First metacarpal osteotomy for trapeziometacarpal osteoarthritis

Abstract

We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Trapeziometacarpal osteoarthritis is associated with degeneration of the palmar beak ligament 10 and articular degeneration starts on the joint surfaces adjacent to it. The cartilage of the dorsoradial joint surface is spared until late in the disease process. 10 A recent cadaver study has shown that extension osteotomy of the first metacarpal shifts the area of joint contact from the worn palmar cartilage to the normal dorsal surface. 11 We describe our experience of osteotomy in a large series of patients over a period of 12 years. Patients and MethodsWe carried out 50 operations in 42 patients; 41 thumbs (82%) in 33 patients were available for review at a mean of 6.8 years (2 to 12) from operation. The average age at operation was 57 years (20 to 73). Nine of the operations were in men and 32 in women, and the dominant hand was involved in 20 patients. Nine patients were lost to followup. Three had died, one had moved and could not be contacted, and three very elderly patients could not be traced. Another elderly man was too confused to co-operate. One patient was contacted by telephone but did not wish to be reviewed. When last seen she had complete relief of pain, full abduction and a strong grip. The patients were reviewed by a surgeon who had not been involved in the operation. Pain and hand function were assessed by the patient, using a self-administered questionnaire. Grip strength was measured with a Jamar dynamometer (Asimov Engineering Company, Los Angeles, California), and pulp to pulp (pinch) and lateral pinch (key-grip) with a B & L hydraulic pinch meter (B&L Engineering, Santa Fe Springs, California). The mean of three readings was compared with normal ranges matched for age and sex. 12 The range of movement and maximum abduction were measured clinically with a goniometer. Thumb opposition and the ability to flatten the palm were assessed and recorded. Indications for operation. Surgery was carried out when pain which interfered with everyday activities had not responded to conservative treatment with a splint, nonsteroidal anti-inflammatory drugs or injection with lignocaine and hydrocortisone. Osteotomy was only considered for mild and moderate degenerative changes confined to the trapeziometacarpal joint, scaphotrapezial wear being a contraindication. The preoperative radiographs were graded as described by Eaton and Littler 13 : grade 1, no radiological changes; grade 2, osteophytes or intra-articular fragments of <2 mm with no narrowing of

Trapeziometacarpal joint arthritis

“…Furthermore, in a retrospective review of 50 consecutive patients at mean follow-up of 6.8 years, 80 % of patients had goodexcellent pain relief, and 82 % of patients had normal grip and pinch strength. As expected, patients with stage I or II disease had improved outcomes compared with patients with stage III or IV disease [18].…”

Osteoarthritis of the Trapeziometacarpal Joint (TMJ): A Review of the Literature

“…This then causes cartilage erosion and the symptoms and signs of osteoarthritis (Bettinger et al, 2001). It has been shown that articular degeneration occurs on the palmar side first and gradually progresses to dorsoradial cartilage degeneration in the later stages of osteoarthritis of the joint (Pellegrini, 2005;Hobby et al, 1998). Radiological studies looking at the angle of the trapezium compared to the second metacarpal have shown that there is an increased radial trapezial tilt in Eaton stages III and IV compared to Eaton stages I and II osteoarthritis of the base of the thumb (Bettinger et al, 2001;Kapandji AI and Heim, 2002).…”

“…This ensures that the metacarpal base is covered by the trapezium and joint stability is increased, reducing metacarpal subluxation and wear of the joint cartilage (Zancolli and Cozzi, 1992). Depending on the severity of the symptoms the splint may be effective if just worn nocturnally (Goubau et al, 2007;Hobby et al, 1998). For temporary relief of symptoms, lignocaine and steroid injections into the joint are effective.…”

“…It transfers load bearing from the worn volar cartilage to the more intact dorsal articular surface. As well as giving symptom relief it also slows the progression to more severe osteoarthritis (Hobby et al, 1998). Another more experimental method of reconfiguring the joint alignment is wedge osteotomy of the trapezium.…”

“…For more severe disease with significant degenerative changes the surgical options include trapeziectomy, arthrodesis and total joint arthroplasty. Trapeziectomy is associated with good pain relief but can lead to weakness and instability lasting several months so is often reserved for Eaton Stages III and IV osteoarthritis (Hobby et al, 1998;Gwynne-Jones et al, 2006;Wilson and Bossley, 1983). Trapeziectomy may be performed in isolation or in combination with tendon sling interposition or ligament reconstruction.…”