PREOPERATIVE DIAGNOSIS: Right thumb basal joint arthritis with right carpal tunnel syndrome and right trigger thumb.
POSTOPERATIVE DIAGNOSIS: Right thumb basal joint arthritis with right carpal tunnel syndrome and right trigger thumb.
PROCEDURE PERFORMED: Right thumb basal joint arthroplasty using ligament reconstruction, tendon interposition technique with right carpal tunnel release and right trigger thumb release.
BRIEF HISTORY: This is a 67-year-old woman who has had progressive problems with pain at the base of the right thumb. Evaluation has shown this is due to rather severe osteoarthritis at the right thumb basal joint. In addition, she has numbness and tingling in the right hand and nerve conduction study has demonstrated carpal tunnel syndrome. Finally, she has triggering of the right thumb. A PARQ conference was held for all of this and she wished to proceed with the basal joint arthroplasty, the right carpal tunnel release, and the right trigger thumb release.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room and placed in supine position and general anesthesia was obtained without complication. We then prepped and draped the right arm with Techni-Care in the usual sterile fashion. I then exsanguinated the arm and inflated a tourniquet on the upper arm to 250 mmHg.
A somewhat curvilinear incision was made over the right thumb basal joint with the proximal extent of this coming down parallel to the radial side of the flexor carpi radialis tendon. The incision was carefully carried down through the skin and subcutaneous tissue to avoid injury to the radial nerve branches. I then retracted the radial artery dorsally. I then incised the basal joint capsule longitudinally. Capsular flaps were retracted volarly and dorsally. I then removed the entire trapezium in a piecemeal fashion using first a saw to crosscut the bone and fracture it, and then the rongeur was used to remove the bone. All this was done very carefully to avoid injury to the flexor carpi radialis tendon at the base of the trapezium. I then sawed off the base of the thumb metacarpal perpendicular to its long axis. I also sawed off the volar beak of the thumb metacarpal. All of this wound was then irrigated out with saline. At this point I also drilled about a 4 mm drill hole through the base of the thumb metacarpal diametrically opposed to the insertion point of that flexor carpi radialis tendon. Again, the wound was irrigated out with saline and a moist dressing was placed on that wound. Then, I made several stair-step incisions on the volar forearm and harvested the radial half of the flexor carpi radialis tendon. That was passed into the trapezium fossa and then split all the way up to its insertion at the index metacarpal. Half the tendon was then passed through this drill hole in the thumb metacarpal, brought back, and sewn to itself with a 4-0 nylon suture thereby creating a sling to support the base of the thumb metacarpal. Two 4-0 nylon stitches were placed deep in the trapezium fossa and left long. A moist dressing was placed on that wound.
We performed the carpal tunnel release by making a 2 cm incision that began just distal to the wrist flexion crease and just ulnar to the thenar crease. The incision was carried down through the skin and subcutaneous tissue in a radial direction down to the transverse carpal ligament. I then divided that structure completely. I made sure the ligament was completely divided such that an instrument could be put on the median nerve and advanced proximally up into the wrist and distally out into the palm without any further evidence of entrapment of the nerve. That wound was irrigated out with saline.
I then performed the right thumb trigger finger release by making a 1 cm incision in the MP flexion crease and carefully dissecting down through the subcutaneous tissue to avoid injury to the neurovascular bundles. The A1 pulley was found to be quite thickened and I divided that completely. Passive motion of the thumb allowed free tendon motion. That wound was also irrigated out with saline.
We then deflated the tourniquet. I closed the forearm wounds with interrupted 5-0 nylon stitches. Accurate hemostasis was obtained in all the wounds. I then used 4-0 nylon stitches in the trapezium fossa to anchovy the flexor carpi radialis tendon and bring it down into the trapezium fossa. The other 4-0 nylon stitch was used to close the trapezium joint capsule in a purse string fashion. The wound was irrigated out with saline. Then 4-0 Monocryl was used to close the dermis and the skin was closed with 5-0 nylon stitches. The carpal tunnel wound was closed with 5-0 nylon stitches after irrigating it out. The same was done with the trigger thumb wound.
I injected the median and radial nerves using 0.25% Marcaine. A bulky dressing was then applied with a splint to keep the thumb in the anatomic position. There was normal return of color and capillary refill at the digits. The patient was then aroused from anesthesia and taken to the recovery room in satisfactory condition.