Thumb basal joint: Utilizing new technology for the treatment of a common problem

Trapeziectomy and Suture-Button Suspensionplasty for Basilar Thumb Arthritis: Is It Enough to Prevent First Ray Subsidence?

Introduction  Trapeziectomy and suture-button suspensionplasty (SBS) are a novel option to treat end-stage trapeziometacarpal (TMC) osteoarthritis. Our purpose is to evaluate our outcomes with this technique and in this setting, with a minimum of 18 months of follow-up. Materials and Methods  Twenty-eight patients were included, operated between 2016 and 2018. We recorded demographic data, preoperative Eaton stage, follow-up and operative times. The patients completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire and tip pinch, key pinch, and grip strength were measured. First metacarpal subsidence was calculated, and postoperative complications were documented. Results  The average follow-up was 34 months. The mean QuickDASH was 32 at the final follow-up. The average strength results were 20 kg for grip, 3.6 kg for tip pinch, and 4.2 kg for key pinch. The rate of first ray subsidence was 10.7%. We encountered three complications: a hardware intolerance, a second metacarpal fracture, and a suture rupture. There was one reoperation to remove an implant. Conclusion  Trapeziectomy and SBS functional results are similar to other techniques, with less subsidence of the first ray and allowing for early mobilization and fast recovery. This procedure is a safe and promising option in the treatment of TMC osteoarthritis, with good medium-term outcomes.

Trapeziectomy with suture-button suspensionplasty versus ligament reconstruction and tendon interposition: a randomized controlled trial

The purpose of the present study was to compare the results of patients operated with trapeziectomy and ligament reconstruction and tendon interposition (LRTI) using flexor carpi radialis tendon versus trapeziectomy followed by suspension of the first metacarpal to the second metacarpal using a Mini TightRope® suture button (suture button suspension: SBS). A single-center prospective randomized controlled trial was performed, comparing 37 patients with SBS and 39 with LRTI. All surgeries were performed by the same fellowship-trained hand surgeon. Patients were assessed by an independent observer at 40 months' follow-up. Pre- and postoperative strength, trapezial space ratio (TSR), range of motion, QuickDASH and visual analogue pain score were recorded. Both procedures improved functional parameters of pain, key strength, tip strength and grip strength while maintaining range of motion, without significant differences. In the SBS group, TSR decreased by 17%, compared to 28% in the LRTI group. The mean operative time was shorter in SBS (63 vs 91 minutes; p < 0.0001), as was immobilization time (2 vs 6 weeks; p < 0.0001), and patients resumed normal activity sooner (10 vs 12 week; p = 0.0138) and required less physical therapy (19.3 vs 13.1 weeks; p < 0.0001). We believe that our results are related to the hypothesis suggested by biomechanical studies that revealed better initial load bearing profile and maintenance of trapezial space following serial loading in cadaver models.

Mini TightRope® suture button indications for thumb basal joint arthritis

Our aim was to explore the different indications of the Mini TightRope® suture button whether during first-line treatment or secondary surgery of thumb carpometacarpal osteoarthritis (OA). The indications for this new device are presented and discussed based on our own small case series and published data. Twenty-one patients treated with the Mini TightRope® were included in a prospective study. One of them was operated on both sides. Fourteen devices were used in first intention for Eaton stage IV OA; the patients underwent trapeziectomy and suture button suspensioplasty only. Four cases consisted of revision surgery for painful proximalization of the first metacarpal after trapeziectomy and ligamentoplasty. Four cases consisted of secondary surgery after trapeziectomy and implant interposition (two silicone implants and two pyrocarbon implants). We captured the demographic data, follow-up time, pain level, pinch strength before and after surgery, range of motion, metacarpal subsidence, and postoperative complications. The average age of the patients was 60 years. There were 19 women and 2 men. The average follow-up time was 2.5 years (1-4). The average pain level, according to a visual analog scale (1-10) was 3.5 (2-5) preoperatively and 2 (1-4) postoperatively at rest and 7 (6-8) preoperatively and 4 (3-6) postoperatively with maximum load. The mean Kapandji score was 9 (7-10) and the retropulsion score was 3 (1-4). The average key pinch and tip pinch strengths were 80% and 78% of the contralateral side at the final follow-up. The trapeziectomy-suspensioplasty group had greater average trapezial space height compared to the revision surgery group (7.0 mm vs. 4.5 mm). There are several indications for the Mini TightRope® device in the treatment of severe thumb carpometacarpal OA: first metacarpal suspension during open or arthroscopic total or partial trapeziectomy and secondary surgery after failure of trapeziectomy with or without implant interposition. The advantage of this new device, which suspends the first metacarpal off the second metacarpal, is the very short immobilization period contrary to other suspensioplasty procedures.

Novel dynamic stabilization method for medial instability of the first metatarsophalangeal joint

Medial collateral ligament injury of the first metatarsophalangeal (MTP) joint is rare. If it is missed, chronic instability and traumatic hallux valgus develop, requiring surgical treatment. Different methods have been reported in the limited available literature aiming to restore the balance between the lateral and medial stabilizers by tightening the medial joint capsule with or without additional tendon graft. Our described method utilizes a suture button device (Mini TightRope, Arthrex, Naples, Florida) for reconstruction. This device applies tension to hold the hallux in the correct position, providing stability. Relevant diagnostic regimen, surgical technique, and postoperative care are described, along with a case of a handball player who underwent this procedure. He continues to perform at the same level 38 months postoperatively. Mini TightRope fixation for chronic medial first MTP instability has not been reported. It does not require postoperative immobilization and allows faster return to sport, so it seems superior to other methods when treating athletes.

Navigating the Intersection of Evidence and Policy in Hand Surgery Practice

Collaboration with organizations beyond the clinical setting is necessary to identify safety hazards that contribute to the high incidence and severity of hand conditions. Hand surgeons are acutely aware of obstacles patients face while navigating the health care system. Advocacy efforts encourage the development of equitable insurance policies and improve health resource allocation so that hand surgeons can treat a larger patient population. Participation in quality initiatives supports the development of evidence-based clinical guidelines. Further evidence must be generated to ensure that surgeons remain proficient in the latest techniques and uphold high standards of care as hand surgery procedures evolve.

Suture Button Suspensionplasty in the Treatment of Carpometacarpal Arthritis: A Retrospective Analysis of One Surgeon’s Experience Over 9 Years

Purpose

Trapeziectomy with suture button suspensionplasty (SBS) to treat thumb carpometacarpal (CMC) arthritis has been proposed as an alternative to ligament reconstruction tendon interposition. There have been limited large-scale or long-term reports regarding SBS outcomes. Single-surgeon intermediate follow-up is reported.

Methods

We conducted a retrospective review of patients undergoing SBS procedures by a single surgeon. Implant manufacturer and postoperative immobilization protocol were recorded. Surgical outcomes, complications, and revision procedures were identified. Postoperative Disabilities of the Arm, Shoulder, and Hand scores were collected.

Results

A total of 242 SBS surgeries were included, involving 215 patients, average age 64.82 years (range, 42–86 years). Average follow-up was 35 ± 25 months. In all, 183 Arthrex and 59 Stryker systems were used, 42 of which were immobilized for 6 weeks after surgery and 200 of which were mobilized at 2 weeks afterward. Postoperative Disabilities of the Arm, Shoulder, and Hand surveys were completed by 122 patients (57%), with an average score of 12. No scaphometacarpal abutment was reported. Thirteen complications were reported (5%), 7 of which were implant-associated (3%) and 6 of which were not (2%). Implant-associated complications consisted of 3 suture button pull-outs, 2 thumb–index metacarpal abutments, one suture tail irritation, and one index metacarpal fracture. Operative revision was required in 4 of 7 implant-associated cases and 5 of 6 non–implant associated cases. No suture button pull-outs required revision surgery.

Conclusions

Results for a large series of SBS for CMC arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates.

Clinical relevance

Suture button suspensionplasty as an alternative to ligament reconstruction tendon interposition may be a viable option for treating thumb CMC arthritis. In addition, a technique to manage thumb–index metacarpal abutment is described.

Long-term results of modified ligament reconstruction and tendon interposition for thumb basal joint arthritis

BACKGROUND

Thumb basal joint arthritis is a common, disabling condition of the hand. Ligament reconstruction and tendon interposition (LRTI) is one of the more common surgical solutions. We performed a retrospective study to evaluate long-term radiological and clinical outcomes of modified LRTI procedures in treating thumb basal joint arthritis.

METHODS

A total of 91 hands (84 patients) with full chart records were enrolled in this study. The average age was 65.4 years, and the mean follow-up was 11.7 years (range, 1-21.6 years). We evaluated pain, joint stability, power-grip and key pinch strength, and thumb radial abduction angle as the functional outcomes, and measured the height of the trapezial space as the radiographic result.

RESULTS

There were 66 and 23 hands with excellent and good results, respectively. The diminution of the trapezial space was 4.2 mm in the stage III group and 5.2 mm in the stage IV group. Power-grip and key pinch strength, and thumb radial abduction angle were better in those with stage III than in those with stage IV arthritis. Sixty-eight hands were followed up >5 years, and of them, 66 showed excellent or good results.

CONCLUSION

With good and durable surgical outcomes, the modified LRTI procedure could be a good treatment for thumb basal joint arthritis.

Basilar Thumb Arthritis: The Utility of Suture-Button Suspensionplasty

BACKGROUND

We sought to compare the functional outcomes, radiographic outcomes, and complications of trapeziectomy and flexor carpi radialis (FCR) to abductor pollicis longus (APL) side-to-side tendon transfer with or without suture-button suspensionplasty for thumb basilar joint arthritis.

METHODS

Patients treated with and without suture-button suspensionplasty were compared over a 6-year period. Data were reviewed for complications and functional outcomes, including grip and pinch strength, range of motion, and visual analog scale (VAS) pain scores. Plain radiographs were independently reviewed at initial presentation and at final follow-up, including proximal phalanx length, trapezial space height, and trapezial height ratio.

RESULTS

Seventy thumb arthroplasties were performed in 70 patients. Trapeziectomy with FCR-APL side-to-side tendon transfer was performed in 39 patients, and trapeziectomy with FCR-APL side-to-side tendon transfer with suture-button suspensionplasty was performed in 31 patients. Mean length of follow-up was 28.4 ± 3.9 and 23.8 ± 2.6 months, respectively. Postoperative grip, oppositional and appositional pinch strength, and VAS pain scores improved compared with preoperative values, but were not significantly different based on suture-button suspensionplasty. Percentage decline in trapezial space ratio was significantly different between groups at 36.7% and 20.4% for procedures with and without suture-button suspensionplasty, respectively indicating that the trapezial space was better maintained within the suture suspension cohort. The incidence of postoperative complications, including surgical site infection, paresthesias, reoperation, complex regional pain syndrome, and symptomatic subsidence, was not significantly different between groups.

CONCLUSIONS

Trapeziectomy with FCR to APL side-to-side tendon transfer with and without suture-button suspensionplasty results in comparable improvement in pain, grip strength, and functional parameters. Suture-button suspensionplasty results in significantly greater preservation of trapezial space.

Radiographic and surgical considerations in arthritis surgery of the hand

Indications for hand surgeries include unremitting joint pain, deformity and stiffness, often secondary to arthritis. Several surgical options are available, including arthrodesis (fusion) and joint arthroplasty. Classically arthrodesis is performed in situations with poor bone stock and supporting soft tissues. Arthroplasty is reserved for patients and joints in which preservation of function is important and bone stock and soft tissue support are adequate. In this article we will review various techniques for arthrodesis and arthroplasty, their post-surgical imaging appearance, including key findings important to surgeons, and the findings that indicate post-surgical complications. Radiographs are the mainstay for postoperative evaluation and will be the focus of the imaging portions of this review. Advanced imaging modalities will be reviewed when applicable.

Extensor Pollicis Longus Rupture after Mini TightRope Suspensionplasty

Background Arthritis of the first carpometacarpal (CMC) joint has been surgically treated in multiple ways with varying levels of success as measured by subjective and objective measures. Trapeziectomy with numerous variations in suspensionplasty comprises one of the more commonly used surgical procedures. Recently, the Mini TightRope apparatus has been utilized as a new method for achieving suspensionplasty, and as such lacks significant review of use and safety in the literature. Case Description An extensor pollicis longus (EPL) rupture following a trapeziectomy and Mini TightRope suspensionplasty for CMC arthritis of the thumb is presented. The patient successfully underwent an extensor indicis proprius (EIP) to EPL transfer to treat this complication. Literature Review There is well-established documentation of injury to the extensor tendons from orthopedic hardware such as volar locking plates. Regarding use of the Mini TightRope apparatus, guidelines for placement of the suture button include caution to place the button away from the EPL tendon to minimize the chance of tendon irritation. Additionally, FiberWire sutures, a component of the apparatus, have been shown to demonstrate soft tissue reactions with adjacent inflammatory response. Published reports on adverse events utilizing this device have been limited to case reports including an index metacarpal fracture. Clinical Relevance The aim of this case report was to cite an occurrence of EPL rupture following its use and discuss the possibilities of its direct contribution.

Double tightrope for basilar thumb arthritis

Several surgical options exist for the treatment of basilar thumb joint arthritis. Suspending the thumb metacarpal with a suture button device provides a stabilizing force to maintain pinch strength, precludes the necessary healing time associated with ligamentous reconstruction and allows for earlier motion and return to work, and creates a stable construct that may prevent metacarpal subsidence over time. One of the concerns with this technique is over-tightening of the suture device, which results with impingement of the thumb and index metacarpal bases. We present a surgical technique of open trapeziectomy, simultaneous application of 2 Mini TightRope button devices to provide additional stabilization that prevents impingement of the thumb and index finger metacarpal, with imbrication of the flexor carpi radialis and abductor pollicis longus tendons as reinforcement of the construct.