Partial trapeziectomy and interpositional arthroplasty for trapeziometacarpal osteoarthritis of the thumb

PARTIAL TRAPEZIECTOMY AND INTERPOSITIONAL ARTHROPLASTY FOR TRAPEZIOMETACARPAL OSTEOARTHRITIS OF T H E T H U M B J. MENON From the Department of Orthopaedic Surgery, Kaiser Permanente Medical Center, Fontana and Loma Linda University Medical Center, Loma Linda, California, USA

Partial excision including the articular surface of the trapezium and interpositional arthroplasty using one half of the flexor carpi radialis tendon was done in 36 hands. The joint capsule was reattached to the trapezium and the thumb immobilized for 4 weeks post-operatively. No ligament reconstruction was done. 30 hands (83.6%) had complete relief of pain. The average post-operative pinch strength was 11 lb. Three patients who complained of weakness of pinch had hyperextension of the MP joint. Correction of MP hyperextension is recommended to improve pinch strength. The outcome of this operation is comparable to any of the techniques described in the literature. The technique is simple and easy to perform. Since the capsule is closed the operation is truly an interpositional arthroplasty. Journal of Hand Surgery (British and European Volume, 1995) 20B." 5:700-706 then elevated from the volar capsule. This exposes the volar capsule (Fig 1). The abductor pollicis tongus tendon is then retracted radially. Retraction is facilitated if the abductor tendon sheath is released. The capsule of the trapeziometacarpal joint is then opened in such a fashion that a large tongue-shaped flap is left attached to the base of the first metacarpal (Fig 2). This exposes the trapeziometacarpal joint. The articular surface of the trapezium is then osteotomized using an oscillating saw and is removed (Fig 3). Care is taken to make sure that all the medial osteophytes are removed. The joint cavity is irrigated and cleaned. Through the proximal limb of the incision the flexor carpi radialis tendon is exposed. The tendon is split into two halves using an 11-blade knife. One half is detached at the musculotendinous junction and dissected free all the way up to the trapeziometacarpat joint. The tendon is left attached to the second metacarpal base (Fig 4). The detached portion is then rolled in the form of a ball. 2/0 chromic catgut sutures are inserted in a criss-cross fashion through this rolled-up tendon to maintain the shape. Using two Keith needles the suture is guided through the trapeziometacarpal joint and to the dorsal aspect of the hand. By pulling these sutures the rolled-up tendon is introduced into the trapeziometacarpal joint. Prior to introducing the rolled-up tendon, two drill holes are made through the trapezium. 2/0 Vicryl sutures are passed through these holes in order to reattach the capsule. After inserting the rolled-up tendon, the capsule is reattached to the trapezium by the previously inserted Vicryl sutures (Fig 5). Several additional sutures are inserted to reinforce the capsular repair. A Kirschner wire is inserted through the base of the first metacarpal and into the second to hold the thumb in abduction. The thenar muscle mass is repositioned in its normal place. The chromic catgut sutures are tied on the dorsal aspect of the hand over a button. The hand is immobilized in a bulky dressing for about 4 weeks. The cast and the K-wire are then removed and range of motion

Arthritic processes involving the trapeziometacarpal joint causes considerable impairment to the overall function of the hand. A variety of surgical procedures such as ligament reconstruction (Eaton and Littler, 1973), arthrodesis (Leach and Bolton, 1968; Mattsson, 1969), excisional arthroplasty (Dell et al, 1978; Gervis, 1949; Murley, 1960) and implant arthroplasty (Haffajee, 1977; Swanson, 1972; Swanson et al, 1977; Weilby and Sondorf, 1978) has been proposed for this condition. Carroll (1977), Froimson (1970), Buck-Gramcko (1972), Menon (1983) and Menon et al (1981 ) published the use of FCR as interpositional material after total excision of the trapezium, and reported satisfactory results. The purpose of this paper is to report the results of partial trapeziectomy and interpositional arthroplasty (Menon et al, 1994) using flexor carpi radialis tendon for trapeziometacarpal joint arthritis without ligament reconstruction. MATERIALS AND METHODS Indications for surgery All patients received conservative treatment with non-steroidal anti-inflammatory medication, steroid injections and splints. Patients who did not respond to conservative treatment and did not have peri-trapezial arthritis were considered to be candidates for modified tendon interpositional arthroplasty. Surgical technique (Menon et al, 1994) The procedure is usually done under intravenous regional anaesthesia. The incision starts on the radial border of the first metacarpal running across the trapeziometacarpal joint towards the tubercle of the scaphoid. This is then prolonged along the line of the flexor carpi radialis tendon. The sensory branches of the radial nerve are identified and protected. The thenar muscle mass is 700

PARTIAL TRAPEZIECTOMY

70 l

The rl

io-

joint

br.

Fig 1

The incision and approach for partial trapeziectomy. The radial artery and sensory branch of the radial nerve should be protected from injury.

exercises are started. A protective splint is worn for the next 8 weeks. 33 patients with 36 hands had partial trapeziectomy and interpositional arthroptasty for trapeziometacarpal joint arthritis. Three were male and 30 female. The mean age at the time of surgery was 59.5 years (range 54-81 years). The follow-up ranged from 24 to 91 months with a mean of 50.5 months. All patients had osteoarthritis of the trapeziometacarpal joint. All but five patients were personally evaluated by the author. Information about the five patients who could not come for follow-up was obtained from the records and by telephone interview. RESULTS 27 patients with 30 hands (83.6%) had complete relief of pain and would consider a similar procedure on their opposite side. Two patients complained of mild pain following activity. Four patients continued to complain of pain and they were not satisfied with the outcome of the procedure and considered as failures (11.1%). All of these four patients had revision surgery and insertion of Eaton's prosthesis (Eaton, 1979; DePuy, Warsaw, Indiana, USA). Three patients did not have any pain but complained of weakness of pinch. There was excellent range of motion of the thumb following surgery.

32 patients using 35 hands were able to touch the base of the little finger with the thumb. The pre-operative and post-operative grip and pinch strengths are given in Table 1. Post-operative pinch strength varied from 61b to 20lb. Pinch (43%, P<0.0005) and grip (27%, P - 0 . 0 1 7 ) strength increased significantly after surgery. There was a slight decrease in both pinch (-10%) and grip (-2.8%) strength in the unoperated (contralateral) thumbs with time. Men, in general, had stronger pinch strength compared to women in the same age group.

Complications There were no post-operative infections. One patient developed sensitive scar and required neurolysis of the sensory branch of the radial nerve. DISCUSSION Excision of the trapezium and insertion of a Silicone implant, or any interpositional material, for trapeziometacarpal joint arthritis is based on the reports that peritrapezial joints are involved in a significant percentage of patients and if left untreated could become a source of symptoms in the future. Swanson (1972) reported trapezio-index metacarpal involvement in 86%, trapeziotrapezoid in 35% and trapezio-scaphoid in 48% of

702

THE JOURNAL OF HAND SURGERY VOL. 20B No. 5 OCTOBER 1995

Thenar

Muscles If/ flap T.M. joint ------Trapezium - - Rad. a.

R0~LRI HAR.OLP

MNIAI$~N~AUg~

Fig 2

A capsular flap is raised, exposing the trapezium and TM joint.

patients with trapeziometacarpal joint arthritis. Haffajee (1977) reported 57% involvement of trapezio-index, 27% of trapezio-trapezoid and 16% of the scapho-trapezial joint. Stark et al (1977) reported trapezio-index involvement in 77%, trapezio-trapezoid in 20%, and trapezioscaphoid in 30%. Fusion of the trapeziometacarpal joint is an accepted procedure in the management of trapeziometacarpat joint arthritis and favourable results are reported in the literature (Leach and Bolton, 1968; Mattsson, 1969). Fusion has been shown to eliminate pain and improve pinch and grip strength. Poor results after successful fusion of trapeziometacarpal joint due to peri-trapezial arthritis has not been reported. Adaptive changes in the MP joint following fusion have been noted by Carroll and Hill (1973), but aggravation of peri-trapezial arthritis, if any, has not been clearly

documented. North and Eaton (1983) compared the radiological findings with anatomical dissection in 68 cadaver hands. They found significant discrepancies between radiological and anatomical findings. They found that trapezio-index and trapezio-trapezoid joints are seldom involved along with trapeziometacarpal joint arthritis even though radiological appearance suggests that. This is because of the overlapping of osteophytes around the adjacent joints. They found that radiological findings in the scapho-trapezial joint correlated well with the anatomical dissections. Only 34% of specimens showed changes in the scapho-trapezial joint, so excision of the trapezium should be considered only in patients with scapho-trapezial joint arthritis. Even though various materials have been used to fill the defect left by removal of the whole trapezium, they seldom fill the

Table 1--Pinch and grip strength

n** Pinch strength Grip strength

Operated thumb No surgery Surgery Non-operated thumb

Values are mean lb ± SD. *from paired t-tests. **ns vary due to missing data on some thumbs.

23 20 19 15

Before 7.4 + 11.5 + 28.3 + 36.2 +

3.3 4.8 12.5 11.9

Aider

% change

P value*

10.6 -t- 3.4 10.5 ± 3.9 36.0 + 13.1 35.2 + 15.7

+ 43% -- 10% + 27% - 2.8%

< 0.0005 0.875 0.017 0.721

PARTIAL TRAPEZIECTOMY

703

:ium

Fig 3

The distal part of the trapezium is excised.

space effectively. The metacarpal is essentially held in place by the intermetacarpal ligament. In partial trapeziectomy only the articular surfaces of the trapezium is excised. This is technically easier than dissecting the entire trapezium. The space is smaller and can be effectively packed with interpositional material. Closure of the trapeziometacarpal joint capsule creates an enclosed space, thus making the procedure a true interpositional arthroplasty. The remaining trapezium supports the first metacarpal during activities of pinch and grasp. Burton and Pellegrini (1986) and Eaton et al (t985) reported interpositional arthroplasty with intermetacarpal ligament reconstruction. Ligament reconstruction has not been necessary because the attachment of the volar oblique ligament and the intermetacarpal ligament is undisturbed in this technique, and Kirschner wire fixation of the first metacarpal for 4 weeks postoperatively with reattachment of the capsule to the trapezium provides sufficient stability of the base. Three patients complained of weakness of pinch postoperatively and noted difficulty in using the involved hand. Their pinch strengths varied from 6 to 9 lb. All of them had significant hyperextension of the MP joint of the thumb and adduction contracture of the first metacarpal (Table 2). Fisher's Exact test showed a significant association of weakness with the structural changes in the thumb (P=0.015). Nine patients in this

series had severe hyperextension of the MP joint of the thumb. This was left untreated since there was no concern of any prosthetic dislocation. Weakness of pinch can result from residual pain or structural alteration of the thumb. These patients did not complain of pain, and only three subjectively felt that the pinch was weak. Based on the analysis of post-operative pinch strength it seems wise to correct hyperextension of the MP joint of the thumb either by volar plate plication or by fusion in a slightly flexed position, even if an implant is not used. Distal advancement of APL is another option. This will direct the resultant force during pinch and grasp towards the second metacarpal base, increasing the pinch strength and reducing the chance of first metacarpal subluxation. Most articles in the literature on interpositional arthroplasty for the trapeziometacarpal joint have not emphasized the importance of correcting MP joint hyperextension and first metacarpal adduction for increasing strength. This could be because the trapezium excision corrects adduction deformity of the first metacarpal to a certain extent (Gotdner and Clippinger, 1959). Pinch strength varies from person to person and decreases with advancing age. Women, in general, have a lower pinch strength than men. Even though the quantitative values are lower than those of men, women perform tasks of day-to-day living equally well. Pre-operative pinch strength varied from 2 to 14 lb

THE JOURNAL OF HAND SURGERY VOL. 20B No. 5 OCTOBER 1995

704

\

1. joint

Rolled tendc

is

Fig 4

Half of FCR tendon is rolled up and placed in the cavity, still attached at its distal insertion.

with a m e a n of 7.5 lb, a n d post-operative p i n c h strength was 6 to 201b with a m e a n of 11 lb (Table 1). This corresponds well to other reported series (Table 3). Postoperative p i n c h strength was 11 lb on average, n o m a t t e r which technique was utilized ( A m a d i o et al, 1982). 13

patients o b t a i n e d 100% p i n c h strength c o m p a r e d to the opposite side, seven 90% a n d four 75% in this series. I n the r e m a i n i n g nine, the pinch strength c o u l d n o t be c o m p a r e d with the opposite side. Patients who h a d no p a i n a n d greater t h a n 60% of the opposite h a n d ' s p i n c h

Table 2--Structural alteration/pinch strength

Pre-op.

Post-op.

R

L

R

L 8 lb

1.

L.T.

11 lb

13 lb

10 lb

2.

F.G.

10 lb

1! lb(c/o weakness of pinch)

N/A(phone interview)

3.

E.H.

8 lb

8 lb

6 lb

6 lb

4.

M.J.

3 lb

9 lb(c/o weakness of pinch)

6 lb

7 lb

Severe hypertension of the MP joint Severe adduction of the 1st metacarpal, arthritis of other joints Severe adduction of the 1st metacarpal, metacarpal subluxation MP hyperextension

5. 6. 7.

R.F. J.K. Y.K.

N/A 6 lb 16 lb

11 lb 10 lb

8 lb 10 lb 9 lb

MP hyperextension MP hyperextension Adduction 1st metacarpal

7 lb 9 lb

5 lb 10 lb

MP hyperextension Valgus at MP

8. D.R. 8 lb 9. E.V. 9 lb (Operated side underlined)

7 lb 10 lb (c/o weakness of pinch) 8 lb 11 lb

13 lb

PARTIAL TRAPEZIECTOMY

705

osed capsule

~O~&RTHAROLP NNA~&N~U~r:

Fig 5

The capsule is closed.

Table 3--Comparison of key pinch measurements

Pre-op. Resection of trapezium and tendon arthroplasty (Menon et al, 1981) Trapezium implant (Swanson) Eaton's prosthesis (Eaton, 1979) 'Tie-in' trapezium prosthesis (Poppen and Niebauer, 1978) LTRT ~Burton and Pellegreni, 1986) Tendon suspension sling (Kleinman and Eckenrode, 1991) Partial resection and interposition (Froimson, 1987) Partial resection and interposition Ligament reconstruction (Eaton et al, 1985) Partial resection and interposition (Menon) Trapezium resection silicone/tendon interposition (Amadio et al, 1982)

3 lllb 10 lb

F 14 M1 F 100 Mll F 40 M6 M and F M and F 25 F31 M7 (no details)

Post-op.

71b 20 lb

11 lb 23 lb 7.4-16.06 lb 9.9-25.9 lb 5-15 lb F 9.9 lb M 14.7 lb F 11.6 lb M 11.3 lb 14 lb F 11.7 lb M 18 lb 11 lb

24 silicone implants 25 tendon

l l lb 10.2 lb

706

strength did well functionally (Menon et al, 1981). Four patients required a second operation because of persistent pain. Unrecognized peri-trapezial arthritis was the source of their pain. It is very important to rule out scapho-trapezial and scapho-trapezoid arthritis by appropriate pre-operative X-rays. In doubtful cases exploration of these joints should be done at the time of surgery. The most frequently used classification of trapeziometacarpal joint arthritis is based on the radiological appearance of the joint (Eaton and Litter, 1973) but this does not correlate well with symptoms. A patient with advanced changes on X-ray may have very little discomfort to recommend an operative procedure. Treatment should depend not only on the radiological appearance of the joint but also on the degree of symptoms and structural alteration of the thumb. Acknowledgement I would like to thank Floyd F. Peterson, MPH, Center for Health Research, Loma Linda University, for the statistical analysis of the results.

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Trapeziectomy and Interpositional Art,~roplasty: Technical Tips for Hand Surgery. Hanley and Belfus, 1994, 48 49. MENON, J. (1983). The problem of trapeziometacarpat degenerative arthritis. Clinical Orthopaedics and Related Research, 175:155 165. MENON, J., SCHOENE, H. R. and HOHL, J. C. (1981). Trapeziometacarpal arthritis: Results of tendon interpositional arthroplasty. Journal of Hand Surgery, 6: 5: 442-446. MURLEY, A. H. G. (1960). Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint. Journal of Bone and Joint Surgery, 42B: 3: 502 507. NORTH, E. R. and EATON, R. G. (1983). Degenerative joint disease of the trapezium: A comparative radiographic and anatomic study. Journal of Hand Surgery, 8: 160-167. POPPEN, N. K. and NIEBAUER, J. J. (1978). "Tie-in" trapezium prosthesis: Long-term results. Journal of Hand Surgery, 3:445 450. STARK, H., MOORE, J., ASHWORTH, C. R. and BOYES, J. H. (1977). Fusion of the first metaearpotrapezial joint for degenerative arthritis. Journal of Bone and Joint Surgery, 59A: 22-26. SWANSON, A. B. (1972). Disabling arthritis at the base of the thumb. Journal of Bone and Joint Surg, 54A: 456-471. SWANSON, A. B., WATERMEIER, J. J. and SWANSON, G. DeG. (1977). Trapezium implant arthroplasty: Long term evaluation of 150 cases. Orthopedic Transactions, h 15-16. WEILBY, A. and SIONDORF, J. (1978). Results following removal of silicone trapezium metacarpal implants. Journal of Hand Surgery, 3:154-156.

Accepted: 28 February 1995 Jay Menon MD, Department of Orthopaedic Surgery, Kaiser Penaaanente Medical Center, 9985 Sierra Avenue, Fontana, California 92335, USA. © 1995 The British Society for Surgery of the Hand