62: Trapeziectomy and Abductor Pollicis Longus Suspensionplasty

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Procedure 62 Trapeziectomy and Abductor Pollicis Longus Suspensionplasty

Nathan S. Taylor, Kevin C. Chung

imageSee Video 46: Abductor Pollicis Longus Suspension Arthroplasty for Basal Joint Arthritis

Indications

image Eaton stages II to IV disease (see later)

image Pain refractory to conservative treatment, including trapeziometacarpal (TMC) corticosteroid injection, thumb splinting, and isometric exercises

Examination/Imaging

Clinical Examination

image The patient’s thumb metacarpal base may exhibit a dorsoradial prominence secondary to subluxation from ligamentous laxity (Fig. 62-1).

image The patient’s thumb should be evaluated for tenderness along the TMC joint.

image The carpometacarpal (CMC) grind test is performed with axial compression, flexion, extension, and circumduction of the TMC joint, which should elicit crepitus and pain.

image The patient’s thumb metacarpophalangeal (MCP) joint should be assessed during pinch for hyperextensibility. If unaddressed, the suspensionplasty will be stressed by obligatory metacarpal adduction. This hyperextensibility can be corrected with MCP joint capsulodesis or fusion if the deformity is severe.

image The patient should be evaluated for carpal tunnel syndrome, which may coexist in up to 43% of patients with TMC arthritis. Concomitant carpal tunnel release should be performed in these patients because trapeziectomy alone does not sufficiently increase carpal tunnel volume.

image An Allen test should be performed because the procedure typically requires mobilization of and potential injury to the radial artery.

image The patient should also be evaluated for concomitant trigger thumb.

image

FIGURE 62-1

Imaging

image Posteroanterior, oblique, and lateral radiographs of the hand should be obtained to evaluate the extent of arthritis, osteophyte formation, joint loss, and joint subluxation (Fig. 62-2A to C).

image The Eaton classification is a staging system based on radiographic findings only and often does not correlate with the patient’s symptoms. Some patients with severe arthritis may have minimal pain. Treatment should be based on the patient’s symptoms and, most important, on the amount of pain in the arthritic joint.

• Stage I—normal to slightly widened TMC joint secondary to ligamentous laxity or effusion, normal articular contours, and subluxation of less than one third of the joint space
• Stage II—TMC joint narrowing and osteophytes less than 2 mm
• Stage III—further TMC joint narrowing, subchondral cysts, sclerosis, osteophytes greater than 2 mm, subluxation greater than one third of the joint space
• Stage IV—degenerative changes involving the scaphotrapezial joint

image A stress view of the TMC joint is obtained by having the patient press the thumb tips together while obtaining a 30-degree posteroanterior view centered on the thumbs to assess joint space loss and subluxation. Stress view is only obtained in stage I disease for patients with symptomatic joint laxity.

image Partial resection of the trapezoid should be performed if degenerative changes are present between the trapezoid and the scaphoid.

image

FIGURE 62-2

Surgical Anatomy

image The anterior oblique (beak) ligament inserts volarly onto the trapezium from its confluence with articular cartilage on the beak of the thumb metacarpal.

image The radial artery traverses the anatomic snuffbox and overlies the dorsal capsule of the CMC joint.

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

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

image The flexor carpi radialis (FCR) tendon traverses the volar and ulnar aspect of the trapezium.

Positioning

image 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

image The APL suspensionplasty requires two incisions (Fig. 62-3).

• A longitudinal incision centered over the anatomic snuffbox and TMC joint
• A small chevron incision over the first extensor compartment about 5 cm proximal to the radial styloid
image

FIGURE 62-3

Pearls

The dorsal approach provides easy access to the trapezium.

For the trapeziectomy, one must identify and protect four structures: radial sensory nerve branches, radial artery, EPL tendon, and APL tendon.

Retract the EPL ulnarly and the APL radially and identify the radial artery, which will be located deep to the fatty tissue between these structures.

Pitfalls

If the distal incision is not centered on the metacarpal or the trapezium, the capsular elevation may be more challenging.

Procedure

Step 1

image The distal skin incision is made extending from 1 to 2 cm distal to the TMC joint to the radial styloid proximally.

image The proximal skin incision is made over the course of the first extensor compartment tendons after the trapeziectomy has been completed.

Step 1 Pearls

The EPL is identified at the ulnar aspect of the anatomic snuffbox.

The radial sensory nerve branches should be mobilized and retracted.

Perforating vessels from the radial artery to the dorsal capsule should be cauterized as the artery is mobilized and retracted ulnarly to gain access to the joint capsule.

Step 1 Pitfalls

Failure to identify and adequately mobilize the radial artery can result in arterial injury.

Step 2

image Sharply incise the TMC joint capsule and elevate the capsular flaps radially and ulnarly to expose the scaphotrapezial joint, the trapezium, and the thumb metacarpal base (Fig. 62-4).

image

FIGURE 62-4

Step 2 Pearls

The capsule should be sharply elevated to preserve these flaps for closure at the completion of the procedure.

Step 2 Pitfalls

The radial artery is at risk for injury owing to its close proximity to the joint capsule.

Step 3

image An oscillating saw is used to cut the trapezium into three pieces (Figs. 62-5A and B), and an osteotome is then used to fracture the bone into separate pieces (Fig. 62-5C). Trapeziectomy is performed with a rongeur (Fig. 62-5D). If scaphotrapezoid arthritis is present, partial proximal trapezoidal resection is performed such that axial loading produces no contact between the scaphoid and trapezoid.

image

FIGURE 62-5

Step 3 Pearls

The orientation of the saw cuts should be parallel to the course of the FCR tendon to avoid injury to this tendon as it passes volar to the trapezium at its proximal radial corner.

Traction on the thumb helps facilitate exposure of the trapezium.

There will be a substantial amount of osteophyte attaching to the volar joint capsule and the thenar muscle. All the osteophytes must be excised using both the scalpel and the rongeur.

In certain situations in which the interval between the trapezium and the scaphoid is blurred because of severe degenerative changes, it is useful to obtain a view using the fluoroscopy to be sure the correct bone is removed. It is conceivably possible to remove a portion of the distal scaphoid if not careful.

After trapeziectomy, traction should be exerted on the index and long fingers to assess the scaphotrapezoid joint.

Step 3 Pitfalls

If partial proximal trapezoidectomy is performed, one must be careful not to inadvertently resect some of the capitate.

Step 4

image Identify and release the first extensor compartment (Fig. 62-6). Identify the musculotendinous junction of the APL, divide the most radial slip of the APL at this junction (Fig. 62-7A), and begin to split it distally to its insertion on the base of the thumb metacarpal (Fig. 62-7B).

image

FIGURE 62-6

image

FIGURE 62-7

Step 4 Pearls

One must take care to preserve the ulnar half of the APL tendon at its musculotendinous junction.

Step 5

image A hemostat is used to pass the APL tendon subcutaneously and into the arthroplasty space, and the remaining portion is split distally to its insertion at the base of the thumb metacarpal (Fig. 62-8). The ECRL tendon is then identified ulnar and deep to the EPL tendon, inserting into the base of the index metacarpal.

image

FIGURE 62-8

Step 6

image The APL tendon is passed volar to the EPL (Fig. 62-9A). A small incision is made in the ECRL tendon, and the APL slip is woven into the ECRL with a tendon passer (Figs. 62-9B and C).

image image

FIGURE 62-9

Step 7

image Tension is set such that the thumb metacarpal base is suspended at the level of the index metacarpal base. The tendon weave is secured with two 3-0 braided permanent horizontal mattress sutures (Fig. 62-9D and E). The remaining tendon is cut, and a 4-0 braided absorbable suture is used to fashion the cut tendon into an accordion-like ball that is placed in the arthroplasty space (Fig. 62-10A and B).

image

FIGURE 62-10

Step 8

image Close the joint capsule with 4-0 braided absorbable suture. The tourniquet is then released, and all bleeding points are cauterized.

Step 9

image The skin is closed in layers with 4-0 absorbable monofilament dermal sutures and a 4-0 absorbable monofilament running subcuticular suture. The hand is placed in a thumb spica splint.

Postoperative Care and Expected Outcomes

image A postoperative thumb spica splint is worn for 4 weeks. Sutures are removed at the first postoperative visit (10 to 14 days after surgery) as needed, and scar massage techniques are taught to the patient. (Fig. 62-11 shows postoperative radiographic appearance.)

image Four weeks after surgery, hand therapy is begun for passive and active range-of-motion exercises. The splint is worn in between exercises.

image Six weeks after surgery, light strengthening exercises are begun, and unrestricted passive range of motion is allowed. Splint is worn in between exercises.

image Eight weeks after surgery, the splint is removed, and heavy strengthening is begun with grip and pinch exercises. Soft neoprene splint is worn as needed.

image

FIGURE 62-11

Evidence

Chang EY, Chung KC. Outcomes of trapeziectomy with a modified abductor pollicis suspension arthroplasty for the treatment of thumb carpometacarpal joint osteoarthritis. Plast Reconstr Surg. 2008;122:1-12.

The authors present the outcomes of 21 thumbs in 18 patients with thumb CMC arthritis treated with trapeziectomy and a variation of APL suspension arthroplasty. Prospective outcomes data were collected, and results were compared with the senior author’s retrospective series of 35 flexor carpi radialis ligament reconstructive procedures and with the literature. The authors noted in their series a 32% loss of CMC joint height and 11% proximal migration of the metacarpal at 1 year. Results of improved grip strength were comparable to the literature, although this improvement was not statistically significant. Michigan Hand Outcomes Questionnaire results showed statistically significant improvements in activities of daily living, work, patient satisfaction, and pain. Shorter tourniquet times were reported for the APL suspensionplasty compared with the FCR ligament reconstruction procedure. The authors concluded that the APL suspension arthroplasty is a faster and technically easier technique that avoids any additional deficit by using an accessory tendon and produces acceptable patient-rated outcomes, especially in pain relief and satisfaction. (Level IV evidence)

Sigfusson R, Lundborg G. Abductor pollicis longus tendon arthroplasty for treatment of arthrosis in the first carpometacarpal joint. Scand J Plast Reconstr Hand Surg. 1991;25:73-77.

The authors described a technique in which a portion of the APL was used in a figure-of-eight fashion around the FCR and remaining portion of the APL. Grip and pinch strengths more than 80% of the estimated normal hand were found. Scaphometacarpal height reduced to about 2 mm with pinch. Arthrosis of the scaphotrapezoid joint was a presumed potential cause of suboptimal results. (Level IV evidence)

Soejima O, Hanamura T, Kikuta T, et al. Suspensionplasty with the abductor pollicis longus tendon for osteoarthritis in the carpometacarpal joint of the thumb. J Hand Surg [Am]. 2006;31:425-428.

The authors report their experience with trapeziectomy and APL suspensionplasty without tendon interposition for painful trapeziometacarpal arthritis in 21 thumbs. Ten thumbs were classified as Eaton stage III, and 11 were classified as stage IV; all patients complained of pain with activity; and average follow-up was 33.3 months. Subjectively, 13 of the 21 thumbs were associated with no pain after surgery, 5 thumbs were associated with mild pain with strenuous activity, and 3 thumbs were associated with mild pain with light work. Objectively, radial and palmar abductions, grip strength, and key-pinch strength all improved postoperatively compared with preoperative assessment, although these findings were not statistically significant. The authors concluded that APL suspensionplasty has a favorable outcome in trapeziometacarpal osteoarthritis and that the APL tendon can be removed as a deforming force without any abduction weakness. They recognized the small sample size of their study as well as a short follow-up period and recommended additional prospective randomized studies of larger numbers with a longer follow-up. (Level IV evidence)

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81: Ulnar Shortening Osteotomy 61: Trapeziometacarpal Ligament Reconstruction 25: Flexor Pronator Slide 50: Open Reduction and Internal Fixation of Phalangeal Shaft Comminuted Fractures 21: Steindler Flexorplasty 37: Duplicated Thumb Reconstruction