The Effect of an Open Carpal Tunnel Release

on Thumb CMC Biomechanics

Marc A Tanner, MD; Bryan P Conrad, PhD;
Paul C Dell, MD; Thomas W. Wright, MD

Department of Orthopaedics and Rehabilitation
University of Florida, Gainesville, FL



Running Title: Thumb CMC Biomechanics

Corresponding Address:
Thomas W. Wright, PhD
Professor of Orthopaedic Surgery
Department of Orthopaedics and Rehabilitation
Orthopaedics and Sports Medicine Institute
3450 Hull Road
Gainesville FL 32608
Phone: 352-273-7375
Fax: 352-273-7388
Email: [email protected]
There was no financial or other support received for this research and none of the authors have a
conflict of interest.
No human subjects were included in this study; therefore, IRB approval was not required. At the time
this project began, no approval was needed for cadaver study.
KEY WORDS: biomechanics; cadaver; carpal tunnel; carpal tunnel release; carpometacarpal (CMC)
arthritis; thumb CMC biomechanics



ABSTRACT
Purpose
We have observed worsening thumb pain following carpal tunnel release (CTR) in some
patients. Our purpose was to determine the effect of open CTR on thumb carpometacarpal
(CMC) biomechanics. We hypothesized that a CTR would cause rotation of the trapezium,
altering biomechanics of the first CMC joint.

Methods
Five fresh-frozen cadaver arms with intact soft tissues were used. Each specimen was secured to
a jig which fixed the forearm at 45
o
supination, and the wrist at 20
o
dorsiflexion, with thumb
pointing up. The thumb was axially loaded with a force of 130 N. We measured 3-D translation
and rotation of the trapezium, radius, and first metacarpal, before and after an open CTR.
Motion between the radius and first MC, radius and trapezium and first MC and trapezium
during loading was calculated using rigid body mechanics. Overall stiffness of each specimen
was also determined.


Results
Total construct stiffness following CTR was reduced in all five specimens, but the reduction was
not statistically significant. No significant changes were found in adduction, pronation, or
dorsiflexion of the trapezium with respect to the radius after open CTR. Motion between the



radius and first MC1, between radius and trapezium, or between MC1 and trapezium after an
open CTR was not decreased significantly.

Conclusion
From this data, we cannot determine if releasing the transverse carpal ligament alters the
kinematics of the CMC joint.




1. Introduction
Carpal tunnel syndrome and basal joint arthritis often coexist [1]. A study of 246 patients with
basal joint arthritis of the thumb reported that 39% of the study patients also had carpal tunnel
syndrome [2]. Anecdotally, we have observed worsening thumb carpometacarpal (CMC) pain
in some patients with previously asymptomatic (or minimally symptomatic) first CMC arthritis
after undergoing a carpal tunnel release. The thumb CMC joint is the most common site for
reconstruction in the upper extremity secondary to osteoarthritis [3]. It is a semi-constrained
joint composed of two saddle-shaped articulations with opposing axes perpendicular to each
other. Minimal congruence and bony stability allow for a wide range of motion [4].
The anterior border of the carpal tunnel is formed by the transverses carpal ligament
(TCL) [5]. The transverse carpal ligament proper inserts into the scaphoid tubercle and trapezial
ridge radially and the hamulus and pisiform ulnarly [6]. Studies have noted increase in carpal
tunnel volume, increase in the carpal arch width, and an overall decrease in carpal stiffness after
carpal tunnel release (CTR) [6-12]. Rotational changes of the hamate, pisiform, and the
trapezium have also been reported, as well as an increase in the distance between the trapezium
and the hook of the hamate [5]. Previous research suggests a direct relationship between
widening of the transverse carpal arch and loss of grip strength [13]. Pillar pain is a common
complaint after CTR [14], perhaps as a result of the division of the TCL during surgery [6].
Pain originates most commonly over the piso-triquetral joint, possibly secondary to
displacement of the pisiform or alteration of forces over the joint [11,15]. The same type of
biomechanical changes could occur with the trapezium and the CMC joint. The purpose of this
study is to determine the effect of open CTR on the kinematics of the trapezium and first CMC



joint. Our hypothesis was that a CTR will allow rotation of the trapezium altering the
biomechanics of the first CMC joint. These changes could result in the clinical observation of
increased first CMC joint pain in patients with previous subclinical CMC arthritis.

2. Materials and Methods
Five fresh frozen cadaver arms with intact soft tissues were used. There were three male
specimens and two female specimens (donor age was not available). Each specimen was secured
to a custom- made jig with 3.0 threaded Steinman pins, two at the distal radius and two placed in
the second metacarpal (Figure 1).

Figure 1: Photograph of a specimen
secured in the custom-made jig. The
forearm is at 45 degrees supination and
the wrist at 20 degrees dorsiflexion,
thumb pointing up.

The jig fixed the forearm at 45
o
supination and was designed to allow free motion at the
thumb CMC joint and radiocarpal joint while the wrist was fixed in 20
o
of dorsiflexion. A
threaded 2.0 mm K-wire was placed from the tip of the thumb distal phalanx into the thumb
metacarpal, leaving 2 cm of wire out of the skin. The wire out of the skin was placed into an
MTS machine (MTS Systems, Eden Prairie, MN) and the jig secured to the base of the testing
machine.



An electromagnetic tracking system (Liberty, Polhemus Inc, Colchester, VT) was used to
measure the 3-D translation and rotation of the trapezium, radius, and first metacarpal.
Electromagnetic sensors were attached to the radius and first metacarpal using custom-made
fiberglass brackets. A threaded K-wire was placed into the trapezium, ensuring that the joint
capsule remained intact, and a third electromagnetic sensor was attached to the K-wire to track
the trapezium. The electromagnetic source was positioned within 20 cm of the sensors to
minimize the effect of distortion created by the testing machine and jig. Internal electronics of
the Polhemus Liberty system are capable of detecting distortions and when present, the testing
setup was adjusted to eliminate them. After loading at 10 N once to remove any slack, the thumb
was axially loaded with a 130 N force.
The total motion of the first MC relative to the radius (R-MC1), between the radius and
trapezium (R-T) and between the first MC and trapezium (MC1-T) during loading was
calculated using rigid body mechanics. The stiffness of each specimen was also determined by
measuring the slope of the load-displacement curve during loading. The measurements were
collected from each specimen before and after an open CTR. An open CTR was performed in
the standard fashion and verified visually and with palpation. The release was performed
without removing the specimen from the jig. A paired t-test was used to determine differences in
rotation and translation of the specimen pre and post CTR.



3. Results
Motion and stiffness data is presented in Table 1.

TABLE 1. Summary of Mechanical Properties for Each Combination of Bones
Before and After Open Carpal Tunnel Release.

Measurement Intact After Release Difference P-Value
(mean SD) (mean SD)



Rad-Met1 Rx (adduction) (deg) 2.2 1.3 2.1 1.6 6.6% 0.69

Rad-Met1 Ry ( pronation) (deg) 0.7 0.6 0.7 0.4 -7.9% 0.56

Rad-Met1 Rz (dorsiflexion) (deg) 3.5 1.4 3.4 1.5 3.0% 0.78

Rad-Met1 X (dorsal deviation) (mm) 1.9 1.6 2 1.7 -3.3% 0.48

Rad-Met1 Y (subluxation) (mm) 1.4 0.7 1.5 0.7 -9.1% 0.12

Rad-Met1 Z (ulnar devation) (mm) 1.5 0.7 1.5 0.6 -5.5% 0.54

Rad-Trap Rx (adduction) (deg) 1.9 1.1 2.1 1.2 -10.2% 0.17

Rad-Trap Ry (pronation) (deg) 2.9 2.2 2.9 2.4 -0.9% 0.83

Rad-Trap Rz (dorsiflexion) (deg) 2.0 2.7 1.9 2.3 4.1% 0.70

Rad-Trap X (dorsal deviation) (mm) 1.3 0.9 1.1 0.8 11.0% 0.13

Rad-Trap Y (subluxation) (mm) 1.0 1.1 1.0 1.1 -6.0% 0.32

Rad-Trap Z (ulnar deviation) (mm) 1.2 0.5 1.3 0.6 -8.6% 0.31

Trap-Met1 Rx (adduction) (deg) 9.0 9.8 8.6 8.8 5.1% 0.60

Trap-Met1 Ry (pronation) (deg) 2.7 1.7 2.6 2.0 2.5% 0.83

Trap-Met1 Rz (dorsiflexion) (deg) 12 11.2 11.9 11.2 1.3% 0.80

Trap-Met1 X (dorsal deviation) (mm) 0.5 0.2 0.6 0.5 -32.4% 0.36

Trap-Met1 Y (subluxation) (mm) 1.2 1.2 1.2 1.2 -2.8% 0.55

Trap-Met1 Z (ulnar devation) (mm) 0.7 0.4 0.6 0.4 5.3% 0.39

Overall Specimen Stiffness (N/mm) 48.9 23.4 41.4 18.4 15.3% 0.11


Rad-Met: radius to 1
st
metacarpal; Rad-Trap: radius to trapezium; Trap-Met: trapezium to 1
st
metacarpal


All five specimens demonstrated a reduction in the total construct stiffness following CTR,
however, the difference was not statistically significant (p=0.1). The average adduction,



pronation, and dorsiflexion of the trapezium with respect to the radius did not change
significantly after open CRT. No significant decrease in range of motion was measured between
the radius and first MC1 (P=0.12), between the radius and trapezium (P=0.32), or between the
MC1 and trapezium (P=0.55) after an open CTR.



4. Discussion
The purpose of this study was to determine the effect of open CTR on the kinematics of the first
CMC joint. Our hypothesis, that a CTR would cause rotation of the trapezium altering the
biomechanics of the first CMC joint, was not supported by the data from this study. Less
stiffness was seen in all of the specimens at the radius-metacarpal interface after CTR; however,
the difference was not statistically significant. The magnitude of change at the trapezium that
would cause symptoms is not known. It may have been that the small changes in stiffness we
observed were not statistically significant because the study did not have sufficient power. We
do not know what increasedecrease in stiffness would be enough to account for a perceived
increase in post-operative pain at the thumb CMC joint in patients with prior subclinical CMC
arthritis. Likewise rotation of the trapezium would likely affect the scapho trapezial trapezoid
(STT) joint. This could also cause pain near the base of the thumb. We did not specifically
evaluate the STT joint in this study.
The only previous study which addressed this issue was presented in 2009 at the
American Academy of Orthopaedic Surgery meeting in 2009 [16]. Changes in rotation of the
trapezium were noted in their study but were not statistically significant. Outward rotational
changes in the trapezium of 2.25 degrees ( 1.6 degrees) were found after CTR. They also
reported rotational changes in the pisiform and hamathamate; the magnitude of these changes
was greater than those found at the trapezium (3.83 degrees and 4.5 degrees, respectively).
A weakness of this study is the small sample size and the inherent variability of cadaveric
specimens. Even though the specimens were preconditioned it is probable that in the normal
physiologic state some biomechanical changes may occur over time as the constraints further



stretch out. The native musculature was not used to dynamically load the CMC. In a cadaver
specimen it is challenging to reproduce physiological loading and it is possible that the tested
condition does not reproduce normal CMC loading. The strengths of the study are the
surrounding soft tissues of the forearm were not disturbed, and the carpal tunnel release was
performed without removing the arm from the custom jig. Many other factors come into play
concerning the clinical onset of 1
st
CMC joint pain including deconditioning or increased activity
level once the patient has recovered from carpal tunnel surgery.
Our goal was to explore changes in kinematics at the trapezium following CTR If
present, these. These changes could be a result of the changes in the anatomic relationship due
to the release of the TCL affecting the forces at its insertion onto the trapezial ridge. Small
rotational changes could affect the normal kinematics of the CMC joint during physiologic
loading. Based on the methodology of this cadaver study, we were unable to prove our
hypothesis that releasing the TCL would result in kinematic changes of the trapezium with
secondary effects on the 1
st
CMC joint that could be responsible for post operative pain in a
previous arthritic but asymptomatic CMC joint.




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