Stage Disease

•  Until recently, surgical treatment has centered on reconstruction of the palmar beak ligament with a slip of flexor carpi radialis (FCR) tendon as described by Eaton and Littler4 (Figure 24—3). However, for this procedure to provide pain relief, the joint surfaces must be free of eburnation and demonstrate only early changes of chondromalacia, at most, in the contact areas of the palmar compartment. The TM joint can be exposed effectively using a modified Wagner approach, with an incision centered over the dorsoradial aspect of the thumb metacarpal. The decision to perform ligament reconstruction without trapezium excision is predicated upon intraoperative confirmation of satisfactory articular surfaces. The surgeon and patient must be prepared to exercise an alternative treatment option if the degenerative changes are more extensive.

•  The objective of ligament reconstruction in the treatment of the hypermobile TM joint is restoration of a static restraint to dorsal translation. Eaton et al.8 reported long-term follow-up on 50 thumbs following the

Figure 24-3:

Eaton ligament reconstruction. Abd P. L., abductor pollicis longus; F. C.R., flexor carpi radialis.

Procedure. For eight thumbs with stage 1 disease and a normal TM joint space, excellent pain relief and complete restoration of pinch strength resulted. Freedman, Eaton, and Glickel9 showed that ligament reconstruction restored pain-free TM stability and prevented the development of TM osteoarthritis in 15 (65%) of 23 thumbs at an average follow-up of 15 years.

The biomechanical analysis by Pellegrini et al.10 of the effect of thumb metacarpal osteotomy inspired Tomaino’s11 prospective investigation of this procedure’s efficacy for treatment of stage 1 disease (Figure 24—4).

The rationale for thumb metacarpal extension osteotomy involves dorsal load transfer and a shift in force vectors during pinch. A 30-degree closing wedge extension osteotomy effectively unloaded the palmar compartment and shifted the contact areas to the intact dorsal articular cartilage. Tomaino reported on 12 patients enrolled between 1995 and 1998, with an average follow-up of 2.1 years, and showed that all osteotomies healed at an average of 7 weeks, and 11 patients were satisfied with outcome. Grip and pinch strength increased an average of 8.5 and 3 kg, respectively. Thumb metacarpal extension osteotomy is an effective “biomechanical alternative” to ligament reconstruction as treatment for Eaton stage I disease of the TM joint.10

Figure 24-4:

Stage 1 basal joint disease. A, Preoperative stress x-ray film demonstrates stage 1 disease (normal trapeziometacarpal joint). B, Preoperative lateral x-ray film with the planned 30-degree extension osteotomy.

Figure 24-4: cont’d

C, Lateral x-ray film after osteotomy.

•  TM arthroscopy arguably is the newest procedure available for treating stage 1 disease. The technical pearls have been published by Berger,12 and some surgeons advocate arthroscopic synovectomy, ligament thermal shrinkage, and temporary TM pinning. The absence of published reports of outcome justifies a modicum of resistance before adopting this alternative. Hopefully prospective assessment of efficacy are forthcoming (Figure 24-5).

Advanced Stages: Surgical Treatment Options

•  Advanced disease implies end-stage degeneration of the TM joint (stages 2-4), salvageable only by a procedure that removes or replaces the entire articular surface. Although a number of reports have underscored superlative pain relief with TM joint fusion, mobility

Is limited, and abnormal wear at adjacent unfused joints can develop.7’13

• Simple trapezium excision avoids the problems associated with fusion and the complications of material wear and instability associated with implant arthroplasty. Weakness and instability historically have compromised long-term functional results in the absence of concomitant ligament

B

Figure 24-5:

Trapeziometacarpal (TM) Arthroscopy. A, TM arthroscopy setup. B, Arthroscopic photo of TM synovitis.

Figure 24-5: cont’d

C, Arthroscopic photo after synovectomy.

Reconstruction. Even the addition of fascial or tendon interposition by Froimson,14 in an effort to improve grip strength and reduce metacarpal shortening, failed to improve long-term results. Simple trapezium excision in conjunction with temporary distraction and pinning has gained popularity—the so-called hematoma-distraction arthroplasty.15 Long-term follow-up has not yet been reported for this procedure, and the potential for a decline in pinch strength with time seems inevitable, at least in higher-demand thumbs.

•  Cemented arthroplasty has been associated with an unacceptably high loosening rate and has fallen from favor. The de la Caffiniere prosthesis has undergone design revisions intended to reduce the incidence of early metacarpal loosening by enlarging the stem diameter, adding a circumferential collar and providing a modular head-neck segment. The polyethylene trapezial component remains unchanged. Meaningful results using this new component design will not be available for several years.

•  Hemiarthroplasty is an effective treatment (Figure 24—6 A, B).

•  We recommend the LRTI arthroplasty for basal joint reconstruction for pantrapezial involvement. This procedure includes trapezium excision, ligament reconstruction, and tendon interposition. The LRTI, as originally described by Burton and Pellegrini,16 used half the width of the FCR tendon for ligament reconstruction. Many surgeons, including Burton, altered this procedure to include the entire width of the FCR tendon in order to facilitate harvest and provide a bulkier tendon for interposition. Tomaino and Coleman17 reported no morbidity following the use of the entire tendon. Passing the entire width of the FCR tendon through a bony channel in the thumb metacarpal is facilitated by tapering the proximal width of the tendon and using a Carrol tendon passer (Figure 24—6 C through F and Box 24-2).

•  With respect to LRTI arthroplasty, results seem to improve for several years following the operation, underscoring the protracted time necessary to achieve maximum strength following the procedure. Documentation of durable long-term performance following this procedure18 contrasts markedly with the long-term outcomes after prosthetic trapezium replacement and trapezium excision with fascial interposition.

•  Tissue interposition appears to promote repopulation of the arthroplasty space with denser, less “fatty” scar tissue, theoretically providing a more effective “secondary restraint” to proximal metacarpal migration over time. However, Gerwin et al.19 and Kriegs-Au et al.20 demonstrated that tissue interposition probably does not matter, at least in the short term. Furthermore, there appears not to be a correlation between some degree of subsidence and outcome unless scaphometacarpal impingement occurs, which is more likely when no ligament reconstruction has been performed.

•  Many surgeons have elected to use alternative methods of suspending the metacarpal, and some have stopped pinning it for 4 weeks. Appreciation of underlying principles and technically sound execution will increase the likelihood of functional improvement, which should be measured against very favorable long-term outcomes reported in 1995 following long-term assessment of the LRTI, regardless of the method.

•  Thompson21 has been credited with describing use of a slip of the abductor pollicis longus (APL) tendon using tunnels through both thumb and index metacarpal bases. Others have avoided using any bony tunnel, simply by weaving a slip of APL around the FCR and sewing it back dorsally to itself and/or periosteum.22 The world’s literature uniformly describes favorable outcome following such suspensionplasties, characterized by excellent pain relief and significantly improved strength.

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