Trapezium excision arthroplasty and flexor carpi radialis tendon interposition
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Trapezium excision-arthroplasty is an effective solution for symptomatic trapezio-metacarpal arthritis or pan trapezoidal arthritis. There also are a number of adjunctive soft tissue procedures which need to be considered at the same time. Their purpose is to create a degree of stability of the thumb after the excision or to produce soft tissue interposition, which reduces the risk of proximal migration of the thumb metacarpal base and impingement against the scaphoid and trapezoid. The exact method of soft tissue stabilisation is probably of limited importance, however a well-performed and stable excision arthroplasty may be mobilised more rapidly than a simple excision arthroplasty alone. The case presented is using a dorsal approach to the thumb carpometacarpal joint (CMCJ). There is some risk of sensitisation, scarring or injury to the superficial radial nerve (SRN) terminal branches using the dorsal approach. Some surgeons therefore prefer a volar approach to the CMCJ.
This unfortunate patient sustained an injury to the SRN during a steroid injection for the CMCJ arthritis. The consequent neuroma was explored, resected and capped. There was a temporary improvement in the neuropathic pain but the skin on the dorsum of thumb over the radial side of the wrist and hand remained sensitive with allodynia and a strong static Tinel’s sign. The arthritis pain deteriorated over 2 years and a second ultrasound guided injection of the CMCJ using a radial volar approach did not provide more than 4 weeks of pain improvement. The decision was made to undertake a trapezium excision arthroplasty. The dorsal approach was selected to allow simultaneous re-explorartion of the neuroma site, further resection and targeted muscle reinnervation (TMR) of the SRN to the terminal branch of the anterior interosseous nerve (AIN) to the pronator quadratus (PQ). The TMR is covered as a separate procedure elsewhere on the Orthoracle site.
Please note that the incision used for this procedure is therefore longer, extending more proximally than the typical dorsal approach to the CMCJ of the thumb.
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Author:Dominic Power MA MB BChir FRCS FRCS TR Orth
Institution: Consultant Hand and Peripheral Nerve Surgeon