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Trapeziectomy with capsuloperiosteal flap interposition arthroplasty

    Overview

    Learn the Trapeziectomy with capsuloperiosteal flap interposition arthroplasty 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 capsuloperiosteal flap interposition arthroplasty surgical procedure.

    The technique described is a resection arthroplasty for advanced arthritis of the 1st Carpo-metacarpal joint (CMCJ) plus or minus associated Scapho-trapezio-trapezoid (STT) arthritis. Following sucessful surgery there is often a level of residual pain, from arthritis in the adjacent joints, but the expected outcome from a successful trapeziectomy is significant pain relief in the majority of patients (about 80%). One should however expect some loss of grip strength, though this is often not an in issue in the more elderly population for which this operation is indicated. The procedure can on occasion be complicated by excessive 1st metacarpo-phalangeal joint (MCPJ) hyperextension which can be quite a defunctioning condition in any age group.
    Following a period of 6 weeks in a plaster cast and hand therapy the patient is expected to be much more comfortable using their hand however the pain reduction and strengthening often continue to improve up to 6 months post-procedure.

    Indications

    Indications.
    Symptomatic arthritis effecting the 1st CMCJ and or STT joint, which has failed non-operative management.
    The indication for operative management in the main is for pain management.
    Symptoms.
    The symptoms experienced will be in the main pain and stiffness with possible reduced function if the metacarpal is adducted and there is compensatory 1st MCPJ hyperextension. Patients with degenerative change in the 1st CMCJ and STT joint complain of pain and difficulty when gripping, especially opening jars and turning keys. Pain at rest occurs in more severe cases.
    The patient’s job and hobbies often play a major role in their symptoms and therefore discussing these details and realistic expectations of the post-operative outcomes are essential in treatment selection, especially if a patient has (and requires) good grip strength despite the pain.
    Examination.
    A patient with 1st CMCJ arthritis who requires surgery will usually have a prominence of their 1st CMCJ often described as “squaring of the thumb” due to dorsal subluxations of the metacarpal of the trapezium. The mechanism underlying these recurrent subluxations is attenuation of the volar oblique and inter-metacarpal ligaments and the pull of abductor pollicis longus (APL). The metacarpal may also be adducted into the palm and if there is a fixed adduction this is often accompanied by a 1st MCPJ hyperextension and in very severe cases 1st MCPJ pain due to sesamoid arthritis and loss of MCPJ flexion past neutral. There may also be thenar wasting due to disuse and an association with carpal tunnel syndrome is recognised.
    Pain can be elicited by direct palpation over the joint due to synovitis, a Grind test in which the MCPJ is stabilised and the CMCJ rotation while applying compression to the joint. If subluxed pain may also be elicited buy a joint reduction test in which the examiner runs their thumb along the radial border of the wrist and dorsal CMCJ to reduce the subluxation which can cause pain and a palpable reduction of the joint.
    If there is STT joint arthritis this has a very similar presentation but would be less exacerbated by the Grind and Reduction test and most by performing a Kirk-Watson type test – direct pressure over the scaphoid tubercle and radial and ulnar deviation of the wrist.
    Investigations.
    Investigations include plain Postero-anterior (PA) and lateral radiographs of the 1st CMCJ, taken at 90 degrees to the hand.
    If it is unclear which joint the pain is from a local anaesthetic (+/-) steroid injection under Image intensifier can be a diagnostic investigation as well as part of the initial management plan.
    Non-operative Management
    Non-operative management for arthritis includes analgesia, activity modification, wrist splinting, physiotherapy with grip strengthening and occasionally steroid and local anaesthetic injections.
    Alternative operative Management.
    Alternative procedures for 1st CMCJ arthritis include:
    -Trapeziectomy with an alternative stabilising/interposition procedure such as :
    A Tightrope reconstruction of the ligament post-trapeziectomy is of use in revision cases where the local soft tissue available may be poor.
    The interposition of the Flexor Carpi Radialis tendon is commonly performed along with trapeziectomy. However this additional technique has not been shown to have an advantage over simple a trapeziectomy.
    A volar approach can be used, as opposed to the dorsal approach described here. One of its advantages is that the soft tissue attachments on the volar aspect of the trapezium can be more easily separated. However, it needs more dissection of soft tissues and the scar can be more tender afterwards.
    -CMCJ Fusion is an option is the young patient with post-traumatic arthritis. The main disadvantage is the loss of movement in the joint.
    -Denervation: which has been shown to significantly improve pain but it does not address the deformity of the thumb and is not successful in advanced cases of arthritis.
    -CMC joint replacement: whose role is open to debate, with results in many cases not significantly different in outcome from a trapeziectomy.
    Alternative procedures for STT arthritis include:
    STT fusion, distal scaphoid excision (arthroscopic or open), joint interposition, wrist denervation, four corner fusion, scaphoid excision, proximal row carpectomy (PRC), radioscapholunate fusion with distal scaphoid excision.
    Contraindications.
    There are few contra-indications to a simple trapeziectomy. However when a patient has marked 1st MCPJ arthritis the surgeon may consider additional procedures to stabilise the MCPJ and prevent deterioration of hand function if the compensatory MCPJ hyperextension become painful. Options include MCPJ or sesamoid fusion and possible inclusion of a silastic interpositional joint replacement in the trapeziectomy space to maintain thumb length in this circumstance.

    Setup

    Pre-operative preparations and Equipment
    The operation can be performed under general or regional anaesthetic. The patient lies supine with their arm on an arm board.
    The procedure takes 30-45mins and is performed under and upper arm tourniquet set to 250mmHg.
    A single dose of antibiotics are given pre-operatively and a plaster cast is applied at the end of the procedure.
    Equipment
    Fine bone nibblers, vascular sloops, osteotome and toffee hammer.

    Operation – 1

    The hand is prepped, draped and positioned on the hand table. A Huck towel(cotton towel) and Lead hand are useful to position the hand.

    The skin incision is centred on the anatomical snuff box and extended 3cm proximally and distally.An incision is marked over the dorsum of the hand.
    The anatomical snuff box is bounded by abductor pollicis longus and extensor pollicis brevis on the radial side and extensor pollicis longus on the ulnar side.
    Cross-hatchings are useful to match up the wound edges during the closure.

    A rolled up Huck towel is kept on a Lead hand, which helps to support the hand. This provides a good exposure to the first CMC joint.

    An Eshmarch bandage is used to exsanguinate the hand. The arm is elevated and bandage applied distal to proximal. With the bandage applied tourniquet is inflated to 250mm Hg.

    The skin incision is made using a No.15 blade.

    Once the incision is made down to subcutaneous tissues, skin hooks are applied to wound edges. The superfical veins are cauterised using a bipolar electrocautery.

    Blunt dissection with tenotomy scissors is required to identify the superficial radial nerve branches which are just below the superficial veins and within the subcutaneous fat layer.The anatomy of the superficial radial nerve branches are variable and sometimes one may not see them during the dissection. If they are encountered they should be carefully dissected away from the plane of dissection. Excessive handling of the nerve branches risk scarring of the nerves and resultant neuropathic pain.

    Once through the fat the abductor pollicis longus and extensor pollicis brevis tendon are on the radial side and extensor pollicis longus on the ulnar side. However in this case the tendons are not visualised.As the dissection progresses the capsule of the first CMC joint can be seen. A West self-retaining retractor is used to improve visualization.

    The radial artery runs across the anatomical snuff box, is the landmark for the STT joint and needs to be mobilised to allow its protection.It is at risk during trapeziectomy and

    Using tenotomy scissors radial artery and its accompanying venae comitantes are mobilised.

    A plane is developed under the radial artery and venae comitantes and a vascular sloop is passed around them.

    There are small articular branches from the radial artery. They have to cauterised while the artery is mobilised.

    The first CMC joint is identified using a blue hypodermic needle.

    Keeping the joint as the midpoint a rectangular flap is drawn over the capsule of the joint. The proximal extent is the proximal edge of the trapezium(STT joint).The flap is drawn free hand and the width is the same as the base of the metacarpal.

    The flap is distally based and includes the capsule over the joint and the periosteum over the trapezium.

    Using a No.15 blade a capsulo-periosteal flap is raised. This step needs sharp dissection down to the bone and careful separation of the flap from the trapezium.

    As the flap is raised and reflected distally the joint comes into view.

    With the flap reflected, the joint between the first metacarpal and trapezium can be seen. It is important to confirm that it is, in fact, the first CMC joint and not the STT(Scapho-trapezio-trapezoid) joint. The saddle shape of the trapezium is distinctly different from the dome shape of the scaphoid.
    If in doubt, as can be in the case with very arthritic joints, one can hold and move the thumb metacarpal confirming its position.

    Periosteum is reflected from the trapezium exposing it proximally, radially and ulnar-wards, once the joint has been opened.I prefer a No.15 blade to a periosteal elevator.

    Mobilising the trapezium takes time and has to be done carefully.
    It articulates with scaphoid proximally and with the trapezoid on the ulnar side. The joint between trapezium and trapezoid is a syndesmosis and it takes careful dissection to separate them.
    While removing the trapezium there is a risk of inadvertently removing part of the trapezoid. If a significant part of the trapezoid is removed, it can cause instability of the base of the index metacarpal.

    The joint between scaphoid and trapezium should be sought.

    The joint between trapezium and trapezoid is identified and a small osteotome is used to develop the plane between the two.

    The osteotome is used to lever the trapezium free from its attachments.

    Trapezium is broken into small pieces using an osteotome.

    While performing the osteotomy it is important to break the trapezium all the way to the volar side. If it is done incompletely, removing the bone fragments from the volar side can be difficult.

    Operation – 2

    The trapezium has to be broken into at least four or five pieces before it can be removed using bone nibblers.

    While removing the bone pieces using nibblers it is necessary to use a No.15 blade to sharply divide the soft tissue attachments on the volar and radial side.
    Removing the trapezium can be a time-consuming step in the operation as the pieces have several soft tissue attachments.

    Apart from visually inspecting the wound, feeling with a finger for bone remnants help to check the completeness of excision.
    The thumb is now devoid of any ligamentous attachments and is quite flail.

    Capsular interpositionA 3-0 Ethibond suture is passed through the Capsuloperiosteal flap as shown.

    On the volar side of the wound, the FCR tendon can be seen passing obliquely.
    The capsular suture is passed through the FCR tendon. This is difficult to visualise in this photographs as the tendon is in the depth of the wound. Please refer to the diagrammatic representation in the next slide.
    The FCR tendon is tight across the palm. Flexing the wrist slightly gives enough slack on the tendon to allow taking the sutures.

    This is a diagramatic representation of the capsular flap being sutured to FCR tendon. This helps to stabilise the joint-space and also to position the thumb in an anatomical position.
    As a final step the capsule and periosteum, raised from the trapezium, are sutured to the capsule over the base of the thumb metacarpal, closing the joint.

    The suturing of capsule and periosteum to complete the repair is shown.
    Once the capsule repair is complete, the thumb should sit in an abducted position. On moving the thumb gently, it should feel reasonably stable.

    The radial artery can be seen held in the sloops. The capsular repair is complete and wound ready for closure.
    It is important to avoid injury to the artery during closure. The wound edges are mobilised and wound closed in layers.
    The cutaneous nerves lie in the subcutaneous plane and while closing the dermal layer it is important not to take deep bites into subcutaneous tissues to avoid injury to the nerves.

    The tourniquet is released. It is important to check for any bleeding from radial artery at this point.
    If there is a rent in the radial artery, once can repair it under loupe magnificantion. Using microvascular clamps haemostasis is obtained and vessel repair done using 8-0 Ethilon.
    If one lacks expertise for vessel repair it can be ligated. There is inflow from the ulnar artery so the hand will remain well perfused.

    Skin closed in layers using 4-0 Monocryl.

    The wound is now completely closed.

    Jelonet and gauze dressings are being applied.

    Plenty of gauze is applied to provide padding for the wound.

    Velband is applied.

    POP back slab is applied. My technique is to use double layers of four-inch POP cut into this shape.
    The back slab sits on the volar aspect of the forearm, wrist and supports the thumb up to the MCP joint. I do not find it necessary to extend it to the tip of the thumb in the initial POP back slab.

    Bandage is applied.

    Post Operative

    The patient is discharged on the same day as surgery in a sling which is used for the next 3-4 days until much of the swelling has reduced.
    The patient is discharged with Paracetamol, Codeine and if elderly a laxative such a Senna.
    The patient is encouraged to keep there fingers moving until reviewed in the clinic 1-week post-operation. At this point, the plaster is removed and wound checked.
    The patients then sees the hand therapist to encourage further finger movements and a POP cast applied for a further five weeks. The POP cast extends from proximal forearm to the thumb IP joint.
    Postoperative radiographs are not routinely taken but may be useful if the patient has ongoing pain not expected following the surgery.
    To provide a realistic expectation for the patient they are informed that the patient will be worse than there arthritis pain up to 6 weeks then between 6-12 weeks will improve greatly and between 12-24 weeks strength will greatly improve.

    Recommended Reading

    Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition.
    Gangopadhyay S1, McKenna , Burke F, Davis TR.
    J Hand Surg Am. 2012 Mar;37(3):411-7. doi: 10.1016/j.jhsa.2011.11.027. Epub 2012 Feb 3.
    Message: 174 randomised patients were assessed with a minimum of 5 year follow up to trapeziectomy alone or with palmaris interposition or with FCR ligament reconstruction plus interposition. No difference in pain, grip or key pinch strength or complication rate. 78% had good outcomes.
    Six year outcome excision of the trapezium for trapeziometacarpal joint osteoarthritis: is it improved by ligament reconstruction and temporary Kirschner wire insertion?
    Salem H1, Davis TR.
    J Hand Surg Eur Vol. 2012 Mar;37(3):211-9. doi: 10.1177/1753193411414516. Epub 2011 Oct 24.
    Message: Randomised prospective study with 6 year follow up of trapeziectomy alone versus trapeziectomy and FCR ligament reconstruction and k-wire. 114 thumbs in 99 patients revealed no statistical difference in DASH (Disability arm, shoulder, hand) and PEM (Patient Evaluation Measure) scores between groups but significantly better then pre-operative. Key pinch also showed no difference between groups AND no difference from pre-operative strength.

    Reference

    • orthoracle.com

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