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Scaphotrapeziotrapezoid joint arthritis: a pilot study of treatment with the scaphoid trapezium pyrocarbon implant
ARTICLE IN PRESS SCAPHOTRAPEZIOTRAPEZOID JOINT ARTHRITIS: A PILOT STUDY OF TREATMENT WITH THE SCAPHOID TRAPEZIUM PYROCARBON IMPLANT L. PEGOLI, I. P. ZORLI, G. PIVATO, G. BERTO and G. PAJARDI From the Hand Surgery Unit, Multimedica Group, Plastic Surgery Department, University of Milan, Milan, Italy
Isolated scaphotrapeziotrapezoid osteoarthritis is rare but can cause weakness and wrist pain. We present the results of a pilot study of interposition arthoplasty with a scaphoid trapezium pyrocarbon implant (STPI) by an open and arthroscopic approach for this problem. We performed this procedure in 10 hands in eight patients, all women, with a mean age of 60.5 (range 51–70) years. The average follow-up was 19 (range 2–24) months. Pre-operative X-rays in all cases identified an isolated degenerative arthritis of the scaphotrapeziotrapezoid joint. Average DASH evaluation pre-operatively of 49 was reduced to 39. All of the patients had functional improvement and returned to daily activities after 3 months. The results of this pilot study suggest that the STPI may prove a useful compromise treatment for this problem. Journal of Hand Surgery (British and European Volume, 2006) 31B: 5: 569–573 Keywords: scaphotrapeziotrapezoid joint, osteoarthritis, prostheses, arthroscopy
Scaphotrapeziotrapezoid joint arthritis is often associated with trapeziometacarpal joint arthritis (Crosby et al., 1978; Linsched et al., 1990). Armstrong et al. (1994) reported a 10% incidence of arthritic degeneration of the scaphotrapeziotrapezoid joint in association with trapeziometacarpal joint arthritis in 90% of examined patients (Armstrong et al., 1994). However, an autopsy study of 68 wrists by North and Eaton (1983) found only 6% of cadaver wrists of patients of age greater than 50 years old with an isolated arthritis of the scaphotrapeziotrapezoid joint. So, in isolation, scaphotrapeziotrapezoid joint arthritis is a rare arthritis. The purpose of this study was to evaluate the preliminary results of the use of a new pyrocarbon implant after partial resection of the distal pole of the scaphoid, for isolated scaphotrapeziotrapezoid joint arthritis.
scaphotrapeziotrapezoid joint arthritis and a history of at least 2 years of chronic pain on the dorsoradial side of the first ray, with worsening problems of grip and pinch activities. All of the patients had previously undergone unsuccessful conservative treatment with a resting night splint for the wrist and first ray as far distally as the metacarpophalangeal joint and anti-inflammatory drugs for 3 months. Pre-operative assessment All patients were evaluated before surgery by measurement of grip strength using a JAMARs Hydraulic Hand Dynamometer, pinch strength using a JAMARs Hydraulic Pinch Gauge and pain according to a visual analogue scale (VAS) (100 mm line with verbal anchors of 0 as ‘‘no pain’’ and 100 as the ‘‘worst possible pain’’). Maximum palmar abduction was measured and thumb opposition was evaluated using Kapandji’s method (Kapandji, 1986) Patients were also evaluated using the DASH questionnaire (Hudak et al., 1996). All of the patients had routine X-rays taken, including a lateral and an anterioposterior radiograph with the wrist in the neutral position.
PATIENTS AND METHODS In this prospective study, ten hands with scaphotrapeziotrapezoid arthritis in eight patients were treated between January 2003 and December 2004. Only patients who presented with isolated scaphotrapeziotrapezoid arthritis were included. All of the patients were women and housewives, with a mean age of 60.5 (range 51–70) years. According to the Crosby’s classification, six hands were in Stage 3 and four were in Stage 1 (Crosby et al., 1978) (Table 1). In three patients, the left hand was involved and, in three, the right hand was involved. Two patients had bilateral involvement. All patients presented with radiographically documented
The implant The scaphoid trapezium interposition implant (STPI) is made of graphite coated with pyrocarbon [STPI, BIOProfile, Grenoble Cedex 1, France]. This material was developed in the 1960s from a collaboration between the CEA (French Commission for Atomic Energy) and General Atomic (US) for nuclear applications, as a coating for nuclear fuel. In the 1970s, the haemocompatibility of pyrocarbon was established and
The authors have no financial interest in this prosthesis and no benefit has been received 569
ARTICLE IN PRESS 570
THE JOURNAL OF HAND SURGERY VOL. 31B No. 5 OCTOBER 2006
Table 1—Crosby’s classification Stage Stage Stage Stage
0 1 2 3
No apparent anomaly Reduction to half of the normal joint space Hardly visible articular line Presence of erosions, scleroses and irregularity of the articular interline space
all mechanical heart valves in the world since 1970 have been made of this material. Use for carpal implants was developed in the 1990s. This material has the nearest Young’s modulus to bone and does not cause adverse reaction from surrounding tissues. This prosthesis has a button-like shape, with one convex and one concave surface. The former faces the remaining part of the scaphoid, while the latter faces the trapezium and trapezoid. Two sizes are available. Sizing is done using two templates. Surgical technique All of the patients were treated under brachial plexus anaesthesia and tourniquet control. Six patients underwent resection of the distal scaphoid and interposition of an STPI implant, through an open approach (Figs 1A and B). In four patients, the procedure was carried out as an arthroscopically assisted procedure. For the open procedure, a transverse incision was made dorsally at the level of the scaphotrapeziotrapezoid joint. The joint capsule was isolated and a distally based flap lifted. The scaphotrapeziotrapezoid joint was visualised and at least 3 mm of the distal pole of the scaphoid resected using an osteotome. While performing this, it is important to create a slight slope from the radial to the ulnar side of the bone to minimise the chance of dislocation of the implant. An STPI prosthesis of appropriate size was chosen with the help of the templates and inserted. Intraoperative passive mobilisation manoeuvres were performed to assess the stability of the implant. The capsule was then sutured. After careful haemostasis, the skin was closed with a reabsorbable, intradermal suture. For arthroscopic insertion, a 1.9 mm arthroscope was used. With the thumb suspended by 3 kg of traction in Chinese finger traps, two scaphotrapeziotrapezoid joint approaches were used. Both portals are located dorsally at the level of the midcarpal row, one radial to the tendons of the first compartment and the other ulnar to the tendons of the third compartment Debridement of the joint synovitis was performed with a 2.5 mm full radius shaver, to gain a better view of the joint and evaluate the cartilage damage. Resection of at least 3 mm of the distal pole of the scaphoid was then performed using a 2.5 mm burr. As with the open operation, a slight slope from the radial to the ulnar side of the bone was made to minimise the chance of dislocation of the implant. Furthermore, great care must
be taken to preserve as much as possible of the main ligament system of the joints, viz. the scaphotrapezial and scaphocapitate ligaments, being as these two ligaments are the most important in avoiding a DISI deformity. The two arthroscopic portal incisions were then joined by a small transverse incision and the appropriate size prosthesis chosen with the help of a template and then inserted. Postoperative rehabilitation The same postoperative protocol was used for the open and the arthroscopic-assisted procedures. Immediately after surgery, an irremovable thermoplastic splint which included the wrist and the metacarpophalangeal joint of the thumb was applied by the Occupational Therapist in the operating theatre. The following day, the hand was checked for oedema and splint position. The splint was then worn continuously for 3 weeks, during which time the patient was instructed to perform active exercises to dispel oedema. At 3 weeks, a removable splint, similar to the previous one, was applied and gentle active and passive mobilisation of the base of the thumb started. Strengthening exercises were started at 4 weeks postoperatively. On average, the removable splint was used for an additional 3 weeks. Postoperative assessment The same parameters measured pre-operatively were repeated at 3, 6 and 12 months postoperatively and the same standard radiographs were taken immediately after surgery, at 1 week and at 3 months. Complications were also recorded and treated.
RESULTS The average follow-up was 19 (range 2–24) months. All of the patients returned to their normal daily activities within 3 months and all reported an improvement of function. The average grip strength was 18 (range 13–24) kg force pre-operatively and 24 (range 21–26) kg force postoperatively. Pinch grip strength was 5 (range 4–6) kg force pre-operatively and 7 (range 6–8) kg force postoperatively. The VAS pain score averaged 6 (range 5–7) at rest and 9 (range 8–10) under load pre-operatively and 2 (range 0–4) at rest and 5 (range 4–7) under load postoperatively. The Kapandji score averaged 8 (range 7–9) pre-operatively and 9 (range 7–10) postoperatively. The ten procedures obtained a mean DASH score of 49 (range 43–60) pre-operatively and 39 (range 34–51) postoperatively. Two of the ten (20%) prostheses dislocated. This high percentage related to the learning curve. The two dislocations occurred in the first two patients and were due to inadequate resection of the distal scaphoid. One
ARTICLE IN PRESS SCAPHOTRAPEZIOTRAPEZOID JOINT ARTHRITIS
571
DISCUSSION
Fig 1 (A) Pre-operative X-ray showing scaphotrapeziotrapezoid arthritis, (B) Postoperative X-ray showing the prosthesis in site immediately after surgery.
occurred 1 week postoperatively and the other after 2 months. In the first case, the patient, treated by the arthroscopic-assisted approach, suddenly developed pain while still in the splint and X-ray identified the dislocation. The following day, the patient underwent secondary surgery by the open approach, followed by the standard postoperative rehabilitation protocol (Figs 2A–C) The other dislocation, treated originally by an open procedure, underwent secondary surgery 1 day after dislocation. The implant was repositioned by the open approach and the standard postoperative protocol followed. Both thumbs proceeded, thereafter, to satisfactory healing and are included in the results above. No infections, or other complications, occurred in this small series.
When we treat arthritis of the first ray, it is important to distinguish how many joints are involved in order to choose the best surgical procedure. This seems to be an obvious statement, but pathology of the scaphotrapeziotrapezoidal joint is not always recognized as such and is sometimes treated as an arthritis of the trapeziometacarpal joint. It is also mandatory to make the correct differential diagnosis, because scaphotrapeziotrapezoid arthritis can be associated with other pathologies (Cooney, 2003; Pinto et al., 2003; Srinivasa and Matthews, 1996; Wadhwani et al., 1998). Surgical treatment for scaphotrapeziotrapezoid arthritis is indicated when symptoms are no longer controlled by conservative treatment. If not correctly diagnosed and treated by removing the scaphotrapeziotrapezoidal impingement, pain and functional limitation will continue. Various surgical approaches have been described for treatment of scaphotrapeziotrapezoid arthritis, viz. arthrodesis of the scaphotrapeziotrapezoidal joint (Srinivasa and Matthews, 1996; Watson et al., 2003), resection of the distal scaphoid (with, or without, biological tissue interposition) (Garcia Elias et al., 1999), insertion of a silicone spacer (Kessler et al., 1976; Zemel, 1990) and arthroscopic debridement (Ashwood et al., 2003). Arthrodesis of the scaphotrapeziotrapezoidal joint can suffer complications such as residual pain and non-union (Fortin and Louis, 1993). Furthermore, it is a difficult procedure. Great care must be taken to position the scaphoid correctly and it may lead to limitation of scaphoid motility, essential to carpal kinematics (Fortin and Louis, 1993; Rodgers and Watson, 1989). Simple resection of the distal pole of the scaphoid has been described (Garcia Elias et al., 1999). This procedure may lead to greater destabilisation of the carpus, needing an associated capsuloplasty. Silicone prostheses may be complicated by reactive synovitis (Garcia Elias et al., 1999; Khoo, 1993; Srinivasa and Matthews, 1996; Watson et al., 1999). Only one paper has been published describing the results in 12 patients of the use of a pyrocarbon implant as a spacer after resection of the distal scaphoid (Pequinot et al., 2005).The results of this pilot study lend further support to the suggestion that the STPI pyrocarbon prosthesis may have a place in treatment of this arthritis as a compromise between the other surgical techniques. It avoids the loss of mobility of fusion procedures, while the use of a spacer maintains midcarpal mobility. The biconcave shape of the STPI prosthesis adapts well to the shape of the gap after resection of the distal pole of the scaphoid. The dislocations which occurred in this study were early in the learning curve, occurring in the first two patients as a result of inadequate resection of the distal scaphoid. Making the spacer of a material other than silicone eliminates the risk of silicone synovitis. Pyrocarbon has
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THE JOURNAL OF HAND SURGERY VOL. 31B No. 5 OCTOBER 2006
Fig 2 (A) Pre-operative X-ray, showing scaphotrapeziotrapezoid arthritis, (B) X-ray showing dislocation of the implant and (C) X-ray after repositioning of the implant.
excellent biocompatibility (Pequinot et al., 2005). The small operative procedure necessary to insert the spacer allows early mobilisation. If necessary, secondary conversion to a fusion at a later date would be possible and easy, although not found necessary to date in any patient in this series. References Armstrong A, Hunter JB, Davis TRC (1994). The prevalence of degenerative arthritis of the base of the thumb in postmenopausal women. Journal of Hand Surgery, 19B: 340–341.
Ashwood N, Bain GI, Fogg Q (2003). Results of arthroscopic debridement for isolated STT arthritis. Journal of Hand Surgery, 28: 729–732. Cooney WP (2003). Commentary: multidirectional instability of STT joint. Journal of Hand Surgery, 28: 751–752. Crosby EB, Linscheid RL, Dobyns JH (1978). Scaphotrapezial trapezoidal arthritis. Journal of Hand Surgery, 3A: 223–234. Fortin PT, Louis DS (1993). Long-term follow-up of scaphoid–trapezium–trapezoid arthrodesis. Journal of Hand Surgery, 18A: 675–681. Garcia Elias M, Lluch L, Ferreres A (1999). Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis. Journal of Hand Surgery, 24B: 448–452. Hudak PL, Amadio PC, Bombardier C (1996). Development of an upper extremity outcome measure: the DASH (disability of the
ARTICLE IN PRESS SCAPHOTRAPEZIOTRAPEZOID JOINT ARTHRITIS
arm, shoulder and hand)[corrected]. The Upper Extremity Collaborative Group (UECG). American Journal of Industrial Medicine, 29: 602–608. Kapandji AI (1986) Cotation clinique de l’opposition et de la contrapposition du pouce, Ann Chir Main Memb Super, 5: 67–73. Kessler I, Baruch A, Hecht O et al. (1976). Osteoarthritis of the base of the thumb. Acta Orthopaedica Scandinavica, 47: 361–369. Khoo CTH (1993). Silicone synovitis. The current role of silicone elastomer implants in joint reconstruction. Journal of Hand Surgery, 18B: 679–692. Linsched RL, Lirette R, Dobyns JH, L’artrose de´ge´ne´rative scaphotrape´zienne. In: Saffar PH (Ed.) La Rhizarthrose. Monographies du GEM. Paris, Expansion Scientifique Franc¸aise, 1990: 185–194. North ET, Eaton RG (1983). Degenerative joint disease of the trapezium: a comparative radiographic and anatomic study. Journal of Hand Surgery, 8: 160–167. Pequinot JP, D’Ansnieres deVeigy, Allieu Y (2005). Traitement de l’arthrose STT par un implant en pyrocarbone, Premiere resultats. Chirurgie de la Main, 24: 117–206. Pinto CH, Obermann WR, Deijkers RL (2003). Non traumatic instability of STT joint: a cause of scaphotrapeziotrapezoid osteoarthritis and static distalintercalated segment instability. Journal of Hand Surgery, 28A: 744–750. Rodgers WD, Watson HK (1989). Radial styloid impingement after triscaphe arthrodesis. Journal of Hand Surgery, 14A: 297–301.
573
Srinivasa VB, Matthews JP (1996). Results of scaphotrapeziotrapezoid fusion for isolated idiopathic arthritis. Journal of Hand Surgery, 21: 378–380. Wadhwani A, Carey J et al. (1998). Isolated scaphotrapeziotrapezoid osteoarthritis: a possible radiographic marker of chronic scapholunate ligament disruption. Clinical Radiology, 53: 376–378. Watson HK, Weinzweig J, Guidera PM et al. (1999). One thousand intercarpal arthrodeses. Journal of Hand Surgery, 24B: 307–315. Watson HK, Wollstein R, Joseph E et al. (2003). Scaphotrapeziotrapezoid arthrodesis: a follow-up study. Journal of Hand Surgery, 28A: 397–404. Zemel NP. Traitment de l’arthrose isole´ de l’articulation scaphotrapezio-trape´zoididienne. In: Saffar PH (Ed.) La Rizarthrose. Monographies de GEM. Paris, Expansion Scientifique Franc¸aise, 1990: 194–202. Received: 12 May 2005 Accepted after revision: 11 May 2006 Dr Loris Pegoli, Department of Plastic Surgery, University of Milan, Via Milanese 300 20099 Milan, Italy. Tel.: +39 022 420 9476; fax: +39 022 420 9308. E-mail: [email protected]
r 2006 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2006.05.006 available online at http://www.sciencedirect.com
Isolated scaphotrapeziotrapezoid osteoarthritis is rare but can cause weakness and wrist pain. We present the results of a pilot study of interposition arthoplasty with a scaphoid trapezium pyrocarbon implant (STPI) by an open and arthroscopic approach for this problem. We performed this procedure in 10 hands in eight patients, all women, with a mean age of 60.5 (range 51–70) years. The average follow-up was 19 (range 2–24) months. Pre-operative X-rays in all cases identified an isolated degenerative arthritis of the scaphotrapeziotrapezoid joint. Average DASH evaluation pre-operatively of 49 was reduced to 39. All of the patients had functional improvement and returned to daily activities after 3 months. The results of this pilot study suggest that the STPI may prove a useful compromise treatment for this problem. Journal of Hand Surgery (British and European Volume, 2006) 31B: 5: 569–573 Keywords: scaphotrapeziotrapezoid joint, osteoarthritis, prostheses, arthroscopy
Scaphotrapeziotrapezoid joint arthritis is often associated with trapeziometacarpal joint arthritis (Crosby et al., 1978; Linsched et al., 1990). Armstrong et al. (1994) reported a 10% incidence of arthritic degeneration of the scaphotrapeziotrapezoid joint in association with trapeziometacarpal joint arthritis in 90% of examined patients (Armstrong et al., 1994). However, an autopsy study of 68 wrists by North and Eaton (1983) found only 6% of cadaver wrists of patients of age greater than 50 years old with an isolated arthritis of the scaphotrapeziotrapezoid joint. So, in isolation, scaphotrapeziotrapezoid joint arthritis is a rare arthritis. The purpose of this study was to evaluate the preliminary results of the use of a new pyrocarbon implant after partial resection of the distal pole of the scaphoid, for isolated scaphotrapeziotrapezoid joint arthritis.
scaphotrapeziotrapezoid joint arthritis and a history of at least 2 years of chronic pain on the dorsoradial side of the first ray, with worsening problems of grip and pinch activities. All of the patients had previously undergone unsuccessful conservative treatment with a resting night splint for the wrist and first ray as far distally as the metacarpophalangeal joint and anti-inflammatory drugs for 3 months. Pre-operative assessment All patients were evaluated before surgery by measurement of grip strength using a JAMARs Hydraulic Hand Dynamometer, pinch strength using a JAMARs Hydraulic Pinch Gauge and pain according to a visual analogue scale (VAS) (100 mm line with verbal anchors of 0 as ‘‘no pain’’ and 100 as the ‘‘worst possible pain’’). Maximum palmar abduction was measured and thumb opposition was evaluated using Kapandji’s method (Kapandji, 1986) Patients were also evaluated using the DASH questionnaire (Hudak et al., 1996). All of the patients had routine X-rays taken, including a lateral and an anterioposterior radiograph with the wrist in the neutral position.
PATIENTS AND METHODS In this prospective study, ten hands with scaphotrapeziotrapezoid arthritis in eight patients were treated between January 2003 and December 2004. Only patients who presented with isolated scaphotrapeziotrapezoid arthritis were included. All of the patients were women and housewives, with a mean age of 60.5 (range 51–70) years. According to the Crosby’s classification, six hands were in Stage 3 and four were in Stage 1 (Crosby et al., 1978) (Table 1). In three patients, the left hand was involved and, in three, the right hand was involved. Two patients had bilateral involvement. All patients presented with radiographically documented
The implant The scaphoid trapezium interposition implant (STPI) is made of graphite coated with pyrocarbon [STPI, BIOProfile, Grenoble Cedex 1, France]. This material was developed in the 1960s from a collaboration between the CEA (French Commission for Atomic Energy) and General Atomic (US) for nuclear applications, as a coating for nuclear fuel. In the 1970s, the haemocompatibility of pyrocarbon was established and
The authors have no financial interest in this prosthesis and no benefit has been received 569
ARTICLE IN PRESS 570
THE JOURNAL OF HAND SURGERY VOL. 31B No. 5 OCTOBER 2006
Table 1—Crosby’s classification Stage Stage Stage Stage
0 1 2 3
No apparent anomaly Reduction to half of the normal joint space Hardly visible articular line Presence of erosions, scleroses and irregularity of the articular interline space
all mechanical heart valves in the world since 1970 have been made of this material. Use for carpal implants was developed in the 1990s. This material has the nearest Young’s modulus to bone and does not cause adverse reaction from surrounding tissues. This prosthesis has a button-like shape, with one convex and one concave surface. The former faces the remaining part of the scaphoid, while the latter faces the trapezium and trapezoid. Two sizes are available. Sizing is done using two templates. Surgical technique All of the patients were treated under brachial plexus anaesthesia and tourniquet control. Six patients underwent resection of the distal scaphoid and interposition of an STPI implant, through an open approach (Figs 1A and B). In four patients, the procedure was carried out as an arthroscopically assisted procedure. For the open procedure, a transverse incision was made dorsally at the level of the scaphotrapeziotrapezoid joint. The joint capsule was isolated and a distally based flap lifted. The scaphotrapeziotrapezoid joint was visualised and at least 3 mm of the distal pole of the scaphoid resected using an osteotome. While performing this, it is important to create a slight slope from the radial to the ulnar side of the bone to minimise the chance of dislocation of the implant. An STPI prosthesis of appropriate size was chosen with the help of the templates and inserted. Intraoperative passive mobilisation manoeuvres were performed to assess the stability of the implant. The capsule was then sutured. After careful haemostasis, the skin was closed with a reabsorbable, intradermal suture. For arthroscopic insertion, a 1.9 mm arthroscope was used. With the thumb suspended by 3 kg of traction in Chinese finger traps, two scaphotrapeziotrapezoid joint approaches were used. Both portals are located dorsally at the level of the midcarpal row, one radial to the tendons of the first compartment and the other ulnar to the tendons of the third compartment Debridement of the joint synovitis was performed with a 2.5 mm full radius shaver, to gain a better view of the joint and evaluate the cartilage damage. Resection of at least 3 mm of the distal pole of the scaphoid was then performed using a 2.5 mm burr. As with the open operation, a slight slope from the radial to the ulnar side of the bone was made to minimise the chance of dislocation of the implant. Furthermore, great care must
be taken to preserve as much as possible of the main ligament system of the joints, viz. the scaphotrapezial and scaphocapitate ligaments, being as these two ligaments are the most important in avoiding a DISI deformity. The two arthroscopic portal incisions were then joined by a small transverse incision and the appropriate size prosthesis chosen with the help of a template and then inserted. Postoperative rehabilitation The same postoperative protocol was used for the open and the arthroscopic-assisted procedures. Immediately after surgery, an irremovable thermoplastic splint which included the wrist and the metacarpophalangeal joint of the thumb was applied by the Occupational Therapist in the operating theatre. The following day, the hand was checked for oedema and splint position. The splint was then worn continuously for 3 weeks, during which time the patient was instructed to perform active exercises to dispel oedema. At 3 weeks, a removable splint, similar to the previous one, was applied and gentle active and passive mobilisation of the base of the thumb started. Strengthening exercises were started at 4 weeks postoperatively. On average, the removable splint was used for an additional 3 weeks. Postoperative assessment The same parameters measured pre-operatively were repeated at 3, 6 and 12 months postoperatively and the same standard radiographs were taken immediately after surgery, at 1 week and at 3 months. Complications were also recorded and treated.
RESULTS The average follow-up was 19 (range 2–24) months. All of the patients returned to their normal daily activities within 3 months and all reported an improvement of function. The average grip strength was 18 (range 13–24) kg force pre-operatively and 24 (range 21–26) kg force postoperatively. Pinch grip strength was 5 (range 4–6) kg force pre-operatively and 7 (range 6–8) kg force postoperatively. The VAS pain score averaged 6 (range 5–7) at rest and 9 (range 8–10) under load pre-operatively and 2 (range 0–4) at rest and 5 (range 4–7) under load postoperatively. The Kapandji score averaged 8 (range 7–9) pre-operatively and 9 (range 7–10) postoperatively. The ten procedures obtained a mean DASH score of 49 (range 43–60) pre-operatively and 39 (range 34–51) postoperatively. Two of the ten (20%) prostheses dislocated. This high percentage related to the learning curve. The two dislocations occurred in the first two patients and were due to inadequate resection of the distal scaphoid. One
ARTICLE IN PRESS SCAPHOTRAPEZIOTRAPEZOID JOINT ARTHRITIS
571
DISCUSSION
Fig 1 (A) Pre-operative X-ray showing scaphotrapeziotrapezoid arthritis, (B) Postoperative X-ray showing the prosthesis in site immediately after surgery.
occurred 1 week postoperatively and the other after 2 months. In the first case, the patient, treated by the arthroscopic-assisted approach, suddenly developed pain while still in the splint and X-ray identified the dislocation. The following day, the patient underwent secondary surgery by the open approach, followed by the standard postoperative rehabilitation protocol (Figs 2A–C) The other dislocation, treated originally by an open procedure, underwent secondary surgery 1 day after dislocation. The implant was repositioned by the open approach and the standard postoperative protocol followed. Both thumbs proceeded, thereafter, to satisfactory healing and are included in the results above. No infections, or other complications, occurred in this small series.
When we treat arthritis of the first ray, it is important to distinguish how many joints are involved in order to choose the best surgical procedure. This seems to be an obvious statement, but pathology of the scaphotrapeziotrapezoidal joint is not always recognized as such and is sometimes treated as an arthritis of the trapeziometacarpal joint. It is also mandatory to make the correct differential diagnosis, because scaphotrapeziotrapezoid arthritis can be associated with other pathologies (Cooney, 2003; Pinto et al., 2003; Srinivasa and Matthews, 1996; Wadhwani et al., 1998). Surgical treatment for scaphotrapeziotrapezoid arthritis is indicated when symptoms are no longer controlled by conservative treatment. If not correctly diagnosed and treated by removing the scaphotrapeziotrapezoidal impingement, pain and functional limitation will continue. Various surgical approaches have been described for treatment of scaphotrapeziotrapezoid arthritis, viz. arthrodesis of the scaphotrapeziotrapezoidal joint (Srinivasa and Matthews, 1996; Watson et al., 2003), resection of the distal scaphoid (with, or without, biological tissue interposition) (Garcia Elias et al., 1999), insertion of a silicone spacer (Kessler et al., 1976; Zemel, 1990) and arthroscopic debridement (Ashwood et al., 2003). Arthrodesis of the scaphotrapeziotrapezoidal joint can suffer complications such as residual pain and non-union (Fortin and Louis, 1993). Furthermore, it is a difficult procedure. Great care must be taken to position the scaphoid correctly and it may lead to limitation of scaphoid motility, essential to carpal kinematics (Fortin and Louis, 1993; Rodgers and Watson, 1989). Simple resection of the distal pole of the scaphoid has been described (Garcia Elias et al., 1999). This procedure may lead to greater destabilisation of the carpus, needing an associated capsuloplasty. Silicone prostheses may be complicated by reactive synovitis (Garcia Elias et al., 1999; Khoo, 1993; Srinivasa and Matthews, 1996; Watson et al., 1999). Only one paper has been published describing the results in 12 patients of the use of a pyrocarbon implant as a spacer after resection of the distal scaphoid (Pequinot et al., 2005).The results of this pilot study lend further support to the suggestion that the STPI pyrocarbon prosthesis may have a place in treatment of this arthritis as a compromise between the other surgical techniques. It avoids the loss of mobility of fusion procedures, while the use of a spacer maintains midcarpal mobility. The biconcave shape of the STPI prosthesis adapts well to the shape of the gap after resection of the distal pole of the scaphoid. The dislocations which occurred in this study were early in the learning curve, occurring in the first two patients as a result of inadequate resection of the distal scaphoid. Making the spacer of a material other than silicone eliminates the risk of silicone synovitis. Pyrocarbon has
ARTICLE IN PRESS 572
THE JOURNAL OF HAND SURGERY VOL. 31B No. 5 OCTOBER 2006
Fig 2 (A) Pre-operative X-ray, showing scaphotrapeziotrapezoid arthritis, (B) X-ray showing dislocation of the implant and (C) X-ray after repositioning of the implant.
excellent biocompatibility (Pequinot et al., 2005). The small operative procedure necessary to insert the spacer allows early mobilisation. If necessary, secondary conversion to a fusion at a later date would be possible and easy, although not found necessary to date in any patient in this series. References Armstrong A, Hunter JB, Davis TRC (1994). The prevalence of degenerative arthritis of the base of the thumb in postmenopausal women. Journal of Hand Surgery, 19B: 340–341.
Ashwood N, Bain GI, Fogg Q (2003). Results of arthroscopic debridement for isolated STT arthritis. Journal of Hand Surgery, 28: 729–732. Cooney WP (2003). Commentary: multidirectional instability of STT joint. Journal of Hand Surgery, 28: 751–752. Crosby EB, Linscheid RL, Dobyns JH (1978). Scaphotrapezial trapezoidal arthritis. Journal of Hand Surgery, 3A: 223–234. Fortin PT, Louis DS (1993). Long-term follow-up of scaphoid–trapezium–trapezoid arthrodesis. Journal of Hand Surgery, 18A: 675–681. Garcia Elias M, Lluch L, Ferreres A (1999). Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis. Journal of Hand Surgery, 24B: 448–452. Hudak PL, Amadio PC, Bombardier C (1996). Development of an upper extremity outcome measure: the DASH (disability of the
ARTICLE IN PRESS SCAPHOTRAPEZIOTRAPEZOID JOINT ARTHRITIS
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r 2006 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2006.05.006 available online at http://www.sciencedirect.com