VII. Reconstructing The Joint: Restore The Anatomy
Steven Z. Glickel, MD
- A. Great mobility with little bony constraint
- B. Large contact stresses within the joint
- C. Limited surface area available to transmit load
- D. Joint reactive force at CMC surface12 times that generated at the tip of the thumb in lateral pinch
- E. Majority of force in pinch transmitted proximally and dorsoradially
- F. Anterior oblique (volar) and dorsoradial ligaments are principal restraints to subluxation
- A. AOL (beak) ligament degeneration is precursor of basal joint disease (Pellegrini)
- B. Primary loading area during lateral pinch is volar
- C. Attritional changes of deep AOL (beak) ligament occur at MC insertion
- C. Ligament becomes incompetent
- D. Shear forces increase in the volar contact area
- E. Degeneration of the cartilage in the volar part of articular surface
- F. Progressive degeneration of the joint
- G. Eburnation of the volar compartment associated with detachment of AOL
III. Rationale for ligament reconstruction
- A. Stabilizes the thumb metacarpal
- 1. Prevents subluxation
- 2. Prevents metacarpal subsidence in the absence of all or part of the trapezium
- 3. Fixes relationship between thumb and index MC base by suspension
- B. Recapitulates normal anatomy
- 1. Stage I
- a. Reconstructs anterior oblique (volar) ligament
- i. Extraarticular
- ii. Half of distally based FCR through volar to dorsal hole in the MC base 1 cm distal to TMC joint
- b. Collateral benefit
- i. Restores dorsoradial lig. by dorsal exit and suture to APL
- ii. Restores intermetacarpal lig.; FCR insertion on index MC
- c. Retains normal bony architecture
- d. May slow degenerative process
- 2. Stage II and III: partial trapeziectomy
- a. Distal trapezial articular surface resected
- b. Gap between MC base and trapezium
- c. Volar/dorsal extraarticular hole or oblique hole from MC base articular surface to dorsum
- d. Half of FCR tendon distally based used for reconstruction; rest interposed filling void from resected bone
- 3. Stage II, III, IV: complete trapeziectomy
- a. Total trapeziectomy
- b. Large gap between MC base and trapezium
- c. Half or entire FCR tendon; latter leaves more to interpose
- A. Simple trapeziectomy associated with subsidence, impingement
- B. Hematoma distraction uses temporary K-wire to control fibrous tissue
- C. Most trapeziectomy studies are short term F/U; ? if results hold up
- D. Studies of arthroscopic debridement are limited and short term F/U
- A. Half distally based FCR from volar to dorsal 1 cm distal to MC base
- B. Initially developed to treat recurrent instability after CMC dislocation
- C. Results: Eaton RG, Lane LB et al. J Hand Surg, 1984
- 1. 38 thumbs; average 7 year F/U
- 2. Stages I through IV (38 patients)
- a. Good or excellent 84%
- b. Fair 16%
- 3. Pinch 90% of contralateral in all but 4
- D. Long term results: Freedman DM, Eaton RG, Glickel SZ. J Hand Surg, 2000
- 1. Twenty-four thumbs, 19 patients; F/U 14.7 years
- 2. Pain: No pain 7; mild pain with strenuous use 13; pain with ADL 4
- E. Lane, LB, Henly DH. J Hand Surg, 2001
- 1. 37 thumbs; F/U 5.2 years (range 1 to 17 years)
- 2. Pain: No pain 67%; markedly improved 30%
- 3. Clinical evaluation: Excellent/good 97%; fair 0%; poor 3%
- A. Partial vs. complete trapeziectomy
- 1. Partial appropriate for Stage II and III
- a. Retains most of trapezium
- b. Decreases MC subsidence
- c. ST joint may degenerate over time
- 2. Complete trapeziectomy
- a. ST joint eliminated; cannot degenerate
- b. Facilitates exposure of FCR for ligament reconstruction
- c. Ligament reconstruction prevents subsidence/impingement
- B. LRTI most commonly used basal joint reconstruction
- a. Initial half of distally based FCR used
- b. Entire FCR more common; little or no functional consequence
- C. Results
- 1. Tomaino MM, Pellegrini VD, Burton RI. J Hand Surg 1995
- a. 24 thumbs; 9 year F/U
- b. Proximal migration 13% of arthroplasty space
- c. Grip 93%, key pinch 34%, tip pinch 65% improvement
- d. Patient satisfaction and pain relief 95%
- 2. Interposition may not be necessary (Gerwin M, Griffith A, et al. CORR 1997)
- a. No difference in arthroplasty space with or w/o interposition
- b. No difference in grip, pinch, ROM, ADL or patient satisfaction
- 3. Decreased flexion extension torque ratio but no functional deficit from using entire FCR (Naidu SH, Poole J, Horne A. J Hand Surg 2006)
- A. Thompson
- 1. Distally based slip of APL
- 2. Oblique fixation hole in index MC metaphysis
- B. Diao Modification
- 1. Entire APL, distally based
- 2. Volar to dorsal fixation hole in index MC more distal than Thompson
- C. Suspensionplasty results comparable to LRTI: Soejima O, Hanamura T et al. J Hand Surg 2006
- 1. 21 thumbs; 33 mos. F/U
- 2. No pain 13; mild pain with strenuous use 5; mild pain with light use 3
IV. Without ligament reconstruction, what stabilizes the metacarpal?
V. Volar ligament reconstruction
VI. Ligament reconstruction and tendon interposition arthroplasty (LRTI)
VII. APL Suspensionplasty
VIII. Alternative reconstructions e.g. ECRL usually reserved for salvage
1. Burton RI, Pellegrini VD Jr: Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty. J Hand Surg 11A:324-332, 1986.
2. Cooney WP III, Chao EYS: Biomechanical analysis of static forces in the thumb during hand function. J Bone Joint Surg 59A: 27-36, January, 1977.
3. Doerschuk SH, Hicks DG, Chinchilli VM, Pellegrini VD Jr: Histopathology of the palmar beak ligament in trapeziometacarpal osteoarthritis. J Hand Surg 24A(3):496-507, May, 1999.
4. Eaton RG, Lane L, Littler JW, Keyser J: Ligament reconstruction for the painful thumb carpometacarpal joint. A long term assessment. J Hand Surg 9A:692-699, 1984.
5. Eaton, RG, Littler JW: Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg 55A:1655-1666, December, 1973.
6. Eaton RG, Glickel SZ, Littler JW: Tendon interposition arthroplasty for degenerative arthritis of the trapezio-metacarpal joint of the thumb. J Hand Surg 10A:645-53, 1985.
7. Freedman D, Glickel SZ, Eaton RG: Long term follow-up of volar ligament reconstruction of the thumb. J Hand Surg 25A:297-304, 2000.
8. Gervis WH, Wells T: A review of excision of the trapezium for osteoarthritis of the trapeziometacarpal joint after twenty-five years. J Bone Joint Surg 55B (1):56-57, 1973.
9. Gerwin M, Griffin A, Weiland A, Hotchiss R, McCormack R: Ligament reconstruction basal joint arthroplasty without tendon interposition. CORR 342:42-45, 1997.
10. Lane LB, Henley DH: Ligament reconstruction of the painful, unstable nonarthritic thumb carpometacarpal joint. J Hand Surg 26A:686-691, 2001.
11. Naidu SH, Poole J, Horne A: Entire flexor carpi radialis tendon harvest for thumb carpometacarpal arthroplasty alters wrist kinetics. JHand Surg 31A (7):1171-7, 2006.
12. Pellegrini VD Jr: Osteoarthritis of the trapeziometacarpal joint: The pathophysiology of articular cartilage degeneration. II. Articular wear patterns in the osteoarthritic joint. J Hand Surg 16A:975- 982, 1991.
13. Soejima O, Hanamura T, Kikuta T, Lida H, Naito M: Suspensionplasty with the abductor pollicis longus tendon for osteoarthritis in the carpometacarpal joint of the thumb. J Hand Surg March, 31A(3):425-8, 2006.
14. Thompson JS: Complications and salvage of trapeziometacarpal arthroplsties. In: Instructional Course Lectures, The American Academy of Orthopaedics Surgeons. Vol. 38, pp.3-13. Park Ridge, Illinois, The American Academy of Orthopaedic Surgeons, 1989.
15. Tomaino MM, Pellegrini VD Jr, Burton RI: Arthroplasty of the basal joint of the thumb: Long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg 77A: 346-355, 1995.