The next speaker is Dr. Henry Backe. Henry is a close friend of mine who I've known since we were in training together more than 20 years ago. He's also the immediate past president of the Eastern Orthopedic Association. Henry is a very clear thinker and there's no question that he's a very talented surgeon. He's going to show us a nice technique. Thank you, David, Craig, and I thank the Hand Society for allowing me to participate in this great day. I'm amazed that these moderators have kept us all on time and we're actually ahead of schedule. So I'm going to talk today about my approach to basal joint orthoplasty. I know there's several ways to do this. I've gone through about four or five throughout my career. I'll just give you a little bit of my experience. So here are my disclosures. They have no relevance to this topic. Let's do a little bit of anatomy lesson. First, we know that the basal joint is a biconcavo-convex universal joint, otherwise known as a saddle joint. And without the stabilizing ligament, it would be inherently unstable. When I was a fellow 20-some years ago, I was taught that the main stabilizing ligament was the AOL, or the palmar oblique, or otherwise known as the beak ligament. We know over years that that's probably not correct and that it's really the dorsal radial ligament complex and the inner metacarpal ligament that adds the most stability to the CMC joint. So classically, we're taught that this ligament was the stabilizing ligament, but it really is the dorsal radial complex. And over here you can see the dorsal radial complex and the inner metacarpal ligament, which stabilize the joint in pinch and power grip. So I'll have you refer to this article in the Journal of Hand Surgery 2011. Unfortunately, my bibliography got cut off, so it's not on there. But this is a great review by Edmonds on the current concepts of the basal joint. And in a nutshell, basically, there's a screw home torque phase of our pinch. And as we pinch, the beak portion of the metacarpal goes down into the trapezial recess and the dorsal radial complex tightens and gives us stability. If you see here, actually that palmar oblique ligament is really lax and really does not help in preventing any subluxation or stability to the joint during power pinch. So it is thought now that compressive loads that are repetitive between that volar beak and the trapezial recess start to develop articular wear and eventual degenerative arthritis. Also as the dorsal radial ligament complex stretches out, as we see in postmenopausal women, we get repetitive shear and stress, which adds to the degenerative arthritis. We also see degenerative arthritis changes in the rheumatoid. That's a different pathology. And we see it in posttraumatic, either from articular disruption or ligamentous disruption. You can see here the volar beak ligament. You can see wear on that volar beak of the metacarpal base. You can see a taut dorsal ligament complex. And here is that recess when you go into pinch, where that beak kind of falls down in and locks into place. So surgical objectives for a basal joint arthroplasty. Number one, you want pain relief. Number two, you want metacarpal stability. Three is thumb motion. And four is pinch strength. Historically, we are about pain relief. And most of the common procedures early on were arthrodesis and I think Peter Stern is going to talk to us later about that. But the disadvantage of an arthrodesis is that you lose motion in the thumb. You can't put your hand flat on the table. And if you have pan-trapezial arthritis, as in most patients that come to me with basal joint pain have, it's contraindicated. Next came along trapezial excision. While this worked fine for pain relief, but there really was no effort in stabilizing the metacarpal base. If you didn't get good scarring, your metacarpal base was unstable and you had significant loss of pinch and grip strength. So then we went on to trying to stabilize the metacarpal base. And we can thank Dr. Carroll, as well as Burton, Pellegrini, Posner, and Green for their interpositional arthroplasties, which really didn't address any ligament instability, but gave us a spacer and a scar formation to try and stabilize the metacarpal base and protect the metacarpal from hitting onto the scaphoid. I was trained by Dr. Posner. He'll probably shoot me when I tell him this, but he taught me how to do the abductor pulsus longus advancement in an effort to stabilize the metacarpal base. To me, it wasn't really an anatomic fix, and I always kind of longed for a better anatomic procedure. So I went on to look into the LRTI, and I modified that technique, which I'll show you in a minute. So the LRTI is the most common arthroplasty procedure performed on the basal joint. There was a recent survey done in the Journal of Hand Surgery, which confirmed this. It maintains the length of the thumb column. It's supposed to maintain trapezoidal space, although the literature with long-term follow-up doesn't necessarily prove that, but the results are still good. The ligament reconstruction, as described early on, was to reconstruct that volar ligament. However, if you really look at the direction of your ligament reconstruction, the FCR or the APL, whichever you use, really mimics the inner metacarpal ligament rather than the beak ligament. So I started out, after my fellowship, doing an abductor pulse, longest advancement, and pinning the thumb for about four to five weeks. It wasn't really what I thought was anatomic. I had a lot of patients where the base of the metacarpal over time would kind of roll out, and they would complain that the thumb was too mobile. So I went to the LRTI, and I started taking half the FCR as originally described. To me, that was technically a pain in the neck. And finally, I went to taking the entire FCR, and I've never had a patient complain to me about a lack of wrist flexion. I also found that the entire FCR was much more stout and robust, and to me, it seemed like it would possibly prevent metacarpal subsidence over time. Well, in the day of trying to get many surgeries done in a day, you try and cut mints down in the OR. So I've gone to doing a percutaneous flexor carpi radialis harvest, where it obviates the need for a second incision, cuts down the tourniquet time five to six minutes. So here's just a little diagram of my procedure, where I leave the FCR at its insertion. I pass it through in the typical way. I come back, but instead of bringing the tendon slip back down to the graft, I take it down, and I suture it to the trapezial margin of the transverse carpal ligament. And that direction is the same direction as that dorsal radial complex. And by putting it further to the scaphoid, you're changing the vector, so you get much better stability to prevent dorsal subluxation. So over 12 years, I've done 243 cases. Most of them are females. You see 197. I've had to do seven revisions, most of them for intermetacarpal pain, where the first metacarpal base will rub up against the second metacarpal base. I've just done sort of a more graft jacket type interposition arthroplasty to separate them. The bases do seem more stable, and although I don't have data to prove it, anecdotally, to me it seems like they have better pinch strength. So I'm going to just play this video. So crex site surgery is important. I use an incision between the glabrous and non-glabrous skin of the thumb. I make a little mark at the junction of the tendon muscle. I infiltrate with lidocaine and marcaine for preemptive analgesia as well as postoperative analgesia. I inject the subcutaneous tissues, and then I inject the joint. It's done under a tourniquet after exsanguination with an Esmark. Curviline incision is made as described previously. I go just through the skin. I use a pair of iris scissors to dissect out the subcutaneous tissue and protect all the dorsal radial sensory neurobranches. You take an incision through the abductor pollicis longus and the abductor pollicis brevis to expose the capsule and the trapezium. You can see that there's some radial sensory branches here and up here. I then do a subperiostral dissection of the trapezium, dissecting all the way down to the edge of the transverse carpal ligament. And once I get adequate exposure, I remove any loose bodies. And then I use an osteotome after I've done about two-thirds of the section of the trapezium to split the trapezium into quarters. Care should be taken not to take the osteotome all the way through the trapezium because your FCR tendon is at the base of the wound, and if you're not careful, you can slice it. So I kind of do a little twisting maneuver on the osteotome to kind of break the trapezium into four quarters. Then use a ranjour to remove the trapezium in piecemeal, still making sure that I'm looking out for the FCR. Many times the trapezial osteophytes will actually encase the FCR, and you have to be careful to sort of peel the bone away so that you don't disrupt the insertion or the integrity of the tendon. Here you can see here, the tendon's underneath and the trapezial bone is wrapping around. Here's the FCR tendon protected. Now I use a malleable in a U-shape, and I slide it right under the metacarpal. It protects the FCR. It protects the trapezoid surface, and it stabilizes my metacarpal base. You can see here the articular disruption down that vulva area. I look at the longitudinal axis of the skull, and I remove this articular surface to try and bring more bleeding and cancellous bone against my subsequent anchovy. I mark my spot where I want to come through, from dorsal to volar, and I use a 4mm pineapple bur. Then I take the FCR on tension and you can palpate it all the way up the forearm and then with an 11 blade I go just through the surface and I make sure I feel the tense tendon and I release it bit by bit. And then you can pull it right out through the same incision and just remove any residual muscle. The tendon is then passed through in the standard fashion and I use a pointed tendon passer to bring it across the metacarpal, ulnar to the abductor pollicis longus insertion and bring it back down into the trapezial space. You have to take care to make sure that your extensor pollicis brevis is free and you don't trap the EPV. Here I'm putting the suture in the transverse carpal ligament and switches where I'm going to recreate the dorsal radial complex and add stability in the 90-degree plane to the inner metacarpal ligament. That's the extra suture, just to make sure if one pulls out I still have another one to maintain stability because I don't like to pin them. You can see here we're stressing it. You have stability in both a radial and a dorsal direction. I then take the stay suture and weave it through the remainder of the tendon so that I can accordion it and make an anchovy. And I slip it right underneath up against that metacarpal base Tie down the anchovy so it doesn't slip out and then I close the capsule I have been starting to take a cancellous bone from trapezium and fill in the bone tunnel To try and get a more secure press fit of my tendon Can you fast forward this One second The capsule is closed with the abductor pollicis brevis up against the APL the tourniquet is in released We do hemostasis with the bipolar So for the sake of time, I'll cut through I do splint it for five weeks in opposition and This is not the only way to do it. There are many ways to skin a cat. Thank you

Dr. Henry Backe

basal joint orthoplasty

dorsal radial complex

basal joint arthroplasty

Ligament Reconstruction Tendon Interposition (LRTI)