- Email: [email protected]
The early results of the Brunelli procedure for trapeziometacarpal instability
THE EARLY RESULTS OF THE BRUNELLI PROCEDURE TRAPEZIOMETACARPAL INSTABILITY
FOR
S. N. J. ROBERTS, J. N. BROWN, M. G. HAYES and A. SALES
From SPORTSMED. SA, Stepney, Australia We report the results of Brunelli's abductor pollicis longus transfer for symptomatic instability of the trapeziometacarpal joint in 15 hands (14 patients) at a mean follow-up of 21 months. Patients were assessed subjectively, and objectively by an independent observer. All but one of the patients were very satisfied with the result of the operation, including the six patients who had significant degeneration of the carpometacarpal joint surface preoperatively. Four patients said they had no pain and the mean pain score overall on a visual analogue scale was 1.2 (out of a maximum of 10). Overall the outcome was rated good or excellent in 11 of the 15 thumbs.
Journal of Hand Surgery (British and European Volume, 1998) 23B: 6." 758-761 Painful degenerative change in the trapeziometacarpal (TM) joint is common, particularly in middle-aged women, with or without a history of injury. Instability may cause or exacerbate these changes. Surgical options include osteotomy (Molitol, et al. 1991), arthrodesis (Bamberger et al. 1992) and either excision (Varley et al, 1994) or replacement arthroplasties (Eaton, 1991). However, little attention has been paid to the surgical management of early disease with instability in an attempt to alleviate symptoms as well as to prevent progression. There is evidence that trapeziometacarpal instability may be a cause rather than an effect of premature osteoarthritis (Pelligrini, 1991). Brunelli et al. (1989) described the biomechanics of the TM joint and pointed out that the two main forces acting on the joint (the a:lductor pollicis and abductor pollicis longus) form a force couple that tends to dislocate the base of the thumb metacarpal. They described a relatively simple procedure to stabilize the joint using the abductor pollicis longus tendon which removes one of the dislocating forces. We report the results of this procedure in 15 thumbs (14 patients) at a mean follow-up of 21 months.
contraindication. Only one patient had radiographic degenerative changes elsewhere in the carpus. Patients were recalled for interview and clinical examination by a surgeon who had had no previous involvement in the treatment. New radiographs were made if clinically indicated. Subjective assessment
Pain was assessed on a 10 cm visual analogue scale, and any difficulty with six activities of daily living was recorded. Patients scored their ability to turn a door knob, open a car door, a jar, a door with a key, do up buttons and write. Points were awarded as follows: unable to perform the activity - 0 points; able with great difficulty - 1 point; able with some difficulty - 2 points: and able to perform the activity easily 3 points. This made a total score for activities of daily living of between 0 and 18 points. Overall satisfaction was graded poor, fair or good. Objective assessment
Patients were examined for generalized ligamentous laxity (Beighton et al. 1969), and laxity of the thumb metacarpophalangeal and carpometacarpal joints. Adduction extension range of motion was assessed by the ability to place the hand fiat on a table and the tip of the thumb to the radial side of the index finger metacarpophalangeal joint. Functional flexion - adduction was scored on a ten point scale according to how far proximally on the little finger ray the thumb tip could reach actively (Kapandji, 1986). Key pinch and grasp strength were measured. Radiographs were graded using the method of Eaton et al. (1984) into four groups: stage I, normal articular contours, with widening of the joint space if an effusion is present; stage II, slight joint narrowing, normal contours and osteophytes less than 2 mm; stage iII, significant TM joint destruction, sclerosis, cysts and osteophytes over 2 mm in size; stage IV, multiple diseased articulations including the scaphotrapezial j oint.
PATIENTS AND M E T H O D S Between November 1995 and August 1996 the senior author (MGH) stabilized the thumb carpometacarpal joint in 16 hands using the technique described by Brunelli et al (1989). One woman could not be traced, leaving a study population of 14 patients (15 thumbs), all of whom attended for review. There were 10 women and four men with a mean age of 53 years (range, 45 62). Two patients were left handed including the single bilateral case. In total there were five left and 10 right - sided operations. The mean follow-up was 21 months (range, 15 25). The diagnosis was made clinically, but supported by plain radiographs. Stress views and ultrasonography were not found to be helpful. The procedure was not performed for instability in the presence of advanced degenerative changes, but early osteoarthritis in the presence of significant instability was not considered a 758
BRUNELL1 P R O C E D U R E F O R TMJ INSTABILITY
759
Operative technique
Objective assessment
The abductor pollicis longus tendon was harvested through a 6 cm linear incision extending proximally from the base of the thumb metacarpal, selecting the largest slip (if multiple) and sacrificing the others. A 6 cm length of tendon was reflected distally, and passed through a drill hole in the bases of the thumb and index metacarpals, made with the thumb in full abduction. A second incision was made at the base of the index metacarpal to retrieve the graft, which was then sutured under tension to periosteum and fascia (Fig 1). A below-elbow cast was applied with the thumb in abduction for 6 weeks, followed by a programme of mobilization.
Range of movement No patient had generalized ligamentous laxity, but four of the 14 patients had asymmetrical hyperextension of the metacarpophalangeal joint. None had laxity to adduction or abduction of the MCP joint, and no patient ha&recurrent instability of the TM joint. All patients could rest the hand flat on a table. All were able to place the thumb tip on the proximal little finger crease and in 12 the thumbs could touch the distal palmar crease (9 and 10 points respectively on Kapandji's scale) (Kapandji, 1986).
Strength RESULTS
Complications One patient suffered an undisplaced fracture o f the index metacarpal after an injury playing hockey, but made an excellent recovery to return to her work as a physiotherapist. There were no infections or neuromas.
Subjective outcome Patient satisfizction One patient graded the result fair and all the other 13 rated the result as good and said they would recommend the operation to a friend. Four patients reported no pain at all and the mean visual analogue pain score was 1.2 (of a maximum of 10) (Fig 2). Patients could perform most activities of daily living without difficulty within 3 months of surgery, although opening a tight jar was the most sensitive test giving some difficulty in 11 thumbs. The mean score for activities of daily living was 15.4 (of a maximum of 18 points), (Fig 2).
Figure 3 shows the key pinch and grip strength as a percentage of the opposite side. It should be noted that five patients had symptoms on the other side and considered the operation to have made the operated thumb the "strong side".
Radiographs Preoperatively, four thumbs had stage I degeneration, four stage II and six stage III. One hand showed scaphotrapezial changes and was therefore stage IV. At followup, new radiographs were made in nine cases, and there was no evidence of progression in any of these. The six patients with stage III and IV changes did not show any clear differences in either subjective or objective measures although this group did include the single patient classed as a failure. All of these patients with radiographic degenerative changes were very satisfied with the outcome of the procedure.
¢1
i
I,
l
Jll ~
Fig. 1 Operative technique (reproduced by the kind permission of Churchill Livingstone from: Brunelli G, Monini L, Brunelli F [I989]. Stabilization of the trapezio-metacarpaljoint. Journal of Hand Surgery, 14B:209-212).
760
THEJOURNALOF HANDSURGERYVOL.23BNo. 6 DECEMBER1998 160
1816 1412
1
I I 1
• ADL Score (max 18)
140
[] Pain (max10)
120
* Bilateral
I~ Grasp ] Key Pinch/
100-
10-
80-
864-
60
40 20
7 0
* Bilateral
•
7
7 I
7
I !
II
III
Radiographic Stage
II
III
IV
Radiographic Stage
IV
Fig. 3 Grasp and key pinch strengths (% of opposite side).
Fig. 2 Activities of daily livingand pain scores. Overall
We classified the results as excellent, good, fair and failure, in order to be rated excellent, the patient must have had no pain at all, key pinch and grip within 90% of the unoperated side, and be able to perform all the activities of daily living to a score of 17 or 18. G o o d results signified pain less than two on the visual analogue scale, strength within 80% of the unoperated side, and score two or three in each of the activities of daily living. Fair results had a pain score less than three, strength greater than 70% of the contralateral side, and a score of 12 or over for activities of daily living. Failures scored lower than this. By these criteria, there were four excellent, seven good, and three fair results. The one patient classed as a failure was subjectively quite satisfied with the result. However, he had multiple involvement of other joints in the same limb with psoriatic arthropathy and was unable to distinguish the thumb pain and disability from the other problems.
of experiments, and correlated degenerative changes with the status of the "beak" ligament (Pelligrini, 1991; Pellegrini et al. 1993; 1994a; 1994b). This research supports the hypothesis that pathological joint instability is the main cause of T M osteoarthritis by the mechanism of abnormal translation of the joint. Laxity of a joint is expected when there is loss of joint space as the ligamentous insertions approach one another, causing relative lengthening, but the abnormal biomechanics may also initiate and propagate degenerative change. Eaton et al. (1984) described the technique and results of T M stabilization using a strip of the flexor carpi radialis tendon. Although the outcomes were good or excellent in 74% of patients with advanced (stages III and IV) osteoarthritis, they recommended the procedure only when radiological degenerative changes were minimal or absent (stages I and II). We believe that the abductor pollicis longus is a better choice for tenodesis as it is a contributor to the abnormal translation of the joint.
DISCUSSION It has been suggested that variations in the insertion of the slips of the abductor pollicis longus tendon are associated with degenerative changes in the thumb carpometacarpal joint (Bouchlis et al. 1997). If all the fibres of the tendon insert into the base of the thumb metacarpal, rather than some inserting into the trapezium as has been described as the normal arrangement (Brunelli and Brunelli, 1991), it forms a force couple with the adductor pollicis with an increased tendency to displace the metacarpal base laterally on the trapezium (Fig 4), especially in the adducted position (Zancolli et al. 1987). In addition to this biomechanical theory, there are clinical signs that suggest that instability of the T M joint is a common cause of osteoarthrosis. Pellegrini and co-workers have analysed the patterns of contact pressure and degenerative changes in the joint in a series
3
Fig. 4 Biomechanical theory for the aetiology of TM osteoarthritis. (reproduced by the kind permission of Churchill Livingstone from: BrunelliG, Monini L, Brunelli F [1989]. Stabilizationof the trapezio-metacarpaljoint. Journal of Hand Surgery, 14B: 209 212).
BRUNELLI PROCEDURE FOR TMJ INSTABILITY
There was a surprisingly high level of satisfaction in these patients and very low morbidity even in the presence of pre-existing degenerative changes. The one patient who rated her satisfaction as only "fair" reported no pain and scored 15 out of 18 for the activities of daily living. She had greater pinch and grip strengths on the operated side compared with the unoperated side. The procedure is technically relatively simple and quick. It has produced satisfactory early results and it does not prevent subsequent arthrodesis or arthroplasty. References Bamberger HB, Stern PJ, Kiefhaber TR, McDonough JJ, Cantor RM (1992). Trapeziometacarpal joint arthrodesis: a functional evaluation. Journal of Hand Surgery, 17A: 605-611. Beighton R Price A, Lord J, Dickson E (1969). Variants of the Ehlers-Danlos syndrome. Clinical, biochemical, haematological, and chromosomal features of 100 patients. Annals of the Rheumatic Diseases, 28: 228~45. Bouchlis G, Bhatia A, Asfazadourian H, Touam C, Vacher C, Oberlin C (1997). Distal insertions of abductor pollicis longus muscle and arthritis of the first carpometacarpal joint in 104 dissections. Annals of Hand and Upper Limb Surgery, 16: 326-338. Brunelli G, Monini L, Brunelli F (1989). Stabilisation of the trapezio-metacarpal joint. Journal of Hand Surgery, 14B: 209~12. Brunelli GA, Brunelli GR (1991). Anatomical study of distal insertion of the abductor pollicis longus. Concept of a new musculo-tendinous unit: the abductor carpi muscle. Annales de Chirurgie de la Main et du Membre Superiem; 10: 56%576. Eaton RG (1991). Surgical management of basal joint disease of the thumb. Journal of Hand Surgery, 16B: 368 369.
761 Eaton RG, Lane LB, Littler JW, Keyser JJ (1984). Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment. Journal of Hand Surgery, 9A: 692 699. Kapandji A (1986). Clinical test of apposition and counter-apposition of the thumb. Annales de Chirnrgie de la Main, 5:67 73. Molitor PJ, Emery RJ, Meggitt BF (1991). First metacarpal osteotomy for carpometacarpal osteoarthritis. Journal of Hand Surgery, 16B: 424427. Pelligrini VD (1991). Osteoarthritis of the trapeziometacarpal joint: the pathophysiology of articular cartilage degeneration. II. Articular wear patterns in the osteoarthritic joint. Journal of Hand Surgery, 16A: 975 982. Pellegrini VD,"Olcott CW, Hollenberg G (1993). Contact patterns in the trapeziometacarpal joint: the role of the palmar beak ligament. Journal of Hand Surgery, 18A: 238-244. Pellegrini VD, Smith RL, Ku CW (1994a). Pathobiology of articular cartilage in trapeziometacarpal osteoarthritis. I. Regional biochemical analysis. Journal of Hand Surgery, 19A: 70-78. Pellegrini VD, Smith RL, Ku CW (1994b). Pathobiology of articular cartilage in trapeziometacarpal osteoarthritis. II. Surface ultrastructure by scanning electron microscopy. Journal of Hand Surgery, 19A: 79 85. Varley GW, Calvey J, Hunter JB, Barton NJ, Davis TR (1994). Excision of the trapezium for osteoarthritis at the base of the thumb. Journal of Bone and Joint Surgery, 76B: 964-968. Zancolli EA, Zaidenberg C, Zancolli E (1987). Biomechanics of the trapeziometacarpal joint. Clinical Orthopaedics and Related Research, 220: 14~26.
Recewed: 21 April 1998 Accepted after revision.29 June 1998 S.N.J. Roberts FRCS(Orth), SPORTSMED. SA, 32 Payneham Road, Stepney,SA 5069, Australia. E-mail: [email protected] © 1998The British Societyfor Surgeryof thc Hand
FOR
S. N. J. ROBERTS, J. N. BROWN, M. G. HAYES and A. SALES
From SPORTSMED. SA, Stepney, Australia We report the results of Brunelli's abductor pollicis longus transfer for symptomatic instability of the trapeziometacarpal joint in 15 hands (14 patients) at a mean follow-up of 21 months. Patients were assessed subjectively, and objectively by an independent observer. All but one of the patients were very satisfied with the result of the operation, including the six patients who had significant degeneration of the carpometacarpal joint surface preoperatively. Four patients said they had no pain and the mean pain score overall on a visual analogue scale was 1.2 (out of a maximum of 10). Overall the outcome was rated good or excellent in 11 of the 15 thumbs.
Journal of Hand Surgery (British and European Volume, 1998) 23B: 6." 758-761 Painful degenerative change in the trapeziometacarpal (TM) joint is common, particularly in middle-aged women, with or without a history of injury. Instability may cause or exacerbate these changes. Surgical options include osteotomy (Molitol, et al. 1991), arthrodesis (Bamberger et al. 1992) and either excision (Varley et al, 1994) or replacement arthroplasties (Eaton, 1991). However, little attention has been paid to the surgical management of early disease with instability in an attempt to alleviate symptoms as well as to prevent progression. There is evidence that trapeziometacarpal instability may be a cause rather than an effect of premature osteoarthritis (Pelligrini, 1991). Brunelli et al. (1989) described the biomechanics of the TM joint and pointed out that the two main forces acting on the joint (the a:lductor pollicis and abductor pollicis longus) form a force couple that tends to dislocate the base of the thumb metacarpal. They described a relatively simple procedure to stabilize the joint using the abductor pollicis longus tendon which removes one of the dislocating forces. We report the results of this procedure in 15 thumbs (14 patients) at a mean follow-up of 21 months.
contraindication. Only one patient had radiographic degenerative changes elsewhere in the carpus. Patients were recalled for interview and clinical examination by a surgeon who had had no previous involvement in the treatment. New radiographs were made if clinically indicated. Subjective assessment
Pain was assessed on a 10 cm visual analogue scale, and any difficulty with six activities of daily living was recorded. Patients scored their ability to turn a door knob, open a car door, a jar, a door with a key, do up buttons and write. Points were awarded as follows: unable to perform the activity - 0 points; able with great difficulty - 1 point; able with some difficulty - 2 points: and able to perform the activity easily 3 points. This made a total score for activities of daily living of between 0 and 18 points. Overall satisfaction was graded poor, fair or good. Objective assessment
Patients were examined for generalized ligamentous laxity (Beighton et al. 1969), and laxity of the thumb metacarpophalangeal and carpometacarpal joints. Adduction extension range of motion was assessed by the ability to place the hand fiat on a table and the tip of the thumb to the radial side of the index finger metacarpophalangeal joint. Functional flexion - adduction was scored on a ten point scale according to how far proximally on the little finger ray the thumb tip could reach actively (Kapandji, 1986). Key pinch and grasp strength were measured. Radiographs were graded using the method of Eaton et al. (1984) into four groups: stage I, normal articular contours, with widening of the joint space if an effusion is present; stage II, slight joint narrowing, normal contours and osteophytes less than 2 mm; stage iII, significant TM joint destruction, sclerosis, cysts and osteophytes over 2 mm in size; stage IV, multiple diseased articulations including the scaphotrapezial j oint.
PATIENTS AND M E T H O D S Between November 1995 and August 1996 the senior author (MGH) stabilized the thumb carpometacarpal joint in 16 hands using the technique described by Brunelli et al (1989). One woman could not be traced, leaving a study population of 14 patients (15 thumbs), all of whom attended for review. There were 10 women and four men with a mean age of 53 years (range, 45 62). Two patients were left handed including the single bilateral case. In total there were five left and 10 right - sided operations. The mean follow-up was 21 months (range, 15 25). The diagnosis was made clinically, but supported by plain radiographs. Stress views and ultrasonography were not found to be helpful. The procedure was not performed for instability in the presence of advanced degenerative changes, but early osteoarthritis in the presence of significant instability was not considered a 758
BRUNELL1 P R O C E D U R E F O R TMJ INSTABILITY
759
Operative technique
Objective assessment
The abductor pollicis longus tendon was harvested through a 6 cm linear incision extending proximally from the base of the thumb metacarpal, selecting the largest slip (if multiple) and sacrificing the others. A 6 cm length of tendon was reflected distally, and passed through a drill hole in the bases of the thumb and index metacarpals, made with the thumb in full abduction. A second incision was made at the base of the index metacarpal to retrieve the graft, which was then sutured under tension to periosteum and fascia (Fig 1). A below-elbow cast was applied with the thumb in abduction for 6 weeks, followed by a programme of mobilization.
Range of movement No patient had generalized ligamentous laxity, but four of the 14 patients had asymmetrical hyperextension of the metacarpophalangeal joint. None had laxity to adduction or abduction of the MCP joint, and no patient ha&recurrent instability of the TM joint. All patients could rest the hand flat on a table. All were able to place the thumb tip on the proximal little finger crease and in 12 the thumbs could touch the distal palmar crease (9 and 10 points respectively on Kapandji's scale) (Kapandji, 1986).
Strength RESULTS
Complications One patient suffered an undisplaced fracture o f the index metacarpal after an injury playing hockey, but made an excellent recovery to return to her work as a physiotherapist. There were no infections or neuromas.
Subjective outcome Patient satisfizction One patient graded the result fair and all the other 13 rated the result as good and said they would recommend the operation to a friend. Four patients reported no pain at all and the mean visual analogue pain score was 1.2 (of a maximum of 10) (Fig 2). Patients could perform most activities of daily living without difficulty within 3 months of surgery, although opening a tight jar was the most sensitive test giving some difficulty in 11 thumbs. The mean score for activities of daily living was 15.4 (of a maximum of 18 points), (Fig 2).
Figure 3 shows the key pinch and grip strength as a percentage of the opposite side. It should be noted that five patients had symptoms on the other side and considered the operation to have made the operated thumb the "strong side".
Radiographs Preoperatively, four thumbs had stage I degeneration, four stage II and six stage III. One hand showed scaphotrapezial changes and was therefore stage IV. At followup, new radiographs were made in nine cases, and there was no evidence of progression in any of these. The six patients with stage III and IV changes did not show any clear differences in either subjective or objective measures although this group did include the single patient classed as a failure. All of these patients with radiographic degenerative changes were very satisfied with the outcome of the procedure.
¢1
i
I,
l
Jll ~
Fig. 1 Operative technique (reproduced by the kind permission of Churchill Livingstone from: Brunelli G, Monini L, Brunelli F [I989]. Stabilization of the trapezio-metacarpaljoint. Journal of Hand Surgery, 14B:209-212).
760
THEJOURNALOF HANDSURGERYVOL.23BNo. 6 DECEMBER1998 160
1816 1412
1
I I 1
• ADL Score (max 18)
140
[] Pain (max10)
120
* Bilateral
I~ Grasp ] Key Pinch/
100-
10-
80-
864-
60
40 20
7 0
* Bilateral
•
7
7 I
7
I !
II
III
Radiographic Stage
II
III
IV
Radiographic Stage
IV
Fig. 3 Grasp and key pinch strengths (% of opposite side).
Fig. 2 Activities of daily livingand pain scores. Overall
We classified the results as excellent, good, fair and failure, in order to be rated excellent, the patient must have had no pain at all, key pinch and grip within 90% of the unoperated side, and be able to perform all the activities of daily living to a score of 17 or 18. G o o d results signified pain less than two on the visual analogue scale, strength within 80% of the unoperated side, and score two or three in each of the activities of daily living. Fair results had a pain score less than three, strength greater than 70% of the contralateral side, and a score of 12 or over for activities of daily living. Failures scored lower than this. By these criteria, there were four excellent, seven good, and three fair results. The one patient classed as a failure was subjectively quite satisfied with the result. However, he had multiple involvement of other joints in the same limb with psoriatic arthropathy and was unable to distinguish the thumb pain and disability from the other problems.
of experiments, and correlated degenerative changes with the status of the "beak" ligament (Pelligrini, 1991; Pellegrini et al. 1993; 1994a; 1994b). This research supports the hypothesis that pathological joint instability is the main cause of T M osteoarthritis by the mechanism of abnormal translation of the joint. Laxity of a joint is expected when there is loss of joint space as the ligamentous insertions approach one another, causing relative lengthening, but the abnormal biomechanics may also initiate and propagate degenerative change. Eaton et al. (1984) described the technique and results of T M stabilization using a strip of the flexor carpi radialis tendon. Although the outcomes were good or excellent in 74% of patients with advanced (stages III and IV) osteoarthritis, they recommended the procedure only when radiological degenerative changes were minimal or absent (stages I and II). We believe that the abductor pollicis longus is a better choice for tenodesis as it is a contributor to the abnormal translation of the joint.
DISCUSSION It has been suggested that variations in the insertion of the slips of the abductor pollicis longus tendon are associated with degenerative changes in the thumb carpometacarpal joint (Bouchlis et al. 1997). If all the fibres of the tendon insert into the base of the thumb metacarpal, rather than some inserting into the trapezium as has been described as the normal arrangement (Brunelli and Brunelli, 1991), it forms a force couple with the adductor pollicis with an increased tendency to displace the metacarpal base laterally on the trapezium (Fig 4), especially in the adducted position (Zancolli et al. 1987). In addition to this biomechanical theory, there are clinical signs that suggest that instability of the T M joint is a common cause of osteoarthrosis. Pellegrini and co-workers have analysed the patterns of contact pressure and degenerative changes in the joint in a series
3
Fig. 4 Biomechanical theory for the aetiology of TM osteoarthritis. (reproduced by the kind permission of Churchill Livingstone from: BrunelliG, Monini L, Brunelli F [1989]. Stabilizationof the trapezio-metacarpaljoint. Journal of Hand Surgery, 14B: 209 212).
BRUNELLI PROCEDURE FOR TMJ INSTABILITY
There was a surprisingly high level of satisfaction in these patients and very low morbidity even in the presence of pre-existing degenerative changes. The one patient who rated her satisfaction as only "fair" reported no pain and scored 15 out of 18 for the activities of daily living. She had greater pinch and grip strengths on the operated side compared with the unoperated side. The procedure is technically relatively simple and quick. It has produced satisfactory early results and it does not prevent subsequent arthrodesis or arthroplasty. References Bamberger HB, Stern PJ, Kiefhaber TR, McDonough JJ, Cantor RM (1992). Trapeziometacarpal joint arthrodesis: a functional evaluation. Journal of Hand Surgery, 17A: 605-611. Beighton R Price A, Lord J, Dickson E (1969). Variants of the Ehlers-Danlos syndrome. Clinical, biochemical, haematological, and chromosomal features of 100 patients. Annals of the Rheumatic Diseases, 28: 228~45. Bouchlis G, Bhatia A, Asfazadourian H, Touam C, Vacher C, Oberlin C (1997). Distal insertions of abductor pollicis longus muscle and arthritis of the first carpometacarpal joint in 104 dissections. Annals of Hand and Upper Limb Surgery, 16: 326-338. Brunelli G, Monini L, Brunelli F (1989). Stabilisation of the trapezio-metacarpal joint. Journal of Hand Surgery, 14B: 209~12. Brunelli GA, Brunelli GR (1991). Anatomical study of distal insertion of the abductor pollicis longus. Concept of a new musculo-tendinous unit: the abductor carpi muscle. Annales de Chirurgie de la Main et du Membre Superiem; 10: 56%576. Eaton RG (1991). Surgical management of basal joint disease of the thumb. Journal of Hand Surgery, 16B: 368 369.
761 Eaton RG, Lane LB, Littler JW, Keyser JJ (1984). Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment. Journal of Hand Surgery, 9A: 692 699. Kapandji A (1986). Clinical test of apposition and counter-apposition of the thumb. Annales de Chirnrgie de la Main, 5:67 73. Molitor PJ, Emery RJ, Meggitt BF (1991). First metacarpal osteotomy for carpometacarpal osteoarthritis. Journal of Hand Surgery, 16B: 424427. Pelligrini VD (1991). Osteoarthritis of the trapeziometacarpal joint: the pathophysiology of articular cartilage degeneration. II. Articular wear patterns in the osteoarthritic joint. Journal of Hand Surgery, 16A: 975 982. Pellegrini VD,"Olcott CW, Hollenberg G (1993). Contact patterns in the trapeziometacarpal joint: the role of the palmar beak ligament. Journal of Hand Surgery, 18A: 238-244. Pellegrini VD, Smith RL, Ku CW (1994a). Pathobiology of articular cartilage in trapeziometacarpal osteoarthritis. I. Regional biochemical analysis. Journal of Hand Surgery, 19A: 70-78. Pellegrini VD, Smith RL, Ku CW (1994b). Pathobiology of articular cartilage in trapeziometacarpal osteoarthritis. II. Surface ultrastructure by scanning electron microscopy. Journal of Hand Surgery, 19A: 79 85. Varley GW, Calvey J, Hunter JB, Barton NJ, Davis TR (1994). Excision of the trapezium for osteoarthritis at the base of the thumb. Journal of Bone and Joint Surgery, 76B: 964-968. Zancolli EA, Zaidenberg C, Zancolli E (1987). Biomechanics of the trapeziometacarpal joint. Clinical Orthopaedics and Related Research, 220: 14~26.
Recewed: 21 April 1998 Accepted after revision.29 June 1998 S.N.J. Roberts FRCS(Orth), SPORTSMED. SA, 32 Payneham Road, Stepney,SA 5069, Australia. E-mail: [email protected] © 1998The British Societyfor Surgeryof thc Hand