Chuang et al.

Journal of Orthopaedic Surgery and Research (2015) 10:184

DOI 10.1186/s13018-015-0329-y

RESEARCH ARTICLE Open Access

Arthroscopic partial trapeziectomy and

tendon interposition for thumb
carpometacarpal arthritis
Min-Yao Chuang1, Chang-Hung Huang2,3, Yung-Chang Lu1,2,4* and Jui-Tien Shih5*

Abstract
Background: The purpose of this study was to introduce arthroscopic partial trapeziectomy and tendon
interposition for the treatment of symptomatic thumb carpometacarpal arthritis of Eaton stage II or III.
Methods: From August 2001 to April 2009, 23 patients with thumb carpometacarpal arthritis were treated using
this technique. Pain score, range of motion, and pinch strength were clinically evaluated and compared with the
preoperative values after a minimum follow-up duration of 24 months.
Results: Significant reduction in pain score and increases in range of motion and pinch strength were found
(all p < 0.001) after a 2-year follow-up. The mean ± SD (median) postoperative pain score was 1.0 ± 0.7 (1.0) at rest
and 1.3 ± 0.9 (1.0) during daily activities. The postoperative range of motion was 19.1° ± 4.2° (20°) for extension and
35.7° ± 7.1° (35.0°) for flexion, and the postoperative pinch strength was 86.5 % ± 19.9 % (90.0 %). No complications
were observed in our patient series.
Conclusions: Arthroscopic partial trapeziectomy and soft tissue interposition could be an alternative treatment
method for patients with symptomatic thumb carpometacarpal arthritis of Eaton stage II or III.
Keywords: Thumb carpometacarpal joint, Arthroscopic, Arthritis, Trapeziectomy, Level of evidence: level IV

Background volar ligament reconstruction [14], and various com-

Thumb carpometacarpal (CMC) joint arthritis is a binations of these procedures. The most common sur-
common disease and usually affects women in the gical treatment currently used is trapezium excision
postmenopausal age group [1–3]. Typical conservative combined with LRTI [4].
treatment includes functional education, activity modifica- The specific types of surgical procedures for thumb
tion, anti-inflammatory medications, intra-articular ster- CMC joint arthritis are usually divided between those
oid injections, and splinting. The indication for operative for Eaton stage I and II–IV disease, depending on
intervention is failure of conservative treatment. Numer- whether the cartilage of the basal joint remains un-
ous surgical techniques have been described, including affected or has existing evidence of degeneration [15].
ligament reconstruction and tendon interposition (LRTI) Procedures for stage I disease include volar ligament
[4], suspensionplasty [5], first metacarpal extension reconstruction, arthroscopy, and first metacarpal exten-
osteotomy [6], arthrodesis [7], hematoma distraction sion osteotomy. Volar ligament reconstruction has the
arthroplasty [8], artificial prosthesis replacement [9], advantages of halting the radiographic progression of the
osteochondral allografting [10], hemitrapeziectomy disease and the disadvantage of relatively poor pain re-
[11], complete trapeziectomy [12], arthroscopy [13], lief. Arthroscopy is a less invasive procedure and can be
used simultaneously in the treatment of ligament laxity.
* Correspondence: yungchanglu@hotmail.com; jui_tien_shih@hotmail.com First, metacarpal extension osteotomy has the benefit of
1
Department of Orthopaedic Surgery, MacKay Memorial Hospital, No. 92 Sec. correction of an adduction contracture but is associated
2 Zhongshan N. Rd., Taipei City, Taiwan
5
Department of Orthopaedic Surgery, Taoyuan Armed Forces General
with the possibility of nonunion and implant problems.
Hospital, No. 168 Zhongxing Rd, Longtan District, Taoyuan City, Taiwan
Full list of author information is available at the end of the article

© 2015 Chuang et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Chuang et al. Journal of Orthopaedic Surgery and Research (2015) 10:184 Page 2 of 7

For stage II–IV disease, surgical treatment options and capsule, soft tissue interposition with palmar longus
have evolved over the past 50 years, including trapeziect- tendon, and temporary K-wire fixation for support, per-
omy, hemitrapeziectomy, arthrodesis, artificial prosthesis formed with the aid of arthroscopy, would be an alterna-
replacement, LRTI, suspensionplasty, osteochondral allo- tive technique for the treatment of stage II and III
grafting, and hematoma distraction arthroplasty. Simple thumb CMC joint arthritis.
trapeziectomy/hemitrapeziectomy has the advantages of
decreased operative time, pain relief, and minimal donor Methods
site morbidity. Its disadvantages include significant func- Patient cohort
tional problem and loss of pinch strength. Arthrodesis is Our institutional review board approved this study. The
mainly performed in workers with heavy workload and study included all patients treated between August 2001
cases of posttraumatic arthritis in young patients and as and April 2009 whose conditions required surgical inter-
a salvage procedure for failed reconstructive surgery. vention and who met the inclusion criteria. Patients with
Although this technique preserves pinch strength, con- symptomatic Eaton stage II or III thumb CMC joint
current problems occur, including nonunion, degenera- arthritis based on preoperative radiographs (Fig. 1a) and
tive changes in neighboring joints, and loss of mobility. previous failure of at least 6 months (range, 6–12
The artificial prosthesis replacement procedure shows months) of conservative treatment were included in this
good short-term results [9], but its application is dimin- study. Conservative treatment included a regimen of
ished by reports of prosthetic failure, instability, foreign rest, thumb brace, activity modification, nonsteroidal
body synovitis, cold flow, and wear debris. With high pa- anti-inflammatory medications, and a mean of two corti-
tient satisfaction and preservation of function, LRTI has sone injections (range, one to six injections). Patients
increased in popularity and is considered by many to be with previous thumb trauma and other concomitant
the standard surgical procedure for these cases. Suspen- diagnoses that probably caused confusion in the diagno-
sionplasty is an easier procedure with several advantages, sis and affected the interpretation of the results (e.g.,
including decreased deforming force of the abductor Bennett’s fracture and de Quervain’s tenosynovitis) were
pollicis longus, preservation of the flexor carpi radialis, excluded. As a result, 23 patients (23 thumbs) were in-
and release of both the first dorsal compartment and the cluded in this study. The patients underwent arthro-
more distal position of the suspension. Disadvantages scopic partial trapeziectomy and interposition of the
include possible injury to the superficial radial nerve and palmar longus tendon. Of the 23 patients, 3 were men
a cosmetically unappealing bump. Osteochondral allo- and 20 were women, with a mean age of 59.0 years
grafting has shown promising short-term results, but (range, 54–68 years), and 10 had Eaton stage II disease
with problems of allograft fracture and infection. and 13 had stage III disease. All the patients were right-
Hematoma distraction arthroplasty is a less complicated hand dominant, and only two patients underwent sur-
procedure but with similar good results. However, meta- gery for nondominant thumbs. The medical conditions
carpal subsidence is a frequent concern. of the old patient group were allowed surgical treatment.
We introduced arthroscopic treatment of stage II and
III disease to achieve a minimally invasive surgery [13]. Surgical technique
In addition, partial trapezium resection and interposition All of the operations were performed under general
arthroplasty have been used to preserve stability [11]. It anesthesia and tourniquet control. A single finger trap
is hypothesized that partial resection of the trapezium was used on the thumb with 5 to 10 lb of longitudinal
combined with thermal shrinkage of the volar ligaments traction by using a traction tower. The CMC joint was

Fig. 1 a Preoperative radiographic images demonstrating Eaton stage III osteoarthritis of the right thumb carpometacarpal joint. b Immediate
postoperative radiograph showing a K-wire used for fixation across the thumb carpometacarpal joint. c Radiographs obtained at 24 months after
surgery showing a stable thumb carpometacarpal joint
Chuang et al. Journal of Orthopaedic Surgery and Research (2015) 10:184 Page 3 of 7

identified and localized by palpation or fluoroscopy. The sutures were removed after approximately 10 postop-
Two incision portals were marked. One was located ra- erative days, and a short-arm cast was applied for an add-
dial to the first extensor compartment tendons, while itional 4 weeks, at which time the pin was removed.
the other was ulnar to the first extensor compartment Formal occupational therapy was started, and a removable
tendons along the line of the joint. The distance between brace was worn for an additional 4 weeks.
each portal and insertion of the first extensor compart-
ment tendons was about 1 cm (Fig. 2). The radial portal Clinical evaluations
was used for assessment of the joint cartilage, as well as Preoperative assessment
the dorsoradial, posterior oblique, and ulnar collateral All patients complained of preoperative pain at the
ligaments. The ulnar portal was helpful for treating and thumb base that impaired performance of daily activities.
visualizing the volar ligaments. Joint distension with 2 to Physical examinations of the patients included an assess-
3 mL of normal saline solution facilitated the placement ment of the thumb CMC joint range of motion (flexion
of a 1.9-mm, 30° short-barreled arthroscope. A full-radius and extension) with a protractor goniometer (Fig. 5b),
mechanical shaver and a burr with suction were used for determination of the site of tenderness and pain by using
debridement and partial trapeziectomy (Fig. 3a). Liga- a 10-point visual analog scale (VAS), axial stress grind
mentous laxity and capsular attenuation were treated with test, and the identification of the thumb pinch strength
thermal capsulorrhaphy with a radiofrequency shrinkage with a Jamar dynamometer (Therapeutic Equipment,
probe (Fig. 3b). The Oratec MicroTAC-S probe Clifton, NJ, USA). Plain radiographs of the thumbs were
(MicroTAC-S, Oratec Interventions, CA) was inserted obtained from all patients (Fig. 1a).
through the portals and used at a setting of 67° and 40-W
power. The probe was gently swept over the volar Postoperative assessment
ligaments. Radiofrequency energy was applied slowly and Each patient was assessed clinically at 2, 3, 6, 12, and
deliberately to allow tissue shortening and blanching to be 24 months after surgery. After 24 months, they returned
visualized. A 10-cm-long tendon graft taken from the for evaluation according to their own volition. The as-
palmar longus tendon (Fig. 4a) was rolled and sutured into sessment included pain (VAS score), thumb pinch
a ball measuring approximately 1 cm in diameter (Fig. 4b). strength measured with a Jamar dynamometer, and
The ball was pushed into the CMC joint via the portal thumb CMC joint range of motion (Fig. 5a). The pres-
(Fig. 4c). The correct position of the ball was confirmed ence of any complications was also recorded. Standard
under arthroscopy, and the tendon ball was subsequently anteroposterior and lateral radiographs of the thumb
anchored to the capsule by absorbable sutures. A 1.2-mm were also obtained during each assessment and used
K-wire was used for fixation across the CMC joint to ensure that the CMC joint had not subluxated or
(Fig. 1b), and a short-arm thumb spica splint was applied. collapsed (Fig. 1c).

Fig. 2 Intraoperative image demonstrating the radial and ulnar portals of arthroscopy
Chuang et al. Journal of Orthopaedic Surgery and Research (2015) 10:184 Page 4 of 7

Fig. 3 Intraoperative arthroscopic images. a Arthroscopic view of a 2.0-mm burr that was used to partially remove the trapezium. b Arthroscopic
view demonstrating thermal shrinkage of the volar ligaments (AOLs) with the use of a radiofrequency electrothermal probe

Statistical analysis in Table 1. None of the patients required or opted for

Statistical analysis was performed with the SPSS software further surgery of the thumb, and improvements in all
(SPSS version 10.0, Chicago, IL, USA). Continuous data parameters (i.e., pain score, ROM, and pinch strength)
were presented as mean ± SD. Categorical variables were were observed after the operations. Significant reduction
presented as frequency (%). The Wilcoxon signed-rank in pain score and increases in the ROM and pinch
test was used to compare postoperative thumb pain, strength were subsequently observed (all p < 0.001). The
range of motion of the thumb CMC joint, and thumb mean postoperative pain score was 1.0 ± 0.7 (median,
pinch strength with the preoperative measurements. 1.0) at rest and 1.3 ± 0.9 (1.0) during daily activities. The
Statistical significance was defined as a p value <0.05. postoperative ROM was 19.1° ± 4.2° (20°) for extension
and 35.7° ± 7.1° (35.0°) for flexion, and the postoperative
Results pinch strength was 86.5 % ± 19.9 % (90.0 %).
At enrollment, the mean pain scores at rest and during None of the patients who underwent the procedure
daily activities were 5.7 ± 0.5 (median, 6) and 7.0 ± 0.6 had infections or other complications. All patients were
(7.0), while the extension and flexion ranges of motion satisfied with the surgical results within three postopera-
(ROMs) and pinch strength were 15.9° ± 3.9° (15.0°); tive months. Follow-up radiographs obtained at 24 post-
27.8° ± 8.2° (30.0°); and 47.2 % ± 9.4 % (50.0 %), respect- operative months were compared with the immediate
ively. The data of the clinical outcomes are summarized postoperative radiographs and demonstrated a mean

Fig. 4 a The palmar longus tendon is harvested by a tendon stripper. b The tendon graft is rolled into a ball. c The tendon ball is pushed into
the basal joint using the portal
Chuang et al. Journal of Orthopaedic Surgery and Research (2015) 10:184 Page 5 of 7

Fig. 5 a Schematic diagram showing the range of motion of the thumb carpometacarpal joint at postoperative follow-up. b Measurement of
range of motion

proximal subsidence of 2.1 mm (0–4 mm) of the meta- and synovectomy in a series of 23 patients with stage I
carpal shaft (Table 1). No cases of radiographic basal and II disease. Good or excellent results in terms of pain
joint subluxation or scaphotrapezium joint arthritis were relief, functional scores, subjective outcomes, and pinch
found. strength were reported in 83 % of the surgical patients.
Arthroscopy is currently considered reliable for the
Discussion evaluation and treatment of thumb CMC joint arthritis
Small joint arthroscopy for the smaller joints of the [13]. Our study introduced arthroscopic treatment for
hand, first introduced by Watanabe [16], has been re- patients with Eaton stage II or III thumb CMC arthritis.
fined over the years by other authors [17, 18]. Arthros- The stability of the thumb CMC joint depends on
copy of arthritic thumb CMC joint, a minimally invasive static ligamentous restraints because of the lack of bony
procedure first described by Menon [19], allows for joint congruity [21]. Laxity of the ligaments has been pro-
visualization, treatment, and disease staging. Furia [20] posed as a mechanism of the development of thumb
described his experience with arthroscopic debridement CMC joint osteoarthritis [22]. Thus, addressing joint in-
stability is a vital component of surgical treatment. The
anterior oblique ligament is believed to be the primary
Table 1 Preoperative and postoperative outcomes of the
stabilizer. This belief is supported by the clinical success
patients
of the reconstructive procedures for this ligament [23].
Outcomes Preoperative Postoperative p value
(n = 23) (n = 23) In order to recreate this ligament, researchers have used
Pain at rest (points) 5.7 ± 0.5 1.0 ± 0.7 <0.001
several methods, which are technically challenging. Elec-
trothermal shrinkage would be an alternative simple
(1.948E-5)
method for the treatment of volar ligament laxity [24].
Pain during daily activities 7.0 ± 0.6 1.3 ± 0.9 <0.001 In this study, we selected this surgical technique to
(points)
(2.330E-5) minimize damage of soft tissues.
Extension ROM (degrees) 15.9 ± 3.9 19.1 ± 4.2 <0.001 Total excision of the trapezium results in good pain
(2.750E-4) relief but also in substantial loss of thumb strength and
Flexion ROM (degrees) 27.8 ± 8.2 35.7 ± 7.1 <0.001
stability [25]. To avoid the negative results, many sur-
geons have elected to excise just the articular surface of
(1.58E-4)
the trapezium [26, 27]. In our patients, hemitrapeziect-
Pinch strength (%) 47.2 ± 9.4 86.5 ± 19.9 <0.001 omy was conducted to avoid these sequelae.
(2.548E-5) After hemitrapeziectomy, interposition arthroplasty
Proximal subsidence of the - 2.1 ± 0.9 - preserves the stability of the thumb CMC joint by main-
metacarpal shaft (mm) taining the joint space [4]. The best interpositional ma-
Abbreviations: ROM range of motion terial is an autologous tendon graft, and it is important
Data were presented as mean ± SD and analyzed using the signed-rank test.
Values with bold emphasis indicate a significant change after surgery (p < 0.05).
to pack the joint space with as much tendon as possible
The dash denotes the same data and that no comparisons were needed to keep the first metacarpal and trapezium apart. The
Chuang et al. Journal of Orthopaedic Surgery and Research (2015) 10:184 Page 6 of 7

tendon ball should be larger than the removed bone. In This study has some inherent limitations. First, the
addition, bleeding from the subchondral bone fills the number of patients was small, and the male to female
interspaces of the coiled tendon graft. The clot then orga- patient ratio in the group was less than that reported
nizes and is eventually converted into fibrous tissue that previously [1–3]. Second, the study was a retrospective
acts as a spacer, keeping the opposing bones apart. In the review with intermediate follow-up. Moreover, we did
present study, interposition arthroplasty with a palmar not administer a questionnaire to assess function and
longus tendon graft was chosen to help improve stability. conduct a test to assess grip strength, range of motion
Long-term clinical studies on arthroscopic hemitrape- with abduction/adduction, and which crease the thumb
ziectomy with interposition arthroplasty have not been can reach.
well reported in the literature. Pegoli et al. [28] evaluated
the clinical outcomes of 16 patients with Eaton stage I Conclusions
and II arthritis and reported that 12 of these patients Arthroscopic partial trapeziectomy and soft tissue inter-
had good to excellent results at a mean follow-up period position could be an alternative treatment method for
of 12 months. In addition, Earp et al. [29] investigated a patients with Eaton stage II and III symptomatic thumb
similar procedure in patients with stage II and III CMC arthritis. Longer-term follow-up would be more
arthritis and a mean follow-up period of 11 months. helpful to validate the superiority of this procedure to
They observed improved pain scores and a high rate the conventional approach.
of patient satisfaction. In our series of 23 patients,
pain score, pinch strength, and range of motion sig- Abbreviations
CMC: carpometacarpal; SD: standard deviation; VAS: visual analog scale.
nificantly improved after a minimal postoperative
period of 24 months, which was longer than those in Competing interests
previous studies. The authors declare that they have no competing interests.
Furthermore, in our previous study [24], we recorded
pain scores, range of motion, and pinch strength of the Authors’ contributions
MY collected the study data and wrote the paper. YC and CH helped with
thumb to assess clinical outcomes of arthroscopic ther- the paper revision. JT created the study concept and performed the
mal treatment in patients with Eaton stage I and II arth- operations. All the authors read and approved the manuscript.
ritis. Significant improvement was observed in pain
Author details
score during daily activities, in flexion ROM, and in 1
Department of Orthopaedic Surgery, MacKay Memorial Hospital, No. 92 Sec.
pinch strength after surgery at a mean follow-up period 2 Zhongshan N. Rd., Taipei City, Taiwan. 2Department of Medical Research,
of 24 months. In the present study, we further modified MacKay Memorial Hospital, New Taipei City, Taiwan. 3Department of
Dentistry, National Yang-Ming University, No. 155 Sec. 2 Linong St, Taipei
the surgical procedure to treat patients with stage II and City, Taiwan. 4Department of Cosmetic Application and Management,
III arthritis by using the same evaluation methods. MacKay Junior College of Medicine, Nursing, and Management, No. 92
Hemitrapeziectomy and tendon interposition were Shengjing Rd, Taipei City, Taiwan. 5Department of Orthopaedic Surgery,
Taoyuan Armed Forces General Hospital, No. 168 Zhongxing Rd, Longtan
added to the treatment procedures for the patient group District, Taoyuan City, Taiwan.
with advanced disease stage. Although the clinical evalu-
ation methods used in each study varied, these simplified Received: 6 May 2015 Accepted: 30 November 2015
evaluation methods might provide relatively objective in-
formation to demonstrate the possibility of using this References
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