Exterior carpi radialis longus tendinoplasty for thumb basal joint arthritis

Thumb carpometacarpal arthritis has been successfully treated with a combination of trapezium excision, ligament reconstruction, and tendon interposition (most commonly with the flexor carpi radialis [FCR] tendon). We describe a technique using the extensor carpi radialis longus (ECRL) tendon and show, through dissection of 36 cadaver hands, the close relationship between this tendon and the intermetacarpal ligament. Of 16 patients (19 hands) managed with this technique, 95% were satisfied at a mean follow-up of 42 months. We conclude that ligament reconstruction and ECRL tendon interposition constitute a viable treatment option for carpometacarpal joint arthritis, especially when the FCR tendon is unavailable or its use is undesirable.     

Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb

Arthrosis of the trapeziometacarpal joint of the thumb is a predictable sequelae of ligament laxity. A new technique of tendon interposition arthroplasty with ligament reconstruction using the flexor carpi radialis tendon for a painful arthritic trapeziometacarpal joint of the thumb is described. Twenty-one patients had 25 operative procedures; 14 were women and seven were men. All of the patients presented with intractable pain, crepitus, and varying degrees of laxity of the basal joint. Pinch strength was diminished. Follow-up averaged 37 1/2 months. After surgery, 91.7% of patients had good to excellent results, and 56% were completely pain free. Range of motion and grip and pinch strengths were equal on the operated and unoperated sides.     

Thumb carpometacarpal arthroplasty using flexor carpi radialis

Ligament reconstruction-tendon interposition arthroplasty using flexor carpi radialis has become a popularprocedure in the surgical treatment of osteoarthrosis of the trapeziometacarpal joint at the base of the thumb. Principles of the surgical reconstruction include partial or complete trapeziectomy, stabilization of the metacarpal at the base of the thumb with a distally based strip of flexor carpi radialis tendon that discourages both dorsal subluxation and proximal migration of the thumb metacarpal, and interposition arthroplasty with the remaining flexor carpi radialis tendon packed into the trapezial fossa. Concurrent stabilization of the metacarpophalangeal joint is performed when there is greater than 30° of hypertension or valgus laxity. Carpal tunnel syndrome, de Quervain's extensor tenosynovitis, and stenosing flexor tenosynovitis are specifically sought as coexistent conditions and are treated operatively at the time of basal joint arthroplasty. Postoperative immobilization for 1 month with Kirschner wire fixation of the thumb metacarpal is followed by a directed rehabilitation program of active and passive motion and progressive resistive strengthening exercises over a 3 to 6 month period. Pain relief has been uniformly excellent and, at greater than 10-year follow-up, grip strength has improved by an average of 100%, tip pinch strength by more than 50%, and key pinch strength by nearly 35% when compared with preoperative values. Radiographic evaluation demonstrates minimal deterioration of position on stress radiographs, with an average subluxation of 11% of the width of the metacarpal base and an average loss of 13% of the height of the arthroplasty space. This modest radiographic deterioration of the arthroplasty does not correlate with any loss of functional capacity.     

A new modification of trapeziectomy and soft tissue interposition arthroplasty with abductor pollicis longus advancement

A new modification of trapeziectomy, soft-tissue interposition arthroplasty with a one-half slip of the flexor carpi radialis tendon and advancement of the abductor pollicis longus tendon for treatment of thumb carpometacarpal degenerative arthritis and instability is presented. This procedure facilitates tenodesis of the flexor carpi radialis slip at the first metacarpal and realigns and rebalances the thumb posture by using and advancing the abductor pollicis longus tendon. Therefore, this new modification eliminates the need for perioperative pin fixation of the first metacarpal, offers better soft tissue tenodesis of the ligament reconstruction component of the procedure, and results in improved intraoperative thumb alignment.     

Abductor pollicis longus tendon interposition for arthrosis in the first carpometacarpal joint: 55 thumbs reviewed after 3 (1-5) years

We have performed an interposition arthroplasty using the abductor pollicis longus (APL) tendon for arthrosis in the basal joint of the thumb in our department since 1995. Before this, we had been using an interposition with the flexor carpi radialis (FCR) tendon. We re-examined 47 patients (55 thumbs) after a median follow-up of 41 (16-60) months. The pain relief was excellent in 32 thumbs, and 25 patients improved their ability to perform daily tasks. Mobility was well preserved. Key pinch and grip strengths averaged 78% and 89%, respectively, of those in unaffected hands. An excellent general result was reported by 34 patients, while 4 patients would not have consented to the operation if they had known the outcome in advance.     

Abductor pollicis longus tendon interposition for arthrosis in the first carpometacarpal joint: 55 thumbs reviewed after 3 (1-5) years

We have performed an interposition arthroplasty using the abductor pollicis longus (APL) tendon for arthrosis in the basal joint of the thumb in our department since 1995. Before this, we had been using an interposition with the flexor carpi radialis (FCR) tendon. We re-examined 47 patients (55 thumbs) after a median follow-up of 41 (16-60) months. The pain relief was excellent in 32 thumbs, and 25 patients improved their ability to perform daily tasks. Mobility was well preserved. Key pinch and grip strengths averaged 78% and 89%, respectively, of those in unaffected hands. An excellent general result was reported by 34 patients, while 4 patients would not have consented to the operation if they had known the outcome in advance.     

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition

PURPOSE: To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improved the outcome of excision of the trapezium for the treatment of painful osteoarthritis of the trapeziometacarpal joint. METHODS: 183 thumbs with trapeziometacarpal osteoarthritis were randomized for treatment by either simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void during each of the 183 surgeries to hold the base of the thumb metacarpal at the level of the index carpometacarpal joint and was retained for 4 weeks in every case. All patients wore a thumb splint for 6 weeks. Each patient had subjective and objective assessments of thumb pain, stiffness, and strength before surgery and at 3 months and 1 year after surgery. RESULTS: The 3 treatment groups were well matched for age, dominance, and presence of associated conditions. Complications were distributed evenly among the 3 groups and no cases of subluxation/dislocation of the pseudarthrosis were observed. Of the 183 thumbs 82% achieved good pain relief and 68% regained sufficient strength to allow normal activities of daily living at the 1-year follow-up evaluation. Neither of these subjective outcomes nor the range of thumb movement was influenced by the type of surgery performed. Thumb key-pinch strength improved significantly from 3.5 kg before surgery to 4.6 kg at 1 year but the improvement in strength was not influenced by the type of surgery performed. CONCLUSIONS: The outcomes of these 3 variations of trapeziectomy were very similar at 1-year follow-up evaluation. In the short term at least there appears to be no benefit to tendon interposition or ligament reconstruction.     

Ligament reconstruction tendon interposition arthroplasty for basal joint arthritis: simplifying flexor carpi radialis tendon passage through the thumb metacarpal

During the ligament reconstruction tendon interposition arthroplasty for basal joint arthritis, the flexor carpi radialis tendon is passed through the base of the thumb and out an exit hole on its dorsum. When the entire width of the tendon is harvested, this aspect of the procedure can be difficult. Tapering the width of the proximal tendon and using a Carroll tendon retriever simplify the procedure and eliminate the need for enlarging the transosseous hole in the thumb metacarpal.     

Tendon interposition arthroplasty of carpometacarpal joint of the thumb

Osteoarthritis of the thumb carpal metacarpal joint is effectively managed by complete excision of the trapezium or excision of the distal half of the trapezium with maintenance of the space by insertion of interposition tendinous material from palmaris longus or flexor carpi radialis. The more recent modification of partial trapezium excision has improved pinch strength and maintenance of thumb length and so has enhanced the final results. Carpal metacarpal ligament reconstruction is demonstrated because it is occasionally necessary.     

Entire flexor carpi radialis tendon harvest for thumb carpometacarpal arthroplasty alters wrist kinetics

PURPOSE: To investigate the clinical outcome of thumb carpometacarpal arthroplasty with entire-thickness flexor carpi radialis (FCR) ligament reconstruction and tendon interposition and to investigate the isokinetic wrist flexion/extension torque and flexion fatigue strength of the surgically treated wrist compared with the nonsurgically treated wrist. METHODS: Thirty-nine patients with osteoarthritis who had unilateral thumb carpometacarpal arthroplasty with the entire FCR tendon were studied prospectively with a minimum follow-up period of 24 months. Preoperative Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, grip, pinch, and postoperative DASH score, grip, pinch, and Biodex (Shirley, NY) isokinetic wrist flexion/extension torques were recorded. The nonsurgically treated extremity served as the control for each patient with unilateral ligament reconstruction and tendon interposition. Peak torque ratios and fatigue were measured for the control and surgically treated extremities with the Biodex. RESULTS: Postoperative DASH scores were 12 +/- 4 and were improved significantly from preoperative scores of 43 +/- 4. The surgically treated extremity showed a significantly lower wrist flexion-to-extension peak torque ratio than the control extremity. The control extremity had 2.5 times greater wrist flexion fatigue resistance than the surgically treated side. After surgery the surgically treated extremity had significantly improved grip strength and thumb-index tip pinch compared with the preoperative status. CONCLUSIONS: Our data show conclusively that wrist flexion extension torque ratio decreases and wrist flexion fatigue resistance decreases when the entire FCR tendon is harvested even though the final outcome is favorable and uniformly based on traditional DASH, grip, and pinch scores.     

Ligament reconstruction of the painful, unstable, nonarthritic thumb carpometacarpal joint

Thirty-seven cases of ligament reconstruction of the nonarthritic thumb carpometacarpal joint were performed in 35 patients, 29 female and 6 male, between 1980 and 1996. Follow-up ranged from 1 to 17 years with an average of 5.2 years. The procedure described by Eaton and Littler in which a slip of the flexor carpi radialis (FCR) weaved through the first metacarpal and around the abductor pollicis longus and FCR was used. All patients had marked pain before surgery, and 65% were unable to work. No patient had radiographic evidence of arthritis before surgery. Sixty-seven percent had excellent results, and 30% had good results. All but 1 had complete or nearly complete pain relief. One hundred percent had good stability and improved pinch strength. All patients were able to return to work, 94% to their prior level of performance. There was no clinical or x-ray evidence of osteoarthritis in any patient at final follow-up.     

Dynamic suspension-sling arthroplasty with intermetacarpal ligament reconstruction for the treatment of trapeziometacarpal osteoarthritis

Our new dynamic suspension-sling arthroplasty of the trapeziometacarpal joint stabilizes the base of the first metacarpal after the removal of the trapezium in patients who have trapeziometacarpal joint osteoarthritis. Other techniques involving ligament reconstruction are accompanied by complications such as proximal migration, dorsal subluxation of the first metacarpal base, and impingement of the first and second carpometacarpal joints. In our technique, the first metacarpal is suspended by using a series of tendon loops derived from one-half of the flexor carpi radialis tendon and, therefore, anatomically reconstructs the intermetacarpal and palmar oblique ligaments. From 1988 to 2000, 197 patients (238 thumbs) underwent this procedure. Follow-up was an average of 1.92 years. After surgery, pain decreased, grip strength increased from 24 to 48.7 lb, key pinch increased from 4 to 7.6 lb, and Kapandji scores increased from 6 to 9.3 (averages). Our technique provides an interposition between the bases of the thumb and index metacarpals, resulting in decreased pain, greater strength, and increased flexibility of the trapeziometacarpal joint.     

Long-term results of tendon shortening trapeziometacarpal arthroplasty

Multiple soft tissue arthroplasties have been described for reconstruction of trapeziometacarpal arthritis. Trapeziectomy with abductor pollicis longus tendon shortening has been reported to have favorable short-term results, with 95% to 100% good or excellent pain relief at an average of 18 to 31 months. No long-term results of this reconstruction have been published. In the current study, 29 abductor pollicis longus shortening arthroplasties were reviewed at an average of 5.1 years. Although 83% of patients experienced good or excellent pain relief, pinch weakness, a small arthroplasty space, and first metacarpal instability were present in numerous patients. Because of these problems observed at long-term followup, the authors now use ligament reconstruction tendon interposition as the primary trapeziometacarpal arthroplasty.     

A preliminary report: cementless trapeziometacarpal arthroplasty

A cementless ball and socket trapeziometacarpal arthroplasty was used for the treatment of Eaton and Littler stage II and III trapeziometacarpal osteoarthritis. Forty-two joints were placed in 36 patients between 1986 and 1992. Five joints in 4 patients required revision. Thirty-four joints in 30 patients were evaluated with a mean follow-up period of 47 months (range, 15-86 months). Of the 33 monitored patients (39 joints), 79% reported good to excellent pain relief and excellent functional improvement and 12% reported poor to fair pain relief and functional improvement. Five joints required revision surgery and constituted 13% of the original arthroplasties. Thirty-three functional tests were graded before and after surgery and improvement was noted in all categories. Dramatic improvement was noted in the typical complaints for trapeziometacarpal joint disease, which are encountered in the activities of daily living. Radiolucent lines were present in 13 of 25 implants (52%), which were radiographically monitored. Radiographic loosening was present in 32%; 12 were around the trapezial component and 1 was around the metacarpal component. Radiographic loosening did not correlate with less satisfactory clinical results. Cementless trapeziometacarpal arthroplasty provides an operative alternative to arthrodesis in properly selected patients with trapeziometacarpal joint osteoarthritis. This joint is not intended to replace excisional or ligament reconstruction tendon interposition arthroplasty in lower demand patients or in those with pantrapezial arthritis. It also is not recommended in patients with rheumatoid arthritis or poor bone stock. It offers the advantages of maintaining excellent motion and stability. The cementless arthroplasty failures can be effectively salvaged by converting them to ligament reconstruction tendon interposition arthroplasty.     

The isolated scapho-trapezio-trapezoid ligament injury : Diagnosis and surgical treatment in four cases

Isolated injuries of the scapho-trapezial ligament complex are not well recognized. The ligament complex comprises the stout scapho-trapezial ligament, the floor of the flexor carpi radialis (FCR) tendon sheath and the scapho-capitate ligament.Between August 1991 and May 1992, we diagnosed and treated four cases of partial chronic post-traumatic lesions of this ligament complex. There was chronic pain at the base of the thenar eminence and instability of the thumb-index-middle finger pinch. Standard X-rays were normal. The diagnosis of ligament rupture was confirmed by mid-carpal arthrography showing filling of the sheath of FCR tendon. Surgical exploration showed complete rupture of the tendon sheath of FCR in two cases, associated in the other two cases with complete rupture of the scapho-trapezial ligament. Direct repair of the ligamentous elements was performed in all cases. The tendon of FCR was sutured to the tubercle of scaphoid to protect and to reinforce the ligament repair.The patients have been followed-up for between 6 and 12 months. All four patients recovered normal pinch strength to the middle finger. One patient suffered from chronic pain at work.     

Trapeziectomy and intermetacarpal ligament reconstruction with the extensor carpi radialis longus for osteoarthritis of the trapeziometacarpal joint: surgical technique and long-term results

PURPOSE: To report the long-term results of excision of the trapezium and intermetacarpal ligament reconstruction with the extensor carpi radialis longus for thumb trapeziometacarpal osteoarthritis. METHODS: Fourteen women and 5 men were retrospectively reviewed after an average of 9 years of follow-up evaluation. Trapeziectomy was performed and the extensor carpi radialis longus was harvested by a dorsoradial approach to reconstruct the intermetacarpal ligament. All patients wore a below-elbow cast for 6 weeks. Each patient had objective and subjective assessments. Thumb shortening was measured in follow-up radiographs. RESULTS: At the final follow-up evaluation, 16 (84%) patients were free of pain and 17 patients (89%) were satisfied with the results. Grip, key strength, and pinch strength improved compared with preoperative values. The trapezium space lost 14% of its height compared with preoperative values. Thumb motion improved, and there were no cases of instability. CONCLUSIONS: Resection-arthroplasty of the trapezium with intermetacarpal ligament reconstruction with the extensor carpi radialis longus is an effective procedure that permits motion restoration and pain relief in the trapeziometacarpal joint in the long term without affecting thumb stability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Post-traumatic instability of the trapeziometacarpal joint of the thumb. Diagnosis and the results of reconstruction of the beak ligament

In 28 patients with a solitary diagnosis of instability of the trapeziometacarpal joint because of a rupture of the anterior oblique ligament, reconstruction was carried out using a slip of the tendon of flexor carpi radialis. We were able to review 26 patients. The results after a follow-up of four years seven months showed that most (87%) had significant relief from pain and symptoms. Seventeen were graded as good to excellent. The mean grip strength recovered to 86% of the contralateral side. Most patients (81%) felt that they had subjective improvement and would have undergone the operation again. A lesser functional result was seen in those who developed a flexion deformity because of overtightening of the reconstruction. Increased awareness of this lesion can lead to an early and clear diagnosis so that the patient may be advised adequately. We describe a specific, diagnostic, clinical test which we have used consistently and successfully.     

The wire interlock technique for harvesting a partial-width distally attached tendon graft

A wire interlock technique useful for harvesting a partial-width tendon graft with an intact insertion for local reconstructive procedures is described. This technique is rapid and reliable for procuring attached tendon grafts with minimal exposure. The technique was used to harvest a flexor carpi radialis tendon graft for basal joint interposition arthroplasty in 12 patients. This method also may be readily applicable for other procedures requiring local ligament reconstruction with a partial-width tendon graft. (J Hand Surg 2000; 25A:176-182.     

Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective,single-surgeon study including outcomes measures

PURPOSE: Many surgeons have abandoned the simple trapeziectomy as a surgical treatment option for thumb basal joint arthritis secondary to reports of postoperative weakness. The thumb metacarpal subsiding into the trapezial void has been proposed as the causative factor. The goal of the present study was to evaluate the results of trapeziectomy and postoperative K-wire immobilization of the thumb metacarpal in a distracted position without the use of ligament reconstruction or tendon interposition. METHODS: Twenty-six thumbs in 26 patients from a single surgeon's practice were entered into a prospective single-arm study for surgical treatment of peritrapezial arthritis. Treatment consisted of piecemeal excision of the entire trapezium and 5 weeks of K-wire immobilization of the first metacarpal in slight distraction and opposition. No ligament reconstruction or tendon interposition was used. Motion, strength, stress radiographs, standardized dexterity tests, and outcomes questionnaires including the Arthritis Impact Measurement Scales 2 (AIMS2) were evaluated before surgery and 6 and 24 months after surgery. RESULTS: At 6 months 19 of 26 patients (73%) reported complete relief of pain and at 24 months 92% were entirely pain free. Range of motion evaluation showed 24 of 26 thumbs adducted fully into the plane of the palm and 25 of 26 opposed to the fifth metacarpal head. Comparisons between preoperative and 24-month postoperative strength measurements showed an average 47% increase in grip strength, 33% increase in key pinch strength, and a 23% increase in tip pinch strength over preoperative values. AIMS2 data showed postoperative improvement in "hand and finger function" and "arthritis pain" scales. CONCLUSIONS: After trapezial excision K-wire immobilization in a slightly overcorrected position without tissue interposition or ligament reconstruction restores a stable, pain-free thumb that has superior strength and motion compared with published reports of the more complicated interventions.