Does Arthroscopic Débridement With or Without Interposition Material Address Carpometacarpal Arthritis?

Abstract

Background

Thumb carpometacarpal (CMC) joint arthritis is a common problem in clinical practice with a variety of treatment options. Arthroscopic procedures can preserve all or part of the trapezium in the setting of treatment of basilar joint arthritis, and such procedures (even without stabilization or ligament reconstruction) have high reported success rates. However, little is documented about the limitations of these procedures in terms of patient selection, the optimal type of interposition, if any, and rehabilitation.

Questions/purposes

A systematic review was performed to determine the influence of (1) interposition material (manufactured, biological, or none); and (2) patient-related factors (including metacarpophalangeal joint hyperextension, ligamentous laxity, and severity of arthritis) on pain, functional scores, and postoperative complications unique to each approach.

Methods

A systematic review of the English language literature regarding thumb basilar joint arthritis and arthroscopic partial trapeziectomy or débridement was performed. Those procedures including ligament reconstruction or stabilization were excluded.

Results

Biological materials and no interposition were both associated with satisfactory improvement and low rates of complications; complication rates with synthetic materials were higher. Eaton Stages I to III were treated successfully with this technique. The effect of scaphotrapeziotrapezoid (STT) changes was variably described across series. In most series, metacarpophalangeal hyperextension did not seem to have an adverse effect on outcomes, although these patients were excluded in some series.

Conclusions

Arthroscopic débridement with or without interposition can be used for treatment of Eaton Stages I to III CMC osteoarthritis with satisfactory outcomes. Some series suggest satisfactory outcomes in the setting of STT changes and metacarpophalangeal hyperextension.

Introduction

Basilar joint arthritis of the thumb is a very common condition, particularly in women [26, 30, 35]. Although some patients are asymptomatic, many develop pain, particularly with pinch and grip, which can interfere with daily activities. When nonoperative means of treatment such as activity modification, hand therapy, injections, and splints fail, surgery is an option.

Surgical options have included reconstruction of the ligaments about the thumb with or without removal of the joint surface, arthroscopic shrinkage of the ligaments or débridement, corrective osteotomy to redistribute contact forces in early stages of arthritis, arthroscopic and open procedures, thumb carpometacarpal (CMC) fusion, and excision of all or part of the trapezium with or without interposition of any materials [7, 11, 16, 22, 24, 36, 38, 40].

Perceived disadvantages of complete trapeziectomy include the potential loss of thumb axis length and thus lever arm for pinch as well as risk of subsidence and scaphoid-metacarpal abutment. Thus, partial excision of the trapezium by arthroscopic or open means, without ligament stabilization, has been proposed as a potential treatment for basilar joint arthrosis that might obviate these concerns. Arthroscopic treatment allows for joint visualization and treatment and staging of disease in a minimally invasive fashion. Proponents of these techniques also suggest the ability to revise the surgery to complete trapeziectomy if necessary with progression of symptoms [3].

Therefore, a systematic review was performed of the English-language literature to determine the influence of (1) interposition material (manufactured, biological, or none); and (2) patient-related factors (including metacarpophalangeal joint hyperextension, ligamentous laxity, and severity of arthritis) on pain, functional scores, and postoperative complications unique to each approach.

Search Strategy and Criteria

A PubMed (NCBI http://www.ncbi.nlm.nih.gov/pubmed; 1996 to October 2012) and Cochrane Database search was performed using the following key words and combinations: thumb, interposition, arthroplasty, CMC, arthritis, arthroscopy, partial trapeziectomy, and trapeziometacarpal resurfacing (Fig. 1). One hundred ninety-five studies were identified. Studies were initially screened by review of the titles and abstracts. Studies were excluded if they were not written in English and the subject matter was not related to partial trapeziectomy (154 articles). The remaining 41 articles were specifically assessed and review articles without clinical data were excluded; the references of these articles were inspected and any manuscripts related to the subject matter were added (leaving 22 manuscripts). Manuscripts were included if the following criteria were met: English language, human study, and partial trapeziectomy or débridement with or without interposition arthroplasty. Review articles without original clinical outcomes data were excluded. Inclusion was not limited to prospective or controlled studies. Manuscripts involving concomitant procedures for stabilization or other treatment of the CMC joint (eg, corrective metacarpal osteotomy) or concomitant procedures to address the scaphotrapeziotrapezoid (STT) joint were excluded. To evaluate interposition materials, open partial trapeziectomy series without stabilization were reviewed when associated with relevant interposition materials that might be amenable to arthroscopic interposition or have been used arthroscopically or for information related to implications of STT changes or metacarpophalangeal (MCP) hyperextension.

Fig. 1.

Flow chart demonstrating meta-analysis.

The manuscripts that formed the major portion of the review (n = 22) include those focused on arthroscopic débridement or partial trapeziectomy with case series and adequate outcomes data (n = 11) [2, 9, 14, 15, 17, 18, 21, 25, 27, 28, 34]; open series that provided information regarding the interposition material or changes in the STT joint or MCP hyperextension (n = 7) [8, 10, 23, 31–33, 39]; and review or techniques articles or a case study with some limited original clinical data (n = 4) [4, 5, 12, 41].

Three review-type articles included limited patient outcomes data. Culp and Rekant [12] reported on 24 thumbs treated with arthroscopic débridement, hemi- or complete trapeziectomy, and thermal capsular shrinkage, noting 88% good to excellent results and improvement in pinch strength at 1.2 to 4 years followup. If complete eburnation of the joint was noted intraoperatively, arthroscopic partial trapeziectomy was performed. The STT joint was inspected arthroscopically through the midcarpal joint, and if arthritic, a complete trapeziectomy was performed. Those who underwent partial or complete trapeziectomy also were pinned with a temporary Kirschner wire. Yao and Park [41] likewise described partial trapeziectomy in patients with Eaton Stages I to III and partial trapeziectomy and distal pole of scaphoid resection in those with Type IV disease. Interposition with palmaris longus or Artelon^® (Small Bone Innovations, Morrisville, NJ, USA) was used. MCP hyperextension > 20° was addressed. Patients with ligamentous instability were included and underwent electrothermal radiofrequency shrinkage to address this problem with posttrapezial pinning. Badia described a technique for arthroscopic trapezial débridement and interposition with Artelon^® with limited outcomes data [4].

One of the open partial trapeziectomy series provides interesting information regarding MCP hyperextension and STT changes. In an open partial trapeziectomy series, Tropet and colleagues [39] described resurfacing with costal cartilage autograft from the ninth rib without stabilization. Of 88 patients with minimum followup of 4 months (mean, 68 months; range, 4–159 months), seven patients had persistent pain (five required revision to trapeziectomy, two required recontouring of the graft), and four cases of complex regional pain syndrome (CRPS) and one pleural wound were noted. Patients were very satisfied in 85% of patients and pain-free in 84% of patients. Presence or extent of MCP hyperextension and presence or absence of STT arthrosis preoperatively made no difference in the final outcome, although STT arthrosis tended to progress. Statistically significant improvements in grip and pinch, pain, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were noted postoperatively [39].

Results

In general, results following varying techniques for arthroscopic treatment of CMC joint arthritis were satisfactory across series. Most series suggest improvement in pinch and grip strength, although one [2] demonstrated no statistically significant difference in pre- and postoperative values. In contrast, another series [21] documented statistically significant improved pinch strength but not grip strength. All series suggest pain relief and improved subjective satisfaction, which are similar to the improvement documented in open studies; these seem to be durable over time, although the longest followup over all series was an average of 7.6 years [21].

Role of Interposition Material

Manufactured Materials

In general, manufactured materials were associated with more frequent—and different—complications than biological materials and procedures that used no interposition. Seven manuscripts in the literature described outcomes in patients treated with hemiresection of the trapezium and interposition of an Artelon^® spacer. This material has been described for interposition arthroplasty arthroscopically [1, 3, 4, 41]. However, because of the paucity of manuscripts available for evaluation of arthroscopic interposition of this material, use of this material in open procedures without ligament stabilization were also reviewed in addition to two level V manuscripts [4, 41]. Two manuscripts were case series or reports documenting inflammatory response and unsatisfactory results in terms of pain relief [8, 37] resulting in revision surgery and explantation. Others [23, 31, 32] documented comparison studies between the Artelon^® spacer and tendon arthroplasty. Patients with the Artelon^® implant had a higher rate of swelling and revision surgery in two series, generally as an explantation and conversion to arthroplasty (six of 72 [32] and two of 13 [23]). Although both groups demonstrated pain relief and improved pinch strength [23, 32], the Artelon^® implant was not superior to traditional procedures. At average followup of 8 months, Clarke et al. [10] found a substantial complication rate (n = 12 of 29) in patients who underwent Artelon^® interposition after hemitrapeziectomy; it is unclear which patients will do well with the material and which ones do poorly. Likewise, it is unclear from the existing literature if outcomes overall with arthroscopic interposition of Artelon^® differ from those seen in open procedures, as some limited data imply [4, 41].

Diaconu et al. [14] reported on arthroscopic débridement of the thumb CMC joint without partial trapeziectomy and interposition of a polylactic acid implant (Arex™; Arex, Palaiseau, France) for basilar joint arthrosis. In this series, those with dysplastic changes in the trapezium or metacarpal amenable to osteotomy or realignment were excluded, although Dell Stages 2 to 4 were included (which implies some STT changes might be present, because Dell Stage 3 includes patients with pantrapezial arthritis) [13]. Twenty-five patients were included in the series, and minimum followup was 6 months (average, 14 months; range, 6–25 months). Statistically significant improvements in pain and pinch and grip strengths were noted. Complications were noted, including a single case of sepsis, one of CRPS, and transient inflammatory reactions presumed to be related to degradation of the polylactic acid. One case of subluxation of the joint, presumed to be related to too thick of an implant, was seen. The authors suggest this may be an option in the short term for pain relief [14].

GORE-TEX™ (WL Gore, Flagstaff, AZ, USA), a polytetrafluoroethylene product, has been described in one series as interposition material after arthroscopic débridement [28]. However, series around the same date were published associating use with unacceptable osteolytic changes in the open setting [20, 29] as well as this arthroscopic series [28], resulting in its use being abandoned.

Biologic Materials

A variety of allograft and autograft native and processed materials have been used as interposition materials, including autologous abductor pollicis longus tendon, palmaris longus, part of the flexor carpi radialis tendon, allogeneic fascia lata, and allogeneic cellular dermal matrix allograft [2, 3, 5, 15, 25, 27, 28, 34, 41].

The autologous materials obtained from native tendon seem to have low donor site morbidity and patients have a high rate of satisfactory outcomes. Tendon extrusion can be a complication as documented in this author’s experience and in the literature [15].

Allogenic fascia lata graft was implanted in four patients in only one series. Two of these patients had persistent pain; this was believed to be associated with absorption of the implant and failure and use was believed to be inferior to autologous implants [28]. Use of acellular dermal matrix graft (GraftJacket™; Wright Medical, Arlington, TN, USA) resulted in a high rate of satisfactory outcomes in one series [2].

No Interposition

There is growing evidence that techniques involving use of no interposition result in a high rate of satisfactory outcomes (Table 1). Because of satisfactory results after open simple trapeziectomy without interposition or reconstruction of the ligaments [22, 24], arthroscopic joint débridement with or without partial trapeziectomy, without interposition, has been proposed. A few series likewise provide data suggesting satisfactory results after surgery without interposition of any material after débridement and/or capsular shrinkage or partial trapeziectomy (Table 1).

Table 1.

Studies describing use of no interposition material

Surgical procedure	Reference	Stage	Followup	Number	Average Age (years)	Preoperative pain	Postoperative pain	Preoperative grip	Postoperative grip
Arthroscopic débridement and synovectomy without hemitrapeziectomy	Furia [18]	Eaton I, II	20 months (range, 14–24)	23	53.7 (range, 30–70)	7.7* (of 10)	2.7*	–	–
Electrothermal capsular shrinkage and joint débridement without hemitrapeziectomy	Chu et al. [9]	Eaton I, II	41 months (range, 24–80)	17	35.3 (range, 20–60)	4.9 rest/5.9 activity* out of 10	0.4 rest/1.2 activity*	–	–
Arthroscopic hemitrapeziectomy and capsular shrinkage, no interposition	Hofmeister et al. [21]	Eaton I–III	7.6 years (range, 6.5–8.4)	18	48 (range, 38–56)	–	–	55 lbs	55 lbs
Arthroscopic débridement, hemitrapeziectomy, thermal capsulorraphy	Edwards and Ramsey [17]	Eaton III	48 months	23	Not specified	8.3* out of 10	1.5*	10.5 kg	17.3 kg
Arthroscopic hemitrapeziectomy and capsular shrinkage, no interposition	Culp and Rekant [12]	Not Specified	14–48 months	24 thumbs	Not specified	–	–	–	–

Surgical procedure	Preoperative pinch	Postoperative pinch	Preoperative DASH	Postoperative DASH	Rate	Complication list	Revision rate	Outcomes	Level of evidence
Arthroscopic débridement and synovectomy without hemitrapeziectomy	4.2 kg*	6.2 kg*	55.6*	26*	8.70%	Transient numbness; superficial infection	0	83% G-E	III
Electrothermal capsular shrinkage and joint débridement without hemitrapeziectomy	36% of contralateral side*	93% contralateral side*	–	–	0%	None	0	94% satisfactory	IV
Arthroscopic hemitrapeziectomy and capsular shrinkage, no interposition	8 lbs key*/4 lbs tip*	11 lbs*/5 lbs*	–	–	22%	FPL rupture, Superficial radial neuritis, skin necrosis	0	Improvement in “thumb function score” 90° to > 60*	IV
Arthroscopic débridement, hemitrapeziectomy, thermal capsulorraphy	1.4 kg	2.7 kg	61	10	4.3%	Neuroma	4%	83% “pleased with outcomes of surgery, 13% “satisfied”	IV
Arthroscopic hemitrapeziectomy and capsular shrinkage, no interposition	–	Improved 22%	–	–	0%	None	0	88% good to excellent results	IV

* Statistically significant; FPL = flexor pollicis longus.

Furia [18] reported on arthroscopic débridement and synovectomy without partial trapeziectomy or interposition in 23 patients with Eaton Stages I and II disease compared with a control group (21 patients) treated nonoperatively. Patients with fixed deformity or MCP hyperextension were excluded. Patients underwent arthroscopy and débridement with a 2.0-mm full radius resector. At a minimum followup of 14 months, substantial improvements over preoperative levels and control levels were noted in visual analog scale pain score, DASH scores, and pinch strength; good to excellent results were noted in 83% of patients in the surgical group.

Chu and colleagues [9] described results of electrothermal capsular shrinkage and joint débridement without hemitrapeziectomy for patients with basal joint instability and Eaton Stages I and II disease. Although those with moderate or severe degenerative changes visualized at time of surgery were excluded from analysis, of the remaining patients, pain and pinch strength improved at a mean followup of 41 months. The patients in this series notably were of average younger age (35.3 years) than in most other series.

Likewise, satisfactory results after partial trapeziectomy without interposition have been noted. Hofmeister and colleagues [21] reported on the previously described technique of Culp and Rekant [12] in which patients underwent arthroscopic débridement and hemitrapeziectomy with capsular shrinkage but no interposition. Fourteen patients with Stages I to III disease and four patients with posttraumatic changes were reported on in this series with average 7.6-year followup. No patient required revision surgery and seven patients elected for the same procedure on the contralateral side. Edwards and Ramsey [17] described arthroscopic débridement, partial hemitrapeziectomy, and thermal capsuloraphy of the thumb CMC joint without interposition in Stage III disease in 23 thumbs; patients with followup of 4 or more years had satisfactory results, durable and comparable to open procedures. One patient required revision to a ligament reconstruction tendon interposition.

Patient-related Factors and Surgical Outcomes

Metacarpophalangeal Hyperextension

Based on the review of these articles, there is little evidence for or against the idea that presence or treatment of MCP hyperextension alters outcomes after CMC joint treatment. Several studies excluded MCP hyperextension or patients with a fixed deformity in Eaton Stages I and II disease [18], and others excluded it in Stage III disease [12, 15, 17]. Yao and Park included those with MCP hyperextension but addressed those patients with > 20° of hyperextension deformities with fusion or capsulodesis [41]. Others included those with MCP hyperextension [2, 25, 27, 28, 39] but in two reports by one author, it was suggested that MCP hyperextension was associated with weakness of pinch or failures of the procedure, although six of nine patients with preoperative MCP hyperextension did not have complaints [27, 28]. In contrast, the other series have noted no such association [2, 25, 39]. Several manuscripts did not specify inclusion or exclusion of those with MCP hyperextension [6, 12, 21].

Ligamentous Laxity

The literature on these procedures in the setting of ligamentous laxity is scant and inconclusive. One case report specifically described a patient with Ehlers-Danlos and bilateral thumb arthritis treated with arthroscopic partial trapeziectomy, capsular shrinkage, and interposition of the abductor pollicis longus tendon with good results at 4 and 12 months postoperatively [5]. In contrast, other studies specifically excluded the ligamentous lax population [34]. Several series specifically include the ligamentous laxity patient population and address the laxity with thermal capsulorrhaphy and/or pinning with satisfactory results [9, 12, 17, 21, 41]. At present it remains unclear if presence and or treatment of ligamentous laxity has an effect on outcomes.

Severity of Arthritis (Eaton stage)

Across reported series, satisfactory results were obtained in Eaton Stages I to III and, in some cases, Eaton Stage IV. All reported series investigated one or more of Eaton Stages I to III; no stage reported on Eaton Stage IV, although some series [27, 28, 39] did not specify preoperative stages or used stages of a classification system that did not exclude STT changes and imply inclusion of Stage IV, and two included Stage IV disease but performed complete trapeziectomy in this group [12, 41]. Pegoli and colleagues excluded patients with excessive subluxation of the basilar joint [34]. Failures in one manuscript were suggested to be related to unrecognized STT changes [27]. However, Tropet and colleagues [39] in describing their open procedure suggested that STT changes were not associated with any difference in outcomes, although the authors cautioned severe changes at the STT might prompt consideration of an alternative procedure.

Certainly concern exists regarding the effect of STT arthrosis and potential evolution of this and the effect on outcomes. One manuscript addressed specifically this concern in patients undergoing open partial trapeziectomy [33]. This series evaluated 13 patients (16 thumbs) after partial trapeziectomy at minimum followup of 5 years (average, 9 years; range, 5–13 years). Although most patients had mild arthritic changes at the STT, there was no direct pain on examination of the STT joint, and 12 of 13 patients remained very or extremely satisfied. Grip and pinch were symmetric to the contralateral nonoperated hand. Glickel and colleagues likewise demonstrated in a study of hemitrapeziectomy with ligament reconstruction that radiographic evidence of STT changes poorly correlated with surgical findings or clinical symptoms at time of surgery or at 8-year followup [19].

Discussion

Arthroscopic or open débridement with or without partial trapeziectomy and with or without interposition has been described as a treatment for basilar joint arthritis. This systematic review evaluated interposition materials and patient factors to determine how these influence patients’ pain and function after these procedures.

Limitations of this review relate to the frailties and limited number of available series in the literature; series vary in the methodology used, definitions used, duration of followup, inclusion criteria, and documentation. Only one of these series on arthroscopic procedures included a control group (nonoperative treatment), and many have limited documentation on patient outcomes. Series are small and most have limited followup and limited outcomes data.

An additional limitation that should be noted is that the selection and review process in this study was performed by one individual.

Continued areas of controversy include the type of interposition material, if any, although there appears to be an increasing body of evidence that no interposition of any material may result in favorable outcomes. Synthetic materials seem to have different complications and a higher complication rate when compared with biologic materials. Certainly early-stage disease may be amenable to simple débridement alone with thermal capsular shrinkage if ligamentous laxity is present; likewise, later stages (II, III) seem to be amenable to partial trapeziectomy with or without interposition.

It appears that Eaton Stages I to III can be treated with these procedures, and there is some evidence that the presence of STT changes is not necessarily a contraindication. Regarding the presence of ligamentous laxity or MCP hyperextension, the available literature does not provide compelling evidence that presence or treatment of these factors alters the outcomes after treatment of CMC arthritis. Hyperextension of the MCP joint has been suggested by some series to adversely alter the outcome, whereas it does not seem to be a factor in other series.

Further large and well-designed series carefully investigating the role of interposition material and the patient exclusion criteria and the duration of immobilization are needed and will further delineate the role of arthroscopic thumb CMC joint débridement or partial trapeziectomy with or without interposition.