CPT® Code 25448

1. Indications

The procedure is indicated for patients experiencing significant pain and functional limitations due to arthritis affecting the intercarpal or carpometacarpal joints. Specific indications include:

• Painful Arthritis - Patients suffering from painful arthritis in the thumb or wrist that has not responded to conservative treatments.
• Joint Instability - Conditions where joint instability is present, necessitating surgical intervention to restore function.
• Loss of Function - Individuals who have a marked loss of hand function due to degenerative joint disease.

2. Procedure

The surgical procedure involves several critical steps to ensure successful arthroplasty of the intercarpal or carpometacarpal joints. Each step is designed to address the specific anatomical and functional needs of the joint being treated.

• Step 1: Incision and Dissection - An incision is made over the base of the first metacarpal and trapezium. The surgeon carefully dissects down to the joint capsule, taking care to protect the radial nerve and radial artery during this process.
• Step 2: Joint Access - The joint capsule is opened, and the first carpometacarpal joint is incised. The periosteum of the trapezium is elevated to allow for further access to the joint structures.
• Step 3: Triscaphe Joint Dissection - Dissection continues to open the triscaphe joint, which is located between the scaphoid, trapezium, and trapezoid bones, facilitating the removal of the trapezium.
• Step 4: Trapezium Removal - Using osteotomes and a rongeur, the trapezium is removed in pieces while ensuring the flexor carpi radialis (FCR) tendon is protected. Any bone spurs present are also excised during this step.
• Step 5: Tendon Preparation - A tunnel is created for threading the FCR tendon through the base of the first metacarpal. The tendon is exposed and transected proximally at the musculotendinous junction, then pulled into the distal wound for further manipulation.
• Step 6: Splitting the Tendon - The FCR tendon is dissected or split lengthwise to its insertion at the second metacarpal, with the ends prepared for threading through the bone tunnel.
• Step 7: Tendon Transfer - A looped suture passer is utilized to thread the FCR tendon through the prepared hole in the first metacarpal. After positioning the first ray appropriately for tendon transfer, the two limbs of the FCR tendon are sutured together, and tension is assessed to prevent collapse of the trapezial space.
• Step 8: Finalizing the Procedure - Motion is assessed to ensure there is no impingement. The remainder of the tendon is rolled up and sutured to itself, then secured deep in the trapeziectomy wound bed. Finally, the carpometacarpal capsule, periosteum, and scaphotrapezial capsule are repaired, and a dressing and splint are applied to support the area post-surgery.

3. Post-Procedure

Post-procedure care involves monitoring the surgical site for any signs of complications and ensuring proper healing. Patients are typically advised to keep the hand elevated and immobilized in a splint to minimize swelling and promote recovery. Pain management strategies may be implemented, and physical therapy may be recommended to restore mobility and strength in the affected joint. Follow-up appointments are essential to assess healing and functionality, and to make any necessary adjustments to the rehabilitation plan.