Modified total trapezial and partial trapezoidal excision and ligament reconstruction tendon interposition reduces symptoms in isolated scaphotrapezial-trapezoid arthritis of the wrist

Introduction

Osteoarthritis of the scaphotrapezial-trapezoid (STT) articulation is an established cause of wrist pain. It is most commonly associated with degenerative arthritis of the basal joint of the thumb and occurs less commonly in isolation (Brown et al., 2003; North and Eaton, 1983; Pinto et al., 2003; Tomaino et al., 1995; 1999; Pinto et al. 2003). Tomaino et al. (1999) examined the prevalence of STT osteoarthritis in patients undergoing trapezium excision arthroplasty for basal joint arthritis of the thumb and found a prevalence of 62%. Historically, isolated STT osteoarthritis has been treated with STT arthrodesis or distal scaphoid excision (Garcia-Elias et al., 1999; Watson et al., 2003). Although Watson et al. (2003) reported favourable outcomes with few complications in STT arthrodesis, other studies have reported notable rates of non-union, infection, radioscaphoid impingement, limited range of motion, and progressive arthrosis (Ishida and Tsai, 1993; Kleinman, 1989; Rogers and Watson, 1989). Distal scaphoid excision is also associated with some morbidity. Very little outcome data is available for this technique, but Garcia-Elias et al. (1999) reported the development of dorsal intercalated segmental instability after distal scaphoid excision in 57% of his patients.

Trapezium excision ligament reconstruction and tendon interposition (LRTI) has been shown to provide excellent pain relief and high patient satisfaction in long-term studies when used in the setting of first carpometacarpal joint osteoarthritis (Tomaino et al., 1995). In patients with concomitant first carpometacarpal osteoarthritis and STT osteoarthritis, Tomaino et al. (1999) described a modification of the procedure combining the trapezium excision LRTI procedure with resection of the proximal trapezoid. Resection of the proximal trapezoid was not associated with any increased morbidity and resulted in similar outcomes in grip and pinch strength compared with a group of patients who did not undergo proximal trapezoid excision. We postulated that, because trapezium excision LRTI with proximal trapezoid excision addresses the entire STT joint, it could serve as an alternative for the treatment of isolated STT osteoarthritis (Figure 1). Using this combined procedure for isolated STT arthritis has not previously been reported. The purpose of our study was to determine if the modified total trapezial partial trapezoidal excision and LRTI can be effectively used in patients with isolated STT osteoarthritis in the clinical setting.

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Figure 1.

Excision of the trapezium and proximal trapezoid addresses all the surfaces of scaphotrapezial-trapezoid osteoarthritis.

Methods

Between January 2003 and December 2006, LRTI with total trapezial resection and proximal trapezoid excision was performed on 12 wrists in 10 patients who presented with painful arthritis of the STT joints. All patients experienced disabling pain that compromised activities of daily living. The average age of patients was 59 (range 48–65) years. There was a minimum of 11 months follow-up, with a mean of 18 (11–42) months. All but one patient was female. All patients had failed nonoperative measures that included nonsteroidal anti-inflammatory medication, splinting, occupational therapy, and at least one intra-articular steroid injection in every case. Surgical treatment involved complete trapezium excision, resection of the proximal one-quarter of the trapezoid, harvesting of the entire flexor carpi radialis tendon, which was then used for the ligament reconstruction, and tendon interposition (Figure 2). Pre- and post-operatively, all patients had their wrist range of flexion and extension as well as their grip and lateral pinch strength measured. In addition, they were asked to report pain pre- and post-operatively on an analog scale of 1–10. The outcomes were graded using the Modified Mayo Wrist Score (Minami et al., 1999). All patients had pre- and post-operative radiographs. All surgeries and follow-up examinations were performed by the senior author. Data were obtained through retrospective review of chart data. Pre- and post-operative values were compared for statistical significance using the paired Student’s t-test. Institutional review board approval was obtained for this study.

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Figure 2.

A. Radiograph of a patient with severe scaphotrapezial-trapezoid osteoarthritis. B. Post-operative radiographs after modified trapezial excision ligament reconstruction, tendon interposition surgery with proximal trapezoid resection.

Results

Range of motion measurements significantly improved at final follow-up. Wrist flexion increased from 48° (range 38–60°) to 53° (range 38–65°, p < 0.05). Extension also showed a significant increase, with an improvement of 52° (range 45–65°) to 55° (range 50–65°, p < 0.05). Other functional outcomes included the measurement of grip and pinch strength. Pre-operative grip strength measured 15.5 (range 4–37) kg, and post-operatively it improved to 19.2 (15–40) kg. Pinch strength also showed an improvement from 3.5 (range 2–9.5) kg to 4.3 (range 3–15) kg. The improvement in strength demonstrated a trend, but did not reach statistical significance. Ten of the twelve wrists had improvement in strength, with only two showing a mild decrease. Radiographically, there was no evidence of scaphoid-metacarpal impingement due to proximal migration of the first metacarpal. No carpal instability pattern developed or was detected. Thumb abduction in the palmar plane measured post-operatively averaged 46.3° (range 36–55°).

Pain scores universally decreased, with an improvement from a pre-operative mean of 8.5 (range 8–10) to 1.8 (range 0–3, p < 0.001) at final follow-up. Using the Modified Mayo Wrist Score, six patients were graded excellent, three were good, one fair, and none were poor. There were no cases of infection.

Discussion

Isolated STT osteoarthritis occurs at a reported incidence of 2–16% (Brown et al., 2003; Chamay and Piaget-Morerod, 1994; Garcia-Elias et al., 1999; Garcia-Elias and Lluch, 1999; North and Eaton, 1983). It more commonly occurs in conjunction with trapeziometacarpal arthritis and has been identified as a potential source of residual pain after trapezial resection LRTI when the arthritic scaphotrapezoid articulation is neglected (Irwin et al., 1995). North and Eaton (1983) reported that 46% of hands with severe trapeziometacarpal osteoarthritis also had scaphotrapezoidal arthritis, while Brown et al. (2003) found concomitant trapeziometacarpal and STT arthritis in 60% of cadaveric specimens. Symptomatic STT arthritis in the absence of trapeziometacarpal arthritis is less common.

Typically, isolated STT osteoarthritis has been treated primarily with either arthrodesis or distal scaphoid excision. Watson et al. (2003) reported on long-term follow-up of STT fusions performed primarily for the treatment of rotatory subluxation of the scaphoid, Kienbock’s disease, and STT osteoarthritis. In the study, they reported an overall complication rate of 13% with 4% non-union rate, 3.6% of patients developed reflex sympathetic dystrophy, and a < 1% incidence of infection. Range of motion measured 70–80% of the non-operated side and strength from 69% to 89%. Other studies, however, have reported a higher incidence of complications. Ishida and Tsai (1993) reported a non-union rate of 21% and Frykman et al. (1988), 25%. STT arthrodesis has also been associated with radioscaphoid impingement, limited range of motion, and progressive arthrosis (Ishida and Tsai, 1993; Kleinman 1989; Kleinman and Carroll, 1990), with an overall complication rate reported as high as 52% (Kleinman, 1989) and 58% (Ishida and Tsai, 1993).

Garcia-Elias et al. (1999) described a technique for distal scaphoid excision in the treatment of STT osteoarthritis using flexor carpi radialis tendon as an interposition arthroplasty. Outcomes of the technique included a 26–40% increase in strength at average 29 month follow-up, but residual pain in 40% of patients (Garcia-Elias et al., 1999). In addition, 57% of patients developed a dorsal intercalated segmental instability pattern with uncertain long-term implications. In a later techniques paper, Garcia-Elias (2011) explained that capitate instability after distal scaphoid excision should compel the surgeon to consider a partial arthrodesis. Corbin and Warwick (2009) also reported a case of profound carpal collapse after distal scaphoid excision and suggested lunocapitate fusion as a salvage procedure. In a letter responding to that report, Garcia-Elias (2010) reiterated the need for intra-operative determination of stability. It has also been suggested that patients with radiographic evidence of a hypermobile scaphoid would be better served with excision of the STT joint and interpositional arthroplasty (Stanley, 2010).

More recent treatments for STT osteoarthritis include arthroscopic debridement. Early results have been promising, with significant short-term improvements in range of motion, pain, and strength (Ashwood et al., 2003; Cobb and Davenport, 2009). It is unclear whether these results will be maintained in long-term follow-up.

Trapezium excision and LRTI is one of the most commonly performed procedures for trapeziometacarpal osteoarthritis. Long-term data show high patient satisfaction, improved strength, improved range of motion, and pain relief (Tomaino et al., 1995). Although first metacarpal subsidence has been known to occur with the LRTI procedure, it does not significantly impact on functional outcome as long as impingement against the scaphoid is avoided (Yang and Weiland, 1998). Tomaino et al. (1999) sought to address the presence of concomitant STT osteoarthritis by performing a proximal trapezoid excision during trapezium excision arthroplasty. The modified procedure yielded results as good as the standard trapezium excision LRTI and no increased morbidity.

We believe that because the modified total trapezium, partial trapezoid excision, and LRTI have been shown to have excellent long-term results with a low complication rate in pan-trapezial arthritis, its indications could be extended to patients with isolated STT osteoarthritis. When the proximal trapezoid is also resected, all STT articulations are addressed, and this should result in pain relief. Our results showed that patients’ pain scores universally improved, as did range of motion. Although there was a trend toward an improvement in grip and pinch strength, it did not reach statistical significance in our population. Tomaino et al. (1995) reported that pinch strength requires more time to return than grip, and our follow-up may have been too short to allow for full strength recovery. The majority of patients had outcomes that were excellent or good; no patient had a poor outcome. Limitations of our study include a limited follow-up, lack of a validated outcome measure such as a disability of the arm, shoulder and hand (DASH) questionnaire, and the retrospective nature of the project.

Another concern is that there are reports of carpal instability developing after trapezial excision arthroplasties when done in conjunction with proximal trapezoid excision. Rectenwald et al. (2005) reported two such cases of patients developing severe, symptomatic DISI instability following surgery for pan-trapezial osteoarthritis. He surmised that the critical amount of ligamentous compromise might be related to the amount of trapezoid excised. We resected only one-quarter of the proximal trapezoid, while Rectenwald describes removing half. Although we identified no radiographic signs of instability in our series, a longer follow-up and larger sample size could identify this as a problem. Even with trapeziectomy alone for trapeziometacarpal arthritis, Yuan et al. (2009) found that the frequency of dorsal intercalated segmental instability (DISI), as measured using the radiolunate angle, increased from 27% before surgery to 50% after surgery. The subset of patients with concomitant STT arthritis had a higher incidence of DISI: 62%, after surgery. These authors suggest that patients with stage IV basal joint arthritis are more likely to progress to instability after surgery. This might also be true for isolated STT arthritis. Tay et al. (2007) noted that STT arthritis sometimes presents with a DISI instability pattern. It is unclear if these patients are predisposed to the instability secondary to the arthritis or if the instability results in STT arthritis. These authors postulate that surgical intervention in such patients could lead to radiographic progression of the instability.

The findings from our study suggest that modified total trapezium partial trapezoid excision and LRTI is an effective means of treating isolated STT osteoarthritis. The procedure may prove to be a viable alternative to STT arthrodesis and distal scaphoid excision. Currently, there is evidence that simple trapezial resection without ligament reconstruction or tendon interposition is sufficient in the treatment of basal joint arthritis (Davis et al., 2004; Davis and Pace, 2009; Kuhns et al., 2003). This may prove to be true in the treatment of isolated STT arthritis as well. Other possible surgical interventions could include simple proximal hemiresection of the trapezium and proximal trapezoid resection with or without soft tissue interposition. Certainly, further study is necessary to ascertain the best treatment option.