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Review Question - QID 214671

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QID 214671 (Type "214671" in App Search)
A 60-year-old Nintendo purist presents with basal thumb pain and weakness after decades of dedicated gameplay. He is found to have Stage IV osteoarthritis (OA) of the carpometacarpal joint (CMC) of the thumb and undergoes a simple single-bone carpectomy. He returns 1 year later and new radiographs are taken (Figure A). Which of the following is most indicated at this time?
  • A

A Flexor Carpi Radialis (FCR) interposition and suspension

20%

318/1578

An Extensor Carpi Radials Longus (ECRL) interposition and suspension

6%

88/1578

An Abductor Pollicis Longus (APL) interposition and suspension

7%

109/1578

A suture button suspension

4%

60/1578

Observation

62%

985/1578

  • A

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Metacarpal subsidence after trapeziectomy has not been shown to affect clinical outcomes and therefore nothing further is warranted in this case.

There are many surgical options for CMC OA. This includes volar ligament reconstruction and closing wedge dorsal extension osteotomy for early Stage I disease. Late disease is treated with trapeziectomy with/without metacarpal base stabilization, CMC fusion, or prosthetic arthroplasty. There is no difference in the results of trapeziectomy alone vs trapeziectomy with LRTI. Silastic arthroplasty is complicated by silicone synovitis. Pyrocarbon prosthetics are complicated by subluxation attributed to a shallow trapezial cup. Fusion is indicated for young (age < 50) high demand patients who wish to maintain grip strength.

Jones et al. reviewed salvage options for FCR disruption during LRTI. For partial FCR injury, the authors recommend using the remaining tendon for a Weilby suspensionplasty, or the entire FCR for LRTI (if enough length is available). For complete FCR avulsion, they recommend ECRL LRTI.

Yang and Weiland followed 15 LRTIs for 32 months. Radiographs were obtained at rest and during pinch. The first metacarpal subsided in 21% of patients at rest and in an additional 11% during key pinch. They found that clinically, key pinch improved postoperatively, and they concluded that there was no correlation between subsidence and clinical outcome.

Figure A shows the subsidence of the thumb metacarpal after trapeziectomy.

Incorrect Answers:
Answer 1: While FCR is commonly used for suspension, it is not indicated at this time.
Answer 2: The ECRL can be used for suspension in cases when the FCR is not available, but it is not indicated in this setting.
Answer 3: While the APL has been described for suspension, it is not indicated at this time.
Answer 4: Although suture button suspension has limited supporting evidence, it although can be used as an adjunct in the treatment of basilar thumb arthritis.

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