1. Excision of the Trapezium
K.MOHAN IYER
M.Ch.Orth(Liverpool, U.K.),M.S.Orth(BOM)
F.C.P.S.Orth(BOM),D’Orth(BOM),
M.B.,B.S.(BOM).

2. Original Work

1.The Results of Excision of the Trapezium
K.Mohan Iyer(Oct.1981) The Hand,Vol.

13,No.3:246-250.
 2.Arthrography of the Metacarpo-Scaphoid
 Joint following Excision of the Trapezium
 -K.Mohan Iyer & G.H.Whitehouse(Oct.
 1981) The Hand,Vol.13,No.3:251-256.

3. Work quoted in Literature
(From 1985 till 2002)
1.Osteoarthritis of the Carpometacarpal Joint
of the Thumb-L.Kvarnes & O.Reikeras(Feb.1985)
J.of Hand Surgery,Vol.10-B,No.1,117-120.
2.Rheumatoid Arthritis at the base of the Thumb
treated by Trapezium Resection or Implant
Arthroplasty-L.Kvarnes & O.Reikeras(June 1985)
J.of Hand Surgery,Vol.10-B,No.2,195-196.
3.Interposition Arthroplasty of the
Trapeziometacarpal Joint for Osteoarthritis-Paul
C.Dell & Ruth B.Muniz(July 1987) Clinical
Orthopaedics & Related Research,No.220,27-34.

4. Work quoted in Literature
(From 1985 till 2002)
4.Replacement of the Trapezium with a
Silicone Elastomer Universal Small Joint
Spacer-B.Helal & I.McPherson(Nov.1989)
J.of Hand Surgery,Vol.14B,No.4:456-459.
5.Revision Procedures for complications of
Surgery for OA of the CMC Jt.of the
Thumb-W.B.Conolly & S.Rath(Aug.1993)
J.of Hand Surgery,Vol.18B,No.4:533-539.

5. Work quoted in Literature
(From 1985 till 2002)
6.Excision of the Trapezium for OA at the
base of the Thumb-Varley G.W,Calvey
J,HunterJ.B,BartonN.J,DavisT.R.C(Nov.19
94)JBJS(Br),76-B,Vol.6,964-968.
7.Simple Trapezectomy for Treatment of TM
OA of the Thumb-Vandenbrouche J,De
Schrijver F,De Smet L,Fabry G(1997)
Clin.Rheumatology;16,239-242.

6. Work quoted in Literature
(From 1985 till 2002)
8.A comparison of Trapeziectomy with or without
ligament reconstruction & Tendon interpositionHJCR Belcher & JE Nicholl (Aug.2000) J.ofHand
Surgery,Vol.25B,No.4:350-356.
9.Early versus late mobilisation after simple excision
of the Trapezium-N.Horlock&HJCR Belcher(Nov.
2002) JBJS(Br),Vol.84-B,No.8:1111-1115.

7. The Trapezium
Surfaces









1.Palmar Surface-Groove and a Tubercle.
2.Dorsal Surface-Related to Radial Artery.
3.Lateral Surface-Lateral collateral ligament
of the wrist joint & capsular ligament of
the carpometacarpal joint.
4.Medial Surface-Facet for the Trapezoid.
5.Proximal Surface-Facet for the Scaphoid.
6.Distal Surface-Saddle shaped for the base of the
first metacarpal.

8. Normal Wrist Joint
Compartments

1.Radiocarpal Joint.
 2.Inferior Radioulnar Joint.
 3.Midcarpal Joint.
 4.Isolated Carpometacarpal Joint of the
 Thumb.

10. Intercarpal Joints








1.Joints between bones of the proximal row.
2.Joints between bones of the distal row.
3.Midcarpal Joint
- Between these two rows of bones.
- S shaped cavity lined by synovial
membrane.
- Has 2 projections proximally and
3 projections distally.

11. Pathology

Stage I:
 Pain
 Synovitis
 Local Swelling
 Effusion into the joint

13. Pathology

Stage II:
 Severe pain
 Joint space narrowing
 Medial osteophyte

16. Pathology
Stage III:
Severe pain
Marked decrease of joint space
Subluxation of the metacarpal

18. Pathology
Stage IV:
Subluxated metacarpal fixed by fibrosis &
contracture
Marked hyperextension deformity of the MCP joint
Flexion deformity of the IP joint
Pain minimal or nil
Fixed adducted thumb


20. Carpometacarpal Arthritis of
the Thumb








Age:60 Years
Sex:Women(Post Menopausal)
Side:Right side;Both sides frequent
Predisposing Factors:
1.Trauma(30%)
2.Developmental Anomalies
3.Occupational
4.Anatomical

21. Carpometacarpal Arthritis of
the Thumb

Symptoms:
 1.Severe pain-Base of the thumb

-Aggravated by movements
 2.Swelling over the base of the thumb
 3.Stiffness of the Thumb
 4.Weak Grip

22. Carpometacarpal Arthritis of
the Thumb-Treatment

(A)Conservative Treatment:

1.Physiotherapy

2.Radiotherapy

3.Splint

4.Intra-articular Steroids

23. Carpometacarpal Arthritis of
the Thumb








(B)Surgical Treatment:1.Forage
2.Intra-articular Tenodesis
3.Excision of the Trapezium
4.Arthrodesis
5.Silicone rubber interpositional
arthroplasty
6.Prosthetic Replacement

24. Carpometacarpal Arthritis of
the Thumb

Charcot and Leri(1926)
 Robert(1936)
 Forestier(1937)
 Lasserre,Pauzat and Derennes(1949)

26. Excision of the Trapezium
Gervis(1949) 18 wrists with 16 good results.
(1973) 12 wrists followed up for 6 to 22 years.
Goldner & Clippinger(1955) Excison of the
Trapezium piece-meal.
Murley(1960) 39 wrists with 36 good results.
Marmor & Peter(1969) 7 wrists with 5 good
results.
Sims & Bentley(1970) 27 Trapeziectomies with
excellent results in 15,Good in 6,Fair in 5 & Poor
in one.Incidence of 54% of patients with
associated Trapezio-Scaphoid Arthritis.

28. Clinical Evaluation

1.Name
 2.Age
 3.Sex
 4.Dominant Hand
 5.Occupation
 6.Time off work:Pre-op,Post-op & Total.

29. Clinical Evaluation

7.Return to original occupation.
 8.History of Injury.
 9.Duration of complaints pre-op.
 10.Time since surgery.

30. Clinical Evaluation

Associated Conditions:
 1.Cervical Spondylosis.
 2.Periarthritis Shoulders.
 3.Stenosing Tenovaginitis.
 4.Median nerve compression.
 Surgical – Incision.

- Post operative management.

32. Results
Thumb Movements:1.Abduction-Normal range+Power -18 wrists
-Less than 50%
-8 wrists
2.Opposition-Normal range+Power -14 wrists
-N.range+50%Power - 9 wrists
-Less than 50% R+P - 3 wrists
3.Adduction-Normal Power - 25 wrists
-Poor
- 1 wrist
4.Circumduction-Normal -25 wrists
-Poor
- 1 wrist

44. Results

Associated Features:
1.Cervical Spondylosis
-13/18 patients.
2.Periarthritis Shoulders
-9/18 patients.
3.Stenosing Tenovaginitis -3/18 patients.
4.Median nerve compression -4/18 patients.
(Surgical Decompression in 2 patients)

47. Results

Functioning tendons of Flexor carpi radialis

and Flexor pollicis longus =26/26 wrists.
 Decreased sensations over the dorsum of

the base of the thumb =3/26 wrists.
 Keloid formation = 5/26 wrists.
 Palpable Neuroma = None.

48. Results

Opposition Grip:

Normal Power
= 6 wrists

Decreased power = 20 wrists

Pinch Grip:

Normal Power
= 7 wrists

Decreased Power = 19 wrists

55. Radiographic Assessment









1.Level of first metacarpal base.
2.Accessory Ossicles.
3.Radiologic gap.
4.Telescoping.
5.Stress views.
6.Degenerative changes:
-Base of first metacarpal
-Distal Scaphoid
-Elsewhere in the carpus

56. Radiographic Features
1.Telescoping
2.Accessory Ossicles
3.Radiological Gap
4.Degenerative changes:
-Base of first metacarpal
-Distal Scaphoid
-No changes
=14 wrists(55%)
= 9 wrists(40%)
= 1mm to 6mm
=14 wrists
= 8 wrists
=11 wrists

58. Radiographic Features
5.Residual Cartilage:
Base of first MC – Nil in 3 wrists
- Present in 22 wrists
Distal Scaphoid - Nil in 2 wrists
- Present in 23 wrists
6.Lateral subluxation of 1st MC on Abduction
Marked subluxation in 3 wrists
Moderate subluxation in 22 wrists

60. Radiographic Features
7.Maintenance of joint space despite subluxation of
the 1st MC on the Scaphoid on radial deviation of
the wrist.
8.Stress views of the wrist:
No changes
= 9 wrists
Widening of the Sc-Trap.Jt
=12 wrists
Widening of the Sc-Cap.Jt
= 6 wrists
Widening of gap between
the bases of 1st & 2nd MC’s = 6 wrists

64. Arthrography of the
Metacarpo-Scaphoid joint

Technique

67. Arthrographic Assessment

1.Amount of dye injected.
 2.Ease of location of the joint & injection.
 3.Residual articular cartilage over:
-Base of the first metacarpal.

-Distal Scaphoid.

68. Arthrographic Assessment

4.Joint Features
(A)Isolated.
(B)Communications-Midcarpal
-Radiocarpal
-Radioulnar
-Tendon Sheaths
-Pouch between 1st &
2nd metacarpal bases
5.Stress Views
6.Per operative Arthrogram

71. Arthrographic Features
1.Distinct Joint Space
- 25 wrists
2.Comm.with midcarpal joint - 10 wrists
3.Comm.with radiocarpal joint - 2 wrists
4.Comm.with distal RU joint - 1 wrist
5.Comm.with tendon sheaths - 4 wrists
6.Contour-Irregular & small – 16 wrists
-Regular & larger - 9 wrists

76. Conclusion
1.Excision of the Trapezium gives good
results with respect to relief of pain.
2.Good hand function despite some reduction
in the power of Opposition grip and Pinch
grip.
3.Carpal Instability or Laxity may account for
decreased Opposition grip & Pinch grip.

77. Conclusion
4.Arthrographic Features:
-Distinct joint space
-Small & Irregular within 6 months of
Surgery
-Large & Regular thereafter
-Marked subluxation indicates weak grip
5.Late deterioration of pseudoarthrosis in one
patient