. Journal of Hand Surgery, 16A: 504-509. Sigfusson R, Lundborg G (1991). Abductor pollicis longus tendon arthroplasty for treatment of arthrosis in the first carpometacarpal joint. Scandinavian Journal of Plastic, Reconstructive and Hand Surgery, 25 : 73 77. Slocum DB (1943). Stabilization of the articulation of the greater multangular and the first metacarpal. Journal of Bone and Joint Surgery, 25 : 626-630. Stark HH, Moore JF, Ashworth CR, Boyes JH (1977). Fusion of the first metacarpotrapezial joint for degenerative arthritis. Journal of Bone and Joint Surgery, 59A: 22 26. Swanson AB (1972). Disabling arthritis at the base of the thumb. Journal of Bone and Joint Surgery, 54A: 456-471. Uriburu IJ, Olazfibal AE, Ciaffi M (1992). Trapeziometacarpal osteoarthritis: Surgical technique and results of"stabilized resection-arthroplasty". Journal of Hand Surgery, 17A: 598-604. Wilson JN (1973). Basal osteotomy of the first metacarpal in the treatment of arthritis of the carpometacarpal joint of the thumb. British Journal of Surgery, 6 0 : 8 5 4 858. Received: 1 August 1995 Accepted after revision: 23 August 1996 A. Damen MD, Department of Plastic, Reconstructiveand Hand Surgery,UniversityHospital Groningen, PO box 30.001, 9700 RB Groningen, The Netherlands. © 1997 The British Societyfor Surgery of the Hand