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Perioperative management - Resection-Suspension Arthroplasty according to Epping for Rhizarthrosis

hand surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Indications

    • Pain
    • Failed conservative therapy
    • Radiologically proven advanced thumb carpometacarpal joint osteoarthritis

    Staging of rhizarthrosis according to the clinical pain symptomatology according to Alnot and Saint Laurent

    Stage 0

    No complaints

    Stage I

    Pain during certain activities

    Stage II

    Pain during everyday activities

    Stage III

    in addition to Stage II, episodes of rest pain

    Stage IV

    (almost) constant pain

  2. Contraindications

    • Local or general conditions that surgically or anesthesiologically contraindicate an elective operation or are preoperatively improvable

  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 metacarpal bone I

    Stage II

    Slight joint space narrowing, osteophytes smaller than 2 mm, pronounced subluxation of the metacarpal bone I

    Stage III

    Pronounced joint space narrowing up to elimination of the joint space, osteophytes larger than 2 mm

    Stage IV              

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

    (STT joint = Scapho-trapezo-trapezoidal joint)

  4. Special Preparation

    • no special preparation of the patient necessary
    • basically outpatient procedure
    • Assessment of contraindication for bloodless field (e.g. existing shunt in dialysis)

  5. Informed Consent

    Informed consent about

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

  6. Anesthesia

    • intravenous regional anesthesia
    • plexus anesthesia
    • general anesthesia

  7. Positioning

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

  8. OR Setup

    • The surgeon should sit on the side where the dominant hand with the scissor tip points distally
    • An assistant sits opposite if necessary
    • The scrub nurse positions themselves at the head end of the hand table

  9. Special Instrumentation and Holding Systems

    • It is recommended to apply an upper arm tourniquet
    • It is recommended to use magnifying optics such as e.g. loupes
    • A hand instrument set is used, possibly microinstrumentation for reconstruction of the radial artery or nerves
    • possibly image intensifier
    • possibly drill/surgical motor as in the film example

  10. Postoperative Treatment

    Postoperative Analgesia

    Medical Aftercare

    • Regular wound inspection, elastic compressive bandage (Caution: Constriction!) for a few days
    • Suture removal after 14 days
    • Immobilization in thumb splint for 4 weeks
    • If necessary, recommendation of greasy ointment for scar care (special scar ointment not necessary)
    • Release for loading after cast removal

    Thrombosis Prophylaxis

    • not applicable

    Mobilization

    • immediate

    Physiotherapy

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

    Diet Build-up

    • not applicable

    Stool Regulation

    • not applicable

    Incapacity for Work

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