Scientific Publications


ARTROTENOPLASTICA DELLA T.M. CON ALLUNGAMENTO E DECENTRAMENTO DEL LUNGO ABDUTTORE SECONDO GHEZZI

ISTITUTI CLINICI DI PERFEZIONAMENTO UNITA’ OPERATIVA DI CHIRURGIA PLASTICA E RICOSTRUTTIVA DELLA MANO


Dr. M. Ghezzi – Dr D. Ongaro – Dr. G. P. Gobbato
Dr. L. Lucaccini – Dr. C. M. Gentili – Dr. L. Ponzoni

 

INTRODUCTION

As arthrosis of the trapeziometacarpal joint begins, the usual ample freedom of movementn of the first ray – which has the fundamental characteristic of guaranteeing both the hand’s function of “ pinching” and making a full fist – is progressively lost. An optimized intervention performed at our Operating Unit allows us to act during the initial stages of arthrosis of the trapeziometacarpal joint, when an initial deegree of articular instability accompanied by pain and decreased prehensile strength is observed, and when radiograhy shows less than one-third metacarpal subluxation. Such degree of arthrosis of the trapeziometacarpal joint corresponds to the initial Eaton stages I or II.

ANATOMY OF THE TRAPEZIOMETACARPAL JOINT

The trapeziometacarpal joint consists of reciprocal contact between the trapezium and the base of the first metacarpal. The trapezium belongs to the second carpal row and is articulated between the scaphoid, the base Of the first and second metacarpal, and the trapezoid. Different ligamentous structures are inserted on the surface such as the scaphotrapezial ligament, the metacarpal trapezium, and the inner anular carpal ligament. The trapeziometacarpal joint has a wide capsule reinforced by the insertion of the aforementioned ligamentous structures. Dorsally, the ulnar and radial oblique ligaments extend from the trapezium to the tuberculum of the base of the first metacarpal and their tension opposes adduction, whereas on the volar side the anterior oblique ligament opposes abduction of the thumb.

ARTICULAR BIOMECHANIS

Movements making the thumb go away from the hand when the fingers are aligned are called abduction and adduction, respectively, while movements making the thumb go forward or backward with respect to the palm are called anteposition and retro position. The result of these movements is a very characteristic movement called circumduction. Finally pronation is the movement which makes the thumb go towards the palm and, on the contrary, supination the tendency of the thumb to move upward and away from the palm.

ETHIOPATHOGENETIC MECHANISMS OF THUMB ARTHROSIS

The trapeziometacarpal joint is exposed to continuous mechanical stress and particularly to the subluxating action produced by the long abductor tendon. As time goes by, such destabilizing forces can induce the loss of capsulo-ligamentous integrity therefore giving origin to the beginning of arthrosis. Rizo arthrosis prevails in the female subjects and appears after the age of 40. In the approximately 80% of the cases, rizo arthrosis is also associated with arthrosis between the trapezium and the base of the second metacarpal and, in approximately 40% of the cases, with arthrosis between the trapezium and the scaphoid. This data assume clinical importance at the time of the surgical choice. The classic symptom at the beginning of the illness is pain that occurs both following particularly hard activities, and as a result of simple anteposition and opposition movements of the thumb. Such a pain is mostly localized at the volar face of the thumb base of the finger. The main anatomical pathological aspect is represented by reduction of the articular rime of the metacarpal trapezium witch is often associated to subchondral sclerosis leading, in the most advanced evolutionary stages of the illness, to the formation of osteophytes and geodes. Morphologic alteration consists in the progressive subluxation of the base of the first metacarpal. According to the classic literature, the degrees of stadiation of rizo arthrosis are classified as follow: Phase 1: subluxation of the base of the first metacarpal smaller than one third of width of the articular rime and reduction of the articular spacing. Phase 2: subluxation equal to one third and appearance of initial osteophytosis phenomena. Phase 3: subluxation greater than one third with osteophyte size larger than 2 mm and signs of initial disappearance of the articular rima. Phase 4: serious erosive phenomena on the articular surface with the appearance of subchondral cysts.

THERAPY

In our experience is it more appropriate at the beginning of the illness to carry out therapeutic treatment including ( ultrasound in water, magneto therapy, laser therapy) non steroidal anti inflammatories, and patient use of the thumb splint for a few hours a day. It would be better if patients repeat treatment cyclically up to two or three times a year. If such therapies are not beneficial, the possibility of proceeding with a surgical intervention needs to be evaluated at that time. The surgical treatment of rizo arthrosis includes many different techniques such as arthrodesis prosthesic substitution of the trapezium metacarpal joint and suspension arthroplasty. Arthrodesis of the trapezial metacarpal joint is a very invalidating intervention in that it involves a consistent limitation of functionality, but at the same time it is correctly indicated for patients who do heavy manual labor and in those patients in witch the extent of bone and articular end destruction does not allow any other kind of intervention. Good result are obtained whit a prosthesis of the trapezial metacarpal joint using one of the various prosthesic models. It is preferable that such intervention be carried out in specialized centers for hand surgery. The limitation of such surgical intervention as time passes are possible mobilization of the prosthesic implant which is usually due to bone reabsorption and/or to incorrect positioning of the implant itself. Other techniques described in the literature require suspension arthroplasty which is executed whit trapecziectomy and interpositioning of the tendon between the scaphoid and the base of the first metacarpal. Initially this kind of intervention Produces good results taking away the pain and giving renewed functionality to the hand. However, after some time, it involves ulnar sliding of the entire first carpal row with the consequent appearance of secondary radiocarpal arthrosis causing considerably more serious functional invalidity.

SURGICAL TECNIQUE

In our Reconstructive Hand Surgery Center a personal surgical technique has been developed which aims at treating cases at the first and second initial levels of arthrosis of the thumb base, in which there is a subluxation but at the same time, sufficiently well conserved integrity of the articular ends.

Such surgical technique originated from our conviction that the resulting strength produced by the abductor tendon along the thumb at its distal insertion level is the main cause of destabilization of the normal articular relationships between the trapezium and the first metacarpal, thus determining an increase in sliding friction between the surfaces of the joint, which is the first cause of initial degeneration evolving inexorably towards trapezium metacarpal arthrosis. The intervention consists of restoring a harmonic alignment of the articular ends by stabilizing them with a reinforcing capsuloplasty and with the lengthening and repositioning of the abductor tendon along the thumb. After having performed a curvilinear incision at the radial margin of the dorsal base of the thumb and isolating the short extensor tendon, disinsertion of the long abductor tendon follows. Then a capsular quadrangular margin is cut whit the base of the trapezium thus allowing access to the trapezial metacarpal joint. Complete section of the periarticular ligamentous structures is then carried out which, due to their retraction (secondary to the pathology) contributes to the maintenance of the subluxation of the articular ends. In case there are intaarticular osteophytic formation they need to be removed. It is then possible to reduce any articular incongruence (subluxation) and stabilized the obtained reduction by reinserting the articular cap whit “coat” plasty at the base of the first metacarpal using one small anchor. It is thus possible to proceed whit the lengthening (approximately o,5 cm) of the long abductor tendon by means of Z plasty. When this is done distal reinsertion is performed using another small anchor, brought to the third proximal medium of the first metacarpal and centered on itself.

The lengthening of the tendon involves a decrease in the resulting force the tendon exercise on the articular ends, while the distalization of its insertion point and the centering on medium diaphisary axis allow better articular stability to be obtained. The intervention is followed by a period of immobilization in a plaster cast for 25 days corresponding to the time of tendon healing. Whit this work we intended to evaluate the results of trapeziometacarpal arthrotenoplasty on patients affected by rizoarthrosis and treated our operating unit. It seemed to us opportune to carry out a clinical appraisal which would not only comprise objective results but also the subjective judgment of the patients regarding the final result. In our Plastic and Reconstructive Hand Surgery Center we have treated 63 patients whit this kind of surgical intervention since 1998, and thus have had the possibility of a follow up of six years. The number of female patients was far larger than that of the male patients, whit a prevalence of 83%. Mean age was between 46 and 54. Follow up varied from a minimum of three months to a maximum of six years. Patients underwent a regimen of daily hospitalization and on the 25th day, upon removal of the plaster cast, were free to begin the gradual functional recovery on their own without any physiokinetic therapy. Subjective evaluation of the results was carried out by asking patients to express the extent of their satisfaction about the results of the intervention on the following scale: Clinical symptomatology much worse than before the intervention; Clinical symptomatology worse than before the intervention; Unchanged situation; Clinical picture improved whit respect to the preoperative one; Clinical picture much improved whit respect to the pre operative one. Objective evaluations instead comprised long term study of the radiographic picture keeping into account possible worsening whit the appearance of zones of bone rarefaction and geodes. Moreover, preoperative and postoperative strength was studied whit an increase in grip strength considered positive and a reduction in strength deemed negative. All strength measurements were made by means of a analogic dynamometer. Collection of the subjective data showed that three percent of the patients were slightly satisfied whit the results of the intervention, one percent found the situation to be unchanged, 36% considered the obtained results satisfactory and the remaining 60% were very satisfied whit the results. Objectively we found a reasonable improvement in grip endurance and strength in most of the treated patients even if this strength, from subjective point of view, was always considered less than that expected by the patient. However in 33% of the cases radiography showed worsening whit the appearance of zone of bone rarefaction and geodes. The intervention we have developed can certainly be considered as a valid alternative to other surgical techniques already in use for the treatment of trapezio-metacarpal arthrosis. In case of possible failure, this intervention does not exclude the possibility of executing a new intervention using a different surgical technique such as trapeziometacarpal arthrodesis and/or construction of a prosthesis for the articulation of the joint itself. The simplicity of such an intervention and its easy of execution allows the patient to have a postoperative course whit scarce or no pain thus making the intervention possible whit only one day hospitalization.

BIBLIOGRAFIA

Allieu Y. Comunicazione personale
Bedeschi P. – Mele R.
Presentazione di una nuova protesi non cementata per la trapezio-metacarpica. Atti XIV Congresso Nazionale della Società Italiana di Ricerche in Chirurgia della Mano. Monduzzi, Bologna pag.659-651, 1989
Bedeschi P. – Mele R.
Protesi della trapezio-metacarpale. Atti del LXXIX Congresso SIOT, Firenze 1994
Bonola A. – Caroli A. – Celli L.
“La mano” Piccin. Padova
Burton R.I. – Pellegrini V.D.
Surgical management of basal joint of the thum. Ligament reconstruction with tendon interposition arthroplasty. J. Hand Surg. 11A,324,1986
Caffiniére (de la) J.Y.
Replacement de l’articulation trapèzo-mètacarpiennne par une prothése totale articulèe scellèe. Proceedings SICOT 12(2),617,1972
Caffiniére (de la) J.Y.
Prothése totale trapezo-mètacarpienne. Rev. Chir. Orthop. 59,299,1973
Caffiniére (de la) J.Y.
Prothése totale trapèzo-mètacarpienne à dix ans. Acta Orthop. Belg. 51,699,1985
Caroli A. – Celli L. – Galli G.
Aspetti di biomeccanica articolare del primo raggio in relazione alla sostituzione protesica. Riv. Chir. Mano 16,45-52,1979
Clough D.A. – Crouch C.C. – Bennett J.B.
Failure of trapezio-metacarpal arthrodesis with use of the Herbert screw and limited immobilizzazion. J. Hand Surg.15A,706,1990
Cornacchia M.
Considerazioni sulla meccanica articolare del pollice con particolare riguardo alla articolazione trapezio metacarpica. Chi. Org. Mov. 33 (3), 137-153,1949
Dell P.C. - Brushart T.M. – Smith R.J.
Treatment of trapezio-metacarpal arthritis: results of resection arthroplasty. J. Hand Surg.3,243,1978
Duparc J. – Caffiniére (de la) J.Y. – Pineau H.
Approche biomècanique et cotation des mouvements du premier mètacarpien
Eaton R.G.
Replacement of the trapezium for arthritis of the basal articulation. J. Bone Joint Surg. 61A,76,1979
Eaton R.G. – Glickel S.Z. – Littler J.V.
Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb. J. Hand Surg.10A,645,1985
Florack T.M. – Miller R.J. – Pellegrini V.D. – Burton R.I. – Dunn M.G.
The prevalence of carpal tunnel syndrome in patients with basal joint arthritis of the tumb. J. Hand Surg.17A,624,1992
Froimson A.I.
Tendon arthroplasty of the trapezio-metacarpal joint. Clin. Orthop. 70,191,1970
Gervis W.H.
Excision of the trapezium for ostheoarthritis of the trapezio-metacarpal joint. J. Bone Joint Surg.31B,573,1949
Gervis W.H.
A review of excision of trapezium for ostheoarthritis of the trapezio-metacarpal joint after twenty five years. J.Bone Joint Surg. 55B,56,1973
Kapandji I.A.
La rotation du pouce sur son axe longitudinal lorside l’opposition. Rev. Chir. Orthop. 58,273-289,1972
Le Viet D., Kerboull L., Lantieri L.A.,Collins D.E.
Stabilized resection arthroplasty by an anterior approach in trapeziometacarpal arthritis: result and surgical technique. J. Hand Surg. 21A,194,1996
Lins R.E., Gelberman R.H., Mc Keowen L.,Katz J.N., Kadiyala R.K.
Basal joint arthritis trapeziectomy with ligament reconstruction and tendon interposition arthroplasty. J. Hand Surg. 21A,202,1996
Mele R.
Comunicazione alla giornata di studio: “ La rizoartrosi”. Milano Maggio 1996
Melone C., Beavers B., Isdani A.
The basal joint pain syndrome. Clin Orthop. 220,58,1987
Menon J., Shoene H.R., Holt J.C.
Trapezio-metacarpal arthritis: result of tendon interpositional arthroplasty. J. Hand Surg.6,442,1981
Muller G.M.
Arthrodesis of the trapeziometacarpal joint for osteoarthritis. J. Bone Joint Surg. 31B,540,1949
Niebauer J.J., Shaw J.L., Doren W.W.
Silicone – dracon prosthesis for the metacarpophalangeal and interphalangeal joints. Hand 3,55,1971
Smith R.J., Atkinson R.E., Jupiter J.B.
Sylicone synovitis of the wrist. J. Hand Surg. 10A,47,1985
Swanson A.B.
Silicone rubber implants in trapezio-metacarpal joint arthritis. J. Bone Joint Surg.51,799,1969
Swanson A.B.
Disabling arthritis of the base of the thumb. Treatment by resection of the trapezium and flexible implant arthroplasty. J. Bone Joint Surg. 54A,456,1972
Swanson A.B. – Swanson G. – Watermeyer J.B.
Trapezium implant arthroplasty: long term evaluetion of 150 cases. J. Hand Surg. 6,125,1981
Weilby A.
Tendon interposition arthroplasty of the first carpo-metacarpal joint. J. Hand Surg. 31B,421,1988
Worsing R.A., Engber W.D., Lange T.A.
Reactive synovitis from particulate silastic. J. Bone Joint Surg. 65A,581,1982
Zancolli E.A., Aponte Azzarola F., Zancolli E.R.
Arthrosis Trapecio-metacarpiana. Capsuloplastica con estabilizacion metacarpiana activa. Rev. Soc. Argentina de Cirurgia de la Mano 1,13,1981
Zancolli E.A., Ziadenberg C., Zancolli E.R.
Biomechanics of the trapeziometacarpal joint. Clin. Orthop.220,14,1987

 

Home Page