Clinical Orthopaedics and Related Research®
Clin Orthop Relat Res DOI 10.1007/s11999-013-3374-z
A Publication of The Association of Bone and Joint Surgeons®
SYMPOSIUM: THUMB CARPOMETACARPAL ARTHRITIS
Surgical Treatment of Trapeziometacarpal Joint Arthritis A Historical Perspective Vincent R. Hentz MD
Ó The Association of Bone and Joint Surgeons1 2013
Abstract Background The trapeziometacarpal (TMC) joint’s unique anatomy and biomechanics render it susceptible to degeneration. For 60 years, treatment of the painful joint has been surgical when nonoperative modalities have failed. Dozens of different operations have been proposed, including total or subtotal resection of the trapezium or resection and implant arthroplasty. Proponents initially report high levels of patient satisfaction, but longer-term reports sometimes fail to support initial good results. To date, no one procedure has been shown to be superior to another. Questions/purposes This review sought to identify factors responsible for the development of many different procedures to treat the same pathology and factors influencing whether procedures remain in the armamentarium or are abandoned. Methods I performed a nonsystematic historical review of English-language surgical journals using the key words ‘‘carpometacarpal arthritis’’, or ‘‘trapeziometacarpal arthritis’’, and ‘‘surgery’’ in combination with ‘‘history’’ using the PubMed database. In addition, bibliographies of pertinent articles were reviewed. Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. V. R. Hentz (&) Robert A. Chase Center for Hand and Upper Limb Surgery, Stanford University, 770 Welch Road, Suite 400, Stanford, CA 94305, USA e-mail: [email protected]
Results The factors that led to many surgical innovations appear to be primarily theoretical concerns about the shortcomings of previously described procedures, especially about proximal migration of the thumb metacarpal after trapezial resection. Longevity of a particular procedure seems to be related to simplicity of design, especially for prosthetic arthroplasty. The evolution of surgery for TMC joint arthritis both parallels and diverges from that in other joints. For example, for most degenerated joints (even many in the hand), treatment evolved from resection arthroplasty to implant arthroplasty. In contrast, for the TMC joint, the 60-year-old procedure of trapezial resection continues to be performed by a majority of surgeons; many modifications of that procedure have been offered, but none have shown better pain reduction or increased function over the original procedure. In parallel, many differently designed prosthetic total or hemijoint arthroplasties have been proposed and performed, again with as yet unconvincing evidence that this technology improves results over those obtained by simple resection arthroplasty. Conclusions Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. In the absence of evidence for the superiority of any one procedure, surgeons should consider using established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissueengineered solutions are an important area of current research but have not yet reached the clinical trial stage.
Introduction The uniqueness of the human thumb’s carpometacarpal (CMC) joint has long fascinated anatomists and anatomist-surgeons.
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The complex skeletal, muscular, and ligamentous anatomy of the trapeziometacarpal (TMC) joint challenged early investigators who sought to understand how such a joint could, at the same time, be so mobile and yet so stable when performing forceful pinch. Yet, it is this very feature that, under intrinsic and extrinsic influences still only partially understood, renders this key joint exceedingly susceptible to injury and stressinduced degeneration. In the early 18th century, Josias Weitbrecht, a physician and professor of anatomy and physiology and member of the St Petersburg Academy of Science, studied the joints and ligaments of more than 100 cadavers and, in 1742, published in Latin his monograph entitled Syndesmologia sive historia ligamentorum corporis humani quam secundum observationes anatomicas concinnavit et figuris ad objecta recentia adumbratis illustravit [Syndesmology or a description of the ligaments of the human body, arranged in accordance with anatomical dissections and illustrated with figures drawn from fresh subjects]. Although Weitbrecht’s interest was on structure rather than movement, he aptly termed this joint a ‘‘wachelgelenke’’ or a toggle joint. We are indebted to Emanuel B. Kaplan, whose English translation of this book was published in 1969 [37]. The ubiquitous prevalence of osteoarthritis (OA) of this joint combined with its biomechanical duality has long challenged bioengineers and clinicians to better understand the biomechanical basis of its diadochal movement and anatomists to continually redefine its anatomy [23, 24]. This fascination continues today. The development of radiography allowed early clinicians an appreciation of the consequences of OA affecting the TMC joint and eventually led to surgical treatment of this condition whose importance is clearly expressed in the hundreds of publications focusing on this condition and its treatment. For example, a PubMed search using only the term ‘‘thumb carpometacarpal surgery’’ yielded 426 citations. Working through them traces the progress and evolution of treatment for the severely affected TMC joint.
Evolution of Arthroplasty for TMC Joint Arthritis While OA of the TMC joint is a unique entity, in analyzing the trajectory of surgical treatments, one can see certain corollaries to the trajectory of surgical treatment of OA in other joints. In general, the early treatments of many arthritic joints focused on relieving pain while preserving some motion by resecting all or part of one of the two bones constituting the joint to create, by resection arthroplasty, a pseudarthrosis. Familiar examples include resection of the head of the femur for arthritis of the hip, the resection of the distal ulna for OA of the distal radioulnar joint, clavicle resection for OA of the
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acromioclavicular joint, and trapezial resection for OA of the thumb’s basal joint. Dissatisfaction with the outcome of resection arthroplasty for hip arthritis and advances in biomechanics and material research led to prosthetic joint arthroplasties for both large and small joints. For most arthritic joints, implant arthroplasty has largely replaced resection arthroplasty as the mainstay of treatment. This same materials research also led to implant arthroplasty techniques for the arthritic TMC joint, but unlike other joints, these two approaches (resection arthroplasty and implant arthroplasty) for the TMC joint evolved and continue to evolve in parallel and in waves of popularity. In contrast to the management of severe arthritis for many joints, resection arthroplasty for the TMC joint continues to be performed by most surgeons, despite the existence of several effective prostheses. The current literature includes numerous examples of novel soft tissue procedures or prosthetic designs, each with good short-term results and each with one or more developer-champions of the approach [4, 7, 17, 19, 20, 22, 25, 35, 40]. Focusing on patients with advanced arthritis (rather than those treated for joint laxity associated with synovitis and/or very early arthrosis), this review seeks to identify those factors responsible for the development of many different procedures to treat the same pathology and to identify the factors that have influenced whether procedures remain in the armamentarium or are abandoned.
Evolution of Resection Arthroplasty: Total Trapezial Excision In the 1940s, for the painful, arthritic TMC joint, the most direct approach was resection of the trapezium. Sixty years ago, Gervis [13] published his clinical results after excising the trapezium in 15 patients with painful thumb CMC joint arthritis. No wires or pins were used to augment initial stabilization and the patient was encouraged to begin moving the thumb the day after surgery. A decade later, in 1959, Goldner and Clippinger [16] published their results after trapezial resection in patients with traumatic thumb adduction contractures and in patients with OA. Whereas Gervis performed simple excision and immediate motion, these authors described inserting an absorbable gelatin sponge into the space created by excision of the trapezium and supporting the thumb’s position for several weeks with a K-wire. The article does not inform us precisely why these authors added a K-wire as part of their procedure when the original description by Gervis does not mention wire fixation. In 1960, Murley [26] published his experience with 39 trapeziectomies performed between 1946 and 1956. His operative procedure differed little from that described by
Surgical Treatment of TMC Joint Arthritis
Gervis but did include plaster immobilization for 3 weeks. In 1973, now having performed more than 100 such procedures, Gervis [14] wrote: ‘‘thirty years of resection of the trapezium for osteoarthritis of the trapezio-metacarpal joint has found this simple operation to be entirely effective.’’ He had changed neither his initial operative procedure nor his early postoperative movement and, in fact, 2 years before publishing his review, had the procedure performed on himself. There continue to be many advocates for Gervis’ excision of the trapezium, but most have made their own modifications, including arthroscopic excision of all or part of the trapezium, with or without the insertion of substances into the space [36].
Excision of the Trapezium Plus Ligament Reconstruction/Augmentation/Interposition During the 1970s, operative and rehabilitation recommendations continued to change, presumably because of some dissatisfaction (not clearly delineated in subsequent publications) with the simpler approach advocated by Gervis. In 1970, Froimson [12], collaborating with Carroll, excised the trapezium and interposed a rolled-up portion of the flexor carpi radialis (FCR) tendon into the space, the ‘‘anchovy’’ technique [7]. He did not pin the thumb; rather, he employed only a soft dressing for 3 weeks followed by active use and suggested that no specific rehabilitation program was needed. Many surgeons adopted techniques that incorporated filling the empty space, but with autologous tissue, typically tendon, combined with techniques that reconstructed or reinforced the intrinsic ligaments of the TMC joint, such as the ligament-reconstruction-tendon-interposition procedure championed by Pellegrini and Burton [4, 34]. In subsequent publications, hand surgeons have reported a variety of personalized modifications, including various methods to provide some additional internal stability for the thumb, with the stated goal of reducing the tendency for proximal and dorsal migration of the metacarpal. Most employed portions of the tendons of the FCR or abductor pollicis longus (APL) in many combinations, including suspending the base of the first metacarpal to the second (suspensionplasty [7]), creating a sling between the APL and FCR tendons to support the base of the metacarpal, or sutures that anchor the first to the second metacarpal as ligament substitutes [36]. Others advocated a more simplistic return to Gervis concept of trapezial resection, maintaining the normal space between scaphoid and metacarpal base by temporary K-wire fixation of the first to the second metacarpal, presumably allowing this space to fill in with scar (hematoma/distraction arthroplasty [17, 20, 22]). Currently, the surgical pendulum swings back and
forth between two seemingly opposing schools of thought: a simple complete trapezial excision, almost regardless of the stage of disease, plus K-wire pinning of the distracted thumb metacarpal versus complete trapezial excision followed by more or less complex manipulations of regional tendons such as the FCR and/or APL to support/stabilize the thumb, with or without inserting some material into the void. All recommend some period of immobilization varying from 2 to 5 weeks.
Resection Arthroplasty by Subtotal Trapezial Excision While most surgeons simply followed the advice of those preceding them and resected the entire trapezium, others asked a very basic question: Why, if most patients with TMC joint arthritis have pain only at the CMC joint and none at the scaphotrapezial (ST) joint, and most patients have notable radiographic abnormality only at the CMC joint, do we resect the entire trapezium? For on this joint depends, in the words of Sir Charles Bell, ‘‘the length, strength, free lateral motion and perfect mobility of the thumb’’ [2]. Because of this concern, surgeons challenged earlier approaches and began resecting only the distal part of the trapezium [25], with or without the insertion of autologous tissue such as tendon or fascia lata, allograft tissue such as frozen or irradiated costal cartilage [35], or prosthetic materials initially felt to be biocompatible such as Artelon1 [27], and reported initial and long-term outcomes equivalent to those reported for complete trapezial removal [29]. Allograft costal cartilage has a certain appeal as an interpositional material. It can be carved to precisely fit the space left by partial trapezial excision, has initial structural integrity to maintain the base of the thumb metacarpal out to proper length, avoiding the need for K-wire fixation, and is essentially hypoantigenic. To date, there are no reports of allograft cartilage eliciting any microparticulate reaction. Advocates for preserving the proximal trapezium suggested that conserving the ST ligaments preserved scaphoid mechanics and potentially reduced the possibility that the scaphoid might become unstable as a consequence of disrupting these ligaments. Yuan et al. [41] reported rotational instability of the scaphoid and attributed this to trapezial resection for TMC joint arthritis. Still, most surgeons continue to resect the entire trapezium, arguing that the procedure succeeds in relieving pain and suggesting that leaving behind the proximal trapezium might result in patients subsequently developing ST joint pain, with the potential for additional surgery. Most surgeons remained unconvinced even after the 1992 report of Glickel et al. [15], which indicated little likelihood of ST arthritic progression.
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My colleagues and I recently assessed the risk of retaining the ST joint in patients who presented with mildly radiographically abnormal but asymptomatic ST joints [28]. Twenty-two patients who underwent a partial trapeziectomy and allograft cartilage interposition between 1995 and 2005 were evaluated at an average of 8 years postsurgery. No examined patient had pain at the ST joint with direct palpation or stress testing. None reported any symptoms of ST arthritis, although the majority had radiographic evidence of ST arthritis to some degree. Mean pinch strength averaged 53 N on both the operated and nonoperated hands. Nineteen of 22 patients were very satisfied or extremely satisfied, one was slightly satisfied, and two were not satisfied. This satisfaction rate (88%) was equivalent to other published series. From this study, we concluded that partial trapeziectomy for TMC joint arthritis provides long-lasting relief of symptoms and maintains ST joint stability. The radiographic appearance of the ST joint did not correlate with symptoms at this joint. Unless the patient has symptomatic ST arthritis, we concluded that the ST joint may be retained.
Perspective Of the many surgical techniques described over the last 60 + years to treat TMC joint arthritis, no one technique has yet been firmly established as superior in terms of the metric most important to most patients, namely, relief of pain. What is common to all resection arthroplasty procedures is the creation of a sufficiently stable pseudarthrosis. One can argue that, as long as this is achieved, further surgical interventions may be considered superfluous until proven otherwise by properly designed randomized trials. In 1979, Eaton [8] proposed a radiographically based classification system still used by most to stage the severity of arthritis. Other than patients with joint laxity and synovitis or early joint space narrowing, most surgeons perform their operation of personal preference, essentially regardless of the radiographic stage of the disease, ie, they excise the trapezium.
Prosthetic Evolution The 1960s witnessed, for many arthritic joints, the transition from bony resection and pseudarthrosis to resection plus joint arthroplasty with a prosthesis. Advances in material sciences offered a potential compromise between the more predictable pain relief but great functional liability of arthrodesis and the less predictable pain relief and possibly less functional liability of pseudarthrosis. For OA of the TMC joint, the initial prosthetic design was greatly
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influenced by what had become for many the typical treatment, ie, resection of the trapezium. In 1973, Swanson [32] extended his idea of a silicone metacarpophalangeal and proximal interphalangeal joint prosthesis with stabilization via a stem inserted into bone on either side of the resected joint to his design for a spacer that would maintain the length of the thumb ray after total trapezial resection. His prosthesis was composed of a cylinder whose base rested on the distal scaphoid and a distal stem inserted into a hole excavated in the base of the thumb metacarpal. He conceptualized reinforcing initial stability by, during exposure and resection of the trapezium, preserving as much of the capsuloligamentous tissue as possible and then imbricating these tissues around the inserted prosthesis. This prosthesis became widely accepted [33] and there followed several modifications including that of Eaton [8] who borrowed the basic shape of the Swanson design but conceptualized a simple but elegant modification that took advantage of his and Littler’s experience in reconstructing the ligamentous stabilization of the lax TMC joint using portions of the adjacent FRC tendon [9]. Some surgeons questioned the consequences seen on longer-term followup radiographs of erosion of the base of the silicone cylinder, and soon thereafter, perhaps as a consequence of the prosthetic manufacturer changing to a more dense form of silicone, surgeons reported the development of radiolucencies in surrounding bones, termed silicone synovitis [5]. There was a rapid retreat from the use of silicone as the material for TMC implant arthroplasty.
Nonsilicone Total Joint and Hemijoint Prosthetic Implants In the 1970s and early 1980s, a number of different nonsilicone prostheses for TMC joint arthritis were introduced. Their materials differed widely, but their design can be conceptualized as a constrained ball and socket, a total joint prosthesis, or a hemijoint arthroplasty, frequently termed resurfacing. European colleagues pushed the development of a variety of prosthetic concepts including component total joint implants that might more closely reproduce the normal mechanics of TMC joint motion. The earliest ball-and-socket total joint arthroplasty was introduced by de la Caffiniere and Aucouturier [6]. The metal ball and polyethylene cup were cemented to the base of the metacarpal and the trapezium. Other noncemented designs soon followed with intrametacarpal stems that incorporated bone ingrowth technology originally introduced for larger implants. Most were introduced into publication as preliminary studies [3, 31]. The second prosthetic design concept has been termed joint resurfacing and utilized a spherical or hemispherical
Surgical Treatment of TMC Joint Arthritis
While initial results seemed favorable, longer-term studies of some initially successful implants have shown an increasing incidence of prosthetic failure requiring revision [1, 21]. The dearth of reports of new prosthetic designs in the more recent literature would seem to reflect a shift away from this approach while, during the same period, there continue to be reports introducing new modifications of resection arthroplasty [19, 36].
many of the newer biomaterials and designs. A prosthetic implant may be a reasonable salvage procedure when a resection arthroplasty procedure fails. No one procedure has been determined to be superior to any other. In the absence of such evidence, surgeons should focus on established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissue-engineered solutions are an important area of current research with the promise of an off-the-shelf, decellularized bone-ligamentbone construct that heals to the base of metacarpal and the proximal trapezium [11]. This technology has not yet reached the clinical trial stage. While one cannot predict the future of treatment of OA of the TMC joint, if we pay attention to the past, we note that historically the treatment of many arthritic joints has evolved from resection pseudarthrosis to joint arthroplasty. Ladd and others [18, 23, 24] have recently asked whether there is more that might be learned about the ligamentous anatomy, innervation, and wear characteristics of this joint. They have used modern imaging and histochemical techniques to try to answer basic questions, with the hypothesis that answering these questions might lead to a better prosthetic design or a more biomechanically sound soft tissue procedure. Materials have evolved beyond silicon or titanium. Still lacking, though, are techniques or materials to reconstruct the normal ligamentous support that endows the normal joint with its ‘‘free lateral motion and perfect stability’’ [2].
Future Evolution: Addressing Key Issues
References
Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. This review of the historical literature does not clearly identify the factors that have led to the many published modifications of Gervis’ simple trapezial resection. The factor most often cited is concern, anecdotal or theoretical, over proximal migration of the base of the metacarpal leading to instability, weakness, or painful impingement [40]. However, studies addressing the effect of shortening fail to correlate shortening with results [39]. Based on published data, all that seems necessary is the establishment of a sufficiently stable and relatively pain-free pseudarthrosis [29]. The less complicated procedures that achieve this simple goal continue to be performed, such as hematoma-distraction arthroplasty [17]. There continue to be advocates for prosthetic arthroplasty using various designs [6, 30, 31, 38], with reports of good clinical results including, for one design, a 5-year survival rate of 95% [10]. Most current reports are from European surgeons [21, 22, 31], a consequence of the difficulty in obtaining FDA approval for
1. Adams BD, Pomerance J, Nguyen A, Kuhl TL. Early outcome of spherical ceramic trapezial-metacarpal arthroplasty. J Hand Surg Am. 2009;34:213–218. 2. Bell C. The Hand—Its Mechanism and Vital Endowments as Evincing Design. 2nd ed. London, UK: William Pickering; 1833. 3. Braun RM. Total joint replacement at the base of the thumb— preliminary report. J Hand Surg Am. 1982;7:255–251. 4. Burton RI. Basal joint arthritis: fusion, implant, or soft tissue reconstruction? Orthop Clin North Am. 1986;17:493–503. 5. Carter PR, Benton LJ, Dysert PA. Silicon rubber carpal implants: a study of the incidence of late osseous complications. J Hand Surg Am. 1986;11:639–644. 6. de la Caffiniere JY, Aucouturier P. Trapezio-metacarpal arthroplasty by total prosthesis. Hand. 1979;11:41–46. 7. Diao E. Trapezio-metacarpal arthritis: trapezium excision and ligament reconstruction not including the LRTI arthroplasty. Hand Clin. 2001;17:223–236. 8. Eaton RG. Replacement of the trapezium for arthritis of the basal articulations: a new technique with stabilization by tenodesis. J Bone Joint Surg Am. 1979;61:76–82. 9. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973;55: 1655–1666. 10. Eecken SV, Vanhove W, Hollevt N. Trapeziometacarpal joint replacement with the Arpe prosthesis. Acta Orthop Belg. 2012;78:724–729.
prosthesis inserted between the trapezium and metacarpal. The hemispherical design mimicked Swanson’s original silicone prosthesis, having a stem that was placed into the proximal metacarpal shaft [30]. Material choice for these prostheses paralleled their use for other implants, all a result of a search for the most biocompatible material, one that was stable and did not erode the surrounding bone. Initially, various metals such as titanium were used, followed by ceramic implants. The great compressive forces to which these prostheses were subject led to frequent loosening and osteolysis. More recently, and mirroring the evolution of small joint implant material technology, several pyrocarbon implants have been introduced [38]. Advocates for resurfacing procedures point to the potential benefit of preserving some trapezium so that more salvage options remain should the implant fail.
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Hentz 11. Endress R, Woon CY, Farnebo SJ, Behn A, Bronstein J, Pham H, Yan X, Gambhir SS, Chang J. Tissue-engineered collateral ligament composite allografts for scapholunate ligament reconstruction: an experimental study. J Hand Surg Am. 2012;37:1529–1537. 12. Froimson AI. Tendon arthroplasty of the trapeziometacarpal joint. Clin Orthop Relat Res. 1970;70:191–199. 13. Gervis WH. Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg Br. 1949;31:537– 539. 14. Gervis WH. The review of excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint after 25 years. J Bone Joint Surg Br. 1973;55:56–57. 15. Glickel SZ, Kornstein AN, Eaton RG. Long-term follow-up of trapeziometacarpal arthroplasty with coexisting scaphotrapezial disease. J Hand Surg Am. 1992;17:612–620. 16. Goldner JL, Clippinger FW. Excision of the greater multangular bone as an adjunct to mobilization of the thumb. J Bone Joint Surg Am. 1959;41:609–625. 17. Gray KV, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up evaluation. J Hand Surg Am. 2007;32:23–29. 18. Hagert E, Lee J, Ladd AL. Innervation patterns of the thumb trapeziometacarpal joint ligaments. J Hand Surg Am. 2012;37: 706–714. 19. Harenberg PS, Jakubietz MG, Jakubietz RG, Schmidt K, Meffert RH. Treatment of osteoarthritis of the first carpometacarpal joint by resection-suspension-interposition arthroplasty using the split abductor pollicis longus tendon. Oper Orthop Traumatol. 2013;25:95–103. 20. Jones NF, Maser BM. Treatment of arthritis of the trapeziometacarpal joint with trapeziectomy and hematoma arthroplasty. Hand Clin. 2001;17:237–243. 21. Kaszap B, Daecke W, Jung M. High frequency failure of the Moje thumb carpometacarpal joint arthroplasty. J Hand Surg Eur Vol. 2012;37:610–616. 22. Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective, single-surgeon study including outcomes measures. J Hand Surg Am. 2003;28:381–389. 23. Ladd AL, Lee J, Hagert E. Macroscopic and microscopic analysis of the thumb carpometacarpal ligaments: a cadaveric study of ligament anatomy and histology. J Bone Joint Surg Am. 2012;94: 1468–1477. 24. Marzke MW, Tocheri MW, Marzke RF, Femiani JD. Threedimensional quantitative comparative analysis of trapezialmetacarpal joint surface curvatures in human populations. J Hand Surg Am. 2012;37:72–76. 25. Menon J. Partial trapeziectomy and interpositional arthroplasty for trapeziometacarpal osteoarthritis of the thumb. J Hand Surg Br. 1995;20:700–706. 26. Murley AH. Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint. J Bone Joint Surg Br. 1960;42:502–507.
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Clinical Orthopaedics and Related Research1 27. Nilsson A, Liljensten E, Bergstrom C, Sollerman C. Results from a degradable TMC joint spacer (Artelon) compared with tendon arthroplasty. J Hand Surg Am. 2005;30:380–389. 28. Noland SS, Saber S, Endress R, Hentz VR. The scaphotrapezial joint after partial trapeziectomy for trapeziometacarpal joint arthritis: long-term follow-up. J Hand Surg Am. 2012;37:1125– 1129. 29. Park MJ, Lichtman G, Christian JB, Weintraub J, Chang J, Hentz VR, Ladd AL, Yao J. Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995– 2005. Hand (N Y). 2008;3:304–310. 30. Parker WL, Rizzo M, Moran SL, Hormel KB, Beckenbaugh RD. Preliminary results of nonconstrained pyrolytic carbon arthroplasty for metacarpophalangeal joint arthritis. J Hand Surg Am. 2007;32:1496–1505. 31. Perez-Ubeda MJ, Garcia-Lopez A, Marco Martinez F, Junyent Vilanova E, Molina Martos M, Lopez-Duran Stern L. Results of the cemented SR trapeziometacarpal prosthesis in the treatment of thumb carpometacarpal osteoarthritis. J Hand Surg Am. 2003; 28:917–925. 32. Swanson AB. Disabling arthritis at the base of the thumb: treatment by resection of the trapezium and flexible (silicone) implant arthroplasty. J Bone Joint Surg Am. 1972;54:456–571. 33. Swanson AB, Herndon JH. Flexible (silicone) implant arthroplasty of the metacarpophalangeal joint of the thumb. J Bone Joint Surg Am. 1977;59:362–368. 34. Tomaino MM, Pellegrini VD Jr, Burton RI. Arthroplasty of the basal joint of the thumb: long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am. 1995;77:346–355. 35. Trumble TE, Rafijah G, Gilbert M, Allan CH, North E, McCallister WV. Thumb trapeziometacarpal joint arthritis: partial trapeziectomy with ligament reconstruction and interposition costochondral allograft. J Hand Surg Am. 2000;25:61–76. 36. Varley GW, Calvey J, Hunter JB, Barton NJ, Davis TR. Excision of the trapezium for osteoarthritis at the base of the thumb. J Bone Joint Surg Br. 1994;76:964–968. 37. Weitbrecht J. Syndesmology or A Description of the Ligaments of the Human Body. Kaplan EB, trans. Philadelphia, PA: WB Saunders Co; 1969. 38. Woodward JF, Heller JB, Jones NF. PyroCarbon implant hemiarthroplasty for trapeziometacarpal arthritis. Tech Hand Up Extrem Surg. 2013;17:7–12. 39. Yang SS, Weiland AJ. First metacarpal subsidence during pinch after ligament reconstruction and tendon interposition basal joint arthroplasty of the thumb. J Hand Surg Am. 1998;23:879–883. 40. Yao J, Song Y. Suture-button suspensionplasty for thumb carpometacarpal arthritis: a minimum 2-year follow-up. J Hand Surg Am. 2013;38:1161–1165. 41. Yuan BJ, Moran SL, Tay SC, Berger RA. Trapeziectomy and carpal collapse. J Hand Surg Am. 2009;34:219–227.
Clin Orthop Relat Res DOI 10.1007/s11999-013-3374-z
A Publication of The Association of Bone and Joint Surgeons®
SYMPOSIUM: THUMB CARPOMETACARPAL ARTHRITIS
Surgical Treatment of Trapeziometacarpal Joint Arthritis A Historical Perspective Vincent R. Hentz MD
Ó The Association of Bone and Joint Surgeons1 2013
Abstract Background The trapeziometacarpal (TMC) joint’s unique anatomy and biomechanics render it susceptible to degeneration. For 60 years, treatment of the painful joint has been surgical when nonoperative modalities have failed. Dozens of different operations have been proposed, including total or subtotal resection of the trapezium or resection and implant arthroplasty. Proponents initially report high levels of patient satisfaction, but longer-term reports sometimes fail to support initial good results. To date, no one procedure has been shown to be superior to another. Questions/purposes This review sought to identify factors responsible for the development of many different procedures to treat the same pathology and factors influencing whether procedures remain in the armamentarium or are abandoned. Methods I performed a nonsystematic historical review of English-language surgical journals using the key words ‘‘carpometacarpal arthritis’’, or ‘‘trapeziometacarpal arthritis’’, and ‘‘surgery’’ in combination with ‘‘history’’ using the PubMed database. In addition, bibliographies of pertinent articles were reviewed. Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. V. R. Hentz (&) Robert A. Chase Center for Hand and Upper Limb Surgery, Stanford University, 770 Welch Road, Suite 400, Stanford, CA 94305, USA e-mail: [email protected]
Results The factors that led to many surgical innovations appear to be primarily theoretical concerns about the shortcomings of previously described procedures, especially about proximal migration of the thumb metacarpal after trapezial resection. Longevity of a particular procedure seems to be related to simplicity of design, especially for prosthetic arthroplasty. The evolution of surgery for TMC joint arthritis both parallels and diverges from that in other joints. For example, for most degenerated joints (even many in the hand), treatment evolved from resection arthroplasty to implant arthroplasty. In contrast, for the TMC joint, the 60-year-old procedure of trapezial resection continues to be performed by a majority of surgeons; many modifications of that procedure have been offered, but none have shown better pain reduction or increased function over the original procedure. In parallel, many differently designed prosthetic total or hemijoint arthroplasties have been proposed and performed, again with as yet unconvincing evidence that this technology improves results over those obtained by simple resection arthroplasty. Conclusions Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. In the absence of evidence for the superiority of any one procedure, surgeons should consider using established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissueengineered solutions are an important area of current research but have not yet reached the clinical trial stage.
Introduction The uniqueness of the human thumb’s carpometacarpal (CMC) joint has long fascinated anatomists and anatomist-surgeons.
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The complex skeletal, muscular, and ligamentous anatomy of the trapeziometacarpal (TMC) joint challenged early investigators who sought to understand how such a joint could, at the same time, be so mobile and yet so stable when performing forceful pinch. Yet, it is this very feature that, under intrinsic and extrinsic influences still only partially understood, renders this key joint exceedingly susceptible to injury and stressinduced degeneration. In the early 18th century, Josias Weitbrecht, a physician and professor of anatomy and physiology and member of the St Petersburg Academy of Science, studied the joints and ligaments of more than 100 cadavers and, in 1742, published in Latin his monograph entitled Syndesmologia sive historia ligamentorum corporis humani quam secundum observationes anatomicas concinnavit et figuris ad objecta recentia adumbratis illustravit [Syndesmology or a description of the ligaments of the human body, arranged in accordance with anatomical dissections and illustrated with figures drawn from fresh subjects]. Although Weitbrecht’s interest was on structure rather than movement, he aptly termed this joint a ‘‘wachelgelenke’’ or a toggle joint. We are indebted to Emanuel B. Kaplan, whose English translation of this book was published in 1969 [37]. The ubiquitous prevalence of osteoarthritis (OA) of this joint combined with its biomechanical duality has long challenged bioengineers and clinicians to better understand the biomechanical basis of its diadochal movement and anatomists to continually redefine its anatomy [23, 24]. This fascination continues today. The development of radiography allowed early clinicians an appreciation of the consequences of OA affecting the TMC joint and eventually led to surgical treatment of this condition whose importance is clearly expressed in the hundreds of publications focusing on this condition and its treatment. For example, a PubMed search using only the term ‘‘thumb carpometacarpal surgery’’ yielded 426 citations. Working through them traces the progress and evolution of treatment for the severely affected TMC joint.
Evolution of Arthroplasty for TMC Joint Arthritis While OA of the TMC joint is a unique entity, in analyzing the trajectory of surgical treatments, one can see certain corollaries to the trajectory of surgical treatment of OA in other joints. In general, the early treatments of many arthritic joints focused on relieving pain while preserving some motion by resecting all or part of one of the two bones constituting the joint to create, by resection arthroplasty, a pseudarthrosis. Familiar examples include resection of the head of the femur for arthritis of the hip, the resection of the distal ulna for OA of the distal radioulnar joint, clavicle resection for OA of the
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acromioclavicular joint, and trapezial resection for OA of the thumb’s basal joint. Dissatisfaction with the outcome of resection arthroplasty for hip arthritis and advances in biomechanics and material research led to prosthetic joint arthroplasties for both large and small joints. For most arthritic joints, implant arthroplasty has largely replaced resection arthroplasty as the mainstay of treatment. This same materials research also led to implant arthroplasty techniques for the arthritic TMC joint, but unlike other joints, these two approaches (resection arthroplasty and implant arthroplasty) for the TMC joint evolved and continue to evolve in parallel and in waves of popularity. In contrast to the management of severe arthritis for many joints, resection arthroplasty for the TMC joint continues to be performed by most surgeons, despite the existence of several effective prostheses. The current literature includes numerous examples of novel soft tissue procedures or prosthetic designs, each with good short-term results and each with one or more developer-champions of the approach [4, 7, 17, 19, 20, 22, 25, 35, 40]. Focusing on patients with advanced arthritis (rather than those treated for joint laxity associated with synovitis and/or very early arthrosis), this review seeks to identify those factors responsible for the development of many different procedures to treat the same pathology and to identify the factors that have influenced whether procedures remain in the armamentarium or are abandoned.
Evolution of Resection Arthroplasty: Total Trapezial Excision In the 1940s, for the painful, arthritic TMC joint, the most direct approach was resection of the trapezium. Sixty years ago, Gervis [13] published his clinical results after excising the trapezium in 15 patients with painful thumb CMC joint arthritis. No wires or pins were used to augment initial stabilization and the patient was encouraged to begin moving the thumb the day after surgery. A decade later, in 1959, Goldner and Clippinger [16] published their results after trapezial resection in patients with traumatic thumb adduction contractures and in patients with OA. Whereas Gervis performed simple excision and immediate motion, these authors described inserting an absorbable gelatin sponge into the space created by excision of the trapezium and supporting the thumb’s position for several weeks with a K-wire. The article does not inform us precisely why these authors added a K-wire as part of their procedure when the original description by Gervis does not mention wire fixation. In 1960, Murley [26] published his experience with 39 trapeziectomies performed between 1946 and 1956. His operative procedure differed little from that described by
Surgical Treatment of TMC Joint Arthritis
Gervis but did include plaster immobilization for 3 weeks. In 1973, now having performed more than 100 such procedures, Gervis [14] wrote: ‘‘thirty years of resection of the trapezium for osteoarthritis of the trapezio-metacarpal joint has found this simple operation to be entirely effective.’’ He had changed neither his initial operative procedure nor his early postoperative movement and, in fact, 2 years before publishing his review, had the procedure performed on himself. There continue to be many advocates for Gervis’ excision of the trapezium, but most have made their own modifications, including arthroscopic excision of all or part of the trapezium, with or without the insertion of substances into the space [36].
Excision of the Trapezium Plus Ligament Reconstruction/Augmentation/Interposition During the 1970s, operative and rehabilitation recommendations continued to change, presumably because of some dissatisfaction (not clearly delineated in subsequent publications) with the simpler approach advocated by Gervis. In 1970, Froimson [12], collaborating with Carroll, excised the trapezium and interposed a rolled-up portion of the flexor carpi radialis (FCR) tendon into the space, the ‘‘anchovy’’ technique [7]. He did not pin the thumb; rather, he employed only a soft dressing for 3 weeks followed by active use and suggested that no specific rehabilitation program was needed. Many surgeons adopted techniques that incorporated filling the empty space, but with autologous tissue, typically tendon, combined with techniques that reconstructed or reinforced the intrinsic ligaments of the TMC joint, such as the ligament-reconstruction-tendon-interposition procedure championed by Pellegrini and Burton [4, 34]. In subsequent publications, hand surgeons have reported a variety of personalized modifications, including various methods to provide some additional internal stability for the thumb, with the stated goal of reducing the tendency for proximal and dorsal migration of the metacarpal. Most employed portions of the tendons of the FCR or abductor pollicis longus (APL) in many combinations, including suspending the base of the first metacarpal to the second (suspensionplasty [7]), creating a sling between the APL and FCR tendons to support the base of the metacarpal, or sutures that anchor the first to the second metacarpal as ligament substitutes [36]. Others advocated a more simplistic return to Gervis concept of trapezial resection, maintaining the normal space between scaphoid and metacarpal base by temporary K-wire fixation of the first to the second metacarpal, presumably allowing this space to fill in with scar (hematoma/distraction arthroplasty [17, 20, 22]). Currently, the surgical pendulum swings back and
forth between two seemingly opposing schools of thought: a simple complete trapezial excision, almost regardless of the stage of disease, plus K-wire pinning of the distracted thumb metacarpal versus complete trapezial excision followed by more or less complex manipulations of regional tendons such as the FCR and/or APL to support/stabilize the thumb, with or without inserting some material into the void. All recommend some period of immobilization varying from 2 to 5 weeks.
Resection Arthroplasty by Subtotal Trapezial Excision While most surgeons simply followed the advice of those preceding them and resected the entire trapezium, others asked a very basic question: Why, if most patients with TMC joint arthritis have pain only at the CMC joint and none at the scaphotrapezial (ST) joint, and most patients have notable radiographic abnormality only at the CMC joint, do we resect the entire trapezium? For on this joint depends, in the words of Sir Charles Bell, ‘‘the length, strength, free lateral motion and perfect mobility of the thumb’’ [2]. Because of this concern, surgeons challenged earlier approaches and began resecting only the distal part of the trapezium [25], with or without the insertion of autologous tissue such as tendon or fascia lata, allograft tissue such as frozen or irradiated costal cartilage [35], or prosthetic materials initially felt to be biocompatible such as Artelon1 [27], and reported initial and long-term outcomes equivalent to those reported for complete trapezial removal [29]. Allograft costal cartilage has a certain appeal as an interpositional material. It can be carved to precisely fit the space left by partial trapezial excision, has initial structural integrity to maintain the base of the thumb metacarpal out to proper length, avoiding the need for K-wire fixation, and is essentially hypoantigenic. To date, there are no reports of allograft cartilage eliciting any microparticulate reaction. Advocates for preserving the proximal trapezium suggested that conserving the ST ligaments preserved scaphoid mechanics and potentially reduced the possibility that the scaphoid might become unstable as a consequence of disrupting these ligaments. Yuan et al. [41] reported rotational instability of the scaphoid and attributed this to trapezial resection for TMC joint arthritis. Still, most surgeons continue to resect the entire trapezium, arguing that the procedure succeeds in relieving pain and suggesting that leaving behind the proximal trapezium might result in patients subsequently developing ST joint pain, with the potential for additional surgery. Most surgeons remained unconvinced even after the 1992 report of Glickel et al. [15], which indicated little likelihood of ST arthritic progression.
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My colleagues and I recently assessed the risk of retaining the ST joint in patients who presented with mildly radiographically abnormal but asymptomatic ST joints [28]. Twenty-two patients who underwent a partial trapeziectomy and allograft cartilage interposition between 1995 and 2005 were evaluated at an average of 8 years postsurgery. No examined patient had pain at the ST joint with direct palpation or stress testing. None reported any symptoms of ST arthritis, although the majority had radiographic evidence of ST arthritis to some degree. Mean pinch strength averaged 53 N on both the operated and nonoperated hands. Nineteen of 22 patients were very satisfied or extremely satisfied, one was slightly satisfied, and two were not satisfied. This satisfaction rate (88%) was equivalent to other published series. From this study, we concluded that partial trapeziectomy for TMC joint arthritis provides long-lasting relief of symptoms and maintains ST joint stability. The radiographic appearance of the ST joint did not correlate with symptoms at this joint. Unless the patient has symptomatic ST arthritis, we concluded that the ST joint may be retained.
Perspective Of the many surgical techniques described over the last 60 + years to treat TMC joint arthritis, no one technique has yet been firmly established as superior in terms of the metric most important to most patients, namely, relief of pain. What is common to all resection arthroplasty procedures is the creation of a sufficiently stable pseudarthrosis. One can argue that, as long as this is achieved, further surgical interventions may be considered superfluous until proven otherwise by properly designed randomized trials. In 1979, Eaton [8] proposed a radiographically based classification system still used by most to stage the severity of arthritis. Other than patients with joint laxity and synovitis or early joint space narrowing, most surgeons perform their operation of personal preference, essentially regardless of the radiographic stage of the disease, ie, they excise the trapezium.
Prosthetic Evolution The 1960s witnessed, for many arthritic joints, the transition from bony resection and pseudarthrosis to resection plus joint arthroplasty with a prosthesis. Advances in material sciences offered a potential compromise between the more predictable pain relief but great functional liability of arthrodesis and the less predictable pain relief and possibly less functional liability of pseudarthrosis. For OA of the TMC joint, the initial prosthetic design was greatly
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influenced by what had become for many the typical treatment, ie, resection of the trapezium. In 1973, Swanson [32] extended his idea of a silicone metacarpophalangeal and proximal interphalangeal joint prosthesis with stabilization via a stem inserted into bone on either side of the resected joint to his design for a spacer that would maintain the length of the thumb ray after total trapezial resection. His prosthesis was composed of a cylinder whose base rested on the distal scaphoid and a distal stem inserted into a hole excavated in the base of the thumb metacarpal. He conceptualized reinforcing initial stability by, during exposure and resection of the trapezium, preserving as much of the capsuloligamentous tissue as possible and then imbricating these tissues around the inserted prosthesis. This prosthesis became widely accepted [33] and there followed several modifications including that of Eaton [8] who borrowed the basic shape of the Swanson design but conceptualized a simple but elegant modification that took advantage of his and Littler’s experience in reconstructing the ligamentous stabilization of the lax TMC joint using portions of the adjacent FRC tendon [9]. Some surgeons questioned the consequences seen on longer-term followup radiographs of erosion of the base of the silicone cylinder, and soon thereafter, perhaps as a consequence of the prosthetic manufacturer changing to a more dense form of silicone, surgeons reported the development of radiolucencies in surrounding bones, termed silicone synovitis [5]. There was a rapid retreat from the use of silicone as the material for TMC implant arthroplasty.
Nonsilicone Total Joint and Hemijoint Prosthetic Implants In the 1970s and early 1980s, a number of different nonsilicone prostheses for TMC joint arthritis were introduced. Their materials differed widely, but their design can be conceptualized as a constrained ball and socket, a total joint prosthesis, or a hemijoint arthroplasty, frequently termed resurfacing. European colleagues pushed the development of a variety of prosthetic concepts including component total joint implants that might more closely reproduce the normal mechanics of TMC joint motion. The earliest ball-and-socket total joint arthroplasty was introduced by de la Caffiniere and Aucouturier [6]. The metal ball and polyethylene cup were cemented to the base of the metacarpal and the trapezium. Other noncemented designs soon followed with intrametacarpal stems that incorporated bone ingrowth technology originally introduced for larger implants. Most were introduced into publication as preliminary studies [3, 31]. The second prosthetic design concept has been termed joint resurfacing and utilized a spherical or hemispherical
Surgical Treatment of TMC Joint Arthritis
While initial results seemed favorable, longer-term studies of some initially successful implants have shown an increasing incidence of prosthetic failure requiring revision [1, 21]. The dearth of reports of new prosthetic designs in the more recent literature would seem to reflect a shift away from this approach while, during the same period, there continue to be reports introducing new modifications of resection arthroplasty [19, 36].
many of the newer biomaterials and designs. A prosthetic implant may be a reasonable salvage procedure when a resection arthroplasty procedure fails. No one procedure has been determined to be superior to any other. In the absence of such evidence, surgeons should focus on established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissue-engineered solutions are an important area of current research with the promise of an off-the-shelf, decellularized bone-ligamentbone construct that heals to the base of metacarpal and the proximal trapezium [11]. This technology has not yet reached the clinical trial stage. While one cannot predict the future of treatment of OA of the TMC joint, if we pay attention to the past, we note that historically the treatment of many arthritic joints has evolved from resection pseudarthrosis to joint arthroplasty. Ladd and others [18, 23, 24] have recently asked whether there is more that might be learned about the ligamentous anatomy, innervation, and wear characteristics of this joint. They have used modern imaging and histochemical techniques to try to answer basic questions, with the hypothesis that answering these questions might lead to a better prosthetic design or a more biomechanically sound soft tissue procedure. Materials have evolved beyond silicon or titanium. Still lacking, though, are techniques or materials to reconstruct the normal ligamentous support that endows the normal joint with its ‘‘free lateral motion and perfect stability’’ [2].
Future Evolution: Addressing Key Issues
References
Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. This review of the historical literature does not clearly identify the factors that have led to the many published modifications of Gervis’ simple trapezial resection. The factor most often cited is concern, anecdotal or theoretical, over proximal migration of the base of the metacarpal leading to instability, weakness, or painful impingement [40]. However, studies addressing the effect of shortening fail to correlate shortening with results [39]. Based on published data, all that seems necessary is the establishment of a sufficiently stable and relatively pain-free pseudarthrosis [29]. The less complicated procedures that achieve this simple goal continue to be performed, such as hematoma-distraction arthroplasty [17]. There continue to be advocates for prosthetic arthroplasty using various designs [6, 30, 31, 38], with reports of good clinical results including, for one design, a 5-year survival rate of 95% [10]. Most current reports are from European surgeons [21, 22, 31], a consequence of the difficulty in obtaining FDA approval for
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prosthesis inserted between the trapezium and metacarpal. The hemispherical design mimicked Swanson’s original silicone prosthesis, having a stem that was placed into the proximal metacarpal shaft [30]. Material choice for these prostheses paralleled their use for other implants, all a result of a search for the most biocompatible material, one that was stable and did not erode the surrounding bone. Initially, various metals such as titanium were used, followed by ceramic implants. The great compressive forces to which these prostheses were subject led to frequent loosening and osteolysis. More recently, and mirroring the evolution of small joint implant material technology, several pyrocarbon implants have been introduced [38]. Advocates for resurfacing procedures point to the potential benefit of preserving some trapezium so that more salvage options remain should the implant fail.
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