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Hand Surgery Unit, Department of Plastic Surgery, St Vincent’s Hospital, Melbourne, AustraliaHand and Wrist Biomechanics Laboratory, O’Brien Institute, St Vincent Institute, Melbourne, Australia
Victorian Hand Surgery Associates, Melbourne, AustraliaHand Surgery Unit, Department of Plastic Surgery, St Vincent’s Hospital, Melbourne, AustraliaHand and Wrist Biomechanics Laboratory, O’Brien Institute, St Vincent Institute, Melbourne, Australia
Corresponding author: Stephen K. Tham, MBBS, Victorian Hand Surgery Associates, Suite C37, Level 3, Building C, St Vincent’s Hospital, 41 Victoria Parade, FitzroyVictoria 3065, Australia.
Victorian Hand Surgery Associates, Melbourne, AustraliaHand Surgery Unit, Department of Plastic Surgery, St Vincent’s Hospital, Melbourne, AustraliaHand and Wrist Biomechanics Laboratory, O’Brien Institute, St Vincent Institute, Melbourne, Australia
Patients undergoing surgery for trapeziometacarpal (TMC) joint arthritis require preoperative counseling on the expectations of surgery. This study aims to document the objective and functional recovery over the initial 12 months following trapeziectomy and ligament reconstruction with tendon interposition (LRTI).
Methods
We prospectively followed 55 patients with symptomatic TMC joint osteoarthritis after trapeziectomy and LRTI. Patients were assessed on functional outcome measures, pain, and objective outcomes of grip, tip and key pinch strength, and range of motion. Outcomes were recorded preoperatively and at 3, 6, 9, and 12 months after surgery.
Results
Outcome measures of Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and pain, improved significantly after surgery at each 3-month interval up to 9 months. Palmar and radial abduction were significantly improved compared to their preoperative ranges, but opposition was unchanged. Power grip significantly exceeded the preoperative strength at 6 months and further increased at 9 months. Tip pinch significantly exceeded the preoperative strength at 12 months. There was no difference in the key pinch strength compared to the preoperative strength.
Conclusions
Over a follow-up period of 12 months, trapeziectomy and LRTI is an effective treatment in significantly reducing pain in 80% of patients. Although normal patient-reported outcome measures of DASH and PRWE are not regained, when compared to normative values, these measures are significantly improved; the improvement plateaus at 9 months. Patients can expect to attain 37% and 46% of their eventual measured DASH and PRWE scores, respectively, at 3 months, and 82% and 79% of their eventual measured DASH and PRWE scores, respectively, at 6 months. Grip strength exceeded the preoperative strength by 15% at 6 months and by 30% at 9 months. Tip pinch strength significantly exceeded the preoperative strength by 20% at 9 months.
The Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details.
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Disclosures for this Article
Editors
Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose.
Authors
All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.
Planners
Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.
Learning Objectives
Upon completion of this CME activity, the reader will understand:
•
The timeline of postoperative change in pain and motion of the thumb after ligament reconstruction with tendon interposition (LRTI).
•
Expected alterations in grip strength associated with LRTI.
•
The length of time after LRTI during which outcome measures continue to evolve after LRTI.
Deadline: Each examination purchased in 2021 must be completed by January 31, 2022, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
Trapeziometacarpal (TMC) joint osteoarthritis is common, especially in postmenopausal women, and surgical treatment is considered when the pain symptoms are sufficiently severe to interfere with activities of daily living despite nonsurgical measures.
The efficacy of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is well documented, although the necessity for LRTI has been questioned.
Long-term follow-up of trapeziectomy with abductor pollicis longus tendon interposition arthroplasty for osteoarthritis of the thumb carpometacarpal joint.
A number of surgical techniques to treat arthritis of the TMC joint have been described, and the variety of ways in which these techniques have been analyzed and reported make it challenging to compare the clinical outcomes of the different procedures or to counsel patients on what to expect from their symptomatic and functional recovery. The published literature on the results within the first 12 months after trapeziectomy is heterogeneous, with different measures of physical and functional recovery.
Suspension arthroplasty versus interposition arthroplasty in the treatment of trapeziometacarpal osteoarthritis: a clinical and magnetic resonance imaging study.
Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis.
Basal joint osteoarthritis of the thumb treated with Weilby arthroplasty: a prospective study on the early postoperative course of 106 consecutive cases.
While surgery has been shown to yield functional benefits, there is a need for an objective and current resource for the preoperative counseling of patients considering trapeziectomy and LRTI, to prepare these patients for their perioperative recovery.
The purpose of this study was to prospectively document the objective and functional recovery during the first 12 months following trapeziectomy and LRTI using the flexor carpi radialis (FCR) tendon, in order to counsel patients on their expectations after trapeziectomy and LRTI.
Materials and Methods
Institutional ethics approval was obtained from St Vincent’s Hospital (Melbourne) Human Research Ethics Committees (approval number HREC-A 129/14) for a prospective, nonrandomized, interventional study on patients undergoing trapeziectomy and LRTI over a 12-month period from March 2015 to March 2016. Patients were included in this study if they had radiologically confirmed TMC joint osteoarthritis, reported persistent symptoms, and complained of impaired function after a failure of nonsurgical treatment comprising splinting and nonsteroidal anti-inflammatory medication for at least 3 months. Informed consent was obtained from all volunteers as per institutional ethics review board protocol. The exclusion criteria included patients who had previously undergone surgical procedures to the TMC or scaphotrapezium-trapezoid (STT) joints, who underwent other procedures to the same hand or thumb at the time of the trapeziectomy and LRTI, and who had systemic inflammatory arthropathy. Three fellowship-trained hand surgeons performed all the procedures.
Baseline demographic information on age, sex, hand dominance, and the affected limb was collected. Preoperative and follow-up outcome measures were assessed at each interval by certified hand therapists not involved in the study.
Outcome measures
Each patient completed the Disabilities of Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE).
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
Palmar and radial abduction angles were measured using a goniometer placed between the first and second metacarpals. Grip strength (kg) was measured using a Jamar hand dynamometer (Preston Company) in position 2 with the shoulder adducted, elbow flexed at 90°, and forearm and wrist in a neutral position.
Lateral key and tip pinch strength (kg) were measured using a Jamar pinch dynamometer (Preston Company), with the average of 3 serial strength measurements recorded.
All objective and patient-rated outcome measures were performed preoperatively and at 3, 6, 9, and 12 months after surgery. Radiographic assessments of the thumb TMC joint were performed in 3 planes to confirm the diagnosis before surgery.
All patients underwent trapeziectomy and LRTI using a distally based portion of the FCR tendon, 3–4 mm in width, similar to the procedure originally described by Burton and Pellegrini.
The thumb was immobilized in a forearm-based plaster splint for 2 weeks, then in a thermoplastic splint for 4 weeks. A graduated mobilization program was undertaken under the supervision of a hand therapist from 2 weeks after surgery, commencing with unloaded short arc range of motion and opposition, depending on the patient’s symptoms. The thermoplastic splint was weaned and a gradual increase in use and loading of the thumb was allowed from the sixth week after surgery. No specific strengthening exercises were performed.
Analysis
Given the absence of a control group, the analysis measured changes in DASH and PRWE scores from baseline values. Generalized estimating equations were used to model the average change in an outcome at each follow-up point, with significance set at a P value < .05 and power for a clinically relevant difference for each measure set at 80%. Generalized estimating equations assume that the relationship between time and outcome is linear, but make no other parametric assumptions, unlike alternative statistical methods. Power calculations showed that there was sufficient power to determine clinically relevant differences in outcomes.
Age and sex were expected to be strong predictors of outcomes and were adjusted for in the model by including these variables as fixed covariates in the generalized estimating equations; the coefficients have been included in the Tables. Mulders et al
showed that female sex and increasing age are positively correlated with an increased PRWE. The small number of men enrolled (n = 10) precluded a full comparison of outcomes by sex.
Results
There were 68 patients enrolled in the study. Of these, 12 patients had insufficient follow-up data recorded and 1 patient underwent an ipsilateral shoulder procedure in the early postoperative period. Thus, 13 patients were excluded from the final analysis. The results from 55 patients were analyzed. Patient demographics are outlined in Table 1. The mean patient age was 63 years, and 82% of the patients were women. Preoperative radiological evidence of STT arthritis was found in 23 patients.
Compared to their preoperative baseline measures, all patient-reported outcome measures were improved after surgery and reached statistically significant levels by 3 months (Fig. 1). Both DASH and PRWE improved significantly at each 3-month interval to 9 months (Table 2). The decrease in pain, as measured by VAS, also improved significantly at each 3-month interval up to the 9-month follow-up, reaching an average pain score of 1.3 (range, 0.7–1.8). Pain scores at 12 months (Table 3) were clustered at the bottom end of the scale, with 84% of the patients having a pain score of 2 or less and 36% reporting no pain. Two patients with a VAS pain score of 6, 1 with a VAS score of 3, and 1 with a VAS score of 4 at the 12-month follow-up were subsequently treated for FCR tendinitis with a corticosteroid injection. Their symptoms had resolved at a subsequent review after the study period.
Figure 1Changes in patient-reported outcome measures. ∗Statistically significant at P < .05 compared to preoperative measure.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Age is the effect of being over 60 years compared to being under 60 years.
-0.2 (-0.8 to 0.4)
.43
∗ Significance was compared to the preoperative measure.
† Significance was compared to the previous 3 months.
‡ Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
§ Age is the effect of being over 60 years compared to being under 60 years.
Opposition, as measured by the Kapandji score, declined significantly at 3 months, to 7.7 (range, 7.3–8.1); however, the score recovered to the preoperative score at 6 months (Table 4). There was no further significant improvement in the Kapandji score at 9 or 12 months. Palmar abduction improved significantly at 3 months and further improved at 9 months compared to the preoperative range, but did not improve further. Radial abduction improved significantly from the preoperative range at 6 months and did not improve thereafter. Power grip strength was reduced at 3 months but significantly exceeded the preoperative strength at 6 months, with a further significant increase at 9 months. Key pinch strength was significantly reduced at 3 months and recovered to the preoperative strength at 6 months. The key pinch strength measurements at 9 and 12 months were not significantly different compared to the preoperative strength. Tip pinch strength was significantly reduced 3 months after surgery and significantly increased between 3 to 6 months and between 6 and 9 months, but was only significantly improved compared to the preoperative strength at 12 months.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
Age is the effect of being over 60 years compared to being under 60 years.
0.2 (-0.7 to 1.0)
.72
∗ Significance was compared to preoperative measure.
† Significance was compared to the previous 3 months.
‡ Sex is the effect of being male compared to being female. Positive numbers denote higher scores for males and negative numbers denote lower scores for males.
§ Age is the effect of being over 60 years compared to being under 60 years.
There was no evidence that the patients with STT arthritis did not improve at the same rate as those without STT arthritis, and none of the patients with a 12-month VAS of 4 or greater had radiological evidence of STT osteoarthritis. Complications were noted in 5 patients, with 4 cases of FCR tendinitis and 1 case of De Quervain’s tenosynovitis at the 12-month follow-up. All complications had resolved with a corticosteroid injection after the completion of this study.
Discussion
A recent Cochrane report noted that though surgery for TMC joint arthritis can successfully alleviate pain and improve physical function and quality of life, no procedure demonstrated a benefit or superiority over any of the other techniques reported, including trapeziectomy with or without LRTI, interposition arthroplasty, joint resurfacing, arthrodesis, and Swanson joint resurfacing.
The study designs or methodologies in the studies reviewed were not of sufficient quality to allow a comparative evaluation. Thus, although the various surgical options used can alleviate the pain symptoms and help patients regain function, the surgical technique used for the treatment of TMC joint arthritis may be influenced by radiological and patient factors, but also by the experience of the surgeon and influence from surgical mentors.
determined that 68% of respondents treated advanced TMC joint osteoarthritis by trapeziectomy and ligament reconstruction, and 72% used either the whole or a part of the FCR for the ligament reconstruction. Similar findings were reported by Yuan et al
suggest that ligament reconstruction results in notable improvements in joint kinematics compared to trapeziectomy alone. In this study, we treated all the patients with trapeziectomy and LRTI using the technique described by Burton and Pellegrini,
technique with those of other techniques, but to prospectively document the recovery after surgery using validated and commonly used outcome measures, and to use this to counsel patients about to undergo the procedure. Other prospective studies have reported on the recovery during the first 12 months after trapeziectomy and LRTI. Ulrich-Vinther et al,
Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis.
Basal joint osteoarthritis of the thumb treated with Weilby arthroplasty: a prospective study on the early postoperative course of 106 consecutive cases.
technique, reported on 112 and 106 patients, respectively, but did not include functional scores or patient-reported outcome measures. Vermeulen et al,
technique, reported on 20 patients, but the pain was evaluated at the final review using a questionnaire and not a VAS. The chronological changes in pain were not documented. Using the technique described by Burton and Pellegrini,
reported on objective outcome measures before surgery and at a final follow-up. No functional scores or patient-reported outcome measures were reported. Similarly, Guzzini et al
Suspension arthroplasty versus interposition arthroplasty in the treatment of trapeziometacarpal osteoarthritis: a clinical and magnetic resonance imaging study.
only reported the subjective and objective outcome measures of 36 patients before surgery and at a 12-month review.
We observed that patients will notice a significant decrease in pain, measured by VAS, and significant improvements in DASH and PRWE at 3 months. Further significant improvements in these measures will occur at 6 and 9 months, after which no further improvement will occur. In total, 80% of the patients can expect little or no pain (VAS scores 0–2). Only 2 patients in our cohort complained of notable pain (VAS score 6) at 12 months, and both had tendinitis of the FCR tendon that resolved after treatment with corticosteroid injections administered after the 12-month study period. There were no differences in outcomes in patients with preoperative radiological evidence of STT arthritis.
The minimal clinically important difference (MCID) is the smallest change or difference in any outcome measure score that is associated with a clinically relevant change. For the DASH, it has been suggested that a change in score of 15 represents a clinically relevant change in patient function.
Our results show that the MCID for DASH occurred between the 3- and 6-month period and the MCID for PRWE occurred both in the first 3-month period after surgery and between the 3- and 6-month period.
Although normal function varies with the specific needs of each individual, Hunsaker et al
reported a normative value of 10.1 for the DASH score. In our cohort, the mean DASH score at 9 months was 15.5 (standard deviation, 10.5–20.5). Although not quite reaching the normative value for DASH as quoted by Hunsaker et al,
at 9 months the 95% confidence interval was within 1 standard deviation. In the first 12 months after LRTI, the outcome, as measured by DASH and PRWE, reaches a plateau after 9 months. Patients can expect to attain 37% of their eventual measured DASH score at 3 months and 82% at 6 months. Alternatively, patients can expect to attain 46% of their eventual measured PRWE score at 3 months and 79% at 6 months. Gervis and Wells
Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis.
Basal joint osteoarthritis of the thumb treated with Weilby arthroplasty: a prospective study on the early postoperative course of 106 consecutive cases.
We found that grip strength was reduced 3 months after surgery but was significantly better than the preoperative strength at 6 months and further increased significantly at 9 months. Patients can expect their grip strength to exceed their preoperative strength by 15% at 6 months after surgery and by 30% at 9 months. There was no further increase at 12 months. Tip pinch strength significantly exceeded the preoperative strength by 20% at 9 months. Although the mean key pinch strength at 9 and 12 months exceeded the preoperative strength, the increase was not significant (Table 4). The power grip, key pinch, and tip pinch strengths may be improved by a supervised hand therapy program, though previous studies did not report the use of a strengthening program.
Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis.
Basal joint osteoarthritis of the thumb treated with Weilby arthroplasty: a prospective study on the early postoperative course of 106 consecutive cases.
In our patient cohort, the mean power grip, key pinch, and tip pinch strengths at 12 months for men (n = 10) were 33.8 kg (range, 27.4–40.1 kg), 6.2 kg (range, 4.9–7.4 kg) and 6.3 kg (range, 5.2–7.5 kg), respectively, and for women (n = 45) were 20.7 kg (range, 18.4–22.9 kg), 4.2 kg (range, 3.7–4.7 kg), and 3.9 kg (range, 3.4–4.4 kg), respectively. However, these mean strength measures were reduced compared to the normative values for men and women, measured from right and left hands, in the 60- to 64- year age group.
determined that the mean normative values of thumb movement in a cohort of volunteers with a mean age of 26 years, of which 63% were women, was palmar abduction of 61°, radial abduction of 63°, and a Kapandji score of 9. Follow-up of the patients in our study showed that radial and palmar abduction increased significantly compared to the preoperative ranges at 6 months and 9 months, respectively. Opposition, measured by determination of the Kapandji score, exceeded the preoperative mobility from 6 months, but not significantly. Patients with osteoarthritis of the TMC joint have reduced preoperative mobility scores, and while trapeziectomy and LRTI in our study did not restore the thumb mobility to normative values, there were modest improvements in palmar and radial abduction after surgery.
This study was limited by size and was underpowered for subgroup analyses of the effects of sex and age. The analyzed results were performed on the basis of means and may not reflect individual responses. Additionally, the study period is limited to the first 12 months after surgery, and the response after surgery beyond this period cannot be inferred.
Preoperative counseling can better prepare patients for their expected recovery and can decrease negative outcomes, such as pain and anxiety after surgery.
Long-term follow-up of trapeziectomy with abductor pollicis longus tendon interposition arthroplasty for osteoarthritis of the thumb carpometacarpal joint.
Suspension arthroplasty versus interposition arthroplasty in the treatment of trapeziometacarpal osteoarthritis: a clinical and magnetic resonance imaging study.
Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis.
Basal joint osteoarthritis of the thumb treated with Weilby arthroplasty: a prospective study on the early postoperative course of 106 consecutive cases.
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
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