Arthroscopic Hemitrapeziectomy for First Carpometacarpal Arthritis: Results at 7-year Follow-up

The purpose of this study was to determine the outcome of arthroscopic hemitrapeziectomy combined with thermal capsular plication and temporary K-wire fixation in patients with painful thumb basal joint due to either osteoarthritis or posttraumatic arthritis. There were 18 thumbs that were evaluated in this retrospective study of arthroscopic hemitrapeziectomy of the distal trapezium in addition to a pancapsular thermal shrinkage at an average of 7.6-year follow-up. No patient has required further surgery. A subjective improvement in pain, pinch activities, strength, and range of motion (ROM) was noted in all patients, and no patient had further surgery on their thumb. On exam, no patient had a first carpal-metacarpal grind or laxity. Total ROM of the thumb axis decreased by 20%, but all patients could oppose to the fifth finger. Grip strength remained unchanged, key pinch improved from 8 to 11 lbs, and tip pinch improved from 4 to 5 lbs. Radiographs showed a metacarpal subsidence of 1.8 mm (0-4 mm). Four complications were noted: two cases of dorsal radial nerve neuritis, one rupture of the flexor pollicis longus, and one prolonged hematoma. Results demonstrate that arthroscopic hemitrapeziectomy and capsular shrinkage for first carpometacarpal arthritis is an effective technique that provides high patient satisfaction, a functional pain-free thumb, and a reliable rate of return to activity.     

Arthroscopic surgery of the trapeziometacarpal joint

Treatments of 1st CMC joint arthritis are numerous. Arthroscopic surgery allows distal trapezium resection in early stage of CMC arthritis, avoiding more extensive classical open surgery. The distal trapezium resection is performed under arthroscopic control, associated to tendinous interposition. Between 2000 and 2005 we treated 32 patients. There were 26 women and 6 men. The average age was 56 years old (range 48-78). In 4 cases we had to transform the procedure in open surgery with trapezectomy. Postoperative pain were usual and long. We had technical fault with foreign bodies in one case, insufficient resection in 2 cases. One case presented a secondary joint collapses with necessity of other operation.     

Thumb carpal metacarpal arthritis

The thumb carpometacarpal (CMC) joint is the most common site of surgical reconstruction for osteoarthritis in the upper extremity. In patients older than age 75 years, thumb CMC osteoarthritis has a radiographic prevalence of 25% in men and 40% in women. The thumb CMC joint obtains its stability primarily through ligamentous support. A diagnosis of thumb CMC arthritis is based on symptoms of localized pain, tenderness and instability on physical examination, and radiographic evaluation. A reproducible radiographic classification for disease severity is based on the four-stage system described by Eaton. Nonsurgical treatment options include hand therapy, splinting, and injection. Surgical treatment is tailored to the extent of arthritic involvement and may include ligament reconstruction, metacarpal extension osteotomy, arthroscopic partial trapeziectomy, implant arthroplasty, and trapeziectomy with or without ligament reconstruction and tendon interposition.     

Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon

Fifty-eight patients (62 joints) with arthritis of the thumb carpometacarpal joint were treated with resection arthroplasty, ligament reconstruction, and tendon interposition with the entire flexor carpi radialis tendon. The mean age of the patients at the time of surgery was 58.4 years (range, 28-80 years), and the average followup was 42.5 months (range, 21-86 months). The entire flexor carpi radialis tendon was used for reconstruction and interposition. In 32 of the 62 joints, a partial trapezoidectomy was performed for scaphotrapezoidal arthritis. Finger-tip pinch improved by 88%, key pinch improved by 86%, and grip strength improved by 69%. Palmar and radial abduction also improved by 8% and 10%, respectively. Fifty-five (95%) patients reported excellent pain relief, whereas three patients reported only mild pain. No patients experienced an increase in pain. All thumbs were stable radiographically. This study indicated ligament reconstruction with tendon interposition, accompanied by partial trapezoidectomy when indicated, provides excellent pain relief and restoration of function. No morbidity was observed with use of the entire flexor carpi radialis tendon.     

Arthroscopic evaluation and treatment by tendon interpositional arthroplasty of first carpometacarpal joint arthritis.

Basal joint arthritis of the thumb is usually seen in females beginning from the fourth and fifth decades. In the last two decades, arthroscopic techniques have brought new chances of diagnosis and treatment for this condition. In this paper, the authors describe the indications and their experience concerning arthroscopic hemitrapezectomy and tendon interposition using the palmaris longus tendon. A series of 16 patients with a maximum follow-up of 12 months is analysed. All of the 16 patients were followed and assessed with grasp strength, pinch strength, DASH and MAYO evaluation score both pre- and post-operatively at 12 months follow-up. According to the MAYO score, there were six excellent results, six good, three fair and one poor. No complications occurred. According to our preliminary results, this procedure with the proper indications gives a valid option for the treatment of thumb carpometacarpal joint arthritis in stages I and II according to Eaton's classification.     

Treatment of advanced carpometacarpal joint disease: carpometacarpal arthroplasty with ligament interposition

Basal joint arthritis is a common condition, primarily affecting postmenopausal women. Persistent pain and functional impairment despite conservative treatment are indications for operative intervention. Ligament reconstruction and tendon interposition (LRTI) arthroplasty is one of the most popular and time-tested operations to treat metacarpal instability and basal joint arthritis. LRTI incorporates three fundamental principles that address the underlying anatomic pathology: (1) trapezium excision, either partial or complete, to eliminate eburnated bone and the source of pain; (2) anterior oblique ligament reconstruction for carpometacarpal joint stability; and (3) tendon interposition to minimize axial shortening and prevent bony impingement.     

Tendon arthroplasty of the fifth carpometacarpal joint for treatment of posttraumatic arthritis

Resectional arthroplasty with interposition of a rolled tendon spacer was used to treat posttraumatic arthritis of the fifth metacarpal-hamate joint in eight patients. The average follow-up was 5 years. All of the patients subjectively rated the functional capability and the cosmetic appearance of their hands as good or excellent. After operation, there was a net increase of 30% in the average grip strength of the study group. The motion preserved at the small finger carpometacarpal joint facilitated power function of the hand.     

Autogenous tendon graft substitution for absent knee joint meniscus: a pilot study.

The purpose of this pilot study was to explore the potential of an autogenous tendon graft to substitute for an absent human knee joint meniscus. Based on the results of animal studies and human reports, it was hypothesized that autogenous tendon tissue would substitute for human knee joint meniscus: maintain mechanical integrity, convert to fibrocartilage, preserve the joint compartment, and provide symptomatic relief for the patient. Five patients, 2 men and 3 women, average age 41 years, had surgical absence of the lateral meniscus, genu valgum, and severe degenerative arthritis of the lateral compartment, but a stable knee. All patients were offered alternative treatments: do nothing, medication, arthroscopic debridement, osteotomy, and knee replacement. The operations were performed by arthroscopy. An accompanying arthroscopic debridement procedure was performed in the same compartment. In 4 cases, the donor graft was the semitendinosus tendon. In 1, the patellar tendon was used because the semitendinosus had been previously used in an anterior cruciate ligament reconstruction. Four of the 5 patients had a second-look arthroscopy and biopsy between 9 and 24 months. There was partial physical integrity to the tendon graft. The tendon graft did not completely convert to fibrocartilage. The joint surface was not preserved. Only 1 patient had minimal clinical improvement; the others were not improved. No patient was made worse. One patient had a total knee replacement 1 year later. Another had a knee fusion after 4 years. All other patients are considering future reconstructive surgery. The autogenous tendon graft as used in this pilot study was not successful as a substitute for an absent meniscus. The hypothesis was not realized. The observations from this pilot study should be helpful in future study protocol design.     

Tendon interposition arthroplasty versus arthrodesis for the treatment of trapeziometacarpal arthritis: a retrospective comparative follow-up study

Long-term subjective and objective outcomes of 24 tendon interposition arthroplasties in 17 patients and 32 trapeziometacarpal (TMC) arthrodeses in 26 patients were compared retrospectively in a standardized manner. Tendon interposition arthroplasty led to complications less often (27%) than TMC arthrodesis (39%). Patients in the tendon interposition arthroplasty group reported significantly less pain, less temperature intolerance, and better thumb mobility and were more satisfied with pain symptoms than patients in the arthrodesis group. Patients undergoing tendon interposition arthroplasty had better thumb opposition, interphalangeal joint mobility, and radial and palmar TMC joint range of motion. No statistically significant differences were found in tip pinch, key pinch, and grip strength between the 2 groups. Proximal first metacarpal collapse occurred in the tendon interposition patients without affecting subjective or objective outcome. Seven of 25 patients with TMC arthrodesis had pseudarthrosis. Tendon interposition arthroplasty seems to be preferable to TMC joint arthrodesis for the treatment of TMC arthritis.     

Suspensionplasty with the abductor pollicis longus tendon for osteoarthritis in the carpometacarpal joint of the thumb

PURPOSE: Many surgical procedures have been described for treating painful osteoarthritis at the carpometacarpal joint of the thumb. This article reports our clinical and radiographic results in performing suspensionplasty using the abductor pollicis longus (APL) tendon without tendon interposition after a complete trapeziectomy for patients with painful osteoarthritis in the carpometacarpal joint of the thumb. METHODS: Eighteen patients (2 men, 16 women), including 21 thumbs with advanced arthritis of the first carpometacarpal joint, who were treated by suspensionplasty using the APL tendon after a complete trapeziectomy were evaluated both clinically and radiographically. Ten thumbs were classified as stage III and 11 were classified as stage IV (Eaton's classification). The average follow-up period was 33.3 months. RESULTS: All patients (18 patients, 21 thumbs) reported pain with daily use before surgery; after surgery 13 of the 21 thumbs had no pain, 5 thumbs had mild pain with strenuous activity, and the remaining 3 thumbs had mild pain with light work. At the final follow-up evaluation the radial and palmar abductions each were 56 degrees +/- 9 degrees and 56 degrees +/- 6 degrees. The grip and key-pinch strengths were 16 +/- 6 kg and 4 +/- 1 kg, respectively. The first metacarpal subsidence at rest was 15% and the additional subsidence when performing a 2-kg key pinch was 6% in the final follow-up radiographic findings. CONCLUSIONS: This study showed that the APL suspensionplasty has a favorable outcome for painful osteoarthritis in the carpometacarpal joint of the thumb and that the APL tendon can be removed as a deforming force without any abduction weakness. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Arthroscopic hemiresection for stage II-III trapeziometacarpal osteoarthritis

Trapeziometacarpal osteoarthritis is a common problem, due to the anatomy of the first ray and the forces applied to the trapeziometacarpal joint throughout activities of daily living. Numerous treatment options exist, and continue to be developed, for this problem. The current goal is to eliminate pain and restore function and strength in a timely manner. New advances allow for earlier return to function with minimally invasive techniques. Arthroscopic hemitrapeziectomy combined with interposition arthroplasty and/or suspensionplasty is a treatment option for Stage II and III trapeziometacarpal arthritis that uses a minimally invasive technique and allows for earlier return of function.     

Poor results after interpositional arthroplasty with fascia lata allograft for arthritis of the trapezio-metacarpal joint

Arthrodesis or autologous tendon interposition can relieve pain associated with arthritis of the carpo-metacarpal joint of the first ray (CMC-I), but has its limitations. The aim of this study was to assess whether trapezium resection and fascia lata allograft (Tutoplast) interposition is a good alternative. Thirty-eight such combined CMC-I arthroplasties in 36 patients with a median age of 57 years and a median follow-up of 25 months were analysed for complications; Disabilities of Arm, Shoulder, and Hand questionnaire (DASH) scores; pain; and patient satisfaction. Complications occurred in 13 of the 36 patients (36%). The median DASH score was 25, and pain was reduced in 22 patients (85%). Thirteen of the 36 patients (36%) were not satisfied. Trapezium resection and fascia lata allograft interposition do not seem to be good alternatives for CMC-I arthritis.     

Trapezio-metacarpal arthritis. Trapezium excision and ligament reconstruction not including the LRTI arthroplasty

For trapeziometacarpal arthritis, trapezium excision and ligament reconstruction that is distinct from the ligament reconstruction tendon interposition (LRTI) arthroplasty has a distinct role. Emphasis is placed on the use of the abductor pollicis longus for tendon interposition and "suspensionplasty" for the arthritic thumb carpal metacarpal joint. The advantages of the abductor pollicis longus techniques as originally advocated by Thompson, and modified by Diao, are reviewed. The surgical technique for this procedure, clinical results and biomechanical cadaver analysis comparing abductor pollicis longus suspensionplasty done with two techniques, as they compare to the LRTI procedure, are included. The abductor pollicis longus suspensionplasty is an excellent treatment choice both for index procedures for carpometacarpal (CMC) thumb arthritis, and for salvage of the failed thumb CMC arthroplasty.     

掌、背侧韧带同时重建治疗第一腕掌关节脱位

目的 通过对第一腕掌关节掌背侧韧带的同时重建，为治疗第一腕掌关节脱位提供一种新的术式。方法 利用桡侧腕屈肌腱和桡侧腕长伸肌腱桡侧部分腱束移位，与拇长展肌腱交叉后编织缝合，起到同时重建掌、背侧韧带，并将第一掌骨悬吊的作用，使脱位的第一腕掌关节复位并稳定。结果 临床应用3例，效果满意。结论 桡侧屈腕肌腱和桡侧腕长伸肌腱部分移位与拇长展肌腱交叉缝合法符合第一腕掌关节韧带重建的解剖要求，操作简单，疗效满意，是治疗第一腕掌关节脱位的一种可靠方法。     

Surgical Treatment of Thumb Carpometacarpal Joint Arthritis: A Single Institution Experience from 1995–2005

There are numerous techniques for the surgical management of thumb carpometacarpal (CMC) joint arthritis. The four senior authors of this study employ three such techniques: trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition (LRTI). This study examines the three commonly utilized procedures at a single institution. This study examines the 10-year experience from 1995–2005 with a minimum 3-month follow-up. Disabilities of the arm, shoulder, and hand (DASH) scores, pre-and postoperative pinch strength, and operative time were examined. After approval from the institutional review board of our institution was obtained, all patients treated surgically by three of the senior authors were contacted via mail and phone. Each patient was asked to complete and return a DASH questionnaire. Of the 115 patients treated during that period, 60 participated in this study. Each patient’s final postoperative pinch measurement was obtained from occupational therapy and clinic records. This pinch strength was compared to the preoperative pinch and contralateral pinch strength. Lastly, the total operative time for each procedure was obtained from the operative record. The only significant finding in this study was a shorter mean operative time with the trapeziectomy group (76.90 min) and osteochondral allograft group (90.45 min) when compared to the LRTI group (139.00 min; p = 0.001 and p = 0.001, respectively). We found no significant difference between groups in terms of DASH score and pinch strength. There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of the LRTI. This presents further evidence that potentially, “less is more” in the treatment of thumb CMC arthritis. We used a retrospective study design to evaluate potential differences between the three surgical techniques described above, therapeutic, levels III–IV.     

Interposition arthroplasty using an acellular dermal matrix scaffold

We have used arthroscopic debridement and interposition arthroplasty with an acellular dermal matrix allograft in treatment of first carpometacarpal joint arthritis successfully in a limited number of patients. The purpose of this investigation was to study the use of an acellular dermal matrix graft in a rabbit model of interposition arthroplasty. Eleven rabbits underwent excision of the lunate bone and interposition of extensor tendon (control) or dermal matrix graft (experimental). Radiographic analysis and either histological or vascular studies were performed. No adverse immunological response was noted. Increasing fibroblast like cells were noted over time in both groups with greater infiltration in control specimens. Vascular infusion showed infiltration in both arthroplasty groups. Both groups maintained the resection space and promoted cellular ingrowth without adverse immune response. Vascular infiltration occurred in both arthroplasty groups. These results support use of this graft in interposition arthroplasty.     

Arthroscopic interposition arthroplasty of the trapeziometacarpal joint

Purpose

In carpometacarpal (CMC) arthritis of the thumb, the use of interposition techniques (polylactic acid, pyrocarbon, dacron) has been increasing recently. These techniques are most often combined with open or arthroscopic complete or partial trapeziectomy. This article reports the results at one year of the arthroscopic interposition of an absorbable implant performed without trapeziectomy.

Methods

Our series included 25 patients aged 60.5 years on average, presenting with osteoarthritis of the trapeziometacarpal joint that had been medically treated for 18.5 months on average. All patients were operated using 1-ulnar (U) and 1-radial (R) portals. After joint debridement, a polylactic acid implant was inserted under arthroscopic control. Outcome evaluation consisted of the assessment of pain intensity, grip strength, pinch strength, opposition, thumb abduction and Dell radiological staging.

Results

The average follow-up was 14 months. Postoperative radiological data showed significant differences from baseline clinical data regarding all evaluated variables: 0.68 vs. 3.5 for pain, 24.76 Kg vs. 16.64 Kg for grip strength, 6.44 Kg vs. 3.64 Kg for pinch strength, 8.6 vs. 7.28 for opposition, 81.2° vs. 69.6° for thumb abduction, and 1.08 vs. 2.88 on the Dell stage. Eleven complications occurred, including a type 1 complex regional pain syndrome, one sepsis, and nine inflammatory reactions that resolved after an average of 3 weeks.

Conclusions

Our technique is simple, rapid, cost-effective, and does not necessitate trapeziectomy, even partial. It has the same indications as other non-radical interventions. The follow-up duration of our study was too short for long-term evaluation but short-term outcome appeared superior to that in other published series. The regional inflammatory reactions that occurred in our series were transient and probably related to implant resorption. Our promising results suggest extending the indication of arthroscopic interposition to more advanced stages of proximal joint osteoarthritis.     

Arthroscopic interposition arthroplasty of the first carpometacarpal joint

First carpometacarpal joint arthritis is a common condition encountered by hand surgeons. Traditionally, surgical approaches have included arthrodesis, trapeziectomy or reconstructive arthroplasty techniques. Previously, we described a technique for arthroscopic debridement and interposition arthroplasty of the first carpometacarpal joint. Patients with Eaton stages II and III symptomatic first carpometacarpal joint arthritis recalcitrant to >6 months of non-operative therapy underwent arthroscopic debridement of the first carpometacarpal joint with interposition of an acellular dermal matrix allograft (GRAFTJACKET). In this paper, we describe outcomes following this procedure. Postoperatively, all patients reported symptomatic relief and 94% stated that they were partially, or completely, satisfied. More than 70% of patients reported no to mild difficulty in performing activities of daily living (average grip strength = 18.5 kg, pinch strength = 3.9kg). Complications were minimal. Outcomes from this study compare favourably to those of other series, demonstrating that this technique is a viable option for treatment of Eaton stages II and III first carpometacarpal arthritis.     

Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review

The aim of this article is to provide an updated systematic review on the 8 most commonly used surgical procedures to treat trapeziometacarpal osteoarthritis. A thorough literature search was performed using predetermined criteria. A total of 35 articles fulfilled the inclusion criteria. Nine of these 35 articles were not included in previous systematic reviews. Systematic evaluation demonstrated the following: (1) there is no evidence that trapeziectomy or trapeziectomy with tendon interposition is superior to any of the other techniques. However, when interposition is performed, autologous tissue interposition seems to be preferable. (2) Trapeziectomy with ligament reconstruction or trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is not superior to any of the other techniques. However, follow-up in the studies with a higher level of evidence was relatively short (12 mo); therefore, long-term benefits could not be assessed. In addition, trapeziectomy with LRTI seems associated with a higher complication rate. (3) Because the studies on thumb carpometacarpal (CMC) arthrodesis were of less methodological quality and had inconsistent outcomes, we are not able to conclude whether CMC arthrodesis is superior to any other technique. Therefore, high-level randomized trials comparing CMC arthrodesis with other procedures are needed. Nevertheless, findings in the newly included studies did show that nonunion rates in the literature are on average 8% to 21% and, complications and repeat surgeries are more frequent following CMC arthrodesis. (4) A study on joint replacement showed that total joint prosthesis might have better short-term results compared to trapeziectomy with LRTI. However, high-level randomized trials comparing total joint prosthesis with other procedures are needed. In addition, there is no evidence that the Artelon spacer is superior to trapeziectomy with LRTI. We conclude that, at this time, no surgical procedure is proven to be superior to another. However, based on good results of CMC arthrodesis and total joint prostheses, we postulate that there could be differences between the various surgical procedures. Therefore randomized clinical trials of CMC arthrodesis and total joint prostheses compared to trapeziectomy with long follow-up (>1 y) are warranted.     

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.