After the administration of either a general or a regional anesthetic, the
patient is placed in the supine position and a tourniquet, preset to 250 mm
Hg, is placed around the arm. A single hockey-stick-shaped incision,
approximately 3.5 to 4.5 cm in length, is made in a dorsoradial direction over
the metacarpal and trapezial bones. The incision is oriented from distal to
proximal, and it should curve for a short distance palmarly just proximal to
the scaphotrapezial joint (Fig.
1). Careful separation of the subcutaneous tissues is mandatory to
ensure that the underlying superficial branches of the radial sensory nerve
and the radial artery are not harmed. The radial artery, which courses within
the anatomical snuff
box5, is retracted
within the space between the thumb extensor and abductor tendons to minimize
the risk of damage.
The trapeziometacarpal joint is exposed through a longitudinal incision
between the extensor pollicis brevis and the abductor pollicis longus tendons.
The incision is continued slightly proximal to the scaphotrapezial joint
(Fig. 2). The capsule is
sharply dissected from the trapezium as far as possible. Then, a properly
sized Kirschner wire equipped with a short thread at its point is carefully
introduced into the trapezium for use as a joystick to mobilize that bone. It
is important that the trapezium is firmly attached to, but not completely
penetrated by, the partially threaded Kirschner wire so that, when
manipulated, it will not harm the adjacent bones
(Fig. 3). The combination of
gentle manipulation of the trapezium with the wire by the surgeon and careful
traction on the thumb by the surgical assistant will facilitate removal of the
trapezium in one piece. After the capsule and the ligaments are further
sharply dissected at their insertions on the adjacent carpal bones, the
trapezium is removed in one piece if possible. Alternatively, when resection
in one piece is not possible, the trapezium can be cut with an osteotome or a
small saw and the trapezial fragments can be removed with a rongeur. During
the entire process, it is imperative to keep in mind that the tendon of the
flexor carpi radialis courses close to the palmar crest of the trapezium. Care
has to be taken to ensure that damage to this structure is prevented,
regardless of whether the trapezium is removed in pieces or as a whole.
It is important to inspect the edges of the base of the first metacarpal
and to use a small rongeur to smooth them if they appear to be extended and
sharp. If the synovium is inflamed, a synovectomy is performed. Furthermore,
all loose bodies, particularly those occurring in the intermetacarpal space,
should be removed.
CRITICAL CONCEPTSINDICATIONS:Recurrent, therapy-resistant pain with or without substantial disability
during activities of daily living, repetitive activities, sports, or work
(especially during activities requiring tip-pinch) in a patient with
osteoarthritis of the carpometacarpal joint of the thumbA patient with lower demands for thumb strengthA compliant patient, especially one who will be compliant with the
relatively long interval of postoperative care, which may last for as long as
three to six monthsCONTRAINDICATIONS:Active infection at or near the operative siteInstability at the basal joint of the thumb without degenerative
changesA patient with high demands for thumb strengthA noncompliant, unreliable patientPITFALLS:Injury to the branches of the superficial radial nerve. As the skin
incision is carefully made and the joint is approached, protection of these
branches is essential and requires a thorough knowledge of the anatomy of the
hand. Injuries may cause numbness, dysesthesias, and painful neuromas.Injury to the radial artery. During the dissection, this structure should
be carefully retracted and protected to prevent the risk of creating a false
aneurysm.Perforation of the trapezium and potential damage to the underlying carpal
bones. The partially threaded Kirschner wire must be inserted carefully into
the trapezium. Excessive force should never be used during insertion.Inadequate length of the split tendon. It is essential to create a tendon
strip that is long enough to be drawn in its entirety through the drill canal
in the metacarpal base.Injury to the tendon of the flexor carpi radialis. The tendon runs in a
groove that opens to the ulnar side of the trapezium and is overlapped by its
palmar tubercle. Therefore, the flexor carpi radialis tendon may be easily
injured when the trapezium is approached and then resected in its entirety or
piecemeal. This tendon should be carefully isolated and protected because
partial or complete transection will necessitate a change in the operative
procedure.Continued postoperative pain at the basal joint of the thumb. Potential
reasons for postoperative pain may be the presence of an infection, synovitis,
fragments that become detached from the base of the first metacarpal, bone
chips from the drill canal, loose bodies in the intermetacarpal space, and
osseous contact between the metacarpal base and the adjacent bones. Attention
must be paid to all of these factors to eliminate potential postoperative
symptoms.Inadequate tension of the tendon. The key to successfully achieving an
adequate suspensory ligament reconstruction is the proper tensioning of the
flexor carpi radialis tendon strip. Excessive tightening will result in
impingement of the base of the first metacarpal against the neighboring bones,
causing osteolytic changes and/or postoperative pain. Conversely, a very loose
tendon strip may slip out of the drill canal and become squeezed between the
base of the first metacarpal and the adjacent bones, possibly causing pain and
jeopardizing the objective of the suspension arthroplasty.Insufficient rehabilitation. Postoperatively, the patient must be well
instructed with regard to the hand-therapy program—and must also comply
with it—to ensure a successful result.AUTHOR UPDATE:Since the time that our prospective randomized study was published in
February 2004, no changes have been made to the surgical technique.
CRITICAL CONCEPTS
INDICATIONS:
Recurrent, therapy-resistant pain with or without substantial disability
during activities of daily living, repetitive activities, sports, or work
(especially during activities requiring tip-pinch) in a patient with
osteoarthritis of the carpometacarpal joint of the thumbA patient with lower demands for thumb strengthA compliant patient, especially one who will be compliant with the
relatively long interval of postoperative care, which may last for as long as
three to six months
Recurrent, therapy-resistant pain with or without substantial disability
during activities of daily living, repetitive activities, sports, or work
(especially during activities requiring tip-pinch) in a patient with
osteoarthritis of the carpometacarpal joint of the thumb
A patient with lower demands for thumb strength
A compliant patient, especially one who will be compliant with the
relatively long interval of postoperative care, which may last for as long as
three to six months
CONTRAINDICATIONS:
Active infection at or near the operative siteInstability at the basal joint of the thumb without degenerative
changesA patient with high demands for thumb strengthA noncompliant, unreliable patient
Active infection at or near the operative site
Instability at the basal joint of the thumb without degenerative
changes
A patient with high demands for thumb strength
A noncompliant, unreliable patient
PITFALLS:
Injury to the branches of the superficial radial nerve. As the skin
incision is carefully made and the joint is approached, protection of these
branches is essential and requires a thorough knowledge of the anatomy of the
hand. Injuries may cause numbness, dysesthesias, and painful neuromas.Injury to the radial artery. During the dissection, this structure should
be carefully retracted and protected to prevent the risk of creating a false
aneurysm.Perforation of the trapezium and potential damage to the underlying carpal
bones. The partially threaded Kirschner wire must be inserted carefully into
the trapezium. Excessive force should never be used during insertion.Inadequate length of the split tendon. It is essential to create a tendon
strip that is long enough to be drawn in its entirety through the drill canal
in the metacarpal base.Injury to the tendon of the flexor carpi radialis. The tendon runs in a
groove that opens to the ulnar side of the trapezium and is overlapped by its
palmar tubercle. Therefore, the flexor carpi radialis tendon may be easily
injured when the trapezium is approached and then resected in its entirety or
piecemeal. This tendon should be carefully isolated and protected because
partial or complete transection will necessitate a change in the operative
procedure.Continued postoperative pain at the basal joint of the thumb. Potential
reasons for postoperative pain may be the presence of an infection, synovitis,
fragments that become detached from the base of the first metacarpal, bone
chips from the drill canal, loose bodies in the intermetacarpal space, and
osseous contact between the metacarpal base and the adjacent bones. Attention
must be paid to all of these factors to eliminate potential postoperative
symptoms.Inadequate tension of the tendon. The key to successfully achieving an
adequate suspensory ligament reconstruction is the proper tensioning of the
flexor carpi radialis tendon strip. Excessive tightening will result in
impingement of the base of the first metacarpal against the neighboring bones,
causing osteolytic changes and/or postoperative pain. Conversely, a very loose
tendon strip may slip out of the drill canal and become squeezed between the
base of the first metacarpal and the adjacent bones, possibly causing pain and
jeopardizing the objective of the suspension arthroplasty.Insufficient rehabilitation. Postoperatively, the patient must be well
instructed with regard to the hand-therapy program—and must also comply
with it—to ensure a successful result.
Injury to the branches of the superficial radial nerve. As the skin
incision is carefully made and the joint is approached, protection of these
branches is essential and requires a thorough knowledge of the anatomy of the
hand. Injuries may cause numbness, dysesthesias, and painful neuromas.
Injury to the radial artery. During the dissection, this structure should
be carefully retracted and protected to prevent the risk of creating a false
aneurysm.
Perforation of the trapezium and potential damage to the underlying carpal
bones. The partially threaded Kirschner wire must be inserted carefully into
the trapezium. Excessive force should never be used during insertion.
Inadequate length of the split tendon. It is essential to create a tendon
strip that is long enough to be drawn in its entirety through the drill canal
in the metacarpal base.
Injury to the tendon of the flexor carpi radialis. The tendon runs in a
groove that opens to the ulnar side of the trapezium and is overlapped by its
palmar tubercle. Therefore, the flexor carpi radialis tendon may be easily
injured when the trapezium is approached and then resected in its entirety or
piecemeal. This tendon should be carefully isolated and protected because
partial or complete transection will necessitate a change in the operative
procedure.
Continued postoperative pain at the basal joint of the thumb. Potential
reasons for postoperative pain may be the presence of an infection, synovitis,
fragments that become detached from the base of the first metacarpal, bone
chips from the drill canal, loose bodies in the intermetacarpal space, and
osseous contact between the metacarpal base and the adjacent bones. Attention
must be paid to all of these factors to eliminate potential postoperative
symptoms.
Inadequate tension of the tendon. The key to successfully achieving an
adequate suspensory ligament reconstruction is the proper tensioning of the
flexor carpi radialis tendon strip. Excessive tightening will result in
impingement of the base of the first metacarpal against the neighboring bones,
causing osteolytic changes and/or postoperative pain. Conversely, a very loose
tendon strip may slip out of the drill canal and become squeezed between the
base of the first metacarpal and the adjacent bones, possibly causing pain and
jeopardizing the objective of the suspension arthroplasty.
Insufficient rehabilitation. Postoperatively, the patient must be well
instructed with regard to the hand-therapy program—and must also comply
with it—to ensure a successful result.
AUTHOR UPDATE:
Since the time that our prospective randomized study was published in
February 2004, no changes have been made to the surgical technique.
The next step is to identify and prepare the flexor carpi radialis tendon
in the depths of the trapezial void. That tendon is then grasped with a
tendon-grasping ring forceps. With the wrist flexed, as much tendon mass as
possible is carefully drawn into the wound to mobilize a few millimeters of
its length. It is very important to harvest an adequate length of the tendon
to ensure that a complete passage of the split tendon through the drill canal
can be performed. A 2.0 Vicryl suture is threaded as proximally as possible
through the radial substance of the tendon mass
(Fig. 4). The radial half of
the tendon is then incised proximal to the suture and along the length of its
midportion for a short distance. The forceps are removed. By pulling gently on
the suture, the split in the tendon is extended distally, with the tendinous
insertion being left intact on the base of the index metacarpal (Figs.
5-A and
5-B). At the end of the split,
a 4.0 Vicryl suture is placed to secure the tendon strip in the depths of the
arthroplasty space (Fig.
6).
Approximately 1 cm proximal to the base of the first metacarpal, a canal is
created with a 3.2-mm burr, running from a dorsoradial to a palmar-ulnar
direction through the metacarpal base (Fig.
7). A small rongeur is useful for squaring off any sharp edges
that may be present at the exit and/or entry point of the canal. Next, a very
thin wire snare is introduced into the canal to pass, with a slow and gentle
movement, the 2.0 Vicryl suture back through the canal
(Fig. 8). Tension is then
applied to the suture to pull the entire tendon strip out of the drill-hole in
the first metacarpal.
With gentle traction applied to the first metacarpal, the strip of the
flexor carpi radialis tendon is adequately tensioned and wedged in place
through the packing of smooth corticocancellous and cancellous bone chips into
the canal. These fragments originate from the trapezium, which has been
resected, morselized, and saved for intraosseous fixation of the tendon strip
(Fig. 9). It is of utmost
importance to take care that proper tension is applied to the tendon strip to
avoid osseous impingement against the index metacarpal or the trapezoid
(Fig. 10). Proper spacing
should be confirmed radiographically during the procedure if the surgeon is
not quite sure whether there is optimal distance between the metacarpal base
and the neighboring bones. By moving the thumb in all directions, gently
applying slight traction on the thumb, and pulling on the segment of the
tendon strip that is protruding from the dorsoradial drill hole, the surgeon
should evaluate whether the fixation of the tendon strip is firm enough to
provide reliable stability. When secure fixation of the tendon strip is
confirmed, the end of the tendon strip is tacked to the periosteum of the base
of the first metacarpal with 4.0 Vicryl sutures
(Fig. 11). The wound is
irrigated with saline solution, and the tourniquet is deflated. After
hemostasis has been achieved, a suction drain is placed into the arthroplasty
space. The capsule is closed with 4.0 Vicryl sutures, and the skin is closed
with 5.0 Ethilon sutures.
Postoperatively, the thumb is immobilized in a split forearm-based
thumb-spica cast. The suction drain is removed on the first or second day
after surgery. The sutures are removed on the tenth postoperative day. A new
closed spica cast is then fashioned. This cast must be left on until the end
of the twenty-first postoperative day, at which time it is then replaced with
a short thumb-spica splint, which is individually fashioned by a hand
therapist and is intended to be worn at all times for an additional three
weeks. At six weeks, active and active-assisted range-of-motion and thenar
muscle-strengthening exercises are started under the supervision of an
experienced hand therapist.