Excision of the Trapezium
Krishna Mohan Iyer*
Orthopaedic Surgeon, India
Submission: December 19, 2016; Published: January 23, 2017
*Corresponding author: K Mohan Iyer, K Mohan lyer, Senior Consultant, Orthopaedic Surgeon, Flat No: 120/H-2K, First Floor, Kailash Apartments, 8th Main Road, Malleswaram, Bangalore, 560003, Karnataka State, India, Tel: +919632683264; Email; kmiyer28@hotmail.com
How to cite this article: Krishna M I. Excision of the Trapezium. Ortho & Rheum Open Access J. 2017; 4(3): 555640. DOI: 10.19080/OROAJ.2017.04.555640
Original Work
- The Results of Excision of the Trapezium- K Mohan Iyer (Oct.1981) The Hand, Vol. 13,No. 3: 246-250.
- Arthrography of the Metacarpo-Scaphoid Joint following Excision of the Trapezium- K Mohan Iyer & GH Whitehouse (Oct.1981) The Hand, Vol.13,No. 3: 251-256 [1-39].
The Trapezium Surfaces
- Palmar Surface-Groove and a Tubercle.
- Dorsal Surface-Related to Radial Artery.
- Lateral Surface-Lateral collateral ligament of the wrist joint & capsular ligament of the carpometacarpal joint.
- Medial Surface-Facet for the Trapezoid.
- Proximal Surface-Facet for the Scaphoid
- Distal Surface-Saddle shaped for the base of the first metacarpal.
Normal Wrist Joint Compartments
- Radiocarpal Joint.
- Inferior Radioulnar Joint.
- Midcarpal Joint.
- Isolated Carpometacarpal Joint the Thumb (Figure1)
Intercarpal Joints
- Joints between bones of the proximal row.
- Joints between bones of the distal row.
- Midcarpal Joint
- Between these two rows of bones.
- S shaped cavity lined by synovial membrane.
- Has 2 projections proximally and 3 projections distally.
Pathology
Stage I:
- Pain
- Synovitis
- Local Swelling
- Effusion into the joint (Figure 2)
Stage II:
- Severe pain
- Joint space narrowing
- Medial osteophyte (Figures 3 & 4).
Stage III:
- Severe pain
- Marked decrease of joint space Subluxation of the metacarpal (Figure 5).
Stage IV:
- Subluxated metacarpal fixed by fibrosis & contracture
- Marked hyperextension deformity of the MCP joint Flexion deformity of the IP joint
- Pain minimal or nil Fixed adducted thumb (Figure 6).
Carpometacarpal Arthritis of the Thumb
Stage I:
- Age: 60 Years
- Sex: Women(Post Menopausal)
- Side: Right side; Both sides frequent
- Predisposing Factors:
- Trauma (30%)
- Developmental Anomalies
- Occupational
- Anatomical
Symptoms
- Severe pain-Base of the thumb
- Aggravated by movements
- Swelling over the base of the thumb
- Stiffness of the Thumb
- Weak Grip
(A)Conservative Treatment
- Physiotherapy
- Radiotherapy
- Splint
- Intra-articular Steroids
(B)Surgical Treatment
- Forage
- Intra-articular Tenodesis
- Excision of the Trapezium
- Arthrodesis
- Silicone rubber interpositional arthroplasty
- Prosthetic Replacement
- Forage
- Intra-articular Tenodesis
- Robert(1936)
- Forestier(1937)
- Lasserre,Pauzat and Derennes(1949)
- Muller (1949) and Brittain (1952) - Arthrodesis of the carpometacarpal joint of the thumb. Stressed the difficulty of obtaining a successful fusion of this small joint.
- Dickson (1976):
- Silicone rubber sponge interposition arthroplasty
- Excellent results in 15 of the 16 wrists.
- Silicone promotes development of repair fibrous tissue.
- Swanson (1972) - Heat molded, intramedullary stemmed silicone rubber implant. Early results not encouraging due to advancement of insertion of abductor pollicis longus with reinforcement of capsule with a slip from flexor carpi radialis.
- Gervis (1949) 18 wrists with 16 good results. (1973) 12 wrists followed up for 6 to 22 years.
- Goldner & Clippinger (1955) Excison of the Trapezium piece-meal.
- Murley (1960) 39 wrists with 36 good results. Marmor & Peter (1969) 7 wrists with 5 good results.
- Sims & Bentley (1970) 27 Trapeziectomies with excellent results in 15, Good in 6, Fair in 5 & Poor in one. Incidence of 54% of patients with associated Trapezio- Scaphoid Arthritis.
- Gervis (1949) 18 wrists with 16 good results.
- Gervis (1973) 12 wrists followed up for 6 to 22 years
- Murley (1960) 39 wrists with 36 good results
- Goldner and Clippinger (1955) Excision of the Trapezium piece-metal.
- Marmor and Peter (1969) 7 wrists with 5 good results.
- Sims and Bentley (1970) 27 Trapeziectomies with excellent results in 15, good in 6, fair in 5 and poor in one. Incidence of 54% of patients with associated Trapezio- Scaphoid arthritis.
- Iyer (1981) 26 wrists with 25 good results.
Clinical Evaluation
- Name
- Age
- Sex
- Dominant Hand
- Occupation
- Time off work: Pre-op, Post-op & Total.
- Return to original occupation.
- History of Injury.
- Duration of complaints pre-op.
- Time since surgery.
Associated Conditions
- Cervical Spondylosis.
- Periarthritis Shoulders.
- Stenosing Tenovaginitis
- Median nerve compression
- Surgical -Incision.
- Post operative management (Table 1) (Figures 7-17).
Results
Thumb Movements:
- Abduction
- Normal range + Power -18 wrists
- Less than 50% -8 wrists
- Opposition
- Normal range + Power -14 wrists
- N.range+50%Power - 9 wrists
- Less than 50% R+P - 3 wrists
- Adduction
- Normal Power - 25 wrists
- Poor - 1 wrist
- Normal -25 wrists
- Poor - 1 wrist
Associated Features:
- Cervical Spondylosis -13/18 patients.
- Periarthritis Shoulders -9/18 patients.
- Stenosing Tenovaginitis -3/18 patients.
- Median nerve compression -4/18 patients (Surgical Decompression in 2 patients)
- Follow up- 2 months to 14 years
- Duration of complaints pre-operative- 1 year to 10 years
- Total time off work- 3 months
- Return to original occupation- 11 patients
- History of injury- 7/26 wrists
- Dominant hand- 13/18 patients
- Hand span
- Bilateral cases (8 patients)- equal
- Rest (10 patients)- 1.25 cms (average)
- Bilateral cases (8 patients) - equal
- R est (10 patients) - 1 cm (average)
- Bilateral cases (8 patients) - equal
- R est (10 patients) - 1 cm (average)
- Normal -23/26 wrists
- Less than normal -3/26 wrists
- Functioning tendons of Flexor carpi radialis and Flexor pollicis longus =26/26 wrists.
- Decreased sensations over the dorsum of the base of the thumb =3/26 wrists.
- Keloid formation = 5/26 wrists.
- Palpable Neuroma = None.
- Opposition Grip:
- Normal Power = 6 wristsDecreased power = 20 wrists
Radiographic Assessment
- Level of first metacarpal base.
- Accessory Ossicles.
- Radiologic gap.
- Telescoping.
- Stress views.
- Degenerative changes:
- Base of first metacarpal
- Distal Scaphoid
- Elsewhere in the carpus
Radiographic Features
- Telescoping =14 wrists (55%)
- Accessory Ossicles = 9 wrists (40%)
- Radiological Gap = 1mm to 6mm
- Degenerative changes:
- Base of first metacarpal =14 wrists
- Distal Scaphoid = 8 wrists
- No changes =11 wrists (Figure 24).
- Residual Cartilage:
- Base of first MC -Nil in 3 wrists
- Present in 22 wrists Distal Scaphoid - Nil in 2 wrists
- Present in 23 wrists 6.Lateral subluxation of 1st MC on Abduction
- Marked subluxation in 3 wrists Moderate subluxation in 22 wrists (Figure 25).
- Maintenance of joint space despite subluxation of the 1st MC on the Scaphoid on radial deviation of the wrist.
- Stress views of the wrist:
- No changes = 9 wrists
- Widening of the Sc-Trap.Jt =12 wrists
- Widening of the Sc-Cap.Jt = 6 wrists
- Widening of gap between the bases of 1st & 2nd MC’s = 6 wrists (Figures 26-28).
Arthrography of the Metacarpo-Scaphoid joint
Technique
(Figures 29 & 30)
Arthrographic assessment
- Amount of dye injected.
- Ease of location of the joint & injection.
- Residual articular cartilage over:
- Base of the first metacarpal
- Distal Scaphoid.
Arthrographic Assessment
- Isolated.
- Communications-
- Midcarpal
- Radiocarpal
- Radioulnar
- Tendon Sheaths
- Pouch between 1st & 2nd metacarpal bases
Arthrographic Features
- Distinct Joint Space - 25 wrists
- Comm. with midcarpal joint - 10 wrists
- Comm. with radiocarpal joint - 2 wrists
- Comm. with distal RU joint - 1 wrist
- Comm. with tendon sheaths - 4 wrists
- Contour-Irregular & small - 16 wrists
- Regular & larger - 9 wrists (Figures 33-36).
- Excision of the Trapezium gives good results with respect to relief of pain.
- Good hand function despite some reduction in the power of Opposition grip and Pinch grip.
- Carpal Instability or Laxity may account for decreased Opposition grip & Pinch grip.
- Distinct joint space
- Small & Irregular within 6 months of Surgery
- Large & Regular thereafter
- Marked subluxation indicates weak grip
- Late deterioration of pseudoarthrosis in one patient
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Conclusion