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Compression arthrodesis of the thumb
Compression arthrodesis of the thumb A retrospective study of all patients who had undergone thumb arthrodeses at the Denver Orthopedic Clinic since 1972 was undertaken to determine the incidence of satisfactory results with the Micks External Compression Fixator. Sixty-six patients underwent 82 metacarpophalangeal or interphalangeal arthrodeses that resulted in bony fusion in 81 cases. Indications for surgery included pain, instability, and collapse-type thumb deformity. Complications in the 81 successful cases included three that required a second procedure, one for nonunion and two for loss of position. There were eight cases of pin track drainage that cleared with removal of the device and did not adversely influence the outcome. Joints arthrodesed with external compression formed bony union in approximately half the time required for bony unions with Kirschner wire fixation. The fused position of either metacarpophalangeal or interphalangeal joints did not influence patient satisfaction, and all patients were satisfied with their surgery and demonstrated satisfactory use of the thumb. (J HAND SURG 8:207-10, 1983.)
Donald C. Ferlic , M.D. , Barry D. Turner, M.D., and Mack L. Clayton , M.D., Denver, Co/a. , and Leawood, Kan. The multiplicity of methods used to obtain thumb fusion indicates the lack of an ideal operation . Several authors have reported 91 % to 100% successful long fusion rates regardless of the method employed. I - 3 Lister l reported a 100% fusion rate in fi ve interphalangeal (lP) and four metacarpophalangeal (MP) arthrodeses with an intraosseous wiring technique. Brumfield and Conaty4 reported an 80% fusion rate (74 of 92) at the MP joint with crossed Kirschner wires for fixation, and Beckenbaugh5 reported a 100% fusion rate in 36 arthrodeses with the same technique . Harrison et al. 6 used polypropylene peg fixation and reported an 85% fusion rate (85 of 1(0) in the thumb MP joint and a 57% fusion rate (eight of 14) in the thumb IP joint; the arthrodeses that did not form bony union proceeded to stable, pain-free fibrous union. Other methods have been used to gain solid bony fusion . Moberg 3 and Potenza7 used bone grafts. Wexler et al. 8 used rubber band compression with anteriorlyposteriorly placed Kirschner wires. In 1972 Tupper9 developed a small compression arthrodesis device designed to be implanted beneath the skin. In 1968 Micks and Hager! Odemonstrated the Micks External Compression Fixator (MECF), a small compression device that accelerates small joint fusion. They did not separate finger from thumb joint fusions
but reported an average of 7 weeks for bony fusion versus 141/2 weeks for arthrodeses fixed with multiple Kirschner wires. In 1979 Leonard and Capen l ! reported on 21 thumb joint arthrodeses (14 MP and seven IP) accomplished with the MECF. Twenty of these arthrodeses proceeded to bony union, which was usually attained in 6 weeks.
From the Denver Orthopedic Clinic, Denver , Colo .
A longitudinal skin incision is made directly over the dorsum of the joint. In the case of the MP joint, the extensor pollicis longus is separated from the extensor pollicis brevis . The joint is then entered, and the soft
Received for publication Jan . 7, 1982. Reprint requests: Donald C. Ferlic , M.D .. Denver Orthopedic Clinic, 2005 Franklin SI. , Denver , CO 80205 .
Material and methods We reviewed all patients who had undergone thumb arthrodeses at the Denver Orthopedic Clinic since 1972 to determine the incidence of satisfactory results with the MECF (Fig. 1). Indications for surgery included pain, instability, and collapse-type thumb deformity . We then attempted to correlate the angle of fusion with the functional result. This series included 66 patients who underwent a total of 82 arthrodeses (69 MP and 13 IP fusions). The average patient age was 44 years (ranging from 15 to 88) . The patients were followed up until the outcomes of the arthrodeses were known. Fifty-five patients were afflicted with rheumatoid disease, four with posttraumatic degenerative arthritis , one with arthrogryposis, one with lupus erythematosus, three with osteoarthritis, and two with cerebral palsy .
Technique
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Fig. 1. A, Micks External Compression Fixator. B, X-ray film of thumb fused with compression clamp in place.
pass the wire at a point midway from palmar to dorsal at the interface so that the compression force will not tend to angulate the fusion site (Fig. 2). The compression clamp is then applied. A longitudinal Kirschner is usually passed across the joint to prevent palmar or dorsal angulation because it is difficult to measure the exact center in these small bones. Soft tissues and skin are closed. No other postoperative immobilization is necessary , and the compression clamp is removed when bony union is present, usually at 6 weeks. The preferred position for the IP joint ranged from 0° to 15° of flexion . The MP joints were fused in positions varying from 0° to 40° of flexion.
Results Fig. 2. Kirschner wires should be placed midway between palmar and dorsal cortices measured at cut surface to provide maximum stability (left). If wires are placed too far palmarward, palmar angulation may result (middle) . If placed too far dorsally, forces will dorsally angulate arthrodesis (right) .
tissue attachments are released around the joint surfaces, including the collateral ligament origins. The reciprocating power saw is used to resect the joint surfaces at the desired angle. No. 0.062 Kirschner wires are then passed perpendicularly across the shafts of both bones with a mini power driver. Care is taken to
Sixty-six patients with 82 arthrodeses obtained solid bony fusion in 81 of these cases. However, three patients required a second operation to obtain solid union. One patient with a longitudinal stabilizing wire required readjustment of the MECF as the joint gradually slipped into more flexion. The arthrodesis proceeded to bony union 6 weeks after the initial operation and obtained satisfactory thumb function with a fusion angle at 35°. Another patient proceeded to nonunion , and a second operative procedure with bone graft and reinsertion of compression clamps was done and resulted in solid bony fusion (Fig. 3). The third patient went into
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Fig. 3. This patient appeared to be progressing to union as expected but developed pain after 3 months. Repeat fusion was necessary to obtain union. A, Two months postoperatively. Union appears to be satisfactory. B, Three months postoperatively showing nonunion. C, Six months after repeated arthrodesis showing solid union.
hyperextension with delayed union (Fig. 4), and the arthrodesis was redone. It resulted in solid bony fusion after 6 weeks. One 65-year-old rheumatoid patient developed a pseudoarthrosis in spite of 12 weeks of total fixation time because the compression pin was placed too close to the joint and allowed the wire to cut into the joint and loosen fixation and compression (Fig. 5). This resulted in a pain-free, functionally placed fibrous ankylosis. All patients were satisfied with their operations and demonstrated satisfactory use of the thumb. There were eight cases of pin track drainage, and all resolved with removal of the fixation device. One pin track culture grew out Staphylococcus aureus. In addition to removal of the device, the patient was started on cephalosporin therapy. The arthrodesis was splinted externally for another 3 weeks and proceeded to bony union without further sequelae. There was one case of delayed union in which the MP joint took 10 weeks to fuse radiographically.
Discussion Compression is a proven technique for obtaining fusion in large joints where an external fixation device may be used or as an aid in obtaining union in long bone fractures. Several authors have emphasized the importance of compression in the treatment of fractures and joint arthrodeses in the small bones and joints of
Fig. 4. X-ray film showing loss of position with compression clamps due to placement of wires too far dorsally, as depicted in Fig. 2, drawing on right.
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Fig. 5. Attempted arthrodesis of IP joint that went into nonunion in 65-year-old woman with rheumatoid arthritis . A, Preoperative. B, Pin placement too close to joint. C, End result: Lack of bony fusion.
the hand. 1. 8- 11 Leonard and Capen II reported an average time of 6lh weeks to bony fusion with the MECF. Micks and HagerlO cited an average time of 7 weeks to bony fusion with the MECF but reported an average of 14Y2 weeks for bony fusion in arthrodeses transfixed with multiple Kirschner wires. Brumfield and Conaty4 and Beckenbaugh5 likewise reported a l2-to-l6-week period for bony fusion with crossed Kirschner wires used for internal fixation. Micks* demonstrated that the MECF exerts compressive forces throughout the entire treatment period. Roentgenograms taken both prior to and after compression clamp removal show that the pins that were bowed prior to removal straightened out immediately after clamp removal. Micks emphasized that pin placement is critical to prevent bowing and flexion deformities at the arthrodesis site. On the lateral view the line formed between the two pin sites should be placed so that it falls in line with the axis of the arthrodesis. Proper pin placement may preclude the need for a longitudinal Kirschner wire for stabilization. However, in the very small bones and in rheumatoid arthritics it may be difficult to get the exact pin placement, and a longitudinal Kirschner wire is a very effective method to prevent angulation . Furthermore, correct pin placement ensures that equal compressive forces are exerted on all portions of the resected articulating surfaces . • Micks JE: Personal communication, 1981.
REFERENCES I. Lister G: lntraosseous wiring of the digital skeleton . J HAND SURG 3:427-35, 1978 2. Carroll RE, Hill NA: Small joint arthrodesis in hand reconstruction. J Bone Joint Surg [Am] 51 : 1219-21, 1969 3. Moberg E: Arthrodesis of finger joints . Surg Clin North Am 40:465-70, 1960 4. Brumfield RH, Conaty JP: Reconstructive surgery of the thumb in rheumatoid arthritis . Orthopedics 3:529-33, 1980 5. Beckenbaugh RD: Arthrodesis of the metacarpophalangeal joint of the thumb . Orthop Trans 4:291 , 1980 6. Harrison S, Smith P, Maxwell D: Stabilization of the first metacarpophalangeal and terminal joints of the thumb. Hand 9:242-9 , 1977 7. Potenza AD: A technique for arthrodesis of finger joints. J Bone Joint Surg 55: 1534-6, 1973 8. Wexler MR, Rousso M, Weinberg H: Arthrodesis of finger joints by dynamic external compression. Plast Reconstr Surg 60:882, 1977 9. Tupper JW: A compression arthrodesis device for small joints of the hand . Hand 4:62-4, 1972 10. Micks JE , Hager DL: Exhibit. A method of accelerating fusion of small joints. J Bone Surg [Am] 50: 1269 , 1968 II. Leonard MH, Capen DA: Compression arthrodesis of finger joints. Clin Orthop 145: 193-8, 1979
Donald C. Ferlic , M.D. , Barry D. Turner, M.D., and Mack L. Clayton , M.D., Denver, Co/a. , and Leawood, Kan. The multiplicity of methods used to obtain thumb fusion indicates the lack of an ideal operation . Several authors have reported 91 % to 100% successful long fusion rates regardless of the method employed. I - 3 Lister l reported a 100% fusion rate in fi ve interphalangeal (lP) and four metacarpophalangeal (MP) arthrodeses with an intraosseous wiring technique. Brumfield and Conaty4 reported an 80% fusion rate (74 of 92) at the MP joint with crossed Kirschner wires for fixation, and Beckenbaugh5 reported a 100% fusion rate in 36 arthrodeses with the same technique . Harrison et al. 6 used polypropylene peg fixation and reported an 85% fusion rate (85 of 1(0) in the thumb MP joint and a 57% fusion rate (eight of 14) in the thumb IP joint; the arthrodeses that did not form bony union proceeded to stable, pain-free fibrous union. Other methods have been used to gain solid bony fusion . Moberg 3 and Potenza7 used bone grafts. Wexler et al. 8 used rubber band compression with anteriorlyposteriorly placed Kirschner wires. In 1972 Tupper9 developed a small compression arthrodesis device designed to be implanted beneath the skin. In 1968 Micks and Hager! Odemonstrated the Micks External Compression Fixator (MECF), a small compression device that accelerates small joint fusion. They did not separate finger from thumb joint fusions
but reported an average of 7 weeks for bony fusion versus 141/2 weeks for arthrodeses fixed with multiple Kirschner wires. In 1979 Leonard and Capen l ! reported on 21 thumb joint arthrodeses (14 MP and seven IP) accomplished with the MECF. Twenty of these arthrodeses proceeded to bony union, which was usually attained in 6 weeks.
From the Denver Orthopedic Clinic, Denver , Colo .
A longitudinal skin incision is made directly over the dorsum of the joint. In the case of the MP joint, the extensor pollicis longus is separated from the extensor pollicis brevis . The joint is then entered, and the soft
Received for publication Jan . 7, 1982. Reprint requests: Donald C. Ferlic , M.D .. Denver Orthopedic Clinic, 2005 Franklin SI. , Denver , CO 80205 .
Material and methods We reviewed all patients who had undergone thumb arthrodeses at the Denver Orthopedic Clinic since 1972 to determine the incidence of satisfactory results with the MECF (Fig. 1). Indications for surgery included pain, instability, and collapse-type thumb deformity . We then attempted to correlate the angle of fusion with the functional result. This series included 66 patients who underwent a total of 82 arthrodeses (69 MP and 13 IP fusions). The average patient age was 44 years (ranging from 15 to 88) . The patients were followed up until the outcomes of the arthrodeses were known. Fifty-five patients were afflicted with rheumatoid disease, four with posttraumatic degenerative arthritis , one with arthrogryposis, one with lupus erythematosus, three with osteoarthritis, and two with cerebral palsy .
Technique
THE JOURNAL OF HAND SURGERY
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Fig. 1. A, Micks External Compression Fixator. B, X-ray film of thumb fused with compression clamp in place.
pass the wire at a point midway from palmar to dorsal at the interface so that the compression force will not tend to angulate the fusion site (Fig. 2). The compression clamp is then applied. A longitudinal Kirschner is usually passed across the joint to prevent palmar or dorsal angulation because it is difficult to measure the exact center in these small bones. Soft tissues and skin are closed. No other postoperative immobilization is necessary , and the compression clamp is removed when bony union is present, usually at 6 weeks. The preferred position for the IP joint ranged from 0° to 15° of flexion . The MP joints were fused in positions varying from 0° to 40° of flexion.
Results Fig. 2. Kirschner wires should be placed midway between palmar and dorsal cortices measured at cut surface to provide maximum stability (left). If wires are placed too far palmarward, palmar angulation may result (middle) . If placed too far dorsally, forces will dorsally angulate arthrodesis (right) .
tissue attachments are released around the joint surfaces, including the collateral ligament origins. The reciprocating power saw is used to resect the joint surfaces at the desired angle. No. 0.062 Kirschner wires are then passed perpendicularly across the shafts of both bones with a mini power driver. Care is taken to
Sixty-six patients with 82 arthrodeses obtained solid bony fusion in 81 of these cases. However, three patients required a second operation to obtain solid union. One patient with a longitudinal stabilizing wire required readjustment of the MECF as the joint gradually slipped into more flexion. The arthrodesis proceeded to bony union 6 weeks after the initial operation and obtained satisfactory thumb function with a fusion angle at 35°. Another patient proceeded to nonunion , and a second operative procedure with bone graft and reinsertion of compression clamps was done and resulted in solid bony fusion (Fig. 3). The third patient went into
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Fig. 3. This patient appeared to be progressing to union as expected but developed pain after 3 months. Repeat fusion was necessary to obtain union. A, Two months postoperatively. Union appears to be satisfactory. B, Three months postoperatively showing nonunion. C, Six months after repeated arthrodesis showing solid union.
hyperextension with delayed union (Fig. 4), and the arthrodesis was redone. It resulted in solid bony fusion after 6 weeks. One 65-year-old rheumatoid patient developed a pseudoarthrosis in spite of 12 weeks of total fixation time because the compression pin was placed too close to the joint and allowed the wire to cut into the joint and loosen fixation and compression (Fig. 5). This resulted in a pain-free, functionally placed fibrous ankylosis. All patients were satisfied with their operations and demonstrated satisfactory use of the thumb. There were eight cases of pin track drainage, and all resolved with removal of the fixation device. One pin track culture grew out Staphylococcus aureus. In addition to removal of the device, the patient was started on cephalosporin therapy. The arthrodesis was splinted externally for another 3 weeks and proceeded to bony union without further sequelae. There was one case of delayed union in which the MP joint took 10 weeks to fuse radiographically.
Discussion Compression is a proven technique for obtaining fusion in large joints where an external fixation device may be used or as an aid in obtaining union in long bone fractures. Several authors have emphasized the importance of compression in the treatment of fractures and joint arthrodeses in the small bones and joints of
Fig. 4. X-ray film showing loss of position with compression clamps due to placement of wires too far dorsally, as depicted in Fig. 2, drawing on right.
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The Journal of HAND SURGERY
Ferlic et al.
Fig. 5. Attempted arthrodesis of IP joint that went into nonunion in 65-year-old woman with rheumatoid arthritis . A, Preoperative. B, Pin placement too close to joint. C, End result: Lack of bony fusion.
the hand. 1. 8- 11 Leonard and Capen II reported an average time of 6lh weeks to bony fusion with the MECF. Micks and HagerlO cited an average time of 7 weeks to bony fusion with the MECF but reported an average of 14Y2 weeks for bony fusion in arthrodeses transfixed with multiple Kirschner wires. Brumfield and Conaty4 and Beckenbaugh5 likewise reported a l2-to-l6-week period for bony fusion with crossed Kirschner wires used for internal fixation. Micks* demonstrated that the MECF exerts compressive forces throughout the entire treatment period. Roentgenograms taken both prior to and after compression clamp removal show that the pins that were bowed prior to removal straightened out immediately after clamp removal. Micks emphasized that pin placement is critical to prevent bowing and flexion deformities at the arthrodesis site. On the lateral view the line formed between the two pin sites should be placed so that it falls in line with the axis of the arthrodesis. Proper pin placement may preclude the need for a longitudinal Kirschner wire for stabilization. However, in the very small bones and in rheumatoid arthritics it may be difficult to get the exact pin placement, and a longitudinal Kirschner wire is a very effective method to prevent angulation . Furthermore, correct pin placement ensures that equal compressive forces are exerted on all portions of the resected articulating surfaces . • Micks JE: Personal communication, 1981.
REFERENCES I. Lister G: lntraosseous wiring of the digital skeleton . J HAND SURG 3:427-35, 1978 2. Carroll RE, Hill NA: Small joint arthrodesis in hand reconstruction. J Bone Joint Surg [Am] 51 : 1219-21, 1969 3. Moberg E: Arthrodesis of finger joints . Surg Clin North Am 40:465-70, 1960 4. Brumfield RH, Conaty JP: Reconstructive surgery of the thumb in rheumatoid arthritis . Orthopedics 3:529-33, 1980 5. Beckenbaugh RD: Arthrodesis of the metacarpophalangeal joint of the thumb . Orthop Trans 4:291 , 1980 6. Harrison S, Smith P, Maxwell D: Stabilization of the first metacarpophalangeal and terminal joints of the thumb. Hand 9:242-9 , 1977 7. Potenza AD: A technique for arthrodesis of finger joints. J Bone Joint Surg 55: 1534-6, 1973 8. Wexler MR, Rousso M, Weinberg H: Arthrodesis of finger joints by dynamic external compression. Plast Reconstr Surg 60:882, 1977 9. Tupper JW: A compression arthrodesis device for small joints of the hand . Hand 4:62-4, 1972 10. Micks JE , Hager DL: Exhibit. A method of accelerating fusion of small joints. J Bone Surg [Am] 50: 1269 , 1968 II. Leonard MH, Capen DA: Compression arthrodesis of finger joints. Clin Orthop 145: 193-8, 1979