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EVIDENCE-BASED MEDICINE Metacarpophalangeal Hyperextension Deformity Associated With Trapezial-Metacarpal Arthritis Ryan Klinefelter, MD THE PATIENT A 58-year-old woman presents with a 2-year history of worsening pain at the base of her right, dominant, trapezial-metacarpal (TM) joint. Her thumb metacarpo- phalangeal (MCP) joint hyperextends 45° with lateral pinch. Radiographs demonstrate Eaton stage III degen- erative changes of her TM joint and no arthritis of her thumb MCP joint. She is considering operative inter- vention. When discussing how to treat her MCP joint, she expresses her preference to maintain as much thumb mobility as possible. THE QUESTION In addition to trapezial-metacarpal joint arthroplasty, what is the preferred treatment for her MCP joint hy- perextension? CURRENT OPINION It is generally recommended that thumb MCP joint hyperextension in excess of 30° be addressed during TM joint reconstruction surgery. Thumb MCP joint hyperextensibility during lateral pinch can worsen thumb metacarpal adduction and subsequently increase stresses on the surgical reconstruction. Techniques to stabilize the MCP joint in this setting include temporary transarticular pinning, extensor pollicis brevis tenot- omy, sesamoid arthrodesis, volar tenodesis using a free tendon graft, volar capsulodesis, and MCP joint arthro- desis. It is not clear what, if any, effect MCP joint hyperextension has on function and disability in the setting of TM arthrosis. The indications for surgery and the balance of risks and benefits remain unclear. THE EVIDENCE Pinning the metacarpophalangeal joint in flexion Davis and Poulter 1 found in a prospective cohort study that those with temporary MCP joint pinning of defor- mities less than 30° had no improvement in their hy- perextension deformity or outcome at 1 year. Extensor pollicis brevis tenotomy Kessler 2 tenotomized the extensor pollicis brevis at its musculotendinous junction and passed it around the MCP joint in a volar direction and through a hole in the metacarpal neck as a tenodesis. He described the results in 11 patients with rheumatoid, paralytic, and traumatic lesions at an average of 6.5 years after surgery. Two patients with rheumatoid arthritis had recurrent hyper- extension. Sesamoid arthrodesis One of 21 patients followed up for an average of 2 years after sesamoid arthrodesis to treat thumb MCP joint hyperextension in conjunction with TM arthroplasty had a recurrence. 3 Thumb MCP joint flexion loss aver- aged 8°. Palmaris longus free tendon graft Norris et al 4 describe a volar tenodesis of the thumb MCP joint using a free palmaris longus tendon graft placed volar to the flexor tendon sheath and through drill holes in the proximal phalanx and metacarpal. Among 12 patients (14 thumbs) who were followed up for an average of 31 months, 1 had a recurrence. Volar capsulodesis Eaton and Floyd 5 reported the results of volar capsu- lodesis in 13 patients having thumb TM arthroplasty in From the Department of Orthopaedics, Ohio State University Hand and Upper Extremity Center, Co- lumbus, OH. Received for publication March 18, 2011; accepted May 2, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Ryan Klinefelter, MD, Ohio State University Hand and Upper Extremity Center, Department of Orthopaedics, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212; e-mail: [email protected]. 0363-5023/11/36A12-0027$36.00/0 doi:10.1016/j.jhsa.2011.05.006 Evidence-Based Medicine © ASSH Published by Elsevier, Inc. All rights reserved. 2041

Metacarpophalangeal Hyperextension Deformity Associated With Trapezial-Metacarpal Arthritis

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Page 1: Metacarpophalangeal Hyperextension Deformity Associated With Trapezial-Metacarpal Arthritis

Medicine

EVIDENCE-BASEDMEDICINE

Metacarpophalangeal Hyperextension Deformity

AssociatedWith Trapezial-Metacarpal Arthritis

Ryan Klinefelter, MD

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mMmilpe

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Evidence-Based

THE PATIENT

A 58-year-old woman presents with a 2-year history ofworsening pain at the base of her right, dominant,trapezial-metacarpal (TM) joint. Her thumb metacarpo-phalangeal (MCP) joint hyperextends 45° with lateralpinch. Radiographs demonstrate Eaton stage III degen-erative changes of her TM joint and no arthritis of herthumb MCP joint. She is considering operative inter-vention. When discussing how to treat her MCP joint,she expresses her preference to maintain as muchthumb mobility as possible.

THE QUESTION

In addition to trapezial-metacarpal joint arthroplasty,what is the preferred treatment for her MCP joint hy-perextension?

CURRENT OPINION

It is generally recommended that thumb MCP jointhyperextension in excess of 30° be addressed duringTM joint reconstruction surgery. Thumb MCP jointhyperextensibility during lateral pinch can worsenthumb metacarpal adduction and subsequently increasestresses on the surgical reconstruction. Techniques tostabilize the MCP joint in this setting include temporarytransarticular pinning, extensor pollicis brevis tenot-omy, sesamoid arthrodesis, volar tenodesis using a freetendon graft, volar capsulodesis, and MCP joint arthro-desis. It is not clear what, if any, effect MCP jointhyperextension has on function and disability in the

From the Department of Orthopaedics, Ohio State University Hand and Upper Extremity Center, Co-lumbus, OH.

Received for publication March 18, 2011; accepted May 2, 2011.

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: Ryan Klinefelter, MD, Ohio State University Hand and Upper ExtremityCenter, Department of Orthopaedics, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212;e-mail: [email protected].

0363-5023/11/36A12-0027$36.00/0

ldoi:10.1016/j.jhsa.2011.05.006

©

etting of TM arthrosis. The indications for surgery andhe balance of risks and benefits remain unclear.

HE EVIDENCE

inning the metacarpophalangeal joint in flexion

avis and Poulter1 found in a prospective cohort studythat those with temporary MCP joint pinning of defor-mities less than 30° had no improvement in their hy-perextension deformity or outcome at 1 year.

Extensor pollicis brevis tenotomy

Kessler2 tenotomized the extensor pollicis brevis at itsusculotendinous junction and passed it around theCP joint in a volar direction and through a hole in theetacarpal neck as a tenodesis. He described the results

n 11 patients with rheumatoid, paralytic, and traumaticesions at an average of 6.5 years after surgery. Twoatients with rheumatoid arthritis had recurrent hyper-xtension.

esamoid arthrodesis

ne of 21 patients followed up for an average of 2 yearsfter sesamoid arthrodesis to treat thumb MCP jointyperextension in conjunction with TM arthroplastyad a recurrence.3 Thumb MCP joint flexion loss aver-

aged 8°.

Palmaris longus free tendon graft

Norris et al4 describe a volar tenodesis of the thumbMCP joint using a free palmaris longus tendon graftplaced volar to the flexor tendon sheath and throughdrill holes in the proximal phalanx and metacarpal.Among 12 patients (14 thumbs) who were followed upfor an average of 31 months, 1 had a recurrence.

Volar capsulodesis

Eaton and Floyd5 reported the results of volar capsu-

odesis in 13 patients having thumb TM arthroplasty in

ASSH � Published by Elsevier, Inc. All rights reserved. � 2041

Page 2: Metacarpophalangeal Hyperextension Deformity Associated With Trapezial-Metacarpal Arthritis

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2042 MCP HYPEREXTENSION DEFORMITY AND TM ARTHRITIS

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1988. Twelve of 13 patients had good or excellentresults at a minimum of 12 months of follow-up.Schuurman and Bos6 reported no recurrence in 10thumbs (8 patients) between 6 and 27 months aftersurgery.

Most recently, Davis and Poulter1 described 11 pa-tients treated with thumb MCP joint capsulodesis witha bone anchor, in conjunc-tion with TM arthroplasty.The hyperextension defor-mity was reduced from amean of 48° before surgery(range, 35–70°) to 16° (range,0–35°) at 1-year follow-up.There were no statisticallysignificant differences inpain levels and key and tippinch compared to an un-treated group with preoper-ative hyperextension of lessthan 30°.

Thumb metacarpophalangealjoint arthrodesis

Some surgeons7 recommend MCP joint arthrodesis forhyperextension greater than 40°, but to our knowledge,there are no data regarding this procedure.

SHORTCOMINGS OF THE EVIDENCEThe data regarding MCP joint hyperextension associ-ated with TM arthrosis are limited to a few retrospectivecase series, most promoting a specific technique. Wefound no controlled trials and no data comparing oper-ative and nonoperative treatment of the MCP jointhyperextension.

DIRECTIONS FOR FUTURE RESEARCHWe need to study the effect of MCP joint hyperexten-sion on pain intensity and disability in patients with TMarthrosis. We also need a randomized trial comparingtreatment with no treatment of the MCP joint hyperex-tension in conjunction with TM arthroplasty. Finally,longer-term follow-up on the durability of volar capsu-lodesis and other procedures is needed. In particular, ifthe status of the MCP joint has no influence on painintensity or disability—whether or not it has any effecton objective radiographic measures such as subsid-

EDUCATIONAL OBJEC● State the degree of hyperextens

treatment during trapezial-metasurgery.

● List the various techniques to sarthritis joint reconstruction surg

● Discuss the results of temporary

● Discuss the results following volajoint during TM arthritis joint rec

● Summarize the evidence regardion function and disability in the

Earn up to 2 hours of CME creditarticles and take the online test. Ttest, visit http://www.jhandsurg.o

ence—the rationale for treating the MCP joint hyper-

JHS �Vol A, D

extension to improve the outcome at the TM joint willevaporate.

MY CURRENT CONCEPTS FOR THIS PATIENTDespite evidence that postoperative subsidence doesnot necessarily impact outcome,8 I recommend treat-ment of the MCP joint deformity because I believe

(again, based on observa-tion and rationale ratherthan evidence) that it canreduce the risk of recur-rent longitudinal collapse.Because there are insuffi-cient data supporting oneprocedure over another, Iprefer to preserve motionand would, therefore, rec-ommend a thumb MCPjoint volar capsulodesis inaddition to TM arthro-plasty. I would explain tothe patient that her MCPjoint alignment can be im-proved in the short term,

but little is known about what to expect in the longterm. If the MCP joint deformity recurs and thepatient is symptomatic, I would then recommendan MCP joint arthrodesis.

REFERENCES1. Poulter RJ, Davis TR. Management of hyperextension of the meta-

carpophalangeal joint in association with trapeziometacarpal jointosteorarthritis. J Hand Surg 2011;36E:280–284.

2. Kessler I. A simplified technique to correct hyperextension deformityof the metacarpophalangeal joint of the thumb. J Bone Joint Surg1979;61A:903–905.

3. Tonkin MA, Beard AJ, Kemp SJ, Eakins DF. Sesamoid arthrodesisfor hyperextension of the thumb metacarpophalangeal joint. J HandSurg 1995;20A:334–338.

4. Norris ME III, Samra S, DeMercurio J, Bourianoff TH, Netscher DT.Free palmaris longus graft tenodesis effectively treats swan neckadduction collapse secondary to thumb basilar joint arthritis. PlastReconstr Surg 2007;120:475–481.

5. Eaton RG, Floyd WE III. Thumb metacarpophalangeal capsulodesis:an adjunct procedure to basal joint arthroplasty for collapse deformityof the first ray. J Hand Surg 1988;13A:449–453.

6. Schuurman AH, Bos KE. Treatment of volar instability of the meta-carpophalangeal joint of the thumb by volar capsulodesis. J Hand Surg1993;18B:346–349.

7. Lourie GM. The role and implementation of metacarpophalangealjoint fusion and capsulodesis: indications and treatment alternatives.Hand Clin 2001;17:255–260.

8. Yang SS, Weiland AJ. First metacarpal subsidence during pinch after

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the thumb MCP joint that requires(TM) arthritis joint reconstruction

the thumb MCP joint during TM

g of the MCP joint in flexion.

lodesis to stabilize the thumb MCPction surgery.

effect of MCP joint hyperextensionof TM arthritis.

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ligament reconstruction and tendon interposition basal joint arthro-plasty of the thumb. J Hand Surg 1998;23A:879–883.

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