63: Trapeziometacarpal Fusion

Procedure 63 Trapeziometacarpal Fusion



Nathan S. Taylor, Kevin C. Chung


imageSee Video 47: Fusion of Thumb Carpometacarpal Joint



Indications




image Posttraumatic degenerative osteoarthritis of the trapeziometacarpal (TMC) joint in manual workers who require great stability of the carpometacarpal (CMC) joint, which may not be achieved with trapezium excision and ligament reconstruction


image Patients with substantial joint laxity and severe thumb CMC joint deformity that cannot be treated with soft tissue reconstruction alone


The case presented subsequently is such a situation in a patient with lupus in which the ligaments are so lax and the thumb deformity so severe that thumb CMC fusion will provide a stable platform to achieve proper thumb posture and stability.



Examination/Imaging



Clinical Examination




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


image The 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 that can be corrected with MCP joint capsulodesis.


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



Imaging




image Posteroanterior, oblique, and lateral radiographs of the hand should be obtained to evaluate extent of arthritis, osteophyte formation, and joint subluxation. Figure 63-1A and B demonstrates severe ligamentous laxity and subluxation of the TMC joint.


image

FIGURE 63-1



Surgical Anatomy




image The TMC joint is a biconcave saddle-shaped joint that provides motion in several planes to allow thumb flexion, extension, abduction, adduction, and opposition.


image The volar oblique (beak) ligament inserts volarly onto the trapezium from its confluence with articular cartilage on the beak of the thumb metacarpal and is considered the primary stabilizer of the TMC joint. It serves as the main restraint against dorsal translation of the metacarpal on the trapezium, and laxity of the beak ligament increases the risk for degenerative changes seen in the CMC joint due to loss of joint stabilization.


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.



Positioning


Related posts:

92: Excision of a Dorsal Wrist Ganglion 35: Silicone Metacarpophalangeal Joint Arthroplasty 85: Wrist Denervation 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 63: Trapeziometacarpal Fusion

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