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ScienceDirect www.sciencedirect.com Chirurgie de la main 33 (2014) 118–123

Original article

Anatomical study of the ligamentous attachments and articular surfaces of the trapeziometacarpal joint. Consequences on surgical management of its osteoarthrosis Étude anatomique des insertions ligamentaires et surfaces articulaires de l’articulation trapézo-métacarpienne. Conséquence sur le traitement chirurgical de son arthrose C. Maes-Clavier a,*, P. Bellemère b, A. Gabrion a, E. David a, V. Rotari a, E. Havet a a

Service de chirurgie orthopédique et traumatologie, CHU d’Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France b Nantes assistance main, clinique Jeanne-d’Arc, 21, rue des Martyrs, 44100 Nantes, France Received 20 July 2013; received in revised form 15 December 2013; accepted 21 December 2013 Available online 4 February 2014

Abstract In the goal to optimize conservative surgical techniques of the trapeziometacarpal joint in cases of moderate osteoarthritis, we have defined the relationships between the ligamentous attachments and the articular surfaces onto the trapezium and the first metacarpal bone on the one hand, and the dorsovolar and the transverse diameters of the articular surfaces on the other hand. Thirty-six trapeziometacarpal joints (from 18 fresh cadavers) were studied. They were separated into two groups depending on the macroscopic assessment of chondral disease. Group A included stages I to III (no osteoarthritis or moderate osteoarthritis), group B included stages IV (major cartilage destruction). The dorsovolar and transverse sizes of the articular surfaces were measured. Dorsoradial ligament (DRL), posterior oblique ligament (POL), intermetacarpal ligament (IML), ulnar collateral ligament (UCL) and anterior oblique ligament (AOL) were dissected and the distance between their attachments and the articular surfaces were measured. Group A included 17 joints (71% males) and group B included 19 joints (95% females). For the first metacarpal bone, the average ratio between the dorsovolar diameter and the transverse diameter of metacarpal articular surfaces was significantly higher in group B and the average distance between the ligamentous attachments and the articular surface was more than two millimeters, except for the DRL in group B. For the trapezium, only the posterior ligaments (DRL and POL) of group A were inserted at a mean distance more than two millimeters from the articular surfaces. Dorsovolar length of the metacarpal articular surface was higher for osteoarthritis cases. This difference can be explained by the existence of a palmar osteophyte that was always found in stage IV. Describing a map of the ligamentous attachment distance from the articular surface could help surgeons to avoid the ligamentous injury during minimal osteochondral resection. # 2014 Elsevier Masson SAS. All rights reserved. Keywords: Articular surface; Ligamentous attachment; Thumb CMC osteoarthritis; Trapeziometacarpal joint; Mini-invasive surgery

Résumé Dans le but d’optimiser les techniques chirurgicales conservatrices de l’articulation trapézo-métacarpienne en cas de rhizarthrose débutante, nous avons étudié la distance d’insertion des ligaments trapézo-métacarpiens par rapport aux surfaces articulaires et les dimensions dorsopalmaires et transversales des surfaces articulaires. Trente-six articulations trapézo-métacarpiennes (18 cadavres frais) ont été étudiées. Elles ont été séparées en deux groupes selon le stade visuel de dégénérescence articulaire. Le groupe A comprenait les stades I à III (absence d’arthrose à arthrose modérée), le groupe B les stades IV (destruction cartilagineuse majeure). Les dimensions dorso-palmaires et transversales des surfaces articulaires ont été mesurées. Les ligaments dorso-radial (DRL), postérieur oblique (POL), intermétacarpien (IML), collatéral ulnaire (UCL) et antérieur oblique (AOL) ont été disséqués et la distance séparant leurs insertions des surfaces articulaires ont été mesurées. Le groupe A incluait 17 articulations (71 % masculines). Le groupe B incluait 19 articulations (95 % féminines). Pour le premier métacarpien, le rapport moyen entre le diamètre dorso-palmaire et le diamètre transversal des surfaces articulaires métacarpiennes était significativement plus élevé dans le groupe B et les

* Auteur correspondant. E-mail address: [email protected] (C. Maes-Clavier). 1297-3203/$ – see front matter # 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.main.2013.12.004

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insertions ligamentaires étaient en moyenne situées à plus de deux millimètres de la surface articulaire, sauf pour le DRL dans le groupe B. Pour le trapèze, seuls les ligaments postérieurs (DRL et POL) du groupe A étaient en moyenne insérés à plus de deux millimètres des surfaces articulaires. Le diamètre dorso-palmaire de la surface articulaire métacarpienne était plus important en cas d’arthrose. Cette différence peut être expliquée par la formation d’un ostéophyte palmaire souvent trouvé dans les stades IV. La cartographie des distances d’insertion des ligaments par rapport aux surfaces articulaires peut permettre de diminuer le risque de lésion ligamentaire en cas de résection ostéo-cartilagineuse a minima. # 2014 Elsevier Masson SAS. Tous droits réservés. Mots clés : Surfaces articulaires ; Insertions ligamentaires ; Rhizarthrose ; Articulation trapézo-métacarpienne ; Chirurgie mini-invasive

1. Introduction Many surgical procedures have been proposed to treat thumb carpometacarpal osteoarthritis following failure of the medical treatment. The current evolution of surgical procedures is emphasizing the development of conservative techniques as arthroscopy [1–3], partial trapeziectomy with or without interposition [3–7] and resurfacing [8–10]. The trapeziometacarpal ligaments and the articular capsule must be respected during all of these procedures. Trapeziometacarpal ligaments contribute to the stability of the first column. Their mechanical function is required for a harmonious and powerful motion of opposition. The shape of the articular surfaces and its evolution during osteoarthritis must also be considered for appropriate bone cutting or for the development of anatomical implants. To increase the reliability of osteochondral resections performed during these procedures, we would focus on the relative evolution over time of the articular surfaces of the trapezium and the metacarpal with osteoarthritis. We studied the dorsovolar and transverse sizes of the articular surfaces according to the degree of osteoarthritis. We would also know the possibility to define a safe level of bone cut to preserve the trapeziometacarpal ligaments. We also measured the trapeziometacarpal ligamentous attachments distance relative to the borders of the articular surfaces.

ligament (DRL), the posterior oblique ligament (POL), the ulnar collateral ligament (UCL), the anterior oblique ligament (AOL) and the intermetacarpal ligament (IML) (Figs. 1 and 2). The description of these ligaments by Bettinger et al. [11] and the three-dimensional analysis of the ligamentous attachments performed by Nanno et al. [12] were chosen as reference. Each joint was visually staged according the scale of osteoarthritis described by the Department of Biomedical Engineering at the University of Colombia [13,14] (Table 1, Koff et al.). This visual staging system was used because it has local greater sensitivity to degenerative changes than

2. Materials and method This descriptive study involved anatomical materials. It was conducted in the Laboratory of Anatomy, Medical University of Amiens, France, according the French legislation. Then, no ethical approval was required. Thirty-six trapeziometacarpal joints from 18 fresh-frozen human cadavers were included. The age of the cadavers was unknown. The procedure was similar for all cases. Amputation through the second intermetacarpal space was performed, extended in the capitotrapeziod joint then in scapholunate joint and radioscaphoid joint. It allowed the sampling block of the first and second metacarpals, the trapezium, trapezoid and the scaphoid bones. The trapezoid and scaphoid were then separated from the trapeze. The first and second rays were amputated in the middle of the metacarpal diaphysis. After removal of the skin, the thenar muscles were excised, taking care to respect the capsule and ligaments of the trapeziometacarpal joint with a loupe magnification of 3.5 times. Each trapeziometacarpal ligament was found and then dissected and photographed. Ligaments studied were: the dorsoradial

Fig. 1. Anterior view of a left trapeziometacarpal joint. 1: trapezium; 2: abductor pollicis longus; 3: volar osteophyte; 4: anterior oblique ligament; 5: 2nd metacarpal; 6: flexor carpi radialis; 7: ulnar collateral ligament; 8: intermetacarpal ligament; 9: thumb metacarpal.

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Table 2 Characteristics of the two groups.

Definition

Number of cases Stages

Gender

Fig. 2. Dorsal view of a left trapeziometacarpal joint. 1: trapezium; 2: 2nd metacarpal; 3: posterior oblique ligament; 4: thumb metacarpal; 5: dorsoradial ligament; 6: abductor pollicis longus.

radiographic staging. The visual staging of the joint is almost one full grade higher than the radiographic staging of the joint with Eaton classification [14]. The specimens were divided into two groups (Table 2). Group A included total absence of osteoarthritis to minimal osteoarthritis (stages I, II and III) and group B included significant cartilage destruction (stage IV). Cartilage degenerations were located into five areas: dorsoradial, dorso-ulnar, volar-radial, volar-ulnar and central. The existence of osteophytes was also noted and located. The dimensions of the articular surfaces were measured by a visual caliper with 0.5 millimeter graduations. They concerned the dorso-volar diameter (Mdv for metacarpal and Tdv for the Table 1 Visual staging of osteoarthritis [14]. Visual Stage

Cartilage state

Description

I

Normal

Smooth, shiny, intact surface

II

Early degeneration Localized fibrillation and/or localized pitting Moderate fibrillation and/or localized pitting Pervasive fibrillation and/or localized pitting

Matted, dull surface < 25% of total surface < 25% of depth < 50% of total surface < 25% of depth < 50% of total surface < 25% of depth

Progressive degeneration Pitting with or without fibrillation Fissures, clefts, blisters Deep fissures, clefts to bone

> 25% of depth (localized, moderate or pervasive)

IIa IIb IIc III

IV

End-stage degeneration Bone eburnation Osteophytes

Group A

Group B

Absence of cartilage lesions, early degeneration or progressive degeneration 17 I: 4 II: 6 III: 7 12 males, 5 females

End-stage degeneration

19 IV: 19

1 male, 18 females

trapezium) and the transverse diameter (Mt for metacarpal and Tt for the trapezium). These measurements included the deformities due to osteophytes. The ratio Mt/Mdv and Tt/Tdv were calculated. The smaller distances between the ligamentous attachments and adjacent articular surfaces were noted. All measurements were statistically analyzed (average, standard deviation, minimum, maximum) by Statistica1 (Statsoft) and Excel1 (Microsoft) softwares. Results of the two groups were compared. The Student t test, the Mann-Whitney test and Pearson correlation coefficient were used and a threshold of significance of 0.05 was chosen. 3. Results 3.1. Articular surfaces (Table 3) For trapezium, the differences between the two groups were statistically significant for each diameter but the ratio Tt/Tdv was the same in the two groups. In group A, no osteophyte was found. Among stages III and II, cartilage degeneration concerned the dorso-radial quadrant in 38% of cases, both radial quadrants in 46% cases and was central in the other cases. In group B, 79% of the osteophytes were found on the two horns of the trapezium. In 68% of cases, cartilage destructions were located on both volar quadrants. It was central in the other cases. For 1st metacarpal bone, the dorsovolar diameter and the Mt/ Mdv ratio were statistically different between the two groups Table 3 Measurements of articular surfaces: Results. (SD: standard deviation).

Trapezium Transversal diameter Tt (mm) Dorsovolar diameter Tdv (mm) Tt/Tdv Ratio Metacarpal Transversal diameter Mt (mm) Dorsovolar diameter Mdv (mm) Mt/Mdv Ratio

Group A

Group B

P

16 (SD 2.4)

19.3 (SD 2.3)

0.00021

12.2 (SD 1.8)

14.7 (SD 2.2)

0.00069

1.32 (SD 1.33)

1.32 (SD 1,04)

16 (SD 2)

16.6 (SD 2.6)

> 0.05

13.6 (SD 1.9)

17.8 (SD 2.4)

0.0000019

1.19 (SD 1.05)

0.9 (SD 1.08)

0.000036

C. Maes-Clavier et al. / Chirurgie de la main 33 (2014) 118–123 Table 4 Average distances in millimeter of trapezial ligamentous attachments from the cartilage.

DRL POL AOL

Group A

Group B

P

2.4 (SD 1) 2.6 (SD 0.9) 1.7 (SD 1.1)

1.7 (SD 1.3) 1.7 (SD 1.3) 0.7 (SD 1.46)

> 0.05 > 0.05 0.0095

Table 5 Average distances in millimeter of metacarpal ligamentous attachment compared to the cartilage.

DRL POL IML UCL AOL

Group A

Group B

P

2.2 2.6 3 3.8 4

1.9 2.3 3 3.3 2.9

> 0.05 > 0.05 > 0.05 > 0.05 > 0.05

(SD (SD (SD (SD (SD

1) 0.9) 0.9) 0.8) 1)

(SD (SD (SD (SD (SD

1.2) 1) 1.7) 1.3) 1.8)

and remained after adjustment according the gender ( p = 0.46, by analysis of covariance). In group A, no significant osteophyte was found. In 72% of stages II and III, the incipient cartilage degeneration was located in the radial quadrants. In group B, a volar osteophyte was always found. In 58% of these cases, dorsal osteophytes were associated. In 95% of cases in group B, the degeneration of the cartilage predominated on both volar quadrants. 3.2. Ligamentous attachments (Tables 4 and 5) The differences between the two groups were only statistically significant for the trapezial AOL attachment, which was very close to the articular surface in the group B. For the first metacarpal bone, the average distance between the ligamentous attachments and the articular surface was more than 2 mm, except for the DRL in group B. For the trapezium, only the posterior ligaments (DRL and POL) of group A were inserted at a mean distance more than two millimeters from the articular surfaces.

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trapezium cartilage become thinner firstly in radial area and the evolution quickly progresses towards volar quadrants. These observations were also described in others series [17,18]. However, few authors have studied the sizes of the two articular surfaces. Dahhan et al. [19] have reported an average transversal diameter of 15.5 mm and an average dorsovolar diameter of 12 mm for the trapezium, respectively 16 mm and 12 mm for the metacarpal. These values were very close to our data found in group A. We added that the average dorso-volar metacarpal diameter was significantly higher for the more severe disease in group B. That finding could not relate to a predisposing factor or to a result of the degenerative process. For some authors, the least congruous joints deform and wear prematurely with adaptation to the localized stress [11,20,21]. For others, the most congruous joints would be more affected by trapeziometacarpal osteoarthritis [22]. In a recent review articles, Edmunds [23] described the progressive degradation of this joint as the result of the concentration of compressive shear forces applied on the trapezium recess adjacent to the volar beak during the final phase of opposition combined to the power grip and pinch. For them, the joint instability occurs progressively after numerous years, consecutively to the disappearance of the screw home torque rotation due to a bulky metacarpal beak. Our results developed that concept. Consequently to the development of the volar osteophyte of trapezium, dorsovolar diameter increases (Fig. 4). That pathophysiological hypothesis could be confirmed by a prospective radio-anatomical study on healthy subjects. The evolution of the dimensions of the articular surfaces could affect the conception of anatomical implants in the goal to adapt more exactly the metacarpal prosthesis to the stage of articular wear. If the trapeziometacarpal ligaments were well studied in numerous anatomical works, the functional implications

4. Discussion The major limit of our study was the low number of cases. Moreover, method of measurement would be more precise with the use of a digital caliper with 0.1 mm graduations. We have chosen graduation close to the macroscopically preoperative findings during surgery. The two groups were not similar for the gender, because this pathology is more frequent for women [15]. Because the high incidence of basal thumbs osteoarthritis, many authors wondered about the physiopathology [16] and the anatomical changes of this disease in the goal to improve the therapeutic management. According to Koff et al. [14], we confirmed the topography of the cartilage degeneration. We found mostly mirror lesions in both groups (Fig. 3). The metacarpal cartilage and the

Fig. 3. Superior view of a left trapeziometacarpal joint, stage IV. The red arrows indicate areas without cartilage: the subchondral bone is polished by wear and look shiny. Mirror lesions prevailed at volar quadrants.

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Fig. 4. Comparison of the dorsovolar diameter. 1: trapeziometacarpal joint stage I. 2: trapeziometacarpal joint stage IV.

remain unclear. In our study, we have noted a pellucid aspect of the anterior oblique ligament (AOL). For Pellegrini et al. [24,25] who named the AOL the ‘‘beak ligament’’, and for Imaeda et al. [26], this ligament had a key-role for the stability of the trapeziometacarpal joint. On the contrary, Edmunds [23] has suggested a minor role of this ligament, which is completely laxe in opposition. He showed that the section of AOL did not affect the stability of the trapeziometacarpal joint. Najima et al. [27] have found a relation between the resistance of AOL, POL and IML on the one hand, and the degeneration of the cartilage on the other hand. Van Brenk et al. [28] have focused on the importance of the DRL for the trapeziometacarpal stability. Kulhmann [29] highlighted the role of the posteromedial complex (POL, AOL, IML and ‘‘retinaculometacarpal’’ ligament, which corresponds to the UCL). For Colmann et al. [30] the section of the DRL led to a more important instability than that of the AOL. Edmunds [23] has considered the dorsal ligament complex, including DRL and POL, as the most important because it looks large, strong and thick and could stabilize the screw home torque rotation that occurs during thumb opposition and prevent the metacarpal subluxation. Presence of mechanoreceptors in these ligaments infers them also a proprioceptive role [31,32]. The arthroscopic appearance and location of the dorsal ligaments does not vary, contrary to that of the volar ligaments [33]. The intermetacarpal ligament would be also important for the stability of the joint [23]. Tenodesis using the flexor carpi radialis or the abductor

pollicis longus after trapeziectomy reproduces its function. Rongières emphasized also the role of the intrinsic muscles in the stability of the first metacarpal [16]. Few studies have reported the exact distances of trapeziometacarpal ligamentous attachments related to the cartilage. Nanno et al. [12] have studied ten cases. Their measurements of the metacarpal center of attachment from the cartilage were on average of 8  1 mm, 12  1 mm, 7  2 mm, 3  1 mm for respectively the UCL, the anterior IML, the posterior IML and the DRL. Bettinger et al. [11] reported the attachment of the AOL at 0.5 mm from the trapezium and 2 mm from the metacarpal. Our results were quite similar to theirs, even if we have considered the smaller distances between cartilage and ligaments. We found that the ligamentous attachments were closer to the articular surface in the group B than in the group A. That difference was significant only for the trapezial attachment of the AOL, because of the destruction of the cartilage. On average, the trapeziometacarpal ligaments were inserted at more of 2 mm distance from articular surfaces for normal cases and moderate osteoarthritis, except the trapezial attachment of the AOL. Considering the low role of the AOL for the trapeziometacarpal stability, a safety margin of 2 mm could be surgically considered for visual stages I, II and III, which is equivalent to X-Ray Eaton stage I and II according to Koff [14]. It would reduce the risk of ligament injuries and subsequent instabilities after partial trapeziectomy performed arthroscopically or using open surgery, with or without

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interposition, or after resurfacing prosthesis. Nevertheless, the osteochondral cuttings have to take account the areas of ligamentous attachments. In case of severe degradation of the cartilage, ligaments were inserted less than two millimeters of the articular surface of the trapezium and more than two millimeters of the articular surface of the first metacarpal bone, except the DRL. So, for stages 3 or 4 of Dell, an additional procedure of stabilization (capsular plasty, ligamentoplasty or tenodesis) should be required during partial trapeziectomy, to strengthen the dorsal ligamentary complex.

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Disclosure of interest [18]

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Anatomical study of the ligamentous attachments and articular surfaces of the trapeziometacarpal joint. Consequences on surgical management of its osteoarthrosis.

In the goal to optimize conservative surgical techniques of the trapeziometacarpal joint in cases of moderate osteoarthritis, we have defined the rela...
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