Excision of the trapezium and interposition arthroplasty with gelfoam for the treatment of trapeziometacarpal osteoarthritis

Excision of the trapezium with Gelfoam interposition was performed in 35 thumbs, 34 of which were evaluated after an average 5 years. Twenty-four patients had unilateral procedures. The follow-up examination included a standardized questionnaire and clinical and radiological examinations. Pain relief was achieved in all cases. The patients considered that 32 of their operated hands had improved function, while two had not improved. All patients were satisfied with the final postoperative result. Adduction of the thumb to the index finger, and opposition to the tip of the little finger was possible in all cases. Weakness, in comparison to the other thumb, of lateral pinch (71%; P=0.0001), tip pinch (74%; P=0.007), and grip strength (85%; P=0.006) were observed. The first web span was preserved in all hands. Calculation of the trapezial space ratio demonstrated only slight, insignificant shortening (7%; P=0.06) of the thumb ray. No significant correlations between the postoperative trapezial space ratio and lateral pinch strength, tip pinch strength, and grip strength were observed. We conclude that excision of the trapezium and Gelfoam interposition has no specific complications and is a reliable surgical treatment for osteoarthritis of the trapeziometacarpal joint.

Trapeziometacarpal joint osteoarthritis and carpal tunnel syndrome: a new surgical approach for concomitant treatment

A new approach for the concomitant surgical treatment of trapeziometacarpal joint osteoarthritis and carpal tunnel syndrome through the same incision is described. The technique was used in 25 patients (20 women, five men; mean age, 56 years). At a mean follow-up of 27 months, there was complete disappearance of the symptoms of carpal tunnel syndrome in 20 of the 25 patients, incomplete but substantial relief in four patients, and no improvement in one patient. One patient had scar tenderness and another had a superficial wound infection. The surgical technique is simple, safe and cost-effective as it avoids separate operations for both pathologies. The procedure is not suitable for severe carpal tunnel syndrome or when direct visualization of the median nerve and the carpal tunnel is necessary.

[Bone lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique]

OBJECTIVES

We evaluated the results of lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique.

METHODS

We treated congenitally short metacarpus (n=7) and metatarsus (n=4) of five patients (4 females, 1 male; mean age 15 years; range 10 to 21 years) by callotasis. Callus distraction was performed with the use of mini-Orthofix or Ilizarov type semicircular external fixators. The distraction rate was 0.25x2 mm/day for both types. The mean follow-up period was 23 months (range 12 to 33 months).

RESULTS

The mean metacarpal and metatarsal lengthenings were 20 mm (range 15 to 25 mm) and 25 mm (range 20 to 30 mm), respectively. The mean healing index was 1.4 months/cm for metacarpal lengthening, and 1.8 months/cm for metatarsal lengthening. No neurovascular complications were encountered. One patient required autogenous fibular grafting for union. Pin tract infections were found in three patients. The overall complication rate was 36%.

CONCLUSION

Callotasis is an effective and reliable method for lengthening of short metacarpal and metatarsal bones. In addition, it preserves the periosteal bone tissues, which has a favorable effect on the duration of treatment.

[Conservative treatment of metacarpal fracture]

Conservative treatment of meatacarpale fracture is recommended if there are no joint displacement, rotation failures, displacement over 30 degrees ad axim and shortening over 5 mm. Operative procedures should be done in open fractures and serial of fractures of metacarpale bones. Early functionally treatment should be done in stable, not displaced fractures. Cast can be used only for a short time in full extended position of fingers and flexion in metacarpo-phalangeal joint in 60-90 degrees. Twin-tapes after reduction of edema allowed free range of motion by fixed rotation. Closed reduction of displaced fractures of fifth metacarpal bone (boxer's fracture) isn't successful. Cases with displacement over 30 degrees may be operatively treated by intramedullary stabilization.

[Diagnosis and treatment of complications associated with closed multi-fractures in metacarpals]

OBJECTIVE

To pay attention to the diagnosis and treatment of the complications associated with closed multi-fractures in metacarpals.

METHODS

From 1997 to 2000, out of 382 patients with closed multi-fractures in metacarpals, 12 had complications. In 7 cases of fractures at the second, third, fourth and fifth metacarpal shaft, complicated by acute compartment syndrome in hand, compartmental fascia were incised for decompress; open reduction and internal fixation were performed. In 4 cases of fractures at the metacarpal base, complicated by acute carpal tunnel syndrome, the fracture was reduced and fixed without transection of the transverse carpal ligament. In 1 case of fracture at metacarpal base, complicated by direct contusion of the median nerve, the fracture was reduced without treatment of the median nerve.

RESULTS

All patients were followed up for 3 months. Fracture healed 4-6 weeks postoperatively. No claw deformity and dysfunction of the median nerve occurred. The arc of motion of the proximal interphalangeal and distal interphalangeal joints were normal.

CONCLUSION

During fracture reduction, we should pay attention to the complications associated with closed multi-fractures at metacarpal to decrease hand malfunction.

Closed reduction transarticular Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett's fracture dislocation

Thirty two patients with fracture dislocations of the base of the thumb metacarpal with a single large fracture fragment (Bennett's fracture) were either treated by open reduction and internal fixation or closed reduction and percutaneous transarticular Kirschner wiring. All were assessed at a mean follow up of 7 (range 3-18) years. Patients with an articular step off more than 1mm were excluded. The type of treatment did not influence the clinical outcome or the prevalence of radiological post-traumatic arthritis. The percutaneous group had a significantly higher incidence of adduction deformity of the first metacarpal. This was attributed to Kirschner wire placement near the fracture line or in the compression zone of the fracture, resulting in loss of reduction. This however did not result in an inferior outcome.

Complications of trapeziometacarpal arthrodesis using plate and screw fixation

PURPOSE

This study was designed to determine the complications associated with plate and screw fixation of thumb trapeziometacarpal arthrodesis and to compare these results with a previous report from our institution using K-wire fixation.

METHOD

We retrospectively reviewed 26 trapeziometacarpal arthrodeses that used plate and screw fixation. The most common diagnosis was primary osteoarthritis and the average follow-up evaluation was 40 months. Nineteen patients were available for a clinical follow-up examination and radiographs. These results were compared with the previously published K-wire fixation group that consisted of 59 arthrodeses with an average follow-up period of 84 months.

RESULTS

There were 2 (8%) painful nonunions. There were 6 (23%) hardware malpositions, most frequently associated with a screw in the trapeziotrapezoid joint. Seven (27%) arthrodeses had a second procedure, most commonly hardware removal. Twenty-one (81%) of the patients were satisfied and reported they would have arthrodesis again. In the K-wire fixation group 4 of 59 (7%) arthrodeses went on to nonunion and 2 of 59 required a secondary procedure; patient satisfaction was high (98%).

CONCLUSIONS

K-wire and plate and screw fixation have comparable union rates. In the plate and screw fixation group, however, the satisfaction rate was lower and a second surgery was more common. We now recommend pin fixation when performing trapeziometacarpal joint arthrodesis.

Hemiarthroplasty for trapeziometacarpal arthritis - a useful alternative?

We performed hemiarthroplasty using the Swanson titanium implant for treatment of isolated and advanced trapeziometacarpal joint osteoarthritis Nineteen implants were placed in 18 patients (mean age: 57 years) between 1995 and 1999. One joint required revision and conversion to trapeziectomy. Eighteen joints in 17 patients were evaluated with a mean follow-up period of 34 (range, 14-60) months. Good pain relief was noted in 13 hands. All patients had good hand function as scored using validated questionnaires. Radiographic loosening occurred with five implants and trapezial wear in ten joints. Though radiographic loosening or trapezial wear did not correlate with less satisfactory clinical results, failure of the implant is a concern in the long term. Preliminary results indicate that hemiarthroplasty can be a useful treatment alternative in selected, relatively young patients with isolated trapeziometacarpal osteoarthritis and good bone stock. Good motion and stability can be preserved Failures can be effectively salvaged by trapeziectomy.

Idiopathic avascular necrosis of the metacarpal head

Avascular necrosis of the metacarpal head is a rare condition. Although the condition is associated with trauma, systemic lupus erythematosus, and steroid use, it can occur spontaneously without any obvious cause. Any metacarpal may be affected and the pathologic changes are similar to those described in other bones such as the femur. The diagnosis requires an index of suspicion in a young patient with spontaneous onset of symptoms localized to a metacarpophalangeal joint. Magnetic resonance imaging is a useful early diagnostic tool when the radiographic findings are nonspecific or absent. The natural history of the condition is not known. Although symptoms may resolve with nonoperative treatment, progressive collapse of the metacarpal head and subsequent degenerative arthritis is a possible long-term outcome. Curettage of the lesion and supplementary cancellous bone grafting has been reported to provide symptomatic relief in cases resistant to nonoperative treatment. A case is presented of idiopathic avascular necrosis of the head of the dominant ring finger metacarpal in a 27-year-old woman. The purpose of this report is to highlight the clinical presentation, radiographic features, pathologic findings, and outcome at 2 years after curettage and bone grafting.

[Functional bracing after operative treatment of metacarpal fractures]

Metacarpal fractures are frequently immobilized for several weeks in forearm plaster cast, even after operative stabilisation. The purpose of this study was to assess the results after early functional treatment using metacarpal braces. 87 patients with 105 metacarpal fractures were included in a prospective study from February 1997 until November 2000. The AO-classification of the fractures was assessed for all patients: n=33 A1,n=9 A2,n=3 A3, n=27 B1,n=6 B2,n=7 B3,n=10 C1,n=7 C2, n=3 C3.Exclusion criteria were tendon or nerve injuries,pathological fractures (tumor or metabolic),additional digital fractures of the same ray,and a patients age of less then 18 years. All fractures were treated operatively. 73 patients (84%) were recruited for follow up after an average period of nine months. Average grip strength reached 96% (Jamar II) for the power grip, 97% for the three finger and 98% for the pinch grip compared to the contra-lateral side in the group where the dominant hand was affected. It was 88% for the power grip, 91% for the three finger grip and 94% for the pinch grip after injury of the non-dominant hand. The mean postoperative pain score on the visual analog scale was 0.2 for resting conditions, 0.8 for motion and 2.2 under stress.A decreased total range of motion was observed in 15 of 73 patients (21%). The average DASH score reached 6.5 points. Physical therapy was required for an average of 6.7 weeks. Only 41% of the patients with early functional treatment required further physical therapy after removal of the brace. The metacarpal brace used in this series protects from direct trauma,and provides a high patients comfort.It has no disadvantages considering fracture retention compared to conventional plaster casts or splints. The need for physical therapy is reduced after functional fracture bracing.Thus, the metacarpal brace has proven to be a suitable tool for early functional treatment after operative stabilisation of metacarpal fractures.

Magnetic resonance imaging characteristics of bizarre parosteal osteochondromatous proliferation of the hand: a case report

Bizarre parosteal osteochondromatous proliferation (BPOP) is a reactive lesion of cortical bone. A case of fifth metacarpal BPOP with intramedullary inflammatory extension is shown by magnetic resonance imaging. Histologically the intramedullary extension showed fibrosis with inflammatory cell infiltration. The surrounding adipose tissue showed fibrosis, focal inflammatory cell infiltration, and vascular proliferation. It is important to recognize that BPOP can bear radiologic resemblance to malignant lesions or osteomyelitis when there is an intramedullary inflammatory extension. Preservation of cortical bone under the osteocartilaginous mass on T1-weighted magnetic resonance imaging, and homogenous intramedullary enhancement with gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA), can be helpful for distinguishing BPOP from malignant lesions.

Early versus late mobilisation after simple excision of the trapezium

We randomly selected 39 patients undergoing excision of the trapezium for osteoarthritis of the first carpometacarpal joint into two groups, with mobilisation either at one or at four weeks after operation. The patients were reviewed at a median of six months (6 to 8). The clinical details, the severity of the disease and the preoperative clinical measurements of both groups were similar. Excision of the trapezium resulted in significant improvement in objective and subjective function. Comparison of the outcomes of the two groups showed no differences except that patients found early mobilisation significantly more convenient. Although there was no significant difference in the range of movement between the groups, there was a small loss of movement at the metacarpophalangeal joint in the late mobilisation group. Our findings show that simple excision of the trapezium is an effective procedure for patients with carpometacarpal osteoarthritis of the thumb and that prolonged splintage is neither necessary nor desirable.

A mechanical comparison of bone-ligament-bone autografts from the wrist for replacement of the scapholunate ligament

A study was performed to compare the mechanical properties of two intracarpal ligaments with those of the dorsal component of the scapholunate interosseous ligament (SLIL). Trapezoid-to-second metacarpal, capitate-to-trapezoid ligaments, and the dorsal part of the SLIL were obtained as bone-ligament-bone grafts from fresh frozen cadavers. Their respective load to failure and stiffness were measured under uniaxial load on a servohydraulic machine and compared. The capitate-to-trapezoid ligament closely approximated the load to failure and stiffness of the dorsal SLIL, whereas the trapezoid-to-second metacarpal ligament was significantly stronger and stiffer than the dorsal SLIL. These 2 intracarpal bone-ligament-bone grafts share similar mechanical properties with the dorsal component of the scapholunate ligament and might be used clinically to replace it.

[The "candlestick" technique for the correction of certain types of congenital metacarpal synotosis]

Metacarpal synostosis is a rare congenital hand malformation requiring only occasionally a surgical correction. However in case of divergent epiphyses there is a progressive accentuation of the deformity. In the "Y" type of symmetrical synostosis, the authors propose a trapezoidal osteotomy with upside down relocation allowing realignement of the epiphyses without distant bone donor site.

Stabilization of the pre-arthritic trapeziometacarpal joint using ligament reconstruction

INTRODUCTION

Trapeziometacarpal pre-arthrosis is a common condition with only limited therapeutic possibilities. Eaton and Littler designed a tendon stabilization.

MATERIALS AND METHODS

A series of 21 thumbs with painful carpometacarpal joints, treated with a ligament reconstruction according to Eaton and Littler, is described. Three failed and further surgery was required. The outcome of 18 is evaluated. There were 11 women, 7 men with a mean age of 33.7 years, all having stages I or II of osteoarthritis. Six (30%) had a traumatic event in their history.

RESULTS

In the early stages of degenerative osteoarthritis, the overall outcome was good with a mean DASH score of 23.2. The carpometacarpal joint was stable but a 43% progression of radiographic osteoarthritic deterioration of the joint occurred.

CONCLUSION

Stabilization of a painful pre-arthritic trapeziometacarpal joint is useful and reliable. A traumatic instability had worse results and probably is a contraindication to this technique.

Self-reinforced bioabsorbable versus metallic fixation systems for metacarpal and phalangeal fractures: a biomechanical study

Bioabsorbable fixation devices offer a useful option to treat small bone fractures of the hand if the prerequisite of reliable and stable osteofixation is met. We compared the stabilities of various bioabsorbable fixation devices with metallic fixation devices by using an oblique osteotomy model in radial to ulnar orientation. The 1.5-mm, self-reinforced, poly-L-lactide (SR-PLLA) pins provided fixation rigidity comparable with 1.5-mm K-wires in dorsal and palmar apex bending, whereas in lateral apex bending and in torsion the rigidity was equal to that of 1.25-mm K-wires. The 2.0-mm, self-reinforced, poly-L/DL-lactide (SR-P(L/DL)LA) 70/30 screws provided rigidity comparable with that of 1.5-mm K-wires in all testing modes. The bioabsorbable plate considerably enhanced the bending stabilities of the fixation system, but a single interfragmentary screw provided only limited rotational rigidity. The results show that by using ultra-high strength self-reinforced implants adequate fixation stability for hand fracture fixation can be achieved.

Midcervical tetraplegia with strong wrist extension: a two-stage synergistic reconstruction of the hand

Reconstructive surgery can restore appreciable function of the upper limb in tetraplegic patients. The magnitude of the function regained depends on several factors: (1) the level of the spinal cord lesion, (2) careful patient selection, (3) thoughtful application of the basic principles of tendon transfer, (4) absence of severe spasticity, (5) the remaining sensory function of the hand, and (6) the surgical program and the surgeon's expertise with this type of patient. Reconstructive surgery offers patients not only greater physical independence but also psychological benefits. This article refers to cases with midcervical spinal cord lesion where wrist extension is complete and strong (MRC grading 5). It describes the author's strategy and technical choices in these patients, based on an ever evolving experience of more than 30 years.

Callotasis lengthening in patients with brachymetacarpia

Callotasis lengthening is an established method, but few cases of metacarpal lengthening have been reported. The authors performed callotasis lengthening to treat brachymetacarpia in six digits in three patients. The patient age at the time of distraction ranged from 10 to 19 years. The period of application of an external fixator averaged 13.9 weeks (range 10-19 weeks). All the metacarpals achieved the target length, and all patients were satisfied with the esthetic improvement. The length of the metacarpal distraction averaged 15.2 mm (range 10-18 mm). Complete consolidation of the transport gap was achieved for five of six digits. One digit that had a history of previous lengthening required bone graft. The average healing index was 62.3 days/cm. There were no serious complications. In four digits, the range of flexion of the metacarpophalangeal joint was increased after lengthening, and this enabled the patient to use the digit easily in a palmar grasp. Brachymetacarpia is an appropriate indication for callotasis lengthening in congenital deformities of the upper extremities.

[Long-term results of total trapezium-metacarpal joint arthroplasty using the de la Caffinière cemented prosthesis]

BACKGROUND

We report a series of 13 arthroplasties using De la Caffinière cemented trapezium-metacarpal prostheses which were implanted to treat unstable and painful TM arthrosis in our department. 10 patients were women and 1 was a man. Mean age, 65 years (range 50 to 75 years). 2 patients received bilateral implants. The mean follow-up was 8 years. The mean mobility of the operated side compared with the opposite thumb were: abduction 38 degrees/39 degrees, flexion 7 degrees/9 degrees y extension 29 degrees/31 degrees. The radiography showed in one case a radiolucent area around the trapezium component of the prosthesis with no clinical repercussion. The subjective results were good in 9 cases and acceptable in 2. The good long-term results of this procedure make it a valid alternative for the treatment of painful TMC arthrosis which limits normal function.

[Trapeziometacarpal denervation. Description of surgical technique and preliminary results from a prospective series of 14 cases]

INTRODUCTION

The main goal of first carpometacarpal arthritis surgical treatment is to relieve pain. The main disadvantages of the usual techniques (trapeziectomy, implant arthroplasty) are loss of strength or presence of a prosthetic device. It is difficult to propose such extensive surgery at an early stage of the disease. Selective denervation of the first carpometacarpal joint seems to be an interesting choice. We propose a new technique of denervation based on our previous anatomical investigations.

TECHNIQUE

Two incisions are needed to cut all the articular branches derive from the superficial branch of the radial nerve, the palmar cutaneous branch of the median nerve, the thenar branch of the median nerve and the lateral ante brachial cutaneous nerve.

MATERIAL

Fourteen patients were prospectively included in our study with a mean follow-up of 5 months.

RESULTS

Pain relief was very satisfying in 12 cases (mean decrease 84%). An increase in grip and key pinch strength was noted. Complications were uncommon, excepted temporary paresthésia in the radial nerve area.

DISCUSSION

This technique seems to be promising and a good indication for patients with no disabling deformity, but only long-term results will confirm the place of denervation in the treatment of first carpometacarpal arthritis.

Comparison of insertion time and pullout strength between self-tapping and non-self-tapping AO 4.5-mm cortical bone screws in adult equine third metacarpal bone

OBJECTIVE

To compare screw insertion characteristics and pullout mechanical properties between self-tapping (ST) and non-self-tapping (NST) AO 4.5-mm cortical bone screws in adult equine third metacarpal bone (MC3).

STUDY DESIGN

In vitro biomechanical experiment.

ANIMALS OR SAMPLE POPULATION

Seven pairs of adult equine MC3.

METHODS

Bicortical holes were drilled transversely in proximal metaphyseal, diaphyseal, and distal metaphyseal locations of paired MC3. NST screws were inserted in pre-tapped holes in 3 sites of one bone pair, and ST screws were inserted in non-tapped holes of contralateral MC3. Tapping and screw insertion times and maximum torques were measured. Screw pullout mechanical properties were determined.

RESULTS

Screw insertion time was longer for ST screws. Total time for tapping and insertion (total insertion time) was over twice as long for NST screws. Statistically significant differences were not observed between screws for any pullout mechanical property. From pullout tests, diaphyseal locations had significantly stiffer and stronger structure than metaphyseal locations. Pullout failure more commonly occurred because of screw breakage than bone failure. Bone failure and bone comminution were more commonly associated with ST screws. Bone failure sites had pullout failure loads that were 90% of screw failure sites.

CONCLUSIONS

NST and ST 4.5-mm-diameter cortical bone screws have similar pullout mechanical properties from adult equine MC3. ST screws require less than half the total insertion time of NST screws.

CLINICAL RELEVANCE

Use of ST 4.5-mm-diameter cortical bone screws should be considered for repair of adult equine MC3 fractures; however, bone failures at screw sites should be monitored.

Long-term results of trapeziometacarpal silicone arthroplasty

Long-term results of trapeziometacarpal (TMC) joint silicone arthroplasty were evaluated. From 1975 to 1990, 90 TMC joint silicone implants were placed in 85 patients with TMC joint arthritis caused by osteoarthritis and inflammatory arthritis. Sixty-two implants in 58 patients were available for follow-up evaluation averaging 16.4 years (range, 10-25 years) with a 10-year minimum. Patient satisfaction; range of motion; grip, key pinch, and tip pinch strengths; and radiographs were recorded. Eighty-four percent of the thumbs had satisfactory results with good-to-excellent pain relief and function. Grip, key pinch, and tip pinch strengths increased. The number of thumb tips able to touch the palmar base of the small finger increased. Subluxation was apparent in 19% of implants but was not clinically important; however, implant fracture occurred in 6% and required revision. None of the 62 implants had frank silicone synovitis. Silicone arthroplasty seems to be a reliable option for disabling TMC joint arthritis and is associated with a high degree of patient satisfaction.

A biomechanical comparison of equine third metacarpal condylar bone fragment compression and screw pushout strength between headless tapered variable pitch and AO cortical bone screws

OBJECTIVES

To compare bone fragment compression and the mechanical pushout strength and stiffness of 6.5-mm Acutrak Plus (AP) and 4.5-mm AO cortical (AO) bone screws after stabilization of a simulated equine third metacarpal (MC3) bone complete lateral condylar fracture.

STUDY DESIGN

In vitro biomechanical paired study of screw insertion variables, bone fragment compression, and screw pushout tests using a bone screw stabilized simulated lateral condylar fracture model.

SAMPLE POPULATION

Six pairs of cadaveric equine MC3s.

METHODS

Metacarpi were placed in a fixture and centered on a biaxial load cell in a materials testing system to measure torque, compressive force, and time for drilling, tapping, and screw insertion. Fragment compression was measured with a pressure-sensing device placed between the simulated fracture fragments during screw insertion for fragment stabilization. Subsequently, screws were pushed out of the stabilized bone fragments in a single cycle to failure. A paired t test was used to assess differences between site preparation, screw insertion, fragment compression, and screw pushout variables, with significance set at P <.05.

RESULTS

Measured drilling variables were comparable for AO and AP specimens. However, the AP tap had significantly greater insertion torque and force. Mean maximum screw insertion torque was significantly greater for AO screws. For fragment compression, AP screws generated 65% and 44% of the compressive pressure and force, respectively, of AO screws. AP screws tended to have higher overall pushout strength. Pushout stiffness was similar between both screw types.

CONCLUSION

The 6.5-mm tapered AP screw generated less interfragmentary compressive pressure and force but had similar pushout stiffness. Evaluation of failure patterns demonstrated that AP screws had greater pushout strength compared with 4.5-mm AO screws for fixation of a simulated complete lateral condylar fracture.

CLINICAL RELEVANCE

The 6.5-mm tapered AP screw should provide ample holding strength but would provide less interfragmentary compression than 4.5-mm AO screws for repair of complete lateral condylar fractures in horses.