ligament reconstruction with tendon interposition using an acellular dermal allograft for thumb...

Ligament Reconstruction With Tendon InterpositionUsing an Acellular Dermal Allograft for Thumb

Carpometacarpal ArthritisZinon T. Kokkalis, MD, George Zanaros, MD, and Dean G. Sotereanos, MD

Abstract: Ligament reconstruction tendon interposition arthroplasty iscurrently the preferred technique for carpometacarpal joint arthritis ofthe thumb by most surgeons. Despite its efficacy, morbidity has beenassociated with the harvest of the flexor carpi radialis tendon. Using anallograft as material for arthroplasty, donor site morbidity is avoided.In this report, we present our surgical technique to perform ligamentreconstruction tendon interposition arthroplasty using an acellular der-mal matrix allograft (GraftJacket) in patients with Eaton stages II, III,and IV symptomatic first carpometacarpal arthritis.

One hundred thumbs with trapeziometacarpal osteoarthritis under-went surgical treatment using GraftJacket allograft instead of the flexorcarpi radialis tendon autograft. Each patient was followed for a minimumof 12 months. The surgical procedure included trapezial excision andidentification of the flexor carpi radialis. The allograft was cut to create a15-cm strip. The ligament reconstruction was performed by passing thestrip around the flexor carpi radialis tendon and suturing it to the base ofthe thumb metacarpal base through an intramedullary drill hole. Theremaining portion of the allograft was fashioned as an interposition mass(anchovy) and interposed between the scaphoid and the base of the firstmetacarpal.

All but 1 patient experienced significant improvement in his or herpain scale rating and grip and pinch strengths. Outcomes from this studycompare very favorably with those of other series. No patients expe-rienced a foreign body reaction or infection in this series. We believe thatthe use of an acellular dermal allograft for both ligament reconstructionand tendon interposition provides a safe and an effective alternativetechnique for the treatment of advanced first carpometacarpal arthritis.

Key Words: CMC arthritis, ligament reconstruction, GraftJacket,allograft, tendon interposition

(Tech Hand Surg 2009;13: 41Y46)

HISTORICAL PERSPECTIVEThe carpometacarpal (CMC) joint of the thumb is the mostcommon site of surgery for osteoarthritis in the upper ex-tremity.1,2 Thumb CMC arthritis frequently occurs in postmeno-pausal women and is a common cause of hand disability. Due to

profound impact on hand function and disabling symptoms,surgical reconstruction is often sought. Excision of the trape-zium (trapeziectomy) with ligament reconstruction, with orwithout tendon interposition arthroplasty, has been proved tobe highly effective in restoring a pain-free, stable, and functionalthumb in patients with advanced thumb CMC arthritis.1Y8 Sev-eral tendons have been used for ligament reconstruction, with orwithout interposition, including the abductor pollicis longus9,10

and the flexor carpi radialis. The latter is the most commonlyused tendon, using either half of or the entire tendon.1Y8

Donor site morbidity due to scarring, pain, tendonitis ortendon rupture, and neuroma formation is the main disadvan-tage of harvesting either a split or the entire donor tendon fromthe forearm or wrist. Although previous reports conclude thatusing the entire flexor carpi radialis does not affect hand func-tion,5,11 there is evidence that it may compromise wrist flexionpeak torque and wrist flexion fatigue of the surgically treatedextremity.12

These drawbacks could be avoided by using orthobiologicmaterials. In human studies, the use of xenograft such as a por-cine collagen xenograft was abandoned because of poor patientoutcome and adverse immunological reactions.13 The use of areliable acellular allograft scaffold material derived from freeze-dried human dermis, GraftJacket (Wright Medical Technology,Inc, Arlington, Tenn) has demonstrated promising results inseveral applications.14Y16 In a recent study, GraftJacket wasplaced arthroscopically as an interposition only (ie, withoutligament reconstruction) for the treatment of 17 patients, withEaton stages II and III thumb CMC arthritis.17 The authorsreported that all patients had symptomatic relief, and postoper-ative complications were minimal.17

In the present report, the surgical technique of trapezialexcision with ligament reconstruction and tendon interpositionarthroplasty using GraftJacket for the first CMC arthritis isdescribed. Outcome data, based on 100 cases, indicated that allbut 1 patient experienced significant improvement in his or herpain scale rating and grip and pinch strengths at a minimumfollow-up of 12 months after surgery.18 The detailed review ofthis series is forthcoming.

INDICATIONS/CONTRAINDICATIONSSelection criteria for surgery were persistent symptoms,

such as pain and/or weakness and unresponsive to conservativetreatment. Nonoperative treatment included nonsteroidal anti-inflammatory medication, intra-articular steroid injections, andsplinting for a minimum period of 6 months.

Patients with Eaton stages II, III, and IV symptomatic firstCMC arthritis (Eaton and Littler classification19) were candi-dates for this procedure. Informed consent was obtained in allpatients. Diagnosis of first CMC joint arthritis was confirmed byphysical examination and radiographic studies. Although radio-graphic staginghas been used to develop a treatment plan relatedto the stage of the first CMC arthritis, there is evidence that

TECHNIQUE

Techniques in Hand &Upper Extremity Surgery & Volume 13, Number 1, March 2009 41

From the Department of Orthopaedic Surgery, Hand & Upper ExtremitySurgery, Allegheny General Hospital, Pittsburgh, PA.In support of their research for or preparation of this manuscript, one of

the authors (D.G.S.) received grants or outside funding from WrightMedical Technology, Inc, Arlington, Tenn. Also, a commercial entity(Wright Medical Technology) paid or directed, or agreed to pay ordirect, benefits to a research fund, foundation, educational institution,or other nonprofit organization with which the authors are affiliated orassociated.

Address correspondence and reprint requests to Dean G. Sotereanos, MD,Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery,Drexel University, School of Medicine, Allegheny General Hospital,1307 Federal St, 2nd Floor, Pittsburgh, PA 15212. E-mail: [email protected].

Copyright * 2009 by Lippincott Williams & Wilkins

9Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

radiographs do not always correlate accordingly with the levelof the disease and/or symptom severity of the patient.10

Hyperextension of the thumb metacarpophalangeal jointand pantrapezial arthritis were not contraindications for thisoperation. These deformities were addressed at the same timeduring surgery.

SURGICAL TECHNIQUESurgery is performed under general or regional anesthesia,

with the patient in supine position and the affected hand andarm on a hand table. The procedure is performed using an armtourniquet, preset to 250 mm Hg.

With the forearm in neutral position, a straight incision,approximately 3.0 to 4.0 cm in length, is made from the base ofthe first metacarpal along the first dorsal compartment, centeredover the trapezium (Fig. 1A). The radial dorsal sensory nervesare identified and protected (Fig. 1B). Release of the first dor-sal compartment is usually performed, and a large volar flap ismaintained to avoid tendon subluxation (Fig. 2). The radial ar-tery, which courses within the anatomical snuff box, is retractedand protected dorsally to minimize the risk of injury. Smallvessels from the radial artery are coagulated.

The capsule over the trapeziometacarpal joint is openedlongitudinally between the extensor pollicis brevis and ab-ductor pollicis longus tendons (Fig. 3). The incision is con-tinued slightly proximal to the scaphotrapezial joint. Althoughthumb traction is applied, the trapezoid, trapeziometacarpal, and

scaphotrapezial joints are evaluated. With a knife, the capsuleis sharply dissected from the trapezium and capsular flaps areelevated as thick as possible. The trapezium is excised throughan initial saw or osteotome cut and removed piecemeal with abony rongeur (Fig. 4). Care is taken to avoid injury to the flexorcarpi radialis tendon, which is close to the volar crest of thetrapezium.

A 2-mm portion of the first metacarpal base is excisedusing an oscillating saw (Fig. 5A). A curette is used to open theintramedullary cavity of the first metacarpal, and a side-bitingdrill is used to create a hole in the radial metacarpal cortex, 1 cmdistal to the metacarpal base (Fig. 5B). This hole is used for theligament reconstruction.

The flexor carpi radialis tendon is identified just proximalto its insertion at the second metacarpal base and is dissectedcarefully for the preparation of the GraftJacket transfer (Fig. 6).The GraftJacket dermal matrix is removed from the sterilepackaging and rehydrated in normal saline solution for 10 to15 minutes on the side table. A 12 to 15 cm (length) of ap-proximately 10-mm (width) strip of the GraftJacket is cut onthe side table using a Metzenbaum scissors. Recently, the com-mercially available GraftJacket Maxstrip with standard dimen-sions 1 � 12 cm, is our preferred choice (Fig. 7).

By using a right-angle hemostat, the one end of theGraftJacket is passed around the flexor carpi radialis tendonand sutured to itself with 4-0 FiberWire (Arthrex, Inc, Naples,

FIGURE 1. A, Skin incision is made from the base of the first metacarpal (first MC) along the first dorsal compartment, centered overthe trapezium. B, The dorsal sensory branches of the radial nerve are identified and protected.

FIGURE 2. Release of the first dorsal compartment.

FIGURE 3. The capsule over the trapeziometacarpal joint isopened longitudinally between the extensor pollicis brevis andabductor pollicis longus tendons.

Kokkalis et al Techniques in Hand &Upper Extremity Surgery & Volume 13, Number 1, March 2009

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Fla) (Fig. 8A). Using a Hewson tendon passer (Fig. 8B), theGraftJacket is then passed through the hole previously drilled inthe base of the first metacarpal and is folded back on itself(Fig. 8C). The palmar beak ligament is reconstructed by main-taining the thumb in an abducted position, whereas theGraftJacket is sutured securely on itself with 4-0 FiberWire(Fig. 8D). Excessive tension is avoided on the GraftJacket stripto prevent osseous impingement against the index metacarpalor the trapezoid. The remaining portion of the GraftJacket isfashioned as an interposition mass (anchovy) and interposedbetween the scaphoid and the base of the first metacarpal (ie,the space formerly occupied by the trapezium) (Figs. 8E, F). Theinterposition mass is held in the arthroplasty space with carefuland snug capsular repair with 3-0 Vicryl horizontal mattresssutures (Fig. 8G). Kirschner wire stabilization was not neededin this series.

If there is evidence of scaphotrapezoidal arthritis, the trap-ezoid articular surface is resected (approximately 1Y2mm), anda portion of the GraftJacket is interposed between the trapezoidand the scaphoid.

In thumbs in which there is more than 30 degrees of passivehyperextension of the metacarpophalangeal joint, stabilizationof this joint is performed at the same time of the arthroplasty ofthe basal joint. The metacarpophalangeal joint is arthrodesed in10 degrees of flexion.

The wound is irrigated with saline solution, the tourniquetis released and meticulous hemostasis is achieved by bipolarcautery. The skin is closed with interrupted 4-0 nylon sutures.Postoperatively, the thumb is placed in a short arm thumb spicasplint.

REHABILITATIONOn the tenth postoperative day, the sutures are removed,

and a removable orthoplast thumb spica splint is placed for anadditional 4 weeks. During this period, the patient is instructedto remove the splint, and gentle range of motion of the thumbis allowed. If necessary, occupational therapy is initiated afterthe sixth postoperative week. Physical therapy is usually conti-nued until satisfactory pinch and grip strengths have beenachieved. Radiographic examination is performed in all patientsat the initial postoperative visit, at 6 weeks, and then every6 months after surgery (Figs. 9A, B).

COMPLICATIONSNo serious complications were seen in our series. No

patients experienced a foreign body reaction or infection inthis series. Minor complications can include numbness or

FIGURE 4. The trapezium (Tr) is excised through an initial saw orosteotome cut and removed piecemeal with a bony rongeur.

FIGURE 5. A, A 2-mm portion of the first metacarpal base is excised using an oscillating saw. B, A side-biting drill is used to create ahole in the radial metacarpal cortex, 1 cm distal to the metacarpal base. This hole is used for the ligament reconstruction.

FIGURE 6. The flexor carpi radialis (FCR) tendon is identifiedand dissected carefully for the preparation of the GraftJacketanchoring.

Techniques in Hand &Upper Extremity Surgery & Volume 13, Number 1, March 2009 Acellular Dermal Allograft for Thumb CMC Arthritis

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hypersensitivity in the distribution of the sensory branch ofthe radial nerve.

Only 1 revision occurred in 1 male patient. This patientwas a workers compensation patient with concomitant scapho-trapezotrapezoidal joint arthritis.

DISCUSSIONBiologic scaffold materials composed of mammalian extra-

cellular matrix are commonly used for the surgical reconstruc-tion of numerous tissues.13Y17,20Y22 GraftJacket is derived fromdonated cadaveric dermal tissue that is processed to removecellular components, whereas the extracellular matrix is pre-served.14 The matrix contains biochemical components includ-ing collagen, elastin, and proteoglycans and is not artificiallycross-linked. In vivo studies have demonstrated rapid infiltra-tion of native cellular agents, including fibroblasts and vasculartissue, with minimal host inflammatory response.14,20,23 In arodent model, histologic examination, 112 days after surgery,showed that there was partial degradation of the GraftJacketdevice and replacement with dense, partially organized collag-enous connective tissue.20 In human studies, GraftJacket hasdemonstrated excellent biocompatibility in soft tissue surgery,including achilles tendon reconstruction, first CMC joint ar-thritis, and rotator cuff repair.15,17,24

The mechanical properties of the GraftJacket were alsoinvestigated.21,23 Derwin et al21 concluded that the elasticmoduli of commercial extracellular matrices are an order ofmagnitude lower than that of canine infraspinatus tendon. Onthe other hand, Furukawa et al25 evaluated the outcomes ofmedial collateral ligament reconstruction of the elbow witheither a palmaris longus tendon or GraftJacket as the re-construction material. These authors found both materialscomparable and concluded that GraftJacket might be a viablealternative to the harvesting of autogenous palmaris longustendon grafts.

In our series, no adverse reactions were associated withthe use of this allograft material, and results were durable, atleast in the follow-up available in this series.

SUMMARYIn summary, we believe that ligament reconstruction and

tendon interposition using an acellular human dermal allograftare an effective treatment of first CMC arthritis and a rec-ommended alternative to traditional surgery using an autografttendon. Our surgical outcomes mimic the outcomes with the

FIGURE 7. Side to side comparison between GraftJacket Maxstripand the half of the flexor carpi radialis tendon.

FIGURE 8. A, The GraftJacket is anchored around the FCR tendon and is sutured to itself. B, Using a Hewson tendon passer, theallograft is passed through the hole previously drilled in the base of the first metacarpal. C, The allograft is folded back on itself.D, The palmar beak ligament is reconstructed by maintaining the thumb in abducted position, whereas the GraftJacket is sutured securelyon itself. E and F, The remaining portion of the allograft is fashioned as an interposition mass (anchovy) and interposed in the spaceformerly occupied by the trapezium. G, The interposition mass is held in the arthroplasty space with careful and snug capsular repair.GJ, GraftJacket; FCR, flexor carpi radialis.




use of the flexor carpi radialis tendon. Moreover, donor sitemorbidity is avoided, and complications are minimal.

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18. Zanaros G, Kokkalis ZT, Sotereanos DG. Thumb CarpometacarpalJoint Arthroplasty Using Acellular Dermal Allograft: A Review of

FIGURE 9. A, Preoperative radiograph of CMC arthritis, which shows loss of joint space, radial subluxation, and osteophyte formation.B, Postoperative radiograph (18 months after surgery) showing preservation of the space between the scaphoid and the base of thefirst metacarpal.

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100 Cases. Podium presentation at 63rd Annual Meeting of theAmerican Society for Surgery of the Hand, Chicago,September 18Y20, 2008.

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25. Furukawa K, Pichora J, Steinmann S, et al. Efficacy of interferencescrew and double-docking methods using palmaris longus andGraftJacket for medial collateral ligament reconstruction of the elbow.J Shoulder Elbow Surg. 2007;16(4):449Y453.




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