Arthroscopic versus open hemitrapeziectomy without tendon interposition in osteoarthritis

Osteoarthritis of the CMC joint of the thumb has several different treatment
modalities, so far no difference between the treatment modalities has been
proven. The current study compares three different treatment strategies to
compare long term outcome

Compare three different surgical interventions for osteoarthritis of the thumb,
arthroscopic hemitrapezectomy vs open hemitrapezectomy vs open hemitrapezectomy
with interposition of tendon. All three interventions are widely used for
osteoarthritis of the CMC joint.

Three different interventions will be performed on the patient after
randomization

Arthroscopic technique

The procedure is performed under regional or general anaesthesia.
Tourniquet control is applied, with the elbow flexed 90 degrees and the thumb
in longitudinal traction. Traction applied to the thumb is 3-5 kg. The CMC
joint is identified with palpation and a needle insertion. Small incisions are
made on the radial and ulnar side (1U and 1R [ref]) of the EPB. With small
scissors and blunt clamp the joint capsule is perforated and the 1.9 mm or 2.3
mm 30 degrees arthroscope is introduced. After identification, the joint is
debrided and a synovectomy is performed using the 2.3 shaver. The
hemitrapezectomy is performed with the burr (2.6 or 3.0 mm), debriding the
sclerosed surface of the distal trapezium for about two to three mm. The
instruments and arthroscope are changed from portals to achieve adequate
resection. Debris is rinsed out and the instruments are removed.

Open technique

The procedure is performed under regional or general anaesthesia. Tourniquet
control is applied, with the arm on an arm rest. According to the surgeon a
volar Wagner incison or a dorsal incison is made. Branches of the superficial
radial nerve are identified and retracted. The CMC joint is opened, hereby
creating a capsule flap with can be closed at the end of the procedure. The
distal part of the trapezium is removed using oscillating saw, osteotome and
rongeur in a piecemeal technique. Special attention is given to osteofytes,
around the CMC I joint (if present, between first and second metacarpal). Care
is given not to damage the FCR tendon. Afterwards debris is rinsed out and the
capsule is closed with resorbable braided sutures. Skin is closed with
nonabsorbable nylon suture.


Open technique with tendon interposition

The techinique is the same as described above, however after removal of the
distal part of the trapezium a palmaris longus tendon or part of the flexor
carpi radialis tendon is harvested through small incisions in the volar
forearm, knotted with resorabable suture material and inserted in the space
between the base of the metacarpal and the trapezium, before closing the dorsal
capsular flap.


Rehabilitation

Directly postoperative the thumb is immobilised in a fore arm splint,
with only the interphalangeal joint free to move. The splint is changed at the
first outpatient visit two weeks later and a thumb spica cast is applied for an
additional four weeks. After removal of the cast a handtherapy regime is
started and full motion is allowed, full power and sport a resumed until 12
weeks postoperative.

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