Trapeziectomy and Ligament Reconstruction Using a Reinforced Half-Slip of the Extensor Carpi Radialis Longus Tendon for Thumb Carpometacarpal Osteoarthritis

Abstract

Background: Carpometacarpal (CM) joint osteoarthritis of the thumb is characterized by pain and impaired thumb function in terms of pinch and range of motion. Here, we newly adopted a trapeziectomy with a graft-augmented ligament reconstruction procedure, in which the reconstructed ligament is reinforced using a half-slip extensor carpi radialis longus (ECRL) tendon.

Methods: From 2015 to 2022, 101 hands of 95 patients with CM joint osteoarthritis of the thumb underwent trapeziectomy with graft-augmented ligament reconstruction using the half-slip ECRL tendon to reconstruct the ligament. The reconstructed ligament was reinforced by wrapping 3 times with the half-slip ECRL tendon. All patients underwent a 1-year assessment, and 29 hands of 26 patients were followed up for >4 years postoperatively.

Results: Motion pain, as assessed by visual analogue scale, was significantly improved from 56.9 ± 20.6 preoperatively to 4.2 ± 10.1 at the 1-year assessment (p < 0.001). Radial and palmar abduction also increased significantly from 46.0° ± 11.0° and 49.7° ± 8.8° preoperatively, respectively, to 58.4° ± 6.4° (p < 0.001) and 59.5° ± 6.3° (p < 0.001), respectively, at 12 months postoperatively. Both male and female tip pinch increased significantly from 4.2 ± 1.8 and 3.0 ± 1.4 preoperatively, respectively, to 6.1 ± 1.9 (p = 0.002) and 4.3 ± 1.4 (p < 0.001) at the 1-year postoperative evaluation. We observed no impingement of the first metacarpal and scaphoid bones due to sinking of the first metacarpal bone, and repeat surgery due to rupture of the reconstructed ligament or fractures at the bone hole, was not needed for the 101 hands followed for approximately 1 year and the 29 hands followed over 4 years.

Conclusions: Trapeziectomy combined with graft-augmented ligament reconstruction, using a reinforced half-slip ECRL tendon wrapped 3 times, may serve as an effective treatment option for primary thumb carpometacarpal osteoarthritis. This approach offers significant pain relief, improved range of motion and pinch strength, and prevents postoperative impingement of the first metacarpal across all Eaton stages in the short - medium term.

Level of evidence: Therapeutic Level Ⅳ. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1

Surgical procedures. An approximately 3.5-cm first incision from the metacarpal bone to the dorsal side of the trapezium was made, followed by a second incision of approximately 3 cm (Fig. 1-A). The trapezium was then completely removed (Fig. 1-B). The ECRL tendon insertion and approximately 8 cm proximal to the ECRL tendon from that insertion were dissected. (Fig. 1-C). A distal-based pedicled half-slip of the ECRL tendon was then inserted into the trapeziectomy gap by passing it under the remaining half-slip of the ECRL tendon using it as a pulley (Fig. 1-D). The distal-based pedicled half-slip of the ECRL tendon was then pulled out from the bone hole made in the joint surface of the first metacarpal bone to the dorsal side (Fig. 1-E). The distal-based half-slip of the ECRL tendon drawn to the dorsal side of the first metacarpal bone was folded back into the gap made by the trapeziectomy and woven to reinforce the reconstructed ligament (Fig. 1-F). Illustration showing how the ECRL tendon was woven 3 times (Fig. 1-G). ECRL = extensor carpi radialis longus.

Fig. 2

Pain at the thumb CM joint at rest (Figs. 2-A and 2-C) or in motion (Figs. 2-B and 2-D) is significantly improved by surgery. Pain at the thumb CM joint at rest (Figs. 2-A and 2-C) or in motion (Figs. 2-B and 2-D) was evaluated by the VAS prior to and then at 8 weeks, 12 weeks, 6 months, 1 year and final (average 31.3 months) after surgery. 29 (26 patients) were assessed at more than 4 years after surgery (average 64.3 months). Data represents mean VAS at rest or in motion ± SD (n = 101 in Figs. 2-A and 2-C, 27 in Figs. 2-B and 2-D respectively, *p < 0.05). VAS = visual analogue scale.

Fig. 3

Range of the motion of the thumb CM joint is significantly improved by surgery. Radial (Figs. 3-A and 3-C) or palmar (Figs. 3-B and 3-D) abduction was evaluated prior to and then at 8 weeks, 12 weeks, 6 months, 1 year, and final (average 31.3 months) after surgery. 29 (26 patients) were assessed at more than 4 years after surgery (average 64.3 months). Data represents mean radial or palmar abduction ± SD (n = 101 in both Figs. 3-A and 3-C, 27 in both Figs. 3-B and 3-D, respectively, *p < 0.05).

Fig. 4

Tip pinch force is significantly improved by surgery. Tip pinch force was evaluated in men (Figs. 4-A and 4-C) and women (Figs. 4-B and 4-D) prior to and then at 8 weeks, 12 weeks, 6 months, 1 year, and final (average 31.3 months) after surgery. 29 (26 patients) were assessed at more than 4 years after surgery (average 64.3 months). Data represents mean tip pinch force ± SD (n = 21 (Fig. 4-A), 80 (Fig. 4-B), 7 (Fig. 4-C) and 20 (Fig. 4-D), respectively, *p < 0.05).

Fig. 5

Three finger (thumb, index and middle) pinch is significantly improved by surgery. Three finger pinch force was evaluated in men (Figs. 5-A and 5-C) and women (Figs. 5-B and 5-D) prior to and then at 8w, 12w, 6 m, 1 y, and final (average 31.3 m) after surgery. 29 (26 patients) were assessed at more than 4 years after surgery (average 64.3 months). Data represents mean 3 finger pinch force ± SD (n = 21 (Fig. 5-A), 80 (Fig. 5-B), 7 (Fig. 5-C) and 20 (Fig. 5-D), respectively, *p < 0.05).

Fig. 6

DASH disability and work scores are significantly improved by surgery. DASH disability (Fig. 6-A) and work (Fig. 6-B) scores were evaluated prior to and then at 8 weeks, 12 weeks, 6 months, 1 year, and final (average 31.3 months) after surgery. 29 (26 patients) were assessed at more than 4 years after surgery (average 64.3 months). Data represents mean DASH disability and work scores ± SD (n = 101, *p < 0.05). DASH = disabilities of the arm, shoulder, and hand.