John D Mahoney MD Roy A Meals MD

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Combined Orthopaedic and Plastic Surgery Hand Service, University of California, Los Angeles, 100 UCLA Medical Plaza, #305, Los Angeles, CA 90024, USA

Primary osteoarthritis of the carpometacarpal joint of the thumb is a common problem, especially in women beyond the fifth decade. Patients usually present with activity-related pain at the base of the thumb. The usual first line of treatment may include activity modification, pain-relieving medications, splinting, and possibly corticosteroid injections. When these nonoperative measures have failed to preserve or restore the patient's quality of life, surgical intervention may be appropriate.

Many different surgical alternatives are described for the treatment of thumb carpometacar-pal joint arthritis, and most begin with at least partial trapeziectomy. The first description of simple trapeziectomy was by Gervis in 1949 [1]. He reported good pain relief, but later publications on trapeziectomy by Murley [2] and Iyer [3] noted substantial weakness, which was assumed to be caused by instability at the base of the metacarpal. In all of these patients, no suspension of the thumb metacarpal was performed to prevent subsidence, and the patients were started on an immediate motion protocol postoperatively.

To improve the stability of the thumb carpo-metacarpal joint and thereby the strength of the hand, Eaton and Littler in 1973 [4] first described volar oblique ligament reconstruction. This report was followed by Burton and Pellegrini's report in 1986 [5] of ligament reconstruction and tendon interposition. These techniques were based on three essential components to reconstruct the thumb carpometacarpal joint: (1) reconstruction of the volar oblique ligament, (2) interposition of tendon

* Corresponding author.

E-mail address: [email protected] (R.A. Meals).

graft into the space formerly occupied by the trapezium, and (3) temporary fixation of the thumb metacarpal base to the adjacent index metacarpal [6]. The results of these more complicated techniques were generally excellent.

Subsequent reports have questioned the necessity of each of these components. Trapeziectomy alone, tendon interposition without ligament reconstruction, and ligament reconstruction without tendon interposition have each been reported to result in satisfactory outcome. In fact, a recent prospective, randomized controlled study by Davis and colleagues [7] found that trapeziectomy and Kirschner wire (K-wire) fixation was as effective as ligament reconstruction and placement of a soft-tissue spacer.

The authors believe that simple trapeziectomy with hematoma and distraction arthroplasty is as effective as more complicated procedures. Although it may seem unsettling to remove the trapezium and not replace it with something, or to leave the body to its own devices to reform a functional beak ligament, we know that the body has remarkable capacities to heal itself. The act of trapeziectomy may incite enough sterile commotion to allow a vigorous scar bed to fill in the site of the trapezium. Thus, the base of the thumb metacarpal is held at bay from the scaphoid by this cushion of scar, providing the same benefits of interposition arthroplasty with foreign material without the potential complications.

Surgical technique

Trapeziectomy and hematoma distraction ar-throplasty of the thumb carpometacarpal joint is indicated in both inflammatory and degenerative arthritis that has failed conservative management.

When necessary, the procedure is combined with volar plate capsulodesis of the thumb metacarpophalangeal joint to correct hyperextension. The procedure may be performed under regional block or general anesthesia. The usual operative time for hematoma distraction arthroplasty alone is approximately 35 minutes.

A curved, dorsal radial incision is made over the carpometacarpal joint of the thumb. Sharp dissection is made through the skin only. Blunt subcutaneous dissection is made down to the first dorsal compartment. The branches of the radial sensory nerve are retracted out of the operative field. Blunt dissection then proceeds ulnarly and dorsally from the first dorsal compartment over the capsule of the trapezium until the radial artery is encountered. Dissection between the radial artery and the underlying joint capsule will allow retraction of the artery safely out of the way.

With the radial artery and the branches of the radial sensory nerve safely retracted, the base of the thumb metacarpal is palpated and the carpo-metacarpal joint is identified. A longitudinal capsular incision is made just ulnar and dorsal to the tendons of the first dorsal compartment. The incision begins 5 mm on the base of the metacarpal, and is carried proximally until the scapho-trapezial joint is encountered. The capsule is elevated radially and ulnarly off of the base of the metacarpal and the trapezium. Occasionally, in cases of severe subluxation, the trapezium may be difficult to palpate, and even after capsular incision may be difficult to see. Longitudinal traction on the thumb will distract the joint and allow visual confirmation of the various carpal bones.

Before excision, the trapezium should be definitively confirmed by inspection of the saddle joint and the base of the metacarpal. If there is any doubt, an intraoperative radiograph can be used with a Freer elevator placed into what the surgeon believes is the carpometacarpal joint.

The trapezium is removed piecemeal. The trapezium is first divided longitudinally with an osteotome into three or four pieces. A rongeur, an elevator, and a knife can then be used to free the pieces of the trapezium from the investing capsule. The flexor carpi radialis and flexor pollicis longus tendons must be protected at the base of the wound. The surgeon's finger can be introduced into the wound to palpate for small fragments of bone that may be painful later. These fragments are most commonly in the volar aspect of the wound.

Once the trapezium is removed, the wound is irrigated and the thumb is set for distraction and fixation. The thumb is grasped and held in a position of wide palmar abduction, slight opposition, and distraction until firm resistance is felt. A single 1.6 mm (0.062") K-wire is inserted percutaneously from the base of the thumb meta-carpal in a transverse orientation to anchor into the base of the index metacarpal or into the trapezoid (Fig. 1). A second K-wire may be used to provide additional stability. The wire is cut above the skin. Although transverse placement

Fig. 1. Postoperative radiograph showing proper position of K-wire fixation after hematoma and distraction arthroplasty. H, hamate; MC1, index finger metacarpal; MC1, thumb metacarpal; P, pisiform; S, scaphoid. (From Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective, single-surgeon study including outcome measures. J Hand Surg 2003;28A:381-9; with permission.)

Fig. 1. Postoperative radiograph showing proper position of K-wire fixation after hematoma and distraction arthroplasty. H, hamate; MC1, index finger metacarpal; MC1, thumb metacarpal; P, pisiform; S, scaphoid. (From Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective, single-surgeon study including outcome measures. J Hand Surg 2003;28A:381-9; with permission.)

of the K-wire risks antegrade migration and dorsal hand pain or even ulceration, the authors prefer this to longitudinal K-wire placement, because the thumb metacarpal may slide proximally along the longitudinally-oriented K-wire and close the trapezial void before a dense hematoma and fibroblastic scar can form.

The dorsal capsular remnants are closed to the extent possible. After skin closure, a thumb spica splint is fit to the hand and wrist, with care taken to relieve any pressure from the splint against the trailing end of the K-wire. The sutures are removed at 10 days postoperatively, and a short arm-thumb spica cast is applied, leaving the thumb pulp free for light pinch activities. Again, care is taken with padding the trailing end of the K-wire to preclude pressure against the rigid cast material and subsequent migration. This cast and K-wire are removed 4 weeks later, approximately 5.5 weeks postoperatively. The thumb is protected with a 2" elastic roller bandage, and the patient is advised to gradually wean from use of the bandage over the next 4 to 5 days, and to begin a home exercise program immediately to regain full adduction and opposition of the thumb. The patient is advised to use the hand as normally as pain and postimmobilization stiffness permit. The patients are seen again 2 weeks later, and those patients that cannot abduct the thumb out from the plane of the hand and touch the tip of the thumb to the small finger metacarpal head are referred to hand therapy for range-of-motion exercises. The therapists are instructed not to perform or instruct in formal strengthening exercises, which have been seen to prolong the inflammatory flare. The authors prefer that the patient gradually recover strength through progressively increasing daily use of the thumb over the first 6 to 12 months after surgery.

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