A 47-year-old, right-hand-dominant woman presents with recurrent right thumb pain following surgery at another institution for trapeziometacarpal arthritis. Her initial trapeziectomy and suspension arthroplasty, using the flexor carpi radialis (FCR) tendon, was complicated by postoperative instability and she underwent a revision arthroplasty with reconstruction of the intermetacarpal ligament using the abductor pollicis longus (APL) tendon. At the time of her presentation, she complained of pain at the base of her right thumb and difficulty in performing activities of daily living, including pinching and grasping.
Examination revealed scars from previous surgery. There was no pain with manipulation of the thumb metacarpophalangeal (MCP) joint. The first metacarpal had migrated proximally and the thumb was held in a zigzag posture with 25 degrees of hyperextension at the MCP joint. This hyperextension was correctable with anatomic reduction of the first metacarpal. A residual slip of the FCR tendon and a well-defined palmaris longus tendon were palpable at the wrist.
Following her first operation, radiographs were consistent with trapeziectomy and FCR ligament reconstruction. Notably, the first metacarpal had migrated proximally to impinge on the scaphoid and no arthritis was appreciated at the MCP joint (▶Fig. 45.1a–c). Immediately following her revision arthroplasty, the metacarpal–scaphoid space had been restored, with bone anchors from her APL ligament reconstruction noted (▶Fig. 45.1d–f). However, at 6 months, her first metacarpal had again migrated proximally and lay in contact with the scaphoid (▶Fig. 45.1g–i).
Although her first two operations were performed at another institution, we can assume they were technically well executed, as the patient did have temporary relief of symptoms and improvements in her radiographic appearance. Recurrent proximal migration of the first metacarpal following appropriately performed surgery was strongly suggestive of a loose ligamentous habitus. However, there were no other systemic findings to suggest classic Marfan’s or Ehlers–Danlos syndrome. Given her age and functional status, we elected to reconstruct the intermetacarpal ligament and remove the arthritic base of the first metacarpal. Given that the FCR and APL were no longer present, we elected to reconstruct the intermetacarpal ligament using the palmaris longus tendon as a free graft.
• Excision of the proximal first metacarpal base is key to increase the metacarpal–scaphoid space.
• The tendon graft must be secured firmly to the first metacarpal base.
• The palmaris longus is an excellent local option for tendon graft in this patient with previous harvest of her FCR and APL tendons.
• In the absence of a palmaris longus tendon, one can use other free tendon grafts (plantaris) or transfer of the extensor carpi radialis longus to reconstruct the intermetacarpal ligament.
• A prolonged period of postoperative immobilization and close supervision of gentle range-of-motion exercises are essential to allow healing when a free tendon graft is used. All phases of the rehabilitation program are delayed by 2 weeks.
A periclavicular regional block is performed in the preoperative holding area with an indwelling catheter for postoperative pain relief. The patient is taken to the operating room and placed in the supine position with the extremity on a hand table. The arm is prepped and draped in the standard sterile fashion, exsanguinated, and a proximal arm tourniquet is inflated to 250 mm Hg. The technique is described in ▶Video 45.1.
A Wagner incision is used to access the thumb carpometacarpal (CMC) joint with a small proximal extension to facilitate palmaris longus tendon retrieval. A Z-plasty is incorporated into the longitudinal aspect of the incision to prevent scar contracture across the wrist joint (▶Fig. 45.2). Dissection is carried down to the level of the thenar musculature, taking care to protect the branches of the superficial radial sensory nerve and the radial artery. The thenar muscles are incised along their fascial insertion of the first metacarpal and reflected ulnarly, allowing access to the first metacarpal and CMC joint capsule. A longitudinal capsulotomy is performed in the interval between the APL and the extensor pollicis brevis (EPB) tendons or slips of the APL, and thick capsular flaps are elevated radially and ulnarly. Care must be taken to preserve the integrity of these flaps for subsequent closure.
Fig. 45.1 (a–c) Radiographic appearance following trapeziectomy and flexor carpi radialis suspension arthroplasty. Note the bone tunnel in the base of the first metacarpal as well as proximal migration of the first metacarpal with scaphoid impingement. (d–f) Radiographic appearance following revision arthroplasty. Initial appearance, demonstrating good preservation of the trapezial space. (g–i) Six-month postoperative view, demonstrating proximal migration of the first metacarpal with scaphoid impingement.