CLINICAL RESEARCH
Midterm Results of Total Trapeziectomy and Suture-Button Suspensionplasty for Trapeziometacarpal Osteoarthritis
Ignacio Seré, Marcos Deimundo,
Juan Carrizo, Natalia
Villa, Enrique Gobbi,
Franco Ponce, Matías
Costa Paz
Orthopedics and Traumatology Service,
Hospital Universitario CEMIC,
Autonomous City of Buenos Aires,
Argentina
ABSTRACT
Objective: To retrospectively analyze the results
of total trapeziectomy and suture-button suspensionplasty for trapeziometacarpal
osteoarthritis at a minimum follow-up
of 2 years. Materials and Methods: Twelve patients who underwent
this procedure were evaluated at least
2 years after surgery. Range of motion and metacarpal height were assessed.
All patients completed
the Quick-DASH questionnaire and the Visual
Analog Scale (VAS).
Results: Eight women and four men (mean age, 63 years) were evaluated at a mean follow-up of 75 months.
Adequate opposition was achieved in all patients, with a mean radial abduction of 59.8° and palmar abduction of 61.9°. The mean
QuickDASH score was 21%, and the mean VAS
score was 1.55. The mean distance between the first metacarpal and the scaphoid
was 5.86 mm. There were no major
complications. Conclusions: The favorable results of total trapeziectomy and suture-button suspensionplasty support
its use in the treatment of trapeziometacarpal osteoarthritis, with an
acceptable risk of complications. Subjective and objective outcomes
are similar to
those of other techniques; however,
the benefit of this procedure lies in the initial
stability provided by the implant, which does not depend on tissue healing. Therefore, rehabilitation can begin 10 days after surgery. At a time when total joint arthroplasty
for trapeziometacarpal osteoarthritis is increasingly
used, this technique could provide a simple and safe salvage option after
failed total joint arthroplasty.
Keywords: Trapeziometacarpal osteoarthritis; suture-button suspensionplasty.
Level of Evidence: IV
Resultados a mediano plazo de la trapecectomía total y la suspensoplastia con botón para la rizartrosis
RESUMEN
Objetivo: Analizar retrospectivamente los resultados de la trapecectomía total
y la suspensoplastia con botón para la rizartrosis en un seguimiento mínimo de 2 años. Materiales y
Métodos: Se evaluó a 12 pacientes operados con esta técnica durante 2 años o más después de la cirugía. Se determinaron el rango de movilidad y la altura metacarpiana. Todos completaron el cuestionario QuickDASH y la escala analógica visual. Resultados: Se evaluó a 8 mujeres y 4 hombres
(edad promedio 63 años) con un seguimiento promedio de 75 meses.
En todos, se obtuvo una adecuada oposición, con una abducción radial promedio de 59,8º y una abducción palmar de 61,9º. El puntaje QuickDASH promedio fue del 21%, y el de la escala analógica visual,
de 1,55. El espacio promedio entre el primer metacarpiano y el escafoides fue de 5,86 mm. No
hubo complicaciones mayores. Conclusiones: Los
resultados favorables de la trapecectomía completa y la suspensoplastia con botón alientan su utilización para tratar la rizartrosis, con un riesgo de complicaciones aceptable. Los resultados subjetivos y objetivos son similares a los de otras técnicas, pero el beneficio de este procedimiento consiste en la estabilidad inicial brindada por el implante, que no requiere tiempo de cicatrización; por lo tanto, la rehabilitación se inicia a partir de los 10 días de la cirugía. En el auge de las prótesis totales para rizartrosis, esta técnica podría
ser una alternativa sencilla y segura para el rescate de la artroplastia total fallida.
Palabras clave: Rizartrosis; suspensoplastia con botón.
Nivel de Evidencia: IV
INTRODUCTION
Trapeziometacarpal
osteoarthritis is a common condition that can significantly impair activities
of daily living. The articular surfaces of the two bones involved are
saddle-shaped and articulate perpendicularly to each other, allowing a wide range of
motion but also increasing joint stress and instability. Biomechanically, generating 1 kg of pinch force
at the tip of the thumb results
in a load 10 times
greater at the trapeziometacarpal joint.1,2 Degeneration and
laxity of the carpometacarpal ligaments contribute to dorsal subluxation and
subsequent joint damage.2 When nonoperative treatment fails, surgical
intervention should be considered, with multiple options available. In cases of early-stage disease,
characterized primarily by instability and minimal or no osteoarthritis, dorsal
capsulodesis, volar ligament
reconstruction, or extra-articular osteotomy of the first metacarpal may be indicated. In cases of advanced joint
involvement and substantial damage to the articular surface, treatment options
include trapeziometacarpal joint arthrodesis, total
joint arthroplasty, suspensionplasty with tendon
interposition, partial or complete trapeziectomy, or a combination of these procedures. These
techniques yield similar outcomes at different stages of trapeziometacarpal
osteoarthritis.3 However, trapeziectomy
alone has the lowest complication rate and shortest operative time, although
its main drawback is the frequent proximal migration of the first metacarpal,
with consequent functional impairment.4 Partial or complete trapeziectomy
can be temporarily stabilized with Kirschner wires placed from the first
metacarpal to the second metacarpal or the distal pole of the scaphoid (or to
the remaining trapezium in a hemitrapeziectomy) to
reduce the tendency toward proximal migration of the first metacarpal.2 This fixation
requires prolonged immobilization and a second procedure to remove the wires,
while providing no structural support during the rehabilitation period once the
wires have been removed. When post-trapeziectomy
stabilization is achieved by placing a button between the first and second
metacarpals, early mobilization can be initiated because
the construct provides
firm support throughout the rehabilitation period and
does not require a second procedure for implant removal.
This
article describes the results of a retrospective review of complete trapeziectomy with button suspension-plasty
in patients with more than 2 years of follow-up.
MATERIALS AND METHODS
The
study protocol was approved by the institution’s Ethics Committee, and all
patients provided written informed consent to participate in the study.
Over a five-year period
(2017-2022), 17 patients
underwent complete trapeziectomy and button suspensionplasty performed
by the same surgeon. Patients
with persistent symptoms
of trapeziometacarpal osteoarthritis despite nonoperative treatment and radiographic evidence of trapeziometacarpal osteoarthritis were included. According to the Eaton-Littler classification,5 the cases
were distributed as follows: stage
II (3 patients), stage III (8 patients), and stage IV (1 patient). Five patients were excluded because
of inadequate follow-up, as they had not attended
the scheduled appointments for evaluation. The study group therefore
consisted of eight women and four men, with a mean age of 63 years.
66.6% underwent surgery
on their dominant
hand (8 cases).
The mean follow-up was 6.2 years (Table 1).
Evaluation
Subjective
outcomes were assessed using the QuickDASH, a
validated questionnaire that measures patient-re-ported upper extremity disability on a scale
from 0 to 100.6 Maximum pain during activity
was also assessed
using the visual analog scale (VAS) for pain.7
Thumb
range of motion was assessed by goniometry, with photographic documentation of
opposition, radial abduction, and palmar abduction (Figure
1). Trapezial height was measured as the distance from the most distal
aspect of the distal pole of the scaphoid to the base of the first metacarpal on a Roberts-view radiograph (Figure 2).
Medical records were also reviewed to document operative time and identify any
surgical or postoperative complications.
Surgical Technique
The
procedure was performed on an outpatient basis under regional anesthesia using
the Gedda and Moberg approach.8 The Mini-TightRope® suspension button
(Arthrex, USA) was placed
immediately before trapeziectomy to preserve the trapezial space. The entry
point for the system’s suture-passing pin was located immediately volar to the
insertion of the abductor pollicis longus tendon at the base of the first
metacarpal. This maintains an appropriate line of pull and allows the button to be positioned radial to the abductor pollicis
brevis tendon, thereby reducing the risk of postoperative button prominence.9 The pin was directed
from its entry point at the base of the first
metacarpal toward the ulnar cortex in a distal and slightly volar direction, aiming toward the proximal metaphyseal-diaphyseal junction
of the second metacarpal. A longitudinal dorsal
incision was then made over the second metacarpal, through which the
sutures attached to the proximal button were retrieved. A transverse tunnel was
then drilled through the second metacarpal at the proximal
metaphyseal-diaphyseal junction using the system’s
suture-passing pin, and the suture
was passed through
it. We find this additional step easier than passing through
both metacarpals in a single step;
furthermore, it allows
the button on the second
metacarpal to be positioned deeper
and with less prominence. The resulting oblique
orientation of the suture provides
a tension vector
that more effectively prevents proximal migration of
the first metacarpal than a transverse orientation.
Once
the system had been passed, the button at the level of the second metacarpal
was secured with a simple knot (to allow readjustment if necessary), and the
trapezium was then resected. An H-shaped capsulotomy
was performed on the radiopalmar aspect of the trapeziometacarpal joint, raising
one flap proximally and another distally,
which remained attached
to the distal pole of the scaphoid
and the base of the first metacarpal, respectively. Although a periosteal elevator may be used, we
find a curved bone gouge (or Smith-Petersen bone gouge) to be the most useful instrument for complete release
of the trapezium. If the trapezium could
not be resected in a single piece, the remaining fragments
were removed with a rongeur.
After removal
of the trapezium, manual axial
compression of the first metacarpal was performed, and adequate
stability without proximal migration was confirmed by direct visualization and
fluoroscopy (Figure 3). Once stability had
been confirmed, the system was definitively secured with multiple knots. The trapezial space was then filled with a
resorbable spacer (Spongostan®), the capsule and skin
were closed, and a thumb spica cast was applied for 10 days.
Rehabilitation
Ten days after surgery,
the cast and sutures were removed, and patients began range-of-motion exercises
as part of occupational therapy. They were allowed to use the hand for activities of daily living (eating, personal
hygiene, computer use, and driving), while manual sports
and strenuous activities were restricted. At 6 weeks, strengthening
with resistance exercises was initiated, and unrestricted activity was resumed
at 12 weeks.
RESULTS
Range
of motion was satisfactory in all 12 cases, with adequate thumb opposition to
the distal palmar crease, a mean radial abduction of 59.9° (range,
50-75°), and a mean palmar
abduction of 61.9°
(range, 50-75°) (Figure 1). The mean QuickDASH functional
score was 21 (range, 2.3-54.5). The mean visual analog scale score for pain
during strenuous use of the hand was 1.55/10 (range,
0-5) (Table 2). All patients resumed
their previous activities
and were cleared for
strenuous activities at 3
months.
The mean distance between the scaphoid
and the base of the first metacarpal
on Roberts-view radiographs was 5.86 mm (range,
5-7.5 mm) (Figure 2).
The
mean duration of the procedure, from skin incision to sling application, was
116.8 min (range, 85-180; standard deviation, 28.4).
Two
complications occurred. One patient with rheumatoid arthritis had mild residual
pain (1/10 on the visual analog scale) in the diaphyseal
region of the second metacarpal, probably associated with overall involvement of the hand and poor
soft-tissue quality resulting from chronic corticosteroid therapy. She declined
further procedures on the hand because she did not have significant pain or
functional limitation. The second complication occurred in a patient
who developed symptoms
of complex regional
pain syndrome, which
resolved after one year
of multidisciplinary management including rehabilitation, psychotherapy, and
medication prescribed by the pain management team.
DISCUSSION
In this study, after
a minimum follow-up
of 2 years, subjective outcomes,
as assessed using the QuickDASH and visual analog scale scores, and objective outcomes (range of
motion) were favorable, as was the time to return to previous activities.
Although some proximal migration of the first metacarpal was observed on
radiographs obtained after more than 2 years of follow-up, a mean distance
of 6 mm between the first metacarpal and the scaphoid was maintained. This collapse
did not result
in significant functional impairment, as 11 of the 12 patients
achieved excellent outcomes in
terms of range of motion and subjective scores. Other studies support our
experience, with results similar to those observed in
our case series.10,11
There
was one case of residual pain at the site of the second metacarpal tunnel in a
patient with rheumatoid arthritis and one case of reflex sympathetic dystrophy that responded
to medical treatment
after one year. There were no
injuries to the radial artery,
the sensory branches
of the radial nerve, or the nerve to the first dorsal interosseous
muscle, and cadaveric studies have confirmed that these structures are located
away from the surgical site.12 No metacarpal fractures occurred
with the use of the system’s suture-passing pin, without the need to drill holes with
a drill bit.
Hemitrapeziectomy
or complete trapeziectomy with temporary
stabilization using Kirschner wires and immobilization for 4 weeks provides
good long-term outcomes. In the study by Hofmeister et al., hemitrapeziectomy
with thermal capsular shrinkage and temporary pin fixation resulted in complete
recovery of pinch strength, grip strength, and range of motion, with a mean
proximal migration of 2 mm at a mean follow-up of 7.6 years.13 Although some
proximal migration of the first metacarpal was observed in our series at
follow-up beyond 2 years, it was less
pronounced than that reported after isolated trapeziectomy.3,4 The most common
complications of pin fixation are infection (8%) and pin migration. Similarly,
the classic ligament reconstruction and tendon inter-position technique
provides good outcomes but also requires 4-6 weeks of immobilization to allow
soft-tissue healing.3,4,11,14,15 The technique used in our series simplifies and
shortens the procedure and reduces morbidity compared with ligament
reconstruction using a tendon autograft.
The
main advantage of button suspensioplasty is the
possibility of initiating thumb mobilization soon after the initial postoperative pain period (10 days). This technique would
provide stabilization to prevent proximal
migration of the first metacarpal without requiring prolonged immobilization. Ten days after surgery,
immobilization is
discontinued and rehabilitation is initiated. The implant maintains the position of the first
metacarpal as range-of-motion exercises are initiated,
followed by strengthening exercises.
Regarding button
position, two technical steps may reduce
its prominence, thereby
decreasing the likelihood of irritation and the need for implant removal. At the base of the first metacarpal, the
area immediately volar to the insertion of the abductor pollicis
longus tendon is recommended as the entry
point for the system’s suture-passing pin. This maintains an appropriate line of pull and allows the button to be positioned radial to the abductor pollicis brevis tendon.9 At the proximal metaphyseal-diaphyseal region of the second metacarpal, we drill transversely to the axis of the second
metacarpal using the system’s suture-passing pin, in an additional step
separate from passage through the first metacarpal. This allows the button to be positioned deeper within the
second intermetacarpal space. Although
there are no significant differences in clinical or biomechanical outcomes,9 placement of the second
metacarpal button at the proximal
metaphyseal-diaphyseal junction rather
than at the mid-diaphysis is recommended, as this tends to provide
a range of motion closer to normal, less proximal migration, and greater
distance from the nerve to the first dorsal interosseous muscle.9,12
There
is a clear difference in cost between the button suspensioplasty
device and the Kirschner wires used for temporary stabilization or the simple sutures
used for tendon
ligament reconstruction. However,
we believe that the
shorter immobilization period
and abbreviated rehabilitation afforded by this device represent an important benefit that patients should be made
aware of when deciding on their treatment.
The limitations of this study
include its retrospective design, the absence
of a control group, and the lack of pre-operative scores for comparison with postoperative outcomes.
In addition, pinch strength was not measured
as an objective outcome.
The strengths of our case series include
the description of a simple
technique that would
allow early mobilization for a common condition and the long follow-up
period (mean, 75 months).
The
encouraging results achieved with the button suspensioplasty
device, the high level of patient satisfaction, favorable QuickDASH
and visual analog scale scores,
and excellent range of motion after a minimum follow-up
of 2 years suggest
that button suspensioplasty may be a useful option for the surgical treatment
of trapeziometacarpal
osteoarthritis. Because it does not require a prolonged healing period, it
shortens overall recovery and allows patients to return sooner to work and
activities of daily living. It is a relatively quick, minimally invasive
technique that could also have a role when total prosthetic thumb carpometacarpal arthroplasty fails and requires
removal of the prosthesis.
Multicenter,
randomized studies with larger sample sizes will be needed to more accurately
determine the benefits of this technique.