excision of the trapezium presentation

Excision of the Trapezium

K.MOHAN IYER

M.Ch.Orth(Liverpool, U.K.),M.S.Orth(BOM)F.C.P.S.Orth(BOM),D’Orth(BOM),

M.B.,B.S.(BOM).

Original Work

1.The Results of Excision of the Trapezium- K.Mohan Iyer(Oct.1981) The Hand,Vol. 13,No.3:246-250. 2.Arthrography of the Metacarpo-Scaphoid Joint following Excision of the Trapezium -K.Mohan Iyer & G.H.Whitehouse(Oct. 1981) The Hand,Vol.13,No.3:251-256.

Work quoted in Literature(From 1985 till 2002)

1.Osteoarthritis of the Carpometacarpal Jointof the Thumb-L.Kvarnes & O.Reikeras(Feb.1985) J.of Hand Surgery,Vol.10-B,No.1,117-120.

2.Rheumatoid Arthritis at the base of the Thumb treated by Trapezium Resection or Implant Arthroplasty-L.Kvarnes & O.Reikeras(June 1985) J.of Hand Surgery,Vol.10-B,No.2,195-196.

3.Interposition Arthroplasty of the Trapeziometacarpal Joint for Osteoarthritis-Paul C.Dell & Ruth B.Muniz(July 1987) Clinical Orthopaedics & Related Research,No.220,27-34.

Work quoted in Literature(From 1985 till 2002)

4.Replacement of the Trapezium with a Silicone Elastomer Universal Small Joint Spacer-B.Helal & I.McPherson(Nov.1989) J.of Hand Surgery,Vol.14B,No.4:456-459.

5.Revision Procedures for complications of Surgery for OA of the CMC Jt.of the Thumb-W.B.Conolly & S.Rath(Aug.1993) J.of Hand Surgery,Vol.18B,No.4:533-539.

Work quoted in Literature(From 1985 till 2002)

6.Excision of the Trapezium for OA at the base of the Thumb-Varley G.W,Calvey J,HunterJ.B,BartonN.J,DavisT.R.C(Nov.1994)JBJS(Br),76-B,Vol.6,964-968.

7.Simple Trapezectomy for Treatment of TMOA of the Thumb-Vandenbrouche J,De Schrijver F,De Smet L,Fabry G(1997) Clin.Rheumatology;16,239-242.

Work quoted in Literature(From 1985 till 2002)

8.A comparison of Trapeziectomy with or without ligament reconstruction & Tendon interposition-HJCR Belcher & JE Nicholl (Aug.2000) J.ofHand Surgery,Vol.25B,No.4:350-356.

9.Early versus late mobilisation after simple excision of the Trapezium-N.Horlock&HJCR Belcher(Nov.2002) JBJS(Br),Vol.84-B,No.8:1111-1115.

The TrapeziumSurfaces

1.Palmar Surface-Groove and a Tubercle. 2.Dorsal Surface-Related to Radial Artery. 3.Lateral Surface-Lateral collateral ligament of the wrist joint & capsular ligament of the carpometacarpal joint. 4.Medial Surface-Facet for the Trapezoid. 5.Proximal Surface-Facet for the Scaphoid. 6.Distal Surface-Saddle shaped for the base of the first metacarpal.

Normal Wrist Joint Compartments

1.Radiocarpal Joint. 2.Inferior Radioulnar Joint. 3.Midcarpal Joint. 4.Isolated Carpometacarpal Joint of the Thumb.

Intercarpal Joints

1.Joints between bones of the proximal row. 2.Joints between bones of the distal row. 3.Midcarpal Joint - Between these two rows of bones. - S shaped cavity lined by synovial membrane. - Has 2 projections proximally and 3 projections distally.

Pathology

Stage I: Pain Synovitis Local Swelling Effusion into the joint

Pathology

Stage II: Severe pain Joint space narrowing Medial osteophyte

Pathology

Stage III:Severe pain Marked decrease of joint spaceSubluxation of the metacarpal

Pathology

Stage IV:Subluxated metacarpal fixed by fibrosis &

contractureMarked hyperextension deformity of the MCP jointFlexion deformity of the IP jointPain minimal or nilFixed adducted thumb

Carpometacarpal Arthritis of the Thumb

Age:60 Years Sex:Women(Post Menopausal) Side:Right side;Both sides frequent Predisposing Factors: 1.Trauma(30%) 2.Developmental Anomalies 3.Occupational 4.Anatomical

Carpometacarpal Arthritis of the Thumb

Symptoms: 1.Severe pain-Base of the thumb -Aggravated by movements 2.Swelling over the base of the thumb 3.Stiffness of the Thumb 4.Weak Grip

Carpometacarpal Arthritis of the Thumb-Treatment

(A)Conservative Treatment: 1.Physiotherapy 2.Radiotherapy 3.Splint 4.Intra-articular Steroids

Carpometacarpal Arthritis of the Thumb

(B)Surgical Treatment:- 1.Forage 2.Intra-articular Tenodesis 3.Excision of the Trapezium 4.Arthrodesis 5.Silicone rubber interpositional arthroplasty 6.Prosthetic Replacement

Carpometacarpal Arthritis of the Thumb

Charcot and Leri(1926) Robert(1936) Forestier(1937) Lasserre,Pauzat and Derennes(1949)

Excision of the Trapezium

Gervis(1949) 18 wrists with 16 good results.(1973) 12 wrists followed up for 6 to 22 years.

Goldner & Clippinger(1955) Excison of theTrapezium piece-meal.

Murley(1960) 39 wrists with 36 good results.Marmor & Peter(1969) 7 wrists with 5 good

results.Sims & Bentley(1970) 27 Trapeziectomies with

excellent results in 15,Good in 6,Fair in 5 & Poor in one.Incidence of 54% of patients with associated Trapezio-Scaphoid Arthritis.

Clinical Evaluation

1.Name 2.Age 3.Sex 4.Dominant Hand 5.Occupation 6.Time off work:Pre-op,Post-op & Total.

Clinical Evaluation

7.Return to original occupation. 8.History of Injury. 9.Duration of complaints pre-op. 10.Time since surgery.

Clinical Evaluation

Associated Conditions: 1.Cervical Spondylosis. 2.Periarthritis Shoulders. 3.Stenosing Tenovaginitis. 4.Median nerve compression. Surgical – Incision. - Post operative management.

Results

Thumb Movements:-1.Abduction-Normal range+Power -18 wrists

-Less than 50% -8 wrists2.Opposition-Normal range+Power -14 wrists

-N.range+50%Power - 9 wrists-Less than 50% R+P - 3 wrists

3.Adduction-Normal Power - 25 wrists-Poor - 1 wrist

4.Circumduction-Normal -25 wrists-Poor - 1 wrist

Results

Associated Features:1.Cervical Spondylosis -13/18 patients.2.Periarthritis Shoulders -9/18 patients.3.Stenosing Tenovaginitis -3/18 patients.4.Median nerve compression -4/18 patients.

(Surgical Decompression in 2 patients)

Results

Functioning tendons of Flexor carpi radialis and Flexor pollicis longus =26/26 wrists. Decreased sensations over the dorsum of the base of the thumb =3/26 wrists. Keloid formation = 5/26 wrists. Palpable Neuroma = None.

Results

Opposition Grip: Normal Power = 6 wrists Decreased power = 20 wrists

Pinch Grip: Normal Power = 7 wrists Decreased Power = 19 wrists

Radiographic Assessment

1.Level of first metacarpal base. 2.Accessory Ossicles. 3.Radiologic gap. 4.Telescoping. 5.Stress views. 6.Degenerative changes: -Base of first metacarpal -Distal Scaphoid -Elsewhere in the carpus

Radiographic Features

1.Telescoping =14 wrists(55%)2.Accessory Ossicles = 9 wrists(40%)3.Radiological Gap = 1mm to 6mm4.Degenerative changes:

-Base of first metacarpal =14 wrists-Distal Scaphoid = 8 wrists-No changes =11 wrists

Radiographic Features

5.Residual Cartilage:Base of first MC – Nil in 3 wrists

- Present in 22 wristsDistal Scaphoid - Nil in 2 wrists

- Present in 23 wrists6.Lateral subluxation of 1st MC on Abduction

Marked subluxation in 3 wristsModerate subluxation in 22 wrists

Radiographic Features

7.Maintenance of joint space despite subluxation of the 1st MC on the Scaphoid on radial deviation of the wrist.

8.Stress views of the wrist:No changes = 9 wristsWidening of the Sc-Trap.Jt =12 wristsWidening of the Sc-Cap.Jt = 6 wristsWidening of gap between

the bases of 1st & 2nd MC’s = 6 wrists

Arthrography of the Metacarpo-Scaphoid joint

Technique

Arthrographic Assessment

1.Amount of dye injected. 2.Ease of location of the joint & injection. 3.Residual articular cartilage over:- -Base of the first metacarpal. -Distal Scaphoid.

Arthrographic Assessment

4.Joint Features(A)Isolated.(B)Communications-Midcarpal

-Radiocarpal-Radioulnar-Tendon Sheaths-Pouch between 1st &2nd metacarpal bases

5.Stress Views6.Per operative Arthrogram

Arthrographic Features

1.Distinct Joint Space - 25 wrists2.Comm.with midcarpal joint - 10 wrists3.Comm.with radiocarpal joint - 2 wrists4.Comm.with distal RU joint - 1 wrist5.Comm.with tendon sheaths - 4 wrists6.Contour-Irregular & small – 16 wrists

-Regular & larger - 9 wrists

Conclusion

1.Excision of the Trapezium gives good results with respect to relief of pain.

2.Good hand function despite some reduction in the power of Opposition grip and Pinch grip.

3.Carpal Instability or Laxity may account for decreased Opposition grip & Pinch grip.

Conclusion

4.Arthrographic Features:-Distinct joint space-Small & Irregular within 6 months of Surgery-Large & Regular thereafter-Marked subluxation indicates weak grip

5.Late deterioration of pseudoarthrosis in one patient