62: Trapeziectomy and Abductor Pollicis Longus Suspensionplasty

Procedure 62 Trapeziectomy and Abductor Pollicis Longus Suspensionplasty



Nathan S. Taylor, Kevin C. Chung


imageSee Video 46: Abductor Pollicis Longus Suspension Arthroplasty for Basal Joint Arthritis



Indications




image Eaton stages II to IV disease (see later)


image Pain refractory to conservative treatment, including trapeziometacarpal (TMC) corticosteroid injection, thumb splinting, and isometric exercises



Examination/Imaging



Clinical Examination




image The patient’s thumb metacarpal base may exhibit a dorsoradial prominence secondary to subluxation from ligamentous laxity (Fig. 62-1).


image The patient’s thumb should be evaluated for tenderness along the TMC joint.


image The carpometacarpal (CMC) grind test is performed with axial compression, flexion, extension, and circumduction of the TMC joint, which should elicit crepitus and pain.


image The patient’s thumb metacarpophalangeal (MCP) joint should be assessed during pinch for hyperextensibility. If unaddressed, the suspensionplasty will be stressed by obligatory metacarpal adduction. This hyperextensibility can be corrected with MCP joint capsulodesis or fusion if the deformity is severe.


image The patient should be evaluated for carpal tunnel syndrome, which may coexist in up to 43% of patients with TMC arthritis. Concomitant carpal tunnel release should be performed in these patients because trapeziectomy alone does not sufficiently increase carpal tunnel volume.


image An Allen test should be performed because the procedure typically requires mobilization of and potential injury to the radial artery.


image The patient should also be evaluated for concomitant trigger thumb.


image

FIGURE 62-1



Imaging




image Posteroanterior, oblique, and lateral radiographs of the hand should be obtained to evaluate the extent of arthritis, osteophyte formation, joint loss, and joint subluxation (Fig. 62-2A to C).


image The Eaton classification is a staging system based on radiographic findings only and often does not correlate with the patient’s symptoms. Some patients with severe arthritis may have minimal pain. Treatment should be based on the patient’s symptoms and, most important, on the amount of pain in the arthritic joint.


• Stage I—normal to slightly widened TMC joint secondary to ligamentous laxity or effusion, normal articular contours, and subluxation of less than one third of the joint space

• Stage II—TMC joint narrowing and osteophytes less than 2 mm

• Stage III—further TMC joint narrowing, subchondral cysts, sclerosis, osteophytes greater than 2 mm, subluxation greater than one third of the joint space

• Stage IV—degenerative changes involving the scaphotrapezial joint

image A stress view of the TMC joint is obtained by having the patient press the thumb tips together while obtaining a 30-degree posteroanterior view centered on the thumbs to assess joint space loss and subluxation. Stress view is only obtained in stage I disease for patients with symptomatic joint laxity.


image Partial resection of the trapezoid should be performed if degenerative changes are present between the trapezoid and the scaphoid.


image

FIGURE 62-2



Surgical Anatomy




image The anterior oblique (beak) ligament inserts volarly onto the trapezium from its confluence with articular cartilage on the beak of the thumb metacarpal.


image The radial artery traverses the anatomic snuffbox and overlies the dorsal capsule of the CMC joint.


image The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are within the first extensor compartment.


image The radial sensory nerve becomes subcutaneous after exiting through the interval between the brachioradialis and extensor carpi radialis longus (ECRL) muscles.


image The flexor carpi radialis (FCR) tendon traverses the volar and ulnar aspect of the trapezium.



Positioning




image The procedure is performed under tourniquet control with the patient in the supine position and the extremity abducted with the hand on a hand table.



Exposures




image The APL suspensionplasty requires two incisions (Fig. 62-3).


• A longitudinal incision centered over the anatomic snuffbox and TMC joint

• A small chevron incision over the first extensor compartment about 5 cm proximal to the radial styloid

Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 38: Reconstruction for Congenital Thumb Hypoplasia 65: Arthroscopic Treatment for Septic Arthritis 89: Total Wrist Fusion

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 62: Trapeziectomy and Abductor Pollicis Longus Suspensionplasty

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