Palmar oblique ligament reconstruction combined with tendon interposition (LRTI) arthroplasty with part of the flexor carpi radialis tendon was developed for advanced osteoarthritis of the thumb basal joint. Twenty-five procedures are reviewed with an average follow-up of 2 years, ranging from 1 to 4 1/2 years. LRTI arthroplasty more consistently improved pinch strength, increased grip strength endurance, and restored thumb web space than did silicone implant arthroplasty. Proximal metacarpal migration averaged only 11 % of the initial arthroplasty space versus nearly 50% loss of height with silicone implants. Subluxation averaged only 7% of the width of the thumb metacarpal base relative to the scaphoid versus subluxation of 35% of the base of the implant with silicone arthroplasty. Excellent results were achieved in 23 thumbs or 92% of cases. No deterioration of function or stability has been noted over time, and no revisional procedures have been necessary. On the basis of these encouraging early results, LRTI arthroplasty has become our preferred surgical treatment for advanced basal joint osteoarthritis of the thumb.

Surgical management of basal Joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplast

Seventy-two procedures in 53 patients with advanced basal joint arthritis are retrospectively evaluated with follow-up ranging from 12 months to 8 years. Follow-up of a subset of 32 silicone implant arthroplasties in osteoarthritic thumbs averaged 3.9 years with a 25% failure rate. Despite providing early symptomatic relief, silicone implants lost nearly 50% of vertical height at the ulnar margin secondary to cold flow and wear and subluxed 35% of the width of the prosthesis during the study period. Dynamic tendon transfers did not prevent implant subluxation and had no effect on the magnitude or pattern of implant wear. Ligamentous reconstruction reduced implant instability, but was accompanied by an increase in silicone wear and cold flow. Reactive giant cell synovitis with silicone particulates and adjacent bone resorption was seen in some cases of implant arthroplasty failure. Forces across the osteoarthritic basal joint would seem to preclude a stable silicone implant arthroplasty in the absence of eventual wear and symptomatic foreign body synovitis. Because of this unresolved conflict between implant stability and wear, at the present time we seldom use silicone in the osteoarthritic basal joint, but continue to utilize the silicone hemitrapezium or the cannulated trapezium replacement with satisfactory results in the low-demand rheumatoid thumb.

Surgical management of basal joint arthritis of the thumb. Part I. Long-term results of silicone implant arthroplasty.

Background: There has been considerable controversy regarding the procedure of choice for treatment of any given stage of osteoarthritis of the thumb carpometacarpal joint. This study was designed to directly compare the clinical results of two common surgical procedures for this condition, trapeziometacarpal arthrodesis and trapezial excision with ligament reconstruction and tendon interposition, in similar patient populations.

Methods: Between 1988 and 1998, 109 patients (141 thumbs) who were less than sixty years old were treated with one of the two procedures. In a retrospective review, forty‐two patients (fifty‐eight thumbs) treated with arthro­desis completed an outcome questionnaire and twenty‐nine patients (forty‐four thumbs) treated with arthrodesis completed the questionnaire and were examined. In the group treated with trapezial excision with ligament reconstruction and tendon interposition, thirty‐nine patients (forty‐nine thumbs) completed the questionnaire and thirty patients (thirty‐eight thumbs) completed the questionnaire and were examined. The average duration of follow-up was sixty‐nine months. The groups were similar with regard to age, gender, hand dominance, and duration of follow‐up.

Results: Subjective evaluation of pain, function, and satisfaction demonstrated no significant difference between the two groups, with >90% of patients satisfied following either procedure. Although grip strength did not differ between the groups, the arthrodesis group had significantly stronger lateral pinch (p < 0.001) and chuck pinch (p < 0.01). The group treated with ligament reconstruction and tendon interposition had a better range of motion with regard to opposition (p < 0.05) and the ability to flatten the hand (p < 0.0001). There was a higher complication rate in the arthrodesis group, with nonunion of the fusion site accounting for the majority of the complications. However, despite a persistent nonunion in six thumbs, those thumbs and the thumbs in which union was obtained did not differ with regard to pain; all of the patients with nonunion had improvement in their pain status compared with preoperatively, and all were very satisfied with the outcome. Peritrapezial arthritis developed in nine patients (fourteen thumbs). This finding was not related to age and did not affect overall pain, function, or satisfaction.

Conclusions: Although traditionally arthrodesis and ligament reconstruction and tendon interposition have been indicated in two different patient populations, we compared them in a homogeneous group and found that the two procedures had similar results with regard to pain, function, and satisfaction despite minimal differences in strength and motion. Although complications were more frequent following arthrodesis, most did not affect the overall outcome.

Thumb Carpometacarpal Osteoarthritis: Arthrodesis Compared with Ligament Reconstruction and Tendon Interposition

Trapeziectomy, ligament reconstruction and tendon interposition arthroplasty is one of the most commonly performed procedures to address pain and instability due to osteoarthritis at the basal joint of the thumb. To determine the effect of stress on first metacarpal subsidence, 15 ligament reconstruction and tendon interposition basal joint arthroplasties were evaluated after a mean follow-up of 32 months. Radiographs were obtained of the arthroplasty at rest and then with maximal effort key pinch stress, which is known to subject the first carpometacarpal joint to considerable axial compression stress. Compared with the preoperative x-rays, the first metacarpal had subsided 21% of the arthroplasty space at rest. Under stress, the first metacarpal was found to subside another 10.5% in height. No subluxation of the metacarpal base could be detected. Key pinch strength improved 17% from the preoperative strength. Tip-to-tip pinch strength improved 17% from the preoperative measurement. Grip strength improved 17% from the preoperative measurement. Grip strength was 9% greater than the preoperative grip strength. There was no statistical association between the amount of first metacarpal subsidence and follow-up key pinch, tip pinch, or grip strength. With axial compressive loading of the arthroplasty, such as in lateral pinch, there is some further proximal migration of the first metacarpal, but this is minimal and does not correlate with functional outcome.

First metacarpal subsidence during pinch after ligament reconstruction and tendon interposition basal joint arthroplasty of the thumb

The accuracy of radiographic evaluation of the pantrapezial joints and the anatomic incidence of pantrapezial arthrosis, were studied by comparing radiographs with anatomic dissections of 68 cadaver hands. When the trapezium-thumb metacarpal joint demonstrated degenerative changes, multitrapezial joint changes were noted in 73% radiographically, but in only 46% anatomically. The major reason for this discrepancy was a radiographic misinterpretation of the nature of osteophytes near the trapezium-index metacarpal joint. Anatomic changes of degenerative joint disease were noted in 60% of the trapezium-thumb metacarpal joints and 34% of the trapezium-scaphoid joints. Degenerative joint changes were rare in the trapezium-index metacarpal and trapezium-trapezoid joints. Routine anteroposterior, lateral, and oblique radiographs of the hand cannot be depended upon to provide adequate visualization of all the trapezial joints.

Degenerative joint disease of the trapezium: a comparative radiographic and anatomic study.

(1969). Arthrodesis of the First Carpo-Metacarpal Joint for Osteoarthritis. Acta Orthopaedica Scandinavica: Vol. 40, No. 5, pp. 602-607.

https://www.tandfonline.com/doi/pdf/10.3109/17453676908989525

H. S. Mattsson

Papers

Arthrodesis of the First Carpo-Metacarpal Joint for Osteoarthritis