Stabilization of the pre-arthritic trapeziometacarpal joint using ligament reconstruction

Chirurgie de la main 21 (2002) 277–281 www.elsevier.com/locate/chimai

Original article

Stabilization of the pre-arthritic trapeziometacarpal joint using ligament reconstruction Stabilisation de l’articulation trapézométacarpienne pré-arthrosique par reconstruction ligamentaire N. Van Giffen, H. Van Ransbeeck, L. De Smet * Department of orthopaedic surgery, U.Z. Pellenberg, Weligerveld 1, 3212 Lubbeek (Pellenberg), Belgium

Abstract Introduction: Trapeziometacarpal pre-arthrosis is a common condition with only limited therapeutic possibilities. Eaton and Littler designed a tendon stabilization. Materials and methods: A series of 21 thumbs with painful carpometacarpal joints, treated with a ligament reconstruction according to Eaton and Littler, is described. Three failed and further surgery was required. The outcome of 18 is evaluated. There were 11 women, 7 men with a mean age of 33.7 years, all having stages I or II of osteoarthritis. Six (30%) had a traumatic event in their history. Results: In the early stages of degenerative osteoarthritis, the overall outcome was good with a mean DASH score of 23.2. The carpometacarpal joint was stable but a 43% progression of radiographic osteoarthritic deterioration of the joint occurred. Conclusion: Stabilization of a painful pre-arthritic trapeziometacarpal joint is useful and reliable. A traumatic instability had worse results and probably is a contraindication to this technique. © 2002 E´ditions scientifiques et médicales Elsevier SAS. All rights reserved. Résumé Introduction : L’arthrose débutante de l’articulation trapézométacarpienne est une affection fréquente, mais les possibilités thérapeutiques restent limitées. Eaton et Littler ont décrit une stabilisation tendineuse. Matériel et méthode : Une série de 21 pouces avec une articulation trapézométacarpienne douloureuse a été traitée par la technique de Eaton et Littler. Trois patients sont considérés comme un échec. Les 18 autres, 11 femmes et 7 hommes avec un âge moyen de 33,7 ans font la base de cette étude. Ils ont tous un stade 1 ou 2 d’arthrose. Six ont eu un traumatisme dans leur histoire. Résultats : Le résultat global était favorable avec un score DASH de 23,2. L’articulation était stable dans tous les cas, mais dans 43 % des cas une progression de l’arthrose était visible. Conclusion : Dans les débuts de l’arthrose trapézométacarpienne la stabilisation est utile et reproductible, mais un traumatisme préalable est une contre indication relative. © 2002 E´ditions scientifiques et médicales Elsevier SAS. Tous droits réservés. Keywords: Thumb; Trapeziometacarpal joint; Basal joint; Arthritis; Ligament; Reconstruction Mots clés: Pouce; Articulation; Trapézométacarpienne; Ligament; Reconstruction; Ostéoarthrite

1. Introduction A major part of the stability of the trapeziometacarpal (TMC) joint is provided by its ligamentous support. Joint

* Corresponding author. © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. PII: S 1 2 9 7 - 3 2 0 3 ( 0 2 ) 0 0 1 2 9 - 4

instability due to ligament laxity not only causes effusion and pain, but produces also abnormal joint loading and predisposes to (pre-mature) degenerative arthritis [3]. Cadaver studies have provided insight into the complexity of the ligament structures surrounding the TMC joint. The anterior oblique ligament (AOL) or beak ligament has

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been described as a primary stabilizer [12,14]. It originates from the palmar tubercle of the trapezium and inserts onto the volar tubercle of the first metacarpal [1]. In fact, in an advanced stage of TMC osteoarthritis, eburnation of the articular cartilage occurs exclusively in the volar compartment, adjacent to the AOL. Another consistent finding is the fact that the AOL is detached from its metacarpal insertion in advanced cases of osteoarthritis [12]. The AOL is supported by the ulnar collateral ligament, which originates from the flexor retinaculum and inserts more medially and dorsally on the base of the metacarpal [14]. These ligaments are the primary restraints to volar subluxation. Bettinger et al. [1] also consider the dorsoradial ligament to be an important stabilizer. It originates from the dorsoradial tubercle of the trapezium and inserts broadly onto the dorsal edge of the metacarpal base. Its specific function however is still unclear. Idiopathic and post-menopausal laxity are considered a common cause for basal joint instability. Trauma, ligamentous or bony, can also cause varying degrees of joint laxity. Systemic disorders, such as inflammatory diseases and syndromes with generalized laxity (Ehler-Danlos, Marfan), also lead to instability of TMC joint and osteoarthritis [6]. In 1973, Eaton and Littler [4] described an extra-articular ligament reconstruction to stabilize the thumb basal joint. By using half of the flexor carpi radialis (FCR), tendon stability is given to the TMC joint in two planes. On one hand, the volar ligament structures are reinforced and, on the other hand, a new ligament is created on the radial aspect of the joint, an area devoid of true ligament structures [3]. In addition when the slip of the FCR tendon is passed through the metacarpal drillhole, it exits dorsally and when it is then passed deep to the abductor pollicus longus insertion on the metacarpal base, the graft assumes a dorsoradial position. This actually reinforces the dorsoradial ligament. When this procedure is performed on patients with laxity of the volar ligaments, without radiographic evidence of arthritis, it cannot only relieve the painful subluxation, but also should delay onset of basal joint osteoarthritis [5]. We reviewed our patients with this procedure, in order to analyze the outcome at a medium to long-term follow-up.

2. Materials and methods 2.1. Patients We reviewed a cohort of 21 patients treated with an extra-articular volar ligament reconstruction as described by Eaton and Littler. All patients had pre-operatively a radio-

graphic stages I or II basal joint disease, as described by Eaton and Glickel [2]. None of the patients responded sufficiently to conservative therapy, such as non-steroid anti-inflammatory drugs or splinting. Three thumbs were excluded from the study because further surgery had been performed elsewhere on their thumbs later on and were considered as failures. No further details are available. The other 18 thumbs were included in the study. An independent observer (NVG) reviewed 18 thumbs that underwent a TMC ligament reconstruction between July 1991 and June 1999. There were 11 women and seven men with a mean age of 33.7 years (range 18.6–52.1 years). The average follow-up period was 5.8 years, ranging from 2.0 and 10.0 years. There were nine right thumbs and nine left thumbs operated, 11 were dominant and seven nondominant. None of these patients had been operated bilaterally. Six patients (30%) had a history of trauma to their thumb: two patients with a Bennett’s fracture, initially treated conservatively, one patient with a bony avulsion of the radial pole of the trapezium, one patient with a TMC luxation 7 months earlier, and two patients with ligament ruptures. This relative high percentage of traumatic origin is probably due to recruitment of a university department. Four patients had generalized laxity of the joints, and in eight patients, the etiology was thought to be idiopathic ligament laxity. There were 14 thumbs with a radiographic stage I, and four thumbs with a stage II. 2.2. Evaluation Follow-up assessment included the DASH (disabilities of arm, shoulder and hand) (Table 1) questionnaire. The pain characteristics, global function, agility and patient satisfaction using a visual analog score (VAS) were evaluated (0 meaning no pain, normal function or very satisfied, 10 meaning severe pain, non-functioning thumb or not satisfied at all). The need for analgesia, the type, and frequency was noted. Local tenderness (in)stability, crepitations were noted. Range of motion, grip strength, and key pinch strength were measured and compared to the contralateral side. Dorso-volar stress laxity was rated from 1 to 3; grade 1 corresponds to 1-mm laxity, grades 2 and 3 correspond to 2 and 3-mm laxity, respectively. This was judged by eyeballing. The Kapandji score was used to measure the opposition of the thumb [7]. Finally, dorso-volar and lateral radiographs could be taken in 14 of the 18 patients. The radiographs were then staged according to the Eaton and Glickel classification [2].

N. Van Giffen et al. / Chirurgie de la main 21 (2002) 277–281 Table 1 Result of the DASH score (average per question and average per patient) Domestic activities

Average Range

1. Opening a jar lid 2. Writing 3. Turning a key 4. Prepare a meal 5. Opening a heavy door 6. Placing an object on a high shelf 7. Performing difficult domestic activities 8. Gardening 9. Making your bed 10. Carrying a heavy bag 11. Carrying a heavy object (> 5 kg) 12. Changing a light bulb 13. Washing and drying your hair 14. Washing your back 15. Putting on a sweater 16. Cutting meat with a knife 17. Leisure activities with light load 18. Leisure activities with stress put on the arm 19. Leisure activities with free arm movements 20. Organizing transport 21. Sexual activities 22. To which extent has the hand problem influenced your social activities with friends, family and neighbors 23. Were you limited in some way at work or other daily activities because of the hand problem?

1.94 1.39 1.78 1.67 2.17 2.06 2.50 2.44 1.67 2.28 2.56 1.56 1.44 1.61 1.50 1.72 2.11 2.33 2.56 1.56 1.28 1.53

1–4 1–4 1–4 1–3 1–5 1–5 1–5 1–5 1–4 1–5 1–5 1–5 1–4 1–4 1–4 1–4 1–5 1–5 1–5 1–3 1–2 1–4

1.92

1–4

2.3. Operative technique The surgical technique, according to the 1973 description of Eaton and Littler [4], was used. Creating a new ligament from a slip of FCR reinforces the palmar ligament, dorsal capsule, and radial capsule. The 8 cm FCR slip, harvested from the forearm, consists of the radial half of the FCR tendon and is left attached to the second metacarpal base distally. It is routed through the base of the metacarpal from palmar to dorsal, passed deep to the abductor pollicis longus insertion, then looped around the remaining FCR and secured over the radial side of the joint. The TMC is temporally fixed with a K-wire for 6 weeks.

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procedure was 7.11 (range 0–10). All but two patients were able to return to their pre-operative occupation. Both these patients were not able to return to work for other health reasons. Two patients were students at the time of operation, but they are able to perform the occupation of their choice. Finally, all but two patients would have the same operation done or recommend it to family or friends. There were no significant differences between stages I and II, concerning pain, function, satisfaction and DASH score. The average functional and satisfaction score using the VAS were 7.44 and 7.19, respectively, indicating good hand function. All patients were able to perform normal domestic activities. Thumb tenderness, dorso-volar stress laxity, grind test, and the metacarpal base compression test are presented in Table 2. Fourteen patients (78%) were stable to stress testing and were graded 1+, four patients (22%) had 2+ laxity, which we still considered to be stable. No patient had an unstable thumb basis. Fourteen patients (78%) had no joint tenderness at all, one patient (6%) had tenderness only over the scapho-trapezial (ST) joint, and three patients (17%) had tenderness over both ST- and TMC joint. The grind test was positive in five patients (28%) and the metacarpal base compression test was positive in only one patient (6%). Eleven patients (61%) were able to oppose their thumb to the base of the fifth finger (score 10), six patients (33%) had a score of 9 and one patient had a score of 7 (6%). All patients were able to flatten their palms on the table. The average radial and palmar abduction of the involved vs. the non-operated thumb were 69° and 68° compared with 72° and 71°. There was no statistical difference found between the operated and non-operated thumbs (t = 0.26 for radial abduction and t = 0.77 for palmar abduction, Wilcoxon test). The average metacarpo-phalangeal joint motion was 0–56° on the operated thumb and 0–60° for the contralateral thumb (not significant difference, t = 0.92). The interphaTable 2 Physical finding at follow-up

3. Results The average amount of pain using the VAS was 3.14 (range 0–9). Only three patients of the 18 patients required intermittent use of pain medication (all non-narcotic). One patient needed pain medication 2-4 times per month, another patient needed medication more than three times per week, and another patient used analgesics on a daily basis. There was no significant correlation between the level of pain, hand function, need for analgesics, agility and satisfaction. Results of the DASH score are listed in Table 1. The mean score was 23.2. The overall satisfaction rate of this

Thumb tenderness None ST-joint ST-joint TMC joint AP-stress test Grade 1 Grade 2 Grade 3 Grind test Positive Negative Metacarpal base compression test Positive Negative

N

Percent

14 1 3

77.8 5.5 16.7

14 4 0

77.8 22.2

5 13

27.8 72.2

1 17

5.6 94.4

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langeal motion averaged – 11° to 69° for the operated thumb and from – 7° to 69° for the uninvolved thumb (not significant). The mean key pinch strength for the operated thumbs was 7.78 kgf compared to 8.40 kgf for the non-operated thumbs. The mean grip strength was 36 kgf for the operated hand and 38 kgf for the non-operated hand. The average key pinch strength was 98% of the contralateral thumb for operated dominant thumbs and 94% for operated nondominant thumbs. The grip strength averaged 105% of the contralateral hand for operated dominant hand and 89% for the contralateral hand for operated non-dominant hands. Follow-up radiographs of the thumb base were available in 14 patients. Five patients had a radiographic stage I, six patients had a stage II, and three patients had a stage III. Three patients with a post-operative stage II had already a pre-operative stage II, and thus the TMC degeneration did not worsen. Of the remaining three patients with stage II disease, who all had a pre-operative stage I, one patient had a TMC instability due to a Bennett’s fracture, one patient had a generalized laxity, and the other had an idiopathic laxity of the TMC joint. Of the three patients with a post-operative stage III degeneration, two patients had a pre-operative instability secondary to a trauma. One of these had already a stage II TMC joint (Table 3). The overall satisfaction of patients with stage I disease had an average of 6.3 (out of 10). When one patient who had undergone an STT-fusion for scapho-lunar dissociation, and which was complicated by a pseudarthrosis was excluded, the average satisfaction score was 7.8. The average satisfaction score for stages II and III was 7.5 and 4.3, respectively. The average amount of pain using a VAS in stage I disease was 3.3, and when the same patient was excluded, it was 1.8. For stages II and III disease, the average amount of pain was 3.5 and 5.5, respectively. The four patients who were unwilling to have radiographs taken of the thumb were all satisfied with the result (satisfaction rate 9.5) and had only minor discomfort (average pain score according to the VAS was 1.63 (out of 10)). Table 3 Radiographic characteristics Pre-operative stage I

Post-operative stage

14

I II III a

II

4

a

II III

5 3 2 4 3 1

Four patients were not available for follow-up radiographs.

3.1. Complications One patient developed a hypoesthesia on the radial side of the thumb upon removal of the subcutaneous K-wire. In two patients, the K-wire broke and remained partially dislodged into the carpal bones. One of these patients developed a residual FCR tendinitis. This complication was resolved with conservative therapy including physical therapy and non-steroid anti-inflammatory medication. One patient developed algoneurodystrophy.

4. Discussion This study was designed to evaluate the subjective and objective results of the thumb base ligament reconstruction as described by Eaton and Littler [4]. The TMC joint has a wide range of motion due to its biconcave saddle joint configuration. Besides the bony configuration of the saddle joint, a major part of the stability of the TMC joint is provided by its ligamentous support. It has been suggested that instability of the TMC joint can cause not only a painful effusion that impairs hand function but also cause degenerative arthritis in this joint [5]. Cadaver studies have shown the AOL (volar ligament or beak ligament) to be a primary stabilizer of the TMC joint. Pelligrini has indicated that there is a direct correlation between the status of the articular surfaces and the integrity of the AOL [11]. It has been noted that degeneration of the palmar compartment was associated with attritional detachment of the AOL. Also in another study of the contact pattern of the TMC joint, it has been demonstrated that increased laxity of the volar ligaments leads to dorsal translation of the first metacarpal in pinch maneuver [12]. This leads to increased shear forces in the volar compartment and secondary degenerative changes to the cartilage [6,9,10,13]. It has been suggested by Freedman et al. [5] that a surgically stabilized TMC joint is less prone to increase shear forces and thus less likely to develop degenerative disease. In their study of 24 operated thumbs with an average follow-up of 15 years, there was only a minimal progression (8%) of articular degeneration after surgery. In our study, we had 43% progression, six patients of 14 who had follow-up radiographs, with an average follow-up period of 58 years. This figure is probably less, however, since in four clinically excellent patients, follow-up radiographs were not available. They all had a pre-operative stage I, and at follow-up visit, they had an average satisfaction rate of 9.5 and a pain score of 1.63 VAS. Of the six patients with radiographic progression, three had instability of the TMC joint due to trauma. This was also a patient group which was excluded in the study of Freedman et al. In

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the recent report of Lane and Henley [8] on 37 thumbs, the outcome was very favorable: 67% excellent and 30% good results. None of them progressed to arthritic degeneration. The disappearance of pain in our study was similar to the study of Freedman et al., 79% vs. 71%. Earlier studies by Eaton et al in 1984 [3] included patients of all radiographic stages. They reached a 95% good or excellent result for stages I and II patients. The amount of pain that a patient experienced however did not correlate to the use of and the amount of analgesics that he/she used nor with the radiographic stage. The weakness of this survey is the absence of pre-operative data concerning level of pain and laxity, but some conclusions are possible. Based on the subjective and objective results, a volar ligament reconstruction as described by Eaton and Littler seems to be indicated for symptomatic hypermobile prearthritic TMC joints. When laxity is due to trauma, this procedure is probably not sufficient. Perhaps bony procedures such as an osteotomy of the metacarpal or a TMC arthrodesis are more appropriate.

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