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.     

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.     

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.     

桡侧腕长伸肌腱与拇长展肌腱重建韧带治疗拇指腕掌关节脱位

在手外科工作中，拇指腕掌关节脱位比较常见，治疗方法比较多，但为了使此关节稳定，就必须行韧带重建术。根据拇指腕掌关节的解剖学特点及力学分析，我们应用了桡侧腕长伸肌腱与拇长展肌腱各一半的腱束交叉重建拇指腕掌关节韧带治疗拇指腕掌关节脱位。从１９８７年～１９９０年对１１例病人１２个拇指进行了治疗，术后随访２年以上，疗效满意。我们认为，这种方法比较简单、损伤小，值得推广。     

Rupture of the extensor pollicis longus tendon in trapeziometacarpal joint osteoarthritis: case report

We report a case of rupture of the EPL tendon that occurred in a patient with trapeziometacarpal joint osteoarthritis. We assume that the rupture was secondary to attrition caused by a bony protrusion of advanced trapeziometacarpal joint osteoarthritis.     

An in vitro analysis of ligament reconstruction or extension osteotomy on trapeziometacarpal joint stability and contact area

PURPOSE: Painful instability of the minimally osteoarthritic thumb carpometacarpal (CMC) joint can be treated successfully by either ligament reconstruction or metacarpal extension osteotomy. The purpose of this study was to measure the laxity of cadaveric thumb CMC joints and to determine the influence of ligament reconstruction and metacarpal osteotomy on joint laxity and contact area. METHODS: The baseline laxity of CMC joints from 25 fresh-frozen human cadaveric specimens (average age, 42 y; range, 18-55 y) was measured in the position of lateral pinch on a custom-designed CMC joint laxity tester. Joint laxity was measured again after 2 surgical simulations consisting of either a metacarpal extension osteotomy (at 10 degrees and 15 degrees) or a simulated Eaton-Littler ligament reconstruction (including total, volar, and dorsal ligament reconstructions relative to the plane of the thumbnail). Contact area between the thumb metacarpal and trapezium during testing was determined using stereophotogrammetry. RESULTS: The 15 degrees extension osteotomy significantly reduced CMC joint laxity in the radial-ulnar, dorsal-volar, pronation-supination, and distraction directions in the position of lateral pinch. The 10 degrees osteotomy reduced laxity only in the dorsal-volar direction. The total ligament reconstruction significantly reduced joint laxity in the radial-ulnar, dorsal-volar, and pronation-supination directions. The dorsal ligament reconstruction reduced laxity in the dorsal-volar direction only; the volar ligament reconstruction reduced laxity in both dorsovolar and radioulnar directions. The 10 degrees and 15 degrees osteotomies produced a dorsal shift of the weighted centroid of contact on the metacarpal and trapezium, whereas the ligament reconstruction did not produce such an effect. CONCLUSIONS: In the position of lateral pinch the 15 degrees osteotomy and total ligament reconstruction significantly reduced laxity of the thumb CMC joint in all directions tested. The isolated dorsal or volar ligament reconstructions both reduced dorsal-volar laxity. Metacarpal extension osteotomy may stabilize the thumb CMC joint in lateral pinch to a degree similar to that of a standard ligament reconstruction.     

Chronic scapholunate dissociation: ligament reconstruction combining a new extensor carpi radialis longus tenodesis and a dorsal intercarpal ligament capsulodesis

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.     

A new surgical technique for the ligament reconstruction of the trapeziometacarpal joint

Isolated traumatic dislocation of the trapeziometacarpal joint is rare compared with fracture-dislocation of the joint. The mechanism of injury is usually axial loading on a flexed thumb metacarpal, leading to dorsal dislocation of the joint. Closed reduction with immobilization is an acceptable method of treatment if the joint is stable after the reduction. Otherwise, early ligamentous reconstruction is recommended to reduce the likelihood of secondary arthritis. Various surgical techniques have been used to reestablish the ligamentous integrity of the joint; however, these techniques usually reconstruct only 1 or 2 ligaments around the joint. The current technique is aimed to reconstruct all 4 ligaments of the trapeziometacarpal joint using a half strip of extensor carpi radialis brevis tendon.     

大多角骨切除加肌腱固定术治疗第一腕掌关节炎的疗效观察

目的介绍大多角骨切除加肌腱固定术治疗第一腕掌关节炎的手术方法及疗效。方法以大多角骨完全切除加部分桡侧腕屈肌腱固定第一掌骨基底部的方法治疗第一腕掌关节炎11例。测量患侧手术前后及健侧腕关节和拇指的活动度、握力和捏持力,进行统计学分析。结果11例中的10例随访1～3年,平均2年3个月,比较术后和术前腕关节及拇指活动范围和握力及捏持力,术后有明显的增加,术前、术后相比差异有统计学意义(P<0.01)。术后与健侧对比差异无统计学意义(P>0.05)。结论大多角骨切除加桡侧腕屈肌腱固定第一掌骨基底部治疗第一腕掌关节炎是一种可行的方法值得临床推广。     

桡侧腕屈肌腱悬吊结合掌骨间韧带重建治疗第一腕掌关节骨关节炎

目的 评价大多角骨切除,桡侧腕屈肌腱悬吊结合掌骨基底间韧带重建治疗第一腕掌关节骨关节炎的疗效.方法 采用Schekker技术,应用大多角骨切除,桡侧半桡侧腕屈肌腱重建第一、二掌骨基底间韧带,并与剩余肌腱自身悬吊控制掌骨基底背侧半脱位,并形成肌腱填塞物内置大多角骨切除遗留空间控制掌骨下沉等手术步骤,治疗第一腕掌关节骨关节炎6例.术后手部功能评价指标包括握力(grip strength),捏力(key-pinch),第一腕掌关节直观模拟疼痛标尺法(visual analogue scales,VAS)及第一腕掌关节有效活动度评分(Kapandji score),术后12个月随访X线前后位片第一掌骨基底-舟骨远关节面间距,评价手术疗效.结果 术后随访时间为12～ 26个月,平均15个月.手术前后疼痛(VAS)平均分值为7.0/1.6;握力平均为11/22 kg;捏力平均为1.8/3.4 kg;Kapandji score 平均为6.0/8.7;12个月时测量X线前后位片第一掌骨基底-舟骨远关节面间距平均值为8.8mm.结论 大多角骨切除,桡侧腕屈肌腱动力性悬吊结合掌骨基底间韧带重建,最大程度地接近了该部位韧带解剖及生物力学方面的结构,可有效治疗第一腕掌关节骨关节炎.     

Partial extensor carpi radialis longus turn-over tendon transfer for reconstruction of the extensor pollicis longus tendon in the rheumatoid hand: case report

Reconstruction of a distally ruptured extensor pollicis longus tendon in the rheumatoid patient generally involves a tendon transfer or intercalary graft. We present an alternative technique using the radial half of the extensor carpi radialis longus as a turn-over graft. Using the turn-over technique with a half-slip of the extensor carpi radialis longus avoids the traditional limitations of the extensor carpi radialis longus tendon in distal extensor pollicis longus tendon repairs and precludes the need for a free tendon graft.     

单束等长重建和双束解剖重建内侧髌股韧带的临床研究

目的 对比观察单束等长重建和双束解削重建内侧髌股韧带治疗髌骨脱位的临床效果.方法 回顾性分析自2004年8月至2008年10月行内侧髌股韧带重建治疗的60例(72膝)陈旧性髌骨脱位患者的临床资料,其中单束等长重建组22例(27膝),双束解剖重建组38例(45膝).术后手法检查髌骨稳定性,记录再脱位的病例数,CT测量髌骨外移度及髌骨倾斜角并以Kujala和主观问卷评分进行膝关节功能评估.结果 所有患者均随访12个月以上,无再脱位病例.(1)髌骨不稳发生率,术后单束重建组18.5%,双束重建组2.2%,差异具有统计学意义(P＜0.05).(2)术后两组髌骨倾斜角和髌骨外移率均恢复至正常范围,差异无统计学意义(P＞0.05).(3)Kujala评分,单束组术前59±9,术后87±4;双束组术前62±9,术后94±6,差异具有统计学意义(P＜0.05).(4)术后主观问卷:单束重建优良率85.2%,双束重建组97.8%,差异具有统计学意义(P＜0.05).结论 单、双束重建内侧髌股韧带均明显恢复髌骨稳定性,提高膝关节功能,但临床评价双束重建优于单束重建.     

Long term results of surgical intervention for osteoarthritis of the trapeziometacarpal joint

Trapeziometacarpal osteoarthritis is a common entity, often bilateral and predominantly affecting postmenopausal women. In the case of failure of conservative treatment, surgery is a good option. The aim of this study was to compare three surgical procedures. 63 patients (74 thumbs) with osteoarthritis of the trapezio-metacarpal joint were surgically treated; 54 patients were seen for follow-up, 7 had died and 2 were lost to follow-up. The patients were stratified according to treatment; resection arthroplasty (the joint surface's of the metacarpal and the trapezium are resected) (18 thumbs), trapeziectomy with tendon interposition (17 thumbs) or trapezio-metacarpal arthrodesis (28 thumbs). Baseline characteristics were comparable in the three groups for mean age at operation, Eaton classification, left right distribution and dominant hands operated. The average follow-up was 13 years for the resection group, 8 years for the trapeziectomy group and 9 years for the arthrodesis group. No statistically significant difference between the three groups was found for the visual analogue pain and satisfaction scale, pain frequency nor DASH score. Patients in the trapeziectomy group had significantly less pain compared to the arthrodesis group (p=0.025). Statistically, radial abduction was significantly better after trapeziectomy compared to resection arthroplasty (p<0.01) or arthrodesis (p=0.01). There was no difference among the three groups in grip and tip pinch strength nor in pain on palpation. None of the patients in the trapeziectomy group needed a re-operation, one patient in the resection arthroplasty group had a re-operation, and 22 patients in the arthrodesis group had one or more re-operations for hardware removal or because of a complication. This study shows that the resection arthroplasty has equally good long term results compared to trapeziectomy combined with tendon interposition or arthrodesis. Resection arthroplasty is performed through a single incision and is technically simple. In our clinic resection arthroplasty is therefore the preferred technique for the treatment of osteoarthritis of the trapeziometacarpal joint.     

Reconstruction of a posterior defect of the elbow joint using an extensor carpi radialis longus myocutaneous flap: case report

An extensor carpi radialis longus (ECRL) myocutaneous flap was successfully used for the repair of a posterior defect of the elbow joint in a physically handicapped female with Parkinsonism. This muscle is of value for a one-stage reconstruction of an elbow lesion.