Surgical Treatment of Basal Joint Arthritis of the Thumb
Introduction
Arthritis of the thumb carpometacarpal joint is common, and with advancing age is present in a high percentage of patients
Although symptomatic thumb CMC joint arthritis is common, there are many patients who are asymptomatic or who find adequate treatment with nonsurgical care
Multiple surgical options are available with no clear evidence for a superior procedure; the author uses variation of Thompson’s abductor pollicis longus (APL) suspensionplasty
Patient Selection
Painful Eaton stage II, III, or IV basal joint arthritis
Symptoms that persist despite nonsurgical management such as splints, NSAIDs, cortisone injections, activity modifications, or therapy programs
Diagnostic Imaging
Radiographs useful for preoperative planning, assessment
Radiographic staging does not correlate well with symptoms
Procedure
Room Setup/Patient Positioning
Most commonly, general anesthesia or regional anesthesia is used
Supine position; hand on table/arm board
Apply well-padded tourniquet around upper arm
Surgical Technique
Abductor Pollicis Longus Suspensionplasty
Make Wagner incision transversely over flexor carpi radialis (FCR) tendon curving to glabrous skin junction at radial border of thumb metacarpal distally
Raise skin, subcutaneous flaps and retract; preserve branches of radial sensory nerve
Dissect dorsally to expose extensor mechanism over metacarpal and APL insertion at base
Perform subperiosteal dissection between extensor pollicis longus (EPL) and extensor pollicis brevis (EPB) 1 cm distal to APL insertion
Reflect thenar muscles off radial aspect of metacarpal, including accessory APL
Distract thumb to expose scaphotrapezial (ST) and trapeziometacarpal (TMC) joints; expose trapezium subperiosteally and remove in pieces; remove osteophytes from capsule
Expose base of thumb metacarpal; Carroll elevator is helpful
Pierce center of articular surface with awl, Kirschner wire (K-wire), or drill; make second hole dorsally 1 cm distal to articular surface
Use curet to expand holes and join them with intramedullary tunnel; avoid fracturing bone
Harvest APL at musculotendinous junction with tendon stripper; use rotating action while holding stripper; trim free end of tendon as needed
Pass APL retrograde through dorsal metacarpal hole and out articular hole using tendon passer or loop of wire (Figure 1)
Inspect ST joint for significant wear; if present, remove abnormal cartilage, subchondral bone with curet
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