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Rheumatoid arthritis at the base of the thumb treated by trapezium resection or implant arthroplasty
Rheumatoid Arthritis at The Base of The Thumb Treated by Trapezium Resection or Implant Arthroplasty L. KVARNES and 0. REIKERAS From the Rheumatism Hospital, Oslo, Norway A clinical review is presented of patients with disabling rheumatoid arthritis at the base of the thumb treated by resection of the trapezium or by implant arthroplasty. Both methods resulted in good relief of pain, and the patients experienced better hand function. There were no great differences in results between the two methods. Introduction Rheumatoid arthritis often causes degenerative changes at the base of the thumb. Pain and swelling as well as loss of motion and strength may seriously interfere with normal hand function. The severity of the symptoms and deformity depends upon the degree of destructive changes and secondary imbalancing forces across the thumb ray. Absorptive changes in the trapezium and the base of the metacarpal may leave the metacarpal in radial and proximal subluxation with adduction contracture and associated swan-neck deformity of the thumb. If surgery is indicated resection of the trapezium has been an accepted mode of therapy (Gervis, 1949, 1973; Goldner, 1959; Murley, 1960; Sims, 1970; Iyer, 1981). During recent years the arthroplasty method for replacing the trapezium with a silicone rubber implant has been used by a number of authors (Swanson, 1972; de la Caffini&e,. 1972; Kessler, 1973; Dickson, 1976; Ashworth, 1977; Ferlic, 1977; de la Caffinikre, 1979). It is the purpose of this paper to report long-term results of resection of the trapezium and implant arthroplasty in cases of disabling rheumatoid arthritis at the base of the thumb. Patients and Methods The series comprises forty-nine patients who underwent surgical treatment during the years 1971 to 1981. Thirtysix of the patients were women and thirteen were men, the age averaged fifty-four years. All patients were disabled by pain and thumb deformity due to rheumatoid arthritis of long standing. Twelve of the patients were operated in both hands, so altogether sixty-one operations were performed involving right and left hands equally. All operations were performed through a dorsiradial skin incision. In thirty-nine cases total excision of the trapezium was carried out, and in twenty-two cases implant arthroplasty using a silicone prosthesis was performed according to Swanson (1972). Received for publication June, 1984. Las% Kvarnes and Olav Reikeras, Norway.
VOL.
10-B No.
2
JUNE
1985
Oslo
Sanitetsforening
Rheumatism
Hospital,
Oslo,
The patients were followed-up with an average observation time of seven years for those who underwent trapezium resection and three years for the patients with an implant arthroplasty. Assessment of pinch strength was determined as key pinch between the thumb and index and middle finger and as pulp pinch between the thumb and the index finger. A disc-shaped dynamometer with dimensions of 20x25~8 mm. based on the piezoresistent effect of Silicium was used, and changes in electrical potentials were transmitted to a Beckman Type RS Dynograph recorder (Beckman Instruments, Inc.).
Results During the observation period few complications were recorded. In the resection group there were four cases with dislocation and instability, and three of these were reoperated. Five prostheses dislocated and required reoperation. In the follow-up examination most of the patients found that their hand function was improved with pain relief. In both groups there was better thumb motion and stability, and improvement in power was felt by the patients. The results are summarized in Table 1. The key pinch was recorded to average 2.3 Kp in the resection group and 2.7 Kp in the prosthetic group. The pulp pinch was recorded to average l-5 and l-7 Kp respectively. TABLE 1. Results at follow-up in patients operated for rheumatoid arthritis at the base of the thumb by trapezium resection or by implant arthroplasty.
Pain free Improved function Stability Abduction 30” Opposition first to index finger first to middle finger
Resection N=39
Prosthesis N=22
37 39 35 37
16 19 17 19
39 36
21 21
195
L. KVARNES AND 0. REIKERAS
Discussion
The aims of surgical treatment for disabling rheumatoid arthritis at the base of the thumb are pain relief and improvement in hand function. This was achieved in most of the patients equally by resection of the trapezium as by implant arthroplasty. The key pinch and pulp pinch were poor as compared to normals (Reikergs, 1982). However, in patients with rheumatoid arthritis there is often such involvement of other joints that comparisons of strength to normal hands can not reasonably be performed. The most important motion of the thumb is opposition and palmar abduction. Therefore, patients with adduction-flexion contracture of the thumb are more disabled than patients with an unstable thumb. It is well known that resection of the trapezium gives good results for pain, but there is loss of stability (Gervis, 1949, 1973; Murley, 1960; Sims, 1970; Iyer, 1981). For patients with a fixed contracture this may be of benefit. The present results also showed excellent abduction after resection of the trapezium, and this was not obtained at the cost of loss of opposition. Furthermore, resection of the trapezium is an easy operation which involves a short convalescence. Implant arthroplasty has been reported to give a pain free, mobile and stable thumb in most cases (Swanson, 1981). However, certain points of technique have to be considered to obtain good results (Swanson, 1972). 1. the present study the difference in results between the two methods were not great. As implant arthroplasty is,
196
however, said to give better stability, so it may be preferred in patients with an unstable thumb. References ASHWORTH, C. R., BLATT, G., CHUINARD, R. G. and STARK, H. H. (1977). Silicone rubber interposition arthroplasty of the carpometacarpal joint of the thumb. The Journal of Hand Surgery 2: 345-451. DE LA CAFFINIkRE, J. Y. and AUCOUTURIER, P. (1979). Trapeziometacarpal Arthroplasty by Total Prosthesis. The Hand 11: 41-46. DE LA CAFFINIfiRE, J. Y. (1972). Replacement de I’articulation trapezometacarpienne par une totale articulbe scel&e.SICOT 122: 617-624. DICKSON, R. A. (1976). Arthritis of the Carpometacarpal Joint of the Thumb. Treatment by Silicone Sponge Interposition Arthroplasty. The Hand 8: 197-203. FERLIC, D. C., BUSBEE, G. A. and CLAYTON, M. C. (1977). Degenerative arthritis of the carpometacarpal joint of the thumb: A clinical follow-up of eleven Niebauerprostheses. The Journal of Hand Surgery 2: 212-215. GERVIS, W. H. (1949). Excision of the Trapezium for Osteoarthritis of the Trapezia-metacarpal Joint. The Journal of Bone and Joint Surgery 31B: 537-539. GERVIS, W. H. (1973). A review of excision of the trapezium for osteoarthritis of the trapeziometacarpal joint after twenty-five years. The Journal of Bone and Joint Surgery 558: 56-57. GOLDNER. J. L. and CLIPPINGER. F. W. (1959). Excision of the Greater Multan&ar Bone as an Adjunct toMobilization of the Thumb. The Journal of Bone and Joint Surgery 41A: 609-625. IYER, K. M. (1981). The Results of Excision of the Trapezium. The Hand 13: 246-250. KESSLER, I. (1973). Silicone Arthroplasty of the Trapezia-metacarpal Joint. Journal of Bone and Joint Surgery 55B: 285-291. MURLEY, A. H. G. (1960). Excision of the Trapezium in Osteoarthritis of the First Carpo-Metacarpal Joint. The Journal of Bone and Joint Surgery 42B: 502507. REIKERAS, 0. (1983). Bilateral differences of normal hand strength. Archives of Orthopaedics and Traumatic Surgery, 101: 223-224. SIMS, C. D. and BENTLEY, G. (1970). Carpometacarpal Osteo-arthritis Of The Thumb. The British Journal of Surgery 57: 4.42-448. SWANSON, A. B. (1972). Disabling Arthritis of the Base of the Thumb. The Journal and Joint Surgery 54A: 456-471. SWANSON, A. B., SWANSON, G. de G and WATERMEIER, J. J. (1981). Trapezium implant arthroplasty. Long-term evaluation of 150 cases. The Journal of Hand Surgery, 6: 125-141.
THE JOURNAL OF HAND SURGERY
VOL.
10-B No.
2
JUNE
1985
Oslo
Sanitetsforening
Rheumatism
Hospital,
Oslo,
The patients were followed-up with an average observation time of seven years for those who underwent trapezium resection and three years for the patients with an implant arthroplasty. Assessment of pinch strength was determined as key pinch between the thumb and index and middle finger and as pulp pinch between the thumb and the index finger. A disc-shaped dynamometer with dimensions of 20x25~8 mm. based on the piezoresistent effect of Silicium was used, and changes in electrical potentials were transmitted to a Beckman Type RS Dynograph recorder (Beckman Instruments, Inc.).
Results During the observation period few complications were recorded. In the resection group there were four cases with dislocation and instability, and three of these were reoperated. Five prostheses dislocated and required reoperation. In the follow-up examination most of the patients found that their hand function was improved with pain relief. In both groups there was better thumb motion and stability, and improvement in power was felt by the patients. The results are summarized in Table 1. The key pinch was recorded to average 2.3 Kp in the resection group and 2.7 Kp in the prosthetic group. The pulp pinch was recorded to average l-5 and l-7 Kp respectively. TABLE 1. Results at follow-up in patients operated for rheumatoid arthritis at the base of the thumb by trapezium resection or by implant arthroplasty.
Pain free Improved function Stability Abduction 30” Opposition first to index finger first to middle finger
Resection N=39
Prosthesis N=22
37 39 35 37
16 19 17 19
39 36
21 21
195
L. KVARNES AND 0. REIKERAS
Discussion
The aims of surgical treatment for disabling rheumatoid arthritis at the base of the thumb are pain relief and improvement in hand function. This was achieved in most of the patients equally by resection of the trapezium as by implant arthroplasty. The key pinch and pulp pinch were poor as compared to normals (Reikergs, 1982). However, in patients with rheumatoid arthritis there is often such involvement of other joints that comparisons of strength to normal hands can not reasonably be performed. The most important motion of the thumb is opposition and palmar abduction. Therefore, patients with adduction-flexion contracture of the thumb are more disabled than patients with an unstable thumb. It is well known that resection of the trapezium gives good results for pain, but there is loss of stability (Gervis, 1949, 1973; Murley, 1960; Sims, 1970; Iyer, 1981). For patients with a fixed contracture this may be of benefit. The present results also showed excellent abduction after resection of the trapezium, and this was not obtained at the cost of loss of opposition. Furthermore, resection of the trapezium is an easy operation which involves a short convalescence. Implant arthroplasty has been reported to give a pain free, mobile and stable thumb in most cases (Swanson, 1981). However, certain points of technique have to be considered to obtain good results (Swanson, 1972). 1. the present study the difference in results between the two methods were not great. As implant arthroplasty is,
196
however, said to give better stability, so it may be preferred in patients with an unstable thumb. References ASHWORTH, C. R., BLATT, G., CHUINARD, R. G. and STARK, H. H. (1977). Silicone rubber interposition arthroplasty of the carpometacarpal joint of the thumb. The Journal of Hand Surgery 2: 345-451. DE LA CAFFINIkRE, J. Y. and AUCOUTURIER, P. (1979). Trapeziometacarpal Arthroplasty by Total Prosthesis. The Hand 11: 41-46. DE LA CAFFINIfiRE, J. Y. (1972). Replacement de I’articulation trapezometacarpienne par une totale articulbe scel&e.SICOT 122: 617-624. DICKSON, R. A. (1976). Arthritis of the Carpometacarpal Joint of the Thumb. Treatment by Silicone Sponge Interposition Arthroplasty. The Hand 8: 197-203. FERLIC, D. C., BUSBEE, G. A. and CLAYTON, M. C. (1977). Degenerative arthritis of the carpometacarpal joint of the thumb: A clinical follow-up of eleven Niebauerprostheses. The Journal of Hand Surgery 2: 212-215. GERVIS, W. H. (1949). Excision of the Trapezium for Osteoarthritis of the Trapezia-metacarpal Joint. The Journal of Bone and Joint Surgery 31B: 537-539. GERVIS, W. H. (1973). A review of excision of the trapezium for osteoarthritis of the trapeziometacarpal joint after twenty-five years. The Journal of Bone and Joint Surgery 558: 56-57. GOLDNER. J. L. and CLIPPINGER. F. W. (1959). Excision of the Greater Multan&ar Bone as an Adjunct toMobilization of the Thumb. The Journal of Bone and Joint Surgery 41A: 609-625. IYER, K. M. (1981). The Results of Excision of the Trapezium. The Hand 13: 246-250. KESSLER, I. (1973). Silicone Arthroplasty of the Trapezia-metacarpal Joint. Journal of Bone and Joint Surgery 55B: 285-291. MURLEY, A. H. G. (1960). Excision of the Trapezium in Osteoarthritis of the First Carpo-Metacarpal Joint. The Journal of Bone and Joint Surgery 42B: 502507. REIKERAS, 0. (1983). Bilateral differences of normal hand strength. Archives of Orthopaedics and Traumatic Surgery, 101: 223-224. SIMS, C. D. and BENTLEY, G. (1970). Carpometacarpal Osteo-arthritis Of The Thumb. The British Journal of Surgery 57: 4.42-448. SWANSON, A. B. (1972). Disabling Arthritis of the Base of the Thumb. The Journal and Joint Surgery 54A: 456-471. SWANSON, A. B., SWANSON, G. de G and WATERMEIER, J. J. (1981). Trapezium implant arthroplasty. Long-term evaluation of 150 cases. The Journal of Hand Surgery, 6: 125-141.
THE JOURNAL OF HAND SURGERY