Long-term follow-up of trapeziometacarpal arthroplasty with coexisting scaphotrapezial disease.

Visualization of the scaphotrapezial joint during basal joint arthroplasty has been recommended to establish the stage of degeneration. This study attempts to clarify that recommendation and evaluate whether moderate wear of the joint precludes a good result of trapeziometacarpal hemiarthroplasty. To assess the need for inspection of the scaphotrapezial joint, x-ray films, tomograms, and operative findings in 23 cases of basal joint arthroplasty were reviewed. X-ray findings agreed with operative findings at the scaphotrapezial joint in only 76% of the cases. We also evaluated 18 thumbs in 15 patients who underwent interposition arthroplasty of the trapeziometacarpal joint and at surgery had moderate degenerative changes of the scaphotrapezial joint. The scaphotrapezial joints were left intact and the trapeziometacarpal joints were reconstructed. Follow-up averaged 8 years. In no case was there x-ray or symptomatic progression of the disease at the scaphotrapezial joint. Clinically, 78% were rated excellent, 17% good, and 5% fair.     

Percutaneous transtrapezial fixation of acute scaphoid fractures

Percutaneous screw fixation of undisplaced fractures of the scaphoid waist has gained popularity but remains technically demanding. This study describes a transtrapezial modification of the volar percutaneous technique and reports the results in 41 patients. The patients were evaluated at a mean of 36 months (range 14-68 months) after surgery. All fractures healed within 10 weeks (mean 6.4 weeks). Functional ranges of wrist motion and grip strength were achieved in all patients. Radiographs showed accurate central placement of the screw in all patients and no degenerative changes were seen at the scaphotrapezial joint. In three patients, the screw was removed because it was prominent at the scaphotrapezial joint.     

Silicone rubber implants for arthrosis of the scaphotrapezial trapezoidal joint

Degenerative changes of the scaphotrapezial trapezoidal (ST) joint commonly cause pain and weakness. These patients do not respond to conservative treatment, and for several years effort has been made to find an easy way to relieve symptoms. In a previous report a silicone interposition arthroplasty was described and considered to be a useful method. However, the durability of the elastomer was insufficient, and implant fractures and migration of fragments occurred. Since then the procedure has been modified, and high performance Silastic has been used for interposition. Ten patients have been reviewed, with a follow-up from 6 to 36 months (average 15 months). All patients have had lasting relief from pain and consider they have full hand function, without stiffness or limited thumb or wrist motion. Roentgenographic reviews have neither revealed deterioration nor dislocation or migration of the implant. Untoward bone reactions have not been observed. Implant hemiarthroplasty is indicated only when the degenerative changes are solely confined to the ST joint.     

Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthritis

One method of Herbert screw insertion is to mobilize the scaphotrapezial joint and insert the screw through the articular surface of the distal scaphoid. Because of concern that this might predispose to osteoarthritis in the scaphotrapezial joint, we have investigated joint space width and the presence of osteophytes adjacent to the scaphotrapezial joint using high definition macroradiography.Twenty-eight patients with symptomatic primary osteoarthritis of their hands, 23 with a scaphoid fracture successfully treated conservatively and 18 treated with a Herbert screw were studied. The patients with primary osteoarthritis of their hands had more narrowing of the scaphotrapezial joint compared with the other two groups, but patients treated with a Herbert screw had a significantly higher incidence of osteophytosis on the distal scaphoid than the other two groups. With Herbert screw fixation, osteophytosis on the distal scaphoid may cause impingement and pain, and be a predictor of further degenerative joint changes.     

The scaphotrapezial ligament complex: an anatomic and biomechanical study

An anatomic and biomechanical study of the ligamentous stabilizers of the scaphotrapezial trapezoidal joint was performed in 25 fresh cadaver specimens. A consistent scaphotrapezial ligament complex consisting of four entities was identified. This complex is comprised of a stout scaphotrapezial ligament on the radial and palmar aspects of the scaphotrapezial joint, weak palmar and dorsal capsules, and a scaphocapitate capsular ligament. A biomechanical study subsequently found that these structures were directly related to resisting diastasis of the scaphotrapezial trapezoidal joint. This information is helpful in understanding scaphoid tuberosity fractures, scaphotrapezial instability and arthrosis, scaphoid dislocations, and perhaps scapholunate disassociations.     

Scaphotrapezial trapezoidal arthrosis

Scaphotrapezial trapezoidal degenerative arthritis as an isolated entity or as a preponderant part of a pantrapezial degenerative process was seen in 49 hands of 34 patients. Pain and weakness were the primary complaints. Point tenderness was present in all but two hands. Significant loss of grasp and pinch strength was noted in 18 hands, and loss of wrist motion occurred in 16 hands. Roentgenographic findings included narrowing of the scaphotrapezial trapezoidal joint space, subarticular cortical sclerosis, and cyst formation. A dorsiflexed position of the scaphoid, with a scapholunate angle of less than 45 degrees, was noted in 38 of the 45 hands. Late collapse of the intercarpal joint with dorsiflexion instability of the lunate also was noted. Twenty-nine hands were treated conservatively by protective splints, corticosteroid injections, and avoidance of exacerbating activities. Surgical treatments consisted of fibrous arthroplasty (four), silicone interposition arthroplasty (six), trapezial replacement arthroplasty (three), arthrodesis (five), joint debridement (one), and trapezial excision (one). Late results were more encouraging than were early results and were moderately satisfactory for each method. Improvement in grasp and pinch strength was most predictable for arthrodesis, although wrist motion was diminished.     

Anterior wrist ganglia from the scaphotrapezial joint.

In this series of 104 anterior wrist ganglia evaluated, 35 were found to arise from the scaphotrapezial joint, 1 from the metacarpotrapezial joint, and 68 from the radioscaphoid joint. After dissection of the cyst and identification of the joint of origin, the ganglion was removed and the joint was incised. Of the patients with scaphotrapezial ganglia, 29 were available for follow-up evaluation with a mean follow-up time of 67 months. Relief of symptoms was noted in 93%, wrist motion was maintained in all patients, and there were two recurrences.     

Interposition arthroplasty using trapezium tendon ball for osteoarthritis of the carpometacarpal joint of the thumb

Carpometacarpal (CM) joint arthroplasty of the thumb using a trapezium tendon ball was performed in 11 hands of 9 patients with osteoarthritis. After a total dissection of the trapezium, the palmaris longus was wrapped around the trapezium, with the surfaces of both the CM joint and the scaphotrapezial joint tightly covered. Grafted trapezium was repositioned, and a congruency of the CM joint was confirmed. All patients were relieved from pain, with the radial abduction angle, grip strength, and the pinch strength increased 5 years after surgery. Radiographically, the mean width of the CM joint space increased, and a central migration of the first metacarpal bone was not found. This procedure would be available for the osteoarthritis in both the CM joint and the scaphotrapezial joint.     

Clinical assessment of the thumb trapeziometacarpal joint

Osteoarthritis of the basal joint of the thumb causes pain and disability for a huge segment of the adult population, particularly women. Radiographically, there is a spectrum of disease that has been staged according to severity of involvement of the TM and scaphotrapezial joints. The staging system proposed by Littler and Eaton is used most widely. The severity of clinical symptoms does not necessarily correspond with the radiographic stage of disease, however, so decisions about treatment are predicated upon the notion that we "treat patients, not x-rays." Treatment is based upon the extent to which the pain and functional limitations caused by the disease impact upon the patient's activities of daily living. The evaluation of basal joint disease has been reviewed and modalities of treatment outlined. Conservative treatment includes splinting, nonsteroidal anti-inflammatory drugs, thenar intrinsic strengthening exercise, and corticosteroid injection. Failure of conservative treatment and unremitting pain are indications for basal joint reconstruction by arthroplasty, osteotomy, or arthrodesis. Staging of basal joint disease provides a rationale for selecting the appropriate surgical procedure for a particular patient.     

Biomechanical evaluation of ligamentous stabilizers of the scaphoid and lunate

This study evaluated the effects of sectioning the scapholunate interosseous ligament, radioscaphocapitate ligament, and scaphotrapezial ligament on the kinematics of the scaphoid and lunate. Eight cadaver upper extremities were placed in a wrist joint simulator and moved in continuous cycles of flexion-extension and radial-ulnar deviation. Positional data of the scaphoid and lunate were obtained in the intact state, after the scapholunate ligament was cut; after the scapholunate and scaphotrapezial ligaments were cut; after the scapholunate, scaphotrapezial, and radioscaphocapitate ligaments were cut; and after all 3 ligaments were cut and the specimen was placed through an additional 1,000 cycles of flexion-extension. Cutting the scapholunate ligament caused changes in scaphoid and lunate motion during flexion-extension, but not radial-ulnar deviation. Additional sectioning of the scaphotrapezial ligament followed by the radioscaphocapitate ligament caused further kinematic changes in these carpal bones. One thousand cycles of motion after all 3 ligaments were sectioned caused additional kinematic changes in the scaphoid and lunate. The scapholunate ligament appears to be the primary stabilizer between the scaphoid and lunate. The radioscaphocapitate and scaphotrapezial ligaments are secondary restraints. Repetitive cyclic motion after ligament sectioning appears to have additional deleterious effects on carpal kinematics.     

Radiography and visual pathology of the osteoarthritic scaphotrapezio-trapezoidal joint, and its relationship to trapeziometacarpal osteoarthritis

PURPOSE: To determine and quantify the relationship of osteoarthritis (OA) in the trapeziometacarpal, scaphotrapezial, and scaphotrapezoidal joints; to ascertain the dependability of radiographic assessment of trapeziometacarpal, scaphotrapezial, and scaphotrapezoidal OA; to determine the articular topography of the scaphotrapezio-trapezoidal (STT) joint (composed of the scaphotrapezial and scaphotrapezoidal articulations) using stereophotogrammetry; and to characterize the articular wear patterns of STT OA. METHODS: Sixty-nine fresh-frozen human cadaveric hands were staged radiographically and by gross visual examination for the presence of OA in the trapeziometacarpal and STT joints. Twenty randomly selected joints also were evaluated to determine the topography of the STT joint using stereophotogrammetry. RESULTS: Concomitant severe osteoarthritic degeneration was found in the trapeziometacarpal and STT joint in 60% of our specimens. A correlation was found in the severity of OA in the trapeziometacarpal and STT joints. Radiographic and gross visual evaluation of STT OA concurred in 39% of our specimens. CONCLUSIONS: The prevalence of concomitant trapeziometacarpal and STT OA, and the uncertainty of radiographic evaluation of STT OA, indicate the need to visualize the STT joint intraoperatively to determine the true degree of degenerative changes present.     

SURGICAL MANAGEMENT OF ARTHRITIS OF THE CARPO-METACARPAL JOINT OF THE THUMB

In the years 1970–90, 118 procedures were performed on 100 patients with arthritis (osteoarthritis in all but 13) of the carpo-metacarpal joint of the thumb. The patients were aged 17 to 83 years (mean 54.5 years); 75 were females and 25 males; there were 73 right and 45 left hands; 18 patients had bilateral procedures. The average follow up period was 4.3 years, with a range of 1 to 20 years. Sixteen of the 118 procedures were arthrodeses; all these patients had isolated trapezio-metacarpal joint arthritis. Fifteen procedures were trapeziectomies and soft tissue arthroplasties; they were performed for pan-trapezial arthritis in the older age group, or as a secondary procedure for failed previous operations. Eighty-seven of the 118 procedures were silicone partial or total arthroplasties either for pan-trapezial arthritis or isolated trapezio-metacarpal joint arthritis (53 trapezium, 32 metatarso-phalangeal and 2 condyle implants). The overall results were: arthrodesis (68.7% good, 18.8% fair, 12.5% poor); soft tissue arthroplasty (80% good, 6.7% fair, 13.3% poor); silicone total arthroplasty (73.5% good, 15.1% fair, 11.3% poor); silicone hemiarthroplasty (68.8% good, 15.6% fair, 15.6% poor). No silicone synovitis was found in any of the 87 cases of silicone arthroplasties.     

Volar scaphotrapezial dislocation.

We present a case of volar luxation of the scaphotrapezial bone, in which radiographs suggested luxation of the scaphoid, but unclear relations to the other carpal bones. Computer tomographic reconstruction showed an isolated scaphotrapezial luxation. This was treated by closed reduction and a plaster cast, after which the patient regained normal function of her wrist.     

The basal joint pain syndrome

Disabling trapeziometacarpal osteoarthritis is often associated with other skeletal or soft tissue pathology that necessitates simultaneous treatment. In this study of 100 trapezium arthroplasties, 65% of the patients required at least one concurrent operative procedure and, overall, 75% have received treatment for related problems before, during, or after the arthroplasty. In order of frequency, scaphotrapezial arthritis, carpal tunnel syndrome, hyperextension deformity of the thumb metacarpophalangeal joint, trigger digits, and tenosynovitis of the wrist have been the most prevalent concomitant conditions requiring surgery. Awareness that trapeziometacarpal arthritis is frequently the focal site of a widespread inflammatory process involving other structures of the hand--termed herein the "basal joint pain syndrome"--is essential to optimal management of patients with pain at the base of the thumb.     

Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part III

PURPOSE: This study continued our previous investigations of the ligaments stabilizing the scaphoid and lunate in which we examined the scapholunate interosseous ligament, the radioscaphocapitate, and the scaphotrapezial ligament. In this current study, we examined the effects of sectioning the dorsal radiocarpal ligament, dorsal intercarpal ligament, scapholunate interosseous ligament, radioscaphocapitate, and scaphotrapezial ligaments. In the current study, the scapholunate interosseous ligament, radioscaphocapitate, and scaphotrapezial ligaments were sectioned in a different order than performed previously. METHODS: Three sets of 8 cadaver wrists were tested in a wrist joint motion simulator. In each set of wrists, only 3 of the 5 ligaments were cut in specific sequences. Each wrist was moved in continuous cycles of flexion-extension and radial-ulnar deviation. Kinematic data for the scaphoid and lunate were recorded for each wrist in the intact state, after the 3 ligaments were sectioned in various sequences and after the wrist was moved through 1,000 cycles of motion. RESULTS: Dividing the dorsal intercarpal or scaphotrapezial ligaments did not alter the motion of the scaphoid or lunate. Dividing the dorsal radiocarpal ligament alone caused a slight statistical increase in lunate radial deviation. Dividing the scapholunate interosseous ligament after first dividing the dorsal intercarpal, dorsal radiocarpal, or scaphotrapezial ligaments caused large increases in scaphoid flexion and lunate extension. CONCLUSIONS: Based on these findings, we concluded that the scapholunate interosseous ligament is the primary stabilizer and that the other ligaments are secondary stabilizers of the scapholunate articulation. Dividing the dorsal radiocarpal, dorsal intercarpal, or scaphotrapezial ligaments after cutting the scapholunate interosseous ligament produces further changes in scapholunate instability or results in changes in the kinematics for a larger portion of the wrist motion cycle.     

Silicone implant arthroplasty in patients with idiopathic osteoarthritis of the metacarpophalangeal joint

PURPOSE: The outcome of silicone metacarpophalangeal (MCP) joint implant arthroplasty in the osteoarthritic patient population has not been well established. Typically patients with idiopathic osteoarthritis have no history of underlying systemic disease and may respond well to treatment with MCP joint implant arthroplasty. This study examined the efficacy of silicone MCP joint implant arthroplasty for patients with idiopathic osteoarthritis for whom nonsurgical treatment had failed. METHODS: Of 14 patients (15 arthroplasties) who had silicone MCP joint implant arthroplasty for idiopathic osteoarthritis 12 (13 arthroplasties) returned for follow-up evaluation at an average of 40 months after surgery. There were 9 index finger and 4 middle finger arthroplasties. The average age at the time of surgery was 62 years. Patients completed a subjective questionnaire and were examined by a certified therapist. Range of motion and strength were recorded and the Jebsen-Taylor examination was administered to assess function. Range of motion values at final follow-up evaluation were compared with preoperative and early postoperative values. Radiographs were taken at final follow-up evaluation and compared with preoperative and early postoperative films to assess joint position, wear, and radioulnar alignment. RESULTS: At final follow-up evaluation excellent (9 patients) and good (3 patients) overall improvement were reported. Nine patients (10 implants) reported greater than 75% functional improvement. A notable increase was seen in MCP joint flexion. Grip and lateral pinch strengths were below age-matched normative data. Of the 11 patients (12 implants) who came in for follow-up evaluation 7 performed all tasks of the Jebsen-Taylor examination within the allotted time. At final follow-up evaluation all silicone implants were located and showed no signs of subluxation. Radiographic radioulnar alignment was maintained. One implant was revised at 35 months secondary to fracture. CONCLUSIONS: Silicone implant arthroplasty is a motion-sparing procedure that provides good pain relief and maintenance of function at intermediate follow-up evaluation in patients with idiopathic osteoarthritis of the MCP joint.     

Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment

We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw. The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms. Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work.     

Basal joint arthroplasty using the Roosevelt Hospital techniques

Many reconstructive procedures have been developed to treat osteoarthritis of the basal joint of the thumb. The current article describes techniques used at the Hand Surgery Center at Roosevelt Hospital in New York City. A tonometry applanation radiographic staging system is outlined; it serves as a rationale for selecting which form of arthroplasty is appropriate for a particular patient and is predicated on the extent of involvement of the trapezial articulations. Stage 1 disease implies symptomatic laxity of the trapeziometacarpal joint with normal articular surfaces and is most appropriately treated with volar ligament reconstruction. Stage 2 is an intermediate category and amenable to either volar ligament reconstruction or interpositional arthroplasty of the trapeziometacarpal joint, based on the condition of the articular cartilage at surgery. In stage 3 disease there are significant degenerative changes of the trapeziometacarpal joint with preservation of the articular surfaces of the scaphotrapezial joint. Two variations on ligament reconstruction with interpositional arthroplasty of the trapeziometacarpal joint are described; they have consistently good results. Finally, stage 4 is characterized by pantrapezial degenerative disease and necessitates trapezial resection. Reconstruction may be by silicone rubber implant arthroplasty using a stemmed trapezial implant stabilized by an abductor pollicis longus tenodesis. The alternative is a procedure in which the thumb metacarpal is tethered to the index metacarpal by a ligament reconstruction.     

Volar scaphotrapezial dislocation

We present a case of volar luxation of the scaphotrapezial bone, in which radiographs suggested luxation of the scaphoid, but unclear relations to the other carpal bones. Computer tomographic reconstruction showed an isolated scaphotrapezial luxation. This was treated by closed reduction and a plaster cast, after which the patient regained normal function of her wrist.     

Scaphotrapezial dislocation: a case report

Traumatic dislocation of either trapezium or trapezoid is rare. We found less than 20 cases of each reported in the literature. We describe a case of traumatic dislocation of the scaphotrapezial joint associated with subluxation of the scaphotrapezoidal joint, which to our knowledge has not been reported.