Mini TightRope CMC Fixation

®
Surgical Technique
Mini TightRope® CMC Fixation
Introduction

The Mini TightRope construct provides a unique means Some clinical outcomes for this technique that have
to suspend the thumb metacarpal for treatment of CMC been reported in the literature include:
arthritis. The Mini TightRope construct supports and
maintains the thumb and index metacarpals in the ■ Yao J, Song Y. Suture-button suspensionplasty
proper relationship, while allowing for capsular healing, for thumb carpometacarpal arthritis: a minimum
hematoma and scar tissue formation in the trapezial 2-year follow-up. J Hand Surg Am. 2013;38(6):1161-5.
space. The construct consists of two strands of #2 doi:10.1016/j.jhsa.2013.02.040
FiberWire® suture which are fixed with two oblong,
• “A study of 21 patients who underwent partial or
stainless steel buttons for cortical fixation.
complete trapeziectomy with TightRope fixation,
followed by a 10 day immobilization period,
resulted in 20/21 patients without adverse events
and successful outcomes in all patients at 2 years.
A standard immobilization protocol for K-wire
fixation is 4 weeks”
• “A study of 21 patients who underwent partial or
complete trapeziectomy with TightRope fixation
showed a trapezial height of 74% +/- 20% of the
pre-operative height at two years of follow-up”

C-Ring Aiming Guide

A C-Ring aiming guide is available as an option to assist

with placement of the 1.1 mm tapered suture passing
K-wire through the 1st and 2nd metacarpal. After the
initial dissection, the C-Ring aiming guide can be placed
with the sharp pointed tip on the desired exit point of
the 2nd metacarpal. Care is taken to insure the exit
point is in the proximal one-third of the bone and central
to the bone in a dorsal/volar orientation.

Note: It may be helpful to use the 1.1 mm K-wire to drill

the cortex of the 2nd metacarpal on the ulnar side at
the desired exit point. In doing so, the sharp point of
the C-Ring guide will recess into this hole and prevent
the guide from skiving along the bone.

The ratcheting barrel guide is rotated with the teeth

facing down and advanced until desired starting point
on the 1st metacarpal. Once the guide is in place and
an acceptable trajectory is achieved, the long 1.1 mm
tapered suture passing K-wire is placed into the
inner K-wire sleeve of the guide and advanced with Once the K-wire exits the ulnar side of the 2nd
a wire driver through all four cortices of the 1st and metacarpal, the guide may be dismantled and the
2nd metacarpal. remaining procedure completed as described.

01 I Mini TightRope CMC Fixation

Mini TightRope® CMC Fixation Technique

Create a 3 cm to 4 cm dorsoradial skin incision over the

trapeziometacarpal joint. Safely retract the radial artery
by means of a vessel loop, and take care to protect the
branches of the dorsal radial sensory nerve. Make a
longitudinal incision in the capsule and sharply dissect
around the abductor pollicis longus which is attached to
the radial base of the thumb metacarpal. Perform a hemi
or full trapeziectomy to eliminate the bone-on-bone
contact that is the source of pain.

Inspect the trapezial space and remove any remaining

bone fragments or osteophytes surrounding the joint
space to prevent impingement or continued pain.
Make an additional 2 cm incision between the 2nd
and 3rd metacarpal bases. Elevate the 2nd dorsal
interosseous muscle subperiosteally from the ulnar
aspect of the 2nd metacarpal to view the ulnar base
of the index metacarpal – the eventual exit point of the
K-wire. There is always a branch of the dorsal radial
sensory nerve that should be identified and protected
1
in this wound.

Place the 1.1 mm tapered suture passing K-wire

starting on the proximal dorsoradial aspect of the 1st
metacarpal. The K-wire should start as close to the base
of the 1st metacarpal as possible. The hand should be
in a relaxed neutral position. Providing axial traction,
palmar abduction, and extension at the base of the 1st
metacarpal will help reduce the metacarpal into proper
position. (Placing one rolled towel between the thumb
and palm will help maintain the position of the thumb in
an abducted position.)

The K-wire is advanced through the base of the 1st

metacarpal aiming towards the 2nd metacarpal base.
The trajectory recommended is to place the K-wire
within the proximal one-third of the 2nd metacarpal.
A more proximal trajectory is easier to accomplish and
suggested. The wire must exit in the central portion of
the 2nd metacarpal (wire may tend to travel dorsally).
Confirm the trajectory under fluoroscopy, while
advancing the K-wire. An aiming guide is very useful
and available if desired (see previous page). Note:
2 Advancing the K-wire under oscillation is suggested
and maximizes control of the K-wire.

Mini TightRope CMC Fixation I 02

Mini TightRope® CMC Fixation Technique

3 4

Once proper trajectory is established, continue to Place the single strand of the Mini TightRope construct
advance the K-wire through the 2nd metacarpal exiting into the Nitinol loop of the K-wire. Only place 2 cm to
the small incision in the interspace. Four cortices should 3 cm of suture though the loop, as more may bind in the
be penetrated. Continue to advance the K-wire until the small tunnel.
thinner tapered portion of the guidewire is completely
through all four cortices. The K-wire should now slide
easily by hand.

Pull the opposite end of the suture passing K-wire, bringing the suture completely through and exiting the 2nd
metacarpal. Pull the suture and bring the oblong button to contact the radial side of the thumb metacarpal.

03 I Mini TightRope CMC Fixation

Mini TightRope® CMC Fixation Technique

Cut the suture on the ulnar side to create two strands of the 2nd metacarpal), palmar abduction and extension
of FiberWire® suture and load the second oblong button at base of 1st metacarpal. Over-tightening of the suture
onto the suture, bringing the oblong button down to the is not recommended as it may lead to decreased range
2nd metacarpal. Remove any slack from the construct of motion and possibly impingement of the base of the
and position the thumb into the desired position. The thumb metacarpal on the base of the 2nd metacarpal.
thumb can be reduced into the desired anatomic resting Tie one provisional knot and check the range of motion
position by applying axial traction (to restore height until clinically and under fluoroscopy to confirm full motion
the base of the first metacarpal is in line with the base and no impingement.

Post-op Protocol: Follow up with hand therapy at 10 to

14 days. Provide a thermoplastic, hand-based thumb
spica splint to be worn for lifting > 5 lbs and for sleep.
Otherwise, allow partial mobilization of up to 50%
of grip power between two and six weeks. Increase
7
mobilization steadily and advance to strengthening,
as tolerated, until week 12. Afterwards, allow full
Tie approximately five knots over the second ulnar
mobilization with no activity restrictions.
button to lock the construct into place. Knot strands
may be left long and buried beneath the 2nd dorsal
Device Removal: If removal of the device is required
interosseous to prevent irritation. The 2nd dorsal
a small incision over each cortical button can be made
interosseous fascia, CMC capsule and skin is
to gain access to the oblong button. The sutures
closed in a standard fashion.
through the buttons are cut, the buttons removed,
and the suture construct is removed with a forceps
or other appropriate suture grasping instrument.

Mini TightRope CMC Fixation I 04

Mini TightRope® CMC Fixation Technique (Alternate)

An alternate surgical technique is presented which may allow for a more controlled placement of the Mini TightRope
construct through the 2nd metacarpal. Using the same radial dissection as the standard technique described
previously, attention is directed to making an incision overlying the proximal one-third of the 2nd metacarpal,
measuring approximately 2 cm. Care is taken to protect the dorsal sensory radial nerve branch. The soft tissues are
dissected off the radial and ulnar borders of the base of the 2nd metacarpal so direct visualization of the bone is
achieved.

Soft tissue is dissected approximately 1 cm distal to

the base of the 1st metacarpal, which is just past the
insertion of the abductor pollicis longus. The 1.1 mm
tapered suture passing K-wire is passed through the
radial side of the 1st metacarpal, parallel to the base,
until it exits the ulnar cortex. Pass the K-wire only a few
millimeters through the ulnar side to establish the hole.

The thumb is abducted and the K-wire is advanced

through the 1st metacarpal towards the 2nd, pointing
towards the proximal one-third of the 2nd metacarpal
and exiting through the soft tissue that brings it onto
the dorsal side of the 2nd metacarpal cortex. Do not
pass the K-wire through the 2nd metacarpal at this
time. Allow the wire to exit dorsal to the bone out the
2nd metacarpal incision. Care is taken to protect the
1
dorsal sensory branch of the radial nerve.

2 3

2 cm to 3 cm of the Mini TightRope construct end is A second hole is established through the base of the
placed through the 1.1 mm tapered suture passing 2nd metacarpal using the 1.1 mm tapered suture passing
K-wire loop and pulled through the base of the 1st K-wire to establish a central hole from the radial to the
metacarpal, exiting through only the soft tissue on ulnar side of the 2nd metacarpal proximal diaphysis.
the dorsal 2nd metacarpal incision. This is done under direct visualization of both the radial
and ulnar sides of the 2nd metacarpal. Attention is
paid to central placement of the drill hole in the 2nd
metacarpal.

05 I Mini TightRope CMC Fixation

Mini TightRope® CMC Fixation Technique (Alternate)

Once the hole is established, the nontapered, small diameter, blunt-tipped, flexible suture passing K-wire is used
to pass the Mini TightRope construct through the 2nd metacarpal, exiting the ulnar side of the 2nd metacarpal. The
wire is grasped in the interspace between the 2nd and 3rd metacarpals with a hemostat or needle holder, directed
dorsally out the incision and the suture is pulled taut.

The Mini TightRope construct is cut to free two suture Check thumb position before securing the knot.
ends. The second button is secured on the ulnar side The suture of the tied knot can be buried easily in the
of the 2nd metacarpal using five or six knots. Remove interspace between the 2nd and 3rd metacarpals, and
all slack, but do not overtighten. Over-tensioning of the the soft tissue is closed over the 2nd metacarpal. The
TightRope construct will cause decreased thumb motion, joint capsule of the carpometacarpal joint is closed
abduction, and possible ulnar impingement pain. securely with suture. A thumb-spica forearm splint, or
a hand-based thumb spica splint, is loosely applied to
protect the thumb, hand, and wrist.

Mini TightRope CMC Fixation I 06

Ordering Information

CMC Mini TightRope Repair Kit (a)

Product Description Item Number
Suture Passing K-Wire, short, 1.1 mm AR-8919DS
Suture Passing K-Wire, long, 1.1 mm
Suture Passing Wire, 8 in
Oblong Button for Mini TightRope, 2.6 mm
TightRope Suture Construct, 1.1 mm
Trapeziectomy Tool w/ Handle

Optional Accessories
Product Description Item Number

Parallel Aiming Guide AR-8919G

0.86 mm Sleeve AR-8919G-01
1.1 mm Sleeve AR-8919G-02
1.6 mm Sleeve AR-8919G-03
Drill Guide Instrument Case AR-8919C
C-Ring Aiming Guide AR-8826G
Sterile Trapeziectomy Tool w/ Handle AR-8919-01S
Suture Passing K-Wire, short, 1.1 mm AR-8914K

Products advertised in this brochure/surgical technique guide may not be available in all countries. For information on availability,
please contact Arthrex Customer Service or your local Arthrex representative.

(a)

This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals
in the usage of specific Arthrex® products. As part of this professional usage, the medical professional must use their professional
judgment in making any final determinations in product usage and technique. In doing so, the medical professional should rely on
their own training and experience, and should conduct a thorough review of pertinent medical literature and the product’s Directions
For Use. Postoperative management is patient specific and dependent on the treating professional’s assessment. Individual results
will vary and not all patients will experience the same postoperative activity level and/or outcomes.

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