Postoperative Rehabilitation Following Trapeziectomy and Ligament Reconstruction Tendon Interposition
Condition: Osteoarthrosis of the Carpometacarpal Joint of the Thumb
MeSH terms: Osteoarthritis
Study type: Interventional

Summary: 
      Carpometacarpal (CMC) arthritis of the thumb joint ('basal arthritis') is a common entity
      treated by hand surgeons in our society. It can be a significant source of functional
      disability secondary to a painful, and often weak, grip. Once patients have failed treatment
      by conservative means, such as splinting, anti-inflammatories, and cortisone injections, the
      next option is surgical management. Several surgical options are available depending on the
      severity of the disease. For the early stages of arthritis options include a ligament
      reconstruction or a metacarpal extension osteotomy. For advanced stages, only salvage
      procedures exist. These have included simple trapeziectomy, arthrodesis and implant
      arthroplasty. The most common procedure, however, has been a trapeziectomy with a ligament
      reconstruction tendon interposition
    

Detailed description: 
      Carpometacarpal (CMC) arthritis of the thumb joint ('basal arthritis') is a common entity
      treated by hand surgeons in our society. It can be a significant source of functional
      disability secondary to a painful, and often weak, grip. Once patients have failed treatment
      by conservative means, such as splinting, anti-inflammatories, and cortisone injections, the
      next option is surgical management. Several surgical options are available depending on the
      severity of the disease. For the early stages of arthritis options include a ligament
      reconstruction or a metacarpal extension osteotomy. For advanced stages, only salvage
      procedures exist. These have included simple trapeziectomy, arthrodesis and implant
      arthroplasty. The most common procedure, however, has been a trapeziectomy with a ligament
      reconstruction tendon interposition. During this procedure the arthritic trapezium is excised
      to remove arthritic joint surfaces, the anterior oblique ligament is reconstructed to restore
      thumb metacarpal stability and prevent axial shortening, and a fascial interposition is
      performed to reduce the likelihood of impingement between neighboring bones.

      Postoperative rehabilitation and splinting protocols have varied widely between institutions.
      In fact, no studies have been published looking specifically at these protocols. Some
      institutions have taken a more conservative approach, having their patients immobilized by
      some means for up to twelve weeks with no motion for six weeks. Others advance their patients
      more quickly and start motion at four weeks with discontinuation of splinting at eight weeks.

      There is one Cochrane Review on surgical treatment of trapeziometacarpal joint arthritis that
      compared seven surgical techniques. They looked at outcomes of pain, physical function, range
      of motion, global assessment, strength, CMC imaging and adverse effects. There was no mention
      of a therapy protocol.1

      The Hand Clinics, a comprehensive, state-of-the-art review by experts in the field, provide
      current, practical information of the diagnosis and treatment of conditions affecting the
      hand and wrist. Each issue focuses on a single topic relevant to hand surgery practice. In
      the most recent arthritis issue, Clinics 26 (2010), Bodin et al. discussed many surgical
      techniques and alluded to therapy after eight weeks of casting but no specific protocol is
      defined. 2

      A recent book publication by the American Society for Surgery of the Hand and the American
      Society of Hand Therapists include a chapter on arthritis incorporating rehabilitation
      interventions following soft tissue reconstruction of the CMC joint. They advocate a more
      conservative approach. Up to four weeks a forearm based thumb spica cast is utilized with
      thumb IP range of motion and edema control. At week 5 the patient is changed to a forearm
      based thumb spica splint with addition of active range of motion of the wrist and thumb MP
      and IP joints. CMC joint range of motion is started at week 6. At this point isometric
      strengthening to the wrist, thenar and first dorsal interosseous muscles is initiated. At
      week 10 patients begin light pinch and grip exercises. The splint is discontinued week 12.3

      Hand therapists find the Diagnosis and Treatment Manual by the Hand Rehabilitation Center of
      Indiana to be the 'bible' of hand therapy. They advocate a more aggressive, earlier motion,
      protocol. At week 2, a forearm based thumb spica cast or splint is placed. At week 4 active
      and passive range of motion to the thumb and wrist is started including palmar and radial
      abduction, wrist flexion, extension, ulnar and radial deviation, and thumb circumduction,
      flexion, and extension. At week 6, gentle strengthening is begun with discontinuation of the
      splint.4

      A less popular but frequently used book, Hand and Upper Extremity Rehabilitation, a practical
      guide, their chapter on Thumb CMC arthroplasty included a concise protocol similar to the
      Indiana protocol. At week 2, active and passive MCP and IP range of motion is started. At
      week 4, CMC abduction and extension, CMC opposition and wrist range of motion is started. At
      week 8, pinch and grip strength is stressed. There is no discussion about splinting. 5

      Despite these published protocols, there have been no studies looking at which protocol is
      better. There have been no prospective, randomized trials comparing a conservative approach
      consisting of longer immobilization with a more aggressive approach advocating earlier motion
      and shorter splinting times.
    

Intervention name(s): casts for the thumb; Motion group
Intervention type(s): Other; Other
Intervention description(s): The 'Cast' group will be placed in a thumb spica short arm cast with the thumb IP joint free. They will be allowed digit, thumb IP and elbow range of motion.; The 'Motion' group will be placed in a forearm based thumb spica splint with the thumb IP free. They will be allowed digit, thumb IP and elbow range of motion.
Other intervention name(s): Cast group
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Cast; motion; thumb CMC arthritis; Collateral Ligament of Metacarpophalangeal Joint