Trapeziectomy and Abductor pollicis longus suspensionplasty

Plain films will usually confirm the diagnosis of TMC OA.
You can see the narrowed TMC joint space (J) and the osteophyte at the ulnar aspect of the distal trapezium (O).

Subluxation of the thumb metacarpal on the trapezium is usually best seen on the lateral projection of the TMC joint.
Due to the rotation of the thumb in relation to the plane of the palm, the MC joint is often adequately displayed on a PA projection of the wrist.
Here, you can see subluxation of the thumb metacarpal, due to attenuation of the palmar oblique ligament (that attaches to the beak of the metacarpal base- B). Marginal osteophyte formation of the trapezium can again be seen (O).
In this patient, the STT joint is not well seen, due to flexion of the scaphoid (note the hard cortical “ring” sign created by the scaphoid being imaged along its long axis; the cortical bone of the scaphoid superimposes due to flexion of the bone, causing the circle of bone (R- labelled in the center of the ring of cortical bone); overall, the scaphoid looks like a signet ring). This flexion is due to attenuation of the scapholunate ligament, indicated by widening of the interval between the scaphoid and the lunate (L)).

In some cases, cross-sectional imaging may be required in addition to plain films.
An MRI was obtained in this patient due to relatively diffuse nature of her radial-sided pains; this has shown fluid around the tendons of the 1st dorsal (extensor tendon) compartment (1); this is consistent with an additional diagnosis of de Quervain syndrome, although clinical correlation and, if necessary, assessing the differential responses to diagnostic and therapeutic injections of local anaesthetic and corticosteroid into different suspected anatomical sites can be very important to help plan treatments.
In addition to the tendon sheath pathology, this patient’s scan confirmed the TMC arthritis (T- note the high signal in the bone, which largely appears white on this sequence). Also, you can see the transverse carpal ligament, which forms the roof over the carpal tunnel (C); the darker structures are the flexor tendons, and the median nerve (M- labelled below the nerve) is higher signal. Note that the transverse carpal ligament attaches to the ridge on the deep surface of the trapezium, and the flexor tendons in the carpal tunnel that are close by; you will need to remember this when releasing the transverse carpal ligament from the trapezium around FCR.
I have also marked the pisiform for clarity and to help orientation (P).

Osteochondral elements (O) can become detached and come to lie deep in the interval between the thumb metacarpal (M) and the trapezoid / index finger metacarpal.
You will need to remember to inspect this area carefully having removed the trapezium to ensure these elements are not left behind.
I have labelled the trapezium (T), the distal scaphoid S- note the central signal change, indicating co-existing STT arthritis), and the flexor tendons entering the carpal tunnel (F); the extensor tendons on the 1st dorsal (extensor) compartment have a more oblique course, and can be seen in an elongated cross-section on this coronal slice (1).

The arm is positioned on an arm table with a tourniquet (if used) applied high enough to enable tendon harvesting to be undertaken.As I like to keep my options open in terms of which tendon I will harvest to us for the ligament reconstruction / suspensionplasty (APL, or flexor carpi radialis), I like to expose a reasonable length of the forearm. If the patient is going to have a general anaesthetic, I prefer to use an above elbow tourniquet as anecdotally this seems to provide a better bloodless field; however, if the patient has chosen a regional anaesthetic, then using a forearm tourniquet will help to minimise any tourniquet-related pain (as will applying an above elbow tourniquet relatively low on the arm).

Ensure that you have available any specialist instruments that you think that you may require for the trapezium excision and tendon harvestingW- Small self-retaining retractor; be sure to check that you have been provided with a retractor that has rounded (blunt) teeth, not pointed (sharp) ends as these can damage the neurovascular bundles.
F- A selection of forceps, including Adson Bone Holding Forceps, which have more aggressive, multi-toothed tips to securely hold bone fragments during dissection.
O&M- A selection of small osteotomes (O- to split the trapezium), and a suitably sized mallet (M) to strike the osteotomes with.
S- A curved Carroll tendon retriever, which is useful for defining the path of tendon sheathes in a retrograde fashion, and for delivering the harvested tendon strip into the trapeziectomy field; this is useful to enable you to harvest a longer length of APL, if you feel you need it (such as to provide tendon to fill the excision gap having performed the suspensionplasty, by rolling the remaining tendon into a ball and interposing it), and for harvesting FCR tendon retrograde if you decide or need to use it instead of APL.
B- A sharp-pointed tendon braider, to pass the tendon strip through the remaining FCR or APL tendons, and the capsule, during ligament reconstruction / suspensionplasty; curved tendon braiders can be helpful too.

Make a small split in the dam of the disposable drape (if used) to prevent a venous tourniquet being created by the drape.While the hole is designed to seal the operative field and minimise the likelihood of the drape migrating up the limb, so bringing unprepared skin into the field, if you release the tourniquet before closing the wound the drape will then act as a venous tourniquet, which is very irritating! I prefer to ensure that the arm has been prepared well above the intended level where the skin is exposed to, and to cut a slit in the edge of the hole so that the drape will not dig into the forearm.

Ensure that the forearm is prepared and exposed sufficiently far proximal to leave plenty of room for tendon harvesting.By marking the skin at a level just proximal to the highest level you could need to have available during the operation, you and your team (who may be helping prepare and drape the limb while you scrub) will know to prepare the skin to at least 15cm above the level of the skin marking, and then apply the drape to leave the skin markings visible. As you can see, the slit in the hole (as shown being made in the previous slide) ensures there is no potential for a venous tourniquet, either following exsanguination and tourniquet inflation, or after tourniquet release.
Additionally, by annotating the skin marking arrow that confirms the side to be operated upon, you can be reassured that you are about to undertake the correct procedure, over and above the assurances provided by the now-mandatory WHO pre-operative verbal safety checks. (I use initials and abbreviations- here Trap LRTI; if you are doing a list with multiple hand and wrist cases, I find this very reassuring.)

Establish the surface markings of both the TMC(T) and the STT(S) joints to know the site of the trapezium, between these two joints.The hand is to the right side of the picture, the forearm and elbow to the left. When I am not marking out the surface markings of the nearby structures, I make these markings to cross or abut the junction between the dorsal (hair-bearing) and palmar (glabrous- hairless) skin as I will make my incision along this line; the skin appearance changes at this junction, the palmar skin being smoother and lacking freckles (as well as lacking hair). However, as in this case I have gone on to mark out other structures for clarity in this slide series, I have marked the joint lines further dorsal than is my usual practice.

Palpate the line of passage of the tendons of the 1st dorsal (extensor) tendon compartment over the radial styloid, and plan the surgical incision.I have marked out the 1st dorsal compartment tendons (1), the joint lines (STT-S, and TMC- T). I have also drawn the line of the junction between the dorsal and the palmar skin, for clarity (J; this is away from where I will incise the skin to minimise dye contamination of the surgical field during the procedure, which should not cause tattooing, but would have made the slides messy!) and placed matched dots (D) adjacent to the incision site to guide accurate wound closure at the end of the procedure.

This drawing shows the dorsal wrist compartments topographically.
1.Extensor pollicis brevis & abductor pollicis longus
2.Extensor carpi radialis longus & brevis
3.Extensor pollicis longus
4.Extensor indicis & Extensor digitorum
5. Extensor digiti minimi
6.Extensor carpi ulnaris

This drawing shows the dorsal wrist compartments topographically.
1.Extensor pollicis brevis & abductor pollicis longus
2.Extensor carpi radialis longus & brevis
3.Extensor pollicis longus
4.Extensor indicis & Extensor digitorum
5. Extensor digiti minimi
6.Extensor carpi ulnaris

Incise the skin at the junction of the dorsal (hair-bearing) and palmar (glabrous) skin over sufficient length to safely expose and remove the trapezium.The incision need only be approximately 2.5-3cm long in a slim person as your assistant can move the skin hole proximally and distally to expose the deep structures as needed; However, make the skin incision as long as you need to to achiave safe exposure of all the structures you need to see. (You will find that with experience you can make smaller incisions, but start of with a more generous cut, and extend the incision as you need to if you are finding the exposure difficult.)
For APL suspensionplasty, I bias the incision proximally to aid APL tendon harvesting.
If I am using FCR instead, I will bias the incision distally as I will then need to make a bone tunnel through the base of the thumb metacarpal to pass the tendon through to achieve the ligament reconstruction.

Dissect through the subcutaneous fat being careful to look for and preserve branches of the superficial radial nerve.As the incision runs in the line of the branches of the superficial radial nerve (SRN), the longitudinal incision will minimise the risk of nerve damage, and so the potential for a tender neuroma. Additionally, most of the time the nerve branches will run either palmar or dorsal to the junction of the skin types that the incision runs in, and so lie outside the surgical field; however, as there is the potential for nerves crossing the line of the incision, I will use blunt dissection having cut through the dermis; initially to identify and preserve (SRN branches, but also proximally to identify the radial artery.

Identify the tendons of the 1st dorsal compartment and define the APL and EPB tendons.The APL and EPB tendons form the 1st dorsal (extensor) compartment at the wrist. The tendons (T) will lie deep to any potential nerve branches, but superficial to the radial artery. The precise site of the tendons des vary, and so I am flexible about whether I will dissect deeper in between EPB (which is the more dorsal) and APL, or will pass dorsal to both (in which case, the tendon in the dorsal flap will be extensor pollicis longus).
If you are going to use APL tendon for a suspensionplasty, it is particularly important to accurately identify which tendon is APL and which is EPB before harvesting tendon; I will confirm this when commencing the tendon work, but will usually confirm which tendon is which at this early stage of the operation as well by pulling on the tendons to confirm which attaches to the thumb metacarpal base and do not extend the thumb (the slips of APL), and which pass on the the MCP joint and often beyond, so extending the thumb joints (EPB).

Use a blunt self-retaining retractor to minimise the risk of damage to the radial artery, which crosses from palmar to dorsal at the proximal end of the surgical field.As noted before, be sure that you are not being offered a self-retaining retractor with sharp points (here you can see the tips of the teeth are rounded- R). Also, where possible use a small self-retaining retractor; some will be larger than the incision that you will come to use, but smaller retractors are available, so try to have an appropriately-sized instrument made available.

Place the self-retaining retractor between two tendons, with the handle over the forearm.As previously mentioned, I am flexible as to the path taken to expose the joint beneath the tendons (in between the EPB and APL, or taking both palmar). By putting the handle of the self-retaining retractor proximally (H), it will be less likely to get in your way during the trapeziectomy.
Using a small right-angle retractor (Ragnell or Langenbeck-type; L) is helpful and, once the radial artery has been encountered and mobilised, important to keep it safe, you will need to carefully insert it by passing the shaft between the skin and the handle of the self-retaining retractor, and your assistant will need to control both of these retractors to allow you to focus in the operation itself.

Identify the radial artery, looking out for and controlling any branches crossing the surgical field.The radial artery, with its venae comitantes, can be seen passing from proximal-palmar to dorsal-distal (A); this vascular bundle is a helpful landmark as it crosses at the level of the STT joint, so marking the proximal end of the trapezium.
Branched to and from the artery and veins commonly cross the surgical field in the fat superficial to the joint capsule and the periosteum of the trapezium; these vessels will tether the radial artery, and so need to be controlled and divide to allow the artery to be mobilised away from the STT joint, and so protected throughout the trapeziectomy. Be sure to diathermy the vessels using bipolar diathermy (B), and to use the diathermy for short bursts as far away from the radial artery to minimise the risk of damage to the main artery itself. Similarly, having diathermied the tributary vessels, cut them at the trapezial end of the controlled segment rather than the radial artery end; in this way, it is less likely that the radial artery and venae comitantes will bleed from the cut tributary ends.
If any bleeding were to arise from the trapezial end of the vessels after cutting, this can be safely diathermied again.

Mobilise the radial artery from the tissues over the STT joint, having controlled any branches that come from or to the radial artery and its venae comitantes.I have now moved underneath the radial artery (A) where I look for and control and deep perforating branches / tributaries in order to freely mobilise the vessels.
If the vessels appear to be tethered in the fat or to the underlying periosteum / capsule, there will probably be a branch that you have not noticed; be sure to control this before cutting / blunt dissecting further so that you do not avulse the branch close to the main vessel; controlling bleeding from short vessel stumps will be difficult and will endanger the patency of the radial vessels.

Having mobilised the radial artery, use a small Ragnell-type retractor, tip deep to the vessel, to keep the artery safely out of the field.Note that the handle of the retractor is passing in between the skin and the self-retaining retractor; if it lies superficial to the self-retaining retractor, the angle (A) between the shaft and the blade of the Ragnell will impinge on your view of the deep operative field.

Now expose the dorso-radial aspect of the periosteum of the trapezium.The radial artery is being safely held away from the STT joint; the capsule of the STT joint (C) and the periosteum of the trapezium (P) have been defined in the floor of the field.
You can hopefully see how the view would be obscured if the shaft of the Ragnell retractor (S) was passing superficial to the self-retaining retractor handle.

Confirm that you have identified the TMC joint and the STT joint, as the trapezium will be the bone in between!I am palpating for the joint line of the TMC joint with the tips of the forceps (F).

Incise the capsule of the STT joint, the periosteum over the trapezium, and the capsule of the TMC joint with one continuous longitudinal incision.Before cutting, double-check that your assistant still has safe control of the mobilised radial artery with the Ragnell retractor.

Elevate the capsule of the two joints in continuity with the trapezium periosteum as a continuous sheet dorsally as far as the trapezio-trapezoid joint.I am holding the dorsal capsulo-periosteal flap (P) with the forceps, and working with the scalpel blade to progressively elevate the flap directly off the bone, working as far as the joint between the trapezium and the trapezoid bones. You can see the joint surface of the distal pole of the scaphoid (S) at the proximal end of the wound.

Elevate a similar continuous sheet of capsule and periosteum from the palmar side, elevating the thenar eminence muscles from the trapezium.The extent to which the capsule and periosteum can be elevated from the thumb metacarpal base is limited by the insertion of the APL tendon.
The palmar flap (P) can become less reliable, as the periosteum over the trapezium gets thinner where the thenar muscles attach, but by sticking directly onto the bone and carefully elevating the flap as far as you can safely see, a continuous sheet of tissue can be maintained.

Confirm that you have correctly identified the trapezium at this stage before proceeding with splitting and removal of the exposed bone.Using the curved end of a McDonald’s dissector (M), confirm that the contour of the two joints identified is as you would expect; the domed distal scaphoid should correspond with the curved proximal end of the trapezium with a uni-planar curve, whereas the saddle-shaped TMC joint has a characteristic curve in two planes (palmar-dorsal, and radio-ulnar).
Double check the radiographs at this stage; assuming there is not an un-united scaphoid fracture (or similar), the bone between the two joints will be the trapezium!. If there is any doubt, double check with an on-table x-ray (although personally, I have not found this to be necessary when using a dorsal approach).

The trapezium is now defined and the soft tissues have been released from its dorsal, radial and palmar surfaces.The trapezium (T) lies between the distal pole of the scaphoid (S) and the base of the thumb metacarpal (M); the arthritic distal joint surface of the trapezium (J) can be seen distally.

Split the trapezium obliquely along its length to facilitate removal of the bone.Remember that the flexor carpi radialis tendon (FCR) runs obliquely on the deep surface of the trapezium, from proximal & palmar (P) to dorsal and distal(D); luckily, the initials make this easier to remember. I like to split the trapezium to make it easier to remove, so it is important to orientate the osteotome (O) to reflect the line of the FCR tendon, in order to minimise the risk of damaging the FCR tendon as this will be one of your potential options if you are planning to undertake a ligament reconstruction. In any event, I will use the intact FCR tendon to sling the APL tendon strip around for the suspensionplasty.

DO NOT align the osteotome proximal/dorsal to distal/palmar as the risk of damage to the FCR tendon is greater.The orientation of the osteotome in this picture is intentionally wrong (as marked!) as the FCR tendon runs from proximal / palmar (P) to dorsal / distal (D).

Use an 8-10mm osteotome, but be sure to individually split the subchondral plate bone at the STT and the TMC joints.In this picture, the osteotome is positioned to split the trapezium at its proximal end, so addressing the subchondral plate of bone of the trapezium at the STT joint (S); I try to bury the osteotome by a few millimetres, then move the osteotome distally to extend this provisional split into the TMC joint (T). Be careful not to damage the distal scaphoid inadvertently with the osteotome when splitting the bone; the proximal end of the osteotome has been carefully positioned to minimally overhang the subchondral plate of the trapezium, and the osteotome has been angled to reflect the curve of the STT joint surface.

Rotate the osteotome to confirm that the trapezium has been split into two along its length.Having sequentially advanced the osteotome through the subchondral bone at the proximal and distal ends of the trapezium, once the depth of the bone score being created seems sufficient (8 -10 mm or so, depending on the size of the patient and so of their trapezium), if the trapezium has not split, by rotating the buried osteotome (R) the split can usually be propagated to complete the division of the trapezium (S); remember, the osteotome was orientated proximal / palmar (P) to dorsal / distal (D) while it was being advanced. This minimises the risk of damage to structures deep to the trapezium, such as the FCR tendon, the trapezoid bone, or the contents of the carpal tunnel, depending upon the orientation of the osteotome. In practice, the trapezium commonly splits as you advance the osteotome.

Now remove the entire trapezium piecemeal.Using small bone nibblers (synovectomy rongeurs- N), the trapezium can be removed in manageable-sized fragments of the trapezium (T); grasp the bone securely and then pull and rotate the bone fragment to detach it from the remaining soft tissues. Some fragments will come out easily, but others will require further sharp dissection with a scalpel to remove the bone; be careful when using a scalpel deep in the wound as the carpal tunnel and its contents (notably the flexor pollicis longus tendon and adjacent median nerve) will lie deep to the transverse carpal ligament, which attaches to the deep ridge of the trapezium.

The bone rongeurs can be used to remove large elements of the trapezium.Try different orientations of the rongeurs to see which enables fragments to come out in larger chunks, to make your life easier.

The Adson bone holding forceps are often more helpful for removing elements that are more securely attached as it is easier to dissect around the bone precisely when they are used.The Adson bone holding forceps (A) give a secure hold onto bone fragments (T), even when they are small, to allow you to carefully dissect the soft tissues that are retaining the bone using a scalpel (S); sometimes, it can be helpful to use a Beaver blade on the scalpel as this will cut on both sides of the blade, although you do need to be careful when using a Beaver blade.

Confirm that the whole of the trapezium has been removed by looking, and then feeling into the corners of the excision site, in particular the junction with the index metacarpal distally (into the 1st web space)…This is the site of osteophyte formation, and potentially where loose / reattached osteochondral fragments can come to lie and grow.

… and the palmar, proximal cornerThis is another site where significant bone elements can be inadvertently left.

The trapezium has been removed piecemeal in its entirety.These bony fragments could be sent for histological analysis if there is any concern about a potential bony lesion, or used to fill bony defects in the metacarpal base if there is a significant cyst present (also called a geode).

Look into the scapho-trapezoid element of the STT joint to see if the trapezoid should be undercut or not.By supporting the forearm (to provide counter traction) and pulling on the index finger, the articulation between the distal scaphoid and the trapezoid can be distracted to allow you to visually inspect the articulation and to probe the joint surfaces.

The joint surfaces can be inspected and probed with a McDonald or Watson-Cheyne dissector.I look into the joint, being careful to adjust the light to see deep inside, and use a Watson-Cheyne dissector to probe the joint surfaces, feeling for residual cartilage and defects in the cartilage; however, in the absence of pre-operative symptoms from the STT joint (such as pain on mid-carpal wrist, rather than thumb, motion and stressing, or a positive response to an injection into the STT joint, either isolated, or sequentially-administered following sub-total relief from an injection into the TMC joint) I will only rarely undercut the trapezoid (removing a 3mm sliver to decompress the remainder of the STT joint as well). I will however note the joint condition in case there are persisting or recurrent symptoms following surgery.

Confirm which tendon (APL or FCR) will be used for the suspensionplasty.Having removed the trapezium and inspected the scapho-trapezoid articulation, I move on to the suspensionplasty. Increasingly I use APL for this step, as I find it quicker and easier to undertake. However, if there is a lot of metacarpal descent- it can telescope down onto the distal scaphoid after trapezial excision- or marked thumb metacarpal adduction, then using a distally-based strip of FCR will more accurately reconstruct the palmar oblique ligament, and so in my hands better controls the thumb metacarpal position. Conversely, if the FCR tendon is damaged (either by disease or intra-operative damage) or very tethered, I will certainly use APL.
You should have had a good view of the FCR tendon during the trapezium excision.
Here I am defining the tendons of the 1st dorsal (extensor) compartment; the retinaculum of the compartment (R) can be seen proximally; this patient had symptoms of de Quervain as well as TMC arthritis, but healthy tendons in the 1st dorsal compartment, so release of the 1st dorsal compartment and use of a strip of APL was particularly appropriate in this case. I have identified, defined and isolated the EPB tendon (E), and as is commonly the case, this patient had multiple slips to the APL tendon (A); the forceps are separating the main elements of the APL tendons.

If the patient had any symptoms or signs pre-operatively of de Quervain, formally release the retinaculum of the 1st dorsal compartment along its dorsal edge.The extensor retinaculum is thickened in this patient and, as previously noted, she had symptoms of de Quervain in addition to TMC arthritis (pain radiating into the forearm, reproduced by traction on the thumb, with tenderness along the 1st dorsal compartment in addition to pain at the TMC and metacarpal reproduced by TMC loading and grinding). Formal 1st dorsal compartment release was therefore indicated.
By releasing the retinaculum (R) along its dorsal margin, the palmar attachment of the retinaculum remains securely attached to the radius, so minimising the potential for tendon instability after release (palmar subluxation of the tendons around the edge of the radius). The retractor (L) is keeping and branches of the SRN safe. I am using scissors (S) to divide the retinaculum as it is well-defined distally, and the proximal release will be undertaken under direct vision, but without extending the wound, which can more easily by undertaken by sliding the scissors with the jaws held in a fixed open position.

Before dividing any tendons, confirm which of the multiple tendon slips is which!You can see the thumb extending at the MCP joint but remaining flexed at the IP joint as I pull on the EPB tendon; this confirms the nature of this tendon!

Having identified and retracted EPL, assess the available APL slips to select the most appropriate one.I am pulling on the APL slips to confirm that they abduct the thumb metacarpal (as seen); I will select a strip that has a secure attachment to the metacarpal (to better control the base with the suspensionplasty), but not at the expense of defunctioning abduction; therefore, unless there are multiple strips with secure metacarpal insertions, I will only harvest a portion of the tendon by longitudinally splitting it. (If however there are multiple clear slips with metacarpal insertions, I will harvest all of one of the slips.)

If the APL slip is bulky, up to half of one of the slips can be used.In this case, there was one dominant tendon that inserted into the metacarpal base, with other slips inserting at least in part into the fascia / aponeurosis around the thenar eminence muscles. I am splitting the dominant tendon longitudinally to raise a distally-based, dorsal strip. The incision is being carefully retracted proximally and dorsally, to follow the line of the now-released 1st dorsal compartment, and to protect the SRN branches. The scalpel is splitting the tendon in half along its length, being careful not to damage the other tendons with the tip of the blade. The EPB tendon (E) can be seen coiled at the proximal end of the wound (due to reduced tension from thumb positioning).

Divide the mobilised tendon slip proximally to create a distally-based tendon for the suspensionplasty.Having split the tendon over sufficient length to allow the suspensionplasty to be performed (at least 5 cm), I have turned the blade through 90 degrees to cut and free a distally-based strip. I have selected the more palmar side so that the suspensionplasty will tend if anything to abduct the thumb metacarpal, although I do not think that it really makes a particular difference which side is selected.

Mobilise the half of the tendon intended for use distally as far as its insertion onto the thumb metacarpal base.This has left a distally-based 6cm tendon strip that remains securely attached to the thumb metacarpal.

I pass the mobilised APL tendon strip through the capsule of the former TMC joint using a tendon braider to ensure it enters the excision site adjacent to the base of the thumb metacarpal.To deliver the tendon strip (T) into the cavity, I have elevated the dorsal capsuloperiosteal flap (C) and passed the tendon braider (B) from deep to superficial through the capsule of the former TMC joint, the deep entry point flush with the base of the thumb metacarpal to ensure that the suspensionplasty will sit snugly against the metacarpal base. The radial artery (A) has been retracted dorsally, held safe while the point is delivered through the capsule, but is now sitting in the dorsal fat away from the positioned tendon braider.

Grasp the tip of the APL tendon strip in the jaws of the tendon braider.There is a spike and a reciprocal hole in the tendon braider to penetrate and hold the tendon; passing taking a bite close to the tip of the tendon (T) makes it easier to pull the braider and tendon back through the capsule.

Draw the tendon through the capsule and into the excision site.The braider and tendon (T) have now been drawn through the capsule (C), leaving the attached distal end to lie external to the capsule (O). The free end of the tendon can next be passed deep in the excision cavity to loop around the FCR tendon close to its distal insertion point to fashion a tendon trampoline that will support the thumb metacarpal.

Decide whether to pass the APL tendon strip through the FCR tendon, or to pass it as a sling behind the intact FCR tendon.The APL tendon strip can either be passed to loop around the FCR tendon close to its distal insertion point, or passed through the FCR as distal as possible to fashion the tendon trampoline to support the thumb metacarpal; passing the tendon strip through the FCR tendon will more securely fix its position, but looping it around will allow tension to be generated in the looped APL strip (and so the suspensionplasty) as it can be pulled and tensioned with less deep friction and secured more easily having passed the strip back through the capsuloperiosteal flap. Looping the APL tendon strip around the FCR will also avoid direct damage to the FCR tendon, which may potentially precipitate rupture.
Here, I have chosen to loop the APL strip (A) around the FCR tendon (F). I have passed a small curved artery forcep (mosquito artery forcep- C) around the deep side of the FCR tendon; the tip of the jaws of the forcep can be seen deep in the wound adjacent to the annotation.

The tendon strip is fed into the jaws of the short, curved artery clip to pass the APL tendon strip behind the FCR tendonThe surgical forceps (T) and delivering the end of the APL tendon strip into the jaws of the mosquito artery forcep (C), which is passing deep to the FCR tendon (F).

The APL tendon strip is now fixed superficially by the TMC capsule, and deep by the FCR tendon to create a “trampoline” of tendon that minimises thumb metacarpal descent.By pulling on the APL strip (A), tension will be generated in the suspensionplasty using the FCR tendon (F) as a pulley.

To ensure the APL strip remains distal, it can be sutured onto the FCR tendon.Here, I am pulling on the APL strip (A) to tension the 1st limb of the suspensionplasty, and putting a needle down towards the FCR tendon to demonstrate how the two tendons can be sutured together; in this case, I did not need to suture the tendons together as the mosquito clip had passed through adhesions near the FCR insertion, and so the tendon was remaining distal; this slide is for illustration only.

I then pass the APL tendon strip back through the capsule and suture it onto the capsule and the residual APL tendon.Using the straight tendon braider (B), the APL tendon stump is being drawn back through the capsule (C); the tip of the tendon can be seen (T), about to be pulled through the capsule as I have grasped the tendon approximately 5mm from the cut end.

The base of the thumb metacarpal is drawn into the hand to minimise thumb metacarpal adduction, restoring the position of the thumb.The suspensionplasty helps to reduce the thumb metacarpal adduction that is part of the deformity pattern of TMC arthritis, in patients who had significant adduction contractures improving both the appearance of the hand and the span of the 1st web space. The thumb length will also be maintained, at least initially.

I close the continuous flaps of the capsule and periosteum of the now-excised trapezium as I would for a simple trapeziectomy, using interrupted absorbable sutures.In this case, as there was a length of the harvested APL tendon remaining after the suspensionplasty had been performed, I left the end outside the capsule to reinforce the capsular closure; in the picture the free tip of the tendon (T) is being secured down onto the capsule. (The radial artery (A) lies proximally, and the 1st dorsal compartment tendons palmar (1).)

The remaining tendons of the 1st dorsal compartment and the intact radial artery sit in their anatomical positions over the closed trapezium excision site.Having closed the capsule, there is a sealed layer over the suspensionplasty (C). (The radial artery (A) can be seen proximally, and the 1st dorsal compartment tendons palmar (1).)

I perform a standard 2-layer closure of the skin, and support the wound with Steristrips.The steristrips running across the wrist around its circumference are supporting the incision, cross-hatching to secure one another (X).
The two lengths running along the length of the forearm are each securing one end of the intradermal suture (L), which I do not tie off; this means that the suture can easily be removed as although I use an absorbable suture, the inflammatory reaction that can cause sterile pustules at the site where they pass through the skin can be avoided by removing the suture after 2-3 weeks. As the material is absorbable, if the suture catches and does not pull through, the ends can be trimmed off flush with the skin, allowing the tips to drop back under the dermis, so minimising the risk of pustule formation (which patients find irritating and worrying, and many clinicians that they see about them will call an infection).

To protect the ligament reconstruction amd suspensionplasty, I support the thumb in a forearm-based thumb spica plaster cast.This slide shows the plaster prepared to apply to the patient.
The smaller element (T) is folded longitudinally then laid into the first web space, then wrapped around the thumb so that the tow ends overlap over the thumb metacarpal; this will immobilise the thumb at the MCP joint. The larger element (F) is then applied to the forearm to form a radial-sided gutter slab, overlapping and blending into the plaster applied to the first web space.
The larger element is moulded to form a ridge (already done here (R), although in practice I will commonly make the ridge having applied the plaster and wrapped it in a bandage); after the plaster has set, this ridge will provide additional strength, like the keel of a boat. I place the ridge along the radial side of the forearm to run up to where the two pieces of plaster meet.

The thumb is immobilised in an abducted and extended position.The cast helps with initial post-operative pain control, and protects the ligament reconstruction.