Elsevier

The Journal of Hand Surgery

Volume 43, Issue 5, May 2018, Pages 483.e1-483.e9
The Journal of Hand Surgery

Scientific article
Arthrodesis Versus Carpometacarpal Preservation in Key-Grip Procedures in Tetraplegic Patients: A Comparative Study of 40 Cases

https://doi.org/10.1016/j.jhsa.2017.10.029Get rights and content

Purpose

Constructing a lateral key pinch (KP) is a universal aim of any functional upper limb surgery program for tetraplegia. Three stages are required: (1) activating the pinch mechanism by flexor pollicis longus tenodesis to the radius or by tendon transfer to the flexor pollicis longus, (2) simplifying the polyarticular chain, and (3) positioning the thumb column. We compared 2 techniques for accomplishing the latter stage, 1 utilizing arthrodesis of the carpometacarpal joint (CMC) and 1 that did not require arthrodesis of the CMC.

Materials and methods

We reviewed 40 cases of KP reconstruction at a mean follow-up of 7.4 years: 17 who had undergone CMC arthrodesis and 23 without CMC arthrodesis. In this group, an abductor pollicis longus tenodesis was necessary to properly position the thumb column in 17 patients.

Results

Active KP cases with CMC arthrodesis were significantly stronger than those without an arthrodesis. For passive KP cases, the difference between those cases with CMC arthrodesis and those without was not significant. Regarding opening, for active KP cases with CMC preservation alone, the mean distance between the thumb pulp and the index finger was 4.0 cm at rest and 5.8 cm when passively grasping large objects; for active KP cases without arthrodesis, these values were 3.4 and 6.8 cm, respectively, with the wrist in flexion. For passive KP cases, these values were 2.2 and 3.5 cm with CMC arthrodesis compared with 2.4 and 6.9 cm without arthrodesis. Overall, 23.5% of patients with CMC arthrodesis could not maintain contact between the thumb and the index finger compared with 30.4% without arthrodesis.

Conclusions

Active KP is stronger with than without CMC arthrodesis; however, the KP reconstruction does not open as far when grasping large objects. For passive KP, CMC arthrodesis significantly limits passive opening, with no gain in strength. Neither technique is superior in terms of KP stability.

Type of study/level of evidence

Therapeutic IV.

Section snippets

Materials and Methods

We reviewed 40 KP procedures in 31 tetraplegic patients (mean age, 34 years; sex ratio, 1:4 [F:M]) in groups 1 to 5 of the Giens international classification of tetraplegia levels (Table 1).2 We included all tetraplegic patients admitted to our upper limb functional reanimation program between January 2006 and December 2009 who had undergone KP reconstruction. The inclusion criteria were follow-up greater than 1 year; patients who had undergone a complete surgical program by our team, including

Grip strength

Among patients who had undergone CMC arthrodesis, active KP strength was greater (2.6 kg range, 1.2–5.0 kg) than in those treated with passive KP (1.3 kg, range 0.5–2 kg) (P < .05) (Fig. 2). Passive KP cases with and without CMC arthrodesis were similar in strength. Strength of active KP patients with CMC joint preservation was similar to patients with passive KP, independently of their thumb positioning strategy. Grip strength was slightly greater for KP cases activated by BR than by PT (2.4

Discussion

Few studies have compared thumb position techniques during KP restoration in tetraplegic patients. Furthermore, previous studies focused only on pinch strength.11 To reduce the selection bias inherent in a retrospective study, we included all patients admitted to our institution over 3 years, except patients who did not recover active wrist extension.14, 15

The baseline data for patients with and without CMC arthrodesis were comparable in terms of ASIA scores for wrist extension strength, with

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    No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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