Chapter 23 Partial Arthroscopic Trapeziectomy with Suspension Ligamentoplasty

10.1055/b-0035-121133

Chapter 23 Partial Arthroscopic Trapeziectomy with Suspension Ligamentoplasty

Introduction

Thumb basal joint arthritis is a common condition that is initially treated conservatively with either or both splinting and corticosteroid injections. Many surgical treatments have been proposed to address conditions that are refractory to conservative treatment. Open total or partial trapeziectomy with ligament reconstruction has been shown to be effective for treating basal joint arthritis. But certain complications, such as damage to terminal branches of the radial nerve, collapse of the thumb column, lack of strength, and complex regional pain syndrome, have led to the development of various arthroscopic techniques.1–9

The method described here combines partial trapeziectomy and ligament reconstruction using a strip of the abductor pollicis longus tendon, which creates a suspension ligamentoplasty and reconstructs the intermetacarpal ligament. This procedure is indicated in patients with isolated trapeziometacarpal joint conditions.

Operative Technique (Desmoineaux)

Patient Preparation and Positioning

Surgery is performed on an outpatient basis under regional anesthesia. The patient is placed supine with the arm resting on an arm board. A tourniquet cuff is used with a countersupport pad on the anterior side of the arm. The joint is distracted with finger traps on the thumb and 2 to 3 kg of traction.

**Fig. 23.1a, b** Drawing (a) and intraoperative view (b) of needles being used to pinpoint the location of the 1 dorsal (1D) and 1 palmar (1P) portals on each side of the first compartment.

Trapeziometacarpal Joint Portals

The trapeziometacarpal joint is identified using distal to proximal palpation, then outlined with a skin marker; two parallel vertical lines are drawn on the radial and ulnar side of the nail. Two portals, one dorsoradial (1 palmar [1P]) and one dorsoulnar (1 dorsal [1D]) are located with needles, and the trapeziometacarpal joint is distended with saline ( Fig. 23.1a, b ). The 1P portal is lateral to the abductor pollicis longus slip that inserts on the first metacarpal; the 1D portal is medial to the extensor pollicis brevis. The procedure is performed using a short-barrel, 2.7 mm, 30° arthroscope and standard instruments (shaver, bur).

The risk of radial nerve irritation can be reduced by making the incisions long enough. A scalpel is used to cut through the skin only, and then mosquito forceps are used to spread the veins and nerve branches apart.

Trapeziometacarpal Joint Exploration and Partial Trapeziectomy

The scope is initially placed in the 1P portal to inspect the articular surfaces ( Fig. 23.2 ). After debridement, the bur is introduced via the 1D portal ( Fig. 23.3 ). The distal side of the trapezium is resected, and the remaining bone is shaped until cancellous bone is exposed. The grooves on the bur (3–3.5 mm) are used to determine the required resection depth ( Fig. 23.4 ). The joint surface is subsequently resected to this depth. The goal is to uniformly resect the trapezium and remove any osteophytes or foreign bodies. The base of the second metacarpal (M2) is exposed inside the joint, behind the pommel of the trapezium saddle ( Fig. 23.5 ). The flexor carpi radialis may be seen in front of M2. The instruments are then reversed to finish the trapeziectomy on the lateral side and remove any lateral osteophytes.

The main challenges lie in completely removing foreign bodies and the medial osteophyte on the lateral horn as well as removing the entire dorsolateral peripheral wall.