To The Editor:
In their article "Ligament Reconstruction with or without Tendon
Interposition to Treat Primary Thumb Carpometacarpal Osteoarthritis. A
Prospective Randomized Study"
(2004;86:209-18), Kriegs-Au et
al. concluded that the degree of proximal migration of the thumb metacarpal
may have no effect on postoperative thumb strength, function, and pain. At the
time of final follow-up, there was proximal migration of the thumb metacarpal
compared with the position seen at both the preoperative visit and the initial
postoperative visit. Since this does not appear to affect ultimate outcome, we
would be interested in learning the authors' opinion regarding the role and
utility of ligament reconstruction. Why not perform trapezial resection alone
(without ligament reconstruction or tendon interposition)?
We believe that the technique of ligament reconstruction creates a strong
stabilizing ligament that suspends the first metacarpal. It effectively
minimizes metacarpal subsidence caused by the loss of bone support after
trapezial excision, keeps the opposing articular surfaces apart, and prevents
subluxation, thereby providing stability to the basal joint of the thumb.
The strip of the tendon of the flexor carpi radialis used in the
Epping-Noack technique to establish the ligamentous suspension is firmly
blocked within the canal in the first metacarpal base with trapezial fragments
to counteract the tendency for proximal migration. We agree that some proximal
metacarpal migration occurs even after trapeziectomy coupled with ligament
reconstruction is performed. It is of interest, however, that, after a
considerable percentage loss of the arthroplasty space was noted in both our
patient groups during the first postoperative year, the proximal migration of
the thumb metacarpal was seen to be less progressive by the four-year
follow-up assessment.
The observation that progressive metacarpal subsidence documented during
the early postoperative period diminished over time and the favorable patient
outcomes achieved as measured with the Buck-Gramcko scoring system and with
the use of our additional measurements suggest that ligament reconstruction
has contributed to the suspension of the first metacarpal base, the
preservation of the arthroplasty space, and the stability to the first
carpometacarpal joint in an optimal way.
The authors of previous randomized studies on trapeziectomy without
ligament reconstruction demonstrated preservation of an arthroplasty space in
their patients at a mean of one year postoperatively as
well1-3.
The short-term results suggest that vascular ingrowth may fill the trapezial
void to form a fibrous tissue spacer. On the basis of these previous data,
there seems to be no answer to the question of how fibrous tissue will behave
within the trapezial void. It might act as an autologous gliding layer between
the first metacarpal and the scaphoid, which might protect the articular
surfaces against attritional changes and abutment over time.
According to our statistical analyses, the height of the arthroplasty space
does not seem to be a decisive factor in postoperative pain, thumb strength,
or function after ligament reconstruction. Despite this statistical
conclusion, which is limited by the small number of patients enrolled in our
study, we think that it is of utmost importance to preserve an arthroplasty
space once the diseased trapezium has been excised and to prevent osseous
contact between the articular surfaces. The scenario of progressive metacarpal
subsidence and instability of the trapeziometacarpal joint after trapeziectomy
alone might be abutment and/or subluxation over time. The long-term
consequences for the patient, we fear, might be severe pain and serious
functional impairment. At present, because of the lack of long-term results of
simple trapeziectomy presented in previous randomized studies, we favor the
procedure of ligament reconstruction, but we welcome additional randomized
long-term studies of large numbers of patients evaluated with methodological
criteria similar to those used in our recent paper to determine the effect of
trapeziectomy alone on the surgical outcome. We do agree that a technically
easier procedure is preferred over other, more complex surgical options if its
benefits can be clearly supported by reliable and reproducible long-term
data.
Note: The authors thank Sandra Brezina-Krivda for translating
this letter.
Belcher HJ, Nicholl JE. A
comparison of trapeziectomy with and without ligament reconstruction and
tendon interposition. J Hand Surg [Br].2000;25:
350-6.25350
2000
[PubMed]
Downing ND, Davis TR. Trapezial
space height after trapeziectomy: mechanism of formation and benefits.
J Hand Surg [Am].2001;26:
862-8.26862
2001
[PubMed][CrossRef]
Davis TR, Brady O, Barton NJ, Lunn
PG, Burke FD. Trapeziectomy alone, with tendon interposition or with
ligament reconstruction? J Hand Surg [Br].1997;22:
689-94.22689
1997
[PubMed]