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• W2926982912 abstract "Osteoarthritis of the thumb carpometacarpal joint is common, especially in postmenopausal women. Numerous surgical techniques, including ligament reconstruction, partial or complete trapeziectomy, arthrodesis, and arthroplasty have been introduced. Suspensionplasty combined with trapeziectomy has been introduced to prevent proximal subsidence of the first metacarpal. To prevent excessive release of periarticular capsuloligamentous tissues, resection of the proximal part of the trapezium, and the cosmetically unappealing bump, arthroscopic partial trapeziectomy has been used as a less-invasive treatment option. With advanced techniques and devices, arthroscopic suspensionplasty with the autograft can be performed; thus far, there have been no series reporting on arthroscopic treatment options for this common condition. The purpose of this article is to present a technique for arthroscopic-assisted suspensionplasty using the palmaris longus tendon to reinforce the graft–bone interface, based on the concept of the tension slide technique to treat thumb carpometacarpal osteoarthritis. Osteoarthritis of the thumb carpometacarpal joint is common, especially in postmenopausal women. Numerous surgical techniques, including ligament reconstruction, partial or complete trapeziectomy, arthrodesis, and arthroplasty have been introduced. Suspensionplasty combined with trapeziectomy has been introduced to prevent proximal subsidence of the first metacarpal. To prevent excessive release of periarticular capsuloligamentous tissues, resection of the proximal part of the trapezium, and the cosmetically unappealing bump, arthroscopic partial trapeziectomy has been used as a less-invasive treatment option. With advanced techniques and devices, arthroscopic suspensionplasty with the autograft can be performed; thus far, there have been no series reporting on arthroscopic treatment options for this common condition. The purpose of this article is to present a technique for arthroscopic-assisted suspensionplasty using the palmaris longus tendon to reinforce the graft–bone interface, based on the concept of the tension slide technique to treat thumb carpometacarpal osteoarthritis. Primary osteoarthritis in the thumb joints most commonly occurs in the carpometacarpal (CMC) joint. The incidence in adults of aged more than 30 years is approximately 15%, whereas that in postmenopausal women is up to 36%.1Dahaghin S. Bierma-Zeinstra S.M. Koes B.W. Hazes J.M. Pols H.A. Do metabolic factors add to the effect of overweight on hand osteoarthritis? The Rotterdam Study.Ann Rheum Dis. 2007; 66: 916-920Crossref PubMed Scopus (149) Google Scholar, 2Armstrong A.L. Hunter J.B. Davis T.R. The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women.J Hand Surg Br. 1994; 19: 340-341Crossref PubMed Scopus (351) Google Scholar Conservative treatment is initially adopted, including activity modification, the application of an orthosis, nonsteroidal anti-inflammatory medication, and intra-articular steroid injection.3Berger A.J. Meals R.A. Management of osteoarthrosis of the thumb joints.J Hand Surg Am. 2015; 40: 843-850Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar Surgery may be indicated when conservative treatment fails. Numerous surgical techniques to treat thumb CMC osteoarthritis have been reported, including volar ligament reconstruction, basal osteotomy of the first metacarpal, arthrodesis, arthroplasty, and simple trapeziectomy. Meta-analyses have not demonstrated significant differences in long-term outcomes among ligamentous reconstruction with tendon interposition, arthrodesis, and trapeziectomy with or without tendon interposition.4Martou G. Veltri K. Thoma A. Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review.Plast Reconstr Surg. 2004; 114: 421-432Crossref PubMed Scopus (124) Google Scholar, 5Wajon A. Carr E. Edmunds I. Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis.Cochrane Database Syst Rev. 2009; 4: CD004631PubMed Google Scholar Recently, arthroscopic-assisted techniques were suggested as less-invasive treatment options for thumb CMC osteoarthritis compared with classic open procedures.6Wilkens S.C. Bargon C.A. Mohamadi A. Chen N.C. Coert J.H. A systematic review and meta-analysis of arthroscopic assisted techniques for thumb carpometacarpal joint osteoarthritis.J Hand Surg Eur Vol. 2018; 48: 1098-1105Crossref Scopus (16) Google Scholar, 7Wong C.W. Ho P.C. Arthroscopic management of thumb carpometacarpal joint arthritis.Hand Clin. 2017; 33: 795-812Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar To date, arthroscopic procedures used to treat thumb CMC osteoarthritis have been applied to synovectomies or trapeziectomies; however, advanced arthroscopic techniques may also be used for additional procedures, including graft fixation for suspensionplasty. The purpose of this article is to present an arthroscopic-assisted suspensionplasty technique using the palmaris longus (PL) tendon to treat thumb CMC osteoarthritis. In this procedure, the mechanical properties of the graft–bone interface are reinforced based on the concept of the tension slide technique, which may allow early mobilization and accelerated rehabilitation after surgery. The indication for this technique includes patients with painful thumb CMC osteoarthritis in whom conservative treatment has failed for at least 3 months. Patients with Eaton stage IV scaphotrapeziotrapezoid osteoarthritis on plain radiographs are considered to be contraindicated for this technique.8Logli A.L. Twu J. Bear B.J. Lindquist J.R. Schoenfeldt T.L. Korcek K.J. Arthroscopic partial trapeziectomy with soft tissue interposition for symptomatic trapeziometacarpal arthritis: 6-month and 5-year minimum follow-up.J Hand Surg Am. 2018; 43: 384.e1-384.e7Abstract Full Text Full Text PDF Scopus (9) Google Scholar, 9Chuang M.Y. Huang C.H. Lu Y.C. Shih J.T. Arthroscopic partial trapeziectomy and tendon interposition for thumb carpometacarpal arthritis.J Orthop Surg Res. 2015; 10: 184Crossref PubMed Scopus (14) Google Scholar The technique can also be used in patients who require additional treatment for first MCP joint hyperextension, such as a capsulodesis. The patient is placed in the supine position under general anesthesia. A tourniquet is placed on the upper arm and the arm is secured to a traction tower (Acumed, Hillsboro, OR) with a strap. Two finger traps are used on the thumb and index finger with approximately 5 to 10 lb longitudinal traction by the tower. A 30°, 2.7-mm arthroscope; an electrical tissue ablation device; a full-radius mechanical shaver and burr with suction; and a 3.5-mm cannulated drill with a 1.35-mm guidewire are used. A cortical button (Mini TightRope, Arthrex, Naples, FL), 2 interference screws (DX SwiveLock, Arthrex), and a soft anchor with broad high-strength suture (FiberTak with 1.3-mm SutureTape, Arthrex) are used for arthroscopic-assisted autograft fixation. After identifying the CMC joint by palpation and fluoroscopy, 2 portals are made radial and ulnar to the first extensor compartment tendons (1R and 1U portals). The arthroscope is initially placed in the 1R portal and the presence or absence of synovial tissues, osteophytes, or loose bodies is observed. The articular cartilage and surrounding ligaments, including the dorsoradial, posterior oblique, and ulnar collateral ligaments, are also evaluated. The arthroscope is then placed in the 1U portal to evaluate the volar ligaments. An 18-gauge needle is inserted from the thenar portion of the CMC joint so as to place its tip inside the joint for perfusion. After the synovial tissues are debrided and loose bodies in the joint are removed, a round 3.5-mm arthroscopic burr is used to resect 3 to 4 mm of the distal trapezium. The osteophytes in the trapezium are sufficiently resected once a saddle-shaped surface of the trapezium has been converted to a flat or slightly concave surface (Fig. 1). Determination of whether appropriate resection has been acquired is based on direct arthroscopic visualization. The radial base of the second metacarpal is clearly visualized with the arthroscope placed in the 1U portal after debriding the overlying soft tissue. A 1.35-mm guidewire is inserted in the CMC joint through the 1R portal to create a tunnel at the base of the second metacarpal. A 1-cm incision is made over the ulnar aspect of the second metacarpal at the level of the exit point of the guidewire for the suspensionplasty. A 3.5-mm cannulated drill is then advanced along the guidewire to enlarge the radial part of the tunnel (Fig. 2A, B). The depth of enlargement is determined in advance: 6 mm from the radial cortex of the second metacarpal is usually selected, whereas 10 mm is used for patients with maximum transverse diameter of the base of the second metacarpal greater than 20 mm according to the anteroposterior radiograph. The incision of the 1R portal is extended distally to a length of 2 cm, and the dorsoradial portion of the proximal diaphysis of the first metacarpal is visualized while carefully protecting the superficial branch of radial nerve. Under fluoroscopic control, the 1.35-mm guidewire is advanced through this incision from the first metacarpal to the CMC joint. The arthroscope placed in the 1U portal is employed to confirm the tip of the wire in the joint. The guidewire is overdrilled with the 3.5-mm cannulated drill (Fig. 3A), and a loop of number 2 FiberWire (Arthrex) is advanced through the tunnels, passing from the second to first metacarpals (Fig. 3B). A 1.1-mm suture passing guide pin (Arthrex) or Micro SutureLasso (Arthrex) is useful for this passage. A PL tendon (3 mm wide and 12 mm long) is used for an autograft. If the PL tendon represents insufficient length or width, the gracilis tendon can be used. A soft anchor with 1.3-mm SutureTape is positioned at the base of the first metacarpal. A suspension graft composed of harvested free autograft tendon (PL or gracilis) and the SutureTape from the soft anchor are shuttled through the loop. As shown in Figure 4A and B, the autograft tendon and SutureTape are folded double by the loop-suture. The bilateral edges of the autograft are secured with a suture, and the loop is carefully withdrawn until the suspension graft reaches the enlarged tunnel in the second metacarpal (Fig. 4C, D). The withdrawn loop-suture is secured with a Mini TightRope onto the dorsoulnar cortex of the base of the second metacarpal (Fig. 5A). According to the concept of the tension sliding technique, the suspension graft is also fixed with an interference screw (SwiveLock) in the tunnel of the second metacarpal under arthroscopic guidance (Fig. 5B). For patients who underwent 6-mm-deep enlargement during tunnel preparation, a 3 × 8.5-mm DX SwiveLock SL is used for fixation; for those who underwent 10-mm-deep enlargement, a 3 × 13.5-mm SwiveLock is used. The eyelet is removed from each device in advance to place the screw in the tunnel.Figure 5A Schematic illustration of the suspension graft secured to the second metacarpal. According to the concept of the tension slide technique, both a cortical button and an interference screw are used for fixation. B Arthroscopic view from the 1U portal, confirming the placement of the interference screw in the tunnel of the second metacarpal. The left CMC joint is shown. M2, second metacarpal.View Large Image Figure ViewerDownload (PPT) The autograft with FiberTape derived from the first metacarpal is manually tensioned so that the suspension can prevent subsidence of the first metacarpal. Under tension, the SutureTape is tied with a nonsliding knot (Fig. 6). This knot-tying may have a role in improving the pull-out strength of the graft at the first metacarpal tunnel. The graft is then secured with an interference screw (3 × 13.5 mm SwiveLock without an eyelet), which is placed in the tunnel of the first metacarpal. The wounds are closed in the standard fashion. Patients are immobilized with a short-arm thumb spica orthosis for 10 days after surgery. Subsequently, they undergo range of motion (ROM) exercises, and grip and pinch strengthening exercises taught by hand therapists. Activities on daily activities are aggressively encouraged immediately after removal of the orthosis, excepting axial loading on the thumb. Return to sport and heavy manual labor is generally allowed at 3 months after surgery. After partial trapeziectomy, the radial base of the second metacarpal should be clearly visualized to create a bone tunnel. The tendon graft should not be too narrow or short; a width of 3 mm and length of 12 mm are needed to create the suspension graft. Preoperative ultrasound examination may be helpful to determine whether the PL tendon can be used for the graft. Moreover, the cannulated drill employed to create the bone tunnel at the second metacarpal should not be advanced bicortically. Drilling along the guidewire is needed to enlarge the radial part of the tunnel alone; if the ulnar cortex of the second metacarpal where the Mini TightRope would be placed is enlarged with the 3.0-mm cannulated drill, the Mini TightRope may be malpositioned or oversunk. Finally, the graft should be tightly tensioned. In the current technique for arthroscopic-assisted suspensionplasty for thumb CMC osteoarthritis, we applied dual fixation with an interference screw with a cortical button or suture anchor fixation. Sethi and Tibone10Sethi P.M. Tibone J.E. Distal biceps repair using cortical button fixation.Sports Med Arthrosc Rev. 2008; 16: 130-135Crossref PubMed Scopus (33) Google Scholar advocated the combination of the interference screw and the cortical button, named the tension sliding technique, for the treatment of ruptures of the distal biceps brachii. If a cortical button is placed on the proximal radial cortex without a screw, the healing process of the tendon to the bone within the tunnel could be associated with considerable slippage, which would create a gap between the tendon and bone. Thus, an interference screw is placed in the tunnel to reduce tendon–bone gapping while maintaining a high pull-out strength with cortical button fixation. A biomechanical study11Sethi P. Obopilwe E. Rincon L. Miller S. Mazzocca A. Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation.J Shoulder Elbow Surg. 2010; 19: 53-57Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar also found that this technique could maintain cortical button strength with a significant decrease in tendon–bone gapping and motion at the repair site. Although the optimal strength required for the suspensionplasty remains unclear, this dual fixation mechanism may allow for early and aggressive ROM exercises without sacrificing tendon–bone healing. For the suspension graft, moreover, the autograft tendon and SutureTape are simultaneously used. The initial strength can be secured with the SutureTape, and biological healing of the autograft to the metacarpals and the remodeling processes may consequently contribute to enough strength on the graft–bone interfaces. Thus, we believe this fixation technique for thumb CMC osteoarthritis is useful for accelerating rehabilitation, although this requires using multiple implants. In our rehabilitation protocol, non–axial loading exercises are allowed 10 days after surgery according to the protocol after suture button suspensionplasty.12Yao J. Song Y. Suture-button suspensionplasty for thumb carpometacarpal arthritis: a minimum 2-year follow-up.J Hand Surg Am. 2013; 38: 1161-1165Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar All activities including axial loading on the thumb are allowed 3 months after surgery when remodeling of the tendon graft may be assumed. Regarding the amount of resection of the trapezium, total trapeziectomy has been reported with satisfactory pain relief; however, substantial loss of thumb strength and stability were cautioned.13Field J. Buchanan D. To suspend or not to suspend: a randomised single blind trial of simple trapeziectomy versus trapeziectomy and flexor carpi radialis suspension.J Hand Surg Eur Vol. 2007; 32: 462-466Crossref PubMed Scopus (89) Google Scholar In contrast, partial trapeziectomy with excision of the articular surface of the trapezium have become popular with some surgeons.14Abzug J.M. Osterman A.L. Arthroscopic hemiresection for stage II-III trapeziometacarpal osteoarthritis.Hand Clin. 2011; 27: 347-354Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 15Hofmeister E.P. Leak R.S. Culp R.W. Osterman A.L. Arthroscopic hemitrapeziectomy for first carpometacarpal arthritis: results at 7-year follow-up.Hand (N Y). 2009; 4: 24-28Crossref PubMed Scopus (39) Google Scholar Arthroscopic partial trapeziectomy has the advantage of preserving the capsuloligamentous tissues of the CMC joint, which may contribute to joint stability. For patients who have failed this suspensionplasty, various options for revision surgery can be selected given that the proximal trapezium has been preserved. Although multiple incisions are required, this technique may be useful for preserving tissues providing to the stability to the CMC joint. First, the palpable knot underneath the skin could be a source of irritation for patients. Second, despite the low degree of invasiveness, there is a risk for injury to the sensory branches of the radial nerve. Third, this procedure is technically demanding and requires multiple implants with an associated cost. In addition, there is a potential risk for metacarpal fracture during the creation of bony tunnels or placement of interference screws. Fourth, the presence of adjacent joint pathologies (eg, scaphotrapeziotrapezoid) should be carefully assessed even if radiologic findings are subtle. To identify symptomatic or asymptomatic associated pathology, we routinely perform intra-articular injections of local anesthesia into the CMC joint before surgery. We adopt the current technique for patients with immediate and complete pain relief after the block test. Fifth, overtightening or mechanical failure of the suspension graft may result in symptomatic impingement of the first and second metacarpals or excessive subsidence, which are known potential complications after suture button suspensionplasty. To prevent this structural impingement, the position of the suspension graft is confirmed before the SutureTape is tied. Dynamic assessment of the intra-articular portion of the graft while moving the thumb may be useful to prevent over- or undertightening arthroscopically. Postoperative follow-up with radiologic assessment for subsidence resulting from mechanical failure of the implants is also required. We performed surgery using this technique to treat a 49-year-old, right-handed woman with a 3-year history of left thumb pain, tenderness over the thumb CMC joint, and increasing pain during activities of daily living. Before surgical intervention, conservative treatment failed to improve symptoms. Before surgery, pinch and grip strengths were 71% and 65% of the contralateral limb, respectively. After surgery, she underwent ROM exercises 10 days. She returned to work as a cashier in a supermarket within 1 month after surgery. At 1 year after surgery, the symptoms improved with complete recovery of activities of daily living. Pinch and grip strengths improved 1 year after surgery with 96% and 88% of the contralateral limb, respectively. Postoperative radiographs at 1 year after surgery showed no significant subsidence (Fig. 7). The authors would like to thank Dr Kou Hayashi, Dr Kazushige Hasegawa, and Dr Yoshinori Miyasaka at Senen Rifu Hospital; and Dr Kazuaki Sonofuchi and Dr Hitoshi Goto at Goto Hand Clinic for their helpful discussion." @default.
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• W2926982912 title "Arthroscopic-Assisted Suspensionplasty Using the Palmaris Longus Tendon for Osteoarthritis of the Thumb Carpometacarpal Joint" @default.
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