Trapeziectomy with Ligament Reconstruction and Tendon Interposition (LRTI)

History:  This is a 55-year-old, ambidextrous female who runs her own company.  She has had 10 years of pain in her right thumb base.  The pain has been getting worse over the past 1 year.  She has intermittent symptoms, lasting about 2 or 3 weeks at a time.  She has increased pain with grasping, such as opening jars.  Her symptoms are also interfering with her work.  She is a previous smoker, who quit in 1983.  Previous treatments include:

  • Thumb spica brace
  • Steroid injections

Exam:

Right thumb:  Skin is intact.  There is squaring at the thumb base, also called a “shoulder sign.”  There is a bony prominence on the trapezium.  She has an adduction contracture, but no significant metacarpophalangeal joint hyperextension.  She has tenderness at the carpometacarpal joint with a positive grind test.

Lateral, oblique  and Robert’s views of her right thumb are shown.  She has marked narrowing of the carpometacarpal joint with bone-on-bone contact.  The subchondral bone is sclerotic and there is a small subchondral cyst radially in the trapezium.  She has large osteophytes, >2mm in size.  There is minimal subluxation.  The scaphotrapeziotrapezoid joint does not appear involved.  She is Eaton stage 3 (osteophytes >2mm with no STT joint involvement).

Tests:  Preoperative evaluation was normal.

Options:  She has activity limiting symptoms and has already had a trial of injections and bracing.  While hand therapy, anti-inflammatory medications, heat, ice, and creams and rubs can help with symptoms, she has poor symptom control with bracing and injections and is at a point where surgery can be helpful.  Surgical possibilities include:

  • Simple trapeziectomy—Most surgeons do not choose this option because of a concern that the thumb will settle, however, it can be just as effective as other procedures.
  • Trapeziectomy and ligament reconstruction—This requires a small, but well-anchored tendon graft, typically using all or part of the flexor carpi radialis tendon.
  • Trapeziectomy and tendon interposition arthroplasty—This may use any of a number of tendon grafts that is rolled and placed into the space where the bone was removed.
  • Trapeziectomy with ligament reconstruction and tendon interposition (LRTI)—This is arguably the most common procedure performed, repositioning and suspending the thumb.
  • Implant arthroplasty—Most of these devices are experimental.  Some implants, such as Orthosphere and Swanson silicone spacers, have had disastrous failures.
  • Artelon spacer—This bioabsorbable material is designed to spare bone in lower grades of arthritis.  Early experience suggests good results, but some have reported inflammatory reactions to the material.
  • Arthroscopy with hemiresection and interposition—This is being done in lower grades of arthritis.  Early results are promising.  It is technically challenging to get an arthoscope in this small joint.
  • Consideration can also be made for releasing the adduction contracture and correcting the metacarpophalangeal joint hyperextension, but she has minimal secondary deformity.

Treatment:  She underwent a ligament reconstruction and tendon interposition (LRTI).  She was in a splint until suture removal at about 10 days after surgery.  She then wore a cast for an additional 4 weeks.  She was transitioned to a brace and started hand therapy about 6 weeks after surgery.

Lateral, oblique and Robert’s views of her right thumb are shown.  There are a few specks of trapezium visible in the soft tissues.  There is a wide space between the scaphoid and thumb metacarpal, indicating a good soft tissue suspension of the thumb.

Outcome:  3 months after surgery, she was back to full duties at work and her pain was much improved compared to before surgery.  She was quite pleased with her results.

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