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Effect of Partial and Complete Trapezoid Excision on Radiographic and Functional Results After Abductor Pollicis Longus Suspensionplasty
SCIENTIFIC ARTICLE
Effect of Partial and Complete Trapezoid Excision on Radiographic and Functional Results After Abductor Pollicis Longus Suspensionplasty Kevin J. Renfree, MD,* Ryan Odgers, MD,† Cody Tillinghast, MD,‡ Nan Zhang, MS*
Purpose We hypothesized that adding complete or partial trapezoid excision is associated with greater radiographic carpal collapse and worse functional outcomes compared with a simple trapeziectomy and abductor pollicis longus suspensionplasty.
Methods A total of 69 patients had abductor pollicis longus suspensionplasty (79 hands), 87% of whom were female, mean age 64 years. Scaphotrapezium-trapezoid arthritis noted at surgery was treated with an additional proximal trapezoid excision (PT) in 21 (27%) or complete trapezoid resection (CT) in 22 hands (28%). No trapezoid was excised in 36 hands. The primary outcome was final radiolunate (RL) extension of 15 or greater on lateral radiographs. Logistic regression (for change in RL angle) and linear regression (for continuous variables) with robust variance estimate to account for within-subject correlation (generalized estimating equation method) were used to investigate whether the trapezoid excision groups had an effect on the outcomes of interest. Models were adjusted for age and sex. Results Median follow-up was 92 months. Complete trapezoid resection had the most increase in RL angle,
but PT had a higher incidence (29% vs 26%) of final RL angle of 15 or greater compared with CT. When stratified into groups with a final RL greater than or less than 15 , the former group had worse total function (Patient-Rated Wrist Evaluation) and QuickeDisabilities of the Arm, Shoulder, and Hand scores. Symptomatic index metacarpal migration was seen in 4 CT and 2 PT wrists (18% and 10%, respectively) and was considered to indicate failure.
Conclusions Compared with no trapezoid excised, both PT and CT had a greater incidence of lunate
extension of 15 or greater, consistent with radiographic nondissociative-dorsal intercalated carpal instability, which was associated with inferior functional scores. Symptomatic proximal collapse of the index metacarpal was seen in both CT and PT. Further studies should evaluate whether routine excision of the proximal trapezoid is necessary for scaphotrapezoid arthritis, because any disruption of the scaphotrapezoid ligament complex appears to increase risk for developing carpal instability nondissociative-dorsal intercalated carpal instability over time and may be associated with inferior functional results. Complete trapezoid excision is not recommended. (J Hand Surg Am. 2019;-(-):1.e1-e9. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV. Key words Arthritis, outcomes, thumb, trapeziectomy, trapezoid.
From the *Department of Orthopaedic Surgery, Mayo Clinic Arizona; and †Hand Surgery Private Practice, Phoenix, AZ; and the ‡Department of Orthopaedic Surgery, University of Texas, Houston, TX. Received for publication February 6, 2018; accepted in revised form October 11, 2019.
Corresponding author: Kevin J. Renfree, MD, Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.10.006
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2019 ASSH
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Published by Elsevier, Inc. All rights reserved.
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arthritis is seen in 50% to 60% of patients undergoing basal joint arthroplasty1,2 and is thought to be a potential cause of persistent pain if left untreated.3,4 Resection of the proximal trapezoid1,2,5 or distal pole of the scaphoid6 is often recommended. Neither has been proven to have a negative effect on the clinical results of nonimplant arthroplasty. 1,2,7 Outcome studies comparing cases with and without trapezoid excision are lacking, especially with respect to radiographic carpal alignment and function. There may be cause for concern, though, because Rectenwald et al8 reported symptomatic carpal instability nondissociativedorsal intercalated carpal instability (CIND-DISI) in 2 of 55 patients (4%) after trapeziectomy and partial trapezoid excision. The authors hypothesized that this might have resulted from the amount of trapezoid excised. The volar scaphotrapezium-trapezoid (STT) and dorsal intercarpal (DIC) ligament complexes are thought to be important secondary stabilizers of the lunate; their disruption or attenuation leads to DISI as part of a progressive injury spectrum after traumatic disruption of the scapholunate interosseous ligament. Trapeziectomy alone can disrupt the STT ligamentous complex enough to produce CINDDISI. 9,10 Garcia-Elias et al 6 reported that distal scaphoid excision may produce a similar radiographic pattern, as did another study,11 particularly when the resection height exceeded 3 mm of distal scaphoid. A biomechanical study questioned whether the remaining capsuloligamentous structures would stabilize the distal scaphoid adequately after disruption of the scaphotrapezial ligament,12 and advanced STT arthritis with erosion of the distal scaphoid and loss of integrity of the STT ligament complex can also be associated with carpal instability.13 Anatomic studies demonstrated that the DIC ligament inserts distally on the dorsal surfaces of the trapezium and trapezoid, and therefore is at risk for disruption or attenuation with excision of these bones.14e16 No clear guidelines exist regarding the amount of trapezoid that can be safely excised when scaphotrapezoid arthritis is identified. Recommendations vary from 2 mm to proximal 50%.2,17 Little is known regarding whether resection is necessary, what stage or severity of arthritic changes, how much resection is needed to prevent future scaphotrapezoid impingement, or whether partial trapezoid excision (PT) or complete trapezoid excision (CT) will destabilize the radial wrist column further.8,17 Our hypothesis was that adding PT and CT to trapeziectomy and abductor pollicis longus suspensionplasty would lead to a more severe radiographic ONCOMITANT SCAPHOTRAPEZOIDAL
J Hand Surg Am.
FIGURE 1: Intraoperative photograph of continued impingement between distal pole of scaphoid (solid black arrow) and remaining trapezoid (solid white arrow) after excision of proximal 50% of trapezoid.
CIND-DISI malalignment and worse functional outcomes and more pain over time, compared with hands in which no trapezoid excision was performed. MATERIALS AND METHODS The institutional review board at the Mayo Clinic approved this retrospective study. We included 69 patients who underwent surgery for basal joint arthritis between 2000 and 2010 (79 hands). Inclusion criteria included patients who were able to be contacted and agreed to return for a clinical and radiographic evaluation, were at least 3 years past the surgical date, and had a trapeziectomy and abductor longus pollicis suspensionplasty, as originally described by Thompson,18 modified only by omitting a temporary transfixing K-wire and interposition material. Excluded patients included those with an infection (n ¼ 1), who were deceased (n ¼ 20), who had moved out of state (n ¼ 13), who were unable to contacted or had an unlisted phone number (n ¼ 14), who were unable to participate owing to health issues (n ¼ 5), or who declined to participate (n ¼ 8). All procedures were performed by the senior author at a single academic tertiary care facility. Sixty of 69 patients were female (87%), mean age 64 years (range, 44e81 years). The dominant hand was involved in 57%; 10 patients had bilateral procedures. Advanced STT arthritis (grade 4 chondromalacia) was noted during surgery in 55%; it was treated with resection of the proximal 50% of the trapezoid (PT) in 21 hands (27%) and CT resection in 22 (28%) for persistent impingement. Because the index metacarpal base is supported by the capitate facet and shares a robust intermetacarpal ligament complex with the middle finger metacarpal,19 we r
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FIGURE 3: M2 is the measured distance between parallel lines from the base of the index finger to the proximal pole of the capitate.
(CHR) was calculated by dividing the carpal height by the middle finger metacarpal as described, by Youm et al.21 To assess for proximal migration of the index metacarpal, we used 2 measurements. The first (M1) measured the distance between parallel lines from the base of the index metacarpal to the distal pole of the scaphoid (Fig. 2), the second (M2) measured the distance between parallel lines from the base of the index metacarpal to the proximal pole of the capitate (Fig. 3). Excluding 4 hands in the CT and one in the PT group that had undergone a salvage procedure for symptomatic index metacarpal migration before patient inclusion in the study, all patients completed the Patient-Rated Wrist Evaluation (PRWE) and QuickeDisability of the Arm, Shoulder, and Hand questionnaire (QuickDASH) outcome measures.22,23 The former is a 15-item questionnaire that allows patients to rate wrist pain and disability from 0 to 10; it consists of 2 subscales: Pain and Function. Each subscale is weighted equally to calculate the total score of 100, with disability increasing proportionally with score. The QuickDASH is a shortened version of the original 30-question DASH outcome measure. Because the second component is an optional sport or music and work module, we used only the first component: the disability and symptom section (11 items, scored 1e5).23 Both instruments have been shown to be responsive, reliable, and valid instruments for pain and function associated with traumatic and nontraumatic conditions involving the hand and wrist.24e27
FIGURE 2: M1 is the measured distance between parallel lines from the base of the index finger to the distal pole of the scaphoid.
excised the entire trapezoid when continued contact of the distal portion of the trapezoid (after proximal resection) and scaphoid was noted with passive range of motion (extension combined with radial deviation) during surgery (Fig. 1). No trapezoid excision was required (NT) in 36 hands (45%) because the scaphotrapezoid joint appeared normal during surgery. An independent observer performed active range of motion measurements of the affected thumbs, as well as grip (Jamar Hydraulic Dynamometer, Patterson Medical, Warrenville, IL) and lateral pinch strength (Jamar Hydraulic Pinch Gauge, Patterson Medical). Preoperative and postoperative grip strengths of affected hands were compared (mean value of 3 attempts used). Radiographs included true posteroanterior and lateral views, with the latter reviewed to ensure that the radiusemiddle finger metacarpal axis was less than 20 .13 Preoperative and final radiographic images from a picture archiving and communication system were compared. A positive angle was defined as extension of the lunate relative to the radius, flexion of the scaphoid relative to the radius, and flexion of the capitate relative to the lunate. Based on previous studies, we defined CIND-DISI as an radiolunate (RL) angle greater than 15 .10,20 Angle measurements were made between the longitudinal axis of the involved bones to the nearest degree using a computerized digital goniometer at 250% magnification. The posteroanterior radiographs were used for the rest of the measurements. Carpal height ratio J Hand Surg Am.
RESULTS Median follow-up was 92 months (quartiles, 57.5e129.5 months). There was no difference r
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LS, least-square.
e6 (e27.18 to 14.85), 17 6 (e10.05 to 23.00), 25 Change in RS angle: LS means (95% CI), total n
e6 (e14.30 to 1.83), 11
10 (3.47 to 16.80), 19
47 (33.40 to 59.60), 17
2 (e3.78 to e6.94), 31
31 (20.35 to 41.61), 25
Change in CL angle: LS means (95% CI), total n
Preoperative RS angle: LS means (95% CI), total n
45 (e1.10 to 10.32), 17
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49 (42.43 to 55.33), 11
8 (2.93 to 12.80), 19
Preoperative CL angle: LS means (95% CI), total n
6 (e8.58 to e20.57), 19
7 (e0.31 to 13.90), 17
e15 (e26.29 to e4.51), 17
e2 (e6.97 to 2.76), 31
e17 (e29.07 to e4.28), 31
Change in RL angle: LS means (95% CI), total n
8 (42), 19
7. (1.93 to 12.79), 19
5 (29), 17
7 (e0.01 to 13.16), 17
4 (13), 31
e1 (e5.43 to 3.69), 31
5 (29), 17 1 (3), 31
Preoperative RL angle: LS means (95% CI), Total N
CL angle > 15 : n (%), total n
RL angle > 15 : n (%), total n
TABLE 1.
Changes in RL, CL, and RS Angles
NT
PT
CT
between the 3 groups with respect to preoperative RL, capitolunate (CL), or radioscaphoid (RS) angles (Table 1). As a whole, CT and PT had greater changes (pre- to postoperative) in RL angle (resulting from increased lunate-proximal carpal row extension), in CL angle (resulting from increased capitate-distal carpal row flexion), and RS angle (resulting from increased scaphoid-proximal carpal row extension) when compared to NT, but not when compared to each other (Fig. 4A, B). A final RL angle of 15 or greater was seen in 1 of 31 NT patients (3%). This percentage was lower than for patients in the PT (5 of 17; 29%) and CT (5 of 19; 26%) groups. A final CL angle of 15 or greater was seen in 4 of 31 (13%) in the NT group. This percentage was lower than for patients in the PT (5 of 17; 29%), and CT (8 of 19; 42%) groups. The CT and PT groups had similar changes (proximal collapse of index metacarpal) from before to after surgery in distances M1 and M2 compared with the NT group; CT demonstrated the greatest change (a decrease) (Table 2). The CT and PT groups had better total pain (PRWE) scores compared with the NT group. The CT and PT groups also had a better functional total (PRWE) score compared with the NT group. QuickDASH scores were lower in the PT and CT groups compared with the NT group (Table 3). No differences were seen in the total pain subscore of the PRWE when patients with an RL angle of 15 or greater (CIND-DISI) were compared with those with less than 15 ; however, the function portions of the PRWE and QuickDASH were worse in wrists with CIND-DISI (RL angle of 15 or greater) (Table 4). There were no differences among the 3 groups when active thumb metacarpophalangeal joint motion, opposition distance from the little finger metacarpophalangeal joint flexion crease, or change in grip and lateral pinch strength of the involved hand was compared. Complication rates were higher in the CT (27%) compared with PT (23%) and NT (16%) groups (Table 5). Secondary procedures were highest in the CT group and involved arthrodesis of the index and middle finger carpometacarpal (CMC) joints in 4 of 22 patients for symptomatic proximal migration of the index metacarpal resulting in arthritis at the index CMC joint (Fig. 5). Another patient had satisfactory pain relief with a corticosteroid injection. Two of 21 patients who had PT also developed symptomatic proximal index metacarpal migration; one underwent an arthrodesis of the index and middle finger CMC joints (Fig. 6) and the other was
5 (26), 19
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Variable
1.e4
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e6 (e8.7 to e3.2), 19 e4.3 (e5.8 to e2.8), 17 e2.4 (e4.6 to e0.2), 29 Change in distance (M1): base index metacarpal migration (collapse) to distal pole scaphoid: LS means, mm (95% CI), total n
e3.1 (e4.1 to e2.1), 19 e1.1 (e1.6 to e0.7) 17 e0.4 (e1.2 to 0.4), 27 Change in distance (M2): base index metacarpal migration (collapse) to capitate: LS means, mm (95% CI), total n
TABLE 2.
DISCUSSION Partial trapezoid excision is a popular procedure when scaphotrapezoid arthritis is identified during basal joint arthroplasty, with the aim of addressing a potential source of persistent pain.1e5,13 There are no clinical guidelines demonstrating how much trapezoid can be safely excised, and little is known about its long-term effects with respect to function and radiographic changes. Studies documented CIND-DISI after simple trapeziectomy or excision of the distal quarter of the scaphoid alone.6,10,13,28 When identified, CIND-DISI has not consistently produced inferior clinical results.6,10,29 Nevertheless, 2 studies reported less satisfaction and higher pain and disability scores with CIND- DISI after simple trapeziectomy.8,10 Therefore, it is possible that disruption of the remaining STT and DIC ligament complexes may occur with additional resection of part or all of the trapezoid, because the latter structure is thought to be an important secondary stabilizer preventing lunate extension and subsequent CIND-DISI.28 This may or may not translate into inferior clinical results. Of 11 wrists with a final RL angle of 15 or greater (CIND-DISI), 4 had PT, 6 had CT, and only
PT
given a corticosteroid injection and declined further treatment.
NT
FIGURE 4: A Preoperative and B postoperative (7.6 years) lateral radiographs demonstrating RL angle in a patient who had complete trapezoid excision (CT).
Variable
Proximal Migration (Collapse) of Index Metacarpal: Comparison of CT and PT With NT
CT
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TABLE 3.
PARTIAL AND COMPLETE TRAPEZOIDECTOMY OUTCOMES
Patient-Rated Wrist Evaluation and QuickDASH Scores: Comparison of CT and PT With NT Variable
NT
Pain total score: LS means (95% CI), total n
PT
CT
9.4 (4.6e14.2), 30
4.4 (1.3e7.6), 16
3.6 (0e7.4), 18
Function total score: LS means (95% CI), total n
15.5 (8.3e22.7), 30
9.7 (3.3e16), 16
5.9 (2.2e14), 18
Total QuickDASH score: LS means (95% CI), total n
19.5 (16.1e22.8), 28
16.2 (13.1e19.3), 19
15.5 (12.2e18.7), 18
LS, least-square.
TABLE 4. Patient-Reported Outcomes Comparison Between RL Angle of Less Than 15 (No CIND-DISI) and Greater Than 15 (CIND-DISI)* Variable Pain total score: LS means (95% CI), total n Function total score: LS means (95% CI), total n Total QuickDASH score: LS means (95% CI), total n
RL Angle < 15
RL angle > 15
5.9 (3.4 to 8.4), 46
2.3 (e5.2 to 9.7), 8
8.9 (5.5 to 12.4), 46
19.4 (2.8 to 36.1), 8
15.5 (13.8 to 17.2), 45
22.6 (16.5 to 28.7), 9
LS, least-square. *All models were adjusted for age and sex.
TABLE 5.
Incidence of Complications Among NT, PT, and CT Groups Complication
Symptomatic proximal collapse index metacarpal
NT (n ¼ 36)
PT (n ¼ 21)
CT (n ¼ 22)
0
2 (10%)
5 (23%)
Secondary excision of trapezoid for scaphotrapezoid impingement or arthritis after suspensionplasty procedure
2 (6%)
2 (10%)
NA
Complex regional pain syndrome
1 (3%)
0
0
Acute carpal tunnel syndrome
1 (3%)
0
0
Painful hardware MCP joint fusion
1 (3%)
1 (5%)
1 (5%)
Other
1 (3%)
0
0
NA, not applicable.
1 had NT. The CT group had a greater change in RL angle (lunate extension) compared with the NT group. Thus, CIND-DISI malalignment was more common and severe after CT and least after NT. These differences may have little meaning because the 95% confidence intervals in these data are wide, suggesting a lack of precision. Yuan et al10 reported a percentage (58%) of stage 4 scaphotrapezoidal arthritis in patients undergoing simple trapeziectomy and ligament reconstruction similar to ours (55%), and a mean postoperative change in RL angle of 4.4 , compared with a mean increase of 11.4 in our study. We suspect that the greater change in RL angle in the current cohort was attributable to either the addition of CT or PT (these patients were excluded in the study of Yuan et al) or a longer length of follow-up.
J Hand Surg Am.
The mean follow-up in the study of Yuan et al was only 10.5 months, compared with 74 months in the current CT group. Our analysis did not find an association between longer postsurgical follow-up and greater change in RL angle, which could be because of the small sample size. However, this suggests that length of follow-up is not a factor and this difference likely resulted from chance. In addition, 39% of wrists with STT arthritis in the study of Yuan et al demonstrated radiographic DISI before surgery, which raises the question whether these patients might have had greater preexisting ligamentous injury compared with patients with isolated basal joint arthritis, thereby making them more susceptible to more frequent and/or severe DISI after trapeziectomy, with or without trapezoid resection.
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FIGURE 6: Arthrodesis of index and middle finger CMC joints in patient shown in Figure 5. FIGURE 5: Symptomatic arthritis between index metacarpal and capitate caused by proximal migration of index metacarpal after complete trapezoid excision (CT).
scores compared with the NT group (Table 3). This could be because of either the interval development of painful scaphotrapezoid arthritis or impingement between the thumb metacarpal and trapezoid in the NT group. However, when comparing subgroups of patients with an RL angle greater than 15 (CINDDISI) with those less than 15 , the former group (CIND-DISI) had worse PRWE total functional and QuickDASH scores (Table 4). Because of the small numbers in each group, however, this may not be clinically significant. Garcia-Elias et al found no correlation between DISI and functional outcome after distal scaphoidectomy; however, no validated patient-rated outcomes measures were used in their study. They theorized that despite DISI, congruency of the RL and RS joints was maintained and that, at least in the short term, degenerative changes in the carpus were not seen.6 No hands in the current CT or PT groups developed degenerative carpal changes with a much longer mean follow-up (96 vs 29 months). The results of our study seem to support those of Yuan et al, that a CIND-DISI radiographic pattern after a trapeziectomy procedure may be associated with inferior function. Nevertheless, a small sample size introduces potential bias, and therefore further study is required. Our opinion is that additional excision of part or all of the trapezoid may increase that risk. Although the clinical results of CT have not been reported, a biomechanical cadaveric study evaluated PT and CT and proximal migration of the index metacarpal under axial loading conditions. Resection
Although this is a valid concern, we demonstrated no differences in preoperative RL, CL, or RS angles in the current cohort, although this study was not sufficiently powered to make the comparison statistically. Garcia-Elias et al6 noted a mean increase in the RL angle of 8 at a mean of only 29 months after excision of the distal quarter of the scaphoid, which also disrupts the scaphotrapezoid joint complex compared with a simple trapeziectomy. Evaluation of the RS angle in the current cohort reaffirms the notion that resection of the STT joint complex decreases the flexion moment on the scaphoid, allowing it to extend with the proximal carpal row.6,10 The PT and CT groups in the current study proportionally had a larger change (extension) in RS angle compared with the NT group after surgery. Therefore, the data suggest that additional trapezoid excision (partial or complete) may increase the risk for developing an adaptive type CIND-DISI. All 3 groups demonstrated a decreased CHR from before to after surgery. Yuan et al also noted a decrease in the modified CHR after a simple trapeziectomy.10 Therefore, trapeziectomy alone may be enough to result in a loss of carpal height. In the study of Yuan et al,10 patients with CINDDISI had worse PRWE pain and function subscores, and lower satisfaction. Both CT and PT groups in the current study had better PRWE pain and function subscores as well as better QuickDASH J Hand Surg Am.
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of the proximal 50% did not produce displacement under any loading conditions, and CT only had displacement with higher loads. Nonetheless, the maximum displacement was only 1 mm for the latter, which led the authors to question its clinical relevance. The effect of either resection on carpal kinematics was not assessed.17 Although clinical studies evaluated proximal collapse of the thumb metacarpal at rest and with stress load,30e33 to our knowledge, none reported proximal collapse of the index metacarpal after PT or CT. Biomechanical and anatomic dissection studies detailed stout ligamentous interconnections between the base of the index and middle finger metacarpals.17,18 Our results question the support strength of these ligamentous structures alone on index metacarpal longitudinal stability. In addition, the base of the index metacarpal has support through a facet on the capitate. We used 2 different measurements to assess proximal collapse of the index metacarpal comparing preoperative and postoperative radiographs. Both demonstrated that the PT and CT groups had greater proximal collapse of the index metacarpal compared with the NT group (Table 3). This collapse was symptomatic in 5 of 22 CT and 2 of 21 PT hands (23% and 10%, respectively). Four CT and 1 PT hands (18% and 5%, respectively) underwent arthrodesis of the index and middle finger CMC joints for pain relief at a mean of 32 months (range, 7e56 months). Additional clinical studies would be helpful. This study had several shortcomings. First, it was retrospective and included only patients who were able to return for follow-up. Several were deceased, in nursing facilities, or unable to be contacted. Ideally, any study that evaluates results of treatment should be prospective, randomized, controlled, and blinded when possible. Ideally, we should have included a control group with documented scaphotrapezoid arthritis, but in which no trapezoid excision was performed, because some surgeons have shown acceptable results in patients who had documented scaphotrapezial arthritis, but in whom only trapeziometacarpal arthroplasty was performed.34 Second, although DASH and PRWE are validated outcome instruments, they may be influenced by other comorbidities such as arthritis in other areas of the hand or wrist. These would be expected to affect patients similarly in each of the 3 treatment groups. Patients with 4 of 22 hands in the CT group and 1 of 21 in the PT group that required arthrodesis of the index and middle finger CMC joints did not complete the PRWE or QuickDASH before the revision surgery or at final follow-up. Although they are not J Hand Surg Am.
included in the functional analysis, they are considered failures. Finally, all patients had an abductor pollicis longus suspensionplasty. It is possible that PT or CT would have affected outcomes differently with the use of the flexor carpi radialis tendon as the graft source, thereby eliminating it as a potential proximally directed force on the index metacarpal, and its support of the radial column. Additional PT and CT appear to cause an increased risk for leading to an adaptive type of carpal malalignment (CIND-DISI) with extension posture of the proximal carpal row and flexion of the distal row compared with simple trapeziectomy. When this pattern develops, function may be compromised, although the current cohort was not adequately powered to demonstrate this, and thus the radiologic changes may not be clinically significant. Symptomatic proximal migration of the index metacarpal, or arthritis between it and the capitate, is a risk. Increased pain in the NT group, compared with the remaining hands in the PT and CT groups, may have resulted from interval development of degenerative arthritis in the scaphotrapezoid joint, but without proof of clinically inferior results with PT or CT, this is speculative. This may prove difficult to confirm, because others reported a low sensitivity for radiologic diagnosis of scaphotrapezoid arthritis,2,35 and radiographic severity has been shown to correlate poorly with symptom severity.36 Complete trapezoid excision is not advised because of an increased risk for symptomatic proximal migration of the index metacarpal. Although partial excision of the trapezoid is popular if scaphotrapezoid arthritis is identified at the time of trapeziectomy, future research should be performed prospectively comparing patients with and without partial trapezoid excision using patientreported outcomes and long-term clinical follow-up. REFERENCES 1. Varitimidis SE, Fox RJ, King JA, Taras J, Sotereanos DG. Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon. Clin Orthop Relat Res. 2000;370:164e170. 2. Tomaino M, Vogt M, Weiser R. Scaphotrapezoid arthritis: prevalence in thumbs undergoing trapezium excision arthroplasty and efficacy of proximal trapezoid excision. J Hand Surg Am. 1999;24(6): 1220e1224. 3. Irwin AS, Maffulli N, Chesney RB. Scapho-trapezoid arthritis: a cause of residual pain after arthroplasty of the trapezio-metacarpal joint. J Hand Surg Br. 1995;20(3):346e352. 4. Rhee PC, Shin AY. Complications of trapeziectomy with or without suspension arthroplasty. J Hand Surg Am. 2014;39(4):781e783. 5. Young SD, Mikola EA. Thumb carpometacarpal arthrosis. J Hand Surg Am. 2004;4(2):73e92. 6. Garcia-Elias M, Lluch AL, Farreres A, Castillo F, Saffar P. Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis. J Hand Surg Br. 1999;24(4):448e452.
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7. Davey PA, Belcher HJ. Effect of coexistent scaphotrapezoidal osteoarthrosis on outcome after trapeziectomy. Scand J Plast Reconstr Surg Hand Surg. 2004;38(1):36e42. 8. Rectenwald JP, Green DP, Dobyns JH. Symptomatic carpal collapse after trapeziectomy and partial trapeziodectomy: report of two cases. J Hand Surg Am. 2005;30(4):706e710. 9. Herren DB, Lehmann O, Simmen BR. Does trapeziectomy destabilize the carpus? J Hand Surg Br. 1998;23(5):676e679. 10. Yuan BJ, Moran SL, Tay SC, Berger RA. Trapeziectomy and carpal collapse. J Hand Surg Am. 2009;34(2):219e227. 11. Iida A, Omokawa S, Kawamura K, Shimuzu T, Onishi T, Tanaka Y. Arthroscopic distal scaphoid resection for isolated scaphotrapeziotrapezoid osteoarthritis. J Hand Surg Am. 2019;44(4):337.e1e337.e5. 12. Drewniany JJ, Palmer AK, Flatt AE. The scaphotrapezial ligament complex: an anatomic and biomechanical study. J Hand Surg Am. 1985;10(4):492e498. 13. Tay SC, Moran SL, Shin AY, Linscheid RL. The clinical implications of scaphotrapezium-trapezoidal arthritis with associated carpal instability. J Hand Surg Am. 2007;32(1):47e54. 14. Viegas SF, Yamaguchi S, Boyd NL, Patterson RM. The dorsal ligaments of the wrist: anatomy, mechanical properties, and function. J Hand Surg Am. 1999;24(3):456e468. 15. Mizuseki T, Ikuta Y. The dorsal carpal ligaments: their anatomy and function. J Hand Surg Br. 1989;14(1):91e98. 16. Savelberg HH, Kooloos JG, Huiskes R, Kauer JM. Stiffness of the ligaments of the human wrist joint. J Biomech. 1992;25(4):369e376. 17. Wright TW, Thompson J, Conrad BP. Loading of the index metacarpal after trapezial and partial versus complete trapezoid resection. J Hand Surg Am. 2006;31(1):58e62. 18. Thompson JS. Suspensionplasty technique. Atlas Hand Clin. 1997;2(2):101e126. 19. Dzwierzynski WW, Matloub HS, Yan J-G, Deng S, Sanger JR, Yousif NJ. Anatomy of the intermetacarpal ligaments of the carpometacarpal joints of the fingers. J Hand Surg Am. 1997;22(5):931e934. 20. Kapoutsis DV, Dardas A, Day CS. Carpometacarpal and scaphotrapeziotrapezoid arthritis: arthroscopy, arthroplasty, and arthrodesis. J Hand Surg Am. 2011;36(2):354e366. 21. Youm Y, McMurthy RY, Flatt AE, Gillespie TE. Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexionextension. J Bone Joint Surg Am. 1978;60(4):423e431. 22. MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma. 1998;12(8):577e586. 23. Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038e1046. 24. Dacombe PJ, Amirfeyz R, Davis T. Patient-reported outcome measures for hand and wrist trauma: is there sufficient evidence of
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26.
27.
28.
29.
30.
31.
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33.
34.
35.
36.
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reliability, validity, and responsiveness? Hand (N Y). 2016;11(1): 11e21. Tsang P, Walton D, Grewal R, MacDermid J. Validation of the QuickDASH and DASH in patients with distal radius fractures through agreement analysis. Arch Phys Med Rehabil. 2017;98(6): 1217e1222. Mehta SP, MacDermid JC, Richardson J, MacIntyre NJ, Grewal R. A systematic review of the measurement properties of the patientrated wrist evaluation. J Orthop Sports Phys Ther. 2015;45(4): 289e298. Ochi K, Iwamoto T, Saito A, et al. Construct validity, reliability, response rate, and association with disease activity of the quick disabilities of the arm, shoulder and hand questionnaire in the assessment of rheumatoid arthritis. Mod Rheumatol. 2015;25(2): 241e245. Kamal RN, Chehata A, Rainbow M, Llusa M, Garcia-Elias M. The effect of the dorsal intercarpal ligament on lunate extension after distal scaphoid excision. J Hand Surg Am. 2012;37(11): 2240e2245. Malerich MM, Clifford J, Eaton B, Eaton R, Littler JW. Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion. J Hand Surg Am. 1999;24(6):1196e1205. Kadiyala RK, Gelberman RH, Dwon B. Radiographic assessment of the trapezial space before and after ligament reconstruction and tendon interposition arthroplasty. J Hand Surg Br. 1996;21(2): 177e181. Kaarela O, Raatikainen T. Abductor pollicis longus tendon interposition arthroplasty for carpometacarpal osteoarthritis of the thumb. J Hand Surg Am. 1999;24(3):469e475. Soejima O, Hanamura T, Kikuta T, Iida H, Naito M. Suspensionplasty with the abductor pollicis longus tendon for osteoarthritis in the carpometacarpal joint of the thumb. J Hand Surg Am. 2006;31(3): 425e428. Downing ND, Davis TR. Trapezial space height after trapeziectomy: mechanism of formation and benefits. J Hand Surg Am. 2001;26(5): 862e868. Glickel SZ, Kornstein AN, Eaton RG. Long-term follow-up of trapeziometacarpal arthroplasty with coexisting scaphotrapezial disease. J Hand Surg Am. 1992;17(4):612e620. Moritomo H, Viegas S, Nakamura K, DaSilva M, Patterson R. The scaphotrapezio-trapezoidal joint. Part 1: an anatomic and radiographic study. J Hand Surg Am. 2000;25(5): 899e910. Hoffler CE II, Matzon JL, Lutsky KF, Kim N, Beredjiklian PK. Radiographic stage does not correlate with symptom severity in thumb basilar joint osteoarthritis. J Am Acad Orthop Surg. 2015;23(12):778e782.
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Effect of Partial and Complete Trapezoid Excision on Radiographic and Functional Results After Abductor Pollicis Longus Suspensionplasty Kevin J. Renfree, MD,* Ryan Odgers, MD,† Cody Tillinghast, MD,‡ Nan Zhang, MS*
Purpose We hypothesized that adding complete or partial trapezoid excision is associated with greater radiographic carpal collapse and worse functional outcomes compared with a simple trapeziectomy and abductor pollicis longus suspensionplasty.
Methods A total of 69 patients had abductor pollicis longus suspensionplasty (79 hands), 87% of whom were female, mean age 64 years. Scaphotrapezium-trapezoid arthritis noted at surgery was treated with an additional proximal trapezoid excision (PT) in 21 (27%) or complete trapezoid resection (CT) in 22 hands (28%). No trapezoid was excised in 36 hands. The primary outcome was final radiolunate (RL) extension of 15 or greater on lateral radiographs. Logistic regression (for change in RL angle) and linear regression (for continuous variables) with robust variance estimate to account for within-subject correlation (generalized estimating equation method) were used to investigate whether the trapezoid excision groups had an effect on the outcomes of interest. Models were adjusted for age and sex. Results Median follow-up was 92 months. Complete trapezoid resection had the most increase in RL angle,
but PT had a higher incidence (29% vs 26%) of final RL angle of 15 or greater compared with CT. When stratified into groups with a final RL greater than or less than 15 , the former group had worse total function (Patient-Rated Wrist Evaluation) and QuickeDisabilities of the Arm, Shoulder, and Hand scores. Symptomatic index metacarpal migration was seen in 4 CT and 2 PT wrists (18% and 10%, respectively) and was considered to indicate failure.
Conclusions Compared with no trapezoid excised, both PT and CT had a greater incidence of lunate
extension of 15 or greater, consistent with radiographic nondissociative-dorsal intercalated carpal instability, which was associated with inferior functional scores. Symptomatic proximal collapse of the index metacarpal was seen in both CT and PT. Further studies should evaluate whether routine excision of the proximal trapezoid is necessary for scaphotrapezoid arthritis, because any disruption of the scaphotrapezoid ligament complex appears to increase risk for developing carpal instability nondissociative-dorsal intercalated carpal instability over time and may be associated with inferior functional results. Complete trapezoid excision is not recommended. (J Hand Surg Am. 2019;-(-):1.e1-e9. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV. Key words Arthritis, outcomes, thumb, trapeziectomy, trapezoid.
From the *Department of Orthopaedic Surgery, Mayo Clinic Arizona; and †Hand Surgery Private Practice, Phoenix, AZ; and the ‡Department of Orthopaedic Surgery, University of Texas, Houston, TX. Received for publication February 6, 2018; accepted in revised form October 11, 2019.
Corresponding author: Kevin J. Renfree, MD, Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.10.006
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2019 ASSH
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Published by Elsevier, Inc. All rights reserved.
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arthritis is seen in 50% to 60% of patients undergoing basal joint arthroplasty1,2 and is thought to be a potential cause of persistent pain if left untreated.3,4 Resection of the proximal trapezoid1,2,5 or distal pole of the scaphoid6 is often recommended. Neither has been proven to have a negative effect on the clinical results of nonimplant arthroplasty. 1,2,7 Outcome studies comparing cases with and without trapezoid excision are lacking, especially with respect to radiographic carpal alignment and function. There may be cause for concern, though, because Rectenwald et al8 reported symptomatic carpal instability nondissociativedorsal intercalated carpal instability (CIND-DISI) in 2 of 55 patients (4%) after trapeziectomy and partial trapezoid excision. The authors hypothesized that this might have resulted from the amount of trapezoid excised. The volar scaphotrapezium-trapezoid (STT) and dorsal intercarpal (DIC) ligament complexes are thought to be important secondary stabilizers of the lunate; their disruption or attenuation leads to DISI as part of a progressive injury spectrum after traumatic disruption of the scapholunate interosseous ligament. Trapeziectomy alone can disrupt the STT ligamentous complex enough to produce CINDDISI. 9,10 Garcia-Elias et al 6 reported that distal scaphoid excision may produce a similar radiographic pattern, as did another study,11 particularly when the resection height exceeded 3 mm of distal scaphoid. A biomechanical study questioned whether the remaining capsuloligamentous structures would stabilize the distal scaphoid adequately after disruption of the scaphotrapezial ligament,12 and advanced STT arthritis with erosion of the distal scaphoid and loss of integrity of the STT ligament complex can also be associated with carpal instability.13 Anatomic studies demonstrated that the DIC ligament inserts distally on the dorsal surfaces of the trapezium and trapezoid, and therefore is at risk for disruption or attenuation with excision of these bones.14e16 No clear guidelines exist regarding the amount of trapezoid that can be safely excised when scaphotrapezoid arthritis is identified. Recommendations vary from 2 mm to proximal 50%.2,17 Little is known regarding whether resection is necessary, what stage or severity of arthritic changes, how much resection is needed to prevent future scaphotrapezoid impingement, or whether partial trapezoid excision (PT) or complete trapezoid excision (CT) will destabilize the radial wrist column further.8,17 Our hypothesis was that adding PT and CT to trapeziectomy and abductor pollicis longus suspensionplasty would lead to a more severe radiographic ONCOMITANT SCAPHOTRAPEZOIDAL
J Hand Surg Am.
FIGURE 1: Intraoperative photograph of continued impingement between distal pole of scaphoid (solid black arrow) and remaining trapezoid (solid white arrow) after excision of proximal 50% of trapezoid.
CIND-DISI malalignment and worse functional outcomes and more pain over time, compared with hands in which no trapezoid excision was performed. MATERIALS AND METHODS The institutional review board at the Mayo Clinic approved this retrospective study. We included 69 patients who underwent surgery for basal joint arthritis between 2000 and 2010 (79 hands). Inclusion criteria included patients who were able to be contacted and agreed to return for a clinical and radiographic evaluation, were at least 3 years past the surgical date, and had a trapeziectomy and abductor longus pollicis suspensionplasty, as originally described by Thompson,18 modified only by omitting a temporary transfixing K-wire and interposition material. Excluded patients included those with an infection (n ¼ 1), who were deceased (n ¼ 20), who had moved out of state (n ¼ 13), who were unable to contacted or had an unlisted phone number (n ¼ 14), who were unable to participate owing to health issues (n ¼ 5), or who declined to participate (n ¼ 8). All procedures were performed by the senior author at a single academic tertiary care facility. Sixty of 69 patients were female (87%), mean age 64 years (range, 44e81 years). The dominant hand was involved in 57%; 10 patients had bilateral procedures. Advanced STT arthritis (grade 4 chondromalacia) was noted during surgery in 55%; it was treated with resection of the proximal 50% of the trapezoid (PT) in 21 hands (27%) and CT resection in 22 (28%) for persistent impingement. Because the index metacarpal base is supported by the capitate facet and shares a robust intermetacarpal ligament complex with the middle finger metacarpal,19 we r
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FIGURE 3: M2 is the measured distance between parallel lines from the base of the index finger to the proximal pole of the capitate.
(CHR) was calculated by dividing the carpal height by the middle finger metacarpal as described, by Youm et al.21 To assess for proximal migration of the index metacarpal, we used 2 measurements. The first (M1) measured the distance between parallel lines from the base of the index metacarpal to the distal pole of the scaphoid (Fig. 2), the second (M2) measured the distance between parallel lines from the base of the index metacarpal to the proximal pole of the capitate (Fig. 3). Excluding 4 hands in the CT and one in the PT group that had undergone a salvage procedure for symptomatic index metacarpal migration before patient inclusion in the study, all patients completed the Patient-Rated Wrist Evaluation (PRWE) and QuickeDisability of the Arm, Shoulder, and Hand questionnaire (QuickDASH) outcome measures.22,23 The former is a 15-item questionnaire that allows patients to rate wrist pain and disability from 0 to 10; it consists of 2 subscales: Pain and Function. Each subscale is weighted equally to calculate the total score of 100, with disability increasing proportionally with score. The QuickDASH is a shortened version of the original 30-question DASH outcome measure. Because the second component is an optional sport or music and work module, we used only the first component: the disability and symptom section (11 items, scored 1e5).23 Both instruments have been shown to be responsive, reliable, and valid instruments for pain and function associated with traumatic and nontraumatic conditions involving the hand and wrist.24e27
FIGURE 2: M1 is the measured distance between parallel lines from the base of the index finger to the distal pole of the scaphoid.
excised the entire trapezoid when continued contact of the distal portion of the trapezoid (after proximal resection) and scaphoid was noted with passive range of motion (extension combined with radial deviation) during surgery (Fig. 1). No trapezoid excision was required (NT) in 36 hands (45%) because the scaphotrapezoid joint appeared normal during surgery. An independent observer performed active range of motion measurements of the affected thumbs, as well as grip (Jamar Hydraulic Dynamometer, Patterson Medical, Warrenville, IL) and lateral pinch strength (Jamar Hydraulic Pinch Gauge, Patterson Medical). Preoperative and postoperative grip strengths of affected hands were compared (mean value of 3 attempts used). Radiographs included true posteroanterior and lateral views, with the latter reviewed to ensure that the radiusemiddle finger metacarpal axis was less than 20 .13 Preoperative and final radiographic images from a picture archiving and communication system were compared. A positive angle was defined as extension of the lunate relative to the radius, flexion of the scaphoid relative to the radius, and flexion of the capitate relative to the lunate. Based on previous studies, we defined CIND-DISI as an radiolunate (RL) angle greater than 15 .10,20 Angle measurements were made between the longitudinal axis of the involved bones to the nearest degree using a computerized digital goniometer at 250% magnification. The posteroanterior radiographs were used for the rest of the measurements. Carpal height ratio J Hand Surg Am.
RESULTS Median follow-up was 92 months (quartiles, 57.5e129.5 months). There was no difference r
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LS, least-square.
e6 (e27.18 to 14.85), 17 6 (e10.05 to 23.00), 25 Change in RS angle: LS means (95% CI), total n
e6 (e14.30 to 1.83), 11
10 (3.47 to 16.80), 19
47 (33.40 to 59.60), 17
2 (e3.78 to e6.94), 31
31 (20.35 to 41.61), 25
Change in CL angle: LS means (95% CI), total n
Preoperative RS angle: LS means (95% CI), total n
45 (e1.10 to 10.32), 17
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49 (42.43 to 55.33), 11
8 (2.93 to 12.80), 19
Preoperative CL angle: LS means (95% CI), total n
6 (e8.58 to e20.57), 19
7 (e0.31 to 13.90), 17
e15 (e26.29 to e4.51), 17
e2 (e6.97 to 2.76), 31
e17 (e29.07 to e4.28), 31
Change in RL angle: LS means (95% CI), total n
8 (42), 19
7. (1.93 to 12.79), 19
5 (29), 17
7 (e0.01 to 13.16), 17
4 (13), 31
e1 (e5.43 to 3.69), 31
5 (29), 17 1 (3), 31
Preoperative RL angle: LS means (95% CI), Total N
CL angle > 15 : n (%), total n
RL angle > 15 : n (%), total n
TABLE 1.
Changes in RL, CL, and RS Angles
NT
PT
CT
between the 3 groups with respect to preoperative RL, capitolunate (CL), or radioscaphoid (RS) angles (Table 1). As a whole, CT and PT had greater changes (pre- to postoperative) in RL angle (resulting from increased lunate-proximal carpal row extension), in CL angle (resulting from increased capitate-distal carpal row flexion), and RS angle (resulting from increased scaphoid-proximal carpal row extension) when compared to NT, but not when compared to each other (Fig. 4A, B). A final RL angle of 15 or greater was seen in 1 of 31 NT patients (3%). This percentage was lower than for patients in the PT (5 of 17; 29%) and CT (5 of 19; 26%) groups. A final CL angle of 15 or greater was seen in 4 of 31 (13%) in the NT group. This percentage was lower than for patients in the PT (5 of 17; 29%), and CT (8 of 19; 42%) groups. The CT and PT groups had similar changes (proximal collapse of index metacarpal) from before to after surgery in distances M1 and M2 compared with the NT group; CT demonstrated the greatest change (a decrease) (Table 2). The CT and PT groups had better total pain (PRWE) scores compared with the NT group. The CT and PT groups also had a better functional total (PRWE) score compared with the NT group. QuickDASH scores were lower in the PT and CT groups compared with the NT group (Table 3). No differences were seen in the total pain subscore of the PRWE when patients with an RL angle of 15 or greater (CIND-DISI) were compared with those with less than 15 ; however, the function portions of the PRWE and QuickDASH were worse in wrists with CIND-DISI (RL angle of 15 or greater) (Table 4). There were no differences among the 3 groups when active thumb metacarpophalangeal joint motion, opposition distance from the little finger metacarpophalangeal joint flexion crease, or change in grip and lateral pinch strength of the involved hand was compared. Complication rates were higher in the CT (27%) compared with PT (23%) and NT (16%) groups (Table 5). Secondary procedures were highest in the CT group and involved arthrodesis of the index and middle finger carpometacarpal (CMC) joints in 4 of 22 patients for symptomatic proximal migration of the index metacarpal resulting in arthritis at the index CMC joint (Fig. 5). Another patient had satisfactory pain relief with a corticosteroid injection. Two of 21 patients who had PT also developed symptomatic proximal index metacarpal migration; one underwent an arthrodesis of the index and middle finger CMC joints (Fig. 6) and the other was
5 (26), 19
PARTIAL AND COMPLETE TRAPEZOIDECTOMY OUTCOMES
Variable
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e6 (e8.7 to e3.2), 19 e4.3 (e5.8 to e2.8), 17 e2.4 (e4.6 to e0.2), 29 Change in distance (M1): base index metacarpal migration (collapse) to distal pole scaphoid: LS means, mm (95% CI), total n
e3.1 (e4.1 to e2.1), 19 e1.1 (e1.6 to e0.7) 17 e0.4 (e1.2 to 0.4), 27 Change in distance (M2): base index metacarpal migration (collapse) to capitate: LS means, mm (95% CI), total n
TABLE 2.
DISCUSSION Partial trapezoid excision is a popular procedure when scaphotrapezoid arthritis is identified during basal joint arthroplasty, with the aim of addressing a potential source of persistent pain.1e5,13 There are no clinical guidelines demonstrating how much trapezoid can be safely excised, and little is known about its long-term effects with respect to function and radiographic changes. Studies documented CIND-DISI after simple trapeziectomy or excision of the distal quarter of the scaphoid alone.6,10,13,28 When identified, CIND-DISI has not consistently produced inferior clinical results.6,10,29 Nevertheless, 2 studies reported less satisfaction and higher pain and disability scores with CIND- DISI after simple trapeziectomy.8,10 Therefore, it is possible that disruption of the remaining STT and DIC ligament complexes may occur with additional resection of part or all of the trapezoid, because the latter structure is thought to be an important secondary stabilizer preventing lunate extension and subsequent CIND-DISI.28 This may or may not translate into inferior clinical results. Of 11 wrists with a final RL angle of 15 or greater (CIND-DISI), 4 had PT, 6 had CT, and only
PT
given a corticosteroid injection and declined further treatment.
NT
FIGURE 4: A Preoperative and B postoperative (7.6 years) lateral radiographs demonstrating RL angle in a patient who had complete trapezoid excision (CT).
Variable
Proximal Migration (Collapse) of Index Metacarpal: Comparison of CT and PT With NT
CT
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TABLE 3.
PARTIAL AND COMPLETE TRAPEZOIDECTOMY OUTCOMES
Patient-Rated Wrist Evaluation and QuickDASH Scores: Comparison of CT and PT With NT Variable
NT
Pain total score: LS means (95% CI), total n
PT
CT
9.4 (4.6e14.2), 30
4.4 (1.3e7.6), 16
3.6 (0e7.4), 18
Function total score: LS means (95% CI), total n
15.5 (8.3e22.7), 30
9.7 (3.3e16), 16
5.9 (2.2e14), 18
Total QuickDASH score: LS means (95% CI), total n
19.5 (16.1e22.8), 28
16.2 (13.1e19.3), 19
15.5 (12.2e18.7), 18
LS, least-square.
TABLE 4. Patient-Reported Outcomes Comparison Between RL Angle of Less Than 15 (No CIND-DISI) and Greater Than 15 (CIND-DISI)* Variable Pain total score: LS means (95% CI), total n Function total score: LS means (95% CI), total n Total QuickDASH score: LS means (95% CI), total n
RL Angle < 15
RL angle > 15
5.9 (3.4 to 8.4), 46
2.3 (e5.2 to 9.7), 8
8.9 (5.5 to 12.4), 46
19.4 (2.8 to 36.1), 8
15.5 (13.8 to 17.2), 45
22.6 (16.5 to 28.7), 9
LS, least-square. *All models were adjusted for age and sex.
TABLE 5.
Incidence of Complications Among NT, PT, and CT Groups Complication
Symptomatic proximal collapse index metacarpal
NT (n ¼ 36)
PT (n ¼ 21)
CT (n ¼ 22)
0
2 (10%)
5 (23%)
Secondary excision of trapezoid for scaphotrapezoid impingement or arthritis after suspensionplasty procedure
2 (6%)
2 (10%)
NA
Complex regional pain syndrome
1 (3%)
0
0
Acute carpal tunnel syndrome
1 (3%)
0
0
Painful hardware MCP joint fusion
1 (3%)
1 (5%)
1 (5%)
Other
1 (3%)
0
0
NA, not applicable.
1 had NT. The CT group had a greater change in RL angle (lunate extension) compared with the NT group. Thus, CIND-DISI malalignment was more common and severe after CT and least after NT. These differences may have little meaning because the 95% confidence intervals in these data are wide, suggesting a lack of precision. Yuan et al10 reported a percentage (58%) of stage 4 scaphotrapezoidal arthritis in patients undergoing simple trapeziectomy and ligament reconstruction similar to ours (55%), and a mean postoperative change in RL angle of 4.4 , compared with a mean increase of 11.4 in our study. We suspect that the greater change in RL angle in the current cohort was attributable to either the addition of CT or PT (these patients were excluded in the study of Yuan et al) or a longer length of follow-up.
J Hand Surg Am.
The mean follow-up in the study of Yuan et al was only 10.5 months, compared with 74 months in the current CT group. Our analysis did not find an association between longer postsurgical follow-up and greater change in RL angle, which could be because of the small sample size. However, this suggests that length of follow-up is not a factor and this difference likely resulted from chance. In addition, 39% of wrists with STT arthritis in the study of Yuan et al demonstrated radiographic DISI before surgery, which raises the question whether these patients might have had greater preexisting ligamentous injury compared with patients with isolated basal joint arthritis, thereby making them more susceptible to more frequent and/or severe DISI after trapeziectomy, with or without trapezoid resection.
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FIGURE 6: Arthrodesis of index and middle finger CMC joints in patient shown in Figure 5. FIGURE 5: Symptomatic arthritis between index metacarpal and capitate caused by proximal migration of index metacarpal after complete trapezoid excision (CT).
scores compared with the NT group (Table 3). This could be because of either the interval development of painful scaphotrapezoid arthritis or impingement between the thumb metacarpal and trapezoid in the NT group. However, when comparing subgroups of patients with an RL angle greater than 15 (CINDDISI) with those less than 15 , the former group (CIND-DISI) had worse PRWE total functional and QuickDASH scores (Table 4). Because of the small numbers in each group, however, this may not be clinically significant. Garcia-Elias et al found no correlation between DISI and functional outcome after distal scaphoidectomy; however, no validated patient-rated outcomes measures were used in their study. They theorized that despite DISI, congruency of the RL and RS joints was maintained and that, at least in the short term, degenerative changes in the carpus were not seen.6 No hands in the current CT or PT groups developed degenerative carpal changes with a much longer mean follow-up (96 vs 29 months). The results of our study seem to support those of Yuan et al, that a CIND-DISI radiographic pattern after a trapeziectomy procedure may be associated with inferior function. Nevertheless, a small sample size introduces potential bias, and therefore further study is required. Our opinion is that additional excision of part or all of the trapezoid may increase that risk. Although the clinical results of CT have not been reported, a biomechanical cadaveric study evaluated PT and CT and proximal migration of the index metacarpal under axial loading conditions. Resection
Although this is a valid concern, we demonstrated no differences in preoperative RL, CL, or RS angles in the current cohort, although this study was not sufficiently powered to make the comparison statistically. Garcia-Elias et al6 noted a mean increase in the RL angle of 8 at a mean of only 29 months after excision of the distal quarter of the scaphoid, which also disrupts the scaphotrapezoid joint complex compared with a simple trapeziectomy. Evaluation of the RS angle in the current cohort reaffirms the notion that resection of the STT joint complex decreases the flexion moment on the scaphoid, allowing it to extend with the proximal carpal row.6,10 The PT and CT groups in the current study proportionally had a larger change (extension) in RS angle compared with the NT group after surgery. Therefore, the data suggest that additional trapezoid excision (partial or complete) may increase the risk for developing an adaptive type CIND-DISI. All 3 groups demonstrated a decreased CHR from before to after surgery. Yuan et al also noted a decrease in the modified CHR after a simple trapeziectomy.10 Therefore, trapeziectomy alone may be enough to result in a loss of carpal height. In the study of Yuan et al,10 patients with CINDDISI had worse PRWE pain and function subscores, and lower satisfaction. Both CT and PT groups in the current study had better PRWE pain and function subscores as well as better QuickDASH J Hand Surg Am.
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PARTIAL AND COMPLETE TRAPEZOIDECTOMY OUTCOMES
of the proximal 50% did not produce displacement under any loading conditions, and CT only had displacement with higher loads. Nonetheless, the maximum displacement was only 1 mm for the latter, which led the authors to question its clinical relevance. The effect of either resection on carpal kinematics was not assessed.17 Although clinical studies evaluated proximal collapse of the thumb metacarpal at rest and with stress load,30e33 to our knowledge, none reported proximal collapse of the index metacarpal after PT or CT. Biomechanical and anatomic dissection studies detailed stout ligamentous interconnections between the base of the index and middle finger metacarpals.17,18 Our results question the support strength of these ligamentous structures alone on index metacarpal longitudinal stability. In addition, the base of the index metacarpal has support through a facet on the capitate. We used 2 different measurements to assess proximal collapse of the index metacarpal comparing preoperative and postoperative radiographs. Both demonstrated that the PT and CT groups had greater proximal collapse of the index metacarpal compared with the NT group (Table 3). This collapse was symptomatic in 5 of 22 CT and 2 of 21 PT hands (23% and 10%, respectively). Four CT and 1 PT hands (18% and 5%, respectively) underwent arthrodesis of the index and middle finger CMC joints for pain relief at a mean of 32 months (range, 7e56 months). Additional clinical studies would be helpful. This study had several shortcomings. First, it was retrospective and included only patients who were able to return for follow-up. Several were deceased, in nursing facilities, or unable to be contacted. Ideally, any study that evaluates results of treatment should be prospective, randomized, controlled, and blinded when possible. Ideally, we should have included a control group with documented scaphotrapezoid arthritis, but in which no trapezoid excision was performed, because some surgeons have shown acceptable results in patients who had documented scaphotrapezial arthritis, but in whom only trapeziometacarpal arthroplasty was performed.34 Second, although DASH and PRWE are validated outcome instruments, they may be influenced by other comorbidities such as arthritis in other areas of the hand or wrist. These would be expected to affect patients similarly in each of the 3 treatment groups. Patients with 4 of 22 hands in the CT group and 1 of 21 in the PT group that required arthrodesis of the index and middle finger CMC joints did not complete the PRWE or QuickDASH before the revision surgery or at final follow-up. Although they are not J Hand Surg Am.
included in the functional analysis, they are considered failures. Finally, all patients had an abductor pollicis longus suspensionplasty. It is possible that PT or CT would have affected outcomes differently with the use of the flexor carpi radialis tendon as the graft source, thereby eliminating it as a potential proximally directed force on the index metacarpal, and its support of the radial column. Additional PT and CT appear to cause an increased risk for leading to an adaptive type of carpal malalignment (CIND-DISI) with extension posture of the proximal carpal row and flexion of the distal row compared with simple trapeziectomy. When this pattern develops, function may be compromised, although the current cohort was not adequately powered to demonstrate this, and thus the radiologic changes may not be clinically significant. Symptomatic proximal migration of the index metacarpal, or arthritis between it and the capitate, is a risk. Increased pain in the NT group, compared with the remaining hands in the PT and CT groups, may have resulted from interval development of degenerative arthritis in the scaphotrapezoid joint, but without proof of clinically inferior results with PT or CT, this is speculative. This may prove difficult to confirm, because others reported a low sensitivity for radiologic diagnosis of scaphotrapezoid arthritis,2,35 and radiographic severity has been shown to correlate poorly with symptom severity.36 Complete trapezoid excision is not advised because of an increased risk for symptomatic proximal migration of the index metacarpal. Although partial excision of the trapezoid is popular if scaphotrapezoid arthritis is identified at the time of trapeziectomy, future research should be performed prospectively comparing patients with and without partial trapezoid excision using patientreported outcomes and long-term clinical follow-up. REFERENCES 1. Varitimidis SE, Fox RJ, King JA, Taras J, Sotereanos DG. Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon. Clin Orthop Relat Res. 2000;370:164e170. 2. Tomaino M, Vogt M, Weiser R. Scaphotrapezoid arthritis: prevalence in thumbs undergoing trapezium excision arthroplasty and efficacy of proximal trapezoid excision. J Hand Surg Am. 1999;24(6): 1220e1224. 3. Irwin AS, Maffulli N, Chesney RB. Scapho-trapezoid arthritis: a cause of residual pain after arthroplasty of the trapezio-metacarpal joint. J Hand Surg Br. 1995;20(3):346e352. 4. Rhee PC, Shin AY. Complications of trapeziectomy with or without suspension arthroplasty. J Hand Surg Am. 2014;39(4):781e783. 5. Young SD, Mikola EA. Thumb carpometacarpal arthrosis. J Hand Surg Am. 2004;4(2):73e92. 6. Garcia-Elias M, Lluch AL, Farreres A, Castillo F, Saffar P. Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis. J Hand Surg Br. 1999;24(4):448e452.
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7. Davey PA, Belcher HJ. Effect of coexistent scaphotrapezoidal osteoarthrosis on outcome after trapeziectomy. Scand J Plast Reconstr Surg Hand Surg. 2004;38(1):36e42. 8. Rectenwald JP, Green DP, Dobyns JH. Symptomatic carpal collapse after trapeziectomy and partial trapeziodectomy: report of two cases. J Hand Surg Am. 2005;30(4):706e710. 9. Herren DB, Lehmann O, Simmen BR. Does trapeziectomy destabilize the carpus? J Hand Surg Br. 1998;23(5):676e679. 10. Yuan BJ, Moran SL, Tay SC, Berger RA. Trapeziectomy and carpal collapse. J Hand Surg Am. 2009;34(2):219e227. 11. Iida A, Omokawa S, Kawamura K, Shimuzu T, Onishi T, Tanaka Y. Arthroscopic distal scaphoid resection for isolated scaphotrapeziotrapezoid osteoarthritis. J Hand Surg Am. 2019;44(4):337.e1e337.e5. 12. Drewniany JJ, Palmer AK, Flatt AE. The scaphotrapezial ligament complex: an anatomic and biomechanical study. J Hand Surg Am. 1985;10(4):492e498. 13. Tay SC, Moran SL, Shin AY, Linscheid RL. The clinical implications of scaphotrapezium-trapezoidal arthritis with associated carpal instability. J Hand Surg Am. 2007;32(1):47e54. 14. Viegas SF, Yamaguchi S, Boyd NL, Patterson RM. The dorsal ligaments of the wrist: anatomy, mechanical properties, and function. J Hand Surg Am. 1999;24(3):456e468. 15. Mizuseki T, Ikuta Y. The dorsal carpal ligaments: their anatomy and function. J Hand Surg Br. 1989;14(1):91e98. 16. Savelberg HH, Kooloos JG, Huiskes R, Kauer JM. Stiffness of the ligaments of the human wrist joint. J Biomech. 1992;25(4):369e376. 17. Wright TW, Thompson J, Conrad BP. Loading of the index metacarpal after trapezial and partial versus complete trapezoid resection. J Hand Surg Am. 2006;31(1):58e62. 18. Thompson JS. Suspensionplasty technique. Atlas Hand Clin. 1997;2(2):101e126. 19. Dzwierzynski WW, Matloub HS, Yan J-G, Deng S, Sanger JR, Yousif NJ. Anatomy of the intermetacarpal ligaments of the carpometacarpal joints of the fingers. J Hand Surg Am. 1997;22(5):931e934. 20. Kapoutsis DV, Dardas A, Day CS. Carpometacarpal and scaphotrapeziotrapezoid arthritis: arthroscopy, arthroplasty, and arthrodesis. J Hand Surg Am. 2011;36(2):354e366. 21. Youm Y, McMurthy RY, Flatt AE, Gillespie TE. Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexionextension. J Bone Joint Surg Am. 1978;60(4):423e431. 22. MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma. 1998;12(8):577e586. 23. Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038e1046. 24. Dacombe PJ, Amirfeyz R, Davis T. Patient-reported outcome measures for hand and wrist trauma: is there sufficient evidence of
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