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Trapezium excision arthroplasty and flexor carpi radialis tendon interposition

    Overview

    Learn the Trapezium excision arthroplasty and flexor carpi radialis tendon interposition surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Trapezium excision arthroplasty and flexor carpi radialis tendon interposition surgical procedure.
    Trapezium excision-arthroplasty is an effective solution for symptomatic trapezio-metacarpal arthritis or pan trapezoidal arthritis. There also are a number of adjunctive soft tissue procedures which need to be considered at the same time. Their purpose is to create a degree of stability of the thumb after the excision or to produce soft tissue interposition, which reduces the risk of proximal migration of the thumb metacarpal base and impingement against the scaphoid and trapezoid. The exact method of soft tissue stabilisation is probably of limited importance, however a well-performed and stable excision arthroplasty may be mobilised more rapidly than a simple excision arthroplasty alone. The case presented is using a dorsal approach to the thumb carpometacarpal joint (CMCJ). There is some risk of sensitisation, scarring or injury to the superficial radial nerve (SRN) terminal branches using the dorsal approach. Some surgeons therefore prefer a volar approach to the CMCJ.
    This unfortunate patient sustained an injury to the SRN during a steroid injection for the CMCJ arthritis. The consequent neuroma was explored, resected and capped. There was a temporary improvement in the neuropathic pain but the skin on the dorsum of thumb over the radial side of the wrist and hand remained sensitive with allodynia and a strong static Tinel’s sign. The arthritis pain deteriorated over 2 years and a second ultrasound guided injection of the CMCJ using a radial volar approach did not provide more than 4 weeks of pain improvement. The decision was made to undertake a trapezium excision arthroplasty. The dorsal approach was selected to allow simultaneous re-explorartion of the neuroma site, further resection and targeted muscle reinnervation (TMR) of the SRN to the terminal branch of the anterior interosseous nerve (AIN) to the pronator quadratus (PQ). The TMR is covered as a separate procedure elsewhere on the Orthoracle site.
    Please note that the incision used for this procedure is therefore longer, extending more proximally than the typical dorsal approach to the CMCJ of the thumb.
    Readers will also find of interest the following associated OrthOracle techniques:
    Trapeziectomy
    Trapeziectomy with APL suspensionplasty
    Trapeziectomy with capsuloperiosteal flap interposition arthroplasty

    Indications

    INDICATIONS:
    Severe CMCJ arthritis of the thumb or pan trapezium arthritis involving the scapho-trapezial-trapezoidal joint (STT) in addition to the trapezio-metacarpal joint (TMJ). The firstline treatments for arthritis include regular analgesia, NSAIDs for flare-ups, activity modification, steroid injection, splints and in mild disease in young patients, consideration of a denervation procedure which may provide partial and temporary improvement in the pain.
    Arthroplasty of the CMCJ can also be considered.
    SYMPTOMS & EXAMINATION:
    There is typically a progressive adduction deformity of the thumb with dorsal and proximal migration of the thumb metacarpal base. There may be reduced range of motion of the CMCJ with compensatory hyperextension deformity of the metacarpophalangeal (MCP) joint. There may be rest pain, but in the early phase there is pain on gripping tasks, particularly those involving precision grip, pulp-to-pulp grip, tripod grip and to a lesser extent, key pinch grip.
    More advanced arthritis may be associated with pain and swelling after activity and rest pain, including sleep disturbance due to night pain.
    There is often visible a”squaring-off” deformity of the thumb metacarpal base due to marginal joint osteophyte formation. There may be crepitus on stressing the joint.
    The lateral relocation, direct compression and grind tests can be useful in mild cases to confirm the source of pain.
    Lateral relocation testing involves the examiner stabilising the wrist at the ST joint with their non-dominant thumb and index finger and with the dominant thumb and index the base of the thumb metacarpal is gently grasped. The MC base is pushed laterally at the CMCJ articulation through adduction of the thumb. At is subluxes laterally the patient may report pain which is relieved one relocation. This constitutes a positive test.
    Direct compression testing involves the examiner stabilising the thumb MC with one hand and with the opposite thumb the base of the MC under test is pushed volubly as the thumb is gently flexed and extended through a 30 degree range from the neutral position. Pain in the CMCJ or crepitus constitutes a positive test. Minimising the movement reduces the chances of stressing the STTJ which can also be affected by the degenerative joint disease.
    Grind testing involved axial pressure on the thumb which is pronated and supinated against a stabilised STTJ. Pain and crepitus at the CMCJ constitutes a positive test finding.
    In patients with pan-trapezial arthritis there is additional degeneration of the mid-carpal articulations at the STT joint. In such cases there is usually pain on mid carpal motion. The classic motion to reproduce this is moving the wrist from dorsiflexion and radial deviation to palmar flexion and ulnar deviation.
    In severe cases there may be osteophytes in the volar joint and encroachment on the carpal tunnel. Flexor carpi radialis tendon attrition ruptures can occur across the volar aspect of the trapezium where the tendon lies against a boney ridge. Carpal tunnel syndrome may also be associated with CMCJ arthritis.
    IMAGING:
    CMCJ arthritis is possibly related to the great mobility of the joint associated with high loading forces across a relatively small surface area. Chondral wear may be associated with minor trauma with shearing forces at the articulating surfaces. There may be secondary instability as the joint wears, creating further abnormal loading. As the condition progresses there is defunctioning of the volar beak ligament, risking dorsal subluxation of the MC base at the cMCJ articulation, adduction of the thumb MC ad secondary hyperextension laxity at the MCPJ of the thumb.
    The arthritic process at the CMCJ may also be a consequence of developmental or post-traumatic laxity / instability at the CMCJ. In addition there can be hypoplasia of the trapezium with a steep angle such that the metacarpal base shears dorsoradially against the trapezium during loading activity. The hypoplastic trapezium may be apparent on the plane radiograph. This is however an uncommon association.
    Standard radiographs should include an AP and lateral view of the CMCJ. Ideally the whole thumb should be in the same view to demonstrate the alignment. I advise AP and lateral views of the wrist. These additional views can demonstrate the extent of any pan-trapezial arthritis or more extensive pan-carpal arthritis. The alignment of the mid carpal joint and the scaphoid-lunate (SL) angle can be measured. In severe STT or pan-trapezial arthritis there may be reduced flexion of the scaphoid and a reduced S-L angle.
    Mild cases of arthritis may yield radiographs with an increased CMC joint space due to an effusion and synovitis. In the later stages there is joint space narrowing, subchondral sclerosis, subarticular cysts and marginal osteophytes. There is a classification of CMCJ arthritis (Eaton-Littler) based on progressive degenerative changes on plane radiographs. The classification is useful in planning treatment. Early arthritis may be treated with splints and steroid injections, mild arthritis may be suitable for MC osteotomy in the setting of trapezium hypoplasia, moderate arthritis isolated to the CMCJ can be treated with denervation, excision arthroplasty or joint replacement, and severe pan-trapezial arthritis is suitable only for excision arthroplasty. The classification does not provided useful guidance to the likely clinical outcome of non-operative management. Many patients with pan-trapezial arthritis may settle with progressive stiffening of the arthritic joint and activity modification.
    Stage 0 – Increased joint space
    Stage 1 – Reduced joint space and sclerosis
    Stage 2 – Small marginal osteophytes
    Stage 3 – Large (>2mm) osteophytes
    Stage 4 – Pan-trapezial arthritis
    Mild cases may have nothing visible on radiographs and so stress views taken during active precision grip may demonstrate narrowing of the joint space or subluxation of the CMC joint. MRI at this stage may demonstrate a joint effusion, synovitis or early loss of joint cartilage. Alternative diagnoses can also be identified using MRI.
    ALTERNATIVE OPERATIVE TREATMENT:
    In very mild cases with hypoplasia of the trapezium, an opening wedge osteotomy of the trapezium, coupled with an extension extraarticular osteotomy of the thumb metacarpal base may alter joint loading forces, reduce shear and tighten a lax volar beak ligament at the CMCJ creating neo-stability.
    In pure symptomatic instability, an extra-articular ligament stabilising procedure can be performed to prevent or delay progression.
    In established arthritis with mild radiographic changes a denervation can provide partial and temporary relief, typical with up to a 50% reduction in pain for approximately 12-24 months.
    Established pure CMCJ arthritis with preservation of the STTJ may be managed with arthroplasty. There were high rates of loosening or dislocation with early total joint arthroplasty procedures. Many implants have been removed from the market. There is renewed interest in metal-polyethylene articulations with bipolar articulation following the published results of the MOOVIS implant (SBI). The bipolar articulation reduces the risk of neck-rim impingement causing hinging of the arthroplasty and risking dislocation. The Touch arthroplasty (KerriMedical) uses the same bipolar principle with a ceramic-polyethylene articulation. The surgeon should exert caution as there are no longterm published results of these implants.
    An alternative approach is to use an interposition implant to reduce the risk of shortening of the thumb. The results of a pyrocarbon interposition arthroplasty are similar in terms of pain relief and complications to ligament reconstruction and tendon interposition, although a comparative study has demonstrated improved pinch strength in the pyrocarbon group.
    NON-OPERATIVE MANAGEMENT
    The mainstay of management in the early phase is activity modification, analgesic use, splint of the joint and steroid injections with US or fluoroscopic guidance. There is developing interest in hyaluronic acid injections, platelet rich plasma and lipogem injection therapies, however high quality comparative studies are lacking.
    CONTRAINDICATIONS
    Excision arthroplasty has few contra-indications. There may be a reduction in thumb length from proximal migration of the metacarpal base and there is generally a reduction in thumb grip strength, albeit as a reduction in pain and therefore pain inhibition of grip.

    Setup

    The patient should be consented for the procedure and the discussion should include alternate treatment modalities, complications and expected outcomes.
    The anaesthetic is either a general anaesthetic or most commonly in my practice, a regional anaesthetic block at the axillary level. There is interest in WALANT as a technique and it has been described for trapezium excision to good effect.
    A basic hand instrument tray is required with additional small osteotomes, a small mallet and a McDonalds. Fine bone nibblers are needed to remove the trapezium fragments. Tendon instruments, including a tendon passer can assist with harvest and tunnelling of the FCR tendon for ligament reconstruction and tendon interposition.
    A well-padded pneumatic disposable tourniquet is applied to the upper arm.
    I recommend a single dose of prophylactic iv antibiotics to cover common skin commensals duee to the extensive bone and joint exposure and the temporarily avascular tendon strip that is used for the stabilisation and interposition arthroplasty.

    Operation – 1

    The skin is prepared with alcoholic betadine from the hand to the elbow.
    The first stage of the WHO theatre checklist is completed prior to commencing the anaesthetic nerve block. The anaesthetic block is checked for adequacy. the patient is transferred to the operating theatre. the operation site is confirmed and the second part of the WHO checklist is completed. The limb is elevated for exsanguination. The tourniquet is inflated to 250mmHg pressure and the time is recorded. A stopwatch is commenced with alerts set for 60 minutes.
    The limb is prepared from the hand to the elbow.

    The surgical drapes are applied and the arrow confirms the side and site of surgery.
    The forearm must be exposed to allow harvest of the FCR tendon for the ligament stabilisation and interposition procedure.

    In this case there is a planned trapezium excision through the dorsoradial incision. This will be extended proximally as necessary to identify the SRN neuroma and a decision will be made on whether TMR is needed to manage the neuropathic pain.
    The TMR involves directing the proximal SRN stump after neuroma resection to the AIN terminal branch to the PQ. This will be discussed elsewhere in Orthoracle.
    The volar incision mis placed for the TMR exposure. The FCR can be harvested through the volar incision. If the FCR harvest is needed without TMR, then two 1cm transverse incisions at 50mm and 100mm proximal to the wrist crease, directly over the FCR tendon, can be used for this purpose.
    A surgical pause or “stop moment” is used in our unit prior to incising the skin.
    The rest of this operative technique will concentrate on my approach to trapezium excision and FCR stabilisation and tendon interposition using the dorsal approach to the CMCJ.

    The dorsal incision over the “anatomical snuffbox” is incised.The approach can be performed through a longitudinal dorsal incision or a lazy “S” incision, which I prefer as it provides a wider exposure of the area to identify and mobilise small nerve branches in the subcutaneous plane. In this case there is concomitant surgery to a neuroma in the SRN and the neuroma must be identified, proximally dissected and then re-routed to the volar forearm.
    The anatomical boundaries of the “anatomical snuffbox” are the AP and EPB tendons on the volar aspect and the EPL tendon on the dorsal aspect. The floor is made up of the radial styloid, the scaphoid waist, the trapezium and the thumb metacarpal in a proximal to distal orientation. The floor is crossed by the radial artery obliquely running from volar proximal to distal dorsal.
    Small vessels are cauterised with bipolar diathermy.
    The cutaneous nerve branches from the SRN should be identified, mobilised and protected throughout this approach.

    This operation is combined with resection and TMR for a neuroma effecting the SRN.
    The superficial radial neuroma is identified during the superficial dissection. the nerve emerges at the dorsal brachioradialis tendon in the distal 1/3 of the forearm before branching and passing distally to the dorsoradial aspect of the hand. The small branches cross the EPL tendon and other volar branches may communicate with the lateral cutaneous nerve terminal branches in the distal forearm.
    The nerve is neurolysed and tased with a fine suture. Bipolar cautery is used for haemostasis of small blood vessels in the scarred surgical bed.

    The CMCJ to the thumb is approached through the dorsum between the ulnar side EPL and the radial side EPB and APL.

    The EPB and APL tendons are mobilised radially in their 1st extensor compartment sheath to provide a broad exposure of the CMCJ capsule.Care should be taken during the proximal part of this dissection due to the radial artery crossing obliquely at the level of the STTJ. The forceps are pointing to the thumb carpometacarpal joint.

    The capsule of the CMCJ is incised and then elevated as flaps off the dorsum of the trapezium.The radial artery (RA) is protected in the proximal part of the dissection. The Langenbeck retractor is assisting with the ulnar exposure as for as the trapezium articulation with the trapezoid (TTJ).

    The joint spaces should be confirmed either side of the trapezium once the CMC joint has been opened and the capsule reflected. A McDonalds is the ideal tool for this. The STTJ has a convex distal surface of the scaphoid and a concave proximal surface of the trapezium. The McDonalds has a curved end that can be used to probe the joint articulation and confirm the STTJ.
    The CMCJ to the thumb is flatter in orientation and this too can be probed and compared to the more proximal STTJ. The orientation of the joint confirms that this is the CMCJ and not the STTJ.
    In advanced arthritis there is often severe narrowing of the joint and it may be difficult to insert an instrument without completing the capsulotomy and providing a traction force to the thumb.

    The trapezium is exposed and the saddle shaped TM joint is visible.
    This case has moderate arthritis changes with central cartilage loss.

    An osteotome is used to split the trapezium.The orientation of the osteotome that I advise is perpendicular to the dorsal cortex of the trapezium with a proximal volar to distal dorsal angulation to mirror the orientation of the FCR tendon which passed from volar to dorsal along the volar aspect of the trapezium aligned with the volar ridge. This is a precaution to avoid inadvertent injury to the tendon should the osteotome pierce the volar cortex.

    A small mallet is used to gently tap to initiate the bone cut and then a firm tap to split the bone.
    The osteotome should be introduced approximately 15mm and then can be twisted levered in a volar and dorsal direction and then twisted to split the trapezium without having to fully penetrate the bone. This protects the FCR which will be used for the reconstruction.

    A fine tipped bone nibbler is used to remove the large fragments of the trapezium.
    Usually the scalpel will be required to free the deep soft tissue attachments to the bone fragments.
    The orientation of the self-retaining retractor has been reversed to allow access to the instruments.
    The volar bone fragments are adherent to the deep layer of the thenar muscles.

    The trapezium excision is completed using bone nibblers and the FCR tendon can be seen in the depth of the wound aligned in a volar proximal to distal dorsal orientation.The small fragments of volar bone attached to the deep layers of the thenar muscles must be removed. There may be osteophyte around the volar TT and TM joints and these should be carefully removed. The bone ridges either side of the FCR tendon should be removed to allow full exposure of the tendon for the subsequent reconstruction.

    The FCR is seen in the base of the excision arthroplasty.
    FCR – Flexor carpi radialis tendon
    S – Distal scaphoid pole
    T – Trapezoid

    The forearm is now supinated and placed in a lead hand to allow access to the volar wrist for harvest of a distally based slip of FCR tendon.The normal method of FCR harvest is using two 1cm incisions, 5 and 10cm proximal to the wrist crease directly over the FCR tendon.
    The case illustrated is having TMR for the SRN to the terminal AIN and access requires a longitudinal and ulnar exposure, so the approach illustrated here differs. The method of FCR stripping is similar, however and will be demonstrated here.

    The volar incision is made to expose the FCR tendon.Normally a transverse incision of 1cm is made over the FCR tendon 5cm proximal to the wrist crease, the FCR is exposed, mobilised and lifted with a tendon hook and a further 1cm transverse incision is made over the palpated FCR tendon 10cm from the wrist crease. This approach minimises scarring around the tendons in the volar forearm.
    FCR is the second most radial of the 5 muscles arising from the medial epicondyle of the humerus (PT, FCR, PL, FSD and FCU).
    The course of the FCR is a direct line from the medial epicondyle to the scaphoid tuberosity which is palpated as a small bone prominence on the wrist crease 10-15mm from the midline of the wrist.
    In this case the incision is made more ulnarly and longitudinally to allow access to the anterior interosseous nerve fr a concomitant nerve transfer (TMR) procedure for neuroma pain in the SRN. This additional procedure is covered elsewhere on Orthoracle.

    The FCR tendon is lying obliquely from distal radial to proximal ulnar within a thin superficial paratenon layer.
    This incision is more ulnar than would normal be required for access to the FCR only.

    The FCR paratenon layer is incised to expose the tendon within it.

    The scalpel is used to incise the ulnar 1/3 of the FCR tendon 10 cm proximal to the wrist crease.Sharp dissection in a distal direction along the fibres of the FCR allows the elevation of a distally based FCR strip. The dissection is easier when there is some tension on the tendon and this may be achieved using fine toothed forceps to wrap the end of the strip. Local damage to the collagen structure is not an issue as this will form part of the interposition and is not integral to the ligament reconstruction stabilising aspect of the FCR reconstruction.

    Care should be taken when using the scalpel to separate the tendon bundles to maintain a cleavage plane and avoid cutting any collagen bundles transversely.
    There is a torsion alignment of the tendon bundles as the dissection proceeds distally and this must be traced and followed.

    The splitting should extend to as close to the volar wrist crease as possible.

    The FCR has now been split and will need retrieving and delivering to the dorsal wound and the trapezium excision arthroplasty site.

    A Carroll tendon passer(A) is used to follow the FCR from the bed of the trapezium excision arthroplasty, within the FCR sheath, to the volar wound.The curvature of the tendon passer facilitates this passing.

    Introducing the passer is difficult and the correct passage is essential to avoid causing trauma to the FCR or avulsing the strip during retrieval.
    Start with a vertical orientation of the tip of the tendon passer. The blunt curved tip can be placed alongside the FCR on its volar aspect, the wrist may be extended and the passer lowered to a more horizontal orientation. The passer can then enter Fiton’s canal and can follow the volar soft tissues of the tunnel roof as the canal is straightened through the wrist extension. There is a tight section as it crossed the wrist crease level, but this is usually negotiated by rotating the passer 90 degrees to have the flattened passer tip orientated with the transverse orientation of the canal at this point. The curve of the passer allows the operator to “feel” the way through the canal without significant force required.

    Operation – 2

    The passer may be rotated 90 degrees to allow it to pass against the side wall of the carpal tunnel and then the curve can be used to follow the FCR tunnel through Fiton’s canal to the volar wound.Fiton’s canal is the tunnel for the FCR in the radial wall of the carpal tunnel. The FCR is separate from the carpal tunnel contents. The canal is the continuation of the FCR sheath and is bounded distally and radially by the groove on the volar surface of the trapezium. The FCR passes through the canal and inserts onto the volar aspect of the index metacarpal base.

    The tendon passer is delivered to the volar wound.

    The tendon passer can be seen in the volar wound.
    The forearm is supinated to allow access to the tendon passer tip.

    The tendon passer is in position and is ready to receive the proximal end of the cut FCR tendon strip.

    The FCRs cut proximal end is picked up with fine toothed forceps and placed in the tendon passer open jaws.

    The tendon passer is rotated to facilitate capture of the tendon strip.

    The tendon passer is slowly pulled in a distal direction towards the dorsal wound with the FCR being carefully held.The jaws must remain closed with pressure on the handles to prevent loss of the FCR within the tunnel. The end of the Far strip should be as low profile as possible to facilitate the passage through Fiton’s canal.

    The tendon should be watched carefully to ensure that it doesn’t snag on the soft tissues during retraction of the passer.

    With steady pressure the FCR is delivered through the canal and will gradually strip the last 2-3 cm from the residual FCR due to the developed longitudinal cleavage plane along the tendon.Using the ulnar 1/3 of the FCR facilitates this stripping due to the rotating alignment of the fibres as they pass through the canal.

    The FCR strip is delivered to the dorsal wound and and dissected away from the tendon strip at this pointThis is to avoid avulsing the strip from the remainder of the FCR intact tendon or rupturing the FCR tendon in its bed.

    Gradual traction can help this stripping, however scalpel dissection along the tendon at the junction of the intact FCR and the stripped FCR is usually necessary.The distal separation of the two tendon components is need as far as the volar aspect of the thumb metacarpal.

    In this photograph the incomplete stripping distally is apparent.

    The scalpel is used to facilitate the distal stripping which is a technically demanding part of the procedure that should be done slowly and methodically whilst longitudinal retraction in maintained on the FCR strip.Tray not to pull the FCR strip perpendicularly out of the wound because overzealous traction can tent the residual FCR and the operators view may be blocked by the FCR strip. In such situations there is a high risk of staring too deep into the FCR residual tendon and causing an inadvertent tenotomy.

    The stripping is completed distally anterior to the metacarpal base.This is an important step because when th FCR is used for stabilisation of the MC base, the stripping ensures that there is no later extension of the strip during rehabilitation, which can result in loss of stability in the ligament from what was achieved intra-operatively.

    The FCR stripping is now completed and the ligament stabilising procedure can be commenced.

    The FCR is retracted away from the volar aspect of the thumb MC and a 3.5mm drill is placed against the dorsal cortex of the MC base, 1cm from the articular surface in the mid-axial position.The thumb is adducted, lifting the MC base more superficially into the wound.




    Initially the drill is started perpendicular to the base, however once the cortex is breached, the drill is angled to exit at the volar lip of the MC base.This step avoids a dorsal cortex fracture to the articular surface. The dorsal cortex is thinner than the volar cortex.

    After the dorsal cortex is breached, the drill is angled proximally to exit at the volar lip of the MC base.
    Take care to avoid levering the drill during passage.

    The tips of the scissors are demonstrating the ideal exit point of the drill on the volar side of the MC base.
    Care should be taken to avoid damaging the FCR or the FCR stip on the volar aspect. A soft tissue protector should be put in the gap between the MC and the tendon. A McDonalds is suitable for this purpose.

    The tendon passer can be readily introduced through this 3.5mm drill hole.
    The 45 degree obliquity of the bone tunnel facilitates the curve of the tendon passer. Any marginal bone fragments can be removed at the tunnel entrance and exit to prevent attrition on the tendon later.

    The tendon passer can be rotated 90 degrees to expose the tips of the jaws in the excision arthroplasty site.
    The jaw tips must be fully inserted beyond their hinge to allow opening in the confined space.

    The passer must not be levered to avoid the risk of fracturing the dorsal cortex of the tunnel.

    The FCR strips proximal end is introduced into the tips of the Carroll tendon passer.
    The tendon should be flush with the jaw tips to avoid the bulk jamming in the tunnel.

    The FCR strip is drawn through the MC bone tunnel from volar to dorsal using the Carroll tendon passer

    The FCR is pulled into the tunnel and then tightened as the thumb metacarpal base is adducted.This will create the final approximation of the thumb MC to the index MC base and a stable position that is the aim of the FCR stabilisation aspect of this procedure.

    Operation – 3

    The Carroll passer is now passed dorsal to volar under the intact FCR in the base of the wound.Flexing the wrist during this manoeuvre reduces the tension in the FCR and simplifies this step.

    The tendon is now re-introduced to the jaws and wrapped deep to the intact FCR tendon, creating a sling at the MC base.

    The FCR strip is pulled deep to the intact FCR tendon and as it is tightened, the thumb MC base is adducted again and the sling is drawn tight.

    The thumb adopts the final position and the sling supports the thumb MC base and reduces the risk off proximal migration during loading. As the wrist is extended functional during grip, the FCR will be tightened, further stabilising the thumb MC base.

    The looping of the tendon strip around the FCR intact tendon is repeated, creating a stable anchor point.

    The looping can be repeated 2-3 times. Each time the MC adduction should be repeated to ensure that the position is maintained.

    A further loop under the sling is created to broaden the support for the MC base.

    A Prolene 4’0 suture is is passed as a mattress through the tendons, taking care to avoid a suturing into the residual FCR tendon so that the sling continues to act as a tenodesis with wrist motion.I usually place 3 mattress sutures to achieve the desired strength of the stabilisation.

    The residual FCR strip may be used to create a tendon spacer for insertion to the excision arthroplasty site.The FCR strip is laid across a damp swab and the proline can be used to take intermittent bites along the length of the left-over FCR strip.

    The bites are made in a longitudinal orientation and each are 2-3 mm and separated by 5-10mm.

    The suture bites are taken along from the proximal For to the distal cut end and at this point a transverse bite is taken before continuing in a parallel line in a distal to proximal direction

    The prolene is tightened allowing the FCR strip to coil up into waves.

    The prolene suture is tied when the achieved tendon spacer size is reached.

    The suture ends are trimmed and the tendon spacer is completed and inserted into the excision arthroplasty site.

    The tendon plug is inserted into the excision arthroplasty site.

    The tendon spacer is secured in position using a vicryl 4’0 suture.Two sutures are placed between the tendon spacer and the volar and the dorsal capsule. These secure the spacer in the excision arthroplasty site.
    The vicryl is also used to close the dorsal capsule. The capsule closure can be double-breasted to povided additional stability to the metacarpal base.

    Covering the ligament reconstruction, the sling and the tendon interposition with the capsule flaps provides additional stability to the MC base.

    As the capsule o the CMCJ is closed and tightened, the base of the thumb MC is held in place by pressure from the assistant as the sutures are tied.The MC shaft is abducted while the base is held in adduction.
    The stability achieved using this approach provides sufficient strength for relative early mobilisation after 2-3 weeks.

    The repair should avoid injury or tether to any cutaneous SRN branches and also the radial artery at the proximal end of the capsulotomy.

    The skin is closed with interrupted vicryl sutures and then a subcuticular monacril is used for the final outermost layer.

    The SRN has a neuroma in this case that is recurrent and so the additional component of the procedure is a targeted muscle reinnervation to manage the neuropathic pain.
    TMR involves transfer of a proximal nerve stump to a distal motor nerve branch. This can be performed prophylactically at the time of an amputation to reduce residual limb pain, or used as a salvage for management on an established neuroma. The neuroma is resected and then the residual proximal stump is transferred to the distal stump of a proximally sectioned motor nerve branch.
    The TMR is this case will be described separately on Orthoracle.

    The digital flexor tendons are retracted radially in the volar exposure.
    The terminal branch to the AIN to the pronator quadratus is sectioned proximally. The yellow sloop contains the distal AIN.

    The SRN stump is co-apted to the AIN distal stump without tension.
    A microsurgical neurorraphy is completed with 2 x 9’0 nylon sutures and augmented with Tisseel fibrin glue.
    The procedure will be covered in more detail elsewhere on Orthoracle.

    The wounds are closed with vicryl and monacril sutures.

    Steristrips are applied to the closed wound to support the skin edges.
    The wounds are then covered with absorbent dressings.

    Operation – 4

    Dressing gauze is used to pad the wounds and to wrap and support the thumb maintaining the base adduction with the tip of the thumb in a functional mid-abduction and mid-opposition alignment.

    and the tip of the thumb.A well-padded, loosely wrapped wool bandage is applied to the limb from the proximal forearm to the MCPJs of the fingers

    A Plaster of `Paris slab is cut to size for supporting the wrist, thumb and hand.

    The distal end of the cast has reflected wool bandaging to ensure that there are no sharp edges.
    The same process is necessary for the thumb, allowing support to the distal part of the proximal phalanx but enabling free flexion of the IPJ.

    The bandage is applied to the volar slab and wool bandaging.

    A well-padded volar slab is applied with support to the thumb.
    The cast should allow full flexion of the MCPJs to the fingers and IPJ of the thumb. The tourniquet has been released and the cast should be checked to ensure that it is not too tight. The wrist should be in extension of 15-30 degrees.
    The operation WHO sign-out is completed and the surgical count verified.
    The operation note, discharge summary and prescription for post-operative medications ids completed.

    Post Operative

    The limb is placed in a Bradford sling and elevated. The recovery team are asked to monitor for bleeding, swelling and for dressing constriction with regular limb observations.
    The patient is usually discharged on the same day as surgery, however when undertaking complex procedures such as TMR for neuropathic pain patients may be advised to have an overnight stay and more complex pain management strategies.
    The outer bandages may be released to skin if there is any significant swelling or pain in the per-operative period who the regional anaesthetic block wears off.
    A review in clinic at 5-7 days post-operatively allows the dressing sand volar cast to be removed. The wound is inspected and if there are no problems, a new cast or thermoplastic splint is applied.
    I recommend a thermoplastic splint, because it can be adjusted weekly to accommodate the swelling and then the gradual motion of the thumb can be commenced with interval splint support as soon as pain permits. Typically between 2 and 3 weeks from surgery there can be supervised motion of the thumb and wrist. The stabilisation is sufficiently strong that cast immobilisation for 6 weeks is not necessary.
    After 4 weeks the patent commences progressive flexion and opposition and is encouraged to repeat thumb tip to each digit pinch in turn and then to introduce more flexion, opposing to the middle phalanx, the proximal interphalangeal joint, the proximal phalanx and then the volar MCPJ crease in turn.
    Strengthening can be performed from 6 weeks and the patient should be able to return to full normal activities between 8 and 12 weeks from surgery.
    Scar moisturising scar massage cab help remodelling and scar maturation. In cases where there is no additional nerve surgery, scar desensitisation and massage assists with SRN branch mobilisation and prevents nerve tether in scar and problematic scar sensitivity.

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    The technique of trapezium excision is reliable and usually of low morbidity. There is a small risk of proximal metacarpal migration causing shortening o nth thumb and potentially impingement against the trapezoid or the distal scaphoid. Ligament reconstruction procedures reduce the risk of this migration and many surgeons prefer therefore to perform this adjunctive procedure in all cases. Several different ligament reconstruction, suspensioplasty or interposition procedures have been reported with little to choose between each. The palmaris longus may be used for interposition alone as a free tendon graft. The abductor pollicis longus may have a single slip sectioned proximally and then be used as interposition or wrapped around the FCR to form a sling or even wrapped around the EPB and the FCR to create a sling. The FCR described here may be used as an interposition arthroplasty, however used in the way described there is stability achieved at the base of the thumb MC adduction and additional suspension and interposition with a tenodesis action potentiating the stabilising effect on wrist extension.
    Improving on the results of trapezium excision is challenging and there is interest in the role of arthroplasty. The use of non-anatomical interposition arthroplasty implants is such as a silicone spacer has been largely abandoned. Anatomical implants are now preferred, either a hemiarthroplasty or a full arthroplasty where both the metacarpal base and the trapezium distal surface are replaced. Arthroplasty requires a normal scaphotrapezial joint with no arthritis. The risk of dislocation in early total joint arthroplasty reconstruction has been reduced through development of bipolar articulations that have lower rates of edge loading impingement which can cause leverage on the neck of the implant on the edge of the cup. The current vogue is for osteointegration and primary press fit stability with the bone is preferred to cementation. The challenge with failed arthroplasty is the loss of the metacarpal base which is resected to allow the stemmed thumb metaracp component to be inserted. There are other risks af arthroplasty, including infection, fracture of the bone, loosening of the trapezial component, dislocation and wear. Salvage for a failed arthroplasty may necessitate a suspension procedure to approximate the redial thumb metacarpal to the index metacarpal. A commercially available “tight-rope” fibre wire device is available for this indication.
    An alternative approach to the arthritic thumb CMCJ is joint denervation. The results are usually temporary and partial pain resolution. In the young patient with post-traumatic arthritis, a CMCJ arthrodesis may be preferred as a robust method of achieving stability, relieving pain and preventing the thumb shortening that may accompany excision arthroplasty procedures. The stiffness is challenging for some patients who don’t like not being able to fully flatten the hand. Compromising on the mid-abduction and mid-opposition position for one of more palmar adduction limits the ability of the thumb to oppose well to the ulnar digits.
    References:
    1. Biomed Res Int. 2019 Jul 22;2019:7961507. doi: 10.1155/2019/7961507. eCollection 2019. Tendon versus Pyrocarbon Interpositional Arthroplasty in the Treatment of Trapeziometacarpal Osteoarthritis. Oh WT, Chun YM, Koh IH, Shin JK, Choi YR, Kang HJ
    37 patients (39 wrists) with Eaton-Littler stage II or III TMC arthritis underwent complete trapezium excision with LRTI (n=19) or pyrolytic interpositional arthroplasty (n=20). Visual analog scale (VAS) pain scores; grip and pinch strength; Kapandji scores,Disabilities of Arm, Shoulder, and Hand (DASH) and radiographic parameters were used to compare the groups. Outcome assessments were similar for the two groups including complications. The pinch strength was greater in the arthroplasty group and reached significance.
    2. J Hand Surg Am. 2017 Sep;42(9):685-692. doi: 10.1016/j.jhsa.2017.05.018. Epub 2017 Jun 23. Functional Outcomes of Thumb Trapeziometacarpal Arthrodesis With a Locked Plate Versus Ligament Reconstruction and Tendon Interposition. Hippensteel KJ, Calfee R, Dardas AZ, Gelberman R, Osei D, Wall L
    50 consecutive patients with trapeziometacarpal osteoarthritis were treated with arthrodesis or excision arthroplasty and ligament reconstruction. Functional scores, grip and Michigan hand scores were collected. There was an increased opposition distance in the arthrodesis group. There was a 26% non-union rate in the arthrodesis group with 8% being symptomatic. Revision rate was higher in the arthrodesis group. Compared with excision arthroplasty and stabilisation, arthrodesis failed to demonstrate superior improvement in strength, standardised functional performance, or patient-reported function and is associated with an increased likelihood of revision surgery in the first 12 months.
    3. Hand Surg Rehabil. 2016 Apr;35(2):107-13. doi: 10.1016/j.hansur.2016.01.001. Epub 2016 Feb 26. Use of the entire flexor carpi radialis tendon for basal thumb ligament reconstruction interposition arthroplasty. Werthel JD, Dubert T
    This paper notes that although some studies have failed to demonstrate a difference between impeachment excision arthroplasty of the trapezium compared to addition of a ligament reconstruction, those studies did not measure dorsal subluxation of the metacarpal and the response top loading. The study performed a ligament reconstruction with the whole FCR tendon. Pre- and postoperative pain, range of motion, strength, stability of the base of the first metacarpal and DASH scores were evaluated in 49 thumbs (43 patients) and mean follow-up was more than 3 years. The study reported no dorsal subluxation and improved DASH from 49/100 pre-operatively to 22/100 post-operatively. No ulnar deviation of the wrist was observed at the longest follow-up and grip strength was not altered by the procedure. This study showed that the use of the full FCR tendon for LRTI in combination with trapeziectomy is an efficient and safe treatment for advanced carpometacarpal osteoarthritis as it provides a strong ligamentoplasty with a bulky interposition.
    4. J Wrist Surg. 2014 May;3(2):107-13. doi: 10.1055/s-0034-1372518. Biomechanical Test of Three Methods to Treat Thumb CMC Arthritis. Putnam MD, Rattay R, Wentorf F
    A biomechanics evaluation of trapezium excision, excision and suture suspension and excision plus suspension with 50% of FCR was performed. Height maintenance was most limited in the excision arthroplasty alone group. There was no modelled difference in pinch grip assessment.
    5. Clin Orthop Relat Res. 2014 Apr;472(4):1160-5. doi: 10.1007/s11999-013-2956-0. Degenerative change at the pseudarthrosis after trapeziectomy at 6-year followup. Salem HM, Davis TR
    This study had three aims: Radiographic changes of degenerative joint disease progression, loss of the pseudarthrosis height and outcomes score changes after excision arthroplasty or excision and ligament reconstruction up to 6 years after the index procedure. 25 excision arthroplasty were compared to 29 trapezium excision and ligament reconstruction procedures. 1/29 of the excision and reconstruction versus 7/25 simple excision had increase radiographic degeneration at follow-up. The pseudarthrosis was preserved in 28/29 excision plus reconstruction and 22/25 excision alone cases. PEM, DASH and thumb key pinch strength were not affected by the degenerative change. The summary states that “Increased degenerate-like changes were observed after simple excision of the trapezium but these did not influence the clinical outcome”.
    6. J Hand Surg Eur Vol. 2012 Mar;37(3):211-9. doi: 10.1177/1753193411414516. Epub 2011 Oct 24. Six year outcome excision of the trapezium for trapeziometacarpal joint osteoarthritis: is it improved by ligament reconstruction and temporary Kirschner wire insertion? Salem H, Davis TR
    This is an RCT comparing simple excision with excision, FCR as a ligament reconstruction plus a temporary Kirschner wire insertion. 114 thumbs in 99 patients were followed for a mean of 6 years. There was no significant difference between the two groups using the outcome measures reported at final follow-up including PEM, DASH and grip strength.
    7. J Hand Surg Eur Vol. 2009 Jun;34(3):312-21. doi: 10.1177/1753193408098483. Epub 2009 Mar 25. Trapeziectomy for trapeziometacarpal joint osteoarthritis: is ligament reconstruction and temporary stabilisation of the pseudarthrosis with a Kirschner wire important? Davis TR, Pace A
    This study is a RCT that compares excision, stabilisation with FCR and Kirschner wire plus cast 6 weeks (61 thumbs) to excision and 3 weeks soft bandage immobilisation alone (67 thumbs) with 12 months follow-up. Pain, DASH, PEM, key pinch and tip thumb pinch demonstrated no difference between the two groups at 3 months or 12 months post-surgery.
    8. Hand Clin. 2008 Aug;24(3):263-9, vi. doi: 10.1016/j.hcl.2008.03.008. Treatment of advanced carpometacarpal joint disease: carpometacarpal arthroplasty with ligament interposition. Davis DI, Catalano L 3rd
    “Basal joint arthritis is a common condition, primarily affecting postmenopausal women. Persistent pain and functional impairment despite conservative treatment are indications for operative intervention. Ligament reconstruction and tendon interposition (LRTI) arthroplasty is one of the most popular and time-tested operations to treat metacarpal instability and basal joint arthritis. LRTI incorporates three fundamental principles that address the underlying anatomic pathology: (1) trapezium excision, either partial or complete, to eliminate eburnated bone and the source of pain; (2) anterior oblique ligament reconstruction for carpometacarpal joint stability; and (3) tendon interposition to minimize axial shortening and prevent bony impingement”.
    9. J Hand Surg Am. 2003 May;28(3):390-6. Trapezial space height measurement after trapeziectomy: a comparison of the use of standard and stress radiographs. Bhat M, Davis TR, Bannerjee A
    This study evaluates the 12 month appearance of the pseudarthosis after trapezium excision in 50 thumbs divided into three groups: Excision plus k wire, excision plus ligament suspension and excision plus tendon interposition. The conclusion was that an addition of a ligament suspension or interposition of palmaris did not alter the stress view appearance.
    10. Hand Clin. 2001 May;17(2):223-36, ix. Trapezio-metacarpal arthritis. Trapezium excision and ligament reconstruction not including the LRTI arthroplasty. Diao E
    The abductor pollicis longus suspensionplasty is an excellent treatment choice both for index procedures for carpometacarpal (CMC) thumb arthritis and for salvage of the failed thumb CMC arthroplasty.
    11. J Hand Surg Am. 2004 Nov;29(6):1069-77. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition. Davis TR, Brady O, Dias JJ.
    183 thumbs were allocated randomly to three groups with trapezium excision, excision and palmaris interposition and excision and ligament reconstruction using 50% of FCR. The thumbs all had a Kirschner wire to maintain length and 6 weeks of splint use. There was no functional difference in outcomes between the groups. 82% achieved good pain relief and 68% functional use for ADLs at 12 months.There was no significant difference in outcomes measured at 12 months. The authors conclude that there is no benefit of tendon interposition or ligament reconstruction over simple excision when a Kirschner wire is used to provide initial joint stability.
    12. J Hand Surg Eur 2019.2019 Nov;44(9):887-897. doi: 10.1177/1753193419871671. Medium and long term outcomes for hand and wrist pyrocarbon implants. Bellemere P.
    This paper reports that the results of pyrocarbon arthroplasty do not deteriorate with time and that the surgery can be performed through minimally invasive approaches. The paper emphasises the importance of careful joint surface resection in order to prevent implant instability.
    13. Hand 2019. Jan; (1):59-65. Total Thumb Carpometacarpal Joint Arthroplasty: A Retrospective Functional Study of 28 MOOVIS Prostheses. Dreamt N, Poumellec M-A.
    28 MOOVIS implants in 25 patients were followed for a mean 27.5 months with no dislocations and good symptom relief. The implant is a metal-polyethylene articulation with a bipolar articulation designed to reduce the risk of dislocation.
    14. Biomed Res Int. 2019; 7961507. PMID 31428645. Tendon versus Pyrocarbon Interpositional Arthroplasty in the Treatment of Trapeziometacarpal Osteoarthritis. Won-Taek Oh, Long-Ming Chun, Il-Hyun Koh, Jong-Kwan Shin, Yun-Rak Choi, Ho-Jung Kang.
    39 wrists in 37 patients had either a pyrolytic interpositional arthroplasty (n=20) or trapezium excision and LRTI (n=19). Outcomes were improved and similar in both groups. The interpositional arthroplasty group had greater pinch strength at final follow up (42 months LRTI and 35 months pyrolytic arthroplasty).

    Reference

    • orthoracle.com

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