61: Trapeziometacarpal Ligament Reconstruction

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Procedure 61 Trapeziometacarpal Ligament Reconstruction

Nathan S. Taylor, Kevin C. Chung

See Video 45: Thumb CMC Joint Beak Ligament Reconstruction Using the FCR Tendon

Indications

Chronic posttraumatic instability of the thumb CMC joint

Symptomatic laxity of the thumb CMC joint

Surgical Anatomy

The TMC joint is a biconcave saddle-shaped joint that provides motion in several planes to allow thumb flexion, extension, abduction, adduction, and opposition.

The volar oblique (beak) ligament inserts volarly onto the trapezium from its confluence with articular cartilage on the beak of the thumb metacarpal and is considered the primary stabilizer of the TMC joint. It serves as the main restraint against dorsal translation of the metacarpal on the trapezium (Fig. 61-2).

The thin and less well-defined dorsal ligament is reinforced by an expansion of the insertion of the abductor pollicis longus (APL) tendon onto the dorsal-radial aspect of the metacarpal.

The radial artery traverses the anatomic snuffbox and overlies the dorsal capsule of the carpometacarpal (CMC) joint.

The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are within the first extensor compartment.

The radial sensory nerve becomes subcutaneous after exiting through the interval between the brachioradialis and extensor carpi radialis longus (ECRL) muscles.

The flexor carpi radialis (FCR) tendon is the most radial tendon palpable on the volar aspect of the wrist and is located just ulnar to the radial artery. The palmaris longus tendon, when present, is ulnar to the FCR tendon.

The palmar cutaneous branch of the median nerve is located 1 mm ulnar to the FCR tendon.

FIGURE 61-2

Positioning

The procedure is performed under tourniquet control with the patient in the supine position and the extremity abducted with the hand on a hand table.

Exposures

This procedure requires the following incisions.

• A modified Wagner incision along the junction of glabrous and nonglabrous skin that extends from the distal extent of the thumb metacarpal in a curvilinear fashion along the border of the thenar eminence to just ulnar to the FCR tendon at the wrist crease. This exposes both the TMC joint and the FCR tendon deep to the subcutaneous fat. Skin flaps should be elevated sufficiently to visualize the dorsum of the metacarpal base.

• A series of short volar transverse incisions centered over the FCR tendon at 3 and 6 cm proximal to the wrist crease for tendon harvest (Fig. 61-3). The FCR sheath is identified deep to the subcutaneous fat and sharply opened to expose and isolate the radial half of FCR.

FIGURE 61-3

Pearls

One must identify and protect the radial sensory nerve branches, the radial artery, and the FCR tendon and avoid injury to the palmar cutaneous branch of the median nerve.

Procedure

Step 1

Identify the radial edge of the thenar musculature at its insertion onto the metacarpal and elevate the muscle extraperiosteally to expose the metacarpal base, TMC joint, and trapezium (Fig. 61-4).

The interval between the extensor pollicis longus and brevis is developed to expose the dorsal cortex of the metacarpal base.

A hole is created at the base of the metacarpal from dorsal to volar 1 cm distal to the joint in a plane perpendicular to the axis of the thumbnail using a gouge or small bur. The volar hole should emerge at the apex of the volar beak of the metacarpal.

FIGURE 61-4

Step 1 Pearls

Although preoperative radiographs may appear normal, these can be deceiving, and degeneration of articular cartilage may be underappreciated. If there is clinical suspicion of articular degeneration, a transverse arthrotomy should be made to visualize the TMC joint surface. The arthrotomy is then closed with 3-0 braided absorbable suture.

Step 2

The FCR tendon is identified at the wrist crease, and the sheath is sharply opened proximally and distally.

The radial half of the FCR tendon in the proximal forearm is transected proximally at 6 cm from the wrist crease and separated from the other half of the tendon using two small transverse incisions (Fig. 61-5). At the level of the wrist crease, the FCR is covered by a sheath that needs to be opened to trace the FCR slip close to its insertion at the base of the index metacarpal. The FCR rotates 90 degrees within the sheath; it is important to follow the fibers so that the tendon is not inadvertently transected. One should not slide the scissors through the tendon fibers but rather cut along the fibers to maintain the integrity of the tendon.

FIGURE 61-5

Step 3

The free end of the FCR is redirected across the crest of the trapezium to enter the volar portion of the newly created hole at the beak of the thumb metacarpal and drawn dorsally through the metacarpal with the assistance of a wire suture (Figs. 61-6 and 61-7).

The TMC joint is reduced under direct vision and held in extension and abduction to seat the metacarpal against the deep facet of the trapezium. It is unnecessary to pin the joint because the tendon is adequate to provide stability to the thumb CMC joint.

The tendon is pulled taut and sutured to the dorsal periosteum using a 3-0 braided permanent suture. The tendon is then passed around the metacarpal base deep to the extensor pollicis brevis and APL, through a small split in the intact FCR tendon proximal to its insertion, and finally back across the joint and sutured to the APL tendon using 3-0 braided permanent suture (see Fig. 61-7). Additional 3-0 braided permanent sutures are placed at the junction through the FCR tendon (Fig. 61-8).

FIGURE 61-6

FIGURE 61-7

FIGURE 61-8

Step 4

The thenar musculature is reattached using 3-0 braided absorbable suture.

The tourniquet is released, and all bleeding points are cauterized.

The skin is closed with 4-0 permanent monofilament horizontal mattress sutures, and the hand is placed in a thumb spica splint for 4 weeks.

Postoperative Care and Expected Outcomes

The thumb spica splint is worn for 4 weeks followed by gentle active motion exercises for another 4 weeks. Strengthening is started 8 weeks after surgery.

Thumb CMC joint stiffness typically lasts 4 to 6 weeks but may last as long as 4 months.

The patient can expect complete or near-complete relief of pain with use of the thumb and minimal or no progression of degenerative arthritis when this surgery is performed before onset of significant articular cartilage degeneration. (Fig. 61-9 shows a late postoperative radiograph.)

FIGURE 61-9

Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment. J Hand Surg [Am]. 1984;9:692-699.

This study reviews the first 50 consecutive reconstructions, with an average follow-up of 7 years. Intractable pain was the primary indication for surgery. Each joint was examined both before and after surgery and rated as stage I through stage IV according to the radiographic appearance. Of the patients with zero or minimal articular changes (stages I and II), 95% achieved good or excellent results (little or no postoperative pain). Of the patients with moderate to advanced degenerative changes (stages III and IV), 74% achieved good or excellent results. All stage I cases and 82% of stage II cases were free of recognizable degeneration on follow-up radiographs up to 13 years postoperatively. These findings suggest that ligament reconstruction, which is now recommended only for stage I or stage II disease, will restore stability, reduce pain, and possibly even retard joint degeneration in a large proportion of patients with painful instability of the thumb CMC joint. (Level IV evidence)

Freedman DM, Eaton RG, Glickel SZ. Long-term results of volar ligament reconstruction for symptomatic basal joint laxity. J Hand Surg [Am]. 2000;25:297-304.

The long-term results of volar ligament reconstruction were assessed in 19 patients (24 thumbs). The average age at surgery was 33 years (range, 18 to 55 years). Twenty-three thumbs were radiographic stage I; a preoperative radiograph was not available in one. The follow-up period averaged 15 years (range, 10 to 23 years). At the final follow-up visit, 15 thumbs were stage I, 7 were stage II, and 2 were stage III. Fifteen patients were at least 90% satisfied with the results of the surgery. Only 8% of thumbs advanced to radiographic arthritic disease, which compares favorably with the 17% to 33% reported incidence of stage III/IV basal joint arthritis in the general population. (Level IV evidence)

Takwale VJ, Stanley JK, Shahane SA. Post-traumatic instability of the trapeziometacarpal joint of the thumb: diagnosis and the results of reconstruction of the beak ligament. J Bone Joint Surg [Br]. 2004;86:541-545.

The authors retrospectively reviewed reconstruction of the anterior oblique ligament using a slip of the flexor carpi radialis tendon in 26 patients with a mean age of 34.6 years and a mean follow-up of 55 months. They found that 87% obtained significant relief from pain, and mean grip strength recovered to 86% of the contralateral side. Eighty-one percent of patients noted a subjective improvement. The authors state that although their small sample size precludes statistical analysis, the trends noted in their study suggest that a better outcome may occur if surgery is performed early after a period of nonoperative management. (Level IV evidence)

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Operative Techniques Hand and Wrist Surgery