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Die Arthrodese des Daumensattelgelenks

Arthrodesis of the trapeziometacarpal joint

  • Operative Techniken
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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Zusammenfassung

Operationsziel

Versteifung des Karpometakarpalgelenks des Daumens durch knöcherne Fusion von Trapezium und Basis des ersten Mittelhandknochens.

Indikationen

Hohe Ansprüche an Stabilität und Kraft des Daumens bei primärer oder sekundärer Rhizarthrose (z. B. nach Verletzung des Karpometakarpalgelenks des Daumens), Instabilitäten ohne Arthrosebildung aufgrund von Fehlbildungen, generalisierter Bandlaxizität und Gelenkhypermobilität, zur Verbesserung der Handfunktion bei neurologischen Krankheitsbildern, bei Fehlbildungen, als Rettungsverfahren nach fehlgeschlagener endoprothetischer Versorgung des Karpometakarpalgelenks (bei ausreichender Knochensubstanz).

Kontraindikationen

Arthrose und Einsteifung angrenzender Gelenke; Aktivitäten mit maximaler Beweglichkeit des Daumens; unzureichende Knochensubstanz.

Operationstechnik

Resektion der Gelenkflächen des Karpometakarpalgelenks über dorsalen Zugang. Nach temporärer Kirschner-Draht-Transfixation Anlage einer dorsalen T‑Platte (winkelstabil/nichtwinkelstabil), Ersatz des Kirschner-Drahts durch Zugschraube.

Weiterbehandlung

Ruhigstellung für 8 Wochen (radial umgreifende Gipsschiene mit Einschluss des Daumengrundgelenks); Standardröntgenaufnahmen am 2. postoperativen Tag und nach 8 Wochen; Entfernung des Nahmaterials nach 2 Wochen; bei Konsolidierung der Arthrodese nach Gipsabnahme handtherapeutische Behandlung zur Steigerung von Bewegungsumfang und Kraft; kraftvoller Handeinsatz nach 3 Monaten.

Ergebnisse

Gute bis sehr gute Ergebnisse hinsichtlich Kraftentwicklung, Stabilität und Schmerzreduktion mit hoher Patientenzufriedenheit. Nachteilig sind implantatabhängige Komplikationen und eine Nichtheilungsrate von durchschnittlich 13 %. Dennoch ist die Arthrodese bei jungen, manuell arbeitenden Berufstätigen, die eine gewisse Bewegungseinschränkung tolerieren, indiziert.

Abstract

Objective

Bony fusion of the trapeziometacarpal joint.

Indications

High demands concerning stability and strength of the thumb in primary or secondary osteoarthritis (e.g., posttraumatic osteoarthritis following injuries to the carpometacarpal joint of the thumb); instability in the absence of osteoarthritis due to malformations, ligamentous laxicity, and joint hypermobility; malformations; improvement of hand function in neurological disorders; salvage procedure after carpometacarpal arthroplasty provided bone stock is sufficient.

Contraindications

Osteoarthritis or stiffness of adjacent joints, activities demanding maximal mobility of the thumb, insufficient bone stock.

Surgical technique

Resection of the articular surfaces of the trapeziometacarpal joint via a dorsal approach. After temporary K‑wire transfixation, application of a dorsal T‑shaped plate (fixed angled or not), replacement of the K‑wire with a lag screw.

Postoperative management

Immobilization for 8 weeks (radial below-elbow cast including the thumb metacarpophalangeal joint); standard radiographs on second postoperative day and after 8 weeks; removal of stitches after 2 weeks; with bony healing after removal of the cast, guided exercises to increase strength and mobility; full loading for manual tasks after 3 months.

Results

With regards to strength, stability, and pain reduction, results are rated as good and excellent with a high degree of patient satisfaction. Disadvantages are implant-related complications and nonhealing of the fusion in an average of 13% of patients. Nevertheless, the procedure is still indicated in young manual workers who tolerate some limitations of mobility.

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Authors and Affiliations

  1. Klinik für Handchirurgie, Salzburger Leite 1, 97616, Bad Neustadt an der Saale, Deutschland

    T. Pillukat, M. Mühldorfer-Fodor & J. van Schoonhoven

  2. Klinik für Fußchirurgie, Bad Neustadt an der Saale, Deutschland

    R. Fuhrmann

  3. Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland

    J. Windolf

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Correspondence to T. Pillukat.

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Interessenkonflikt

T. Pillukat, M. Mühldorfer-Fodor, R. Fuhrmann, J. Windolf und J. van Schoonhoven geben an, dass kein Interessenkonflikt besteht.

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F. Unglaub, Bad Rappenau

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Pillukat, T., Mühldorfer-Fodor, M., Fuhrmann, R. et al. Die Arthrodese des Daumensattelgelenks. Oper Orthop Traumatol 29, 395–408 (2017). https://doi.org/10.1007/s00064-017-0515-7

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