The complex lifelong multiplanar forces that a thumb is subjected to commonly result in degeneration at the first carpometacarpal joint (FCMCJ), which can be debilitating and pose a significant health and financial burden to both the individual and the community.1 Upon failure of nonoperative measures, the goals of surgical intervention of late-stage FCMCJ degeneration are pain relief, joint stability, and retention of motion and strength.2 Broad options include either arthrodesis or arthroplasty. Arthrodesis alleviates pain but sacrifices motion.3,4 Arthroplasty can be excisional or interpositional (involving synthetic implants or autologous tissue), and may be associated with various methods of reconstruction of attenuated ligaments or suspension. Synthetic implants have largely been abandoned, due to concerns with instability, fragmentation, particulate synovitis, and cold flow deformation.5
Simple trapeziectomy was first described by Gervis in 1949, with early satisfactory relief of pain reported.6 However, longer term follow-up raised concerns of weakness and instability, with loss of ligamentous support from the trapeziometacarpal ligaments resulting in metacarpal subsidence into the arthroplasty space.7,8 Although more recent analysis suggests that isolated trapeziectomy offers similar patient outcomes to other surgical modalities, concerns regarding the potential adverse effects of subsidence led to the development and adoption of various techniques of metacarpal suspension and ligament reconstruction.9,10
Eaton and Littler11 first described volar oblique ligament reconstruction, utilizing the radial half of flexor carpi radialis (FCR) passed through a sagittal bone tunnel at the base of the first metacarpal and secured to itself, without trapeziectomy. Although effective in early stage osteoarthritis, those with more advanced degeneration reported ongoing disease progression. The same authors later modified their technique by resecting the metacarpal base, planing the trapezium and interposing excess FCR tissue, with improved outcomes in patients with late-stage degeneration.12 This evolved into the modern FCR ligament reconstruction and tendon interposition (LRTI) procedure, whereby complete trapeziectomy is followed by volar oblique ligament reconstruction and interposition of tendon mass (or “anchovy”) to stabilize the arthroplasty space.13,14 Although widely performed, concern exists regarding potential fracture risk through osseous tunnels. Studies have also shown significantly lower average flexion-to-extension peak torque ratio, and diminished wrist flexion fatigue resistance.15 Anecdotally, tendonitis due to partial tendon harvest can be debilitating, and may require further debridement or tenotomy.
An alternative procedure is suspensionplasty without formal ligament reconstruction, whereby the first metacarpal is suspended either by a sling of tendon underneath its base, or by attachment to the base of the second metacarpal. Variations include suspension via the dorsal slip of abductor pollicis longus (APL) passed through osseous tunnels in the bases of the first and second metacarpals, or a sling created by either radial half of FCR looped and tensioned around APL, or vice versa. Sling suspension has a potential for greater loss of trapezial height, although this is of questionable clinical relevance.1 It has been suggested that utilization of APL as graft results in better grip strength, and key and pinch grip, when compared with FCR.16
In recent times, suture-button suspensionplasty utilizing synthetic nondegradable material via bony tunnels has become more popular. Although demonstrating promising results (minimal loss of grip and pinch strength and trapezial height compared with contralateral side), it is significantly more expensive than utilization of autogenous tissue, and poses the same risks of fracture by employing osseous tunnel.17 In addition, fixation buttons are often palpable in the subcutaneous tissue, and can cause irritation.
Given the variety of therapeutic options available, much conjecture exists as to the ideal modality of treatment, with decision-making often driven by surgeon experience and preference. Systematic reviews have been unable to demonstrate that any technique confers a benefit over another in terms of outcomes; nor were they able to conclusively prove that the compared techniques were equivalent.9,18 In particular, tendon interposition has not been proven to improve metacarpal subsidence when compared with ligament reconstruction or suspensionplasty alone.10,19
We describe an alternative technique of suspensionplasty following trapeziectomy, utilizing a single slip of APL. Advantages include cost effectiveness and availability when compared with synthetic grafts, and obviation of fracture risk by eliminating osseous tunnels. Utilization of an APL slip diminishes the risk of donor site tendonitis due to partial tendon harvest, and may result in improved grip strength and key and pinch, and improved wrist flexion fatigue, when compared with FCR grafting. Suspension via a “lasso,” as opposed to a sling at the base of the first metacarpal, aims to diminish metacarpal subsidence. We also present the early results of patients who underwent trapeziectomy and suspensionplasty using this method, following cadaveric testing.
The FCMCJ is shallow, biconcave, and inherently unstable. The major restraints are capsulo-ligamentous, with the volar beak (or palmar oblique) ligament traditionally thought to be the major check-rein against dorsal translation.12,13 This ligament originates from the palmar aspect of the trapezium, and inserts onto the prominent ulnar base of the first metacarpal.1 More recently, cadaveric studies have posited that the broad dorsoradial ligament (from the dorsal trapezium into the base of the thumb metacarpal) may be more relevant, by tightening to act as a buttress against translation.20
The presence of a duplicated APL tendon was first reported in 1871.21 A recent cadaveric study revealed that APL was present in all specimens, with an accessory APL (AAPL) present in 85%.22 Of these, 14% had multiple slips of AAPL. The AAPL attached radial to the APL in all cases, with the majority attaching to the trapezium initially and then on via capsulo-periosteal connections to the base of the first metacarpal (Fig. 1). A minority inserted onto the proximal aspect of the abductor pollicis brevis or opponens pollicis brevis muscles. 20% of AAPL tendons were found to originate from independent muscle bellies. No significant differences were found in terms of width and thickness between the APL (5.2 mm wide and 2.1 mm thick) and AAPL (3.3 mm wide and 1.6 mm thick).22
Patients with late-stage FCMCJ arthritis who have failed nonoperative measures should be considered for this procedure. A careful history and examination should assess for concomitant conditions (such as carpal tunnel syndrome and DeQuervain tenosynovitis) and operative plan should cater for all pathology. The first metacarpophalangeal joint should be assessed for compensatory hyperextension, valgus instability or presence of arthritis on radiographs, and should be addressed with either arthrodesis or soft-tissue procedures if necessary. A preoperative ultrasound of the first dorsal compartment is advisable, to determine presence of multiple slips of APL.
Contraindications include active infection, patient noncompliance with rehabilitation, and a nonfavorable soft tissue envelope. Absence of multiple slips of APL prohibits this technique, and requires conversion to an alternative technique.
The patient is placed supine with an above elbow tourniquet. Prophylactic antibiotics are administered. A 3-incision technique is utilized (Fig. 2). A dorsoradial incision is marked over the FCMCJ, with another incision ~8 to 10 cm proximal and further dorsal (in line with the second metacarpal) and a further incision over the base of the second metacarpal.
The incision over the FCMCJ is performed, with care taken to identify and protect branches of the superficial radial nerve. The plane between the APL and extensor pollicis brevis tendons is developed. The radial artery is identified in this interval, as it courses from volar to dorsal, and is carefully mobilized and retracted, with care taken to coagulate any small branches encountered. The capsule of the FCMCJ, trapezial periosteum, and scaphotrapezial capsule are then incised in a longitudinal fashion. Further dissection is performed in a subperiosteal fashion to ensure safety to both dorsal and volar structures. Dissection is performed until the trapeziotrapezoid joint is visualized dorsally, and the trapezial ridge overlying the FCR is noted volar. Capsular sutures can then be placed to aid retraction and facilitate later closure.
The trapezium is now excised either in toto or piecemeal. The authors prefer to remove it whole, utilizing a combination of blunt dissection with a periosteal elevator, leverage via Homan retractors and sharp dissection. Once removed, the trapezoid is assessed for macroscopic signs of degeneration—if present, a shelf osteotomy is performed to excise surface articulating with the scaphoid. Care must also be taken to assess for trapezial osteophytes and loose bodies between the first and second metacarpal bases, which can be a source of ongoing pain.
Once the trapezium is excised adequately, the proximal incision is utilized. Blunt dissection is performed until the fascia over the first dorsal compartment is identified. This is then incised in a longitudinal fashion. A slip of APL (preferably the more radial, slightly smaller AAPL) is now harvested (Fig. 3). A 2/0 monofilament suture is passed around the distal tendon and brought proximally, allowing removal of any adhesions and identification of the correct slip. Further proximal dissection into the musculotendinous junction to harvest a greater length can be performed if necessary—in cadaveric testing, ~10 cm of tendon was harvested and proved to be more than sufficient. The tendon is transected proximally and passed into the distal wound. Care must be taken not to injure branches of the superficial radial nerve during harvest. First dorsal extensor compartment release can be performed if harvest is proving difficult. The tendon is now prepared with a 3/0 ethibond suture in a whip-stitch fashion, and stretched to remove creep. In the case of an absent or inadequate AAPL tendon (<3-mm width), a distally based APL slip can be harvested for utilization.
The final incision over the base of the second metacarpal is now employed. Blunt dissection is performed until the proximal metacarpal is identified. Interossei musculature is blunt dissected off either side of the proximal metacarpal, and a right-angle hemostat is used to clear the volar aspect of the bone, ensuring circumferential clearance. A subcutaneous tunnel is created between the bases of the first and second metacarpal, and the prepared tendon is passed, deep to the extensor pollicis longus and brevis tendons and then through the subcutaneous tunnel, avoiding branches of the superficial radial nerve. The APL slip is directed over the top of the proximal second metacarpal and then looped around, utilizing 2 right-angle hemostats (Fig. 4). The tendon is now passed through itself in a pulvertaft fashion, creating a lasso around the proximal second metacarpal.
Before tensioning, the lasso is pulled proximally until it rests firmly in the notch between the bases of the second and third metacarpal, preventing future subsidence. An assistant holds the first metacarpal in a reduced position, with the thumb pulled out to length and abducted. Given the biological nature of fixation and the possibility of creep, the authors prefer to overdistract the first metacarpal while fixating. The lasso is tensioned tightly by pulling the free edge of the tendon in a proximal fashion, and a nondissolvable mattress suture is inserted in the initial pulvertaft weave. The tendon is further secured by additional pulvertaft weaves (length permitting) or side-to-side suturing (Fig. 5). Figure 6 summarizes the technique.
The tourniquet is released and hemostasis is achieved. Closure is achieved in layers. The patient is limb is placed in a thumb-spica backslab for comfort. This is removed at the 1-week review, and progressive range of motion is encouraged.
This technique was performed on 3 patients at our tertiary referral institute. All patients were female, and average age was 65.3 years. The underlying etiology was primary arthritis in all cases. For 2 of the patients, average preoperative DASH score was 31.3, which improved to 6.4 at 6 months postoperatively, with symmetrical pinch (3.6 kg) and grip (25 kg) measurements when compared with the contralateral arm. Preoperative and postoperative radiographs and clinical photos demonstrate minimal subsidence and good range of motion (Figs. 7, 8). The last patient developed multiple trigger digits and chronic regional pain syndrome diagnosed by the pain team after the trapeziectomy and suspensionplasty—her preoperative DASH score of 65 regressed to 85 at the 3-month postoperative mark. After trigger digit release and neurolysis of the superficial radial nerve, the DASH had improved to 56 at 6 months postindex operation. This technique was also utilized as an augment to suture button suspension, in the same sitting as a distal radioulnar joint arthroplasty, in a patient with ligamentous laxity and wide-spread osteoarthritis.
Specific complications related to this technique can be either immediate or delayed. In the immediate setting, injury to branches of the superficial radial nerve or radial artery can occur during approach or graft harvest. Careful dissection, retraction and identification of aberrant anatomy is necessary.
In the delayed setting, patients must be warned that they may notice loss of terminal radial abduction, as demonstrated in a study where expenditure of the AAPL as graft for reconstruction of chronic extensor pollicis longus rupture resulted in a functional range of motion in all cases and a mean loss of 10 degrees radial abduction.23 Although long-term in vivo data are lacking, graft failure or elongation is possible in any tendon procedure, and may result in metacarpal subsidence or necessitate revision surgery. The process of harvesting a slip of APL may also predispose to scarring and development of De Quervain stenosing tenosynovitis—surgeons may consider prophylactic first dorsal compartment release.
Base of thumb arthritis is a common problem, and there is no conclusive evidence as to optimal therapeutic option. The technique described is potentially advantageous in that it does not require bony tunnels (reducing the risk of fracture), utilizes APL as opposed to FCR (diminishing risk of tendonitis and potential loss of grip strength, and tip and key pinch) and uses a lasso as opposed to a sling at the base of the first metacarpal (with potential reduced subsidence). The case described good objective and subjective outcome scores at short and medium-term follow-up. Further clinical implementation and biomechanical testing is necessary to ensure external validity.
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