David J. Slutsky


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3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

Office hours: M-F, 9am – 5 pm

Worker’s compensation, Medicare and most insurance plans accepted.

In September 2008, we will be moving to a beautiful new 4,400 sq ft, state of the art dedicated hand center located at 2808 Columbia Ave in Torrance, CA., which will feature onsite nerve conduction studies, occupational hand therapy and digital x-ray.
 


PROCEDURES

ARTHROSCOPIC TREATMENT OF TRAPEZIOMETACARPAL DISEASE

INTRODUCTION
Thumb motion occurs at the trapeziometacarpal joint. This joint is located where the thumb metacarpal articulates with one of the wrist or carpal bones called the trapezium. The trapezium is shaped like a saddle which accounts for the great mobility of the trapeziometacarpal or TM joint. In this manner, the thumb can reach all of the fingertips with ease. This range of motion comes with a price however, since cartilage wear commonly occurs at this joint. Arthritis at the base of the thumb or trapeziometacarpal osteoarthritis is the most common site of osteoarthritis in the hand. It typically starts on the medial or inside of the trapezium (Figure 1 A) , and then progresses to involve the metacarpal base on the other side of the joint (Figure 1 B). Bony outgrowths or osteophytes are common and result in painful impingement between the metacarpal base and trapezium (Figure 1 C). As the joint space narrows the metacarpal base often displaces laterally or “subluxes”. This can be demonstrated on a stress view (Figure 1 D). In advanced cases, the arthritis will also involve the lower surface of the trapezium, where it joins the scaphoid bone. This is termed the scaphotrapezial-trapezoidal (STT) joint. When both the TM and STT joint are involved, this is termed pantrapezial osteoarthritis. Arthroscopic techniques can still provide some relief but an open trapeziectomy is usually necessary.

Symptoms
Symptoms include an aching pain in the ball of the thumb which may radiate up the forearm. The pain often occurs at rest, especially following repetitive pinching activities such as needle point or prolonged writing. There may be the sensation of grinding or popping at the base of the thumb as well as a feeling of joint instability or dislocation. Small fragments of cartilage may break off and create loose bodies, which accentuate the feeling of locking by getting in the way of joint motion (link to Artelon arthroplasty video). The trapeziometacarpal joint may appear quite enlarged. This is due to subluxation or an outward tilting of the base of the thumb metacarpal that commonly occurs when the TM joint becomes arthritic. The mainstay of treatment early on consists primarily of splinting which immobilizes the joint., along with activity modification with avoidance of repetitive pinching activities. Commercially available thumb spica splints are effective but occasionally custom splints are necessary. Non steroidal anti-inflammatory medications (NSAIDs) can provide symptomatic relief. Chondroitin sulfate and glucosamine can provide similar pain relief but unfortunately they do not halt the progression of the osteoarthritis (OA). Injections of cortisone in the TM joint can provide temporary symptomatic relief. Multiple shots however may hasten the progression of the OA hence no more than 3 injections are recommended.

Surgical Treatment
The goal of surgery is to create a stable joint by removing the painful osteoarthritic surfaces and allowing the ingrowth of fibrous tissue. This creates a false joint that allows motion without painful impingement between the 2 bony surfaces. This is termed an “arthroplasty”. There are myriad techniques for open treatment of trapeziometacarpal (TM) osteoarthritis. This has ranged from partial and complete trapezium excision with or without ligament reconstruction and with or without interposition of tendon, fascia lata, gortex, artelon or silicone to name a few. Instances of reactive synovitis have tempered the enthusiasm for interposition of foreign substances. Recent reports in the North American literature [Kuhns, 2003; Jones, 2001 ] of good results following complete trapeziectomy with hematoma arthroplasty have rejuvenated interest in this technique, which has been commonplace in Europe for some time.[Gervis, 1949 ] Arthroscopic techniques for evaluating and treating trapeziometacarpal disease surfaced in 1994.[Menon, 1996; Menon, 1998 ] The question of whether to interpose tendon is still a matter of debate. Proponents of the hematoma arthroplasty cite data which demonstrate no advantages in terms of pinch strength, thumb motion and pain relief following an arthroplasty with tendon interposition as compared to an isolated trapeziectomy.[Davis, 2004 ] The hematoma arthroplasty relies on the development of a stable pseudarthrosis or false joint that develops from the ingrowth of fibrous tissue which replaces the blood that immediately fills the cavity following an excision of the trapezium. Pinning the thumb metacarpal base to the index for 5-6 weeks is integral to the procedure, but augmentation or reconstruction of the TM joint capsule is not. The good results that have been obtained with open trapeziectomy have provided the impetus for the development of arthroscopic techniques.

Surgical Indications
The main indication for surgery is basilar thumb pain that is unresponsive to conservative treatment. This typically includes a trial of splinting with a forearm or palmar based thumb spica splint, NSAIDs and activity modification. A TM joint cortisone injection may be used as a temporizing procedure. Although it is well known that the x-ray findings do not always correlate with the clinical symptoms, they are nevertheless instrumental in determining which patients may be appropriate candidates for an arthroscopic resection.

Littler and Eaton described a radiographic staging classification of TM OA.[Eaton, 1973 ] Stage I comprises normal articular surfaces without joint space narrowing or sclerosis. There is less than 1/3 subluxation of the metacarpal base. Stage II reveals mild joint space narrowing, mild sclerosis or osteophytes < 2mm in diameter. Instability is evident on stress views with > 1/3 subluxation. The STT joint is normal. In stage III there is significant joint space narrowing, subchondral sclerosis and peripheral osteophytes > 2 mm in diameter but a normal STT joint. In stage IV there is pantrapezial OA with narrowing, sclerosis and osteophytes involving both the TM and STT joints. Patients in stage II and possibly early Stage III are appropriate candidates for a hemiresection arthroplasty. This involves the removal of approximately _ of the trapezium along with tendon interposition. The main disadvantage of any resectional arthroplasty is weakness of thumb pinch strength. As a result, many procedures have been devised to minimize the amount of bone resection along with a variety of ligament reconstructive techniques using tendon grafts. Partial trapezial resections will often have less of a risk of weak pinch strength by preserving more of the trapezium. These are termed “hemiresection arthroplasties”.

As a general rule, any patient who is an appropriate candidate for a hemiresection arthroplasty of the TM joint would also be suitable for an arthroscopic hemi-trapeziectomy. This would typically include patients in stage II and stage III with unremitting pain despite appropriate conservative measures. An advantage of an arthroscopic procedure is that it can be performed in younger patients aged 40-60 years who are still very active both at work and recreational activities. This form of treatment does not preclude an open trapeziectomy and/or ligament reconstruction at a later date as a salvage procedure for failed arthroscopic surgery. The presence of Eaton Stage IV disease is a relative contraindication to a hemitrapeziectomy although an arthroscopic hemitrapeziectomy combined with an arthroscopic debridement or limited resection of the distal scaphoid is an option. The rationale for this would be similar to that of the double interposition arthroplasty described by Eaton and Barron in which the TM and STT joints are resurfaced while the body of the trapezium is left intact in order to prevent a loss of height of the thumb ray.[Barron, 1998 ] Failing this, a complete trapeziectomy would be necessary.

Precautions
Any significant lateral subluxation of the thumb metacarpal base will not be corrected without some type of ligament reconstruction or capsular shrinkage, and may compromise the long term result if not corrected. Metacarpophalangeal (MP) joint hyperextension must be treated concomitantly otherwise the reconstruction may ultimately fail. MP hyperextension of 10 -20 degrees may be treated by percutaneous fixation of the MP joint in flexion for 4-6 weeks and/or transfer of the extensor pollicus brevis to the thumb metacarpal base. MP hyperextension of 20-40 degrees can be addressed with a volar plate advancement [Eaton, 1988 ] or capsulodesis [Kessler, 1979 ] or an MP sesamoidesis. MP hyperextension greater than 40 degrees is typically controlled by an MP fusion.

SURGICAL TECHNIQUE (view video)
The patient is positioned supine on the operating table with the arm extended on a hand table. The thumb is suspended by Chinese finger traps with 5 pounds of counter traction, which forces the wrist into ulnar deviation. The relevant landmarks are outlined including the proximal and dorsal edge of the thumb metacarpal base, the tendons of the abductor pollicus longus (APL) and the extensor pollicus longus ( EPL) and the radial artery in the snuff box (Figure 2). The procedure is performed with a tourniquet elevated to 250 mm Hg. Saline inflow irrigation is provided through the arthroscope and a small joint pump or pressure bag. To establish the 1-R portal the thumb metacarpal base is palpated and the joint is identified with a 22 gauge needle just radial to the APL, followed by injection of 2 cc of saline. This step may be facilitated by fluoroscopy. A small skin incision is made followed by wound spread technique with tenotomy scissors. The capsule is pierced and a cannula and blunt trocar are inserted, followed by the arthroscope. An identical procedure is used to establish the 1-U portal, just ulnar to the EPB tendon, followed by insertion of a 3 mm hook probe. The portals are interchangeably used to systematically inspect the joint, which is facilitated by expedient use of a 2.0 mm synovial resector. The cartilage remnants along with scar tissue are then removed or “debrided”.

After joint debridement a 2.9 mm burr is applied in a to and fro manner to resect the distal trapezium (Figure 3 A, Figure 3 B) The diameter of the burr along with fluoroscopy provide a gauge as to the amount of bony resection. A larger burr may be substituted as the space between the metacarpal base and distal trapezium enlarges. It is crucial to remove any medial osteophytes, which will lead to impingement and possibly persistent pain. Access to medial trapezial osteophytes may sometimes be difficult hence I found the use of a distal - dorsal (D-2) accessory portal (inset a link to the D-2 portal paper) to be of some value. Its main utility is that it allows one to look down on the trapezium rather than across it, which facilitates resection of medial osteophytes (Figure 4 A, Figure 4 B). Culp recommends resecting at least 2 of the distal trapezium [Culp, 2001] , although it is my experience that excising 4-5 mm is sufficient, provided that all of the medial osteophytes are removed (Figure 5). At this point the Artelon spacer is interposed between the two bones, covering the exposed raw cancellous bony surface of the resected trapezium (Figure 6). The thumb is then pinned or k-wired in a pronated and abducted position. If there is lateral subluxation of the metacarpal base, thermal shrinkage of the volar oblique ligament can be performed at this time.

Arthroscopic distal scaphoid resection
If there is significant STT OA, the joint can be debrided as described by Ashwood and Bains.[Ashwood, 2003] Alternatively a minimal arthroscopic resection of the distal scaphoid can be performed. The STT joint can be viewed through the midcarpal radial portal (MCR) with the burr in the STT-U portal or STT-R portal (Figure 7 A, Figure 7 B). The portals are likewise interchangeable. The volar and radial scaphotrapezial ligaments are preserved and the bony resection is confined to 2-4 mm to lessen the risk of a dorsal intercalated segmental instability (DISI) pattern.

POSTOPERATIVE MANAGEMENT
The thumb is immobilized in abduction by cast or splint for 4 weeks at which time the TM k-wire is removed. Thumb abduction and extension are instituted, followed by adduction and opposition after 6 weeks. Strengthening ensues once motion has been restored. The rehabilitation protocol is modified as necessary if concomitant surgery on the MP joint has been performed.

RESULTS
Menon reported his results on performing a partial arthroscopic resection of the trapezium and an interposition arthroplasty in 31 patients (33 hands).[Menon, 1996 ] The mean age was 59 years (48 - 81 years) with an average follow up of 37.6 months (24-48 months). Gortex was used in 19 patients and autogenous tendon or allograft in 14. Complete pain relief was obtained in 25 patients/hands (75.7%). Three patients had mild pain (4 hands) and 4 patients had persistent pain that required conversion to an open trapeziectomy and ligament reconstruction. All patients maintained their preoperative motion. Pinch strength improved from 6 p.s.i. preoperatively to 11.1 p.s.i postoperatively. Because of osteolysis in 3 patients/4 hands, the use of Gortex as in interpositional substance was not recommended.

Culp, Osterman et al performed a partial or complete arthroscopic trapeziectomy in 22 patients (24 thumbs) with electrothermal shrinkage. Eighteen thumbs were evaluated at an average of 7.6-years postoperatively. All of the patients reported an improvement in pain, and none required further surgery. Thumb motion decreased by 20%, but all patients could oppose to the fifth finger. Grip strength remained unchanged, key pinch improved from 8 to 11 lbs, and tip pinch improved from 4 to 5 lbs. My own results have echoed those reported above, with maintenance of the joint space and good pain relief and motion at the 2- 5 year follow up (Figure 8 A, Figure 8 B, Figure 8 C, Figure 8 D) with no one requiring a revision to an open trapeziectomy.

Work Considerations
Most people can perform one-handed work activity by the 2nd week followed by light duty including clerical work at 6-8 weeks. Heavy manual labor can often be resumed by 12 - 16 weeks.