Fusion of the thumb metacarpophalangeal jointto treat posttraumatic arthritis

Thumb metacarpophalangeal (MCP) fusion to treat posttraumatic arthritis is retrospectivelyreviewed in 18 patients, 16 of whom were examined and functionally tested, with an averagefollow-up of 18 months. All patients were satisfied. There was 100% fusion In an average of59.9 days, Preoperative disabling MCP pain was present in all patients, and mild postoperativepain and difficulty in picking up small objects were present in 78%. Results did not depend onposition of fusion or preoperative arc of MCP motion. Key pinch strength was significantlyincreased by fusion. Complications included four pin tract infections without sequelae and threecases of prominent tension band hardware, which were removed in two. (J HAND SURG

1988jI3A:750-3.)

Hugh J. Hagan, MD, and Hill Hastings II, MD, Indianapolis. Ind.

Fusion of the metacarpophalangeal(MCP) joint of the thumb is commonly done to treat avariety of arthritic and paralytic conditions. A numberof reports have discussed the specifics of MCP fusionof the thumb.!" especially as it relates to particularfixation techniques. This procedure is believed to leadto few deficits in hand function. In a search of theEnglish-language literature, no study was found to ad­dress the performance of the thumb with a MCP fusionin patients with posttraumatic arthritis but an otherwisenormal hand.

This article retrospectively reviews a group of pa­tients in whom MCP arthrodesis of the thumb was doneto treat posttraumatic arthritis. The following two ques­tions are addressed: (1) Does MCP fusion of the thumbin an otherwise normal hand lead to any SUbjective orobjective functional deficits? (2) What problems orcomplications arise that should be avoided?

From the Indiana Center for Surgery and Rehabilitation of the Handand Upper Extremity. Indianapolis, Ind.

Presented at the Residents and Fellows Conference Forty-second An­nual Meeting, American Society for Surgery of the Hand,San Antonio, Texas, September 9, 1987.

Received for publication Dec. 8, 1987; accepted in revised form Feb.I, 1988.

No benefits in any form have been received or will be received froma commercial party related directly or indirectly to the subject ofthis article.

Reprint requests: Hugh J. Hagan, MD, Roanoke Orthopaedic Center,4064 Postal Dr., Roanoke, VA 24018.

750 TIlE JOURNAL OF HAND SURGERY

Materials and methods

The records of all patients with the diagnosis of post­traumatic MCP arthritis of the thumb treated at theIndiana Center for Surgery and Rehabilitation of theHand over the last 15 years were reviewed. Patientswere selected on the basis of the presence of injuryisolated to the Mep joint of the thumb. Patients withrheumatoid arthritis or non traumatic osteoarthritis wereexcluded.

Twenty-five patients were selected for review. Eigh­teen patients completed a standard questionnaire re­garding the mechanism of injury, preoperative and post­operative symptoms, and postoperative difficult activ­ities. Sixteen of these 18 patients were personallyexamined by one investigator and completed a seriesof functional tests, including the Jebsen hand functiontest? and the Minnesota rate of manipulation test" underthe supervision of a trained hand therapist. Radiographsof the involved thumb were taken and the position offusion was determined on anteroposterior and lateralviews. Seven patients were lost to follow-up.

Thus 18 patients were available for inclusion in thestudy. Diagnoses included 10 patients with chronic ul­nar collateral ligament instability and arthritis; one ofwhom had had an attempted acute ligament repair. Sixpatients had chronic radial collateral ligament instabilityand arthritis; one of whom had had an attempted acuterepair. Two patients had generalized arthritis secondaryto old malunited intra-articular fractures. Mechanismsof injury included a fall in five, blunt injury by fallingmachinery in three, repetitive stress secondary to use

Vol. 13A. No.5September 1988

of hand tools in two, a motorcycle accident in two,door slamming on the thumb in one, blunt injury whilesplitting wood in one, an intra-articular dog bite in one,and four patients had sports-related injuries, one eachin skiing, football, basketball, and softball.

All patients were right handed; 10 right thumbs andeight left thumbs were involved. Age at operationranged from I7 to 64 years, with an average age of 42years. Age at follow-up ranged from 21 to 69 years,with an average of 47.9 years. Follow-up time fromoperation to final evaluation ranged from 13 to 104months, average, 38 months.

Methods of internal fixation included percutaneousKirschner wires in 14 patients and tension band wires,as described by Segmuller," in four. No supplementalbone grafts were used.

Results

In answering the standard questionnaire, all patientsstated that they were satisfied with the results of theiroperation and all believed that their hands were morefunctional than before surgery.

The incidence of fusion was 100%. Time to fusionwas based on pin removal in those patients treated withpercutaneous Kirschner wires and removal of splintingin those treated with tension band wires and rangedfrom 35 to 85 days, average 59 .9 days.

The position of fusion was determined by x-ray filmsthat were obtained at final evaluation and ranged from5 degrees ofextension to 25 degrees of flexion, average,10 degrees of flexion; and 5 degrees ulnar to 10 degreesradial deviation, average, I degree radial deviation. Inthis group of patients, the number of fusions done wasnot adequate to determine a correlation betweenstrength and function of the involved thumb and theposition of MCP fusion.

Before operation all patients had disabling thumbMCP pain, and one patient had mild trapezio­metacarpal pain. After operation 14 out of 18 patients(78%) still had mild occasional thumb pain , usuallyrelated to heavy activity or change in the weather. Inaddition, three of these patients had trapezio -metacarpalpain and two had mild interphalangeal joint pain.

In answering the standard questionnaire, II of 18patients noted difficulty picking up small objects orperforming fine activities with their involved hand. Fivepatients noted no difficult activities , and one patient haslearned to play the piano since her MCP fusion.

The Jebsen hand function test, a functional evaluationrequiring a patient to perform a variety of simple timedactivities, demonstrated 11 (69%) of 16 patients tested

Thumb stc» fusion 751

performing poorly picking up small objects. The Min­nesota rate of manipulation test, an objective measureof manual dexterity requiring the patient to perform arepetitive timed procedure, demonstrated 12 (75%) of16 patients tested performing at or below average onthe involved side.

Measurements were made of the arc of MCP motionof the opposite uninvolved thumb at final evaluation.With the use of this measurement as an estimate ofpreinjury motion on the affected side, an average 50degree arc of motion was recorded, ranging from aslittle as 30 degrees to as much as 100 degrees. Weexpected that patients used to small degrees of motionwould have a higher acceptance of fusion than patientsaccustomed to larger arcs of motion . However, patientsatisfaction with MCP fusion was equally high regard­less of the estimated preinjury range of MCP motion.

We were also interested in the potential harmful ef­fect of MCP fusion on interphalangeal motion . No pa­tient complained of loss of interphalangeal joint flexion,and only one patient complained of loss of interpha­langeal joint extension at final evaluation . To objec­tively determine loss of interphalangeal motion, weused two methods of comparison. The final interpha­langeal motion was compared with preoperative inter­phalangeal motion as recorded in the patient's records,noting an average loss 'of 18.3 degrees . The final in­terphalangeal motion was also compared with inter­phalangeal motion in the opposite thumb at final eval­uation, with an average loss of only 4.1 degrees. Thediscrep ancy in these figures may have arisen from dif­ferences in the technique of measurement used by theinitial evaluator and the final evaluator. Because all finalmeasurements were made by one investigator, the lowervalue would probably represent a more accurate mea­surement of motion lost at the interphalangeal joint.

Of the six patients with recorded preoperative keypinch strength measurements, all were found to bestronger at final follow-up, with a statistically signifi­cant (p < 0.02 paired comparison r-test) average im­provement of 10 pounds. All 16 patients had pinchstrengths comparable to the opposite thumb and aver­aged 0.7 pounds stronger than on the uninjured side(not stati stically significant, paired comparison I test).

Fourteen of 16 patients were employed at the timeof initial injury, and an equal number were employedat final evaluation. One patient required a job changesecondary to trapezio-metacarpal discomfort associatedwith heavy activity and subsequently had ligamentousstabilization of the trapezio-metacarpal joint.

Of the eight patients covered under workmen's com-

752 Hagan and Hastings

pensation, the average time for return to unrestricteduse of the hand was 96 days, range from 42 to 154days.

Seven of 18 patients experienced complications.There were four pin tract infections that were success­fully treated by pin removal and oral antibiotics. Threeof the four patients treated with tension band wiringcomplained of prominent hardware. In two the hard­ware was subsequently removed. One patient hada reconstruction of symptomatic trapczio-rnctacarpaljoint instability, which mayor may not have been re­lated to the MCP fusion. One patient had a carpal tunnelrelease.

Discussion

Position and function of the thumb depend on a com­plex interplay of skeletal anatomy and muscle balance.Normal motion in the MCr joint of the thumb includesa ~ide arc of flexion and extension ," from 30 to 100degrees in this group of patients, as well as significantradial and ulnar deviation and rotation around a lon­gitudinal axis.

According to Kapandgi" and Aubriot;" the MCrjoint is responsible for "locking the grip" in pinch andlarge cylinder grasp. Flexion, radial deviation, andslight pronation through the MCP joint provide thetightest possible grip. It is thus recognized that MCPjoint function must play a significant role in overallhand function.

1. Does MCP fusion in an otherwise normal handlead to significant subjective or objective functionaldeficits? Our series demonstrated that all patients weresatisfied with the results of their MCP fusion. AlI pa­tients believed they had significant improvement com­pared with their preoperative state. It is of note that 14of 18 patients still had some intermittent pain in thethumb, but in all cases patients did not believe this tobe a major problem.

Trapezio-metacarpal and interphalangeal joint dys­function in the thumb after MCP fusion were not majorproblems in these patients. The onset of postoperativetrapczio-mctacarpal or interphalangeal joint pain mayor may not have been related to the MCP fusion. Elevenof 18 patients noted difficulty with actions involvingfine pinch, and these subjective findings were supportedby the results of the Jebsen hand function test.

The results of pinch strength measurements dem­onstrate no functional deficit, with many patientsstronger in the fused thumb as compared both withpreoperative measurements and to the opposite hand atfinal evaluation. Ourpatients did not demonstrate sta­tistically significant correlation between position of fu-

The Journal ofHAND SURGERY

sion and subjective complaints, performance on func­tional testing, or pinch strength; nor was there a cor­relation between estimated preinjury arc of MCP motionand the performance of the thumb after MCP fusion.

The optimal position for MCP fusion of the thumbhas not been determined. Carroll and IIHF recom­mended 20 degrees of flexion. Ferlic, Turner, andClayton? reported a series of patients in which fusionranged from 0 to 40 degrees of flexion. Lister"recommends 20 degrees of flexion . The work ofKapandgi" would suggest some flexion, radial devia­tion, and slight pronation to yield the best result.

2. What problems or complications arise thatshould be avoided? The high incidence of union andfew complications demonstrate the safety and predict­ability of thumb MCP fusion.

In our series, pin tract infections were treated ef­fectively with removal of the pin and oral anti­staphylococcal antibiotics. There were no long-term se­quelae to pin tract infections.

The problem of prominent buried pins and wires mustbe kept in mind when using the tension band fusiontechnique. Special care must be taken to position thebent ends of the Kirschner wires and the twisted endsof the tension band wires deep about the 'neck of themetacarpal or proximal phalanx in such a fashion thatthey will not become prominent and produce laterproblems.

Though not an apparent functional problem, the de­crease in the arc of interphalangeal joint motion inthumbs with fused MCr joints should caution the sur­geon to use special care in handling the dorsal extensormechanism.

REFERENCESI. Hogh J, Jenson PO. Compression-arthrodesis of finger

joints using Kirschner wires and cerclage. Hand 1982;14:149-52.

2. Beckcnbaugh RD. Arthrodesis of the metacarpophalan­geal joint of the thumb . Orthop Transactions 1980;4(3) :291.

3. Fcrlic DC, Turner BC, Clayton ML. Compression ar­throdesis of the thumb. J HAt'O SURG 1983;8:207-10.

4 . Harrison S, Smith P, Maxwell D. Stabilization of thefirst metacarpophalangeal and terminal joints of thethumb . Hand 1977;9:242-9.

5. Allende BT, Engelem JC. Tension -band arthrodesis inthe finger joints. J HAt'D SURG 1980;5:269-71.

6 . Lister G. Interosseous wiring of the dig ital skeleton.J HAND SURG 1978;3:427-35. .

7. Carroll RE, Hill NA. Small joint arthrodesis inhand reconstruction. J Bone Joint Surg 1969;5IA:1219-21.

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8. Wright CS, McMurty RY. AD arthrodesis in the hand.J HAND SURG 1983;9:932-5.

9. Jebsen RH, Taylor N, Trieschmann RH, Trotter MJ,Howard LA. An objective and standardized test of handfunction. Arch Phys Med Rehabil 1969;50:311-19.

10. Gloss DS, Wardle MG. Use of the Minnesota rate ofmanipulation test for disability evaluation. Percept MotSkills 1982;55:527-32.

Thumb Me? fusion

II. Segmuller G. Surgical stabilization of the skeleton of thehand. Baltimore: Williams & Wilkins, 1977:42-59.

12. Kapandgi IA. Biomechanics of the thumb. In: TubianaR, ed. The hand. Vol I . Philadelphia: WB Saunders,1981:404-22.

13. Aubriot JH. The metacarpophalangeal joint of the thumb.In: Tubiana R; cd. The hand. Vol 1. Philadelphia: \VBSaunders, 1981:184-7.

Interpositional vein grafts to restore thesuperficial palmar arch in severe devascularizinginjuries of the hand

The use oC an interpositional vein graft to restore inflow to the digits by recreating the superficialpalmar arch is presented. This technique is best reserved for severe, devascularizing injuries tothe hand, significant damage to the palmar vessels, and when there maya paucity oC donor veinavailable. (J HAND SURG 1988;13A:753·7.)

Burt M. Greenberg, MD, C. Luis Cuadros, MD, and Jesse B. Jupiter, MD, Bas/on, Mass .

Significant devascularizing injuries to thehand have frequently been attributed to an clement ofcrush injury to the vascular inflow. I. 2 The success ofrevascularization depends on precise microsurgicaltechnique and the identification of uninjured vessels.Circumferential intimal lesions and skip lesions in­volving both the intima and media may extend morethan 3 cm from the rupture point3

•4 and arc potential

sites of thrombosis and occlusion. In an effort to ade­quately bridge a large zone of trauma in extensive handinjuries , the use of interpositional vein grafts has beenpopularized.l" We describe an alternative to the use ofmultiple vein grafts with severe injuries in which thesuperficial arch, in part, is reconstructed anatomicallyand digital revascularization is achieved directly from

From the Division of Plastic and Reconstru ctive Surgery, Departmentof Orthopaed ic Surgery, and The Hand Surgery Serv ice , Massa­chusetts General Hospital, Boston, Mass.

Recei ved for publica lion June 30, 1987; accepted in revised formJan . 6 , 1988.

No benefits in any form have been received or will be received froma commercial party related directly or indirectly to the subject ofthis article.

Reprint requests: Burt M. Greenberg, MD, 444 Lakeville Rd. ,Lake Success, NY 11O·n.

the "neoarch." We believe this technique allows a morerapid and accurate performance of arterial anastomosesin a severely devascularized hand.

Case reports

Case I. A 25-year-old right-handed carpenter was trans­ferred to the Massachusetts General Hospital 4 hours after asevere motor vehicle accident for evaluation and treatment ofa crush injury to his left hand (Fig. I). Initial examinationrevealed a cool, pale, and pulseless left hand, altered sensi­bility in both the median and ulnar nerve distribution , and atense, swollen distal forearm . The carpus was grossly unsta­ble. Forearm flexor and interosseous compartment pressuresmeasured 35 mm Hg by the Whiteside method. ' 0 Radiographsshowed palmar translocation of the carpus, with comminutedfractures of the anterior lip of the radius. Additional fractureswere noted in the trapezium and hamate (Fig. 2).

Through an extended palmar incision, the carpal tunnel,canal of Guyon , and flexor aspect of the forearm were de­compressed . At the time of the vascular exploration, both theradial and ulnar arteries were found to be transected at thewrist level. Debridement of the ulnar artery was done for3 em prox imally to identify normal intima by microscopicevaluation. Since the superficial and deep arches were crushedand showed adventitial hemorrhage and possible thrombosis,it was necessary to rcvascularize the digits directly. Identi­fication of the venous anatomy on the dorsum of the foot was

ruE JOURNAL OF HAND SURGERY 753