Hand and Upper Extremity Reconstruction
150
tion. There is a higher risk of non-union than with other
types of preparation.
Cup and cone preparation
Carroll8 fi rst reported this method in 1969 (Fig. 11.3), and
others have proposed a similar procedure.9 In this method,
the distal end of the proximal bone is rounded like a bullet
end using a rongeur, and the proximal end of the distal bone
is curetted until the concavity is large enough to accom-
modate the previously prepared cone end.
Chevron-type preparation
Chevron osteotomy (Fig. 11.4) is useful to create more
contact between the bones and prevent rotation after
surgery.10 However, this is not so easy to perform on smaller
joints.
METHOD OF FIXATION AND PITFALLS
Mechanical properties of fi xation methods
There are various methods of fi xation reported in the litera-
ture. Vanik et al.11 compared the strength of internal fi xa-
tion of Kirschner wires, intraosseous wiring, and plates.
They found that intraosseous wiring was stronger than K-
wiring, and that right-angle double-loop wiring was the
strongest of the intraosseous confi gurations. The strength
of right-angle loop wiring with 26 gauge wire was compa-
rable to that of dorsal plating. Kovach et al.12 compared
strength between methods such as the use of one oblique
and one longitudinal K-wire, intraosseous wiring with one
oblique K-wire, and tension band wiring. They found that
tension band wiring was the strongest in anteroposterior
bending and torsion, and that there was no difference in
lateral bending between the techniques. Wyrsch et al.13
compared strength of Herbert screws with that of tension
band wiring, and found that the Herbert screw had greater
anteroposterior and lateral bending strength and torsional
rigidity.
Kirschner wiring
K-wires are readily available in any operating room and in
different diameters. One can choose the most suitable size
among them, but for small joints 0.7–1.0 mm wires are
preferred in DIP joints, and 1.0 or 1.2 mm in PIP and MP
joints. Although many fi xation devices are now available,
K-wires are preferred because they are cheap, quick and easy
to handle and, more than anything else, serve the purpose
of fusion when properly used.
Usually, two or more wires are used to fuse the joint.
Cross-pinning is preferred to parallel pinning because cross-
pinning is more resistant to separation forces, but it is weak
A
B
FIGURE 11.1 Positions for thumb arthrodesis. A 45º palmar abduction. B 20º radial abduction.
Arthrodesis Techniques
151
against rotational torque when the crossing point lies just
on the joint (Fig. 11.5).
Interosseous wiring
Interosseous wiring is used in situations where more solid
fi xation is needed. Certainly double right-angled interosse-
ous wires are stronger than a single wire.11 In practice,
however, double wiring is more sophisticated and diffi cult,
and the combination of oblique K-wiring and single interos-
seous wiring (Fig. 11.6) is a realistic choice.14 Double wiring
requires more extensive exposure than simple K-wiring, so
that there is a potential danger of reduced blood circulation
to the area.
Tension band wiring
Compared with interosseous wiring the tension band tech-
nique requires only dorsal exposure, and is stronger against
anteroposterior bending stress than against lateral bend-
ing.12,15 It does not usually require immobilization of the
adjacent fi ngers,16 and has a higher union rate and a lower
infection rate than K-wire fi xation.17,18 The disadvantage of
this technique is that the joint to be fused needs to be
fl exed, because the ends of the wire need to protrude from
the cortex to catch the cerclage wire (Fig. 11.7).
Screw fi xation
With the invention of various kinds of small interfragmen-
tary screw, such as the Acutrac screw (Acumed) or the
Herbert screw,19 screw fi xation is an option commonly
accepted by many surgeons today. However, when screws
FIGURE 11.2 Positions for fi nger arthrodesis: 20–30º of fl exion in the
index fi nger, with an increasing angle towards the ulnar digits.
FIGURE 11.3 Cup and cone preparation.
FIGURE 11.4 Chevron-type preparation.
A
B
FIGURE 11.5 Kirschner wiring for joint fi xation. A is weaker than B
against rotational torque.
Hand and Upper Extremity Reconstruction
152
are applied to the digits, the angle cannot be adjusted pre-
cisely to the desired position because most screws are
inserted intramedullary and the angle of fusion cannot be
straight or be more than 45º of fl exion (Fig. 11.8A,B).
Plate fi xation
Smaller, thinner plates are now commercially available for
use in small joint arthrodesis. These have the advantage of
a shorter period of external splinting and less hardware
irritation,20 but plates must be accurately bent to obtain a
precise angulation. Unwanted space may be left at the
osteotomy site when the plate is applied, which may lead
to delayed or non-union.
Staple fi xation
Shapiro21 introduced a new device called a bone stapler to
put thinner staples into smaller bones, such as the meta-
carpals and carpal bones. It is used for intercarpal arthrod-
esis of the carpus, and for arthrodesis of the CMC and MP
of the thumb, but not for IP fi nger joints (Fig. 11.9). The
staples have reasonable power to withhold the tension side
of the fusion, but are not strong enough on the compression
side. At least two staples should be applied on the dorsal
tension side, placed parallel to each other with the legs of
the staples aiming for the center of the tubular bone and
the bodies separated by 60–90º around the bone and per-
pendicular to the bony surface. When the staple becomes
loose, there is the potential danger of attenuating the sur-
rounding soft tissue and extensor tendons. In such cases
the staples should be removed.
External fi xation
Smaller external fi xators are now available (Fig. 11.10).
External fi xation has the advantage of compressing the
A
B
C
FIGURE 11.6 Interosseous wiring.
A
B
C
FIGURE 11.7 Tension band wiring.
Arthrodesis Techniques
153
denuded articular surface as well as achieving the subtle
angle one desires, but at the same time it has the disadvan-
tage of risk of infection or restricting the motion of the
adjacent fi ngers. The rate of union is reasonably high.22,23
Bone (peg) grafting
A bone peg is used as a dowel to adjust and fi x the arthrod-
esis site24 (Fig. 11.11). It is indicated in situations in which
the bone substance is lost and extra length of the digit is
needed. It can be inserted intramedullary to obtain straight
angle fusion, or from the cortex to the medullary cavity to
obtain angled fusion. Drawbacks of this method are the
diffi culty of preparing a bone peg to fi t the canal snugly,
putting it into the canal, and fi xing it at the desired angle.
In addition, it requires bone graft from a distant site, which
may be bothersome for the patient.
PROCEDURES IN EACH JOINT
Interphalangeal joint arthrodesis
Indications and contraindications
Common indications for DIP and PIP joint arthrodesis are
joints that have been destroyed by trauma, painful osteoar-
thritis, and paralytic deformities. The DIP joint arthrodesis
is indicated for old fl exor profundus injuries that are no
A
B
FIGURE 11.8 Arthrodesis with Acutrac screw. A Radiograph showing
severe arthritis of the thumb MCP joint. B Arthrodesis with Acutrac
screw.
FIGURE 11.9 Carpometacarpal arthrodesis with a K-wire and staples.
FIGURE 11.10 Arthrodesis with an external fi xator.
Hand and Upper Extremity Reconstruction
154
longer reparable.25 It is also indicated in fi ngers with
Heberden’s nodules that are too painful and unsightly for
the patient. PIP or DIP joint arthrodesis is also indicated
in fi xed fl exion contracture after burns, or in unstable joints
due to arthritis.26 For severe swan-neck or boutonnière
deformity with advanced destruction of the PIP joint due
to arthritis, fusion is the only choice. Generally speaking,
morbidity from DIP fusion is small but is greater with PIP
fusion.
Operative technique
The dorsal approach is usually applied to the interphalan-
geal joint. In the DIP joint, the extensor tendon is step-cut
and the collateral ligament cut almost entirely to expose
the joint. In the PIP joint, the extensor tendon is divided
in the midline and the joint exposed subperiosteally. When
a fl at cut is made it is easier to cut the head of the middle
phalanx fi rst, and then remove the base of the distal phalanx
in the DIP joint. Likewise, with the PIP joint, cut the head
of the proximal phalanx fi rst. Further resection may be
necessary to adapt the cut surface. It is not always easy to
prepare the cut surface at the desired angle. One should be
prepared to use a small bone chip graft to fi ll the opening
at the fusion site. Any type of fi xation can be chosen. The
cross-pinning technique is introduced here. Two oblique
1 mm K-wires are drilled distally from the distal cut surface
(Fig. 11.12A) and the joint is positioned at the desired angle
(Fig. 11.12B). The wires are drilled in a retrograde fashion
until they reach the proximal cortex (Fig. 11.12C), care
being taken to keep the joint at the desired angle and not
rotated. After confi rming solid fi xation, the extensor tendon
and the skin are closed primarily. Usually hemostasis is
necessary before closing the dorsal skin.
Postoperative care
For DIP fusion, single-digit splinting with an aluminum
splint will suffi ce. This is continued for about 6–8 weeks.
For PIP fusion with K-wires a short arm splint incorporating
a neighbor digit is applied for 2 weeks, and then switched
to a single-digit aluminum splint, continued for an addi-
tional 4–6 weeks until radiological fusion is seen.
Metacarpophalangeal joint arthrodesis
Indications and contraindications
Because MP joints play an important role in hand function,
they should be preserved as much as possible. MP joint
arthroplasty is preferred to arthrodesis in the fi ngers. For
MP joints of the thumb, however, arthrodesis is sometimes
indicated, especially in rheumatoid arthritis or in paralytic
hand.27 Thumb MP joint instability, pain, or deformity
seriously impairs thumb function, and fusion is a good
option, provided both IP and CMC joints are intact. Con-
FIGURE 11.11 Arthrodesis with bone peg graft.
A
B
C
FIGURE 11.12 A Two oblique 1-mm K-wires are drilled distally from the distal cut surface. B The joint is positioned at the desired angle and
without rotation. C The wires are drilled in a retrograde fashion until they reach the proximal cortex.
Arthrodesis Techniques
155
versely, it is less indicated when the neighbor joints are
diseased.
Operative technique
The thumb MP joint is approached dorsally between
the extensor pollicis longus and brevis tendons. The capsule
is excised, and the collateral ligaments are divided as
needed. The joint is shaved and prepared for fusion. A
‘cup and cone,’ ‘fl at cut’ or ‘chevron cut’ can be used,
according to the surgeon’s choice. Methods of fi xation are
similar to those for interphalangeal joints. When the cup
and cone method is employed, the head of the metacarpal
is denuded and shaped like a cone using a rongeur. The cup
is prepared with multiple awl holes created at the base of
the proximal phalanx. These holes are connected with a
small osteotome, and the cartilage is removed from the
area. With a curette, the hole is enlarged until it fi ts snugly
with the cone. Two 1.2-mm diameter K-wires are then
drilled through the cup and the joint is held in the desired
position. The well-contoured cup and cone ends are ap-
proximated, and the wire is drilled back in a retrograde
fashion.
Postoperative care
When a rigid fi xation such as an interfragmentary screw is
used, the MP joint is immobilized in an aluminum splint
for 2–3 weeks. When K-wires are used, it should be immo-
bilized in a thumb spica splint for the fi rst 2 weeks, followed
by an aluminum splint for 4 weeks.
Carpometacarpal joint arthrodesis
Indications and contraindications
Degenerative change is frequently seen in the CMC joint
of the thumb. Its treatment includes ligamentoplasty,
simple excision arthroplasty of the trapezium, anchovy
arthroplasty, and implant arthroplasty. None of these can
withstand strong pinch nor grasp after surgery. Fusion is
indicated when grasping power is of prime importance.
However, the thumb will remain stiff for a couple of years
after the fusion, and the patient may complain of clumsi-
ness when using the hand. Gradually the thumb motion is
compensated by the MP joint and the scaphotrapezial
joint.28 The best indication for the arthrodesis of the thumb
CMC is in manual workers who require a strong grip. It is
contraindicated in the presence of osteoarthritis in either
the MP or the scaphotrapezial joint.29 If the thumb shows
severe swan-neck deformity, i.e. hyperextension of the MP
joint, and adduction contracture of the metacarpal, volar
plate advancement of the MP joint and release of the adduc-
tion contracture should be performed as well.
Operative technique
The most frequently fused CMC joint is in the thumb.
Non-union in this joint is relatively common30 because of
its confi guration: it is a saddle joint, which makes complete
decortication of the joint surface diffi cult when minimal
resection is performed. In order to prepare the fl at cut
surface, one needs to cut well away from the cartilage.
Positioning the metacarpal and the trapezium at the desired
angle and coaptation of the cut surfaces is rather diffi cult.
The author recommends the use of an interpositional iliac
bone graft that is not too thick. Carroll 28 recommended the
technique of cup and cone arthrodesis instead of bone graft-
ing. In the CMC joint, the cup is made on the trapezium
and the cone on the metacarpal.
A 3 cm longitudinal skin incision is made on the dorsal
aspect of the CMC joint. Sensory branches of the radial
nerve are identifi ed and protected, as injury to them will
cause uncomfortable paresthesia or painful neuroma after
surgery. The joint is approached between the extensors pol-
licis longus and brevis, exposed subperiosteally, and two
parallel cuts centering on the joint are made to denude it.
Because of the shape of the joint, the thickness of the bone
to be removed is about 3–4 mm on each side. Preparation
of the surface side is easy, but the deep concavity is rather
diffi cult. The thumb is pulled and held at an angle of 45º
palmar abduction and 20–30º radial abduction (Fig. 11.1).
A piece of iliac bone graft is prepared to fi t the space created
by the excision, varying in thickness between 3 and 7 mm
according to the size of the cavity. Two or three 1.5 mm
K-wires are used to fi x the joint. If staples are available,
pinning with an oblique K-wire and two staples on the
dorsal side at an angle of 90º will enhance stability (Fig.
11.9). One may use interfragmentary screws to compress
the fusion site,31 but must be aware that such screws do
not guarantee union.30 While this being done, attention
must be paid to the position of the CMC joint, which
should be held open and the thumb tip should oppose the
index tip, otherwise a narrower thumb index angle (adducted
thumb) can be problematic.
Postoperative care
A thumb spica cast is used for 6 weeks, followed by 2 weeks
in a removable splint. After clinical and radiological union
is confi rmed, the splint is removed. If questionable union
is suspected, splinting should be continued until union is
confi rmed radiologically. The K-wires and staples can be
removed after 3 months.
Outcomes
Painfree arthrodesis is expected from this procedure.
However, some patients may complain of clumsiness and
stiffness a couple of years after the surgery, which may
resolve eventually.28 A small number of cases can subse-
quently develop scaphotrapezial joint osteoarthritis.
Limited wrist arthrodesis
Limited wrist fusion is intended to eliminate pain and
instability of the affected intercarpal joint while maintain-
ing reasonable wrist mobility. It is indicated when the
pathology is limited to certain areas of the wrist joint, and
contraindicated when the entire wrist joint is affected. In
the latter case total wrist arthrodesis is the procedure of
choice. There are about a dozen limited wrist fusion proce-
dures, several well accepted types of which are discussed
here.
Hand and Upper Extremity Reconstruction
156
STT fusion
Indications and contraindications
Scaphotrapeziotrapezoid (STT) fusion was popularized by
Watson.32 It fuses the scaphoid with the trapezium and the
trapezoid, thereby stabilizing the radial column of the wrist,
and corrects the rotated scaphoid to its normal position. It
is therefore indicated in chronic rotary subluxation of the
scaphoid33 and treats osteoarthritis of the STT joint.32 It
alters the transmission of load through the radial column,
so that it unloads the lunate. Therefore, it is indicated for
Kienbock’s disease of Lichtman stage 3A or B.34,35 Although
there are favorable long-term reports, poor results have also
been reported.36,37 Precise performance of the technique is
of supreme importance, but the patient should be informed
of loss of certain wrist motion and possible persistent
pain.35 The procedure is contraindicated if there is pre-
existing osteoarthritis at the radioscaphoid joint.
Operative technique
The STT joint is approached dorsoradially via a 4-cm trans-
verse incision just distal to the radiocarpal joint. The exten-
sor retinaculum is opened along the extensor pollicis longus.
The STT joint is opened transversely through the trans-
verse incision between the extensors carpi radialis longus
and brevis. The cartilage and subchondral bones between
the trapezium and the trapezoid and the scaphoid are
removed with an osteotome and a rongeur. The volar lip of
the distal scaphoid is removed by elevating the trapezium
and the trapezoid distally. After cartilage excision, two or
three K-wires are preset from the dorsal trapezium and
trapezoid to the STT joint surface. A 3–5 mm thick spacer
is placed into the STT joint to hold the original contour.
The operator’s thumb is then pushed against the distal
tuberosity of the scaphoid, the wrist being placed in full
radial deviation and 45º of dorsifl exion. The preset wires
are driven proximally into the scaphoid body. Care must be
taken that the wires are not driven into the radioscaphoid
joint. Under fl uoroscopy the radioscaphoid angle is checked
to be approximately 55–60º on the lateral view. Watson38
warns that scaphoid fl exion should not be overcorrected in
an attempt to unload the lunate. Cancellous bone chips
from the iliac crest are harvested and densely packed in the
space created between the scaphoid and the trapezium and
trapezoid. The wires are cut underneath the skin, and the
capsule and the skin closed primarily. A short arm thumb
spica cast is applied with the wrist in neutral.
Postoperative care
Usually, the cast is discontinued after 6–8 weeks. X-rays
are taken to confi rm radiological union. When in doubt,
one should continue immobilization for a couple more
weeks. When wearing the cast, patients are encouraged to
move the fi ngers fully to avoid contracture. The pins are
removed after 12 weeks when radiological union is
complete.
Outcomes
The expected arc of motion is 80% and grip power is 77%
of that of the contralateral normal wrist.33 The possibility
of long-term development of osteoarthritis around the STT
joint is yet to be determined.35 Rogers39 reported impinge-
ment between the radial styloid and the scaphoid and modi-
fi ed the procedure to include a radial styloidectomy at the
time of surgery to prevent this. Minami40 reported the
occurrence of osteoarthritis in the radioscaphoid joint in
23% of patients.
Four-corner fusion
Indications and contraindications
Watson and Ballet41 fi rst reported fusion of the capitate, the
hamate, the lunate and the triquetrum to treat SLAC wrist
(Fig. 11.13A). This operation has expanded to treat scaph-
oid necrosis advanced collapse (SNAC) wrist and midcarpal
instability.42 It is contraindicated when there is pre-existing
osteoarthritic change in the radiolunate joint or osteonecro-
sis of the lunate.
Operative technique
A longitudinal skin incision is made on the dorsal wrist and
the extensor retinaculum opened in a zigzag fashion along
the fourth dorsal compartment. The extensor tendons are
retracted radially or ulnarly as needed. The dorsal capsule
is opened transversely at the level of the capitolunate joint.
Radially, the scaphoid is exposed and removed in piecemeal
fashion with a rongeur. Centrally, the lunate is elevated to
confi rm that the radiolunate joint is well preserved. Then,
cartilage and subchondral bones are removed from the
intercarpal joints between the capitate, hamate, triquetrum,
and the lunate using a rongeur and an osteotome. The volar
joint space between the capitate and the lunate is diffi cult
to denude, and so the wrist is pulled and fl exed to expose
the joint for that purpose. In the space thus created cancel-
lous bone is packed, donated from either the distal radius
or the iliac bone. If the lunate is dorsally tilted a K-wire is
temporarily inserted into the lunate and lifted distally to
correct its posture and keep it in the neutral position. If the
capitate has migrated radially and proximally, as is often
seen in advanced collapse, it should be reduced into normal
alignment. 1.5 mm K-wires are then inserted percutane-
ously from the capitate, the hamate, and the triquetrum to
the lunate, and from the triquetrum to the capitate (Fig.
11.13B), and then cut short under the skin. Instead of K-
wires, which can irritate the skin, one can use a Herbert
screw, staples, or a circular plate with six to eight holes,43
but one should be aware that the circular plate has more
frequent complications (e.g., non-union or hardware irrita-
tion) than conventional plates.44,45 The wrist is immobi-
lized in a short arm cast in the neutral position.
Postoperative care
The cast is worn for 6–8 weeks postoperatively until radio-
logic union is confi rmed. While the cast is in place patients
are encouraged to move the fi ngers fully to avoid contrac-
ture. The pins are removed after 12 weeks when radiologic
union is complete. However, if any of the pins are catching
on the extensor tendons, one should not hesitate to remove
them.
Arthrodesis Techniques
157
A
B
FIGURE 11.13 A Preoperative radiograph. B Postoperative
radiograph showing the four-corner fusion.
Radiolunate fusion
Indications and contraindications
This limited fusion provides good pain relief and range of
motion. The indications for radiolunate fusion are degen-
erative change of the lunate fossa in the radius after die
punch fracture and in Kienbock’s disease. It is also indi-
cated to prevent ulnar translation of the carpus in rheuma-
toid wrists.46 It is also performed to treat volar intercalated
segmental instability, ulnar translation of the carpus (Fig.
11.14A) and dynamic midcarpal instability.47 The presence
of degenerative change in the capitolunate joint is a contra-
indication because this midcarpal joint will bear the load
and motion of the wrist after radiolunate fusion.
Operative technique
A longitudinal incision is made on the dorsal wrist and
the extensor retinaculum is opened in a zigzag fashion. The
extensor tendons in the fourth compartment are retracted
with a tape. The posterior interosseus nerve is coagulated
to reduce postoperative pain. The dorsal capsule is opened
transversely at the radiocarpal joint. The proximal surface
of the lunate and fossa lunatum are decorticated with ron-
geurs. A single bone block graft is prepared from either the
iliac crest or the radial styloid, or from the ulnar head when
Darrach’s procedure is combined. It is inserted between the
lunate and the lunate fossa, after adjusting the lunate into
a neutral position. Two parallel K-wires are inserted distally
from the radial aspect of the radius, piercing through the
lunate fossa to the lunate. Alternatively, a staple can be
used (Fig. 11.14B). The height of the lunate should be
maintained to unload the scaphoid. Fluoroscopy is used to
check that the wires do not penetrate the midcarpal joint,
and that the lunate is in normal alignment. Cancellous
bone chips are packed into the residual space between the
lunate and the radius. The wound is closed in layers.
Postoperative care
The arm is immobilized in a long arm cast for 2 weeks,
followed by 6 weeks in a short arm cast. After 8 weeks,
when radiologic union is confi rmed, the wires are removed.
During immobilization the patient is encouraged to move
the fi ngers to avoid contractures.
Outcomes
The postoperative arc of motion is 80% of that of the con-
tralateral wrist. Pain relief is quite acceptable.
Total wrist arthrodesis
Indications and contraindications
Total wrist arthrodesis has been a reliable procedure to
stabilize the wrist joint and relieve pain. It is indicated in
wrists with destruction of both the radiocarpal and midcar-
pal joints due to trauma, arthritis, tumor, or infection. It
is also indicated after failed total wrist arthroplasty or proxi-
mal row carpectomy. It is also used to treat paralytic or
spastic wrist deformities. Wrist fl exion deformity due to
spastic-type cerebral palsy can be corrected with wrist
Outcomes
The expected range of motion is 50–60% and grip power
is 80% of that of the contralateral wrist.45 So far, no in-
creased occurrence of radiolunate osteoarthritis has been
reported.
Hand and Upper Extremity Reconstruction
158
arthrodesis, which helps to improve hygiene and appear-
ance.48 Contraindications are young people whose epiphysis
are still open, and wrists in which either the radiocarpal or
the midcarpal joint is intact. Such wrists can be treated
with limited fusion. It is also contraindicated in quadriple-
gic patients who require active wrist motion when perform-
ing grasp and pinch after tendon transfer.
Operative technique
Non-rheumatoid wrist
A longitudinal incision is made on the dorsum of the wrist,
centered over Lister’s tubercle. The distal end of the inci-
sion is between the index and long metacarpals and the
proximal incision ends at the muscle belly of the abductor
pollicis longus. Care should be taken not to damage the
sensory branches of the radial nerve. The third compart-
ment is opened and the EPL is mobilized, transposed radi-
ally with a tape. The distal radius is exposed subperiosteally,
the dorsal capsule is incised longitudinally, and the carpal
bones are exposed. When exposing the distal radius it is
wise not to enter the fourth or the second compartment,
but rather to elevate the two subperiosteally to avoid irritat-
ing the tendons. All the cartilage of the carpal bones in the
radiocarpal and the midcarpal joints is decorticated. The
joints in the ulnar column, such as the lunotriquetral,
lunohamate, and capitohamate, do not necessarily have to
be prepared because they allow little transverse movement.
Small bone chips packed into the fusion site are harvested
from either the radial styloid, the olecranon, or the iliac
crest, depending on the amount and quality of bone graft
required. One can use the excised ulnar head if Darrach’s
procedure is performed at the same time.
When K-wires are used, bone chips are scattered evenly
in the radiocarpal and midcarpal spaces. The wrist is held
in the desired position of fusion. Two parallel wires 1.8 or
2.0 mm in diameter are inserted obliquely from the proxi-
mal radial side of the radial styloid distal–ulnarwards to fi x
the radius to the scaphoid and the lunate, then the scaphoid
and the lunate to the capitate. Another wire is then inserted
from the radial side of the second metacarpal base towards
the capitate to the distal radius through the lunate (Fig.
11.15). When a stronger plate, such as a low-contact
dynamic compression plate (LC-DCP) from the AO group
is to be used, Lister’s tubercle and the dorsal prominence
of the cortex are removed to obtain a fl at surface to accom-
modate the plate. The LC-DCP plate includes the middle
fi nger CMC joint in the fusion; this joint is also decorti-
cated and prepared. Special attention is required when
A
B
FIGURE 11.14 A Preoperative radiograph. B Radiograph showing screw between the lunate and the radius.
Arthrodesis Techniques
159
placing the distal three screws, as these determine the rota-
tion and angulation of the fusion itself (Fig. 11.16).
A Penrose drain is left in the wound. The retained
capsule is repaired, including the periosteum of the radius
in the closure. The EPL tendon is left transposed radially
on the extensor reticulum to avoid contact with the plate.
Rheumatoid wrist
In the rheumatoid wrist, total wrist arthrodesis is per-
formed in combination with synovectomy and is indicated
when the wrist is very unstable or volarly dislocated, with
severe destruction of the radiocarpal and intercarpal joints.
If the midcarpal joint is relatively intact, radiolunate fusion46
should be chosen, as it leaves some wrist movement. As
the skin in rheumatoid arthritis is usually weak, large hard-
ware such as the LC-DCP plate is not recommended.
Instead, an intramedullary rod (Steinman pin) or K-wire is
preferred.
After excising the distal ulna and completing wrist syno-
vectomy, the surgeon removes the carpal bone cortices of
the radiocarpal and midcarpal joints. If the carpus tends to
fall volarly, the dorsal part of the radial styloid should be
removed to fi t the remaining carpus.49 In cases where the
carpal bones are almost gone, iliac corticocancellous bone
graft3 is occasionally indicated to supplement the carpal
height. The excised ulnar head can be used as a graft. Two
K-wires cross over the radioscaphoid joint from the radial
styloid to the capitate, and another crosses over the radiolu-
nate joint from the sigmoid notch to the capitate. If a
Steinman pin is to be used, the medullary canal of the
radius is prepared with an awl. The Steinman pin is inserted
through the carpus between the index and middle fi nger
metacarpals and tapped retrogradely into the channel of the
radius; the pointed end is then cut to adjust the length of
the pin. It is then countersunk 2 cm proximal to the MP
joint level. Bone chips are packed into the radiocarpal joint
space. Staples4 and oblique K-wires are used to supplement
the fi xation. Instead of one Steinman pin, two thinner
Steinman pins can be used.26
Postoperative care
When the LC-DCP is used an external splint is usually
not necessary, but its use is recommended to reduce swell-
ing and pain in the acute postoperative days. When K-wires
are used, a short arm splint followed by a cast is necessary
for approximately 8 weeks. While the wrist is immobilized,
the patient is encouraged to actively move the fi ngers
fully.
Outcomes
Pain relief is gratifying, but wrist stiffness is bothersome for
a while. An increased incidence of CMC osteoarthritis fol-
lowing total wrist fusion has been reported.50 When the
DCP is used, extensor tendonitis can be a problem.51
FIGURE 11.15 Total wrist fusion with K-wires.
FIGURE 11.16 Total wrist fusion with a plate.
Hand and Upper Extremity Reconstruction
160
COMPLICATIONS
Wound problems
If the skin is closed under undue tension the wound might
develop marginal necrosis or secondary infection as a result
of avascularity. This occurs when too large a plate is applied
at the metacarpal.
● Infection When K-wire fi xation is employed, one tends
to leave the end of the wires exposed above the skin.
This can be a cause of pin tract infection. The exposed
wires or pins should be cleaned meticulously. Once the
pins are infected, it is better to remove them as soon as
possible.
● Malunion Malposition of the joint to be fused will
inevitably lead to malunion and should be corrected at
the time of surgery. Even after surgery, fi xations with
K-wires are weak enough to allow unwanted rotation or
angulation.
● Non-union As in other major joints, non-union in
small joints is always a complication that should be
anticipated. When there is poor blood supply or poor
sensation, the risk of non-union is high. Technically,
poor apposition, inadequate removal of the joint surface
and improper fi xation are the major causes. Cancellous
bone graft might help, but not always.
● Stiffness of the adjacent joints When immobilization
includes adjacent joints and is continued over weeks,
elderly patients are likely to develop stiffness of the
adjacent joints. This is certainly an unwanted complica-
tion and the patients suffer greater morbidity than from
the fusion itself. Contracture of adjacent joints should
be prevented by all means. For this reason external
splinting must be minimal and suffi ciently short,
and motion of the adjacent joints should be initiated
early.
CONCLUSIONS
The procedures of common arthrodesis procedures for the
hand are described. Use of the appropriate indications and
techniques will maximize the patient’s benefi t from the
procedure. Small joint and wrist arthrodesis will remain a
reasonable option for painful, unstable, and destroyed
joints.
REFERENCES
1. Hobby JL, Lyall HA, Meggitt BF. First metacarpal osteotomy for
trapeziometacarpal osteoarthritis. J Bone Joint Surg [Br] 1998; 80:
508–512.
2. Weiss AC, Wiedeman G Jr, Quenzer D, et al. Upper extremity
function after wrist arthrodesis. J Hand Surg Am 1995; 20:
813–817.
3. Carroll RE, Dick HM. Arthrodesis of the wrist for rheumatoid
arthritis. J Bone Joint Surg [Am] 1971; 53: 1365–1369.
4. Clayton M, Ferlic D. Arthrodesis of the arthritic wrist. Clin
Orthop 1984; 187: 89–93.
5. Haddad RJ, Riordan D. Arthrodesis of the wrist. J Bone Joint Surg
1967; 49A: 950–954.
6. Millender L, Nalebuff E. Arthrodesis of the rheumatoid wrist. J
Bone Joint Surg 1973; 55A: 1026–1034.
7. Burton RI, Margles SW, Lunseth PA. Small-joint arthrodesis in the
hand. J Hand Surg Am 1986; 11: 678–682.
8. Carroll RE, Hill NA. Small joint arthrodesis in hand
reconstruction. J Bone Joint Surg [Am] 1969; 51: 1219–1221.
9. McGlynn JT, Smith RA, Bogumill GP. Arthrodesis of small joint
of the hand: a rapid and effective technique. J Hand Surg Am
1988; 13: 595–599.
10. Pribyl CR, Omer GE, McGinty L. Effectiveness of the chevron
arthrodesis in small joints of the hand. J Hand Surg Am 1996; 21:
1052–1058.
11.Vanik RK, Weber RC, Matloub HS, et al. The comparative
strengths of internal fi xation techniques. J Hand Surg Am 1984; 9:
216–221.
12. Kovach JC, Werner FW, Palmer AK, et al. Biomechanical analysis
of internal fi xation techniques for proximal interphalangeal joint
arthrodesis. J Hand Surg Am 1986; 11: 562–526.
13. Wyrsch B, Dawson J, Aufranc S, et al. Distal interphalangeal joint
arthrodesis comparing tension-band wire and Herbert screw: a
biomechanical and dimensional analysis. J Hand Surg Am 1996;
21: 438–443.
14. Lister G. Intraosseous wiring of the digital skeleton. J Hand Surg
Am 1978; 3: 427–435.
15. Mittelmeier W, Lehner S, Gollwitzer H, et al. Comparing
biomechanical investigations about different wiring techniques of
fi nger joint arthrodesis. Arch Orthop Trauma Surg 2005; 125:
145–152.
16. Allende BT, Engelem JC. Tension-band arthrodesis in the fi nger
joints. J Hand Surg Am 1980; 5: 269–271.
17. I. Jsselstein C, van Egmond DB, Hovius SE, van der Meulen JC.
Results of small-joint arthrodesis: comparison of Kirschner wire
fi xation with tension band wire technique. J Hand Surg Am 1992;
17: 952–956.
18. Uhl RL, Schneider LH. Tension band arthrodesis of fi nger joints: a
retrospective review of 76 consecutive cases. J Hand Surg Am
1992; 17: 518–522.
19. Leibovic SJ, Strickland JW. Arthrodesis of the proximal
interphalangeal joint of the fi nger: comparison of the use of the
Herbert screw with other fi xation methods. J Hand Surg Am 1994;
19: 181–188.
20. Buchler U, Aiken MA. Arthrodesis of the proximal interphalangeal
joint by solid bone grafting and plate fi xation in extensive injuries
to the dorsal aspect of the fi nger. J Hand Surg Am 1988; 13:
589–594.
21. Shapiro JS. Power staple fi xation in hand and wrist surgery: new
applications of an old fi xation device. J Hand Surg Am 1987; 12:
218–227.
22. Bishop AT. Small joint arthrodesis. Hand Clin 1993; 9: 683–689.
23. Leonard MH, Capen DA. Compression arthrodesis of fi nger joints.
Clin Orthop Rel Res 1979; 145: 193–198.
24. Moberg E, Henrikson B. Technique for digital arthrodesis. A study
of 150 cases. Acta Chir Scand 1960; 118: 331–338.
25. Schneider LH. Flexor tendons – late reconstruction, In: Green’s
Operative Hand Surgery, 4th ed. Philadelphia: Churchill
Livingstone, 1999.
26. Feldon P, Terrono A, Nallebuff E, Millender L. Rheumatoid
arthritis and other connective tissue diseases, In: Green’s
Operative Hand Surgery, 4th edn. Philadelphia: Churchill
Livingstone, 1999.
27. Hastings H 2nd, Davidson S. Tendon transfers for ulnar nerve
palsy. Evaluation of results and practical treatment considerations.
Hand Clin 1988; 4: 167–178.
28. Carroll RE, Hill NA. Arthrodesis of the carpo-metacarpal joint of
the thumb – A clinical and cinerentogenographic study. J Bone
Joint Surg [Br] 1973; 55: 292–294.
29. Stark HH, Moore JF, Ashworth CR, Boyes JH. Fusion of the fi rst
metacarpotrapezial joint for degenerative arthritis. J Bone Joint
Surg [Am] 1977; 59: 22–26.
30. Clough DA, Crouch CC, Bennett JB. Failure of trapeziometacarpal
arthrodesis with use of the Herbert screw and limited
immobilization. J Hand Surg Am 1990; 15: 706–711.
31. Pardini AG, Lazaroni AP, Tavares KE. Compression arthrodesis
of the carpometacarpal joint of the thumb. Hand 1982; 14:
291–294.
32. Watson HK, Hempton RF. Limited wrist arthrodeses. I. The
triscaphoid joint. J Hand Surg Am 1980; 5: 320–327.
33. Wollstein R, Watson HK. Scaphotrapeziotrapezoid arthrodesis for
arthritis. Hand Clin 2005; 21: 539–543, vi.
Arthrodesis Techniques
161
34. Watson HK, Ryu J, DiBella A. An approach to Kienbock’s disease:
triscaphe arthrodesis. J Hand Surg Am 1985; 10: 179–187.
35. Meier R, van Griensven M, Krimmer H. Scaphotrapeziotrapezoid
(STT)-arthrodesis in Kienbock’s disease. J Hand Surg [Br] 2004;
29: 580–584.
36. Van den Dungen S, Dury M, Foucher G, et al. Conservative
treatment versus scaphotrapeziotrapezoid arthrodesis for
Kienbock’s disease. A retrospective study. Chir Main 2006; 25:
141–145.
37. Ishida O, Tsai TM. Complications and results of scapho-trapezio-
trapezoid arthrodesis. Clin Orthop Rel Res 1993; 287: 125–130.
38. Watson HK, Wollstein R, Joseph E, et al. Scaphotrapeziotrapezoid
arthrodesis: a follow-up study. J Hand Surg Am 2003; 28:
397–404.
39. Rogers WD, Watson HK. Radial styloid impingement after
triscaphe arthrodesis. J Hand Surg Am 1989; 14: 297–301.
40. Minami A, Kato H, Suenaga N, Iwasaki N.
Scaphotrapeziotrapezoid fusion: long-term follow-up study. J
Orthop Sci 2003; 8: 319–322.
41. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced
collapse pattern of degenerative arthritis. J Hand Surg Am 1984; 9:
358–365.
42. Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar
midcarpal instability: results of surgical reconstruction. J Hand
Surg Am 1993; 18: 307–315.
43. Enna M, Hoepfner P, Weiss AP. Scaphoid excision with four-
corner fusion. Hand Clin 2005; 21: 531–538.
44. Chung KC, Watt AJ, Kotsis SV. A prospective outcomes study of
four-corner wrist arthrodesis using a circular limited wrist fusion
plate for stage II scapholunate advanced collapse wrist deformity.
Plast Reconstruct Surg 2006; 118: 433–442.
45. Vance MC, Hernandez JD, Didonna ML, Stern PJ. Complications
and outcome of four-corner arthrodesis: circular plate fi xation
versus traditional techniques. J Hand Surg Am 2005; 30:
1122–1127.
46. Chamay AG. Radiolunate arthrodesis in the rheumatoid wrist. J
Hand Surg Am 1986; 11: 771.
47. Halikis MN, Colello-Abraham K, Taleisnik J. Radiolunate fusion.
The forgotten partial arthrodesis. Clin Orthop Rel Res 1997; 341:
30–35.
48. Rayan GM, Young BT. Arthrodesis of the spastic wrist. J Hand
Surg Am 1999; 24: 944–952.
49. Albright J, Chase R. Palmar-shelf arthroplasty of the wrist
in rheumatoid arthritis. J Bone Joint Surg 1970; 52A:
896–906.
50. Belt EA, Kaarela K, Kautiainen HJ, et al. Does wrist fusion cause
destruction of the fi rst carpometacarpal joint in rheumatoid
arthritis? 18 patients followed for 2–6 years. Acta Orthop Scand
1997; 68: 352–354.
51. Weiss AP, Hastings H 2nd. Wrist arthrodesis for traumatic
conditions: a study of plate and local bone graft application. J
Hand Surg Am 1995; 20: 50–56.
163
C H A P T E R
12
Arthroplasty Procedures in the Hand
Erika Davis Sears and Kevin C. Chung
INTRODUCTION
Post-traumatic arthritis, degenerative arthritis, rheumatoid
arthritis and other connective tissue diseases affect fi nger
joint motion and interfere with the ability to use the hand
in everyday activities. For patients with severe disease that
fails to respond to non-operative treatment, arthrodesis or
arthroplasty are acceptable options. Arthrodesis offers pre-
dictable pain relief at the cost of loss of motion. Arthro-
plasty preserves motion, but the amount of motion is not
ideal. Complications such as implant failure and joint
instability may arise after arthroplasty and hamper hand
function.
In counseling patients about treatment options the
surgeon must have a thorough understanding of joint
mechanics and the underlying disease process affecting the
patient. The disease process may be isolated to a single
joint, as is usually the case in post-traumatic arthritis, or
may affect several joints at the same time, as in the case of
rheumatoid arthritis. Reduced function of the index fi nger
joints affects pinch, whereas abnormal function of the
joints of ulnar digits results in impaired power grip. When
joints of the thumb are diseased, both pinch and grip
strength are affected.
OSTEOARTHRITIS (OA) VERSUS RHEUMATOID
ARTHRITIS (RA)
Osteoarthritis typically affects the basal joint of thumb,
proximal interphalangeal (PIP), and distal interphalangeal
(DIP) joints of the fi ngers (Fig. 12.1). The DIP joint is most
frequently involved, and fusion is a predictable operation to
alleviate pain and enhance the appearance of the fi nger. The
DIP joint needs stability, and the loss of motion after fusion
is not problematic. The thumb carpometacarpal (CMC)
joint is the next most commonly involved joint, followed
by the PIP joints. Osteoarthritis in both CMC and PIP
joints can cause severe functional impairment. With thumb
basal joint arthritis, long-term ligament laxity, whether
idiopathic or post-traumatic, is postulated to be the etio-
logic factor. The trapeziometacarpal (TMC) joint is usually
affected in thumb basal joint arthritis, which may also be
accompanied by scaphotrapezial joint disease. OA rarely
involves the metacarpophalangeal (MCP) joint, but in RA
the MCP joints are commonly affected.
Rheumatoid arthritis is a disorder that results in prolif-
eration of synovial tissue, which can affl ict any joint. The
abnormal synovial hypertrophy results in destruction of
articular cartilage and subchondral bone. The surrounding
soft tissues, including tendons and ligaments that support
the involved joint, become stretched and cause joint imbal-
ance. The synovial tissue may invade fl exor and extensor
tendons, resulting in tendon rupture. Although RA may
affect any joint, the MCP and PIP joints of the hand are
affected early, with the MCP joint being the most com-
monly affected joint in the hand. Patients with RA develop
ulnar deviation and volar subluxation at the MCP joints
(Fig. 12.2). This common deformity can be the result of one
or more of the following deforming forces: carpal collapse
causes radial deviation of the metacarpals and compensa-
tory ulnar deviation of the proximal phalanges; attenuation
or stretching of the radial sagittal bands allows ulnar and
volar subluxation of the extensor mechanism; and unbal-
anced interosseous and fl exor tendon forces from the sub-
luxed extensor tendons cause further fl exion deformity at
the MCP joints. Initially, patients retain passive movement
at the MCP joints. However, when the deformities become
fi xed, the patient is unable to open the hand to grasp
objects. Patients with fl exion and ulnar deviation at the
MCP joints often have other deformities of the PIP and DIP
joints. Dorsal subluxation of the lateral bands, laxity of the
volar plate at the PIP joint, and rupture of the distal inser-
tion of the extensor mechanism result in swan-neck defor-
mity (Fig. 12.3A,B), or hyperextension of the PIP joint and
fl exion at the DIP joint. Patients may have boutonnière
Hand and Upper Extremity Reconstruction
164
deformity in other fi ngers (Fig. 12.4A,B), which is charac-
terized by a fl exed posture at the PIP joint and hyperexten-
sion at the DIP joint. This deformity is caused by persistent
PIP joint synovitis, leading to attenuation of the central slip
and volar subluxation of the lateral bands. Other connec-
tive tissue disorders, such as scleroderma, psoriatic arthri-
tis, and systemic lupus erythematosus, may also have
erosion of bone and cartilage, infl ammation of soft tissues,
and abnormal joint function in the hand.
ARTHRODESIS VERSUS ARTHROPLASTY
Arthrodesis is a predictable procedure and should be con-
sidered for patients presenting with painful destruction of
the hand joints. The question is which joints should
undergo arthrodesis and which should undergo arthro-
plasty? The DIP joints should be fused because pain relief
A
FIGURE 12.1 Bilateral CMC osteoarthritis, with mild DIP and PIP
osteoarthritis.
FIGURE 12.2 Ulnar deviation and volar subluxation at the MCP joints
in the rheumatoid hand.
FIGURE 12.3 A Photograph of swan-neck deformity.
and stability are more important than motion. The thumb
MCP joint should be fused to maintain stability during
pinch. The only exception is when the thumb IP and MCP
joints are both destroyed. Fusing both joints can cause a
stiff thumb that may hinder pinch. Therefore, the IP joint
should be fused and the MCP joint of the thumb should
have the arthroplasty procedure.
Which joints should not be fused? The MCP joints of
the fi ngers should not be fused, unless arthroplasty is tech-
nically not possible. Finger motion is initiated at the MCP
joint fi rst, and fusion of the MCP joint will cause great
functional impairment by limiting the ability of the fi ngers
to curl around objects. The thumb CMC joint typically
should not be fused because most of the mobility of the
thumb arises from this joint. Occasionally, the thumb
CMC joint may be fused in manual workers engaged in
heavy labor because of the anticipated wear on the arthro-
plasty procedure.
Fusion versus arthroplasty in the PIP joints depends on
the digit involved. In general, the PIP joints of the index
and middle fi ngers should be fused because of their partici-
pation in pinch. Pinch causes lateral stress and wear at the
PIP joint that may lead to implant failure. However, more
patients are demanding arthroplasty procedures of the index
and middle fi ngers because of the advancement in implant
technology. The ring and little fi nger PIP joints should have
arthroplasty procedures because these joints are import-
ant in power grip. Thus, preservation of joint mobility is
necessary.
Arthroplasty options
Numerous arthroplasty procedures in the hand have evolved
over time. Thumb CMC, MCP and PIP fi nger joint arthro-
plasty account for the majority of arthroplasty procedures
performed in the hand today. The choice of technique varies
by surgeon preference, underlying disease, and the digit and
Arthroplasty Procedures in the Hand
165
joint involved. Pyrolytic carbon or pyrocarbon implant
arthroplasty is a relatively new technique that is increas-
ingly being used in the reconstruction of MCP and PIP
joints (Ascension Orthopedics, Inc., Austin, TX) (Figs 12.5,
12.6). Pyrolytic carbon is a synthetic material that is depos-
ited as a coating on graphite substrates by heating a hydro-
carbon gas. Pyrocarbon is biocompatible and durable with
excellent wear characteristics, which is verifi ed by more
than 10 million patient-years of experience with the use of
the material as a component of artifi cial heart valves.1
Pyrocarbon implants are unlinked, minimally constrained,
B
A
B
FIGURE 12.4 A Photograph of boutonnière deformity. B X-ray
showing boutonnière deformity.
and are designed to resemble the anatomic surfaces of
joints. Their use requires minimal bone resection, which
allows the preservation of the collateral ligaments for joint
stabilization. Long-term results on a large number of
patients are not yet available.
FIGURE 12.3, cont’d B X-ray showing swan-neck deformity.
Hand and Upper Extremity Reconstruction
166
Silicone arthroplasty remains the most widely used and
studied implant for MCP and PIP joint abnormalities (Fig.
12.7). The Swanson silicone implants (Wright Medical
Technology, Inc., Arlington, TN) have been in use for more
than 40 years. Many different designs of silicone implants
have been proposed and studied; however, the Swanson
remains the preferred choice because of its reported relative
fl exibility and durability, and the inability of newer silicone
implant designs to establish superiority over the Swanson.
The Swanson implant does not attempt to reconstruct the
joint anatomically; rather, it serves as a dynamic spacer to
maintain stability and alignment after resection of the dis-
eased joint. During healing, the body forms a fi brous capsule
around the implant that functions to maintain joint stabil-
ity, even if the implant is fractured. The Swanson MCP
and PIP implants are fl exible not only to allow fl exion and
extension, but also to permit added motion in radial and
ulnar planes. The ability of the implant to glide or piston
within the medullary canal is thought to disperse the forces
generated along the implant–bone interface, which pre-
serves the integrity of the surrounding bone and enhances
the durability of the implant.
Swanson silicone implants have also been devised for
thumb CMC arthroplasty, but the high fracture rate associ-
ated with the stresses on this joint makes this design an
unreliable choice. Today, trapeziectomy with tendon inter-
position or suspension is the most commonly performed
arthroplasty procedure for disease of the thumb CMC joint.
The use of tendon for interposition or suspension allows
reliable joint reconstruction without subjecting the patient
to complications that are inherent with the implantation
of foreign material.
Although the DIP joint is the most commonly affected
joint in OA of the hand, DIP arthroplasty is not performed
for treatment of DIP joint abnormalities. Joint debride-
ment, excision of mucous cysts, and arthrodesis if neces-
sary are the mainstay of surgical treatment for the patient
with DIP joint disease. Usually failure of non-surgical treat-
ment and pain interfering with hand function are indica-
tions for operative intervention, the goal of treatment being
pain relief and not restoration of joint motion.
This chapter will highlight important considerations in
arthroplasty for disease in the thumb CMC and fi nger MCP
and PIP joints. Indications and contraindications, preopera-
tive considerations, procedural descriptions, and complica-
tions for the preferred surgical techniques used in the
treatment of each joint by the senior author (KCC) will be
discussed.
THUMB CMC ARTHROPLASTY
Osteoarthritis, common in middle-aged and postmeno-
pausal women, frequently causes severe impairment at the
basal joint of the thumb. Infl ammatory arthritides may also
produce abnormalities of the thumb basal joint. The sever-
ity of disease at the CMC joint is typically described by the
Eaton classifi cation system.2
● Stage I: Articular contours are normal. TMC joint
space may be widened. This stage precedes cartilage
degeneration.
FIGURE 12.5 MCP pyrocarbon joint implant (drawing from Ascension
Orthopedics, Inc., Austin, TX).
FIGURE 12.6 PIP pyrocarbon joint implant (drawing from Ascension
Orthopedics, Inc., Austin, TX).
FIGURE 12.7 X-ray showing the Swanson implant.
Arthroplasty Procedures in the Hand
167
● Stage II: There is slight narrowing of the TMC joint,
but articular contours appear normal. Joint osteophyte
when present is <2 mm.
● Stage III: There is signifi cant destruction of the TMC
joint with sclerotic or cystic changes in subchondral
bone, osteophytes >2 mm. The scaphotrapezial joint
space appears normal.
● Stage IV: There are degenerative changes in the scapho-
trapezial joint surface, in addition to degeneration of the
TMC joint.
The goal of arthroplasty in the treatment of thumb
CMC arthritis is to relieve pain, stabilize the thumb basal
joint, restore strength, and improve or preserve mobility.
Numerous arthroplasty techniques for thumb CMC arthri-
tis have been described in the literature. Trapeziectomy
alone or trapeziectomy combined with silicone arthropla-
sty, soft tissue interposition, ligament reconstruction, or
suspension arthroplasty are among the many options for
treatment of advanced thumb CMC arthritis. Complica-
tions with silicone arthroplasty, such as joint subluxation,
implant failure, and foreign body reaction requiring implant
removal, have made arthroplasty with the use of biologic
material the preferred option. Partial or complete slips of
tendons – fl exor carpi radialis (FCR), palmaris longus (PL),
or abductor pollicis longus (APL) – are used to interpose or
suspend the thumb metacarpal to prevent shortening of the
thumb ray after trapeziectomy. FCR tendon reconstruction
is the most popular technique used today. Many of the
procedures described in the literature achieve reliable pain
relief, improve function, and are associated with a high rate
of satisfaction.
Indications and contraindications
Advanced thumb CMC joint disease may result in instabil-
ity, subluxation of the thumb metacarpal, MCP joint hyper-
extension, and pain at rest or with activity. In general,
thumb CMC arthroplasty is indicated in patients who have
failed conservative treatments such as immobilization, rest,
non-steroidal anti-infl ammatory drugs (NSAIDs), and
intra-articular steroid injections and have pain at rest or
pain interfering with daily activities. These patients have
stage II–IV disease. Regardless, conservative measures
usually have only a short-lived effect and are unlikely to
help in advanced disease. The use of tendon interposition
or suspension for thumb CMC reconstruction should be
approached with caution in patients with RA or other
infl ammatory conditions because of the likelihood of degen-
erative changes in the tendon, resulting in an unst-
able reconstruction. Arthrodesis is sometimes preferred to
arthroplasty in young patients and heavy laborers with iso-
lated trapeziometacarpal arthritis, because of the greater
ability of the reconstruction to withstand high forces gener-
ated by pinch and grip. Arthrodesis relieves pain and
improves strength and stability. However, the drawbacks
compared to arthroplasty include reduced oppositional
mobility of the thumb, inability to fl atten the hand, require-
ment for a prolonged period of immobility, and a higher
incidence of complications that require reoperation.3
Arthrodesis candidates must have good IP and MCP mobil-
ity. The procedure is contraindicated in patients with
arthrosis of multiple joints of the thumb.
Preoperative history and considerations
Patients frequently present with complaints of weakness
and pain at the base of the thumb, particularly with pinch
and grip. On examination, patients often demonstrate a
painful grind test with axial compression and circumduc-
tion of the thumb, local tenderness, swelling, and crepitus
at the CMC joint. More advanced disease can be accompa-
nied with dorsal subluxation of the thumb metacarpal and
loss of motion due to adduction contracture. All patients
should have radiographic studies of both hands, including
AP, lateral, and stress views. Radiographs will reveal carti-
lage erosion, sclerosis, osteophyte formation, joint space
abnormalities, and instability on stressing the CMC joint.
The decision to proceed with surgery must be based on the
severity of the patient’s complaints. A severely destroyed
joint is not an indication for surgery; rather, incapacitating
pain that affects activities of daily living is the most appro-
priate indication. When planning to proceed with thumb
CMC arthroplasty, it is also important to evaluate whether
there is hyperextension of the thumb MCP joint. Hyperex-
tension deformity of the thumb MCP joint accompanies
CMC arthritis because of the compensatory need for the
patient to abduct and extend the thumb. If more than 30º
of MCP joint hyperextension is present during key pinch,
arthrodesis or volar capsulodesis of the MCP joint should
be considered and can be performed at the same time as
CMC arthroplasty.
Operative approach
Complete trapeziectomy with a modifi ed APL suspension
arthroplasty is the technique preferred by the senior author.
This approach is a simpler alternative to the widely used
FCR technique, and outcomes with its use are similar to
those of other methods reported in the literature.4 The
technique uses a slip of the APL tendon to anchor the
metacarpal base of the thumb to the index fi nger metacar-
pal, which helps to maintain axial and translational stabil-
ity after trapeziectomy. All procedures are performed under
regional or general anesthesia with tourniquet control.
Preferred technique: modifi ed APL
suspension arthroplasty
A 3-cm longitudinal incision is made dorsally over the
anatomic snuffbox (Fig. 12.8). The APL/EPB (extensor pol-
licis brevis) and extensor pollicis longus (EPL) tendons are
identifi ed within the fi rst and third extensor compartments,
respectively, and make up the lateral borders of the snuff-
box (Fig. 12.9). Dissection is carried down between the EPL
and APL tendons, which are retracted ulnarly and radially,
respectively. Radial sensory nerve branches must be pro-
tected with gentle retraction throughout the dissection.
The deep branch of the radial artery is seen as it courses
through the snuffbox and over the scaphotrapezial joint.
Hand and Upper Extremity Reconstruction
168
Small branches of the radial artery to the joint capsule are
cauterized with bipolar electrocautery to allow mobilization
and retraction of the artery. Care must be taken to avoid
injury to the radial artery. The capsule of the fi rst CMC
joint is now visible in the base of the wound. The trapezio-
metacarpal joint is opened with a longitudinal incision
through the joint capsule (Fig. 12.10). An oscillating saw is
used to divide the trapezium into thirds, and this is then
removed in parts with a rongeur. The FCR tendon lies in
the trapezial groove on the volar surface of the bone. It is
protected during the trapeziectomy by not allowing the
oscillating saw to advance entirely through the volar surface
of the trapezium. All remaining osteophytes must be
removed with the rongeur after the trapeziectomy.
Next the APL tendon is harvested from its musculoten-
dinous junction. A separate 2 cm chevron incision is made
at the fi rst extensor compartment over the radial styloid
(see Fig. 12.8). Again, care must be taken to protect branches
of the radial sensory nerve. The fi rst extensor compartment
is released, which contains the APL and EPB tendons. The
two tendons are often contained in separate compartments
within the fi rst extensor compartment, hence only release
of the APL tendon is necessary in this case. Typically the
APL consists of three slips at its origin. The most radial
slip is detached from the musculotendinous junction (Fig.
12.11). The entire APL tendon should not be divided. The
divided end of the tendon is freed from soft tissue attach-
ments and is pulled into the distal incision (Fig. 12.12).
The distal aspect of the divided slip of APL tendon is freed
from remaining attachments all the way to its insertion
at the base of the thumb metacarpal. A length of appro-
ximately 5–6 cm of tendon should be available after
harvest.
The tendon slip will be used to suspend the thumb
metacarpal for added stability after trapeziectomy. The
freed slip of APL tendon is passed under the EPB tendon
and woven into the extensor carpi radialis longus (ECRL)
tendon (Fig. 12.13). The ECRL tendon can be identifi ed as
it inserts on the index metacarpal. The woven APL tendon
is secured to the ECRL tendon using 3/0 non-absorbable
FIGURE 12.8 Distal skin incision over the anatomic snuff box, and
proximal skin incision over the radial styloid.
FIGURE 12.9 APL and EPL tendons are identifi ed and form lateral
borders of the anatomic snuff box.
FIGURE 12.10 The trapezium is exposed through a longitudinal
capsular incision.
FIGURE 12.11 Radial slip of the APL tendon is detached from the
musculotendinous junction.
Arthroplasty Procedures in the Hand
169
braided suture (Fig. 12.14). Any remaining free end of the
tendon is trimmed. Typically, after using the slip of APL
tendon to suspend the thumb metacarpal, there is insuffi -
cient tendon remaining to place in the trapezial space for
interposition.
The joint capsule is closed with absorbable sutures. The
tourniquet is released and hemostasis achieved using bipolar
electrocautery. Both incisions are closed in a layered fashion,
with absorbable sutures placed in the dermal layer and a
running subcuticular suture to approximate the skin. A soft
surgical dressing is applied over the incisions. The patient
is placed in a well-padded spica plaster splint to immobilize
the thumb in slight abduction and pronation.
Alternative techniques
Several variations of the APL technique exist. The Thomp-
son suspension arthroplasty5 uses a slip of the APL tendon
and suspends the thumb metacarpal by tunneling the
tendon through two burr holes created in the base of the
metacarpal. Alternatively, the APL tendon can be tunneled
volar to the EPB and brought around or through the FCR
tendon. It is then brought back into the trapezial void and
can be secured tightly to the EPB or APL tendons to main-
tain suspension of the thumb metacarpal. If suffi cient
tendon remains, it can be rolled and placed in the void as
a spacer, otherwise the remaining APL tendon is trimmed
at its free end. Arthroplasty without suspension has also
been described. The harvested tendon (APL, FCR, or PL) is
rolled or folded onto itself and simply placed in the trapezial
void to function as a spacer.
Suspension or interposition of the thumb metacarpal
with the FCR tendon is also widely used. The disadvantage
of use of the FCR tendon is that the soft tissue dissection
required for harvest is more extensive, and several incisions
are made for the harvest alone. Short transverse incisions
(typically four) over the course of the FCR tendon are made
from the wrist crease, proximal to the musculotendinous
junction. The incisions are spaced 2–3 cm apart to harvest
10–12 cm of tendon. Approximately one-third of the tendon
is dissected free from the musculotendinous junction and
is passed distally to the site, where it is visualized in the
trapeziectomy void. Care must be taken to protect the
palmar sensory branch of the median nerve during tendon
harvest. The tendon can then be used simply as interposi-
tion material alone, or may be used to suspend the thumb
metacarpal, as described by Eaton et al.6 For suspension
arthroplasty, drill holes are made in the base of the thumb
FIGURE 12.12 The APL tendon slip is detached from tissue
attachments and pulled into the trapeziectomy site.
EPB
Dorsal slip
of APL
APL
Weaved
juncture
ECRL
FIGURE 12.13 Overview of APL suspension arthroplasty. The radial
slip of the APL tendon is detached, brought under the EBP tendon
and woven into the ECRL tendon.
FIGURE 12.14 APL slip is woven into the ECRL tendon at the base of
the index metacarpal.
Hand and Upper Extremity Reconstruction
170
metacarpal in the sagittal plane (perpendicular to the nail
plate), and the FCR tendon is passed through the holes
from volar to dorsal. It is then secured to the APL tendon
and capsule. The remaining free end of the tendon is used
as interposition material and is placed in the trapezial
space.
when suspension arthroplasty is performed. Rarely do
patients complain of symptoms indicating impingement of
the metacarpal onto the scaphoid.
Postoperative care
Typically, all arthroplasty procedures can be performed on
an outpatient basis. The patient should return in 2 weeks
for splint removal and the placement of a custom thermo-
plast resting splint. The patient should begin seeing a hand
therapist to begin progressive active range of motion (ROM)
exercises of the thumb and wrist 4 weeks after surgery. The
thermoplast splint should be worn for protection and
comfort between ROM exercises. The patient can gradually
wean from the splint at 6–8 weeks after surgery, at which
time unrestricted passive ROM exercises should be initi-
ated. Gentle strengthening may begin 6–8 weeks after
surgery. Normal use of the hand with daily activities is
anticipated 10–12 weeks after surgery.
MCP ARTHROPLASTY
Stiffness or deformity at the MCP joints can be quite
disabling because the majority of the arc of fi nger fl exion
originates at the MCP joint. MCP joint abnormalities
are most commonly due to the effects of RA, causing
destruction of the joint with volar dislocation and ulnar
drift. Post-traumatic and rarely idiopathic osteoarthritis
may also affect individual MCP joints, causing stiffness and
pain.
Silicone implants are the most reliable arthroplasty
technique to replace destroyed joints in the rheumatoid
hand. Both silicone and pyrolytic carbon implants are used
in post-traumatic and idiopathic arthritis at the MCP joint,
offering an alternative to arthrodesis to preserve motion.
For OA of the MCP joint, the senior author now prefers the
pyrolytic carbon implant because of the much greater
motion than with the silicone type. The ligament structure
at the MCP joint provides excellent support for this two-
piece implant. However, in RA patients the weak ligament
support structures and the deforming forces make the sta-
bility of pyrolytic carbon arthroplasty less predictable.
This implant is not favored by the senior author for the
treatment of the rheumatoid hand. For RA, in general, the
gains in the degree of active arc of motion after arthroplasty
are modest at best. However, great improvement in pain
and a more extended and functional arc of motion is
achieved by allowing the hand to open and grasp larger
objects.7–10
Indications and contraindications
The decision to proceed with arthroplasty must be made
carefully by selecting the patients most likely to benefi t
from the procedure, and excluding those unlikely to see
large improvements in function. Indications include signifi -
cant pain unresponsive to conservative measures, such as
medical management of infl ammatory conditions, splint-
Optimizing outcomes
●
Protect the branches of the radial sensory nerve and radial
artery during dissection. Irritation of or injury to this nerve
is not an unusual complication of this procedure.
Branches of the nerve must be identifi ed and gently
retracted away.
●
If FCR is harvested in an alternative approach, protect the
palmar sensory branch of the median nerve.
●
Completely excise osteophytes, paying particular attention
to the space between the thumb and index metacarpals.
Failure to remove the osteophytes in this area can result
in persistent postoperative pain and the need for
reoperation.
●
Patients should be warned that improvement of symptoms
after surgery is not immediate, and can often continue for
several months and even years after surgery. For men who
engage in manual labor recovery can take several months,
and potential patients must be educated regarding the slow
recovery of grip strength and the unpredictable delay of
return to work.
Complications
The most common complications after surgery include
altered sensibility in the radial sensory nerve distribution,
or neuroma formation, soft tissue infection, and persist-
ent pain. Most of these common complications are easily
treated. Radial sensory nerve dysesthesia usually improves
with time and observation. If symptoms of neuroma are
present, desensitization or excision is required for relief.
Careful dissection and protection of the radial sensory nerve
at the time of the initial operation will keep the incidence
of this complication low. Soft tissue infection most often
resolves with a course of intravenous antibiotics, as no
foreign material is introduced in this arthroplasty method.
Persistent pain at or worse than preoperative levels is rare
in CMC arthroplasty. Most patients note a substantial
improvement in pain. A common source of persistent pain
is the presence of residual osteophytes. Care must be taken
during the initial operation to ensure that all osteophytes
are removed. If not, the patient may require a subsequent
procedure to remove the residual osteophytes. Regional
pain syndrome is a rare complication of thumb CMC
arthroplasty that may result in a poor postoperative
outcome. When suspected, patients should receive early
and aggressive treatment with appropriate pharmacologic
therapy, sympathetic blocks, and hand therapy. Lastly,
some degree of shortening of the thumb ray is to be expected
after trapeziectomy and cannot be completely avoided, even
Arthroplasty Procedures in the Hand
171
ing, activity modifi cation, analgesics, and corticosteroid
injections. Other indications include severe or fi xed defor-
mity at the MCP joints limiting function, which may mani-
fest as joint destruction, subluxation, and severe ulnar
deviation, typically greater than 30º. There are many RA
patients who have signifi cant deformity. However, some of
these are able to maintain a reasonable level of function
and may not improve to a signifi cant degree after joint
reconstruction. Thus, arthroplasty should be limited to
patients who have severe functional impairment, and in
general they should have an arc of motion less of less than
40º and fi ngers in a poor functional fl exed position. Arthro-
plasty is not indicated in patients who are able to achieve
an active arc of motion greater than 60º, as arthroplasty is
typically unable to result in improvement of motion in
these patients, and in fact may result in diminished motion
postoperatively. Other contraindications for arthroplasty
include poor skin coverage or quality, inadequate bone
stock to support an implant, an irreparable musculotendi-
nous system, and active infection. Patients with active
infl ammation of the MCP joint should not undergo implant
arthroplasty until the infl ammation has been adequately
treated to avoid a potential postoperative infl ammatory
response in the hand and infection. Patients with MCP
joint disease of the thumb due to infl ammatory conditions
are usually best served with arthrodesis, which can with-
stand the lateral stresses generated by pinch and can provide
adequate pain relief.
Preoperative history and considerations
The importance of the preoperative assessment of global
function of the patient, the upper extremity, and the hand
cannot be stressed enough. Concentrating solely on the
MCP joints and ignoring higher-priority deformities will
result in poor postoperative results. Lower extremity and
more proximal upper extremity joints should be treated
before fi nger joints. Thus evaluation of the wrist, elbow,
and shoulder is critical in the preoperative examination.
Wrist deformities must be treated fi rst because persistent
uncorrected wrist deformity will result in early recurrence
of ulnar deviation at the MCP joints. The status of the
fl exor and extensor tendons should be documented. The
surgeon should contemplate simultaneous joint and tendon
reconstruction, or perhaps a staged procedure with joint
reconstruction fi rst to achieve good passive joint motion
prior to tendon reconstruction. Adjacent joint deformities
at the PIP and DIP joints should also be noted. Swan-neck
deformities commonly accompany the volar subluxation
and ulnar drift present in the rheumatoid hand, and may
be corrected by soft tissue reconstruction at the same time
as MCP arthroplasty. Three-view radiographs of the hand
and wrist are taken preoperatively to evaluate the extent of
bone erosion, or other areas of destruction in the hand and
wrist that may require treatment. It is critical to remember
that RA is a progressive medical disease. Medical therapy
must be optimized and all patients should be followed
closely by a rheumatologist.
When performing MCP arthroplasty in a patient with
accompanying deformities, such as extensor tendon rupture
or swan-neck/boutonnière deformity, the surgeon should
consider whether it is better to perform a staged or a simul-
taneous reconstruction. If extensor tendons are ruptured,
the traditional approach is to regain joint mobility fi rst,
then perform tendon reconstruction. In a compliant patient
who has good therapist support, joint and tendon recon-
struction may be performed simultaneously. If the pati-
ent has a swan-neck deformity, the surgeon may wish to
perform MCP arthroplasty fi rst, before treating the swan-
neck deformity. Patients with swan-neck deformity of the
fi ngers will need to maximize fl exion at the MCP joint
because of the hyperextension deformity at the PIP joint.
Therefore, theoretically, they will stress the reconstructed
MCP joints to achieve better fl exion and increased joint
motion. On the other hand, patients with boutonnière
deformity already have fl exed digits and may not stress the
MCP joints suffi ciently after MCP arthroplasty. Whether
to perform staged or simultaneous reconstruction depends
on understanding the needs of the patient and the ability
of the surgeon to maximize the biomechanical advantage
of the reconstructive procedures, based on the existing
deformity.
Operative approach
Silicone metacarpophalangeal arthroplasty (SMPA)
Arthroplasty of all four MCP joints of the index through to
the small fi ngers is often needed. A dorsally placed trans-
verse incision is made over the heads of the metacarpals
(Fig. 12.15). Dissection is carried down to the extensor
apparatus, carefully preserving the longitudinal dorsal veins
to limit postoperative swelling. The skin is carefully
retracted with traction sutures. In the rheumatoid hand the
extensor apparatus is probably deviated ulnarly from the
head of the metacarpal (Fig. 12.16). The radial sagittal
bands are incised to expose the MCP joints (Fig. 12.17). A
longitudinal incision is made in the joint capsule to expose
the joint surface. Any synovial tissue present is sharply
excised. An oscillating saw is used to resect the metacarpal
heads just distal to the origin of the collateral ligament
(Fig. 12.18). The metacarpal heads are removed. Remaining
FIGURE 12.15 SMPA dorsal skin incision over the metacarpal heads.
Hand and Upper Extremity Reconstruction
172
synovial tissue should be excised. Mobility of the fi ngers in
the radial and ulnar directions should be assessed. If
there are forces pulling the fi ngers in the ulnar direction,
it is likely to be caused by chronic contracture of the
ulnar intrinsic tendons. The ulnar intrinsic tendons and
abductor digiti minimi are sharply released to remove these
deforming forces. However, if enough of the metacarpal
head is removed, the ulnar deforming forces should be
relieved and resection of the ulnar intrinsic tendons is
unnecessary.
Next, the MCP joint is prepared for fi t and sizing of the
implant. An awl designed for use with the silicone implant
is used to perforate the medullary cavities of the metacar-
pals and proximal phalanges (Fig. 12.19). Sequentially sized
broaches are used to enlarge the medullary cavity to receive
the implant. The largest implant that will fi t in the medul-
lary cavity without impairing the range of motion is used.
FIGURE 12.16 View of extensor apparatus, which is seen ulnarly
deviated from the center of the metacarpal head.
FIGURE 12.17 Exposure of MCP joint after incision of radial sagittal
band. (Removed synovitis on dorsal hand.)
FIGURE 12.18 Resection of metacarpal heads.
FIGURE 12.19 Insertion of awl to prepare medullary cavities for
placement of implants.
FIGURE 12.20 Insertion of non-absorbable suture into metacarpal
shaft for repair of radial collateral ligaments.
Arthroplasty Procedures in the Hand
173
Before placing the permanent implant, two drill holes are
made with a 0.035 inch K-wire through the distal radial
metacarpal shaft. These holes are for repair of the radial
collateral ligament; 3/0 non-absorbable braided sutures are
placed through the two drill holes, keeping the needle
attached and set aside (Fig. 12.20). The permanent implants
are inserted into the medullary canals. The suture attached
to the metacarpal shaft is used to repair the radial collateral
ligament (Fig. 12.21). When tying the suture to secure these
ligaments, the fi ngers are brought into slight radial devia-
tion. If there is tension in doing so, the ulnar intrinsic
tendons (lateral bands) must be released if not already done.
The released ends of the ulnar lateral bands can be trans-
ferred to the radial lateral band of the adjacent fi nger for
added stability against ulnar deforming forces. For example,
the ulnar lateral band of the middle fi nger is released and
secured to the radial lateral band of the ring fi nger (Fig.
12.22). The radial sagittal band is then repaired with 3/0
absorbable braided suture, being sure to imbricate the
closure so that the extensor apparatus is situated centrally
over the MCP joint (Fig. 12.23). If the extensor tendons
cannot be easily centralized over the metacarpal head owing
to tightness of the ulnar sagittal bands, the ulnar sagittal
bands must also be released. The tourniquet is released and
bipolar electrocautery is used to control bleeding. The skin
is closed with interrupted absorbable sutures in the dermis
and interrupted horizontal mattress nylon sutures to
approximate the skin. A soft dressing is applied over the
surgical site, and the patient is placed in a well-padded
plaster splint with the MCP joints in extension and slight
radial deviation.
Pyrocarbon metacarpophalangeal arthroplasty
A dorsal curvilinear incision is made longitudinally over the
MCP joint for single joint replacement. For multiple joint
replacements, a single transverse incision is made over the
dorsal metacarpal heads (Fig. 12.24). Dissection is carried
down to the extensor apparatus, carefully preserving the
longitudinal dorsal veins to limit postoperative swelling.
The radial sagittal band is incised and the extensor tendon
retracted to expose the MCP joint. A longitudinal incision
is made in the joint capsule to expose the joint surfaces. A
starter awl is placed in the metacarpal head one-third of the
distance from the dorsal cortex, advancing one-half to two-
thirds of the metacarpal length (Fig. 12.25). The alignment
guide on the starter awl is used to make a 27.5º distally
tilted proximal osteotomy 1.5 mm distal to the collateral
ligament attachment site (Fig. 12.26). After starting the
osteotomy, the awl will have to be removed to completely
cut through the volar cortical surface. Every effort should
be made to preserve the attachments of the collateral liga-
ments on the metacarpal head and base of the proximal
phalanx.
The starter awl is used to create a medullary canal at
the base of the proximal phalanx, advancing one-half to
two-thirds of its length. Using the awl and alignment guide,
one will make a 5º distally tilted osteotomy (Fig. 12.27). A
series of broaches made specifi cally for the pyrocarbon
implant are inserted into the metacarpal and proximal
phalanx to prepare medullary canals for the implant stems
(Fig. 12.28). The size of broaches used is increased to the
largest that can be fully accommodated within the canal.
Broaches are inserted under fl uoroscopic guidance to ensure
the instrument is fully inserted and directed in the center
of the medullary canal. No mismatching of paired implant
sizes is allowed in MCP pyrocarbon arthroplasty, hence the
same size broach must be used for the metacarpal and
proximal phalanx canals. A trial implant is secured in place
using the proximal and distal impactor, making sure the
implant is press-fi tted tightly in contact with the cortical
surface of the bone (Fig. 12.29). Joint mobility is evaluated.
If there is diffi culty with passive extension, more resection
of the metacarpal is required for a better fi t of the prosthe-
sis. If detachment of the collateral ligaments is required
during bone resection, both radial and ulnar collateral liga-
ments are repaired in a similar fashion as described for the
SMPA technique. If the trial implant allows adequate range
of motion, the permanent implant is press-fi tted into the
medullary cavities (Fig. 12.30) by tapping it gently with the
supplied impactor (Fig. 12.31). The joint capsule and radial
sagittal band are repaired with absorbable sutures. The
tourniquet is released and bipolar electrocautery is used to
control bleeding. The skin is closed with interrupted absorb-
able sutures in the dermis and interrupted horizontal mat-
tress nylon sutures to approximate the skin. A soft dressing
is applied over the surgical site. A well-padded plaster splint
is applied with the MCP joints in extension.
FIGURE 12.21 Radial collateral ligament repair. A Two burr holes are
made in the radial metacarpal shaft, through which non-absorbable
sutures are placed. B The suture is then used to reattach the radial
collateral ligament after the silicone implant is placed in the
medullary canals.
Silicone
arthroplasty
implant
Radial collateral
ligament
A
B
Hand and Upper Extremity Reconstruction
174
MCP joints with
SMPA in place
Central slip of
extension apparatus
Released ulnar
lateral band
ADM
(not transferred)
IF
MF
RF
SF
Lateral bands
FIGURE 12.22 Tightness of ulnar intrinsics
necessitates release of ulnar lateral bands and
ADM. The released lateral band may be
transferred to the adjacent radial lateral band for
added stability.
FIGURE 12.23 Imbrication of the radial sagittal band to relocate the
extensor apparatus over the center of the metacarpal head.
Incision for single
joint replacement
Incision for
multiple joint
replacement
FIGURE 12.24 Skin incisions for single or multiple MCP pyrocarbon
arthroplasty.
Arthroplasty Procedures in the Hand
175
Dorsal third of
metacarpal head
Starter awl
Proximal phalanx
Metacarpal
FIGURE 12.25 The starter awl is placed into the metacarpal head
one-third the distance from the dorsal cortex.
Proximal osteotomy guide
Alignment awl
27.5°
FIGURE 12.26 The alignment guide is placed on the starter awl and
the oscillating saw is used to make a 27.5º osteotomy just distal to
the collateral ligament origin at the metacarpal head.
Distal osteotomy guide
Alignment awl
5°
Electrical saw
FIGURE 12.27 The awl and alignment guide are inserted. A 5º distal
osteotomy is created at the base of the proximal phalanx.
Optimizing outcomes
●
Ensure that proximal joint deformities are addressed before
the fi nger joints, because unaddressed radial deviation of
the wrist will inevitably result in ulnar deviation at the MCP
joints. Focusing solely on the MCP joint will lead to
unsuccessful outcomes if other joints are contributing to
MCP joint deformity and instability.
●
Know the status of fl exor and extensor tendons, and whether
repair is needed prior to arthroplasty. Otherwise, the patient
will gain little motion after arthroplasty if tendons are unable
to function properly.
●
During silicone arthroplasty the proximal phalanx of the
index fi nger is reamed in a slightly supinated position for
better tip pinch position.
●
A no-touch technique with smooth forceps should be used
when handling the silicone implant to avoid damaging its
surface. Such damage can lead to propagation of defects in
the implant and later fracture.
●
Stability of the joint and prevention of early ulnar drift is
maintained by tightening the radial sagittal bands to
centralize the extensor tendons and by dividing or
transferring the ulnar intrinsic tendons in patients with
rheumatoid arthritis.
●
Realistic expectations of the surgeon and patient must be
emphasized. The active arc of motion may not increase
dramatically after any arthroplasty technique, and results are
likely to diminish over time, especially in patients with
rheumatoid arthritis. The active arc of motion achieved after
surgery is usually not more than 60º, but the arc is in a more
extended position that will allow the hand to open to hold
larger objects. Patients have to decide whether large
improvements in the short term justify undergoing the
procedure.
●
The appropriate implant type must be used, based on the
underlying disease, the competence of supporting tissues
and bone, and anticipated functional demands.
Complications
The most common complications of MCP arthroplasty
with both silicone and pyrocarbon implants include soft
tissue infection, implant failure or dislocation, and
Hand and Upper Extremity Reconstruction
176
A
B
FIGURE 12.28 The medullary canals of the proximal phalanx (A) and metacarpal (B) are prepared to receive the implant by inserting broaches
of increasing size.
Trial implant
FIGURE 12.29 The trial implant is gently press-fi tted with the
impactor.
recurrent deformity. Soft tissue infection is rare, requiring
treatment with intravenous antibiotics and removal of the
implant if the infection does not immediately resolve.
Silicone implant fracture in most cases does not require
exchange of the implant because it is most often asymp-
tomatic. The capsule formed around the implant during
healing maintains long-term joint stability. Recurrent ulnar
drift, extensor lag, and loss of motion are expected in the
long term after arthroplasty in patients with rheumatoid
arthritis. Patients should be educated that results in the
immediate postoperative period are not permanent, and
can change with time as their disease progresses and
implants are worn. However, improvement from the pre-
operative level of function and pain is sustained long term.
Patients receiving silicone and pyrocarbon arthroplasty may
have changes in the bone surrounding the implant, with
osseous erosions that may lead to metacarpal or proximal
phalanx shortening or subsidence. Bone erosion is usually
more pronounced with silicone arthroplasty than with
pyrocarbon arthroplasty, probably due to silicone synovitis.
Patients who experience dislocation of the pyrocarbon
implant usually do so in the early postoperative period.
Early dislocation is typically managed with closed reduction
and prolonged immobilization of the joint by external fi xa-
tion or prolonged splinting before hand therapy is begun.
Excluding patients with poor ligamentous support of the
joints will reduce the risk of dislocation of the pyrocarbon
implant.
Arthroplasty Procedures in the Hand
177
FIGURE 12.30 X-ray showing the pyrocarbon MCP implant.
Implant
FIGURE 12.31 The permanent implant is press-fi tted against the
cortical surfaces of the bone.
Postoperative care
The splint placed at the time of surgery is removed at the
fi rst postoperative visit 4–7 days later. An extension resting
splint is fabricated for night use. A dynamic extension
splint is used during the day to control motion during active
exercises. The dynamic splint is worn during the day for
6–8 weeks, and the resting splint is worn at night for 12
weeks. Sutures are removed 2 weeks postoperatively. The
goal of MCP fl exion is 60º at 4 weeks. Patients are able to
progress to light activities with the hand at 6 weeks, and
gentle strengthening at 8 weeks after silicone arthroplasty.
Return to normal activities by 12 weeks with night splint-
ing as needed should be expected. Patients receiving pyro-
carbon arthroplasty are able to progress to full activities as
tolerated 6 weeks after surgery. Night splinting is continued
as needed. Frequent examination by a hand therapist is
required to adjust splints as necessary.
PIP ARTHROPLASTY
Arthroplasty should be considered if the patient desires
motion, and if soft tissue reconstructive procedures such as
capsular release or tendon relocation procedures are no
longer possible because the joint is severely arthritic. For a
patient presenting with a boutonnière deformity, PIP arthro-
plasty, in most cases, should not be performed. These
patients are still able to make a full grip, provided that MCP
joint motion is reasonable. PIP arthroplasty will place the
PIP joint in extension, which will limit grip and can be a
hindrance to the patient. Additionally, the amount of bone
resection necessary to correct fl exion deformity of the PIP
joint will require excision of the collateral ligaments, which
will destabilize the joint. This is particularly problematic
for two-piece pyrocarbon implants, in which the integrity
of the collateral ligament is crucial to the stability of the
reconstructed joint. In most cases, boutonnière deformity
is an aesthetic consideration and not a functional one. On
Hand and Upper Extremity Reconstruction
178
the other hand, patients with swan-neck deformity have
diffi culty with PIP joint fl exion. Their grip is weak because
of limited PIP motion. PIP arthroplasty can enhance PIP
joint fl exion and is a much preferred option. PIP joint
arthroplasty should be considered carefully for the index
fi nger because the supporting ligaments may not be durable
enough to withstand lateral forces, and thus arthrodesis
is recommended to maintain lateral stability for pinch.
Arthroplasty is preferred in the ulnar digits because they
are important in grip, and preservation of motion is needed.
The middle fi nger functions in both grip and pinch, there-
fore either arthrodesis or arthroplasty is reasonable.
The PIP pyrolytic carbon implant was approved for use
in the US as a humanitarian device in 2002. Although no
long-term data are available to show an advantage over sili-
cone arthroplasty, range of motion after pyrocarbon arthro-
plasty is similar to the results of silicone arthroplasty.11
This procedure is a promising alternative in patients who
are poor candidates for silicone arthroplasty. Because of the
anatomic design of the pyrolytic carbon PIP implant, it has
become preferred for OA joints. Again, the senior author is
reluctant to use this implant type for RA patients because
of weak ligament support in RA joints.
Indications and contraindications/preoperative
history and considerations
The considerations for PIP arthroplasty have been discus-
sed and are similar to the issues presented for MCP
arthroplasty.
Operative approach
Pyrolytic carbon PIP arthroplasty
Pyrolytic carbon PIP arthroplasty is very similar to MCP
pyrocarbon arthroplasty, with subtle variations. Under
tourniquet control, a 2–3 cm longitudinal curvilinear inci-
sion is made over the dorsum of the PIP joint. There are
two methods that may be used to retract the extensor
mechanism for joint exposure. The widest exposure is
obtained by making a chevron incision in the extensor
tendon at the level of the mid-proximal phalanx. This
allows the central slip to be detached and retracted distally
to expose the joint (Fig. 12.32). This method will require
tendon repair after implant placement. There is a risk of
stretching the detached and repaired extensor tendon during
therapy, and the resulting extensor lag may require pro-
longed extension splinting. Alternatively, the senior author’s
preference is to expose the joint with a tendon-splitting
incision through the central slip of the extensor mecha-
nism. The tendon is incised longitudinally, taking care not
to disrupt the distal insertion, and the tendon edges are
retracted to expose the joint (Fig. 12.33). At the time of
closure, the tendon is repaired in a side-to-side fashion.
Ideally, adequate joint exposure can be obtained without
detaching the attachment of the central slip. However, if
detachment is necessary, the tendon is repaired by placing
sutures through holes drilled over the dorsal base of the
middle phalanx.
Central extensor tendon
Lateral band
Reflected extensor tendon
Proximal interphalangeal joint
FIGURE 12.32 Exposure of PIP joint by distal refl ection of central slip.
Central extensor tendon
Lateral band
Reflected split
central slip
Exposed PIP joint
FIGURE 12.33 Exposure of PIP joint by making a longitudinal slit
through central slip and retraction. This approach allows preservation
of the continuity of the extensor apparatus.
Arthroplasty Procedures in the Hand
179
The surface of the proximal phalanx is prepared fi rst. A
starter awl with alignment guide is placed between the
condyles of the head of the proximal phalanx to create a
medullary canal for the prosthesis. The vertical cutting
guide with an oscillating saw is used to make a vertical
osteotomy though the head of the proximal phalanx, 1–
2 mm distal to the attachment of the collateral ligaments
(Fig. 12.34). A series of broaches of increasing size are used
to prepare the medullary canal to fi t the largest broach that
can be accommodated. Broaches are inserted under fl uoro-
scopic guidance to ensure the instrument is fully inserted
and directed in the center of the medullary canal. The 60º
oblique cutting guide is placed in the prepared medullary
canal of the proximal phalanx to make a second osteotomy,
oriented in the volar oblique direction (Fig. 12.35). All
osteophytes are gently removed with a rongeur. The proxi-
mal phalanx is now ready to press-fi t the trial implant.
Next, the middle phalanx is prepared. A small oval burr
is used to remove just the articular surface at the base of
the middle phalanx and create a gentle trough to accom-
modate the implant. No osteotomy is made. In a similar
fashion as for the proximal phalanx, a series of broaches
are used to prepare the medullary canal to fi t the largest
implant that can be accommodated. Unlike the MCP pyro-
carbon implants, paired PIP pyrocarbon implants can be
mixed one size up or down, such that the proximal phalanx
and middle phalanx components may differ by one size
increment. The trial implant is press-fi tted into the middle
phalanx. The shoulders of both implants must rest against
the cut edge of the cortical bone for appropriate fi t. Motion
at the PIP joints is assessed with the trial implant in place
to assure smooth, unrestricted movement. If the implant
is so tight as to impede motion, additional bone should be
resected from the proximal phalanx. Tenolysis may be
required if there are any limitations in passive motion. The
permanent implant is press-fi tted by gentle tapping. The
extensor tendon is closed in a side-to-side fashion with
interrupted non-absorbable sutures. The incision is closed
with horizontal mattress nylon sutures to approximate the
skin. A soft sterile dressing is applied over the incision, and
Proximal phalanx
Alignment awl
Alignment guide
Electrical saw
Vertical cutting guide
Alignment awl
A
B
FIGURE 12.34 The starter awl is placed between the condyles at the head of the proximal phalanx (A) and the alignment guide is used to
make a vertical osteotomy (B).
60°
Collateral
ligament
Alignment guide
Electrical saw
Proximal phalanx
Middle phalanx
A
B
FIGURE 12.35 After the medullary canal of the proximal phalanx is
broached, the 60º oblique cutting guide is inserted in the canal and a
second osteotomy is made (A). Both the vertical and 60º oblique
osteotomies are made so as to not disturb the attachment of the
collateral ligament (B).
Hand and Upper Extremity Reconstruction
180
a well-padded plaster splint is applied with the fi nger in full
extension.
Alternative technique
The silicone arthroplasty remains the most widely used
technique for reconstruction of PIP joint deformities, spe-
cifi cally of the ulnar digits. Joint exposure is identical to
that described for the PIP pyrocarbon implant, using the
tendon-splitting technique to avoid disrupting the continu-
ity of the extensor tendon. The head of the proximal phalanx
is resected vertically with an oscillating saw without dis-
rupting the attachments of the collateral ligaments. The
medullary canals of the proximal and middle phalanges are
prepared by inserting broaches of increasing size, identical
to the method used for placement of silicone implants at
the MCP joint. The implant is gently inserted with smooth
forceps and joint mobility is assessed to ensure adequate
implant sizing. The extensor tendon and incision are closed
as described in the PIP pyrocarbon arthroplasty procedure.
The fi nger is splinted in full extension.
The volar approach can be used as well. The advantage
of this technique is that the extensor tendon over the PIP
joint is not violated. The PIP joint is exposed after careful
preservation of the neurovascular bundles. The PIP joint is
exposed via a shotgun approach, and the rest of the proce-
dure is similar to the dorsal approach. The senior author
prefers the dorsal approach because of the ease of
exposure.
occasionally been reported to squeak, but this usually
improves with time. Implant dislocation is a diffi cult com-
plication to treat with the PIP pyrocarbon implant. This is
usually caused by poor patient selection (in boutonnière
deformity) or injudicious detachment of the collateral liga-
ments. This complication can be treated by joint reduction
and prolonged external fi xation stabilization of the reduced
joint (Fig. 12.36). After 6–8 weeks of immobilization, the
scarring around the implant may stabilize the joint.
Postoperative care
The patient returns for the fi rst postoperative visit in 4–7
days, at which time the plaster splint is removed. A forearm-
based resting splint is made to keep the MCPs in slight
fl exion and the IP joints in full extension for night use. A
dynamic PIP extension splint is made for use during the
day. Active range of motion using the dynamic splint is
begun, allowing 0–30º of fl exion; 1–2 weeks after the surgery
up to 45º of fl exion is allowed if no extensor lag is present.
At 6 weeks after surgery the arc of motion is increased to
60º and light activities out of the splint are initiated, avoid-
ing lateral stresses at the joint. Gentle strengthening may
be initiated by 8 weeks after surgery. Patients are weaned
from the dynamic splint in 6–8 weeks and from the night
splint after 3 months. The patient should be closely fol-
lowed by a hand therapist to monitor for hyperextension
or extensor lag. This requires adjustment of splints and
changes in the arc of motion.
CONCLUSION
Arthroplasty procedures in the hand are most commonly
performed at the thumb CMC and at the fi nger MCP and
PIP joints. Most arthroplasty procedures result in a reliable
improvement of pain, maintain some degree of mobility,
restore alignment, and are associated with a high rate of
patient satisfaction. Despite the likelihood that results will
FIGURE 12.36 Photograph showing external fi xator in place to
correct a dislocated implant.
Optimizing outcomes
●
Minimal joint resection helps to preserve the attachments of
the collateral ligaments, and leaves a wider cortical contact
surface area for distribution of compressive loads onto the
implants.
●
The collateral ligament attachments should be preserved
whenever possible to maintain stability.
●
The extensor apparatus should be shortened to correct laxity
in cases of chronic fl exion deformity.
●
Tenolysis may be necessary at the time of arthroplasty, and
can improve motion after surgery.
Complications
Complications common to both pyrolytic carbon and sili-
cone arthroplasty at the PIP joint are similar to those seen
at the MCP joint. Patients may develop changes in the bone
surrounding the implant, leading to erosions, loosen-
ing, subsidence, or instability, which may require implant
removal and arthrodesis. Heterotopic bone formation can
be seen with silicone arthroplasty. Reoperation for implant
fracture seen with silicone implants is rarely needed owing
to the formation of a stabilizing capsule around the implant.
If the joint is unstable, the implant is replaced if bone
quality is adequate, or arthrodesis is performed. Infection
is rarely encountered after PIP arthroplasty, but if the infec-
tion does not resolve patients are treated with intravenous
antibiotics and implant removal. Pyrolytic implants have
Arthroplasty Procedures in the Hand
181
diminish somewhat over the long term, arthroplasty offers
defi nite advantages over arthrodesis.
REFERENCES
1. Haubold AD. On the durability of pyrolytic carbon in vivo. Med
Prog Tech 1994; 20: 201–208.
2. Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction
for the painful thumb carpometacarpal joint: A long-term
assessment. J Hand Surg 1984; 9: 692–699.
3. Mureau MA, Rademaker RP, Verhaar JA, Hovius SE. Tendon
interposition arthroplasty versus arthrodesis for the treatment of
trapeziometacarpal arthritis: A retrospective comparative follow-up
study. J Hand Surg 2001; 26: 869–876.
4. Chang EY, Chung KC. Outcomes of trapeziectomy with a modifi ed
abductor pollicis longus suspension arthroplasty for the treatment
of thumb carpometacarpal osteoarthritis. Plast Reconstruct Surg
2007; (in press).
5. Thompson JS. Surgical treatment of trapeziometacarpal arthrosis.
Adv Orthop Surg 1986; 10: 105–120.
6. Eaton RG, Glickel SZ, Littler JW. Tendon interposition
arthroplasty for degenerative arthritis of the trapeziometacarpal
joint of the thumb. J Hand Surg 1985; 10: 645–654.
7. Chung KC, Kotsis SV, Kim HM. A prospective outcomes study of
Swanson metacarpophalangeal joint arthroplasty for the
rheumatoid hand. J Hand Surg 2004; 29: 646–653.
8. Chung KC, Kowalski CP, Myra Kim H, Kazmers IS. Patient
outcomes following Swanson silastic metacarpophalangeal joint
arthroplasty in the rheumatoid hand: A systematic overview.
J Rheumatol 2000; 27: 1395–1402.
9. Cook SD, Beckenbaugh RD, Redondo J, et al. Long-term follow-up
of pyrolytic carbon metacarpophalangeal implants. J Bone Joint
Surg 1999; 81A: 635–648.
10. Goldfarb CA, Stern PJ. Metacarpophalangeal joint arthroplasty in
rheumatoid arthritis. A long-term assessment. J Bone Joint Surg
2003; 85A: 1869–1878.
11. Squitieri L, Chung KC. A systematic review of outcomes and
complications of vascularized toe joint transfer, silicone
arthroplasty, and pyrocarbon arthroplasty for post-traumatic joint
reconstruction of the fi nger. Plast Reconstruct Surg 2008; 121:
1697–1707.
183
C H A P T E R
13
Surgical Procedures for the Distal Radius
and Distal Radioulnar Joint
Kenji Kawamura and Kevin C. Chung
INTRODUCTION
The distal radius is the most commonly fractured region in
the upper extremity.1 The radius has two functionally
important articulations in the wrist. The fi rst is the radio-
carpal joint, which has an ellipsoid articulation between the
biconcave surface of the distal radius and the convex facets
of the proximal carpal bones. The second is the distal radio-
ulnar joint (DRUJ), which has a trochoid articulation
between the sigmoid notch of the distal radius and the
ulnar head, allowing pronation and supination of the
forearm. Inadequate management of distal radius fractures
can easily result in permanent disability of the wrist because
of injuries to these two critical joints. The purpose of treat-
ment for distal radius fractures is to restore articular con-
gruity and normal anatomic alignment of the distal radius,
and to prevent articular malalignment and the development
of arthritis of the wrist. Although non- or minimally dis-
placed stable fractures of the distal radius can be treated by
cast immobilization, displaced unstable fractures require
surgical treatment. The various techniques available for
treating unstable distal radius fractures include percutane-
ous pinning,2 external fi xation,3 and open reduction and
internal fi xation with customized implants.4–6 The recent
trend for internal fi xation of distal radius fractures is to use
the volar locking plating system (VLPS) with fi xed-angle
implants, which can provide rigid fi xation for fragmented
and even osteoporotic bones that are not normally amena-
ble to screw fi xation.5–8
Malunion is the most common complication that occurs
after distal radius fractures.9 Important radiographic mea-
surements that may affect functional outcomes in the wrist
are radial inclination (normal average: 23º), radial length
(normal average: 12 mm), palmar tilt (normal average: 11º)
and congruity of articular surfaces (Fig. 13.1). Loss of radial
inclination causes radial deviation of the wrist, whereas
radial shortening leads to incongruity of the DRUJ and
positive ulnar variance. Excessive dorsal tilt results in carpal
malalignment, leading to carpal instability and arthritis.
Although corrective osteotomy of the distal radius may be
required for severe malunions,10 salvage procedures such as
the Darrach (resection of the ulnar head)11 or Sauvé–
Kapandji procedures (fusion of the DRUJ)12 are required to
improve overall wrist function if symptomatic DRUJ arthri-
tis exists. This chapter describes the following two impor-
tant surgical procedures for the distal radius and DRUJ:
volar plating of distal radius fractures, and the Darrach
procedure.
VOLAR PLATING OF
DISTAL RADIUS FRACTURES
Indications and contraindications
After closed reduction of distal radius fractures, unaccept-
able reduction parameters requiring surgery include a radial
inclination of <20º, radial shortening of >2 mm, dorsal tilt
of >10º and articular step-off of >2 mm. Volar fi xed-angle
plate fi xation is indicated for both extra-articular and intra-
articular fractures of the distal radius. Furthermore, volar
fi xed-angle plate fi xation can even be applied to dorsally
displaced fractures that have been traditionally treated with
dorsal plate fi xation.13 The use of volar plating can avoid
the complication of dorsal soft tissue irritation associated
with dorsal plate fi xation. The volar anatomy of the distal
radius has obvious advantages over the dorsal aspect for
implant application. Specifi cally, there is more space
between the volar cortex and fl exor tendons, and the prona-
tor quadratus separates these structures, thereby preventing
soft tissue complications such as tendon rupture.14 The
additional space permits the placement of larger implants.
Volar fi xed-angle plate fi xation may be contraindicated
for the less common massively comminuted fractures of the
articular surface because of the technical diffi culty of achiev-
ing proper reduction of the fragmented articular surface.
Hand and Upper Extremity Reconstruction
184
In such cases external fi xation may be recommended.3
Internal fi xation is not amenable to open fractures of the
distal radius in emergency operations owing to concern for
implant infection; external fi xation is applied after debride-
ment and irrigation of the fracture.
Preoperative history and considerations
Diagnosis is usually made by standard radiographs, includ-
ing posteroanterior, lateral, and oblique views (Fig. 13.2).
CT is used only in rare cases to evaluate the amount of
displacement of the articular surfaces. Determination of the
type of fracture is important, which includes assessment of
the displacement, radial shortening, intra-articular involve-
ment, the amount of comminution, and the presence of
an ulnar styloid fracture. Although numerous classifi cation
systems have been suggested for the categorization of distal
radius fracture patterns,15 such as the AO, Frykman, Mayo
and Melone systems, none of these is universal and capable
of predicting outcomes.16 Surgeons should make an effort
to restore the anatomy of the distal radius, including radial
inclination (normal average: 23º), radial length (normal
average: 12 mm), palmar tilt (normal average: 11º) and
congruity of articular surfaces, all of which may affect the
functional outcome of the wrist. Surgeons should fi x an
associated ulnar styloid fracture if DRUJ instability remains
after fi xation of the distal radius fracture.
Operative approach
The operation is performed under regional or general anes-
thesia with an upper arm tourniquet, and carried out with
fl uoroscopic assistance. The surgical approach uses an 8–
10-cm longitudinal incision located directly over the distal
course of the fl exor carpi radialis (FCR) tendon (Fig. 13.3).17
The incision is extended to a V-shape at the wrist crease
to provide wider exposure of the fracture and to prevent scar
contracture from a linear incision over the crease. Note that
the distal incision should not cross into the palm. The FCR
tendon sheath is opened and dissection carried down
between the FCR tendon and the radial artery. The forearm
deep fascia is incised to expose the fl exor pollicis longus
(FPL) muscle belly. The surgeon’s index fi nger is placed in
the wound to gently sweep the FPL ulnarly, and the FPL
muscle belly is partially detached from the radius to obtain
full exposure of the pronator quadratus (Fig. 13.4). The
distal and radial borders of the pronator quadratus are ele-
vated with an L-shaped incision, leaving a small cuff of
A
B
FIGURE 13.1 Radiographic parameters of the distal radius. A Radial inclination (RI) is measured relative to the perpendicular shaft of the radius,
and the normal average is 23º. Radial length (RL) is the diff erence in length between the ulnar head and the tip of the radial styloid, and the
normal average is 12 mm. B Palmar tilt (PT) is measured relative to the perpendicular shaft of the radius on the lateral view, and the normal
average is 11º.
Surgical Procedures for the Distal Radius and Distal Radioulnar Joint
185
A
B
FIGURE 13.2 A Posteroanterior B and lateral radiographs of a distal
radius fracture. The radiographs show a severely comminuted intra-
articular fracture with a fracture of the ulnar styloid. The distal
fracture fragments are displaced and angulated dorsally.
FIGURE 13.3 A skin incision is made directly over the distal course of
the fl exor carpi radialis tendon.
FIGURE 13.4 Dissection is carried down between the fl exor carpi
radialis tendon and the radial artery. After incision of the forearm
deep fascia, the fl exor pollicis longus is gently swept ulnarly by the
surgeon’s index fi nger to expose the pronator quadratus.
Hand and Upper Extremity Reconstruction
186
tissue for subsequent repair, and the muscle is retracted
ulnarly (Fig. 13.5). Reduction of a dorsally displaced frac-
ture is achieved by using a small periosteal elevator as a
lever (Fig. 13.6). The dorsal fragment is reduced by applying
fi nger pressure to the dorsal cortex. For a displaced radial
styloid fracture, releasing the insertion of the brachioradia-
lis from the radial styloid can facilitate reduction. After
confi rming proper reduction by fl uoroscopy, a provisional
K-wire can be used to fi x the distal fragment to the proximal
fragment temporarily. In most cases, temporary fi xation is
unnecessary because distal fi nger traction by an assistant
can maintain reduction while the volar plate is placed. After
placement of the volar plate, a cortical screw is fi rst applied
to the oval plate hole to fi x the plate to the proximal frag-
ment while allowing proximal or distal adjustment (Fig.
13.7). Fluoroscopic imaging is used to confi rm adequate
plate positioning to allow the placement of distal subchon-
dral support pegs 2–3 mm below the subchondral bone.
After accurate pre-drilling with a special threaded drill
A
L-shaped incision
Pronator quadratus
Flexor pollicis longus
Flexor carpi radialis
B
FIGURE 13.5 A An L-shaped incision is made on the distal and radial
borders of the pronator quadratus. B Schematic drawing of an
L-shaped incision on the pronator quadratus based on Figure 13.5A.
FCR, fl exor carpi radialis; FPL, fl exor pollicis longus; PQ, pronator
quadratus.
FIGURE 13.6 A small periosteal elevator is inserted into the fracture
line to serve as a lever to reduce the dorsally displaced fractures.
Surgical Procedures for the Distal Radius and Distal Radioulnar Joint
187
guide, a peg is inserted into the distal fragment. One peg
and one screw provide suffi cient fi xation to stabilize most
fractures temporarily and allow fl uoroscopic inspection.
Fluoroscopic imaging is used to confi rm that there is no
intra-articular penetration of the peg. The remaining pegs
are then inserted. The number of pegs to be inserted depends
on the fracture confi guration. At least two pegs are placed
in each major fracture fragment to obtain stable fi xation.
The radial styloid fragment is fi xed by the radialmost peg,
which is angled for this purpose. The dorsal die-punch frag-
ment is fi xed by the ulnarmost pegs. After insertion of the
distal pegs, the rest of the proximal cortical screws are
inserted to achieve balanced fi xation. Fluoroscopic imaging
is used to confi rm that there are no excessively long pegs
or screws. The pronator quadratus is repaired with 3/0
absorbable sutures and the wound is closed. Postoperative
radiographs should show a well-reduced fracture with suit-
able screw lengths (Fig. 13.8).
FIGURE 13.7 A cortical screw is fi rst applied to the oval plate hole to
fi x the plate to the proximal fragment but allow proximal or distal
adjustment to provide the optimal placement for the distal pegs.
A
B
FIGURE 13.8 A Posteroanterior and B lateral radiographs after volar plating. The postoperative radiographs show a well-reduced fracture with
suitable screw lengths.
Hand and Upper Extremity Reconstruction
188
Postoperative care and expected outcomes
The wrist is immobilized with a plaster wrist splint for 1
week after the operation. After 1 week, the sutures are
removed and active wrist motion is initiated. The wrist is
then placed in a removable Orthoplast splint for 6 weeks.
Patients who are able to engage in their own therapy can
be given a home program. After 6 weeks, the patients will
undergo a strengthening program. The prospective out-
comes by the senior author (KCC) have shown that, despite
the use of an early rehabilitation protocol, reduction of
distal radius fractures can be maintained over long follow-
up periods.6,18
Complications
Complications associated with volar plate fi xation for distal
radius fractures are few, and frequently related to surgical
technique.19 Extensor tendon injuries can occur if the pegs
are excessively long, such that they protrude through the
dorsal cortex and penetrate into the extensor tendon
sheaths. Such injuries can be avoided with careful fl uoro-
scopic inspection at each step of the operative procedure.
Flexor tendon injuries after volar plate fi xation are rare.20
Delayed healing is uncommon, but can occur if there is a
loss of rigid fi xation caused by inadequate reduction or plate
malpositioning. Loss of fi xation can occur if the pegs are
placed too proximally to support the subchondral bone.
Implant breakage is rare. Stiffness and refl ex sympathetic
dystrophy are uncommon with volar plate fi xation, but
must be carefully watched for and treated aggressively in
their early stages if they occur.
THE DARRACH PROCEDURE
Indications and contraindications
Indications for the Darrach procedure (distal ulna resection)
include any conditions that cause DRUJ arthritis or incon-
gruity. The Darrach procedure is most commonly indicated
in low-demand or elderly patients with persistent ulnar-
sided wrist pain and limited forearm rotation caused by
DRUJ arthritis or incongruity following a distal radius frac-
ture (Fig. 13.9).21,22 The procedure is also widely used in
rheumatoid arthritis involving DRUJ problems such as
pain, weakness, and loss of forearm rotation.23 Another
important indication for the Darrach procedure is attri-
tional rupture of the ulnar-side extensor tendons caused by
a dorsally dislocated and eroded ulnar head.
The Darrach procedure may be contraindicated in
younger, high-demand patients.24 The distal ulna and
attached soft tissues are kinematically essential for the
coordination of two important movements, namely forearm
rotation and wrist circumduction.25 The distal ulna is also
important for maintaining adequate tension within the
radioulnar interosseous membrane, allowing normal radio-
ulnar transfer of load. Forearm motion, grip strength, and
the lifting capability of the hand may frequently be impaired
if the Darrach procedure is performed in younger and high-
demand patients. Corrective osteotomy of the distal radius
FIGURE 13.9 Posteroanterior radiographs of severe distal radius
malunion. There is radial shortening with disruption of the distal
radioulnar joint.
may therefore be preferred for such patients with a distal
radius malunion.10 Pre-existing ulnar translation of the
carpus in rheumatoid patients may be a contraindication
for the Darrach procedure because there is a high risk of
postoperative progression of ulnar translation of the
carpus.26 In such patients, the Sauvé–Kapandji procedure
may be preferred.27 This procedure fuses the ulnar head to
the radius, and an osteotomy is performed proximal to the
ulnar head to permit forearm rotation. The intact ulnar
head can support the ulnar carpus to prevent its ulnar
translocation. Alternatively, radiolunate or total wrist
arthrodesis combined with the Darrach procedure can also
be performed.28
Preoperative history and considerations
Rheumatoid and non-rheumatoid patients should be con-
sidered separately because the indications, contraindica-
tions, technical concerns, and expected results following
the Darrach procedure may differ. Poor outcomes are almost
always related to either improper patient selection or
Surgical Procedures for the Distal Radius and Distal Radioulnar Joint
189
improper resection of the ulnar head.29 As mentioned
earlier, failures tend to occur in younger and high-demand
patients. Ulnar stump instability resulting from excessive
ulnar resection is diffi cult to treat. Ulnar resections of
>30 mm commonly result in painful snapping of the ulnar
stump.24 Osteotomy of the ulna should be made at the level
of the proximal margin of the sigmoid notch, which can
contribute to the creation of a stable asymptomatic radio-
ulnar pseudoarthrosis (Fig. 13.10). Another consideration
for osteotomy includes the shape of the ulnar stump. If the
ulna is cut transversely, it can leave a sharp edge to con-
verge on the radius to create stress concentration.24 It is
important to shape the distal ulnar stump in order to reduce
stress concentration by decreasing the potential surface area
for radioulnar contact. The authors usually make an oblique
osteotomy that angles distally towards the ulnar styloid.
Operative approach
The operation is performed under regional or general anes-
thesia with tourniquet control. The surgical approach is
through a 4-cm longitudinal incision over the ulnar head
(Fig. 13.11). The subcutaneous tissue is dissected just above
the level of the extensor retinaculum (Fig. 13.12). Care is
taken to protect the dorsal branch of the ulnar nerve. A
longitudinal incision of the extensor retinaculum is made
between the fi fth and sixth dorsal compartments. The
dorsal capsule of the DRUJ is incised longitudinally to
expose the ulnar head (Fig. 13.13). This is further exposed
subperiosteally just proximal to the DRUJ articulation. An
oscillating saw is used to make an oblique osteotomy at the
level of the proximal margin of the sigmoid notch, with the
bevel of the osteotomy oriented radially and dorsally (Fig.
13.14). The distal ulnar fragment is removed by releasing
the periosteum and triangular fi brocartilage complex from
the ulnar head and styloid. After removal of the ulnar head
Ulnar
Sigmoid notch
Radius
FIGURE 13.10 Osteotomy level of the ulnar head. An osteotomy of
the ulna should be made at the level of the proximal margin of the
sigmoid notch.
FIGURE 13.11 A skin incision is made over the ulnar head. The
dotted line indicates the path of the dorsal ulnar sensory nerve,
which should be carefully protected.
FIGURE 13.12 The extensor retinaculum over the ulnar head is
exposed.
FIGURE 13.13 After incision of the extensor retinaculum and dorsal
capsule of the distal radioulnar joint, the ulnar head is exposed.
Hand and Upper Extremity Reconstruction
190
we stabilize the distal ulnar stump using a variety of tech-
niques, including tenodesis of the distal ulnar stump using
a strip of the extensor carpi ulnaris tendon.30 The authors
nearly always perform the tenodesis procedure in younger,
non-rheumatoid patients because instability of the ulnar
stump is usually related to excessive resection of the ulnar
head and can be avoided with proper osteotomy. The dorsal
capsule and extensor retinaculum are repaired with 3/0
absorbable sutures (Fig. 13.15), followed by wound closure.
Postoperative radiographs should show proper excision of
the ulnar head (Fig. 13.16).
Postoperative care and expected outcomes
A plaster sugar-tong splint is applied with the forearm in
45º supination and the wrist in the neutral position. Active
full mobilization of the fi ngers can begin immediately after
the operation. After 1 week, the sutures are removed. The
FIGURE 13.14 An oblique osteotomy with the bevel oriented radially
and dorsally is made using an oscillating saw.
FIGURE 13.15 After closing the dorsal capsule, the extensor
retinaculum is repaired.
wrist is splinted in a removable Orthoplast supination
splint for another 3 weeks, and fi nger exercises are started.
After this splinting period, supervised therapy is initiated
involving forearm rotation and wrist motion for the next
3 weeks. A strengthening program is initiated 7 weeks
after surgery. Regardless of the underlying diagnosis, most
patients achieve satisfactory relief of ulnar-sided pain and
restoration of forearm rotation.21–23
Complications
Ulnar stump instability, which can develop into radioulnar
impingement and painful crepitus, is the most common
complication after the Darrach procedure.31 A variety of soft
tissue stabilization techniques have been used to reduce
the instability of the ulnar stump.30 However, instability
is usually related to excessive resection of the ulnar
head. Postoperative ulnar translation of the carpus can be
a common complication in rheumatoid patients. This
problem appears to be more related to the natural history
of the rheumatoid arthritis process than to the procedure
itself, because postoperative ulnar translation is uncom-
mon in non-rheumatoid patients.22 Complications such as
FIGURE 13.16 Postoperative radiograph showing proper excision of
the ulnar head.
Surgical Procedures for the Distal Radius and Distal Radioulnar Joint
191
ulnar stump instability and weakness of grip strength may
frequently be encountered in younger and high-demand
patients.
CONCLUSION
The VLPS has been shown to be a reliable plating system
for the fi xation of distal radius fractures, and enables early
motion without compromising fracture reduction. Hand
surgeons who treat distal radius fractures should be familiar
with this technique. The Darrach procedure is still a valu-
able technique for treating DRUJ disorders, but should be
used selectively. An understanding of proper patient selec-
tion and the operative procedure provides satisfactory out-
comes in most patients.
REFERENCES
1. Chung KC, Spilson SV. The frequency and epidemiology of hand
and forearm fractures in the United States. J Hand Surg [Am]
2001; 26: 908–915.
2. Rosenthal AH, Chung KC. Intrafocal pinning of distal radius
fractures: a simplifi ed approach. Ann Plast Surg 2002; 48:
593–599.
3. Margaliot Z, Haase SC, Kotsis SV, et al. A meta-analysis of
outcomes of external fi xation versus plate osteosynthesis for
unstable distal radius fractures. J Hand Surg [Am] 2005; 30:
1185–1199.
4. Ring D, Jupiter JB, Brennwald J, et al. Prospective multicenter trial
of a plate for dorsal fi xation of distal radius fractures. J Hand Surg
[Am] 1997; 22: 777–784.
5. Orbay JL, Fernandez DL. Volar fi xation for dorsally displaced
fractures of the distal radius: a preliminary report. J Hand Surg
[Am] 2002; 27: 205–215.
6. Chung KC, Watt AJ, Kotsis SV, et al. Treatment of unstable distal
radial fractures with the volar locking plating system. J Bone Joint
Surg [Am] 2006; 88: 2687–2694.
7. Musgrave DS, Idler RS. Volar fi xation of dorsally displaced distal
radius fractures using the 2.4-mm locking compression plates. J
Hand Surg [Am] 2005; 30: 743–749.
8. Chung KC, Squitieri L, Kim HM. A comparative outcomes study
of using the volar locking plating system for distal radius fractures
in both young and elderly adults. J Hand Surg [Am] (in press).
9. Amadio PC, Botte MJ. Treatment of malunion of the distal radius.
Hand Clin 1987; 3: 541–561.
10. Sammer DM, Kawamura K, Chung KC. Outcomes using an
internal osteotomy and distraction device for corrective osteotomy
of distal radius malunions requiring correction in multiple planes.
J Hand Surg [Am] 2006; 31: 1567–1577.
11. Darrach W. Anterior dislocation of the ulna. Ann Surg 1912; 56:
802–803.
12. Sauvé L, Kapandji M. Nouvelle technique de traitement chirurgical
des luxations récidivantes isolées de l’extrémité inférieure du
cubitus. J Chir 1936; 47: 589–594.
13. Orbay JL, Touhami A. Current concepts in volar fi xed-angle
fi xation of unstable distal radius fractures. Clin Orthop Relat Res
2006; 445: 58–67.
14. Orbay J. Volar plate fi xation of distal radius fractures. Hand Clin
2005; 21: 347–354.
15. Graff S, Jupiter J. Fracture of the distal radius: classifi cation of
treatment and indications for external fi xation. Injury 1994; 25:
S-D14–25.
16. Chung KC, Kotsis SV, Kim HM. Predictors of functional outcomes
after surgical treatment of distal radius fractures. J Hand Surg
[Am] 2007; 32: 76–83.
17. Chung KC, Petruska E. Treatment of unstable distal radial
fractures with the volar locking plating system. Surgical technique.
J Bone Joint Surg [Am] 2007; 89: 256–266.
18. Kotsis SV, Lau FH, Chung KC. Responsiveness of the Michigan
Hand Outcomes Questionnaire and physical measurements in
outcome studies of distal radius fracture treatment. J Hand Surg
[Am] 2007; 32: 84–90.
19. Arora R, Lutz M, Hennerbichler A, et al. Complications following
internal fi xation of unstable distal radius fracture with a palmar
locking-plate. J Orthop Trauma 2007; 21: 316–322.
20. Klug RA, Press CM, Gonzalez MH. Rupture of the fl exor pollicis
longus tendon after volar fi xed-angle plating of a distal radius
fracture: a case report. J Hand Surg [Am] 2007; 32: 984–988.
21. DiBenedetto MR, Lubbers LM, Coleman CR. Long-term results of
the minimal resection Darrach procedure. J Hand Surg [Am] 1991;
16: 445–450.
22. Tulipan DJ, Eaton RG, Eberhart RE. The Darrach procedure
defended: technique redefi ned and long-term follow-up. J Hand
Surg [Am] 1991; 16: 438–444.
23. Posner MA, Ambrose L. Excision of the distal ulna in rheumatoid
arthritis. Hand Clin 1991; 7: 383–390.
24. Garcia-Elias M. Failed ulnar head resection: prevention and
treatment. J Hand Surg [Br] 2002; 27: 470–480.
25. Hagert CG. The distal radioulnar joint in relation to the whole
forearm. Clin Orthop Relat Res 1992; 275: 56–64.
26. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with
synovectomy of the extensor tendons and the wrist joint combined
with a Darrach procedure. J Hand Surg [Am] 1992; 17:
1109–1117.
27. Millroy P, Coleman S, Ivers R. The Sauvé–Kapandji operation.
Technique and results. J Hand Surg [Br] 1992; 17: 411–414.
28. Ishikawa H, Hanyu T, Saito H, Takahashi H. Limited arthrodesis
for the rheumatoid wrist. J Hand Surg [Am] 1992; 17: 1103–1109.
29. Field J, Majkowski RJ, Leslie IJ. Poor results of Darrach’s
procedure after wrist injuries. J Bone Joint Surg [Br] 1993; 75:
53–57.
30. Leslie BM, Carlson G, Ruby LK. Results of extensor carpi ulnaris
tenodesis in the rheumatoid wrist undergoing a distal ulnar
excision. J Hand Surg [Am] 1990; 15: 547–551.
31. McKee MD, Richards RR. Dynamic radio-ulnar convergence
after the Darrach procedure. J Bone Joint Surg [Br] 1996; 78:
413–418.
193
C H A P T E R
14
Tendon Transfers
Neal Chen, Chai Mudgal, Jesse B. Jupiter, and David Ring
INTRODUCTION
The development of tendon transfer procedures by surgeons
such as Mayer, Bunnell, and Jones contributed to the growth
of hand surgery as an independent discipline.1 Tendon
transfers can transform a deformed and dysfunctional limb
into a functional hand that contributes to basic functional
tasks. The effects of nerve injury, rheumatoid arthritis, and
traumatic or attritional tendon injury can in part be miti-
gated by appropriately selected tendon transfers. In the
current era of rapid technological innovation, the tech-
niques of tendon transfer remain useful with limited modi-
fi cation and are an essential tool in the hand surgeon’s
armamentarium.
INDICATIONS AND CONTRAINDICATIONS
Patients should satisfy all of the following criteria to be
considered for tendon transfer:
● Irrecoverable loss of muscle function owing to direct
injury, nerve injury, or central nervous system injury.
● Adequate joint mobility.
● Stable soft tissue envelope.
● No active infection.
● Adequate cognition and motor control.
● Adequate sensibility.
● Specifi c correctable functional defi cit.
● Available donor tendons.
Principles
Several principles guide decision making when considering
tendon transfer to improve hand function.
● Appropriateness of transfer Tendon transfer is only
appropriate when the function of an available donor
muscle is expendable and when the donor muscle will
work effectively in its new location and role. Alterna-
tives to tendon transfer include reconstruction of exist-
ing motor units with tendon grafts, neurorrhaphy,
neurotization, tenodesis, arthrodesis, or free muscle
transfer.
● Timing Patients should understand the risks and bene-
fi ts of tendon transfer and have realistic expectations.
Tendon transfer is considered when the skin cover is
stable and mobile, the tendons and joints have adequate
mobility, deformity is minimized, and potential donor
muscles have been adequately rehabilitated and strength-
ened. In some patients with substantial scarring, a tem-
porary silicone rod can be used to produce a smooth
gliding scar route along the expected course of the
transfer.4
Donor muscle characteristics
Availability
The donor muscle must be expendable. A general goal is to
retain one wrist fl exor (preferably the fl exor carpi ulnaris –
FCU), one wrist extensor (preferably the extensor carpi
radialis brevis – ECRB), and one extrinsic digital fl exor and
extensor to each fi nger.
Strength
As a rough approximation, strength is proportional to the
physiologic cross-sectional area of a muscle. A common
estimate of strength is 3.65 kg/cm2 multiplied by the cross-
sectional area in square centimeters.2,3 The strength of a
muscle to be transferred should be comparable to the
strength of that to be replaced.
Strength, however, is not equivalent to work capacity.
Work capacity is relative to the volume and hence the mass
of the muscle. The tension fraction – the relative tension
generated by a muscle relative to another – has been
described by a number of authors (Table 14.1).1 After trans-
fer, the donor muscle can be expected to lose one grade of
strength. Subsequent transfer of a muscle that has partially
recovered from paralysis or has weakness should generally
be avoided, if possible.
Hand and Upper Extremity Reconstruction
194
Amplitude
Muscles can contract or lengthen approximately 40% of
their resting length. Amplitude is the difference between
the minimum and maximum lengths of a muscle. Ampli-
tude is proportional to the muscle fi ber length and may be
approximated using the following general guidelines:4
Insertion
Amplitude
Distal to the wrist joint (fl exor carpi radiolis/ 3 cm
fl exor carpi ulnaris)
MP joint/distal thumb (extensor indicis
5 cm
proprius/extensor pollicis longus)
fl exor digitorum profundus/fl exor digitorum
7 cm
superfi cialis
The tenodesis that occurs with wrist motion can provide
an additional 2.5 cm of tendon excursion. When one drops
the wrist, the tenodesis effect extends the fi ngers. Patients
use the tenodesis effect to augment inadequate fi nger exten-
sion caused by insuffi cient amplitude of the tendon transfer
to the extensor mechanism.
Transfer characteristics
Direction
A straight line of pull is preferred during tendon transfers.
A pulley may be used to help reroute the vector of pull;
however, more than one pulley is not helpful and signifi -
cantly diminishes strength and excursion.
Single function/synergy
Each tendon transferred should be used to perform one
single task. In addition, a synergistic muscle – i.e. a muscle
that usually contracts simultaneously with the muscle
being reconstructed to achieve a desired function – is pre-
ferred as a donor. For example, wrist fl exion is synergistic
with fi nger extension. Therefore, transferring wrist fl exors
to fi nger extensors is synergistic, and learning to use the
transfer is quite straightforward.
PREOPERATIVE HISTORY AND CONSIDERATIONS
A systematic approach is used to plan tendon transfers.1
● First the musculotendinous units are cataloged as
follows:
●
What muscles work?
●
Which muscles are available/expendable?
●
What functions are needed?
● Next, an attempt is made to match available muscles
with functions.
● Alternative tendon transfers and other possibilities such
as tenodesis and arthrodesis are considered.
● Finally, when the optimal procedures have been selected,
staging of procedures is considered to optimize rehabili-
tation. This is especially the case in situations when the
functions needed exceed the number of donors available.
For example, if the wrist is fused it eliminates the need
for a donor to power the wrist, and attention may be
devoted to the digits.
OPERATIVE TECHNIQUES
The patient is supine with the arm supported on a hand
table. A tourniquet is used to limit bleeding and improve
visualization and safety. A sterile tourniquet may make it
easier to position and manipulate the arm.
Tendon harvest
The authors prefer to harvest donor tendons by identifying
the distal end of the tendon. An incision is made over the
distal end and a tendon hook is passed underneath the
tendon and tension applied. This should help identify
the distal function of the tendon as well as its course proxi-
mally. A proximal incision is made once the course of the
tendon is identifi ed. Tension is again applied using a tendon
hook, and the appropriate distal effect is sought to ensure
the proper tendon is being harvested. The distal end is then
released sharply with a no. 15 blade scalpel and the tendon
is extracted into the proximal wound (Fig. 14.1).
Tendon passage
Once a donor tendon and an attachment site have
been identifi ed and clearly dissected, a provisional traction
stitch is placed at the end of the tendon. A curved or
straight tendon passer is then passed subcutaneously from
the recipient site to the donor site. The traction stitch is
used to pass the end of the donor tendon through the tunnel
and into the distal wound, where the accepting tendon
lies.
Pulvertaft weave
A Pulvertaft weave is a method of joining tendons used
primarily for tendon mismatch.5 The larger tendon is cut
into a fi sh-mouth shape to accept the initial pass of the
smaller tendon. This is done to improve gliding character-
istics and to accommodate the size mismatch. Using a
tendon weaver, the surgeon passes the smaller tendon
through the larger tendon and sutures it provisionally with
a single stitch to set the proper tension. Once the tension
is set, the end of the smaller tendon is passed through the
larger tendon at a 90º angle from the previous pass, and a
second stitch is placed at the tendon junction. Four passes
in total are preferred. It is preferable if the tendon junction
TABLE 14.1 Potential force of various muscle transfers
Muscle
Potential force
Brachioradialis
2.0
FCU
2.0
Pronator teres
1.5
FCR, ECRL, ECRB, ECU
1.0
EDC, EIP, EDQ
0.5
EPB, PL
0.1
Tendon Transfers
195
is not in close proximity to the wound, although this is
often unavoidable (Fig. 14.2).
An alternative to an end-to-end weave is an end-to-side
weave. This is performed in a similar manner to the origi-
nal Pulvertaft weave, but no fi sh-mouth incision is made
in the larger tendon.
HIGH RADIAL NERVE PALSY
A patient with a high (or complete) radial nerve palsy is a
good candidate for tendon transfer. The sensory defi cit is
not in a functional area and the function to be restored
involves a relatively unsophisticated opening of the hand
and wrist. Tendon transfers for radial nerve palsy were
among the earliest transfers attempted and have been per-
formed since the early 1900s.6,7
In isolated high radial nerve palsy, all of the median and
ulnar innervated wrist and digital fl exors are available as
donors. Reconstruction of thumb, digit, and wrist extension
(hand opening) is made more feasible when all six index
through small digital extensors are consolidated into one
function and all three thumb motors are consolidated
(Table 14.2a). In this manner, one donor will provide wrist
extension, a second fi nger extension, and a third thumb
A
B
C
FIGURE 14.1 Tendon harvest. A The distal end of the tendon is identifi ed and its function is confi rmed. B Tension on the tendon helps to
identify its proximal course. The proximal part of the tendon is isolated in the proximal wound prior to release of the tendon distally. C After
distal tendon release, the tendon is brought into the proximal wound.
Hand and Upper Extremity Reconstruction
196
extension. Amplitude and strength are considered when
selecting donor muscles (Table 14.2b).
Among the two most popular transfers for digit exten-
sion (fl exor carpi ulnaris, FCU and fl exor carpi radialis,
FCR), the FCR transfer has been more popular recently
because preservation of the FCU enhances power grip,
which has better biomechanical advantage in ulnar devia-
tion, and better maintains wrist fl exion strength because
the FCU is twice as strong as the FCR.7 Transfer of the
fl exor digitorum superfi cialis of the ring fi nger has provided
satisfactory digital extension and can be considered as an
alternative in unusual circumstances.8 In the absence of a
palmaris longus (PL), the extensor pollicis longus (EPL) can
be either be included with the extensor digitorum commu-
nis (EDC) tendons (low-demand hand) or the fl exor digito-
A
B
C
D
FIGURE 14.2 Pulvertaft weave: end to end. A The larger tendon is
fi sh-mouthed to accept the smaller tendon. B The smaller tendon is
passed into the fi sh-mouth and through the side of the tendon.
A provisional stitch is placed to test the resting tension. C The smaller
tendon end is passed at a 90º angle to the larger tendon as well as
orthogonal to the previous pass. Further passes may be made into
the larger tendon, each at 90º to the previous pass. D The fi shmouth
is sutured closed over the tendon.
TABLE 14.2a Radial nerve palsy
Functional
groups to be
reconstructed
What
works
What is
available
What is
needed
Thumb
extensors/abductors
PL
PL
APL
EPB
EPL
Wrist extensors
PT
PT
ECRL
FPL
ECRB
ECU
Digit extensors
FDS (i, l, r, s)
FDS (m)
EIP
FCR
FDS (r)
EDC (I, l, r, s)
FCU
FCR
EDM
FCU
TABLE 14.2b Radial nerve palsy
3 cm amplitude
5 cm amplitude
7 cm amplitude
Available
Need
Available
Need
Available
Need
FCR
ECRL
PL
EPL
FDS (m)
FCU
ECRB
FCR + tenodesis
EIP
FDS (r)
PT
ECU
FCU + tenodesis
EDC
APL
PT + tenodesis
EDQ
EPB
rum superfi cialis (FDS) ring can be transferred to the
extensor pollicis longus (EPL). The donor tendons may
either be passed through the interosseous membrane or
routed around the radius.
Operative technique (modifi ed Starr transfer)
Some surgeons prefer to make three separate incisions: one
at the volar wrist to harvest the FCR and PL, one over the
middle third of the forearm for transfer of the pronator
teres, and one over the extensor surface of the wrist to tie
in the FCR and PT transfers (Fig. 14.3). As an alternative,
the procedure can be completed through a single slightly
dorsal radial incision that curves volarwards at the wrist.
Developing broad skin fl aps provides access to all structures
and leaves all sites of tendon insertion away from the
incisions.
The interval between the fl exor carpi radialis and the
brachioradialis is developed and the insertion of the prona-
tor teres onto the radial diaphysis is identifi ed by pronating
the forearm. The pronator teres is mobilized and its tendon
lengthened by elevating it along with a strip of periosteum
to increase its effective length available for tendon repair.
Tendon Transfers
197
Incision for pronator
teres harvest
Incision for FCR and
palmaris harvest
Incision for transfers
FIGURE 14.3 Incisions for Starr transfer. Distal–volar incision for FCR
and palmaris longus harvest, proximal–radial wound for pronator
teres harvest, and dorsal incision for transfers.
The FCR and the palmaris longus tendons are cut at the
level of the transverse wrist creases and brought proximally
into the forearm. The three donor tendons in the forearm
are then wrapped in moist gauze (Fig. 14.4).
The third dorsal compartment is opened and the EPL is
transposed dorsal to the retinaculum and radially, so that
it will function as both an extensor and an abductor of the
thumb. The extensor digitorum communis and the ECRB
are identifi ed and isolated in preparation for donor tendon
insertion.
The donor tendons are passed through subcutaneous
tunnels into the dorsal wound, or directly through the
wound when a single incision is used. The volar wound is
closed now when three separate incisions are used.
The wrist is placed in about 30–40º of extension. The
appropriate tension at which to suture the donors to the
tendons being reconstructed is a matter of debate, but we
prefer to use just submaximal tension for radial nerve
tendon transfers. In addition, some surgeons leave the origi-
nal musculotendinous units intact and suture the donor in
an end-to-side fashion (in case there is any chance of recov-
ery of the original tendons); others prefer to divide the
proximal recipient tendons and suture the donors in more
of an end-to-end fashion.
First, the pronator teres and its periosteal extension is
woven through the tendon of the ECRB using a Pulvertaft
weave. The wrist should rest in a position of about 20–30º
of extension after the sutures are placed.
Next, the EDC and the EIP are sewn together just proxi-
mal to the extensor retinaculum using 3/0 braided non-
absorbable suture to convert them into a single mass. The
extensor digiti quinti (EDQ) is not included to avoid any
excessive extension force on the small fi nger. The FCR is
passed through the EDC and the EIP using the Pulvertaft
weave. Appropriate tension is achieved when, with the
wrist fully extended, full composite digital fl exion is possi-
ble, and, with the wrist in neutral, the fi ngers will extend
via a tenodesis effect.
Finally, the palmaris longus is woven through the trans-
located EPL tendon. The target tension is such that with
the wrist in extension, it is possible to fl ex the thumb 10–
15º at each joint and with the wrist slightly fl exed, the
thumb will extend easily and open the fi rst web space.
The tourniquet is released, hemostasis achieved, and
the wounds are irrigated and closed. A padded dressing is
applied by incorporating a long-arm splint with the wrist
in about 30–40º of extension, the forearm in neutral or
slight pronation, the metacarpophalangeal and inter-
phalangeal joints straight, and the thumb abducted and
straight.
Optimizing outcomes
●
The tendon of the pronator teres is short and the ease and
strength of suturing are both enhanced by taking care to
make a long, reliable tail of periosteum from the radius.
●
The suture used to bind the common extensors and the
extensor indicis together as a unit should be placed away
from the Pulvertaft weave to maintain the mass eff ect and
ensure transfer eff ectiveness.
●
The tension of each transfer should be tested with a stay
stitch prior to proceeding with the Pulvertaft weave.
●
If necessary, forearm fascia can be harvested from the
extensor muscles to augment the tendon-to-tendon
junctions.
Complications
The most common complication of tendon transfers for high
radial nerve palsy is under- or overcorrection. Minor imper-
fections in tensioning are easily accommodated by wrist
positioning. In fact, even the best results of transfer rely to
some degree on the tenodesis effect. Problematic over- or
under-tensioning can be addressed using a second operation
to either lengthen or shorten the tendons in question.
Postoperative care
Sutures are removed at 2 weeks. Splinting is maintained
for 4–6 weeks, and then active range of motion and retrain-
ing are begun.
LOW RADIAL NERVE PALSY
Lower radial nerve palsies can present in two forms. In the
fi rst, the extensor carpi radialis longus (ECRL) is functional
because the injury is distal to the ECRL nerve branch,
which is given off proximal to the posterior interosseous
nerve; however, the ECRB, extensor carpi ulnaris (ECU),
Hand and Upper Extremity Reconstruction
198
A
B
C
D
FIGURE 14.4 Tendon transfers to reconstruct radial nerve dysfunction. A From left to right the pronator teres with periosteal extension, fl exor
carpi radialis, and palmaris longus have been released and brought into the proximal forearm wound. B The recipient tendons are isolated in a
dorsal wound. The extensor digitorum communis is in the Allis clamp, the rerouted extensor pollicis longus is in the tendon hook, and the
extensor carpi radialis brevis is in the inferior portion of the wound. C The rerouted pronator teres is sutured to the extensor carpi radialis brevis
using a Pulvertaft weave. D The rerouted fl exor carpi radialis is sutured to the extensor digitorum communis using a Pulvertaft weave.
and the distal extensors are paralyzed because of nerve
injury distal to the ECRL nerve branch. In this case, the
FCR is transferred to the EDC and the palmaris longus is
attached to the EPL, but because the ECRL is functioning
it is sutured to the ECRB, rather than sacrifi cing the prona-
tor quadratus. In the second form, the muscles proximal to
the EIP and EDQ function, but the EDC, EPL, EPB, and
APL are paralyzed. The EDC of the middle fi nger is sutured
side-to-side to the EIP, and the EDC of the ring fi nger is
sutured side-to-side to the EDQ. The palmaris longus is
transferred to the EPL.
LOW MEDIAN NERVE PALSY
(OPPOSITION TRANSFER)
Thumb opposition is defi ned as ‘when the thumb pad is
diametrically opposed to the distal pad of the middle fi nger.’1
Thumb opposition involves motions of palmar abduction,
fl exion, and thumb pronation. Opposition is accomplished
by the intrinsic muscles of the thumb, which place the
thumb in a position to allow grasp, in concert with the
fl exor pollicis longus. Bunnell9 emphasized the restoration
of two functions when performing a tendon transfer for
thumb opposition: the thumb should be pulled in an appro-
priate direction of palmar abduction and fl exion; and prona-
tion of the thumb.
A number of tendons have been used for opposition
transfer (Table 14.3), but four are in common use: the
fl exor digitorum superfi cialis of the ring fi nger, the palmaris
longus with a strip of palmar fascia (Camitz), abductor
digiti quinti, and extensor indicis proprius. Each transfer
has advantages and disadvantages.
Transfer of the FDS to the ring fi nger provides a strong
muscle with great excursion, but requires the construction
Tendon Transfers
199
E
F
G
FIGURE 14.4, cont’d E The palmaris longus is sutured to the
transposed extensor pollicis longus using a Pulvertaft weave. F The
intraoperative resting tension with slight wrist extension. G The
metacarpophalangeal joints are able to fl ex with greater wrist
extension.
extension after transfer.13 To avoid extensor lag after EIP
transfer, a number of authors have emphasized the impor-
tance of preserving the dorsal hood during harvest.14,15 This
tendon is best harvested proximal to the hood.
To improve thumb pronation, some surgeons recom-
mend splitting the tendon attachments or looping the distal
tendon through the dorsal extensor hood of the thumb
metacarpophalangeal joint.9,16 Others use biomechanical
data to support the use of a single attachment to the APB,
except in the setting of combined nerve palsies.17
Operative technique: FDS ring or Bunnell
opposition transfer
For the FDS ring (Bunnell) transfer, the tendon is detached
through a skin incision over the metacarpal head by releas-
ing the A1 pulley and retrieving the tendon using a 2 cm
incision over the volar forearm just ulnar to the palmaris
longus tendon. A third 2 cm incision is made along the
ulnar border of the wrist at the junction of the glabrous
and non-glabrous skin. The tendon is then passed around
of a pulley to obtain an appropriate vector force. It is most
commonly used for patients with low median nerve palsy
without scarring at the wrist that will impede tendon excur-
sion or loss of extrinsic fi nger fl exors.
Use of the palmaris longus (Camitz transfer) does not
create additional functional loss, but the palmaris longus is
not a constant anatomic structure and its transferred func-
tion relies heavily on the tenodesis effect. The prevalence
of palmaris longus absence ranges from 3% to 24%.10,11 It
is used primarily for the reconstruction of thumb opposi-
tion in the setting of advanced carpal tunnel syndrome with
severe thenar wasting. The Camitz transfer serves more in
the capacity of an abductorplasty.
The ADQ transfer can have a nice aesthetic appearance
in its recreation of a thenar eminence, but it has a short
excursion and this muscle transfer may have the attendant
risks of denervation and ischemic necrosis. It is most com-
monly used in the pediatric setting for hypoplastic thumb
reconstruction.12
The EIP is most useful in combined median and ulnar
nerve palsies, but carries the risk of incomplete index fi nger
Hand and Upper Extremity Reconstruction
200
the fl exor carpi ulnaris, using the pisiform as a pulley. An
alternative is to loop a slip of the FCU tendon for use as a
pulley. Finally, a 3 cm incision is made along the radial
border of the thumb and the abductor pollicis brevis tendon
is identifi ed. A snap is used to make a subcutaneous tunnel
connecting this incision to the previous incision, and the
tendon is withdrawn and sutured to the abductor pollicis
brevis tendon. With appropriate resting tension, the thumb
should be in full opposition when the wrist is fully extended
and wrist extension should not be limited. After wound
closure, a splint is applied that immobilizes the wrist in 30º
of extension with the thumb in full opposition. The splint
is removed after 4 weeks and active motion is initiated
while using a protective long opponens splint for another 4
weeks (Fig. 14.5).
Operative technique: pamaris longus or Camitz
opposition transfer
A palmaris longus opposition (Camitz) transfer is performed
through an extended carpal tunnel release incision that
crosses the transverse wrist creases obliquely and extends
to the distal palmar crease. The palmaris longus is identi-
fi ed in the proximal part of the incision and a strip of
palmar fascia is raised to extend the working length of the
tendon. The palmaris longus is carefully dissected with an
extension of the palmar fascia. The fascia is raised as a strip
about 4–5 cm wide. Because the palmar fascia is thin, it
can be folded on itself to give it substance for later repair.
However, undermining of the skin should be kept to a
minimum to avoid a postoperative hematoma and superfi -
cial skin necrosis. Release of the transverse carpal ligament
is often performed because this procedure is indicated for
long-standing carpal tunnel syndrome with concomitant
thenar atrophy. The palmaris longus tendon is then passed
through a subcutaneous tunnel to an incision at the thumb
metacarpophalangeal (MP) fl exion crease and sutured to the
tendon of the abductor pollicis brevis. Tensioning and post-
operative management are similar to those described for the
Bunnell FDS transfer (Fig. 14.6).
Operative technique: EIP opposition transfer
A longitudinal incision is made over the dorsum of the index
MP joint. The ulnar tendon is the extensor indicis proprius.
Tension is placed on the EIP and the proximal end of the
tendon is identifi ed in a separate incision at the level of
the wrist. The EIP is released proximal to the dorsal hood of
the index fi nger and drawn into the proximal wound. The
EIP tendon is then passed subcutaneously under a 2 cm
incision at the ulnar border of the palm in the junction of
the glabrous and non-glabrous skin. From here it is passed
subcutaneously through the palm into a small incision at
the MP fl exion crease and sutured to the abductor pollicis
brevis (APB) insertion. Tensioning and postoperative man-
agement are as described for the other transfers.
Operative technique: abductor digiti quinti or
Huber transfer
A longitudinal incision along the junction of the glabrous
and non-glabrous skin is made extending from the pisiform
to the PIP joint of the small fi nger. The tendon of abductor
digiti quinti is identifi ed and released and the remainder of
the muscle is freed from distal to proximal. A second inci-
sion is made along the MP fl exion crease of the thumb and
the APB is identifi ed. A curved hemostat is tunneled sub-
cutaneously from the radial wound into the ulnar wound
and the ADQ is passed to the thumb wound. The donor
tendon is stitched to its recipient site. A number of modi-
fi cations of the Huber transfer have been proposed, includ-
ing a neurovascular island pedicle or fractionated lengthening
in order to avoid ulnar nerve compression at Guyon’s
canal18 (Fig. 14.7).
TABLE 14.3 Low median nerve palsy
What works
What is available
What is needed
PT
PT
APB
FCR
FCR
OP
PL
PL
FPL
FPL
FDS (I)
FDS (I)
FDS (m)
FDS (m)
FDS (r)
FDS (r)
FDS (s)
FDS (s)
FCU
FCU
APL
EPB
EPB
ECRL
ECRL
ECRB
ECRB
EPL
EPL
EIP
EIP
EDC
EDC
EDM
EDM
ECU
ECU
ADQ
ADQ
FDQ
ODQ
Interossei
FPB
AddP
Tendon Transfers
201
A
B
C
D
FIGURE 14.5 Transfer of the fl exor digitorum superfi cialis to the ring fi nger (FDS ring) to restore opposition. A The FDS ring has been detached
distally near the A1 pulley and retracted into a volar forearm wound. B The FDS ring is passed around the fl exor carpi ulnaris insertion into the
pisiform. A subcutaneous tunnel has been created. C After passage of the FDS ring tendon through the subcutaneous tunnel, it is woven
through the abductor pollicis brevis tendon. D The transfer achieves a resting position with some palmar abduction.
Optimizing outcomes
●
Before performing an opponensplasty, it is critical to obtain
a radiograph of the thumb to confi rm the absence of
advanced degenerative disease of the carpometacarpal
(CMC) joint, which, if present and if associated with
signifi cant stiff ness of the CMC, can undermine the success
of any opponensplasty.
●
Problems with rotation of the distal FCU pulley can be
avoided by fashioning a pulley using a slip of FCU rather
than the entire tendon.
●
In more complex cases, such as combined nerve palsies or
brachial plexus injury, the distal end of the tendon may need
to be sutured to the dorsal hood to provide more opposition.
●
During tension trials, if the MP joint fl exes with the wrist
extended, the insertion site should be moved dorsally to add
more extension force to the MP joint; if the MP joint
hyperextends, the insertion should be moved volarly.
Complications
Preoperative adduction contracture can limit the effective-
ness of an opposition transfer and should be treated before-
hand. The use of an FCU pulley may lead to scar formation
and adhesions, and if this occurs, rerouting around the
FCU is recommended. Problems with the donor fi nger may
also be encountered, in that a proximal interphalangeal
(PIP) joint fl exion contracture or a swan-neck deformity
may arise because the FDS is detached.
HIGH MEDIAN NERVE PALSY
In high median nerve palsy the FDP to the index, and
perhaps to the long, fi nger is paralyzed. The paralyzed
muscles are sutured side-to-side with an adjacent function-
ing profundus tendon. The brachioradialis is transferred to
Hand and Upper Extremity Reconstruction
202
A
B
C
D
E
F
FIGURE 14.6 Transfer of the palmaris longus to restore opposition in a patient with advanced carpal tunnel syndrome (Camitz transfer). A The
hand is positioned using a lead hand and the incisions are planned. B The palmaris longus tendon is identifi ed and lengthened with a strip of
palmar fascia. C A subcutaneous tunnel is created to the level of the thumb metacarpophalangeal joint. D The palmaris longus is brought
through the tunnel using a curved hemostat. E The tendon is then woven and sutured to the abductor pollicis brevis tendon. F The tension
creates a resting position in palmar abduction.