The Use oJ Palmaris Longus Tendon to Stabilise TrapeziuLm I m p l a n t s - - A Preliminary Report --1. T. Jackson and R. A. St. Onge
THE USE OF PALMARIS LONGUS TENDON TO STABILISE TRAPEZIUM IMPLANTS A Preliminary Report
I. T. JACKSON and R. A. ST. ONGE, Glasgow SUMMARY A method of stabUislng trapezium implants using the palma~is longus tendon is described. It gives a stable result with good movement in the short term. INTRODUCTION The idea of replacing the trapezium with an implant was an appealing one for the treatment of carpometacarpal joint arthritis. However, it was soon realised that radial dislocation of the implant was common unless a ligamentous stabilising procedure was added. Swanson (1972), using his own prosthesis, employed a strip of abductor pollicis longus to buttress the radial side of the joint but had eight radial subluxations in forty-six cases. Weilby (1971) reported four in fourteen cases. Eiken (1971) employed a distally based slip of flexor carpi radialis tendon: this was used to plicate the ulnar and volar ligaments, then looped around the abductor pollieis longus. This operation is good if the tendon slip is stout and its position and tension around the abductor pollicis longus are correct. Unfortunately, the flexor carpi radialis can be damaged to a varying degree when the trapezium is being removed and thus only a thin, ragged slip of tendon may be available. The mechanics of the loop around the abductor pollicis longus requires experience and judgment and because of this good stabilisation is sometimes not obtained and thus consistently satisfactory results may not be achieved. Niebauer attacked the problem by designing a prosthesis which would provide its own stability by means of polyester mesh around the stem and polyester cords for attachment to neighbouring ligamentous or bony structures (Fig. 1). The reported high incidence of post-operative radial subluxation of implants and the difficulties encountered with the Eiken procedure led to the development of an alternative technique.
Fig. 1. Niebauer prosthesis. I. T. Jackson, F.R.C.S., Canniesburn Hospital, Bearsden, Glasgow. 42
The H a n d - - V o l . 9
No. 1
1977
The Use o/Palmaris Longus Tendon to Stabilise Trapezium I m p l a n t s - - A Preliminary Report - - I . T. Jackson and R. A. St. Onge
PL Fig. 2. Fig. 3.
APL
Diagram to show the relative positions of abductor pollicis longus (APL), trapezium (T), Scaphoid (S) and Palmaris Longus (PL). The trapezium has been removed. The osseous canal in the scaphoid has been established and the tendon of palmaris longus passed through it.
APL~
A~PL
PL The trapezium implant has been inserted, the palmaris longus tendon is now looped around the abductor pollicis longus in the manner shown. Fig. 5. Palmaris longus tendon is drawn in an ulnar direction, as shown; the required tension is established and it is sutured to itself proximal to the point of entry into the scaphoid. The extra tendon is spread out by pulling the edges laterally in opposite directions. Fig. 6. The stretched out tendon is now used to cover the whole operative area. Fig. 4.
The H a n d - - V o l . 9
No. 1
1977
43
The Use of Palmaris Longus Tendon to Stabilise Trapeziu~m l m p l a n t s - - A Preliminary Report - - L T. Jackson and R. A. St. Onge METHOD
The N i e b a u e r prosthesis is used since it is considered that the stem fixation will basically give a more stable situation. T h r o u g h a radio-volar curved incision at the thumb base and after identification and retraction of radial nerve branches, the thenar muscles are exposed. These are dissected off subperiosteally and the capsule of the carpometacarpal joint incised longitudinally. As m u c h capsular tissue as possible is spared during the procedure. The trapezium is removed in toto or piecemeal; the metacarpal shaft reamed out and by trial and error the correct size of prosthesis chosen. The latter is now laid aside after removal of the polyester threads since these are now no longer used. The palmaris tendon is harvested as for a tendon graft using short transverse incisions; it is left attached distally and divided at the level of the muscle belly (Fig. 2). The distal pole of the scaphoid is exposed and a hole drilled in i t - - t h e direction of the hole can be altered depending on how much adducting force is to be exerted by the tendon loop (see below), the m a x i m u m will be gained by bringing the tendon through the scaphoid to exit on the articular surface. The palmaris tendon is now passed through the osseous canal (Fig. 3) and the implant is inserted. The tendon is then passed through any ulnar and volar ligamentous tissue present and looped around the abductor pollicis longus on the metacarpal shaft (Fig. 4). It is brought across the prosthesis in an ulnar direction, the required tension adjusted and is sutured to itzelf proximal to the point of entry into the scaphoid; further stabilisation is obtained by suturing it to the joint capsule and periosteum (Fig. 5). The remaining tendon can be used to strengthen any weak area in the repair; since this is not usually necessary it is stretched out widely rather like chewing g u m and used to cover the whole area as a new joint capsule (Figs. 5 and 6). If any significant adduction deformity of the metacarpal is present then an adductor release should also be performed. The thumb is held in abduction by a plaster cast for three weeks. DISCUSSION
In the eight cases in which this method has been used, the stability and movement have been excellent in the short term; longer term follow up is necessary fully to assess this technique. Its virtues are that it is fairly simple to perform and is completely reproducible in every detail in every case. Should the patient not have a palmaris longus then the flexor carpi radialis technique of Eiken is recommended but employing the routing of the slip described here. REFERENCES
EIKEN, O. (1971) Prosthetic Replacement Of The Trapezium. Technical Aspects. Scandinavian Journal of P|astic and Reconstructive Surgery, 5:131-135. SWANSON, A. B. (1972) Disabling Arthritis at the Base of the Thumb. Treatment by Resection of the Trapezium and Flexible (Silicone) Implant Arthroplasty. Journal of Bone and Joint Surgery, 54A: 456-471. WEILBY, A. (1971) Surgical Treatment Of Osteoarthritis Of The Carpo-Metacarpal Joint Of The Thumb. Scandinavian Journal of Plastic and Reconstructive Surgery, 5: 136-141.
44
The H a n d - - V o L 9
No. 1
1977
THE USE OF PALMARIS LONGUS TENDON TO STABILISE TRAPEZIUM IMPLANTS A Preliminary Report
I. T. JACKSON and R. A. ST. ONGE, Glasgow SUMMARY A method of stabUislng trapezium implants using the palma~is longus tendon is described. It gives a stable result with good movement in the short term. INTRODUCTION The idea of replacing the trapezium with an implant was an appealing one for the treatment of carpometacarpal joint arthritis. However, it was soon realised that radial dislocation of the implant was common unless a ligamentous stabilising procedure was added. Swanson (1972), using his own prosthesis, employed a strip of abductor pollicis longus to buttress the radial side of the joint but had eight radial subluxations in forty-six cases. Weilby (1971) reported four in fourteen cases. Eiken (1971) employed a distally based slip of flexor carpi radialis tendon: this was used to plicate the ulnar and volar ligaments, then looped around the abductor pollieis longus. This operation is good if the tendon slip is stout and its position and tension around the abductor pollicis longus are correct. Unfortunately, the flexor carpi radialis can be damaged to a varying degree when the trapezium is being removed and thus only a thin, ragged slip of tendon may be available. The mechanics of the loop around the abductor pollicis longus requires experience and judgment and because of this good stabilisation is sometimes not obtained and thus consistently satisfactory results may not be achieved. Niebauer attacked the problem by designing a prosthesis which would provide its own stability by means of polyester mesh around the stem and polyester cords for attachment to neighbouring ligamentous or bony structures (Fig. 1). The reported high incidence of post-operative radial subluxation of implants and the difficulties encountered with the Eiken procedure led to the development of an alternative technique.
Fig. 1. Niebauer prosthesis. I. T. Jackson, F.R.C.S., Canniesburn Hospital, Bearsden, Glasgow. 42
The H a n d - - V o l . 9
No. 1
1977
The Use o/Palmaris Longus Tendon to Stabilise Trapezium I m p l a n t s - - A Preliminary Report - - I . T. Jackson and R. A. St. Onge
PL Fig. 2. Fig. 3.
APL
Diagram to show the relative positions of abductor pollicis longus (APL), trapezium (T), Scaphoid (S) and Palmaris Longus (PL). The trapezium has been removed. The osseous canal in the scaphoid has been established and the tendon of palmaris longus passed through it.
APL~
A~PL
PL The trapezium implant has been inserted, the palmaris longus tendon is now looped around the abductor pollicis longus in the manner shown. Fig. 5. Palmaris longus tendon is drawn in an ulnar direction, as shown; the required tension is established and it is sutured to itself proximal to the point of entry into the scaphoid. The extra tendon is spread out by pulling the edges laterally in opposite directions. Fig. 6. The stretched out tendon is now used to cover the whole operative area. Fig. 4.
The H a n d - - V o l . 9
No. 1
1977
43
The Use of Palmaris Longus Tendon to Stabilise Trapeziu~m l m p l a n t s - - A Preliminary Report - - L T. Jackson and R. A. St. Onge METHOD
The N i e b a u e r prosthesis is used since it is considered that the stem fixation will basically give a more stable situation. T h r o u g h a radio-volar curved incision at the thumb base and after identification and retraction of radial nerve branches, the thenar muscles are exposed. These are dissected off subperiosteally and the capsule of the carpometacarpal joint incised longitudinally. As m u c h capsular tissue as possible is spared during the procedure. The trapezium is removed in toto or piecemeal; the metacarpal shaft reamed out and by trial and error the correct size of prosthesis chosen. The latter is now laid aside after removal of the polyester threads since these are now no longer used. The palmaris tendon is harvested as for a tendon graft using short transverse incisions; it is left attached distally and divided at the level of the muscle belly (Fig. 2). The distal pole of the scaphoid is exposed and a hole drilled in i t - - t h e direction of the hole can be altered depending on how much adducting force is to be exerted by the tendon loop (see below), the m a x i m u m will be gained by bringing the tendon through the scaphoid to exit on the articular surface. The palmaris tendon is now passed through the osseous canal (Fig. 3) and the implant is inserted. The tendon is then passed through any ulnar and volar ligamentous tissue present and looped around the abductor pollicis longus on the metacarpal shaft (Fig. 4). It is brought across the prosthesis in an ulnar direction, the required tension adjusted and is sutured to itzelf proximal to the point of entry into the scaphoid; further stabilisation is obtained by suturing it to the joint capsule and periosteum (Fig. 5). The remaining tendon can be used to strengthen any weak area in the repair; since this is not usually necessary it is stretched out widely rather like chewing g u m and used to cover the whole area as a new joint capsule (Figs. 5 and 6). If any significant adduction deformity of the metacarpal is present then an adductor release should also be performed. The thumb is held in abduction by a plaster cast for three weeks. DISCUSSION
In the eight cases in which this method has been used, the stability and movement have been excellent in the short term; longer term follow up is necessary fully to assess this technique. Its virtues are that it is fairly simple to perform and is completely reproducible in every detail in every case. Should the patient not have a palmaris longus then the flexor carpi radialis technique of Eiken is recommended but employing the routing of the slip described here. REFERENCES
EIKEN, O. (1971) Prosthetic Replacement Of The Trapezium. Technical Aspects. Scandinavian Journal of P|astic and Reconstructive Surgery, 5:131-135. SWANSON, A. B. (1972) Disabling Arthritis at the Base of the Thumb. Treatment by Resection of the Trapezium and Flexible (Silicone) Implant Arthroplasty. Journal of Bone and Joint Surgery, 54A: 456-471. WEILBY, A. (1971) Surgical Treatment Of Osteoarthritis Of The Carpo-Metacarpal Joint Of The Thumb. Scandinavian Journal of Plastic and Reconstructive Surgery, 5: 136-141.
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The H a n d - - V o L 9
No. 1
1977
