Thumb Trapeziometacarpal Arthritis: Treatment with Ligament Reconstruction Tendon Interposition Arthroplasty
Learning Objectives: After studying this article, the participant should be able to: 1. Understand the pathomechanical and biochemical basis for thumb trapeziometacarpal joint degeneration. 2. Diagnose and grade trapeziometacarpal joint disease based on presentation, physical examination (including provocative testing), and radiographic evidence. 3. Understand the principles of ligament reconstruction and tendon arthroplasty procedures. 4. Describe the surgical technique for ligament reconstruction tendon interposition arthroplasty and its variants.
Background: Osteoarthritis of the trapeziometacarpal joint is the second most common site of degenerative joint disease in the hand, and mostly affects postmenopausal women. Degenerative arthritis of the thumb trapeziometacarpal joint is associated with a lack of bony constraints and laxity of the supporting ligaments, particularly the anterior oblique (“beak”) ligament, which is consistently implicated in disease progression. Resultant increases in joint stress loads leads eventually to metacarpal and trapezial articular destruction, thumb instability,
Results: Ligament reconstruction tendon interposition arthroplasty procedures center on three common principles: (1) excision of the diseased trapezium; (2) reconstruction of the beak ligament; and (3) interposition of a tissue
Trapeziometacarpal arthritis is the second most common degenerative joint disease in the hand, commonly affecting women in their fifth to sixth decades of life. A study by Kelsey et al. estimated that one in six women had radiographic evidence of basal joint arthritis, compared with only 5 percent of men.5 Others report a prevalence of 33 percent in postmenopausal women (with one-third being symptomatic) versus an 11 percent rate in men older than 55 years.6,7 Female predisposition may be attributable to hormonal factors; increased ligament laxity; and presence of a smaller, less congruous
The trapeziometacarpal joint is unique in that it is a biconcave-convex “saddle” joint. In addition,
The goals of treatment are to alleviate pain and restore joint stability. Fortunately, roles for both conservative and surgical options currently exist to successfully treat trapeziometacarpal joint pain and restore joint stability. Surgery is commonly offered to the symptomatic patient when conservative measures have failed or when there is advanced disease. Ligament reconstruction tendon interposition or other surgical techniques are often required in Eaton stage II through IV disease. Numerous technical variations of ligament reconstruction and tendon interposition arthroplasty popularized by Burton
Appropriate treatment of trapeziometacarpal joint arthritis can produce predictable long-term patient satisfaction, making it an important procedure to be understood and applied by hand surgeons with an interest in treating trapeziometacarpal joint arthritis. This report discusses the anatomy, pathophysiology, diagnosis, and current surgical treatment of trapeziometacarpal joint arthritis, particularly the ligament reconstruction tendon interposition–type arthroplasties.
Anatomy and Biomechanics
Comprehensive knowledge of the ligamentous anatomy of the trapeziometacarpal joint is
The trapezium endures both axial and cantilever stress loads, particularly during lateral pinch and grasp maneuvers. Postmortem histologic and biochemical studies have demonstrated a predominant
Joint surface beak ligament attrition plays a fundamental role in the pathophysiology of trapeziometacarpal joint arthritis, which has led to the popularity of ligament reconstruction.The beak ligament is so named because its obliquely oriented fibers originate just ulnar to the volar styloid process of the first metacarpal base (beak) and insert onto the volar central apex of the trapezium.
Biochemical analysis of the arthritic trapeziometacarpaljoint hyaline cartilage reveals a loss of
Six other ligaments play contributing roles in trapeziometacarpal joint stability. The superficial
Historically, several staging systems have been created to correlate radiographic evidence
Along with radiographic evaluation and staging, a thorough history and physical examination
Patients will commonly have tenderness to palpation at the radiovolar aspect of the joint regardless of the disease stage. If the scaphotrapezial joint (approximately 1 cmproximal to the trapeziometacarpal joint) is also tender, this may indicate stage IV disease. Earlier disease stages correlate with greater joint laxity, whereas stiffness is often present in late disease. Crepitus resulting from friction between eburnated joint surfaces is usually present with stage III or IV disease.
Provocative tests that illicit pain in the trapeziometacarpal joint have been described, and include
Plain radiographs are all that are required in evaluation and staging of thumb trapeziometacarpal joint disease. Radiographs should include posteroanterior, lateral, and oblique views. Other views include the stress view, as described by Eaton and Littler,4 and the Roberts view. The stress view involves a posteroanterior view of both thumb trapeziometacarpal joints taken together as the patient
Plain radiographs are all that are required in evaluation and staging of thumb trapeziometacarpal
Thumb trapeziometacarpal arthritis can be confused with several disease entities that can have
Scaphoid fractures, particularly at the distal pole, can illicit pain and tenderness in the trapeziometacarpal joint region. However, a careful history will often reveal the original traumatic event.
Current nonsurgical treatment options for trapeziometacarpal arthritis include trials of nonsteroidal
Surgical reconstruction of the degenerative basal joint is indicated when conservative measures
Extension osteotomy is also a reported option at this stage, provided the joint wear does not
Treatment of stage II disease may vary, depending on the status of the articular wear pattern
Stage III patients require more than beak ligament reconstruction alone. Trapezial excision
Recently, some surgeons have returned to trapezial excision alone as first described by Gervis,56
Ligament Reconstruction Tendon Interposition Arthroplasty
In 1973, Eaton and Littler4 described reconstruction of the anterior oblique beak ligament by
The surgical technique of ligament reconstruction tendon interposition arthroplasty is outlined
Next, the flexor carpi radialis tendon is retrieved distally in the operative site, after it is transected at its musculotendinous junction by means of a separate 2-cm transverse incision. The tendon is mobilized to its insertion at the second metacarpal base. It is important to keep the tendon moistened with gauze soaked in normal saline, as desiccation can weaken the tendon and lead to fraying, particularly during passage through the metacarpal tunnel. Tendon delivery through the bony tunnels can be facilitated
Intraoperative radiographs should be viewed to assess the trapezial space and metacarpal position.
The postoperative regimen consists of immobilization with a short arm thumb-spica cast for 4 weeks. After 4 weeks, range-of-motion exercises are begun, with active motion of the thumb interphalangeal and metacarpophalangeal (if not arthrodesed) joints. Isometric thenar muscle exercises can also be initiated. During this period, the thumb spica splint may be removed four times a day to facilitate exercising. Eight weeks postoperatively, active flexion-adduction exercises at the thumb basal joint begin and the splint is weaned off. Resistive lateral pinch and grip strengthening is initiated at 12 weeks with titration of normal activity.
Ligament Reconstruction Tendon Interposition Results
Tomaino et al.17 evaluated the results of ligament reconstruction tendon interposition arthroplasty
Other reports with shorter follow-up intervals have also shown positive outcomes with ligament
Numerous technical variations of ligament reconstruction tendon interposition arthroplasty have been described in the literature. Some variations simply alter specific steps in the operation. Harvesting of the entire flexor carpi radialis versus one-half flexor carpi radialis has not been shown to produce any more morbidity, with respect to wrist strength or endurance.62,63 There are no reports comparing the importance of pin fixation of the metacarpal with no pin fixation, and the authors of this article do not see the necessity, provided adequate interposition material has been placed. Vartimidis et al.62 believe that lack of Kirschner wire stabilization may actually eliminate a potential source of complications.
The decision to perform partial versus whole trapezial resection can be based on the amount of radiographic and intraoperative scaphotrapezial disease and pantrapezial involvement. Most authors agree that if there is pantrapezial or scaphotrapezial disease progression, the entire trapezium should be resected. Glickel et al.41 reported that scaphotrapezial symptomatology did not advance during an average 8-year follow-up period in 18 patients after ligament reconstruction tendon interposition arthroplasty with hemitrapeziectomy. Irwin et al. attributed unrecognized scaphotrapezoidal involvement as a cause of postoperative discomfort. There is no long-term or short-term morbidity with complete trapezial excision when ligament reconstruction tendon interposition is performed. Given the high possibility for unrecognized scaphotrapezial disease, we recommend pantrapezial excision when performing ligament reconstruction tendon interposition arthroplasty.
Other variations of ligament reconstruction tendon interposition center on the use of different tendons, variations of tendon configurations, and/or interposition material. Thompson65 described a technical modification using the abductor pollicis longus, rather than the flexor carpi radialis tendon. The technique involves detaching half of the abductor pollicis longus at its musculotendinous junction, and leaving its dorsal attachment to the thumb metacarpal intact. The abductor pollicis longus is then passed retrograde through the dorsal bone hole and out the articular surface hole. The abductor pollicis longus tendon is then passed through a second oblique bone tunnel from the trapezial facet of the index metacarpal and heading dorsoulnarly on the index metacarpal. Tension is set by pulling on the abductor
Diao modified the “Thompson suspensionplasty” by orienting the second bone tunnel in the palmar portion of the metaphyseal-diaphyseal junction of the index metacarpal and drilling it dorsally. Diao believes this variation adds (1) added bony stability with more cortical bone hole support and (2) a more distal suspension focus. Results in 38 patients, with 15 thumbs, followed at an average of 23 months, showed complete pain relief in 87 percent, with full opposition and flexion in all but one patient.18 In the same report, cadaveric analysis demonstrated the least proximal migration when compared with ligament reconstruction tendon interposition and Thompson suspensionplasty.
Since Froimson67 added a rolled-up flexor carpi radialis tendon anchovy as interposition
Trapeziometacarpal arthritis is the second most common degenerative joint disease in the hand. It has been postulated to be caused by hormonal and biochemical factors; increased ligament laxity; and the presence of a smaller, less congruous trapeziometacarpal joint. In the year 2005, the beak ligament continues to be considered the primary trapeziometacarpal joint stabilizer, and is still implicated in the pathogenesis of trapeziometacarpal joint arthritis.36 Current techniques that restore trapeziometacarpal joint stability through ligamentous reconstruction such as the ligament reconstruction tendon interposition arthroplasty continue to produce consistently favorable results. Numerous technical variations of ligament reconstruction and tendon interposition arthroplasty, originally popularized by Burton and Pelligrini,15 have been described in the literature,16 –20 and all center on three common
Ashkan Ghavami, M.D.