Discussion

Several questions naturally arise. The hematoma and distraction arthroplasty is a slight variation of the simple trapeziectomy procedure from the 1950s that was discarded because of poor results. What is the difference that makes the hematoma and distraction arthroplasty successful? The authors feel that the immobilization of the thumb in a distracted position for 5 to 6 weeks after surgery allows the hematoma to organize, and the surrounding capsular remnants to consolidate to sufficiently anchor the metacarpal base in a secure position, yet allow for recovery of a normal range of motion. To promote the goal of having the body respond to the surgery with a sufficient inflammatory response to generate supporting scar tissue, it may be valuable to remove the trapezium piecemeal using osteotome, elevator and rongeurs. In this manner, capsular tears are expected, and small flakes of trapezium remain attached to the capsular remnants; all well-suited to aid in a florid inflammatory response. Other authors have advised removing the trapezium in one piece using curved knives and perhaps aided by placing a joystick (large, long cancellous screw or screw tap) to turn and twist the trapezium. The authors find removal of the trapezium piecemeal quicker and technically easier, and think that the additional capsular injury thereby inflicted actually promotes more scar formation and the desired degree of metacarpal stability, without the need for a formal beak ligament reconstruction.

If the results are no different when the K-wire has required removal 2 to 4 weeks after surgery than when leaving it the recommended 5.5 weeks, why not routinely remove it earlier? The authors are uncertain of the minimum length of time needed to achieve the distinct improvement in results of the hematoma and distraction arthro-plasty, as compared with the simple trapezial excisions reported in the 1950s. Based on the appearance of the surgical site and on the patient's comfort, as well as on general principles of wound healing and collagen deposition and maturation, immobilization of the thumb in a splint or cast for 5 to 6 weeks is appropriate. Because the thumb is to be externally immobilized for that length of time and the presence of the K-wire during that time generally presents no problem, the authors see no benefit in testing the lower limit of time actually needed for the distraction afforded by the K-wire.

If the hematoma and distraction arthroplasty is simpler and faster to perform, and the published results are equal to or superior to the procedures that reconstruct a ligament with or without an interposition into the trapezial void, why is it not universally used?

Intuition leads one to replace broken or worn out parts. Patients and doctors alike have experience with car and dishwasher repairs, for example, and it would be illogical simply to remove and not replace a defective spark plug or gasket. So in explaining surgical options to a patient who has basal joint arthritis, it is easy for the doctor to explain and for the patient to understand when a stretched ligament will be reconstructed and the arthritic bone will be replaced with interposed material. More so for patients, but also true for hand surgeons, we do not routinely give the natural healing capacity of the living body the credit it deserves. For example, surgeons tend to state that we "repair" nerves and tendons, whereas we actually only suture them and biology does the actual repair. In this light, the surgeon and the patient must have confidence that the body can actually restore a naturally and durably stable and mobile thumb base without mechanistically reconstructing prearthritic order. Further long-term follow-up on the hematoma and distraction ar-throplasty from multiple centers should enhance confidence that the body does indeed have that needed capacity.

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