Postoperative Rehabilitation Following Trapeziectomy and Ligament Reconstruction Tendon Interposition

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.

Inclusion Criteria:

- Patients over 40 years old with basal arthritis who failed conservative treatment

- Patients receiving LRTI by one of three enrolled surgeons at the U or one of the two
enrolled surgeons at Intermountain who consented to the study

Exclusion Criteria:

- Patients undergoing more procedures in addition to the LRTI that may alter the
postoperative course, not including CTR or thumb MCP capsulodesis, MP fusion, trigger
finger release

- h/o CRPS

- RA

- Revision LRTI