PREOPERATIVE DIAGNOSIS: Severe left thumb basal joint arthritis.
POSTOPERATIVE DIAGNOSIS: Severe left thumb basal joint arthritis.
PROCEDURE PERFORMED: Left thumb basal joint replacement using ligament reconstruction, **__________** turned-under position technique.
ANESTHESIA: General endotracheal
BRIEF HISTORY: This is a 62-year-old woman who has developed severe arthritis of her left thumb basal joint. We have tried treating this conservatively with splints, anti-inflammatory medicines, and steroid injection without adequate relief of the problem. She wishes to proceed to the operating room for basal joint replacement.
PROCEDURE: The patient was taken to the operating room, placed in supine position, and general anesthesia obtained without complication. We then prepped and draped the left arm with Techni-Care in the usual sterile fashion. I then exsanguinated the left arm and inflated a tourniquet on the upper arm to 250 mmHg. A somewhat sickle-shaped incision was then made on the left thumb basal joint extending proximally along the radial border of the flexor carpi radialis. Skin flaps were elevated, being careful to avoid injury to radial nerve branches. The radial artery was retracted dorsally. I then opened the trapezius-metacarpal joint capsule longitudinally. Joint capsule flaps were elevated to allow exposure to the trapezium. I then used a sagittal saw to perform a cruciate splitting of the trapezium. I then used an osteotome to split that apart and then used a rongeur to remove the entire trapezium in a piece-meal fashion. I made sure that the trapezium was completely removed. All this was done very carefully to avoid injury to the underlying flexor carpi radialis tendon. I then sawed off the base of the thumb metacarpal in a perpendicular fashion, that is perpendicular to the long axis of the metacarpal. About a 4 mm drill hole was then placed through the thumb metacarpal diametrically opposed to the insertion of the flexor carpi radialis. All that wound is irrigated out with saline and is packed with a moist gauze.
Several stair-step incisions were then made on the volar forearm to harvest the radial half of the flexor carpi radialis tendon. That was then delivered into the trapezium fossa and then split all the way up to its insertion into the index metacarpal. Half of the tendon was then passed into the drill hole in the thumb metacarpal and brought back and sutured to itself with 4-0 nylon stitches. This created a sling to split the base of the thumb metacarpal.
At that point we deflated the tourniquet. I closed the forearm wounds at that point. Accurate hemostasis was obtained with the electrocautery in all the wounds. I then again irrigated out the trapezium fossa wound and then placed two 4-0 nylon stitches deep into the trapezium fossa. One of those was used to anchovy the remaining portion of the flexor carpi radialis tendon, and the other was used to perform a pursestring closure of the joint capsule over the anchovy tendon. This seemed to create a very secure repair of the trapezium fossa with good stability and motion of the thumb metacarpal.
Again, the wound is irrigated out with saline and I closed the wound with interrupted 4-0 Monocryl sutures. Even prior to starting the anesthetic, I did perform a 1% lidocaine and 0.5% Marcaine median and radial nerve block, but at the end of the procedure I again infiltrated the wound with that same solution.
At the end of the procedure, the digits had normal color and capillary refill. A bulky dressing was applied with a thumb spica splint. She was then taken to the recovery room in satisfactory condition after being aroused from anesthesia.