Arthroplasty, interposition, intercarpal or carpometacarpal joints
PREOPERATIVE DIAGNOSIS: Right basal joint arthritis and left basal joint arthritis.
POSTOPERATIVE DIAGNOSIS: Right basal joint arthritis and left basal joint arthritis.
OPERATIVE PROCEDURE: Right thumb basal joint arthroplasty using a ligament reconstruction tendon interposition technique and then left thumb basal joint steroid injection.
ANESTHESIA: General endotracheal.
BRIEF HISTORY: This is a 61-year-old woman who has developed rather severe pain in both thumb basal joint areas. This especially comes on with pinching activities. We have x-rays show severe arthritis on the right side and slightly lesser severity of arthritis on the left side.
PAR-Q conference was held for this and she wishes to proceed with right thumb basal joint arthroplasty and at the same time have the left thumb basal joint steroid injection performed.
PROCEDURE IN DETAIL: The patient was taken to the operating room, placed in the supine position, and general anesthesia obtained without complication. We then prepped and draped the right arm with Techni-Care in the usual sterile fashion.
I then exsanguinated the right arm and then inflated a tourniquet on the upper arm to 250 mmHg.
I then made a curvilinear incision on the right thumb base, extending proximally along the radial border of the flexor carpi radialis tendon. The incision was made down through the skin and subcutaneous tissue, very carefully to avoid injury to the radial nerve.
I then retracted the radial artery dorsally. The joint capsule was opened longitudinally over the carpal metacarpal joint. I then removed the trapezium in it's entirety in a piecemeal fashion. This was done first by making cruciate saw cuts through the bone and then a rongeur was used to remove the bone. All of this was done very carefully to avoid injury to the underlying flexor carpi radialis tendon.
The base of the thumb metacarpal was then sawed off perpendicular to it's long axis. I then also drilled a 5 mm drill hole through the base of the thumb metacarpal diametrically apposed to the location of the insertion of the flexor carpi radialis tendon. That wound was irrigated out with saline. Then I placed a moist dressing in that wound.
Then we went to the volar forearm where the longitudinal half of the flexor carpi radialis tendon was harvested, being left attached distally. This was done through several stair-step incisions. That tendon was delivered back into the trapezium fossa and separated all the way to the point where it inserted on the index metacarpal. I then passed that tendon slit through the drill hole in the thumb metacarpal and brought it back and sewed to itself, thereby creating a sling which supports the base of the thumb metacarpal.
Two 4-0 nylon stitches are placed deep in the trapezium fossa and the tourniquet is deflated at that point. There was normal return of color and capillary refill to the digits. I then closed the skin wounds using interrupted 5-0 nylon stitches. That was done on the forearm wounds. On the thumb wound, we first obtained accurate hemostasis and then I used one of those 4-0 nylon sutures to antrovy the rest of the flexor carpi radialis tendon down into the trapezium fossa. Then, the other 4-0 nylon stitch was used to close the trapezium joint capsule in a purse-string fashion. That seemed to perform quite securely.
At the end of this, the thumb had normal passive range of motion and seemed quite stable there without any crepitus at all.
I then performed 0.25% Marcaine nerve blocks of the medial and radial nerves and then injected around the skin incisions with some of that solution also.
The wound was then closed with interrupted 4-0 Monocryl in the dermis and interrupted 5-0 nylon in the skin. A bulky dressing was applied with a thumb spica splint.
I then went over to the left thumb where after an alcohol prep, I was able to perform a 10 mg Kenalog steroid injection into the left thumb basal joint without complication.
She was then aroused from anesthesia and taken to the recovery room in satisfactory condition. We will plan to keep her in the hospital here tonight.