Keywords
orthopedic procedures - osteoarthritis - trapezium bone
Introduction
Rhizarthrosis is a progressive degenerative condition affecting the carpometacarpal
joint of the thumb. It is one of the most common forms of osteoarthritis in the hands,
and it is more frequent in women oldr than 50 years of age. This condition can be
debilitating, limiting the subjects' daily living and work capacity.[1] Several therapeutic options are available to manage symptoms and improve quality
of life, including lifestyle changes, motor and analgesic physical therapy, orthoses,
pharmacological treatments, infiltrations, and surgery.[2]
Surgical treatment is an option for patients with rhizarthrosis who do not obtain
symptom relief through nonsurgical therapies.[2] Trapeziectomy is a resection arthroplasty of the trapezius that was first described
is by Gervis, with good outcomes.[3] Some authors described the metacarpal's proximal migration and the compromised functional
outcomes as complications of this technique.[4] Thus, to prevent these complications, techniques associated with trapeziectomy were
described, including tendon interposition,[5] ligament reconstruction,[6] arthroplasty with implants,[7] the distraction hematoma formation technique (Kuhns technique),[8] ligament reconstruction with tendon interposition,[6] and acellular material interposition.[5] Although these associated techniques can be effective, they may increase the risk
of other complications, such as infection, pain, implant loosening, and muscle strength
loss.[4] The current literature has no studies with conclusive evidence regarding the most
effective technique for the surgical treatment of rhizarthrosis.[4]
Therefore, this study aimed to evaluate two surgical techniques: trapeziectomy with
the Kuhns technique and with tendon interposition, in 39 patients, with a minimum
follow-up period of 6 months.
These techniques were chosen due to the high number of patients who underwent these
procedures to provide a comprehensive and representative analysis, allowing a significant
comparison between them and contributing to validating the obtained results.
Materials and Methods
This retrospective cohort study evaluated 39 patients. Inclusion criteria were the
following: patients with clinical and imaging diagnosis of Eaton and Littler grade-III
and -IV rhizarthrosis,[9] from both sexes, who underwent surgical treatment with trapeziectomy using the Kuhns
technique[8] (group 1, n = 18), or trapeziectomy with tendon interposition[5] (group 2, n = 21), from 2018 to 2022, operated by four experienced hand surgeons,
with a minimum follow-up period of 6 months.
Data were collected from the electronic records of the study's hospital, searching
for patients with the following diagnosis codes of the International Classification
of Diseases, Tenth Revision (ICD-10): M18.0, M18.1, and M19.9. Retrieved information
included age, sex, operated side, dominant side, degree of osteoarthritis, and type
of surgical procedure ([Table 1]).
Table 1
|
Data
|
Group 1
|
Group 2
|
Total
|
p-value
|
|
Mean age (in years)
|
62.4
|
58.0
|
60.1
|
0.056
|
|
Sex
|
94.5% F
|
90.5% F
|
92.4% F
|
0.052
|
|
5.5% M
|
9.5% M
|
7.6% M
|
|
Dominant side
|
94.5% R
|
81% R
|
87.2% R
|
0.921
|
|
5.5% L
|
19% L
|
12.8% L
|
|
Operated side
|
44.5% R
|
42.9% R
|
43.6% R
|
0.209
|
|
55.5% L
|
57.1 L
|
56.4% L
|
|
|
Arthrosis grade (Eaton and Littler)
|
67% III
|
72% III
|
70% III
|
|
|
33% IV
|
28% IV
|
30% IV
|
0.748
|
|
Questionnaire application time (in months)
|
Mean: 39.8
|
Mean: 21.6
|
|
|
|
Minimum: 8
|
Minimum: 6
|
Mean: 30
|
0,08
|
|
Maximum: 62
|
Maximum: 50
|
|
|
Exclusion criteria were the following: patients with rheumatological, traumatic, or
neurological diseases affecting hand or wrist joints, those who underwent previous
surgery in the thumb region, those lost to postoperative follow-up, and those who
did not sign the informed consent form for the study.
After inclusion, we invited patients for an in-person assessment in a single outpatient
visit with four residents in hand surgery. We asked the patients to answer questionnaires
about their clinical and functional outcomes, including the Trapeziometacarpal Arthrosis
Symptoms and Disability (TASD),[10] the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH),[11] and the Visual Analog scale (VAS)[12] for pain, as shown in the [Annexes 1], [2], and [3]. The average time between the surgical procedure and the application of the questionnaires
was 30 months.
For statistical analysis, we imported data to the IBM SPSS Statistics for MacOS (IBM
Corp., Armonk, NY, USA) software, version 25.0. The descriptive statistics of categorical
data included absolute and relative frequency. Continuous data underwent the Shapiro-Wilk
normality test, and their description used mean ± standard deviation (SD), median,
and 25th and 75th percentiles. Data with parametric distribution underwent the Student
t test for two independent samples, while those with nonparametric distribution underwent
the Mann-Whitney test for two independent samples. A difference was statistically
significant when the type-I error, that is, the p-value, was lower than 0.05.
Surgical Procedures Performed and Evaluated in the Study
Surgical Procedures Performed and Evaluated in the Study
For the first group, we performed the surgical technique described by Kuhns[8] using a longitudinal dorsal approach of approximately 4 cm in the carpometacarpal
joint of the thumb between the tendon of the abductor pollicis longus muscle and the
tendon of the extensor pollicis brevis muscle. Next, we opened the joint capsule in
a T shape to expose and remove the trapezius; fixation was performed under radioscopy
with two 1.5-mm Kirschner wires between the first and second metacarpals, maintaining
the carpometacarpal joint space ([Fig. 1]). The procedure ended with suturing the joint capsule and skin. Then, a sterile
dressing and an antebracheopalmar plaster splint, including the thumb, were applied
and kept for 4 weeks. We removed the Kirschner wires in the outpatient clinic 4 weeks
after the surgery.
Fig. 1 Completed surgical procedure using the Kuhns technique. Intraoperative images demonstrating
the space (red arrow) after trapezium bone resection and the two Kirschner wires (yellow
arrow) used to fixate the first to the second metacarpal bones.
As for the second group, a trapeziectomy and tenoarthroplasty technique was performed
with the palmaris longus muscle,[5] using the same approach described for group 1. Then, we resected the tendon and
the palmaris longus muscle using three approaches ([Fig. 2]), creating a ball, and interposing it between the scaphoid and metacarpal bones
([Figs. 3]
[4]). We closed the joint capsule ([Fig. 5]), sutured the incision, and applied a bandage and a plaster splint. The sutures
were removed after 2 weeks and immobilization was maintained for 4 weeks.
Fig. 2 Image demonstrating the removal of the palmaris longus muscle for use as a graft.
Palmaris longus muscle's musculotendinous graft (yellow arrow) removal from the three
approaches.
Fig. 3 Palmaris longus muscle graft before being placed at the trapezius site.
Fig. 4 Graft placement at the site of the resected trapezius.
Fig. 5 Joint capsule closure.
Clinical Outcomes
Primary Outcome
The primary outcome was the TASD questionnaire,[10] which consists of a specific self-reported assessment of rhizarthrosis-related functional
limitations. The TASD was translated and culturally adapted to Brazilian Portuguese
in 2021.[13] It contains a series of questions about pain intensity and functional thumb capacity.
The answers are scored from 0 to 100, with higher scores indicating higher dysfunction.
Secondary Outcomes
The QuickDASH[11] assesses upper limb functional disability and pain, listing 11 related activities.
The answers are scored from 0 to 100, and higher scores indicate greater functional
disability and pain reported by the patients.
The VAS[12] assesses the intensity of pain reported by patients. It consists of a horizontal
line with a scale from 0 to 10, in which 0 represents no pain, and 10, maximum pain.
Patients were asked to mark the degree of pain they were feeling at that moment on
the scale.
A single evaluator not linked to the study applied the questionnaires during outpatient
visits to ensure the standardization of data collection.
The ethics committee of our institution approved the study under the CAAE number 71550023.1.0000.5487.
Results
The average time to apply the questionnaire to patients was of 30 months postoperatively,
with a minimum time of 8 and a maximum of 62 months for group 1, and a minimum time
of 6 and a maximum of 50 months for group 2 ([Table 1]).
In the analysis of the primary outcome, the mean TASD score was of 25.2 ± 27.5% in
the Kuhns technique group, and of 24.9 ± 22% in the tendon interposition group ([Fig. 6]).
Fig. 6 Analysis of the TASD scores in patients who underwent the Kuhns or tendon interposition
techniques.
In the analysis of the secondary outcomes, the mean QuickDASH score was of 25.5 ± 30.7%
in the Kuhns technique group and of 31.6 ± 24.6% in the tendon interposition group
([Fig. 7]).
Fig. 7 Analysis of the QuickDASH scores in patients who underwent the Kuhns or tendon interposition
techniques.
As for pain, the mean VAS score was of 3.2 ± 3.2% in the Kuhns technique group, and
of 3.0 ± 2.7% in the tendon interposition group ([Fig. 8]).
Fig. 8 Analysis of the VAS scores in patients who underwent the Kuhns or trapeziectomy + tendon
interposition techniques.
We found a positive correlation between the TASD and QuickDASH scores: an increase
in the score on one questionnaire corresponded to an increase in the score on the
other questionnaire. This suggests that both tools are effective in measuring aspects
related to functionality and disability in rhizarthrosis in a consistent manner ([Fig. 9]).
Fig. 9 Correlation of the QuickDASH and TASD scores in postoperative patients who underwent
the Kuhns or tendon interposition techniques.
Discussion
The study sample was homogeneous and representative, as described in the literature.[1] This study used the TASD questionnaire as the primary outcome, and the QuickDASH
questionnaire and the VAS as secondary outcomes, since these tools assess function
and potential limitations in daily living activities and pain in operated patients.
The literature reports that these are the most appropriate tools to evaluate the effectiveness
of surgical treatment.[10]
[11]
Our positive functional outcomes with the Kuhns technique[8] were consistent with those reported in the literature.[5]
[8]
[14] We observed as advantages of this technique, a shorter surgical time, the lack of
need to make new incisions, and the exemption from tendon graft removal. These benefits
simplify the procedure and result in a faster postoperative recovery, potentially
reducing complications associated with additional incisions and grafting procedures.
Its disadvantages are the potential complications inherent to the insertion and maintenance
of the Kirschner wire and the need for a second procedure for pin removal, which occurred
in the outpatient clinic of the institution in which the present study was conducted.
The technique of trapeziectomy with tenoarthroplasty of the palmaris longus muscle
also seeks to avoid proximal migration of the first metacarpal bone by using the tendon
graft as a biological spacer. The main advantage is the use of an autologous graft
with no synthetic implant requirements. As the main disadvantages of this technique,
we noted that, despite its performance on the same operated limb, it is limited for
patients who lack the palmaris longus muscle and scarring complications from graft
removal. The positive functional outcomes noted with the use of this technique in
the present study are consistent with those of the literature, in which several authors[5]
[15] have reported good and excellent outcomes.
Comparing both surgical techniques, we observed that trapeziectomy with long palmar
muscle tendon interposition was not superior to the Kuhns technique. Although we did
not find studies specifically comparing both procedures, the outcomes were consistent
with the literature addressing similar surgical techniques.[16]
[17]
[18]
[19] The findings of this review support the effectiveness of both approaches in rhizarthrosis
treatment. However, based on the Cochrane Review,[20] we cannot currently make recommendations regarding the superiority of any surgical
procedure over another for this condition.
We observed a positive correlation between the TASD a QuickDASH, a result consistent
with the findings in the literature.[10]
[21]
Conclusion
The two techniques evaluated proved effective for treating patients with rhizarthrosis
per the TASD, with an average postoperative follow-up of 30 months. There was no superiority
in functional outcomes between the groups when comparing trapeziectomy techniques
with tendon interposition or distraction. The specific TASD and the generic QuickDASH
functional questionnaires proved equivalent to measuring the patients' degree of functional
limitation.
