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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 134-138

Trapeziectomy and ligament reconstruction tendon interposition technique experience for the first carpometacarpal joint arthrosis: Review of the literature in the diagnosis and treatment


Department of Plastic Reconstructive and Aesthetic Surgery, Division of Hand Surgery, Selcuk University Faculty of Medicine, Konya, Turkey

Date of Submission04-Nov-2020
Date of Acceptance06-Feb-2020
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. Gokce Yildiran
Department of Plastic Reconstructive and Aesthetic Surgery, Division of Hand Surgery, Selcuk University Faculty of Medicine, Konya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_34_20

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  Abstract 


Osteoarthritis of the hand is rare; however, the most retained joint after the distal interphalangeal joint is the first carpometacarpal (1. CMC) joint. Pain in the rest and increased pain with opposition is the most serious symptom, which significantly decreases the quality of life. The aim of these patients is to obtain a painless and stable thumb. Experience of trapeziectomy and ligament reconstruction tendon interposition technique for a Stage III patient was shared and diagnosis and treatment were discussed through the relevant literature. A 53-year-old female patient was admitted with complaints of pain in the right hand thumb root and unable to open the jar lid. In direct radiography, narrowing in the 1. CMC joint space and osteophytes were detected. After the trapeziectomy, 1st and 2nd metacarpals were fixed with K wire. Flexor carpi radialis tendon was passed from the first metacarpal base to the second metacarpal base in the form of a distal-based tendon flap to mimic the beak ligament. There was no pain at the postoperative 6th month, and the Kapandji opposition score was 10. When diagnosing 1. CMC osteoarthritis, pain during opposition and circumduction movements that is not relieved with analgesics and rest is the most important symptom for a clinician to look for. Many treatment principles have been defined according to the staging for the postdiagnosis period, despite the diagnosis is a challenging process.

Keywords: Arthritis, carpometacarpal joint, trapeziectomy


How to cite this article:
Yildiran G, Tosun Z. Trapeziectomy and ligament reconstruction tendon interposition technique experience for the first carpometacarpal joint arthrosis: Review of the literature in the diagnosis and treatment. Turk J Plast Surg 2021;29:134-8

How to cite this URL:
Yildiran G, Tosun Z. Trapeziectomy and ligament reconstruction tendon interposition technique experience for the first carpometacarpal joint arthrosis: Review of the literature in the diagnosis and treatment. Turk J Plast Surg [serial online] 2021 [cited 2021 Apr 21];29:134-8. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/134/312180




  Introduction Top


The first carpometacarpal (1. CMC) joint is in the form of a biconcave saddle. It is a complex joint that allows flexion and extension, abduction and adduction, as well as opposition and circumduction movements. 1. CMC osteoarthritis is a form of osteoarthritis frequently seen in postmenopausal women.[1] Patients experience pain proximal to the thumb. Although pain is the most common symptom, these patients also have difficulties in gripping and pinching. Both pain and functional impairment cause a decline in patients' quality of life. For this reason, patients are frequently referred to polyclinics for hand surgery.

The causes of pain in the hand are difficult to diagnose, and patients often try to continue their daily lives with analgesics and splints. When diagnosing 1. CMC osteoarthritis, pain in the base of the thumb accompanied by crepitus and swelling, as well as difficulty in pinching and gripping, are helpful symptoms to note. In late-staged cases, hyperextension occurs in the metacarpophalangeal (MP) joint.[2] Therefore, other diseases that should be considered in the differential diagnosis are De Quervain's tenosynovitis, scaphotrapeziotrapezoid (STT) arthritis, radioscaphoid arthritis, and scaphoid nonunions. An accurate diagnosis can be achieved using a grind test and X-ray. The most important step in making a diagnosis of CMC arthritis is to “remember the first CMC arthritis diagnosis.”

Treatments are selected according to the Eaton-Littler classification. The primary goal in the treatment of this arthrosis is to achieve painless movements in which stabilization is not impaired. Stage I is also interpreted as prearthritis, and arthritis findings such as joint-narrowing and osteophytes become more evident in the later stages.[3] CMC arthrodesis, trapeziectomy, trapeziectomy and ligament reconstruction tendon interposition (LRTI), and CMC denervation are the surgical options if there is no pantrapezial involvement and there is pronounced arthritis.

This article discusses the diagnosis and treatment of 1. CMC joint osteoarthritis through a case report and a discussion of the relevant literature.


  Case (Procedure) Top


A 53-year-old female patient was admitted to our hand surgery clinic because she has been enduring severe pain in her right-hand thumb root for 2 years already. She feels weakness and pain when using her right hand to open a jar lid. On further examination of the patient, crepitus, tenderness, and pain were detected on the 1. CMC joint. The CMC grind test was positive. On direct radiographs, a narrowing in the 1. CMC joint space and osteophytes were detected [Figure 1]. The patient had no signs of tenosynovitis. In direct radiographs, there were no signs of arthritis in the STT and radioscaphoid joints. No scaphoid fracture or nonunion findings were observed. In the detailed anamnesis, an injection history was uncovered, but the patient was not able to remember what was injected into the joint. The patient previously used thumb-supported splints and multiple nonsteroidal anti-inflammatory drugs. The patient, who stated that she did not benefit from any of these and that she had increased pain in the last few months, was diagnosed with Eaton-Littler Stage III basilar thumb arthritis, and trapeziectomy and LRTI surgery was planned. Under regional anesthesia and pneumatic tourniquet control, the joint was reached by making an incision on the 1. CMC joint. A total trapeziectomy was performed and trapeziectomy was controlled under the scope [Figure 2]. On the volar side, the flexor carpi radialis (FCR) tendon was found proximal, and the longitudinal half of the tendon was harvested as a tendon flap and distally tunneled [Figure 3]. In the first metacarpal base, a hole was drilled using a 3.0 mm drill and tendon flap was passed through this hole while the metacarpal was suspended through this tendon. The first and second metacarpals were fixed to each other with a K wire in the appropriate position [Figure 4]. Absorbable gelatin sponge was placed in the trapeziectomy area. The incisions were primary sutured and a thumb-spica short-arm cast was implemented. There were no postoperative complications. The patient was recommended for hand elevation, and she was discharged on the first postoperative day. The patient was followed up with a thumb-spica short-arm cast for the first 2 weeks postoperatively and with a thumb-spica splint for the 2 weeks. The K wire was removed at the end of this period and she was made to wear a thumb-spica splint for a further 1 month. During this period, opposition exercises were started. The patient returned to her normal daily activities after 3 months and could have an opposition up to the ring finger (Kapandji score: 9). She had no pain at this time. At the end of 6 months, she could make opposition up to the proximal of the little finger (Kapandji score: 10) and could perform daily work without any problems [Figure 5] and [Figure 6].
Figure 1: Preoperative posteroanterior and oblique X-rays

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Figure 2: Total trapeziectomy intraoperative scopy view

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Figure 3: Half of the flexor carpi radialis tendon was harvested as a tendon flap and distally tunneled

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Figure 4: In the first metacarpal base, a hole was drilled using a 3.0 mm drill and tendon flap was passed through this hole while the metacarpal was suspended through this tendon. The first and second metacarpals were fixed to each other with a K wire in the appropriate position

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Figure 5: Postoperative third month, posteroanterior and oblique X-rays

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Figure 6: Postoperative third month, opposition and grasping views

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  Conclusion Top


Although osteoarthrosis is less common in the hand, it is detected in the second-most common 1. CMC joint following the distal interphalangeal joint.[4] However, being able to diagnose it can be challenging for unfamiliar clinicians, especially if the patient is not giving a clear history such as rheumatoid arthritis. Patients with 1. CMC arthritis experience pain in the thumb root and this pain restricts opposition and circumduction movements.

When tendinopathy and other soft-tissue disorders are excluded, osseous pathology and arthritic changes should be evaluated. Direct radiographs provide enough information on this subject. Staging with direct radiographic findings was described by Eaton et al., in 1984.[3] Robert's view, which is the best direct imaging method of the thumb, may be required. The slightly enlarged 1. CMC joint is evaluated as Stage I. Narrowing in the joint space and osteophytic changes occur in Stages II-III. Stage IV is presented as trapeziometacarpal joint arthritis or panarthritis, including the STT joint. The treatment is also very diverse due to this radiographic diversity.

However, the radiological findings may not be correlated with the clinical assessments of hand function. Weinstock-Zlotnick et al. conducted a cross-sectional observational study in five patients with CMC joint osteoarthritis and they found that only disabilities of the arm, shoulder, and hand scores were showing correlation with radiographic grades.[5]

Nonoperative treatments such as analgesics, splinting, activity modifications, and steroid injections can be performed for patients who are in the early stage of radiology and whose symptoms are mild or moderate.[6] In our clinical experience, oral analgesics are used by most patients before the outpatient application, while splinting is the first-step treatment in many hand and wrist pain issues. Even if previous clinicians were unsuccessful in diagnosis, the patients generally received the first-step treatment. Steroid injection has been reported to provide short-term relief in pain.[7] Heyworth et al. did not find any difference between intra-articular corticosteroid injection and placebo in 1. CMC arthritis.[8]

This arthritis, also called basilar thumb arthritis, is a degenerative condition. Although its etiology is not clearly defined, it is usually caused by traumas such as previous intra-articular fractures, repetitive loading on the thumb, and inflammatory arthropathies such as rheumatoid arthritis. After the degenerative process begins, synovitis, progressive instability, weakening of the beak ligament, and subluxation of the metacarpal basis in the dorsoradial direction cascade is triggered, the thumb is adducted, and the MP joint is positioned as hyperextension.[9] The clinical manifestation of this degenerative process is most often a pain in the thumb root. Therefore, the main objective of the treatment of arthritis of the 1. CMC joint is to obtain a painless thumb that is stabilized and can oppose.

Since the main goal is pain relief, CMC denervation is an option in all stages. CMC denervation is a neurectomy of thin branches, where the superficial branch of the radial nerve is inserted with an incision on the anatomical snuffbox. The superficial branch itself is preserved; only the articular branch is cut.[10] However, as the articular branches can be multiple or very thin, persistent pain can be experienced due to insufficient neurectomy. Donato et al. presented eight patients' CMC joint denervation results and they found that average grip strengths were improved significantly.[10] Because it is a denervation, the pain relief is the expected result. However, if the decrease in grip strength is related with pain, denervation procedures are expected to increase the grip strength. Therefore, we suggest performing the denervation of the CMC joint, only in patients who are sensitive to the block anesthesia of the CMC joint which mimics the denervation procedure before the operation.

An arthroscopic debridement is an option for early-stage patients. Although debridement of synovitis in the joint seems to be a good solution, it is not possible in patients with established arthritis. Kemper et al. evaluated 12 patients who underwent combination of arthroscopic debridement and fat tissue interposition.[11] They suggested combining these procedures to get better pain scores at rest for more than 24 months in patients with early-staged CMC joint arthritis.

First metacarpal osteotomy is the first metacarpal's 30° wedge extension osteotomy and Wilson was to first to define this operation.[12] Osteoarthritic changes in the CMC joint begin from the volar side of the joint. Chou et al. reported that they obtained good results in terms of pain and function with a first metacarpal osteotomy.[13] O'Shaughnessy et al. evaluated 12 patients who underwent Wilson extension osteotomy and they found that the average motion of the patients improved modestly.[14] The main goal of this osteotomy is to reduce the load on the volar side of the trapeziometacarpal joint. Therefore, a metacarpal osteotomy is not a suitable option if the pantrapezial arthritis is established in the joint. We suggest that it should be kept in mind as an early-stage disease treatment option.

The excision of trapezium was defined by Gervis in 1947 and is based on the covering of the trapezium site by the hematoma.[15] Trapeziectomy can be described as a hematoma arthroplasty and can be used in Eaton Stage II-III patients.

The ligament reconstruction and tendon interposition (Tr + LRTI) technique with the excision of trapezium was defined by Burton in 1986.[16] It is a reconstruction that mimics the work of the anterior oblique ligament, preserving thumb length. It is the most common operation to treat 1. CMC arthritis in the United States.[6] After the trapeziectomy is performed partially or totally, the FCR or abductor pollicis longus tendon is passed obliquely through the first metacarpal to reconstruct the beak ligament.[17] The effectiveness of implant arthroplasty is shown in comparison with the LRTI technique.[18] Therefore, it can be considered as the gold standard in most stages of the disease. In the literature, Uzun et al. presented their eight-case report on Tr + LRTI and they found that all patients had improved pain, grip strength, and range of motion.[19] The decision to apply Tr + LRTI suspensioplasty in the case discussed in the report was derived after many factors were considered including the patient's Stage III diagnosis, the many nonoperative treatment options she tried in the past, her age, and her motivation. The operation with the TightRope system (Arthrex, Naples, FL), designed to mimic the LRTI suspension, ends up in a shorter time, and it preserves the FCR tendon but is not cost-effective.

The results of techniques such as arthrodesis and implant arthroplasty often fall below the trapeziectomy equivalents in the literature.

The rehabilitation after the surgical treatment of the CMC joint is crucial. Despite the rehabilitation procedures after arthroplasties for CMC joint osteoarthritis are well known, the hand rehabilitation after Tr + LRTI remains controversial. Wouters et al. reviewed 27 studies and concluded that there are acute, unloaded, and functional phases which are for postoperative 0–6 weeks, 1–12 weeks, and 3–6 months respectively.[20] They emphasized the importance of the first MP joint flexion and palmar abduction and extension of CMC joint.

In conclusion, when diagnosing 1. CMC osteoarthritis, pain during opposition, and circumduction movements that is not relieved with analgesics and rest is the most important symptom for a clinician to look for. Many treatment principles have been defined according to the staging for the postdiagnosis period, despite the diagnosis is a challenging process.

The choice of surgical treatment should always take into consideration the patient's radiological stage, their functional needs, their motivation, and the surgeon's experience.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Egan MY, Brousseau L. Splinting for osteoarthritis of the carpometacarpal joint: A review of the evidence. Am J Occup Ther 2007;61:70-8.  Back to cited text no. 1
    
2.
Yuan F, Aliu O, Chung KC, Mahmoudi E. Evidence-based practice in the surgical treatment of thumb carpometacarpal joint arthritis. J Hand Surg Am 2017;42:104-120.  Back to cited text no. 2
    
3.
Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometacarpal joint: A long-term assessment. J Hand Surg Am 1984;9:692-99.  Back to cited text no. 3
    
4.
Wilder FV, Barrett JP, Farina EJ. Joint-specific prevalence of osteoarthritis of the hand. Osteoarthritis Cartilage 2006;14:953-7.  Back to cited text no. 4
    
5.
Weinstock-Zlotnick G, Lin B, Nwawka OK. Clinical assessments of hand function in first carpometacarpal osteoarthritis do not appear to correlate with radiographic findings. HSS J 2019;15:269-75.  Back to cited text no. 5
    
6.
Pickrell BB, Eberlin KR. Thumb basal joint arthritis. Clin Plast Surg 2019;46:407-13.  Back to cited text no. 6
    
7.
Joshi R. Intraarticular corticosteroid injection for first carpometacarpal osteoarthritis. J Rheumatol 2005;32:1305-6.  Back to cited text no. 7
    
8.
Heyworth BE, Lee JH, Kim PD, Lipton CB, Strauch RJ, Rosenwasser MP. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: A prospective, randomized, double-blinded clinical trial. J Hand Surg Am 2008;33:40-8.  Back to cited text no. 8
    
9.
Turker T, Thirkannad S. Trapezio-metacarpal arthritis: The price of an opposable thumb! Indian J Plast Surg 2011;44:308-16.  Back to cited text no. 9
    
10.
Donato D, Abunimer AM, Abou-Al-Shaar H, Willcockson J, Frazer L, Mahan MA. First carpometacarpal joint denervation for primary osteoarthritis: Technique and outcomes. World Neurosurg 2019;122:e1374-80.  Back to cited text no. 10
    
11.
Kemper R, Wirth J, Baur EM. Arthroscopic synovectomy combined with autologous fat grafting in early stages of CMC osteoarthritis of the thumb. J Wrist Surg 2018;7:165-71.  Back to cited text no. 11
    
12.
Wilson JN. Basal osteotomy of the first metacarpal in the treatment of arthritis of the carpometacarpal joint of the thumb. Br J Surg 1973;60:854-8.  Back to cited text no. 12
    
13.
Chou FH, Irrgang JJ, Goitz RJ. Long-term follow-up of first metacarpal extension osteotomy for early CMC arthritis. Hand (NY) 2014;9:478-83.  Back to cited text no. 13
    
14.
O'Shaughnessy M, Mica MC, Rizzo M. Role of first metacarpal osteotomy in the management of basilar thumb arthritis. J Surg Orthop Adv 2019;28:63-7.  Back to cited text no. 14
    
15.
Gervis WH. Osteo-arthritis of the trapezio-metacarpal joint treated by excision of the trapezium. Proc R Soc Med 1947;40:492.  Back to cited text no. 15
    
16.
Burton RI, Pellegrini VD Jr., Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty. J Hand Surg Am 1986;11:324-32.  Back to cited text no. 16
    
17.
Belcher HJ, Nicholl JE. A comparison of trapeziectomy with and without ligament reconstruction and tendon interposition. J Hand Surg Br 2000;25:350-6.  Back to cited text no. 17
    
18.
Robles-Molina MJ, López-Caba F, Gómez-Sánchez RC, Cárdenas-Grande E, Pajares-López M, Hernández-Cortés P. Trapeziectomy with ligament reconstruction and tendon interposition versus a trapeziometacarpal prosthesis for the treatment of thumb basal joint osteoarthritis. Orthopedics 2017;40:e681-6.  Back to cited text no. 18
    
19.
Uzun M, Tetik C, Kara A. Interposition arthroplasty results of the carpometacarpal joint arthrosis with using flexor carpi radialis tendon. Hand Microsurg 2012;2:22-4.  Back to cited text no. 19
    
20.
Wouters RM, Tsehaie J, Hovius SE, Dilek B, Selles RW. Postoperative rehabilitation following thumb base surgery: A systematic review of the literature. Arch Phys Med Rehabil 2018;99:1177-21200.  Back to cited text no. 20
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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