Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery
ISSN: 0284-4311 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs19
Abductor Pollicis Longus Tendon Arthroplasty for Treatment of Arthrosis in the First Carpometacarpal Joint Rikardur Sigfusson & Göran Lundborg To cite this article: Rikardur Sigfusson & Göran Lundborg (1991) Abductor Pollicis Longus Tendon Arthroplasty for Treatment of Arthrosis in the First Carpometacarpal Joint, Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 25:1, 73-77, DOI: 10.3109/02844319109034926 To link to this article: http://dx.doi.org/10.3109/02844319109034926
Published online: 08 Jul 2009.
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Article views: 64
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Citing articles: 7 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs19 Download by: [McMaster University]
Date: 04 May 2016, At: 00:29
Scand J Plast Reconstr Hand Surg 25: 73-77, 1991
ABDUCTOR POLLICIS LONGUS TENDON ARTHROPLASTY FOR TREATMENT OF ARTHROSIS IN THE FIRST CARPOMETACARPAL JOINT Rikardur Sigfusson and Goran Lundborg From the Department of Hand Surgery, Malmii General Hospital, Malmo, Sweden
Downloaded by [McMaster University] at 00:29 04 May 2016
(Submitted for publication July 2, 1990)
Abstract. A retrospective study of 21 hands in 19 patients was carried out to show the results after excision of the 0s trapezium for the treatment of arthrosis of the first carpometacarpal joint. A technically easy procedure was used that was based on a tendon plasty using the abductor pollicis longus (APL) tendon. Special attention was paid to the effects of compressive load on the stability of the thumb. The mean follow-up time was 25 months (range 11-38) and all patients achieved good mobility. Pain was reduced in all cases but one. In operated hands grip strength was 84% of estimated normal strength and pinch strength 83%. On radiographs of the hands the mean distance between the base of the metacarpal bone and the scaphoid bone was 4.6 mm, this was reduced by 1.9 mm during compression. When radiographs were taken during a compressive load, two dislocations of the thumb base were found that had otherwise been missed.
Key words: trapezium excision, tendon interposition arthroplasty, CMC I arthrosis.
Arthrosis of the first carpometacarpal is common among postmenopausal women (3). Several techniques for surgical treatment of advanced cases have been described. Excision of the 0s trapezium was first described by Gervis in 1947 (10). This procedure reduced pain but resulted in an unstable thumb with a consequent reduction in grip and pinch strength (5, 12, 14). Arthrodesis of the first carpometacarpal joint gives a stable painless thumb but at the cost of reduced range of movement ( 1 , 6, 8, 12, 13, 15). This procedure can, however, be used only when there is an isolated arthrosis of the first carpometacarpal joint. In 1968 Swanson introduced a silicone prosthesis for replacement of the trapezium (2, 7, 19). Good functional and subjective results have been reported as regards pain, and grip and pinch strength. Disolation, subluxation, and breakage of the prosthesis are common and recently the incidence of
disseminated “silicone synovitis” (caused by silicone particles from the prostheses) has become of increasing concern (18). In 1970 Froimson introduced tendon interposition arthroplasty as an alternative to prosthesis (9). He made a roll of the flexor carpi radialis (FCR) tendon to fill out the defect after excision of the 0s trapezium, but in some cases this resulted in instability of the base of the thumb. To avoid this complication Weilby 1979 (17, 22, 23) coiled the FCR tendon strip around the abductor pollicis (APL) tendon (Fig. I). The extensor carpi radialis longus (ECRL) plasty described by Necking et al. (16) was devised to achieve a dorsal as well as a volar anchorage of the base of the thumb (Fig. 1). The present paper describes the clinical results of a tendon arthroplasty using the APL tendon. Special attention has been paid to the stability of the arthroplasty, particularly to the radiographic appearance during compressive load. SURGICAL TECHNIQUE A longitudinal curved dorsoradial incision over the trapezium is made. Care is taken not to damage the branches of the radial nerve and the radial artery that cross the trapezium. A distally based fascia-capsule flap is raised to expose the first carpometacarpal joint. The trapezium is excised in pieces or en bloc, care being taken to avoid damage to the FCR tendon situated on the volar aspect. A distally based strip of the most radial part of the APL tendon 6-7 crn long is prepared. If there are three APL tendons the most radial one should be used; if there are two, half of the radial one. The strip is inserted through the radial part of the capsule and then through a cut in the FCR tendon (Fig. 2). The strip is then pulled up and around one of the remaining parts of the APL tendon, twisting the FCR and APL tendons together. If the strip is long enough this figure of eight may be repeated. In this way base of the first metacarpal bone is secured on the volar and ulnar aspects. The length of the remaining APL Srriird
J Plnst Reconsrr H m d Siirg 25
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R . Sigfusson and G . Lundborg
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pain, and with strength >80% of the contralateral hand; “good” if subjectively satisfied and with pain only during heavy work; and “poor” if they had pain at rest or during ADL function, as well as if they were dissatisfied. Motion Volar and radial abduction was measured as well as opposition. Volar abduction range was 40-58”, mean 45”, and radial abduction range was 32-50”. mean 40.6”. Notmal volar and radial abduction reported in an unselected material was 3&70” and 30-65”, respectively (13). Eighteen cases could reach the fifth metacarpophalangeal joint, and three the proximal phalanx of the little finger. All but one were pleased with their range of motion, and none had noticed shortening of the operated thumb.
Fig. 1 . Diagram showing the basic concept behind the
stabilising tendon arthroplasty. APL = abductor pollicis longus, FCR = flexor carpi radialis, ECRL = extensor carpi radialis longus, PL = palmaris longus, I = metacarpale I, I1 = metacarpale 11.
tendon as well as the extensor pollicis brevis (EPB) tendon can be adjusted if needed. The hand should be immobilised in plaster for 4-5 weeks after operation.
Strength Grip strength was measured by a Martin vigorimeter and key pinch with a Mannerfelt intrinsicmeter. Grip strength range was 0.20-0.98 kp/cm2(1 kp/cm2=98.1 kPa), mean 0.57 kp/cm2. Normal grip for an age and sex matched control population is 0.68 kp/cm2 (21). The pinch strength range was 110-310 units, mean 185 units. One hundred units corresponds to 23 N and normal pinch for sex and age matched population is 223 units (4). The results expressed as a pecentage of the unoperated hand are presented in Table I. One patient was excluded
MATERIAL During a 27-month period 1985-1987 22 APL tendon interposition arthroplasties were carried out on 3 men and 17 women, mean age 64 years (range 51-78) with arthrosis of the first carpometacarpal joint. Seventeen patients also had arthrosis of the scaphotrapezial joint, four of these having arthrosis in the scaphotrapezoid joint. Two patients had both hands operated on. The indications for surgery were pain and problems with normal activities of daily living (ADL) in spite of conservative treatment. Ten patients had adduction contractures, in six combined with hyperextension of the first rnetacarpophalangeal joint. One man with isolated arthrosis of the first carpometacarpal joint w a s lost to follow-up, so 21 have been reviewed.
RESULTS The mean postoperative follow-up time was 25 months (range 11-38). Special attention was paid to range of motion, strength, radiographic findings especially under load, amount of sick leave and the patients’ subjective opinion. Patients were classitied as: “excellent” if subjectively pleased, without Scand J Plast Reconslr H a n d Surg 25
Fig. 2. Volar aspect of the carpus after APL tendon arthroplast y.
Abductor pollicis longus tendon arthroplasty
75
Downloaded by [McMaster University] at 00:29 04 May 2016
nant hand was operated on, grip strength was 94%, and pinch 72% of the contralateral hand. In the operated hands the grip strength was 84% and pinch strength was 83% of the estimated normal strength (4, 21). Radiographic findings All patients had radiographs taken with and without a compressive load (maximal pinch during exposure) at the time of follow-up. Standard lateral and anteroposterior exposures were made with the hand pronated (Fig. 3). The mean distance between the first metacarpal bone and the scaphoid bone was 4.6 mm (range 2-8). The normal distance is 1CL15 mm (16). With a compressive load the mean distance was reduced to 2.7 mm (range &8), the mean reduction being 1.9 mm (range 0-4).In two cases there was a total dislocation of the base of the thumb that became apparently only during the compressive load. These two patients had pain while carrying out their normal activities. Otherwise there was no correlation between the distance measured on the radiograph and subjective results.
Fig. 3. Radiographs of a patient 27 months after operation
with
( N ) and
without ( b )compressive load.
because of a painful arthrosis in the nonoperated hand. When the dominant hand was operated on, the mean grip strength was 97% and pinch strength 92% of the contralateral hand. When the non-domi-
Sick-leave Mean length of sick-leave Was 15 Weeks among those eight patients that returned to work. Four had taken early retirement or are still on sick-leave, and seven had retired before the operation. Patient's opinion Pain was improved in all cases but one. Eight cases had complete pain relief, 10 still had pain during
Table I. Measured strength in operated hands, also shown as percentage of nonoperated hands
Mean pinch strength (units) Range Mean grip strength (kp/cm2) Range
Dominant
Nondominant
(n=12)
(n=9)
Estimated normal measurement in dominant hand (4, 21)
198 110-310
I68 110-250
228 221-300
214 177-293
92 44-121"
72 39-100
185 110-310
0.58
0.57 0.3-0.85
0.69 0.55-0.78
0.68 0.53-0.78
97 56-1 66"
94 63-125
0.57 0.2-0.90
O.Z(M.90
Estimated normal measurement in non-dominant hand (4, 21)
Dominant measured as percentage of contralateral hand
Non-dominant measured as percentage of contralateral hand
Total
One patient is excluded. Sccind J Plus: Rcconstr Hand Surg 25
76
R . Sigfusson and G . Lundborg
Downloaded by [McMaster University] at 00:29 04 May 2016
heavy work, two during their normal activities and one had pain at rest. Two patients were not satisfied, three were satisfied and the remaining 14 were pleased. One patient had local tenderness over the FCR tunnel. No patient with excellent (8 cases) or good (10 cases) results after 6 months has become worse during the period of follow-up time. Three cases were considered to be poor results or failures. Complications There were no hand syndrome or infections. One patient had resistant local tenderness and pain over the FCR tendon, and this was released 9 months after the operation. Pain was relieved but the local tenderness remained. Two patients were considered to have ruptured the FCR anchorage as they were unstable both radiographically and clinically.
DISCUSSION We have described a technically easy tendon interposition arthroplasty based on the APL tendon. In accordance with other reports on tendon arthroplasties (9, 12, 16, 17, 18, 22) a good range of motion was achieved in all patients. The shortening of the thumb resulting from the excision of the 0s trapezium helps to correct the preoperative adduction contracture that was apparent in 10 hands. Before operation six patients had hyperextension in the first metacarpophalangeal joint. Only one case required temporary transfixation of the joint in flexion at operation. After operation there was spontaneous recovery of the hyperextension in the remaining cases and no case had hyperextension of more than 20" at follow-up. Pinch strength (4.3 kg) fell within the same range as that reported for patients after silicone arthroplasty of the same joint (2, 1 1 , 18, 20). In the present study both grip and pinch were compared with the contralateral hand (see Table I). The dates given should be noted in view of the fact that these patients often have bilateral disease. Special attention was paid to the radiographic findings. It was clear that radiography with a compressive load is a useful procedure in evaluating these patients. The two dislocations that we found would have been missed if the investigation had not included compressive load. In all cases there was a considerable shortening of the thumb but only one patient achieved bony contact during compression. In most cases the compression resulted in only Scund J flust Rcconsrr Hond SitrR 25
minimal additional shortening. Apparently the tendon plasty is strong enough to give sufficient stability and spacer effect. The aim of the operation is primarily to relieve pain and in three cases (14%) this was not effective. This is in accordance with some other reports on the use of Weilby's tendon interposition plasty (2, 9, 16) although Weilby has reported better results (23). Reports on the use of a Swanson prosthesis have shown better results, over 90% of those patients being considered as good or excellent (2, 18, 19). With the use of a tendon interposition arthroplasty, however, long term complications such as dislocation, wearing out of the silicone prosthesis, and silicone synovitis are avoided. Six cases of arthrosis in the scaphotrapezoid joint were found. The mean pinch strength in this group was 167 units = 3.85 kg or 70.6% of the estimated normal 237 units or 5.45 kg. In this group only one patient became free of pain, three had pain during heavy work, and two had pain all the time. This group included the only patient with local tenderness. Arthrosis in the scaphotrapezoid joint could explain why the clinical results in this subgroup were not as good as the rest. REFERENCES I . Alberts KA, Engkvist 0 . Arthrodesis of the first carpometacarpal joint. 33 cases of arthrosis. Acta Orthop Scand 1989; 60 (3): 258-260. 2. Amadio PC, Millner LH, Smith RJ. Silicone spacer or tendon spacer for trapezium resection arthroplasty. Comparison of results. J Hand Surg 1982; 7: 237-244. 3 . Aune S. Osteo-arthritis in the first carpo-metacarpal joint. An investigation of 22 cases. Acta Chir Scand 1955; 109: 6: 447456. 4. Brorson H, Werner CO, Thorngren KG. Normal pinch strength. Acta Orthop Scand 1989; 60 ( I ) : 6668. 5 . Dell PC, Brushart TM, Smith RJ. Treatment of trapeziornetacarpal arthritis: Results of resection arthroplasty. J Hand Surg 1987; 3 : 243-249. 6. Eaton RG, Littler JW. A study of the basal joint of the thumb. J Bone Joint Surg 1969; 51-A: 4: 661-668. 7. Eiken 0. Prosthetic replacement of the trapezium. Technical aspects. Scand J Plast Reconstr Surg 1971; 5: 131-135. 8. Eiken 0 , Carstam N . Functional assessment of basal joint fusion of the thumb. Scand J Plast Reconstr Surg 1970; 4: 122-125. 9. Froimson AI. Tendon arthroplasty of the trapeziometacarpal joint. Clin Orthop 1970; 70: 191-199. 10. Gervis WH. Excision of the trapezium for esteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg 1949; 31B 4: 537-539.
Downloaded by [McMaster University] at 00:29 04 May 2016
Abductor pollicis longus tendon arthroplasty I I . Haffajee D. Endoprosthetic replacement of the trapezium for arthrosis in the carpometacarpal joint of the thumb. J Hand Surg 1977; 2: 3: 141-148. 12. Kvarnes L, Reikerds 0. Osteoarthritis of the carpometacarpal joint of the thumb. An analysis of operative procedures. J Bone Joint Surg 1985; IOB: 1 : 117-1 19. 13. Lech RE, Bolton PE. Arthritis of the carpometacarpaljoint of the thumb. J Bone Joint Surg 1968; 50A: 6: 1171-1 177. 14. Murley AGH. Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint. J Bone Joint Surg 1960: 42B: 3: 502-507. 15. Miiller GM. Arthrodesis of the trapezio-metacarpal joint for osteoarthritis. J Bone Joint Surg 1949; 31B: 4: 54C-542. 16. Necking LE. Eiken 0. ECRL-strip plasty for metacarpal base fixation after excision of the trapezium. Scand J Plast Reconstr Surg 1986; 20: 229-234. 17. Nylen S . Juhlin LJ. Lugneglird H. Weilby tendon
18.
19.
20. 21. 22. 23.
77
interposition arthroplasty for osteoarthritis of the trapezialjoint. J Hand Surg 1987; 12B: I : 68-72. Pellegrini V, Burton R. Surgical management of basal joint arthritis of the thumb. Part I. Long term results of silicone implant arthroplasty. J Hand Surg 1986; I1A: 3: 309-332. Sollerrnan C, Herrelin K, Abrahamsson SO, Lindholm A. Silastic replacement of the trapezium for arthrosis-a twelve year follow-up study. J Hand Surg 1988; 13B: 4: 4 2 6 4 2 9 . Swanson AB. Disabling arthritis at the base of the thumb. J Bone Joint Surg 1972; 54A: 3: 456-471. Thorngren KG, Werner CO. Normal grip strength. Acta Orthop Scand 1979; 50: 3: 255-256. Weilby A. Resection of the first carpometacarpal joint. J Hand Surg 1979; 4: 6: 586. Weilby A. Tendon interposition arthroplasty of the first carpometacarpal joint. J Hand Surg 1988; 13B: 4: 42 1-425.
ISSN: 0284-4311 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs19
Abductor Pollicis Longus Tendon Arthroplasty for Treatment of Arthrosis in the First Carpometacarpal Joint Rikardur Sigfusson & Göran Lundborg To cite this article: Rikardur Sigfusson & Göran Lundborg (1991) Abductor Pollicis Longus Tendon Arthroplasty for Treatment of Arthrosis in the First Carpometacarpal Joint, Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 25:1, 73-77, DOI: 10.3109/02844319109034926 To link to this article: http://dx.doi.org/10.3109/02844319109034926
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 64
View related articles
Citing articles: 7 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs19 Download by: [McMaster University]
Date: 04 May 2016, At: 00:29
Scand J Plast Reconstr Hand Surg 25: 73-77, 1991
ABDUCTOR POLLICIS LONGUS TENDON ARTHROPLASTY FOR TREATMENT OF ARTHROSIS IN THE FIRST CARPOMETACARPAL JOINT Rikardur Sigfusson and Goran Lundborg From the Department of Hand Surgery, Malmii General Hospital, Malmo, Sweden
Downloaded by [McMaster University] at 00:29 04 May 2016
(Submitted for publication July 2, 1990)
Abstract. A retrospective study of 21 hands in 19 patients was carried out to show the results after excision of the 0s trapezium for the treatment of arthrosis of the first carpometacarpal joint. A technically easy procedure was used that was based on a tendon plasty using the abductor pollicis longus (APL) tendon. Special attention was paid to the effects of compressive load on the stability of the thumb. The mean follow-up time was 25 months (range 11-38) and all patients achieved good mobility. Pain was reduced in all cases but one. In operated hands grip strength was 84% of estimated normal strength and pinch strength 83%. On radiographs of the hands the mean distance between the base of the metacarpal bone and the scaphoid bone was 4.6 mm, this was reduced by 1.9 mm during compression. When radiographs were taken during a compressive load, two dislocations of the thumb base were found that had otherwise been missed.
Key words: trapezium excision, tendon interposition arthroplasty, CMC I arthrosis.
Arthrosis of the first carpometacarpal is common among postmenopausal women (3). Several techniques for surgical treatment of advanced cases have been described. Excision of the 0s trapezium was first described by Gervis in 1947 (10). This procedure reduced pain but resulted in an unstable thumb with a consequent reduction in grip and pinch strength (5, 12, 14). Arthrodesis of the first carpometacarpal joint gives a stable painless thumb but at the cost of reduced range of movement ( 1 , 6, 8, 12, 13, 15). This procedure can, however, be used only when there is an isolated arthrosis of the first carpometacarpal joint. In 1968 Swanson introduced a silicone prosthesis for replacement of the trapezium (2, 7, 19). Good functional and subjective results have been reported as regards pain, and grip and pinch strength. Disolation, subluxation, and breakage of the prosthesis are common and recently the incidence of
disseminated “silicone synovitis” (caused by silicone particles from the prostheses) has become of increasing concern (18). In 1970 Froimson introduced tendon interposition arthroplasty as an alternative to prosthesis (9). He made a roll of the flexor carpi radialis (FCR) tendon to fill out the defect after excision of the 0s trapezium, but in some cases this resulted in instability of the base of the thumb. To avoid this complication Weilby 1979 (17, 22, 23) coiled the FCR tendon strip around the abductor pollicis (APL) tendon (Fig. I). The extensor carpi radialis longus (ECRL) plasty described by Necking et al. (16) was devised to achieve a dorsal as well as a volar anchorage of the base of the thumb (Fig. 1). The present paper describes the clinical results of a tendon arthroplasty using the APL tendon. Special attention has been paid to the stability of the arthroplasty, particularly to the radiographic appearance during compressive load. SURGICAL TECHNIQUE A longitudinal curved dorsoradial incision over the trapezium is made. Care is taken not to damage the branches of the radial nerve and the radial artery that cross the trapezium. A distally based fascia-capsule flap is raised to expose the first carpometacarpal joint. The trapezium is excised in pieces or en bloc, care being taken to avoid damage to the FCR tendon situated on the volar aspect. A distally based strip of the most radial part of the APL tendon 6-7 crn long is prepared. If there are three APL tendons the most radial one should be used; if there are two, half of the radial one. The strip is inserted through the radial part of the capsule and then through a cut in the FCR tendon (Fig. 2). The strip is then pulled up and around one of the remaining parts of the APL tendon, twisting the FCR and APL tendons together. If the strip is long enough this figure of eight may be repeated. In this way base of the first metacarpal bone is secured on the volar and ulnar aspects. The length of the remaining APL Srriird
J Plnst Reconsrr H m d Siirg 25
74
R . Sigfusson and G . Lundborg
Downloaded by [McMaster University] at 00:29 04 May 2016
pain, and with strength >80% of the contralateral hand; “good” if subjectively satisfied and with pain only during heavy work; and “poor” if they had pain at rest or during ADL function, as well as if they were dissatisfied. Motion Volar and radial abduction was measured as well as opposition. Volar abduction range was 40-58”, mean 45”, and radial abduction range was 32-50”. mean 40.6”. Notmal volar and radial abduction reported in an unselected material was 3&70” and 30-65”, respectively (13). Eighteen cases could reach the fifth metacarpophalangeal joint, and three the proximal phalanx of the little finger. All but one were pleased with their range of motion, and none had noticed shortening of the operated thumb.
Fig. 1 . Diagram showing the basic concept behind the
stabilising tendon arthroplasty. APL = abductor pollicis longus, FCR = flexor carpi radialis, ECRL = extensor carpi radialis longus, PL = palmaris longus, I = metacarpale I, I1 = metacarpale 11.
tendon as well as the extensor pollicis brevis (EPB) tendon can be adjusted if needed. The hand should be immobilised in plaster for 4-5 weeks after operation.
Strength Grip strength was measured by a Martin vigorimeter and key pinch with a Mannerfelt intrinsicmeter. Grip strength range was 0.20-0.98 kp/cm2(1 kp/cm2=98.1 kPa), mean 0.57 kp/cm2. Normal grip for an age and sex matched control population is 0.68 kp/cm2 (21). The pinch strength range was 110-310 units, mean 185 units. One hundred units corresponds to 23 N and normal pinch for sex and age matched population is 223 units (4). The results expressed as a pecentage of the unoperated hand are presented in Table I. One patient was excluded
MATERIAL During a 27-month period 1985-1987 22 APL tendon interposition arthroplasties were carried out on 3 men and 17 women, mean age 64 years (range 51-78) with arthrosis of the first carpometacarpal joint. Seventeen patients also had arthrosis of the scaphotrapezial joint, four of these having arthrosis in the scaphotrapezoid joint. Two patients had both hands operated on. The indications for surgery were pain and problems with normal activities of daily living (ADL) in spite of conservative treatment. Ten patients had adduction contractures, in six combined with hyperextension of the first rnetacarpophalangeal joint. One man with isolated arthrosis of the first carpometacarpal joint w a s lost to follow-up, so 21 have been reviewed.
RESULTS The mean postoperative follow-up time was 25 months (range 11-38). Special attention was paid to range of motion, strength, radiographic findings especially under load, amount of sick leave and the patients’ subjective opinion. Patients were classitied as: “excellent” if subjectively pleased, without Scand J Plast Reconslr H a n d Surg 25
Fig. 2. Volar aspect of the carpus after APL tendon arthroplast y.
Abductor pollicis longus tendon arthroplasty
75
Downloaded by [McMaster University] at 00:29 04 May 2016
nant hand was operated on, grip strength was 94%, and pinch 72% of the contralateral hand. In the operated hands the grip strength was 84% and pinch strength was 83% of the estimated normal strength (4, 21). Radiographic findings All patients had radiographs taken with and without a compressive load (maximal pinch during exposure) at the time of follow-up. Standard lateral and anteroposterior exposures were made with the hand pronated (Fig. 3). The mean distance between the first metacarpal bone and the scaphoid bone was 4.6 mm (range 2-8). The normal distance is 1CL15 mm (16). With a compressive load the mean distance was reduced to 2.7 mm (range &8), the mean reduction being 1.9 mm (range 0-4).In two cases there was a total dislocation of the base of the thumb that became apparently only during the compressive load. These two patients had pain while carrying out their normal activities. Otherwise there was no correlation between the distance measured on the radiograph and subjective results.
Fig. 3. Radiographs of a patient 27 months after operation
with
( N ) and
without ( b )compressive load.
because of a painful arthrosis in the nonoperated hand. When the dominant hand was operated on, the mean grip strength was 97% and pinch strength 92% of the contralateral hand. When the non-domi-
Sick-leave Mean length of sick-leave Was 15 Weeks among those eight patients that returned to work. Four had taken early retirement or are still on sick-leave, and seven had retired before the operation. Patient's opinion Pain was improved in all cases but one. Eight cases had complete pain relief, 10 still had pain during
Table I. Measured strength in operated hands, also shown as percentage of nonoperated hands
Mean pinch strength (units) Range Mean grip strength (kp/cm2) Range
Dominant
Nondominant
(n=12)
(n=9)
Estimated normal measurement in dominant hand (4, 21)
198 110-310
I68 110-250
228 221-300
214 177-293
92 44-121"
72 39-100
185 110-310
0.58
0.57 0.3-0.85
0.69 0.55-0.78
0.68 0.53-0.78
97 56-1 66"
94 63-125
0.57 0.2-0.90
O.Z(M.90
Estimated normal measurement in non-dominant hand (4, 21)
Dominant measured as percentage of contralateral hand
Non-dominant measured as percentage of contralateral hand
Total
One patient is excluded. Sccind J Plus: Rcconstr Hand Surg 25
76
R . Sigfusson and G . Lundborg
Downloaded by [McMaster University] at 00:29 04 May 2016
heavy work, two during their normal activities and one had pain at rest. Two patients were not satisfied, three were satisfied and the remaining 14 were pleased. One patient had local tenderness over the FCR tunnel. No patient with excellent (8 cases) or good (10 cases) results after 6 months has become worse during the period of follow-up time. Three cases were considered to be poor results or failures. Complications There were no hand syndrome or infections. One patient had resistant local tenderness and pain over the FCR tendon, and this was released 9 months after the operation. Pain was relieved but the local tenderness remained. Two patients were considered to have ruptured the FCR anchorage as they were unstable both radiographically and clinically.
DISCUSSION We have described a technically easy tendon interposition arthroplasty based on the APL tendon. In accordance with other reports on tendon arthroplasties (9, 12, 16, 17, 18, 22) a good range of motion was achieved in all patients. The shortening of the thumb resulting from the excision of the 0s trapezium helps to correct the preoperative adduction contracture that was apparent in 10 hands. Before operation six patients had hyperextension in the first metacarpophalangeal joint. Only one case required temporary transfixation of the joint in flexion at operation. After operation there was spontaneous recovery of the hyperextension in the remaining cases and no case had hyperextension of more than 20" at follow-up. Pinch strength (4.3 kg) fell within the same range as that reported for patients after silicone arthroplasty of the same joint (2, 1 1 , 18, 20). In the present study both grip and pinch were compared with the contralateral hand (see Table I). The dates given should be noted in view of the fact that these patients often have bilateral disease. Special attention was paid to the radiographic findings. It was clear that radiography with a compressive load is a useful procedure in evaluating these patients. The two dislocations that we found would have been missed if the investigation had not included compressive load. In all cases there was a considerable shortening of the thumb but only one patient achieved bony contact during compression. In most cases the compression resulted in only Scund J flust Rcconsrr Hond SitrR 25
minimal additional shortening. Apparently the tendon plasty is strong enough to give sufficient stability and spacer effect. The aim of the operation is primarily to relieve pain and in three cases (14%) this was not effective. This is in accordance with some other reports on the use of Weilby's tendon interposition plasty (2, 9, 16) although Weilby has reported better results (23). Reports on the use of a Swanson prosthesis have shown better results, over 90% of those patients being considered as good or excellent (2, 18, 19). With the use of a tendon interposition arthroplasty, however, long term complications such as dislocation, wearing out of the silicone prosthesis, and silicone synovitis are avoided. Six cases of arthrosis in the scaphotrapezoid joint were found. The mean pinch strength in this group was 167 units = 3.85 kg or 70.6% of the estimated normal 237 units or 5.45 kg. In this group only one patient became free of pain, three had pain during heavy work, and two had pain all the time. This group included the only patient with local tenderness. Arthrosis in the scaphotrapezoid joint could explain why the clinical results in this subgroup were not as good as the rest. REFERENCES I . Alberts KA, Engkvist 0 . Arthrodesis of the first carpometacarpal joint. 33 cases of arthrosis. Acta Orthop Scand 1989; 60 (3): 258-260. 2. Amadio PC, Millner LH, Smith RJ. Silicone spacer or tendon spacer for trapezium resection arthroplasty. Comparison of results. J Hand Surg 1982; 7: 237-244. 3 . Aune S. Osteo-arthritis in the first carpo-metacarpal joint. An investigation of 22 cases. Acta Chir Scand 1955; 109: 6: 447456. 4. Brorson H, Werner CO, Thorngren KG. Normal pinch strength. Acta Orthop Scand 1989; 60 ( I ) : 6668. 5 . Dell PC, Brushart TM, Smith RJ. Treatment of trapeziornetacarpal arthritis: Results of resection arthroplasty. J Hand Surg 1987; 3 : 243-249. 6. Eaton RG, Littler JW. A study of the basal joint of the thumb. J Bone Joint Surg 1969; 51-A: 4: 661-668. 7. Eiken 0. Prosthetic replacement of the trapezium. Technical aspects. Scand J Plast Reconstr Surg 1971; 5: 131-135. 8. Eiken 0 , Carstam N . Functional assessment of basal joint fusion of the thumb. Scand J Plast Reconstr Surg 1970; 4: 122-125. 9. Froimson AI. Tendon arthroplasty of the trapeziometacarpal joint. Clin Orthop 1970; 70: 191-199. 10. Gervis WH. Excision of the trapezium for esteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg 1949; 31B 4: 537-539.
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Abductor pollicis longus tendon arthroplasty I I . Haffajee D. Endoprosthetic replacement of the trapezium for arthrosis in the carpometacarpal joint of the thumb. J Hand Surg 1977; 2: 3: 141-148. 12. Kvarnes L, Reikerds 0. Osteoarthritis of the carpometacarpal joint of the thumb. An analysis of operative procedures. J Bone Joint Surg 1985; IOB: 1 : 117-1 19. 13. Lech RE, Bolton PE. Arthritis of the carpometacarpaljoint of the thumb. J Bone Joint Surg 1968; 50A: 6: 1171-1 177. 14. Murley AGH. Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint. J Bone Joint Surg 1960: 42B: 3: 502-507. 15. Miiller GM. Arthrodesis of the trapezio-metacarpal joint for osteoarthritis. J Bone Joint Surg 1949; 31B: 4: 54C-542. 16. Necking LE. Eiken 0. ECRL-strip plasty for metacarpal base fixation after excision of the trapezium. Scand J Plast Reconstr Surg 1986; 20: 229-234. 17. Nylen S . Juhlin LJ. Lugneglird H. Weilby tendon
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interposition arthroplasty for osteoarthritis of the trapezialjoint. J Hand Surg 1987; 12B: I : 68-72. Pellegrini V, Burton R. Surgical management of basal joint arthritis of the thumb. Part I. Long term results of silicone implant arthroplasty. J Hand Surg 1986; I1A: 3: 309-332. Sollerrnan C, Herrelin K, Abrahamsson SO, Lindholm A. Silastic replacement of the trapezium for arthrosis-a twelve year follow-up study. J Hand Surg 1988; 13B: 4: 4 2 6 4 2 9 . Swanson AB. Disabling arthritis at the base of the thumb. J Bone Joint Surg 1972; 54A: 3: 456-471. Thorngren KG, Werner CO. Normal grip strength. Acta Orthop Scand 1979; 50: 3: 255-256. Weilby A. Resection of the first carpometacarpal joint. J Hand Surg 1979; 4: 6: 586. Weilby A. Tendon interposition arthroplasty of the first carpometacarpal joint. J Hand Surg 1988; 13B: 4: 42 1-425.
