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Interpositional arthroplasty with gore-tex, marlex or tendon for osteoarthritis of the trapeziometacarpal joint
INTERPOSITIONAL ARTHROPLASTY WITH GORE-TEX, M A R L E X O R T E N D O N F O R O S T E O A R T H R I T I S OF T H E TRAPEZIOMETACARPAL JOINT A retrospectivecomparative study S. MUERMANS and L. COENEN
From the Algemeen Ziekenhuis Sint Jozef Mechelen, Mechelen, Belgium In this retrospective study of 26 patients with arthritis of the thumb carpometacarpal joint, we report the use of expanded polytetrafluoroethylene (ePTFE) (Gore-Tex) and polypropylene (Marlex) as interpositional materials for resection arthroplasty of the trapeziometacarpal joint. We have compared the results with those of "conventional" tendon interposition and those in the literature. In three patients the use of ePTFE (Gore-Tex) was complicated by marked clinical synovitis, resembling findings in silicone synovitis. Therefore, the use of ePTFE has been discontinued. Polypropylene seems to be a valuable alternative to tendon interposition arthroplasty.
Journal of Hand Surgery (British and European Volume, 1998) 23B: 1:64~58 Arthritic change in the carpometacarpal joint is a common cause of pain at the base of the thumb and can seriously impair overall hand function. Various surgical techniques for its treatment have been described. In our service, the senior surgeon has mainly carried out trapeziectomy with interpositional arthroplasty. Three interpositional materials have been used: a soft tissue patch of expanded polytetrafluoroethylene (ePTFE) (Gore-Tex: Group 1, ten patients), polypropylene mesh (Marlex: Group 2, nine patients) and finally a strip of extensor carpi radialis longus tendon (Group 3, seven patients). Gore-Tex (expanded polytetrafluoroethylene) is a chemically inert, porous and biocompatible material. Fibroblastic and collagenic ingrowth is rather poor with only filmy adhesions and, therefore, ePTFE in its patch form can be used as an interpositional spacer. Polypropylene (Marlex mesh) is a biomaterial that stimulates a dense fibrotic incorporation with strong adhesions. The final result is thus comparable to a fibrous pseudarthrosis. The use of these two materials for this condition has not been described previously. As treatment of trapeziometacarpal osteorthritis is still a controversial subject, we have reviewed and compared the results obtained with all three materials retrospectively.
at the time of operation was 55 years (range 38-79). Fifteen had the dominant hand operated on and 11 the non-dominant. The mean follow-up time was 32 months. All patients complained of pain at the base of the thumb and loss of thumb and hand function. Except for the four revision cases, all were stage 2 to 4 according to the radiographic classification of Eaton and Littler (1973) (Fig 1). The incidence of associated soft tissue dis-
MATERIAL A N D M E T H O D S
In our service, 38 operations were performed on 38 patients with trapeziometacarpal arthritis between August 1987 and November 1994. Only 26 patients were available for this study as two had died and others could not be reached or failed to turn up for investigation. The assessment was carried out by an independent examiner who was not involved in the operations. All 26 patients had a unilateral procedure. Initial preoperative diagnoses included degenerative osteoarthritis in 23 patients and post-traumatic arthritis after a Bennett's fracture in three (male) patients. Four were revision procedures. Twentyone patients were female and five male. The average age
Fig 1
64
Stage 4 osteoarthritis of the trapeziometacarpaljoint in a postmenopausal woman.
INTERPOSITIONAL ARTHROPLASTY OF TMJ
65
orders and the need for other simultaneous surgical treatment has often been stressed (Burton, 1973; Florack et al, 1992). Additional surgical procedures were required at the time of operation in 11 of our patients (Table 1). Clinical assessment included evaluation of pain, pinch and grip strength, motion, instability, subjective improvement and satisfaction with the procedure, ability to return to daily or professional activities, and notification of possible complications. Pain intensity was objectively rated as a grade 1 to 4 as previously described by Alnot and Saint Laurent (1985) (Table 2). In our study, we considered stage 0 and 1 as good, stage 2 as satisfactory, stage 3 or 4 as insufficient. Groups were compared by one-way analysis of variance (Kruskal-Willis test) and Mann-Whitney test. Postoperative pulp-to-pulp pinch strength and grip strength were measured with the Jamar dynamometer. Preoperative data on strength were not available in most of our patients as they often presented with severe pain, limiting most activities. Therefore, strength was expressed as a percentage of the non-operated thumb. Statistical methods included were one-way analysis of variance and the unpaired Student's t-test. Range of motion was assessed for opposition and abduction. Opposition was graded 0 to 10 on the Kapandji scale (Kapandji, 1986) and abduction was expressed as a loss of ability to flatten the hand on a table top with the thumb metacarpal in radial abduction. Instability was assessed by provocative subluxation and the influence of a stabilizing ligamentoplasty was studied (Fisher's exact test). Performance of usual daily or professional activities was compared with the preoperative status. Overall subjective improvement and satisfaction with the procedure was then noted. Complications were looked at individually and reviewed according to the material used. The indication for operation was severely disabling carpometacarpal joint degeneration after failure of conTable 1--Associated surgical procedures
Carpal tunnel release
Group 1
Group2
Group3
Total
2
2
2
6
Trigger t h u m b release
1
Trimming second C M C boss
-
Arthrodesis D I P index
1
1 -
i
-
i
1
Trigger digit release
-
1
B u t t o n hole deformity
1
Release first web
1
-
-
Table 2 ~ t a g i n g of pain (Alnot and Saint Laurent, 1985) Stage Stage Stage Stage Stage
0 1 2 3 4
No pain. Pain in particular activities. Pain in daily activities. As 2 but with episodes of spontaneouspain. Constant or almost constant pain.
servative treatment in 22 patients. Four cases were revision procedures: the first due to thumb shortening after excision-arthroplasty and the second after a failed total joint replacement, both performed elsewhere; they were replaced by Gore-Tex grafts. The other two revised cases were extensor carpi radialis longus arthroplasties, one after a symptomatic subluxation of a Marlex-arthroplasty, and the other after persisting synovitis in a Gore-Tex-arthroplasty, both previously performed in our service.
Operative technique A dorsoradial S-shaped incision was used in all cases. After protection of the superficial branches of the radial nerve and artery, the capsule was freed and carefully dissected off the trapezium and first metacarpal base. The trapezium was removed piecemeal in order to preserve the capsule for subsequent reconstruction. Gore-Tex patch or Marlex mesh were used if there was no severe synovial inflammation. If significant synovitis was found, a tendon graft was indicated because the risk of adverse foreign body reaction to Gore-Tex and Marlex was expected to be increased. If tendon-interposition was performed, a strip of extensor carpi radialis longus was used. If a Gore-Tex patch or Marlex mesh were inserted, these materials were rolled in an "anchovy" fashion and secured on their own with a polyglyconate suture. The size was shaped to match the gap created by the trapeziectomy and to restore the length of the thumb (Fig 2). The "anchovy" was then implanted and the capsule securely closed. One or both slips of the abductor pollicis longus were used for an additional ligamentoplasty in six patients in Group 1, one patient in Group 2 and three in Group 3. Originally, immediate postoperative stability was assured by insertion of a K-wire crossing the first metacarpal, graft and scaphoid but this was later abandoned after one case of pin tract infection. K-wires were used in seven patients in Group 1, one patient in Group 2 and one in Group 3. Postoperatively, a scaphoid-type plaster was applied. After 4 weeks, cast and K-wires were removed and active mobilization started. RESULTS
1
Relief of pain
1
Results of pain relief are detailed in Table 3. In Group 1, all six cases of persisting pain seemed to be caused by
66
THE JOURNAL OF HAND SURGERY VOL. 23B No. 1 FEBRUARY 1998
Pulp pinch and grip strength Mean postoperative pinch and grip strength for all groups are detailed in Table 4. The results are expressed as a percentage of the pinch and grip strength of the opposite non-operated hand.
Range of motion Abduction was evaluated as the ability to flatten the hand on a table top. This was possible in 21 patients. Among the other five patients (two in Group 1, two in Group 2 and one in Group 3), one had a preoperative aduction contracture that was released at the time of operation but recurred as a late complication. Another patient had an associated subluxation and descent of the first metacarpal, despite ligamentoplasty and abductor pollicis longus advancement. The three other patients with lack of aduction also presented with some degree of postoperative aduction deformity. Opposition was graded 9 on the Kapandji scale (thumb pulp to proximal crease little finger) in all but the five patients previously mentioned.
Instability
Fig 2
Restoration of trapezial height after insertion of a polypropylene (Marlex) graft.
Table 3--Results of pain relief
Stage
Group 1 n=lO
0 1 2 3 4 Minor causalgia
4 6
8
Group 2 n=9
Group 3 n=7
2 5 " 2
1 5 1
2
4
minor cansalgia. A temporary causalgia had also previously been noted in two other patients who at the time of review had become completely painfree. In Group 2, both patients with stage 2 pain had demanding jobs and their dominant hand was involved. In one of them, pain was caused by thumb shortening with subsequent impingement between the collapsed first metacarpal and both the second metacarpal and the trapezoid. This resulted in an arthritic second CMC joint. Minor causalgia was only noted in two of the patients with residual pain. In Group 3, the stage 2 patient had tendon-interposition carried out as a revision procedure quite recently and pain still seemed to be improving. Minor causalgia was present in three patients and had subsided in one, thereby becoming completely painfree.
Overall, ligamentoplasty was performed in ten cases. Provocative subluxation of the base of the first metacarpal could only be elicited in two patients of the first group. One of these did not have a ligamentoplasty, the other developed a subluxation despite ligamentoplasty. Subluxation of the first metacarpal had also occurred earlier in one patient with a previous Marlex arthroplasty and was an indication for revision.
Functional improvement and patient sati~sfaction Full patient satisfaction with the operation was noted for six of ten patients in Group 1, six of nine patients in Group 2 and four of seven patients in Group 3. However, subjective functional improvement in performance of daily and professional activities was present in eight Table 4--Average pinch and grip strength (in kg). Results given as mean (SO)
Group 1 n=lO
Group 2 n=9
Group 3 n=7
1.65 (0.88) 1.80 (1.32) 106%
1.39 (0.93) 1.78 (0.97) 81%
1.71 (0.76) 2.42 (0.79) 77%
24.5 (10.7) 28.8 (13.5) 86%
22.9 (9.9) 30.6 (12.6) 75%
23.7 (12.0) 32.6 (11.2) 75%
Pb~ch strength Operated hand Non-operated hand % of non-op, hand
Grip strength Operated hand Non-operated hand % of non-op, hand
67
I N T E R P O S I T I O N A L A R T H R O P L A S T Y OF T M J
patients of ten in Group 1, eight patients of nine in Group 2 and six patients of seven in Group 3. Complications
Complications in all groups are noted in Table 5. There was one superficial infection. Significant clinical synovitis was present in three patients treated with Gore-Tex arthroplasty. The first of these reported a persisting degree of disabling pain at our review, 3 years after surgery. X-rays showed marked generalized carpal osteolysis, most prominent in the capitate and hamate (Fig 3). This resembled the radiolucency seen in silicone synovitis. An extensor carpi radialis longus arthroplasty was performed as a revision procedure after this study. The second patient also had pain and presented with clinical grinding. On X-ray, the Gore-Tex graft seemed to have disintegrated, causing synovitis. The third patient with clinically disabling synovitis had the Gore-Tex graft removed and replaced by an extensor carpi radialis longus tendon-graft at the time of review for this study. Operative inspection confirmed synovitis. Four patients presented with late advanced second carpometacarpal arthritis, two of which were associated with descent of the first metacarpal, impinging on both the second metacarpal base and the trapezoid. Fig 3 Generalized carpal osteolysisafter ePTFE (Gore-Tex)graft. This resemblesthe features seen in siliconesynovitis.
DISCUSSION Osteoarthritis of the trapeziometacarpal joint is common as a degenerative condition in postmenopausal women (Armstrong et al, 1994) but can also occur as a post-traumatic condition after Bennett's fracture. When conservative treatment fails to relieve disabling pain, surgery is often required. Many procedures have been advocated but the selection of a proper, reliable technique remains debatable. In this retrospective study, we report on excisional interposition-arthroplasty using three different materials, Gore-Tex, Marlex and conventional tendon. Overall, 23 of 26 patients were either pain free or showed minimal pain on strenuous activities. There were no significant
differences between the three groups. Residual pain was often found to be caused by minor causalgia: this was not related to the type of procedure but to the site of incision. The majority of our patients experienced marked subjective improvement of thumb and hand grip strength, but overall power still remained lower in the operated hand than the non-operated hand. This is consistent with most previous studies, regardless of the techniques used. Again, variations of strength according to the materials used were not statistically significant. Absolute pinch strength in general was rather low in our
Table 5--Complications Group 1 n=lO
Synovitis Infection Subluxation Adduction deformity Late advanced second CMC OA MC1 descent
Group 2 n=9
Group 3 n=7
-
1 (superficial)
1 (beforerevision) 2
1
1
2
1
1
-
1
3 1 (pin track) (not included) 2 2
68
series as most patients had low-demand hands, were retired or still experienced some pain on occasions. A satisfactory clinical range of abduction and opposition was found in 21 of the 26 patients. This was not related to the material used. We had good results for stability, as subluxation was only found in two patients. One of these occurred despite ligamentoplasty, and from these data no conclusions can be made on the efficiency of this procedure. We noted a discrepancy between overall subjective functional improvement (22 of 26 patients) and the rate of full patient satisfaction with the procedure (16 of 26 patients). These were not significantly related to the materials used. Patients who were dissatisfied despite functional improvement either had demanding jobs, relatively short follow-up or some form of complication. Among our complications was one case of subluxation that required conversion of a Marlex graft into a stabilized tendon arthroplasty. However, the most severe complication in our series was synovitis, found only in three patients with a Gore-Tex arthroplasty, requiring removal of the graft in two cases. We conclude that this is a form of adverse foreign body reaction, as the clinical and X-ray features resembled those of silicone synovitis. We did not encounter any case of synovitis in the Marlex group, nor in the tendon group. Another Gore-Tex graft was removed after the patient developed a pin tract infection. These drawbacks were considered sufficient to discontinue the use of Gore-Tex graft, in favour of the Marlex or tendon-arthroplasty. A perfect surgical treatment for trapeziometacarpal osteoarthritis should create a painless, mobile, strong
T H E J O U R N A L OF H A N D SURGERY VOL. 23B No. 1 FEBRUARY 1998
and stable thumb with long lasting function. Today, none of the available techniques have reached this goal. The use of Gore-Tex has now been discontinued due to a significant complication rate. We have found polypropylene (Marlex) to be an attractive and practical alternative to tendon interposition in the treatment of trapeziometacarpal osteoarthritis, and the results are comparable with those in the literature.
Acknowledgement With many thanks for statistical analysis by Rod Taylor, Research and Development Support Unit, Postgraduate Medical School, Noy Scott House, Haldon View Terrace, Wonford, Exeter EX2 5EQ, UK.
References Alnot J Y, Saint Laurent Y (1985). Total trapeziometacarpal arthroplasty. Report on seventeen cases of degenerative arthritis of the trapeziometacarpal joint. Annales de Chirurgie de la Main, 4:11-2I. Armstrong A L, Hunter J B, Davis T R C (1994). The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. Journal of H a n d Surgery, 19B: 340-341. Burton R I (1973). Basal joint arthrosis of the thumb. Orthopedic Clinics of North America, 4:331-348. Eaton R G, Littler J W (1973). Ligament reconstruction for the painful thumb carpometacarpal joint. Journal of Bone and Joint Surgery, 55A: 1655-1666. Florack T M, Gastonia N C, Miller R J, Pellegrini V D, Burton R I, Dunn M G (1992). The prevalence of carpal tunnel syndrome in patients with basal joint arthritis of the thumb. Journal of H a n d Surgery, 17A: 6 2 4 6 3 0 . Kapandji A (1986). Cotation clinique de l'opposition et de la contre-opposition du pouce. Annales de Chirurgie de la Main, 5:67 73.
Received: 10 October 1996 Accepted after revision: 28 May 1997 S. Muermans MD, Bruul 5, 3220 Kortrijk-Dutsel (Holsbeek), Belgium. © 1997The British Society for Surgery of the Hand
From the Algemeen Ziekenhuis Sint Jozef Mechelen, Mechelen, Belgium In this retrospective study of 26 patients with arthritis of the thumb carpometacarpal joint, we report the use of expanded polytetrafluoroethylene (ePTFE) (Gore-Tex) and polypropylene (Marlex) as interpositional materials for resection arthroplasty of the trapeziometacarpal joint. We have compared the results with those of "conventional" tendon interposition and those in the literature. In three patients the use of ePTFE (Gore-Tex) was complicated by marked clinical synovitis, resembling findings in silicone synovitis. Therefore, the use of ePTFE has been discontinued. Polypropylene seems to be a valuable alternative to tendon interposition arthroplasty.
Journal of Hand Surgery (British and European Volume, 1998) 23B: 1:64~58 Arthritic change in the carpometacarpal joint is a common cause of pain at the base of the thumb and can seriously impair overall hand function. Various surgical techniques for its treatment have been described. In our service, the senior surgeon has mainly carried out trapeziectomy with interpositional arthroplasty. Three interpositional materials have been used: a soft tissue patch of expanded polytetrafluoroethylene (ePTFE) (Gore-Tex: Group 1, ten patients), polypropylene mesh (Marlex: Group 2, nine patients) and finally a strip of extensor carpi radialis longus tendon (Group 3, seven patients). Gore-Tex (expanded polytetrafluoroethylene) is a chemically inert, porous and biocompatible material. Fibroblastic and collagenic ingrowth is rather poor with only filmy adhesions and, therefore, ePTFE in its patch form can be used as an interpositional spacer. Polypropylene (Marlex mesh) is a biomaterial that stimulates a dense fibrotic incorporation with strong adhesions. The final result is thus comparable to a fibrous pseudarthrosis. The use of these two materials for this condition has not been described previously. As treatment of trapeziometacarpal osteorthritis is still a controversial subject, we have reviewed and compared the results obtained with all three materials retrospectively.
at the time of operation was 55 years (range 38-79). Fifteen had the dominant hand operated on and 11 the non-dominant. The mean follow-up time was 32 months. All patients complained of pain at the base of the thumb and loss of thumb and hand function. Except for the four revision cases, all were stage 2 to 4 according to the radiographic classification of Eaton and Littler (1973) (Fig 1). The incidence of associated soft tissue dis-
MATERIAL A N D M E T H O D S
In our service, 38 operations were performed on 38 patients with trapeziometacarpal arthritis between August 1987 and November 1994. Only 26 patients were available for this study as two had died and others could not be reached or failed to turn up for investigation. The assessment was carried out by an independent examiner who was not involved in the operations. All 26 patients had a unilateral procedure. Initial preoperative diagnoses included degenerative osteoarthritis in 23 patients and post-traumatic arthritis after a Bennett's fracture in three (male) patients. Four were revision procedures. Twentyone patients were female and five male. The average age
Fig 1
64
Stage 4 osteoarthritis of the trapeziometacarpaljoint in a postmenopausal woman.
INTERPOSITIONAL ARTHROPLASTY OF TMJ
65
orders and the need for other simultaneous surgical treatment has often been stressed (Burton, 1973; Florack et al, 1992). Additional surgical procedures were required at the time of operation in 11 of our patients (Table 1). Clinical assessment included evaluation of pain, pinch and grip strength, motion, instability, subjective improvement and satisfaction with the procedure, ability to return to daily or professional activities, and notification of possible complications. Pain intensity was objectively rated as a grade 1 to 4 as previously described by Alnot and Saint Laurent (1985) (Table 2). In our study, we considered stage 0 and 1 as good, stage 2 as satisfactory, stage 3 or 4 as insufficient. Groups were compared by one-way analysis of variance (Kruskal-Willis test) and Mann-Whitney test. Postoperative pulp-to-pulp pinch strength and grip strength were measured with the Jamar dynamometer. Preoperative data on strength were not available in most of our patients as they often presented with severe pain, limiting most activities. Therefore, strength was expressed as a percentage of the non-operated thumb. Statistical methods included were one-way analysis of variance and the unpaired Student's t-test. Range of motion was assessed for opposition and abduction. Opposition was graded 0 to 10 on the Kapandji scale (Kapandji, 1986) and abduction was expressed as a loss of ability to flatten the hand on a table top with the thumb metacarpal in radial abduction. Instability was assessed by provocative subluxation and the influence of a stabilizing ligamentoplasty was studied (Fisher's exact test). Performance of usual daily or professional activities was compared with the preoperative status. Overall subjective improvement and satisfaction with the procedure was then noted. Complications were looked at individually and reviewed according to the material used. The indication for operation was severely disabling carpometacarpal joint degeneration after failure of conTable 1--Associated surgical procedures
Carpal tunnel release
Group 1
Group2
Group3
Total
2
2
2
6
Trigger t h u m b release
1
Trimming second C M C boss
-
Arthrodesis D I P index
1
1 -
i
-
i
1
Trigger digit release
-
1
B u t t o n hole deformity
1
Release first web
1
-
-
Table 2 ~ t a g i n g of pain (Alnot and Saint Laurent, 1985) Stage Stage Stage Stage Stage
0 1 2 3 4
No pain. Pain in particular activities. Pain in daily activities. As 2 but with episodes of spontaneouspain. Constant or almost constant pain.
servative treatment in 22 patients. Four cases were revision procedures: the first due to thumb shortening after excision-arthroplasty and the second after a failed total joint replacement, both performed elsewhere; they were replaced by Gore-Tex grafts. The other two revised cases were extensor carpi radialis longus arthroplasties, one after a symptomatic subluxation of a Marlex-arthroplasty, and the other after persisting synovitis in a Gore-Tex-arthroplasty, both previously performed in our service.
Operative technique A dorsoradial S-shaped incision was used in all cases. After protection of the superficial branches of the radial nerve and artery, the capsule was freed and carefully dissected off the trapezium and first metacarpal base. The trapezium was removed piecemeal in order to preserve the capsule for subsequent reconstruction. Gore-Tex patch or Marlex mesh were used if there was no severe synovial inflammation. If significant synovitis was found, a tendon graft was indicated because the risk of adverse foreign body reaction to Gore-Tex and Marlex was expected to be increased. If tendon-interposition was performed, a strip of extensor carpi radialis longus was used. If a Gore-Tex patch or Marlex mesh were inserted, these materials were rolled in an "anchovy" fashion and secured on their own with a polyglyconate suture. The size was shaped to match the gap created by the trapeziectomy and to restore the length of the thumb (Fig 2). The "anchovy" was then implanted and the capsule securely closed. One or both slips of the abductor pollicis longus were used for an additional ligamentoplasty in six patients in Group 1, one patient in Group 2 and three in Group 3. Originally, immediate postoperative stability was assured by insertion of a K-wire crossing the first metacarpal, graft and scaphoid but this was later abandoned after one case of pin tract infection. K-wires were used in seven patients in Group 1, one patient in Group 2 and one in Group 3. Postoperatively, a scaphoid-type plaster was applied. After 4 weeks, cast and K-wires were removed and active mobilization started. RESULTS
1
Relief of pain
1
Results of pain relief are detailed in Table 3. In Group 1, all six cases of persisting pain seemed to be caused by
66
THE JOURNAL OF HAND SURGERY VOL. 23B No. 1 FEBRUARY 1998
Pulp pinch and grip strength Mean postoperative pinch and grip strength for all groups are detailed in Table 4. The results are expressed as a percentage of the pinch and grip strength of the opposite non-operated hand.
Range of motion Abduction was evaluated as the ability to flatten the hand on a table top. This was possible in 21 patients. Among the other five patients (two in Group 1, two in Group 2 and one in Group 3), one had a preoperative aduction contracture that was released at the time of operation but recurred as a late complication. Another patient had an associated subluxation and descent of the first metacarpal, despite ligamentoplasty and abductor pollicis longus advancement. The three other patients with lack of aduction also presented with some degree of postoperative aduction deformity. Opposition was graded 9 on the Kapandji scale (thumb pulp to proximal crease little finger) in all but the five patients previously mentioned.
Instability
Fig 2
Restoration of trapezial height after insertion of a polypropylene (Marlex) graft.
Table 3--Results of pain relief
Stage
Group 1 n=lO
0 1 2 3 4 Minor causalgia
4 6
8
Group 2 n=9
Group 3 n=7
2 5 " 2
1 5 1
2
4
minor cansalgia. A temporary causalgia had also previously been noted in two other patients who at the time of review had become completely painfree. In Group 2, both patients with stage 2 pain had demanding jobs and their dominant hand was involved. In one of them, pain was caused by thumb shortening with subsequent impingement between the collapsed first metacarpal and both the second metacarpal and the trapezoid. This resulted in an arthritic second CMC joint. Minor causalgia was only noted in two of the patients with residual pain. In Group 3, the stage 2 patient had tendon-interposition carried out as a revision procedure quite recently and pain still seemed to be improving. Minor causalgia was present in three patients and had subsided in one, thereby becoming completely painfree.
Overall, ligamentoplasty was performed in ten cases. Provocative subluxation of the base of the first metacarpal could only be elicited in two patients of the first group. One of these did not have a ligamentoplasty, the other developed a subluxation despite ligamentoplasty. Subluxation of the first metacarpal had also occurred earlier in one patient with a previous Marlex arthroplasty and was an indication for revision.
Functional improvement and patient sati~sfaction Full patient satisfaction with the operation was noted for six of ten patients in Group 1, six of nine patients in Group 2 and four of seven patients in Group 3. However, subjective functional improvement in performance of daily and professional activities was present in eight Table 4--Average pinch and grip strength (in kg). Results given as mean (SO)
Group 1 n=lO
Group 2 n=9
Group 3 n=7
1.65 (0.88) 1.80 (1.32) 106%
1.39 (0.93) 1.78 (0.97) 81%
1.71 (0.76) 2.42 (0.79) 77%
24.5 (10.7) 28.8 (13.5) 86%
22.9 (9.9) 30.6 (12.6) 75%
23.7 (12.0) 32.6 (11.2) 75%
Pb~ch strength Operated hand Non-operated hand % of non-op, hand
Grip strength Operated hand Non-operated hand % of non-op, hand
67
I N T E R P O S I T I O N A L A R T H R O P L A S T Y OF T M J
patients of ten in Group 1, eight patients of nine in Group 2 and six patients of seven in Group 3. Complications
Complications in all groups are noted in Table 5. There was one superficial infection. Significant clinical synovitis was present in three patients treated with Gore-Tex arthroplasty. The first of these reported a persisting degree of disabling pain at our review, 3 years after surgery. X-rays showed marked generalized carpal osteolysis, most prominent in the capitate and hamate (Fig 3). This resembled the radiolucency seen in silicone synovitis. An extensor carpi radialis longus arthroplasty was performed as a revision procedure after this study. The second patient also had pain and presented with clinical grinding. On X-ray, the Gore-Tex graft seemed to have disintegrated, causing synovitis. The third patient with clinically disabling synovitis had the Gore-Tex graft removed and replaced by an extensor carpi radialis longus tendon-graft at the time of review for this study. Operative inspection confirmed synovitis. Four patients presented with late advanced second carpometacarpal arthritis, two of which were associated with descent of the first metacarpal, impinging on both the second metacarpal base and the trapezoid. Fig 3 Generalized carpal osteolysisafter ePTFE (Gore-Tex)graft. This resemblesthe features seen in siliconesynovitis.
DISCUSSION Osteoarthritis of the trapeziometacarpal joint is common as a degenerative condition in postmenopausal women (Armstrong et al, 1994) but can also occur as a post-traumatic condition after Bennett's fracture. When conservative treatment fails to relieve disabling pain, surgery is often required. Many procedures have been advocated but the selection of a proper, reliable technique remains debatable. In this retrospective study, we report on excisional interposition-arthroplasty using three different materials, Gore-Tex, Marlex and conventional tendon. Overall, 23 of 26 patients were either pain free or showed minimal pain on strenuous activities. There were no significant
differences between the three groups. Residual pain was often found to be caused by minor causalgia: this was not related to the type of procedure but to the site of incision. The majority of our patients experienced marked subjective improvement of thumb and hand grip strength, but overall power still remained lower in the operated hand than the non-operated hand. This is consistent with most previous studies, regardless of the techniques used. Again, variations of strength according to the materials used were not statistically significant. Absolute pinch strength in general was rather low in our
Table 5--Complications Group 1 n=lO
Synovitis Infection Subluxation Adduction deformity Late advanced second CMC OA MC1 descent
Group 2 n=9
Group 3 n=7
-
1 (superficial)
1 (beforerevision) 2
1
1
2
1
1
-
1
3 1 (pin track) (not included) 2 2
68
series as most patients had low-demand hands, were retired or still experienced some pain on occasions. A satisfactory clinical range of abduction and opposition was found in 21 of the 26 patients. This was not related to the material used. We had good results for stability, as subluxation was only found in two patients. One of these occurred despite ligamentoplasty, and from these data no conclusions can be made on the efficiency of this procedure. We noted a discrepancy between overall subjective functional improvement (22 of 26 patients) and the rate of full patient satisfaction with the procedure (16 of 26 patients). These were not significantly related to the materials used. Patients who were dissatisfied despite functional improvement either had demanding jobs, relatively short follow-up or some form of complication. Among our complications was one case of subluxation that required conversion of a Marlex graft into a stabilized tendon arthroplasty. However, the most severe complication in our series was synovitis, found only in three patients with a Gore-Tex arthroplasty, requiring removal of the graft in two cases. We conclude that this is a form of adverse foreign body reaction, as the clinical and X-ray features resembled those of silicone synovitis. We did not encounter any case of synovitis in the Marlex group, nor in the tendon group. Another Gore-Tex graft was removed after the patient developed a pin tract infection. These drawbacks were considered sufficient to discontinue the use of Gore-Tex graft, in favour of the Marlex or tendon-arthroplasty. A perfect surgical treatment for trapeziometacarpal osteoarthritis should create a painless, mobile, strong
T H E J O U R N A L OF H A N D SURGERY VOL. 23B No. 1 FEBRUARY 1998
and stable thumb with long lasting function. Today, none of the available techniques have reached this goal. The use of Gore-Tex has now been discontinued due to a significant complication rate. We have found polypropylene (Marlex) to be an attractive and practical alternative to tendon interposition in the treatment of trapeziometacarpal osteoarthritis, and the results are comparable with those in the literature.
Acknowledgement With many thanks for statistical analysis by Rod Taylor, Research and Development Support Unit, Postgraduate Medical School, Noy Scott House, Haldon View Terrace, Wonford, Exeter EX2 5EQ, UK.
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Received: 10 October 1996 Accepted after revision: 28 May 1997 S. Muermans MD, Bruul 5, 3220 Kortrijk-Dutsel (Holsbeek), Belgium. © 1997The British Society for Surgery of the Hand