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Perioperative management - Resection-suspension arthroplasty according to Epping for thumb carpometacarpal osteoarthritis

hand surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Indications

    • Pain
    • Failed conservative therapy
    • Radiologically confirmed advanced thumb saddle joint osteoarthritis

    Staging of rhizarthrosis according to clinical pain symptoms by Alnot and Saint Laurent

    Stage 0

    No symptoms

    Stage I

    Pain during specific activities

    Stage II

    Pain during daily activities

    Stage III

    In addition to Stage II, episodes of resting pain

    Stage IV

    (Almost) constant pain

  2. Contraindications

    • Local or general diseases that contraindicate elective surgery either surgically or anesthesiologically, or are improvable preoperatively

  3. Preoperative Diagnostics

    • Clinical Examination:
      • Inspection/palpation of a painful thickened saddle joint with crepitation
      • in advanced cases, adduction contracture of the 1st CMC joint with hyperextension of the MCP joint (so-called 90/90 deformity)
    • X-ray examination in 2 planes

    (CMC joint = Carpometacarpal joint, MCP joint = Metacarpophalangeal joint)

    Radiological Classification of Rhizarthrosis according to Eaton and Littler

    Stage I

    Normal, possibly widened joint space (effusion), slight subluxation of the Os metacarpale I

    Stage II

    Slight narrowing of the joint space, osteophytes smaller than 2 mm, significant subluxation of the Os metacarpale I

    Stage III

    Significant narrowing of the joint space up to obliteration of the joint space, osteophytes larger than 2 mm

    Stage IV

    Joint destruction, cystic, sclerotic remodeling processes, pronounced subluxation of the Metacarpale I, STT arthrosis

    (STT joint = Scapho-trapezo-trapezoidal joint)

  4. Special Preparation

    • no special preparation of the patient necessary
    • generally an outpatient procedure
    • clarification of contraindication for bloodlessness (e.g., existing shunt in dialysis)

  5. Education

    Information about

    • surgical method
    • additional procedures such as reconstruction of the radial artery, nerve, tendon
    • general surgical risks
      • wound healing disorder
      • tendon injury
      • functional deficit of the wrist/hand
      • CRPS = Sudeck's disease
    • specific surgical risks
      • injury to the superficial branch of the radial nerve or the medial antebrachial cutaneous nerve with neuropathic pain
      • injury to the radial artery
      • injury to the FCR tendon with weakening of wrist flexion
      • injury to the base of the first metacarpal during bone drilling
      • reduction in grip strength
      • prolonged scar pain (usually subsides after 6 months)
      • persistent complaints
      • revision surgery
      • risk of recurrence

  6. Anesthesia

    • intravenous regional anesthesia
    • plexus anesthesia
    • general anesthesia

  7. Storage

    • Supine positioning
    • Positioning of the hand on a hand table
    • Recommended application of upper arm tourniquet

  8. OP Setup

    • The surgeon should sit on the side where the leading hand points distally with the scissor tip
    • Opposite, an assistant may be seated
    • The instrument nurse positions themselves at the head of the hand table

  9. Special instruments and holding systems

    • It is recommended to apply a tourniquet to the upper arm
    • The use of magnifying optics such as loupes is recommended
    • A hand instrument set is used, possibly micro-instruments for reconstruction of the radial artery or nerves
    • Possibly an image intensifier
    • Possibly a drill/surgical motor as shown in the film example

  10. Postoperative treatment

    Postoperative Analgesia

    Medical Follow-up Treatment

    • Regular wound inspection, elastic compression bandage (Caution: constriction!) for a few days
    • Suture removal after 14 days
    • Immobilization in a thumb splint for 4 weeks
    • Possibly recommend fatty ointment for scar care (special scar ointment not necessary)
    • Release of load after cast removal

    Thrombosis Prophylaxis

    • not applicable

    Mobilization

    • immediate

    Physical Therapy

    • Active exercise therapy with possible physiotherapeutic support with full extension and fist closure of the fingers from the 1st postoperative day (prevents hand edema and finger stiffness).
    • Specific hand therapeutic measures in advanced cases with movement restriction of the wrist.

    Dietary Progression

    • not applicable

    Bowel Regulation

    • not applicable

    Incapacity for Work

    • Generally 14-21 days depending on manual activity (maximum 6 weeks).