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Trapeziectomy with APL suspensionplasty

    Overview

    Learn the Trapeziectomy with APL suspensionplasty surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Trapeziectomy with APL suspensionplasty surgical procedure.
    Trapezometacarpal arthritis at the thumb base is a common degenerative condition that interferes with the normal function of the hand. It effects all pinch gripping with the thumb which makes many of the activities of daily living difficult. Severe and symptomatic changes may require surgical intervention.
    This is a step-by-step guide to the technique of trapeziectomy along with suspensionplasty using the tendon of the Abductor Pollicis Longus (APL). This particular technique is simpler than other ligament reconstructions following trapeziectomy, as it obviates the need for creating cumbersome bone tunnels and can be done through a single incision

    Indications

    INDICATIONS.
    Eaton and Gickel have classified the trapezometacarpal arthritis into 4 radiological grades according to the severity of the degeneration
    Stage 1 – Normal radiology or mild increase in joint space due to synovitis.
    Stage 2 – Mild narrowing of joint space with possible osteophytes or loose bodies less than 2 mm in size
    Stage 3 – Significant joint space narrowing with osteophytes or loose bodies more than 2 mm in size
    Stage 4 – Same as Stage 3 along with scapho-trapezo-trapezoid (STT) degeneration.
    The goal of treatment in arthritis of the thumb carpometacarpal joint is to relieve pain, improve strength of grip and pinch while maintaining mobility. The ideal surgical treatment would remove the arthritic bone, prevent metacarpal collapse and counteract the cantilever abduction force of the thumb metacarpal base.
    Surgical excision of the trapezium is only indicated in Stage 3 and 4. Earlier and less advanced degeneration (Stage 1 and 2) are treated conservatively or with trapezium sparing procedures. My indications for the procedure are patients with continued pain and dysfunction despite conservative management and with radiological evidence of arthritis.
    The abductor pollicis longus tendon produces a tangential vector force at the base of the thumb metacarpus. This accentuates the symptoms and the deformity in a degenerated joint. Utilising this tendon as a sling will reduce the deforming force, while simultaneously supporting the thumb metacarpal, preventing its subsidence following the excision of the trapezium.
    SYMPTOMS & EXAMINATION.
    The condition is more common in women and the incidence increases with advancing age. The patient usually presents with pain at the base of the thumb, which is exacerbated with activities involving thumb pinches – such as writing, opening doorknobs, using keys, opening jars, crocheting/sewing etc. As the condition worsens, the volar oblique ligament undergoes attenuation, resulting in a dorso-radial subluxation of the metacarpal base. This is manifested as a bony swelling at the thumb base. The metacarpal can become fixed in this adducted state. In an attempt to open up the span of the first web space, the patient begins to hyperextend the thumb at the metacarpophalangeal (MCP) joint resulting in a swan neck deformity of the thumb. The MCP joint may stiffen in this position over time. As the patient continuously flexes the interphalangeal (IP) joint of thumb to achieve pinch, the digit begins to develop a Z deformity.
    Tenderness over the CMC joint is a reliable sign. Axial loading of the joint (grind test) is tender and may demonstrate crepitus. Attempts to reduce the subluxed joint will also elicit pain. It is important to examine for active/passive range of movement at the MCP and IP joints of the thumb. Fixed and stiff deformities at these adjacent joints may need to be addressed at the same time. Additionally, the scaphotrapezial joint should always be examined, as symptomatic degeneration at this joint will affect the choice of treatment. Untreated STT joint arthritis is a cause of failure of the procedure to relieve symptoms. Clinically involvement of the scapho-trapezial joint manifests as pain on dorsiflexion and radial deviation of the wrist and restriction of mid carpal motion.
    IMAGING
    Plain radiographs of the thumb, centered on the carpometacarpal joint, will help diagnose the condition and grade the severity of the degeneration (as per Eaton’s criteria). Further diagnostic investigations are usually not required.
    Other causes of dorsoradial wrist pain may need to be excluded. These include DeQuervain’s tenosynovitis, intersection syndrome and fractures. History and clinical examination are usually sufficient. However, plain radiographs, ultrasound examinations and occasionally MRI scans may be required.
    ALTERNATIVE TREATMENT
    Conservative. This includes splintage, analgesia with NSAIDs and activity modification. These modalities are only useful in early degeneration. For more severe cases, they can be used to provide temporary relief in symptoms while the patient is awaiting surgery.
    Intra-articular steroid injection. This is extremely useful in alleviating symptoms in Stage 1 and 2 (early degeneration). I use it occasionally in Stage 3 if the patient is not keen or not ready to proceed to a more definitive procedure. The anti-inflammatory effects of the steroid allow the symptoms from the synovitis to subside. However the effect is usually transient.
    Volar ligament reconstruction. The FCR tendon is used to reconstruct this primary stabilizer of the carpometacarpal joint through a Wagner approach. The procedure is indicated in thumb CMCJ instability without radiographic evidence of osteoarthritis.
    Selective denervation. This involves division of the intraarticular branches to the carpometacarpal joint that reduce the afferent pain stimulus from the degeneration.
    Extension metacarpal osteotomy. This procedure involves a change in the application of loading force across the CMCJ and protects the beak ligament from further attenuation. In cases with trapezium dysplasia and a steep CMCJ articulation angle, the wedge of bone removed from the metacarpal can be inserted into a wedge opening trapezium osteotomy to reduce the articular slope angle. Osteotomy of the metacarpal is indicated in Stage 2 osteoarthritis and requires no ligament reconstruction. However, the native ligaments stretch out over time resulting in a recurrence of the symptoms.
    Carpometacarpal arthrodesis. I preserve this procedure for the younger patient with post-traumatic degeneration as it helps to preserve the grip strength by maintaining the osseous foundation of the thumb. However, it carries a risk of failure and nonunion necessitating secondary operations.
    Arthroplasty. This may be in the form of interpositional arthroplasty using autogenous or synthetic materials or a replacement arthroplasty utilizing silicon, metal or pyrocarbon implants. The technique of replacement arthroplasty is continuously evolving with newer designs of prostheses. There is very limited clinical data, apart from the reports of the implant manufacturers, regarding the long-term outcomes of these procedures. Currently available options have a risk of failure with loosening and/or breakage of implants. Early total joint arthroplasty designs were associated with high rates of dislocation. Newer designs use a bipolar articulation to minimise leverage of the neck on the cup edge during extremes of motion and thereby reducing loosening and dislocation rates.
    Trapeziectomy alone. This is a relatively simple procedure with reliable outcomes and is therefore extremely popular method of treatment. There is, however, risk of subsidence of the metacarpal bone with shortening and a weakening of the pinch grip. The technique may be combined with distraction pinning to minimize this risk.
    Trapeziectomy with ligament stabilizing procedures. These procedures were designed to overcome the complication of metacarpal subsidence as seen with trapeziectomy alone. Various different techniques have been proposed using flexor carpi radialis, palmaris longus, abductor pollicis longus and synthetic slings.
    Arthroscopy. This modality is recently and slowly becoming popular as a minimally invasive method for joint inspection, capsular shrinkage and limited trapeziectomy. The surgical technique is challenging and requires more long-term data prior to mainstream adoption.
    CONTRAINDICATIONS
    There are few contraindications to this procedure. It is best avoided in younger patients and manual workers, as the reduced grip strength may impact on their professional functions.

    Setup

    Informed consent is an important part of the procedure and the risks and benefits should be clearly explained to the patient. The risk of reduced grip strength is not immediately apparent as patients find a relative improvement to their function once the pain symptoms resolve. The proximity of the branches of the superficial radial nerve to the surgical site can result in numbness over its distribution and occasionally a painful neuroma. This nerve is at risk in the dorsal approach to the trapezium. using a Wagner volar approach for the surgery risks injury to the terminal branches of the palmar branch of the median nerve.
    I prefer regional anaesthesia with axillary block for this procedure. The patient is placed supine with the limb extended on an arm table. Upper arm tourniquet is applied and inflated after exsanguination. A prescrub is performed followed by a sterile prep with Chlorhexidine. A lead hand is used to stabilize the hand. I routinely administer a single prophylactic dose of intravenous antibiotic.

    Operation – 1

    The picture shows the typical deformity of “squaring” of the metacarpal base due to dorso-radial subluxation of the trapeziometacarpal joint. The thumb metacarpal is adducted. Note that the patient has not yet developed any fixed deformity at the metacarpophalangeal joint of the thumb. Radiographs reveal Stage 3 degenerative changes of arthritis. The patient is severely symptomatic with pain in routine function requiring thumb grips. The symptoms were not alleviated despite non-operative treatment with steroid injections and splintage.

    The skin incision is marked as a longitudinal line extending from the tip of the radial styloid until the base of the thumb metacarpal in a dorsoradial plane overlying the 1st extensor compartment of the wrist.

    The incision is made along the marked line as far as the subcutaneous tissues.

    Retraction of the skin flaps allows identification of the thin branches of the superficial radial nerve that lie in the subcutaneous plane.

    Careful blunt dissection is required to isolate these nerve branches so as to prevent damage, scar tether and or neuroma formation. The approach to the joint may be between nerve branches. The nerves should be mobilised within the subcutaneous fat to minimise the risk of direct injury.

    The nerves are retracted and protected with a blunt self-retaining retractor.
    The tendons of EPB (extensor pollicis brevis) and APL (abductor pollicis longus) are identified in the 1st extensor compartment. Dissection plane proceeds between these 2 tendons that are retracted on either side.

    The radial vessels traverse across the snuff box to join the deep palmar arch. These are identified and provide a reliable landmark for the scaphotrapezial joint. The rest of the operation proceeds distal to this important marker. The vessels should be carefully mobilised to allow proximal retraction for exposure of the trapezium.
    The deformity, due to subluxation of the trapeziometacarpal joint, can make the identification of the trapezium difficult. This can result in an inadvertent excision of the distal pole of scaphoid that appears to lie adjacent to the metacarpal base in severe degeneration. Identification of the vascular marker is extremely useful in preventing this disastrous complication.
    This error is avoided by opening and identifying both the scaphotrapezial and the trapeziometacarpal joints.

    The radial vessels are dissected with care.

    The vessels are protected and retracted by the assistant.
    Sharp dissection will now reveal the trapeziometacarpal joint

    The capsule over the trapeziometacarpal and the scaphotrapezial joint is incised in a longitudinal fashion. Unlike in a simple trapeziectomy, a capsular flap is not required for later closure.

    Sharp subperiosteal dissection is carried out over the trapezium to facilitate its excision.

    The scaphotrapezial joint is demonstrated here with a hypodermic needle placed into the joint. Note that this lies at the level of the radial vessels which have been retracted for protection.

    The trapeziometacarpal joint is similarly identified and confirmed with a hypodermic needle. The proximal and distal extent of the trapezium is now in complete view.

    The sharp subperiosteal dissection continues dorsally as well as radially on the exposed trapezium.

    A full set of Lambotte osteotomes of varying sizes are used with a small mallet.

    My favoured technique is to divide the trapezium into three equal thirds using the osteotomes. This helps to accommodate the jaws of a fine tipped bone nibbler and to facilitate subsequent piecemeal excision of the bone.

    A mallet is used to embed the osteotome in the previously marked location. Osteotomy proceeds with gentle tapping of the mallet. It is important to reach the opposite cortex with the osteotome to allow for easier excision of the bone block. Care must be taken not to injure the tendon of teh flexor carpi radialis, which lies closely associated with the volar surface of the trapezium and passes with a proximal volar to distal dorsal orientation.

    Using a fine bone nibbler, the central block of bone is first removed. This helps create space for subsequent excision of the remaining bone fragments which can then be grasped Moore readily with the space created by the recession of the central trapezium.

    The trapezium is excised piecemeal with the fine nibbler until palpation reveals no retained bony fragments. Sharp dissection is often required to detach the bone from the radial capsular attachments. Small pieces of bone lie adjacent to and deep to the FCR tendon in the depths of the wound. These fragments formed the ridge on the trapezium (groove for the FCR tendon) and they must be carefully removed to prevent injury to the tendon.

    Visual inspection confirms that the trapezium is completely excised. Adjacent bones are identified and any remaining osteophytes and loose bodies are removed.
    Sc – Scaphoid (distal end)
    Mc – Metacarpal base
    Tzd – Trapezoid

    The wound is now ready for the next stage of the procedure of reconstruction with APL (abductor pollicis longus) tendon suspensionplasty.

    The 1stextensor compartment is identified and opened. The tendons of EPB (extensor pollicis brevis) and APL (abductor pollicis longus) are identified. The following points can distinguish the two tendons:
    The APL tendon is usually thicker
    APL has multiple tendon slips.
    The muscle belly of APL reaches far distally and can be visualized in the proximal edge of the surgical wound.
    The EPB tendon may sometimes be enclosed in a separate sheath within the 1stextensor compartment.

    The EPB is placed dorsally under the self retiring retractor. The APL tendon is now isolated and may be delivered into the wound. Note the multiple tendon slips within the APL.

    The APL tendon is split longitudinally from its distal attachment on the volar aspect of the metacarpal base up to the musculotendinous junction in the proximal edge of the wound. Careful retraction of the proximal skin edge helps to prevent injury to the superficial radial nerve branches during this part of the dissection.

    The proximal end of one longitudinal half is cut away at the musculotendinous junction, leaving the distal end attached to the metacarpal base.
    The other longitudinal half is left intact.

    Operation – 2

    This provides adequate length of tendon to create a suspension reconstruction of the metacarpal base.

    Tendon instruments will be needed for the next step and include a Carroll Tendon retriever (annotated TR) and a tendon weaver (annotated TW)

    Various modifications of the APL suspensionplasty technique have been described. I prefer to use Sigfusson & Lundborg’s variation first described in 1991. This utilizes the APL tendon slip, which is passed around the intact FCR tendon to create a suspension of the thumb metacarpal. It may then bereaved through self prior to suture after tensioning with the thumb in extension.
    An alternative technique is to weave the APL through the FCR tendon as demonstrated in this image.
    The tendon of FCR (flexor carpi radialis) is identified at the base of the wound. The tendon weaver is passed through the FCR in its midsubstance.

    The free end of the divided APL tendon is grasped with the tendon weaver and delivered through the FCR tendon. Traction on the free end of the APL tendon will create the suspension sling along with the FCR tendon. This will support the metacarpal base improving the biomechanics following trapeziectomy.
    Alternatively, The APL tendon can be passed volar to the FCR tendon using the Carroll tendon retriever to achieve a similar result.
    The risk of rupture of the FCR is lower when the APL is passed around the FCR tendon rather than through it.

    The base of the thumb metacarpal is pushed in and the shaft abducted. Tension is applied to the APL tendon sling to maintain this position. The APL and FCR tendons are then secured to each other with a suture. I prefer to use a braided non-absorbable polyester suture of 4’0 calibre to achieve this. A mattress suture is applied incorporating both the tendons.

    The remnant of the tendon is sutured to the intact half of the APL to provide further secure fixation.
    Alternatively, the remnant can be bunched and interposed in the space left behind by the excised trapezium. or into the residual scaphotrapezoidal articulation after removal of the proximal part of the trapezoid in cases with severe arthritis of this part of the joint.

    The EPB tendon is now replaced back into its original location.

    The suspension sling formed by the secure fixation of the APL to the FCR tendons is confirmed and demonstrated here with the tips of the forceps).

    The correction of the previously visible deformity with reduction of the metacarpal base and abduction of the thumb is confirmed.

    The wound is washed with saline and the subcutaneous tissues are allowed to fall back into their normal locations. A temporary release of the tourniquet at this point will confirm that the radial vessels have remained uninjured. The tourniquet can be reinflated to facilitate wound closure.

    A subcutaneous approximation with absorbable monofilament suture is completed taking care to avoid tether to any of the superficial radial nerve branches during wound closure.

    A monofilament absorbable suture of caliber 5’0 is used in a continuous subcuticular fashion to achieve skin closure

    Nonadherent dressings are applied. I prefer to use the absorbent gauze as strips that are crossed on the dorsal aspect of the thumb so as to support the abduction of the digit.

    The repair needs to be protected in a plaster cast. The plaster is extended onto the volar-ulnar aspect of the thumb to support its abduction. In cases with secondary attenuation of the volar MCPJ capsule and volar plate with early Z thumb deformity, care should be taken when applying the cast to prevent further extension positioning of the MCPJ.
    Severe pre-operative MCPJ hyperextension may require an MCPY sesamoid fusion or MCPJ fusion at the same time as the trapezium excision.

    The wrist is maintained in neutral or slight dorsiflexion. The fingers are left free.

    Post Operative

    The dressings are reduced in the clinic in 48-72 hours and the plaster cast reapplied with thumb in abduction – akin to a Bennett’s cast. Sutures do not require removal.
    The plaster is discarded in 4-6 weeks. A thermoplastic splint is fabricated for rest and comfort and rehabilitation with gentle active mobilization exercises is commenced. Some surgeons change the plaster cast to a splint in 2-3 weeks to commence early mobilisation in the hope of reducing stiffness. Scar massage is also commenced at this stage. Oedema management is instituted as required. The mobilization progresses to include passive exercises and strengthening exercises over the next 6 weeks. The patient is allowed to gently ease back into simple routine activities. Unrestricted activity is allowed after 12 weeks.
    Scar tenderness is a common problem and is best managed by early institution of scar massage. Injury to the superficial sensory nerve branches can result in painful neuromas. This is best avoided by careful dissection, identification and protection of these nerves. Once formed, these neuromas can be extremely debilitating to the comfort and function of the hand and may require surgical exploration.
    Proximal thumb metacarpal subsidence is a problem following all procedures requiring excision of the trapezium. Fortunately, the published literature reveals this to be of no significant functional importance. However, the suspension sling of the APL tendon minimizes this risk significantly. Finally, persistent stiffness may be a concern and is best managed with active mobilisation exercises with supervision by a hand therapist.

    Recommended Reading

    Eaton RG, Glickel SZ: Trapeziometacarpal osteoarthritis: Staging as a rationale for treatment, Hand Clin 3:455-469, 1987. This landmark article examined the radiological appearances at various severities of the disease. They proposed a radiological staging system that can be used as an algorithm in choosing the appropriate treatment for the condition. The staging system is still universally used.
    Sigfusson R, Lundborg G: Abductor pollicis longus tendon arthroplasty for treatment of arthrosis in the first carpometacarpal joint, Scand J Plast Reconstr Surg Hand Surg 25:73-77, 1991. This was the first description of the surgical technique discussed in the above guide. 21 thumbs in 19 patients were treated using this technique. At a mean follow-up of 25 months, pain improvement was noted in all except one patient. Grip strengths and pinch strengths showed marked improvement. The ease of the technique without requiring bone tunnels was emphasized.
    Wajon A, Ada L, Edmunds I. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004631.pub2. DOI: 10.1002/14651858.CD004631.pub2. The authors examined the effects of surgery in reducing pain and improving physical function. Only randomized, quasi-randomised and controlled trials were included in the study. The five treatment modalities compared were trapeziectomy alone, trapeziectomy with interposition arthroplasty, Trapeziectomy with ligament reconstruction, trapeziectomy with ligament reconstruction and interposition and replacement arthroplasty. They concluded that no particular treatment modality had conclusively better outcomes than the other. However, trapeziectomy alone had the lowest rate of complications.
    Rab M, Gohritz A, Gohla T, Krimmer H, Lanz U. Long-term results after resection arthroplasty in patients with arthrosis of the thumb carpometacarpal joint: comparison of abductor pollicis longus and flexor carpi radialis tendon suspension. Handchirurgie, Mikrochirurgie, plastische Chirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse: Organ der V…. 2006 Apr;38(2):98-103. The authors did a retrospective analysis of long-term results in patients who had undergone the above the 2 procedures. They reported highly satisfactory outcomes following each procedure with no statistical difference in terms of pain relief, joint mobility and patient function. However, APL suspensionplasty was found to be technically easier to perform with shorter surgical duration and better recovery of grip strengths.

    Reference

    • orthoracle.com

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