Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main 32 (2013) 408–412
Clinical case
Treatment of a symptomatic trapezial dysplasia with metacarpal instability following thumb metacarpal lengthening with an addition-subtraction osteotomy Traitement d’une dysplasie trapézienne symptomatique avec instabilité métacarpienne, consécutive à un allongement du premier métacarpien, par ostéotomie d’addition-soustraction C.K. Goorens a,b, J.-F. Goubau a,*,b, P. Van Hoonacker a, D. Kerckhove a, B. Berghs a b
a Department of Orthopaedic Surgery, AZ Sint-Jan AV Brugge – Oostende, Campus Brugge, Ruddershove 10, 8000 Brugge, Belgium Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
Received 7 February 2013; received in revised form 5 September 2013; accepted 15 September 2013 Available online 3 October 2013
Abstract The most important problem of trapezial dysplasia with thumb metacarpal instability is of bony origin. Together with the progressive capsuloligamentous decompensation it evolves in a progressive adduction deformity of the thumb metacarpal secondary to the dysplasia of the trapezium with its increased articular slope. The addition-subtraction osteotomy restores the anatomy combining two techniques: an abductionextension osteotomy of the first metacarpal to correct the axis of the first metacarpal and an opening wedge osteotomy of the trapezium to reorientate the trapezial saddle. We present a case of an addition-subtraction osteotomy in a case of symptomatic trapezial dysplasia with metacarpal instability following a thumb metacarpal lengthening in a severely mutilated hand. This technique was especially effective in reducing the instability and pain but mainly in maintaining mobile the only remaining joint of the thumb. # 2013 Elsevier Masson SAS. All rights reserved. Keywords: Addition-subtraction; Osteotomy; Metacarpal lengthening; Trapezial dysplasia
Résumé Le problème le plus difficile à résoudre posé par la dysplasie trapézienne avec instabilité du premier métacarpien est d’origine osseuse. En association avec une décompensation capsuloligamentaire progressive, elle évolue vers une déformation progressive en adduction du premier métacarpien, secondaire à la dysplasie du trapèze qui présente une pente articulaire excessive. L’ostéotomie d’addition-soustraction restaure l’anatomie en combinant deux techniques : une ostéotomie d’abduction et d’extension du premier métacarpien pour corriger son axe, et une ostéotomie d’ouverture du trapèze pour réorienter la selle trapézienne. Nous présentons un cas d’ostéotomie d’addition-soustraction réalisée pour traiter une dysplasie trapézienne symptomatique avec instabilité métacarpienne, consécutive à un allongement du premier métacarpien sur une main sévèrement mutilée. Cette technique s’est révélé particulièrement efficace en diminuant l’instabilité et la douleur et, surtout, en conservant la mobilité de la seule articulation encore mobile du pouce. # 2013 Elsevier Masson SAS. Tous droits réservés. Mots clés : Addition-soustraction ; Ostéotomie ; Allongement métacarpien ; Dysplasie trapézienne
1. Introduction
* Corresponding author. E-mail addresses: [email protected], [email protected] (J.F. Goubau).
Trapeziometacarpal (TM) dysplasia with metacarpal instability can evolve into a disabling condition, characterized by pain, joint instability, decreased motion and strength, and eventually leading to deformity of the joint on the long-term.
1297-3203/$ – see front matter # 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.main.2013.09.005
C.K. Goorens et al. / Chirurgie de la main 32 (2013) 408–412
obtained a lengthening of 2 cm. We did not perform a proximal transplant of the insertion of the adductor pollicis [6]. This resulted in an increased proximo-ulnar adduction force of the reconstructed thumb metacarpal head. An additional rotational osteotomy of the base of the fifth metacarpal and lengthening of the first metacarpal combined with a translocation of the fourth metacarpal head on the thumb metacarpal were necessary to finally achieve full functional pinch between thumb and little finger (Figs. 1 and 2). Apart from two neuromas, which were treated surgically, the evolution was uneventful the following years.
Pain is induced by thumb to finger pinch. When conservative treatment fails, operative options are to be considered. The most important problem is of bony origin: induced subluxation of the base of the thumb metacarpal and dysplasia of the trapezium with its increased articular slope assessed through slope angle (‘‘angle de dévers’’, in French), which is the angle measured between the axis of the second metacarpal and the slope of the trapezium (normal 1298 with range 68) in a frontal view according to Kapandji and Heim [1]. The addition-subtraction osteotomy, reported by Goubau et al. in 2007, combines two techniques: an abduction osteotomy of the first metacarpal to correct the axis of the first metacarpal and an opening wedge osteotomy of the trapezium to reorientate the trapezial saddle in order to restore a normal slope angle. The combination of both techniques restores the anatomy and centers the forces acting across the joint, which mostly results in restoration of an acceptable level of mobility, force, and stability of the thumb column [2–5]. We present a case where was performed an additionsubtraction osteotomy for symptomatic trapezial dysplasia with metacarpal instability following a thumb metacarpal lengthening according to the technique described by Matev [6], in a severely mutilated hand.
2.2. Trapeziometacarpal instability
2. Case report An addition-subtraction osteotomy was performed in a 31year-old right-handed male presenting a symptomatic trapezial dysplasia with progressive metacarpal instability progressively induced by a metacarpal lengthening of the thumb using the Matev technique [6]. 2.1. Presentation of the case In 1999, at the age of 18 years, he sustained an accidental circle saw accident with transmetacarpophalangeal amputation of the thumb, transmetacarpal amputation of the second, third and forth fingers and laceration with multifragmentary fracturing of the fifth finger of his right hand. In emergency were performed replantation of the thumb, replantation of the index finger on the third ray, and replantation of the third finger on the remaining ring finger [7]. The skin defect was closed with a full-thickness graft of the skin envelope of the fourth amputated finger. An arthrodesis of the interphalangeal (IP) joints of the fifth finger was performed in functional position. Unfortunately, venous congestion evolved into necrosis of the three replanted fingers, which eventually were amputated. After 5 months, the fifth finger regained 908 of active flexion in the metacarpophalangeal joint with healed arthrodesis of his proximal interphalangeal (PIP) joint. The distance between the fifth finger and the stump of the thumb was 1.5 cm when pinching was attempted. Possible reconstruction procedures to restore his pollicidigital pinch were discussed with the patient. Because of his soccer practice, he refused for obvious reasons a toe-to-thumb transfer [8]. Therefore, we performed a distraction procedure of the first metacarpal with an external fixator as described by Matev and
409
[(Fig._1)TD$IG]
Six years after the initial accident, pain complaints in the trapeziometacarpal joint increased (Numerical Scale score of 8/ 10). We measured a grip strength of 14 kg (38 kg left), key pinch of 3.5 kg (7.5 kg left) and precision pinch of 3.5 kg (2.5 kg left) using a calibrated hydraulic dynamometer and a hydraulic pinch gauge (Baseline Fabrication Enterprises Inc., New York, USA). He scored a QuickDASH score of 40.9. He was diagnosed with a symptomatic trapezial dysplasia with metacarpal instability, according to the radiographic analysis. Eaton views with radial stressing confirmed thumb metacarpal instability at its base (Fig. 3). Radiographs of the trapeziometacarpal joint according to Kapandji et al. [9] revealed degenerative articular changes and an increased slope angle compared to the contralateral side (Fig. 4). Conservative treatment with immobilization and non-steroidal anti-inflammatory medication failed. In order to correct the bony anatomy, an addition-subtraction osteotomy without ligamentoplasty was performed (Fig. 5). The TM joint was exposed through a proximally extended anterolateral Gedda and Moberg incision. This incision provides excellent visualization of the TM joint and preservation of dorsal vascularity and ligamentary stability of the saddle joint [10]. Under guidance of the image intensifier, an extension-abduction osteotomy in the proximal metaphysis of the thumb metacarpal was performed. The orientation of the closing wedge of 5 mm was slightly larger dorsally and radially
Fig. 1. Functional result after initial reconstruction.
[(Fig._2)TD$IG] 410
C.K. Goorens et al. / Chirurgie de[(Fig._4)TD$IG] la main 32 (2013) 408–412
Fig. 4. Frontal radiograph of the trapeziometacarpal joint showing a high slope angle. The angle was measured by using a 1.5 cm parallel line to a reference line through the third metacarpal, because of the absence of the second metacarpal (preop). Fig. 2. Clinical result after initial reconstruction.
to create somewhat more antepulsion. Under compression, the osteotomy was fixed with a metal clip (Memoclip1, Memometal, Stryker Corporate, Kalamazoo, Michigan, USA). Subsequently, under image intensifier control in a frontal view of the trapezium, an osteotomy was performed in the middle of the trapezium, using an oscillating saw and finishing up with a chisel parallel to the articular surface of the trapezium. Care was taken to keep an ulnar hinge at the ulnar end of the osteotomy. The resected metacarpal wedge was inserted in the opened osteotomy and press-fitted without osteosynthesis. After 6 weeks of immobilization in a short arm cast taking the thumb, mobilization was resumed evolving progressively into a satisfactory functional pinch.
Four years after the addition-subtraction osteotomy, pain complaints of the trapeziometacarpal joint have disappeared completely (Numerical Scale score 0/10). We measured opposition at 9 and retropulsion at 1 according to Kapandji
[(Fig._5)TD$IG]
[(Fig._3)TD$IG]
Fig. 3. Frontal Eaton view with radial stressing showing subluxation of the trapeziometacarpal joint.
Fig. 5. Frontal radiograph of the trapeziometacarpal joint showing postoperative addition-subtraction osteotomy status with a decreased slope angle (postop).
[(Fig._6)TD$IG]
C.K. Goorens et al. / Chirurgie de la main 32 (2013) 408–412
Fig. 6. Overview of the addition-subtraction osteotomy technique.
[11], grip strength of 14 kg, key pinch 3.5 kg and precision pinch 7.5 kg. QuickDASH score improved slightly to a score of 36.4. Initial postoperative radiographs showed a reduction of the slope angle compared preoperative situation. There was at 5 years of follow up on comparative x-rays no further progression of the degenerative osteoarthritis [12] (Fig. 6). 3. Discussion The period of time between the onset of symptoms of trapeziometacarpal instability and eventual irreversible degenerative changes can last for many years. Since the conservative treatment is usually effective enough, surgery is rarely indicated. Joint subluxation after a metacarpal lengthening (incidence of 0.7%) is the result of an adjacent unstable joint, unrecognized ligamentous injury or inadequate rehabilitation. Its prevention should include a careful preoperative assessment of the adjacent joints, initiation of early rehabilitation, and avoidance of injury to any of the ligamentous structures at the adjacent joints [13]. In this case the increased axial load due to distalisation of the insertion of the adductor pollicis (Matev procedure), the absence of mobile – potentially compensatory – joint(s) distal to the dysplastic trapeziometacarpal joint enhanced the onset of symptoms at the thumb base. Techniques that are applicable for arthritic joints in young patients, such as fusion or prosthetic replacement, cannot be used in painful but healthy unstable dysplastic joints [14,15]. Moreover, in this case trapeziometacarpal fusion would have dramatic functional drawbacks for fine pollicidigital prehension. Since the joint was apparently in very good condition, without radiographic signs of dynamic subluxation of the base of the thumb metacarpal or joint space narrowing, we did not
411
perform the additional ligamentoplasty as proposed by Goubau et al. [2,3]. Moreover, the ligamentoplasty tends to favor stiffening of the joint, which in this case had to be avoided since it was the only mobile joint of his thumb column. Isolated ligamentoplasty was in this particular case not an option, since it did not address the bony dysplasia [16]. Metacarpal osteotomies have been reported as treatment of early stage trapeziometacarpal joint arthritis by extension osteotomy. A 5 mm closing wedge corresponds with a metacarpal correction of 20–308. Extension osteotomy of 308 gave good results in terms of pain relief and improved grip and pinch strength. However, extension osteotomy alone does not address the increased trapezial slope [9,14–18]. Furthermore, a recent experimental study in cadavers revealed that a 158 (or 5 mm) opening wedge osteotomy of the trapezium reduced radial subluxation of the metacarpal on the trapezium by 64% of and increased contact pressure and contact area in the ulnar-dorsal region by 76%, away from the diseased compartments of the trapezial surface [19]. Other surgical techniques preserve the joint surfaces as in the addition-subtraction osteotomy. We believe that the addition-subtraction osteotomy causes less morbidity than the more complex vascularized articular osteotomies, which have similar biomechanical outcomes or the trapezial opening wedge procedure, which tends to close the first web [20–22]. With the addition-subtraction osteotomy, high patient satisfaction rate can be obtained. With the combination of both techniques, the morbidity of an extra donor site is also avoided by placing the removed subtraction graft of the thumb metacarpal into the osteotomy of the trapezium. Finally, this technique preserves the trapeziometacarpal joint, allowing other techniques to be used if painful arthritis should develop in the middle- or long-term [2,3]. Theoretically, possible complications of the combined techniques are on short-term peroperative trapezial and metacarpal fractures. On medium-term, dysesthesia, De Quervain’s tenovaginitis and complex regional pain syndromes can be observed [23]. In the long-term one has to pay attention for progression of arthritis and persistent instability [15,16]. We believe that the addition-subtraction osteotomy without ligamentoplasty was particularly effective in this case of acquired trapeziometacarpal dysplasia with metacarpal instability. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Kapandji A, Heim UFA. L’ostéotomie de réorientation de la selle trapézienne. Ann Chir Main 2002;21:124–33. [2] Goubau JF, Ackerman P, Kerckhove D, Van Hoonacker P, Berghs B. Addition-subtraction osteotomy with ligamentoplasty for symptomatic trapezial dysplasia with metacarpal instability. J Hand Surg Eur Vol 2011;37:138–44.
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[3] Goubau JF, Kerckhove D, Berghs B. Addition-subtraction osteotomy with ligamentoplasty for symptomatic trapezial dysplasia with instability. Ann Chir Main 2007;26:26–30. [4] Wilson JN. Basal osteotomy of the first metacarpal in the treatment of arthritis of the carpometacarpal of the thumb. Br J Surg 1973;60:854–8. [5] Wilson JN, Bossley CJ. Osteotomy in the treatment of osteoarthritis of the first metacarpal joint. J Bone Joint Surg Br 1983;65:179–81. [6] Matev I. Thumb metacarpal lengthening. Tech Hand Up Extrem Surg 2003;7(4):157–63. [7] Jandeaux M, Kanhouche R. Amputation of the index finger using Chase’s method. Acta Orthop Belg 1973;39:1162–9. [8] Frykman GK, O’Brien BM, Morrison WA, MacLeod AM. Functional evaluation of the hand and foot after one-stage toe-to-hand transfer. J Hand Surg Am 1986;11:9–17. [9] Kapandji AI, Moatti E, Raab C. La radiographie spécifique de l’articulation trapézo-métacarpienne. Sa Technique, son intérêt. Ann Chir Main 1980;34:719–26. [10] Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett’s fracture in the carpometacarpal joint of the thumb. Acta Orthop Scand 1952;22:249–57. [11] Kapandji A. Biomécanique des articulations trapézo-métacarpienne et scapho-trapézienne. In: Saffar P, editor. La rhizarthrose, 30. Paris: Expansion Scientifique Française; 1990. p. 67–70. [12] Rongières M. Anatomie et physiologie de l’articulation trapézo-métacarpienne humaine. Chir Main 2004;23:263–9. [13] Seitz Jr WH, Shimko P, Patterson RW. Long-term results of callus distraction-lengthening in the hand and upper extremity for traumatic and congenital skeletal deficiencies. J Bone Joint Surg Am 2010;92: 47–58.
[14] Ropars M, Siret P, Kaila R, Marin F, Belot N, Dréano T. Anatomical and radiological assessment of trapezial osteotomy for trapezial dysplasia in early trapeziometacarpal joint arthritis. J Hand Surg Eur Vol 2009;34:264–7. [15] Tomaino MM. Treatment of Eaton stage I trapeziometacarpal disease with thumb metacarpal extension osteotomy. J Hand Surg Am 2000;25:1100–6. [16] Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am 1973;55:1655–66. [17] Parker WL, Linscheid RL, Amadio PC. Long-term outcomes of first metacarpal extension osteotomy in the treatment of carpal–metacarpal osteoarthritis. J Hand Surg Am 2008;33:1737–43. [18] Shrivastava N, Koff MF, Abbot AE, Mow VC, Rosenwasser MP, Strauch RJ. Simulated extension osteotomy of the thumb metacarpal reduces joint laxity in lateral pinch. J Hand Surg Am 2003;28:733–8. [19] Cheema T, Salas C, Morrell N, Lansing L, Reda Taha MM, Mercer D. Opening wedge trapezial osteotomy as possible treatment for early trapeziometacarpal osteoarthritis: a biomechanical investigation of radial subluxation, contact area, and contact pressure. J Hand Surg Am 2012;37:699–705. [20] Messina A. Vascularized surgical rotation of a bi-articular trapezoid– trapeziometacarpal complex for the treatment of severe rhizarthrosis of the thumb. Chir Main 2000;19:134–40. [21] Roux JL. Les transferts osseux vascularisés au poignet et à la main. Chir Main 2003;22:173–85. [22] Roux JL. Arthroplastie trapézo-métacarpienne par rotation trapézo-métacarpienne en îlot, étude anatomique et technique opératoire. Chir Main 2004;23:72–8. [23] Gwynne-Jones DP, Penny ID, Sewell SA, Hughes TH. Basal thumb metacarpal osteotomy for trapeziometacarpal osteoarthritis. J Orthop Surg (Hong Kong) 2006;14:58–63.
ScienceDirect www.sciencedirect.com Chirurgie de la main 32 (2013) 408–412
Clinical case
Treatment of a symptomatic trapezial dysplasia with metacarpal instability following thumb metacarpal lengthening with an addition-subtraction osteotomy Traitement d’une dysplasie trapézienne symptomatique avec instabilité métacarpienne, consécutive à un allongement du premier métacarpien, par ostéotomie d’addition-soustraction C.K. Goorens a,b, J.-F. Goubau a,*,b, P. Van Hoonacker a, D. Kerckhove a, B. Berghs a b
a Department of Orthopaedic Surgery, AZ Sint-Jan AV Brugge – Oostende, Campus Brugge, Ruddershove 10, 8000 Brugge, Belgium Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
Received 7 February 2013; received in revised form 5 September 2013; accepted 15 September 2013 Available online 3 October 2013
Abstract The most important problem of trapezial dysplasia with thumb metacarpal instability is of bony origin. Together with the progressive capsuloligamentous decompensation it evolves in a progressive adduction deformity of the thumb metacarpal secondary to the dysplasia of the trapezium with its increased articular slope. The addition-subtraction osteotomy restores the anatomy combining two techniques: an abductionextension osteotomy of the first metacarpal to correct the axis of the first metacarpal and an opening wedge osteotomy of the trapezium to reorientate the trapezial saddle. We present a case of an addition-subtraction osteotomy in a case of symptomatic trapezial dysplasia with metacarpal instability following a thumb metacarpal lengthening in a severely mutilated hand. This technique was especially effective in reducing the instability and pain but mainly in maintaining mobile the only remaining joint of the thumb. # 2013 Elsevier Masson SAS. All rights reserved. Keywords: Addition-subtraction; Osteotomy; Metacarpal lengthening; Trapezial dysplasia
Résumé Le problème le plus difficile à résoudre posé par la dysplasie trapézienne avec instabilité du premier métacarpien est d’origine osseuse. En association avec une décompensation capsuloligamentaire progressive, elle évolue vers une déformation progressive en adduction du premier métacarpien, secondaire à la dysplasie du trapèze qui présente une pente articulaire excessive. L’ostéotomie d’addition-soustraction restaure l’anatomie en combinant deux techniques : une ostéotomie d’abduction et d’extension du premier métacarpien pour corriger son axe, et une ostéotomie d’ouverture du trapèze pour réorienter la selle trapézienne. Nous présentons un cas d’ostéotomie d’addition-soustraction réalisée pour traiter une dysplasie trapézienne symptomatique avec instabilité métacarpienne, consécutive à un allongement du premier métacarpien sur une main sévèrement mutilée. Cette technique s’est révélé particulièrement efficace en diminuant l’instabilité et la douleur et, surtout, en conservant la mobilité de la seule articulation encore mobile du pouce. # 2013 Elsevier Masson SAS. Tous droits réservés. Mots clés : Addition-soustraction ; Ostéotomie ; Allongement métacarpien ; Dysplasie trapézienne
1. Introduction
* Corresponding author. E-mail addresses: [email protected], [email protected] (J.F. Goubau).
Trapeziometacarpal (TM) dysplasia with metacarpal instability can evolve into a disabling condition, characterized by pain, joint instability, decreased motion and strength, and eventually leading to deformity of the joint on the long-term.
1297-3203/$ – see front matter # 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.main.2013.09.005
C.K. Goorens et al. / Chirurgie de la main 32 (2013) 408–412
obtained a lengthening of 2 cm. We did not perform a proximal transplant of the insertion of the adductor pollicis [6]. This resulted in an increased proximo-ulnar adduction force of the reconstructed thumb metacarpal head. An additional rotational osteotomy of the base of the fifth metacarpal and lengthening of the first metacarpal combined with a translocation of the fourth metacarpal head on the thumb metacarpal were necessary to finally achieve full functional pinch between thumb and little finger (Figs. 1 and 2). Apart from two neuromas, which were treated surgically, the evolution was uneventful the following years.
Pain is induced by thumb to finger pinch. When conservative treatment fails, operative options are to be considered. The most important problem is of bony origin: induced subluxation of the base of the thumb metacarpal and dysplasia of the trapezium with its increased articular slope assessed through slope angle (‘‘angle de dévers’’, in French), which is the angle measured between the axis of the second metacarpal and the slope of the trapezium (normal 1298 with range 68) in a frontal view according to Kapandji and Heim [1]. The addition-subtraction osteotomy, reported by Goubau et al. in 2007, combines two techniques: an abduction osteotomy of the first metacarpal to correct the axis of the first metacarpal and an opening wedge osteotomy of the trapezium to reorientate the trapezial saddle in order to restore a normal slope angle. The combination of both techniques restores the anatomy and centers the forces acting across the joint, which mostly results in restoration of an acceptable level of mobility, force, and stability of the thumb column [2–5]. We present a case where was performed an additionsubtraction osteotomy for symptomatic trapezial dysplasia with metacarpal instability following a thumb metacarpal lengthening according to the technique described by Matev [6], in a severely mutilated hand.
2.2. Trapeziometacarpal instability
2. Case report An addition-subtraction osteotomy was performed in a 31year-old right-handed male presenting a symptomatic trapezial dysplasia with progressive metacarpal instability progressively induced by a metacarpal lengthening of the thumb using the Matev technique [6]. 2.1. Presentation of the case In 1999, at the age of 18 years, he sustained an accidental circle saw accident with transmetacarpophalangeal amputation of the thumb, transmetacarpal amputation of the second, third and forth fingers and laceration with multifragmentary fracturing of the fifth finger of his right hand. In emergency were performed replantation of the thumb, replantation of the index finger on the third ray, and replantation of the third finger on the remaining ring finger [7]. The skin defect was closed with a full-thickness graft of the skin envelope of the fourth amputated finger. An arthrodesis of the interphalangeal (IP) joints of the fifth finger was performed in functional position. Unfortunately, venous congestion evolved into necrosis of the three replanted fingers, which eventually were amputated. After 5 months, the fifth finger regained 908 of active flexion in the metacarpophalangeal joint with healed arthrodesis of his proximal interphalangeal (PIP) joint. The distance between the fifth finger and the stump of the thumb was 1.5 cm when pinching was attempted. Possible reconstruction procedures to restore his pollicidigital pinch were discussed with the patient. Because of his soccer practice, he refused for obvious reasons a toe-to-thumb transfer [8]. Therefore, we performed a distraction procedure of the first metacarpal with an external fixator as described by Matev and
409
[(Fig._1)TD$IG]
Six years after the initial accident, pain complaints in the trapeziometacarpal joint increased (Numerical Scale score of 8/ 10). We measured a grip strength of 14 kg (38 kg left), key pinch of 3.5 kg (7.5 kg left) and precision pinch of 3.5 kg (2.5 kg left) using a calibrated hydraulic dynamometer and a hydraulic pinch gauge (Baseline Fabrication Enterprises Inc., New York, USA). He scored a QuickDASH score of 40.9. He was diagnosed with a symptomatic trapezial dysplasia with metacarpal instability, according to the radiographic analysis. Eaton views with radial stressing confirmed thumb metacarpal instability at its base (Fig. 3). Radiographs of the trapeziometacarpal joint according to Kapandji et al. [9] revealed degenerative articular changes and an increased slope angle compared to the contralateral side (Fig. 4). Conservative treatment with immobilization and non-steroidal anti-inflammatory medication failed. In order to correct the bony anatomy, an addition-subtraction osteotomy without ligamentoplasty was performed (Fig. 5). The TM joint was exposed through a proximally extended anterolateral Gedda and Moberg incision. This incision provides excellent visualization of the TM joint and preservation of dorsal vascularity and ligamentary stability of the saddle joint [10]. Under guidance of the image intensifier, an extension-abduction osteotomy in the proximal metaphysis of the thumb metacarpal was performed. The orientation of the closing wedge of 5 mm was slightly larger dorsally and radially
Fig. 1. Functional result after initial reconstruction.
[(Fig._2)TD$IG] 410
C.K. Goorens et al. / Chirurgie de[(Fig._4)TD$IG] la main 32 (2013) 408–412
Fig. 4. Frontal radiograph of the trapeziometacarpal joint showing a high slope angle. The angle was measured by using a 1.5 cm parallel line to a reference line through the third metacarpal, because of the absence of the second metacarpal (preop). Fig. 2. Clinical result after initial reconstruction.
to create somewhat more antepulsion. Under compression, the osteotomy was fixed with a metal clip (Memoclip1, Memometal, Stryker Corporate, Kalamazoo, Michigan, USA). Subsequently, under image intensifier control in a frontal view of the trapezium, an osteotomy was performed in the middle of the trapezium, using an oscillating saw and finishing up with a chisel parallel to the articular surface of the trapezium. Care was taken to keep an ulnar hinge at the ulnar end of the osteotomy. The resected metacarpal wedge was inserted in the opened osteotomy and press-fitted without osteosynthesis. After 6 weeks of immobilization in a short arm cast taking the thumb, mobilization was resumed evolving progressively into a satisfactory functional pinch.
Four years after the addition-subtraction osteotomy, pain complaints of the trapeziometacarpal joint have disappeared completely (Numerical Scale score 0/10). We measured opposition at 9 and retropulsion at 1 according to Kapandji
[(Fig._5)TD$IG]
[(Fig._3)TD$IG]
Fig. 3. Frontal Eaton view with radial stressing showing subluxation of the trapeziometacarpal joint.
Fig. 5. Frontal radiograph of the trapeziometacarpal joint showing postoperative addition-subtraction osteotomy status with a decreased slope angle (postop).
[(Fig._6)TD$IG]
C.K. Goorens et al. / Chirurgie de la main 32 (2013) 408–412
Fig. 6. Overview of the addition-subtraction osteotomy technique.
[11], grip strength of 14 kg, key pinch 3.5 kg and precision pinch 7.5 kg. QuickDASH score improved slightly to a score of 36.4. Initial postoperative radiographs showed a reduction of the slope angle compared preoperative situation. There was at 5 years of follow up on comparative x-rays no further progression of the degenerative osteoarthritis [12] (Fig. 6). 3. Discussion The period of time between the onset of symptoms of trapeziometacarpal instability and eventual irreversible degenerative changes can last for many years. Since the conservative treatment is usually effective enough, surgery is rarely indicated. Joint subluxation after a metacarpal lengthening (incidence of 0.7%) is the result of an adjacent unstable joint, unrecognized ligamentous injury or inadequate rehabilitation. Its prevention should include a careful preoperative assessment of the adjacent joints, initiation of early rehabilitation, and avoidance of injury to any of the ligamentous structures at the adjacent joints [13]. In this case the increased axial load due to distalisation of the insertion of the adductor pollicis (Matev procedure), the absence of mobile – potentially compensatory – joint(s) distal to the dysplastic trapeziometacarpal joint enhanced the onset of symptoms at the thumb base. Techniques that are applicable for arthritic joints in young patients, such as fusion or prosthetic replacement, cannot be used in painful but healthy unstable dysplastic joints [14,15]. Moreover, in this case trapeziometacarpal fusion would have dramatic functional drawbacks for fine pollicidigital prehension. Since the joint was apparently in very good condition, without radiographic signs of dynamic subluxation of the base of the thumb metacarpal or joint space narrowing, we did not
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perform the additional ligamentoplasty as proposed by Goubau et al. [2,3]. Moreover, the ligamentoplasty tends to favor stiffening of the joint, which in this case had to be avoided since it was the only mobile joint of his thumb column. Isolated ligamentoplasty was in this particular case not an option, since it did not address the bony dysplasia [16]. Metacarpal osteotomies have been reported as treatment of early stage trapeziometacarpal joint arthritis by extension osteotomy. A 5 mm closing wedge corresponds with a metacarpal correction of 20–308. Extension osteotomy of 308 gave good results in terms of pain relief and improved grip and pinch strength. However, extension osteotomy alone does not address the increased trapezial slope [9,14–18]. Furthermore, a recent experimental study in cadavers revealed that a 158 (or 5 mm) opening wedge osteotomy of the trapezium reduced radial subluxation of the metacarpal on the trapezium by 64% of and increased contact pressure and contact area in the ulnar-dorsal region by 76%, away from the diseased compartments of the trapezial surface [19]. Other surgical techniques preserve the joint surfaces as in the addition-subtraction osteotomy. We believe that the addition-subtraction osteotomy causes less morbidity than the more complex vascularized articular osteotomies, which have similar biomechanical outcomes or the trapezial opening wedge procedure, which tends to close the first web [20–22]. With the addition-subtraction osteotomy, high patient satisfaction rate can be obtained. With the combination of both techniques, the morbidity of an extra donor site is also avoided by placing the removed subtraction graft of the thumb metacarpal into the osteotomy of the trapezium. Finally, this technique preserves the trapeziometacarpal joint, allowing other techniques to be used if painful arthritis should develop in the middle- or long-term [2,3]. Theoretically, possible complications of the combined techniques are on short-term peroperative trapezial and metacarpal fractures. On medium-term, dysesthesia, De Quervain’s tenovaginitis and complex regional pain syndromes can be observed [23]. In the long-term one has to pay attention for progression of arthritis and persistent instability [15,16]. We believe that the addition-subtraction osteotomy without ligamentoplasty was particularly effective in this case of acquired trapeziometacarpal dysplasia with metacarpal instability. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Kapandji A, Heim UFA. L’ostéotomie de réorientation de la selle trapézienne. Ann Chir Main 2002;21:124–33. [2] Goubau JF, Ackerman P, Kerckhove D, Van Hoonacker P, Berghs B. Addition-subtraction osteotomy with ligamentoplasty for symptomatic trapezial dysplasia with metacarpal instability. J Hand Surg Eur Vol 2011;37:138–44.
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