1. science
2. medicine
3. surgery

Thumb Trapeziometacarpal Joint
Arthritis: Partial Trapeziectomy
With Ligament Reconstruction and
Interposition Costochondral
Allograft
Thomas E. Trumble, MD, Gregory Rafijah, MD, Mary Gilbert, MA,
Christopher H. Allan, MD, Edward North, MD,
Wren V. McCallister, MD Seattle, WA
Qualitative and quantitative outcomes were assessed clinically and radiographically in 41
patients (46 thumbs) with thumb basal joint arthritis limited to the trapeziometacarpal joint
treated with hemiresection arthroplasty of the trapezium, flexor carpi radialis ligament reconstruction, and allograft costochondral interposition graft. Results of the validated Disability of
Arm, Shoulder, and Hand questionnaire at a mean follow-up time of 42 months (range, 24 – 48
months) revealed that 90% of the patients had a high level of function with minimal
symptoms. Important improvements in web space with increased palmar and radial abduction
and grip and pinch strength measurements were observed. The trapeziometacarpal space had
decreased 21% after surgery while trapeziometacarpal subluxation was 16% compared with
21% before surgery. There was an inverse correlation between the loss of trapezial height and
subluxation and clinical outcome. The results of this study demonstrate that although the
preoperative trapezial height was not maintained, the reconstructed thumbs remained stable,
with little subluxation and improved clinical outcomes. (J Hand Surg 2000;25A:61–76.
Copyright © 2000 by the American Society for Surgery of the Hand.)
Key words: Trapeziometacarpal joint, arthritis, reconstruction, allograft, cartilage.
Although a number of previous reports have indicated that excision arthroplasty has been effective in
the treatment of basal joint arthritis of the thumb by
relieving pain and preserving motion,1– 4 others have
indicated that arthroplasty of the thumb by excision
From the Department of Orthopaedics, University of Washington,
Seattle, WA.
Received for publication July 7, 1999; accepted in revised form
September 13, 1999.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Reprint requests: Thomas E. Trumble, MD, Department of Orthopaedics, University of Washington, 1959 NE Pacific Street, Box
356500, Seattle, WA 98195-6500.
Copyright © 2000 by the American Society for Surgery of the Hand
0363-5023/00/25A01-0018$3.00/0
of the trapezium alone causes a substantial loss of
thumb strength and stability.5–7 In an effort to improve thumb function and prevent proximal metacarpal migration, a number of investigators have recommended ligament reconstruction, particularly the
reconstruction of the palmar oblique ligament.8 –12 In
1983, Burton13 recommended the use of the flexor
carpi radialis (FCR) to reconstruct the palmar
oblique ligament. Biddulph8 subsequently recommended the use of the extensor carpi radialis longus
tendon to reconstruct the palmar oblique ligament.
Swanson14 reported the use of silicone rubber implants to prevent proximal migration of the thumb
metacarpal.
Silicone rubber implants used to replace portions
of the carpus, however, resulted in silicone synovitis
The Journal of Hand Surgery 61
62 Trumble et al / Thumb Trapeziometacarpal Joint Arthritis
due to fragmentation of the implants.15–18 Burton and
Pellegrini9 reported the modification of the ligament
reconstruction technique in 1986 using the entire
FCR so that half of the FCR could be used as a
spacer to avoid using a silicone implant. In this
modification, the FCR is split longitudinally; one of
the tails of the FCR tendon was used for the ligament
reconstruction of the palmar oblique ligament and
the other tail was used as an interposition material by
suturing the tendon into the space left following
excision of the trapezium after the strip of the FCR
had been coiled on itself to form a compacted ball.
The technique of ligament reconstruction and tendon
interposition required the used of a K-wire to stabilize the thumb metacarpal to the index metacarpal for
4 weeks.7 The ligament reconstruction and tendon
interposition arthroplasty of the basal joint of the
thumb did eliminate the problem of the silicone
synovitis, but our experience with the technique
demonstrated that the tendon graft did not provide
the same substantial replacement of volume that was
offered by the silicone implant and that the use of a
K-wire to stabilize the thumb metacarpal to the index
finger metacarpal was often quite irritating to patients. Furthermore, in many cases with the arthritis
limited to only the trapeziometacarpal (TM) joint,
complete excision of the trapezium did not appear to
be warranted.
In 1984, Littler18A developed a technique using as
interposition material shaped like a life saver between the partially resected trapezium and the base
of the thumb metacarpal for patients with arthritis
limited to the TM joint.18A He coined the term Life
Saver technique; the original interposition material
in the design was a silicone rubber implant. Because
of the problems noted with silicone rubber, the interposition material was changed to allograft costochondral cartilage. The allograft cartilage was carved
into a shape resembling a life saver and stabilized by
weaving the FCR tendon through the trapezium, allograft cartilage, and base of the thumb metacarpal.
By replacing the interposition tendon graft with a
carved piece of allograft rib cartilage greater stability
of the reconstructed thumb was noted, especially
when a strip of the FCR tendon was woven through
the allograft cartilage. With this technique there was
no need for temporary pin fixation. The purpose of
this study was to determine the outcome of a cohort
of patients treated with a costochondral allograft
implant and tendon reconstruction with a minimum
follow-up period of 2 years and to correlate the
radiographic findings with patient outcome.
Materials and Methods
Between 1988 and 1996, we performed 62 basal
thumb joint costochondral allograft arthroplasties.
Nine patients (11 thumbs) were excluded from this
study because of inflammatory arthritis, pantrapezial
arthritis, or other concomitant procedures involving
the operated hand that would affect hand function.
Five additional patients during this interval met the
inclusion criteria but could not be located to complete questionnaires and follow-up examinations.
Forty-one patients (46 thumbs) formed the basis of
this study.
This study represents a retrospective clinical and
radiographic assessment of 46 thumbs in 41 patients
with basal joint arthritis limited to the TM articulation that were treated by costochondral allograft interposition arthroplasty coupled with a tenodesis of
the FCR to the thumb metacarpal from January 1,
1988, to December 31, 1996. The average age at the
time of surgery was 64 years (range, 40 – 88 years).
There were 36 women and 5 men.
Thirty-one procedures were performed on the
dominant hand. Although many of the patients had
minor associated medical problems, none had insulin-dependent diabetes or required steroids for their
arthritis or other conditions. At the time of surgery,
17 of the patients were employed and 24 were retired. Of the employed patients, 6 did maintenance
and repair work, 6 did clerical work, 3 were laboratory technicians, and 2 were office managers.
Clinical Evaluation
The diagnosis of TM arthritis of the thumb was
based on both clinical and radiographic findings. The
patients universally described a constant pain at the
base of their thumbs that was exacerbated by activities involving substantial grip or pinch strength.
Physical examination revealed tenderness at the Tm
joint and pain with axial joint loading of the thumb.
Other diagnoses, such as carpal tunnel syndrome, de
Quervain’s disease, and carpal instability, were excluded by history and physical examination. Lateral
radiographs confirmed the diagnosis of osteoarthritis
of the thumb TM joint and excluded degenerative
disease of the radioscaphoid and the scaphotrapezium-trapezoid articulations due to earlier trauma or
primary osteoarthritis. All patients underwent a trial
of nonoperative treatment before surgery that included a splint immobilizing the thumb or an intraarticular injection of 40 mg dexamethasone phosphate.
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 63
Figure 1. An S-shaped incision is used to expose the
thumb TM joint. A second incision is used to expose the
musculotendinous junction of the FCR muscle.
Operative Procedure
The surgery is performed using a curvilinear incision along the base of the thumb. The branches of the
superficial radial nerve and deep branch of the radial
artery are identified and protected (Fig. 1). The distal
half of the incision is placed in the border of the
glabrous skin of the thenar eminence. The base of the
thumb metacarpal is exposed between the abductor
pollicis longus and the extensor pollicis brevis. The
insertion of the abductor pollicis longus on the base
of the thumb metacarpal is split along the natural
division in the tendon. Half is reflected to the ulnar
side; the other half is reflected to the radial side (Fig.
2). A longitudinal capsule incision is made in the
capsule and radial and ulnar flaps are elevated to
expose the thumb TM joint. In addition, a small
arthrotomy is made in the scaphotrapezio-trapezoidal
joint to confirm that the joint is free of degenerative
changes before proceeding with only partial excision
of the trapezium. A small oscillating saw is used to
remove the distal surface of the trapezium, taking
care to protect the FCR tendon (Fig. 3).
The tendon sheath of the FCR is exposed and
separated from the tendon so a Freer elevator can be
placed on the palmar surface of the tendon as it
passes deep to the trapezium. We recommend performing the osteotomy with the power saw to remove
2 to 3 mm of distal articular surface of the trapezium
to avoid injury to the FCR. The remainder of the
osteotomy is completed with small osteotomes. A
12-cm strip of the FCR tendon is obtained through a
single longitudinal incision at the junction of the
distal and medial thirds of the forearm. The proximal
tendon is cut halfway across its width. Half of the
tendon is stripped free of the remaining portion of the
FCR and brought out through the distal incision. A
drill hole is made from the palmar surface of the
trapezium to the distal surface of the trapezium after
the distal articular surface has been removed by the
oscillating saw. A second drill hole is made into the
base of the metacarpal and connected with the drill
hole made in the dorsal radial aspect of the thumb
metacarpal base (Fig. 4). A costochondral allograft
measuring approximately 1.5 ⫻ 2.0 ⫻ 4.0 cm is
fashioned into a disk for interposition into the TM
joint. We obtained our allograft material from the
Northwest Tissue Center, Seattle, WA (Fig. 5).
The allograft tissue is recovered aseptically, sterilized with 14 to 21 kGy of gamma radiation, and
stored at ⫺70°C. Before implantation the graft is
thawed at 37°C for 30 minutes. The donors are
screened for infectious, malignant, neurologic, and
autoimmune disease and other exposures or habits
that might result in unsatisfactory tissue. A blood
sample taken at the time of procurement must test
nonreactive for the human immunodeficiency virus
antibody, hepatitis B surface antigen, hepatitis B core
antibody, hepatitis C antibody, HTLV-1 antibody,
and syphilis using tests licensed by the Food and
Drug Administration. Results of microbiological
64 Trumble et al / Thumb Trapeziometacarpal Joint Arthritis
Postoperative immobilization in a thumb spica cast
is followed at 5 weeks by gentle range of motion
exercises and a removable splint that immobilizes the
thumb. The 5-week period was based on comments
by our patients that they felt comfortable and stable
enough to forego fulltime splinting. The therapy initially focuses on regaining motion of the thumb
metacarpophalangeal and interphalangeal joints with
active and passive exercises. Active exercises are
begun for radial and palmar abduction of the thumb
but passive exercises are avoided to prevent stress of
the ligament reconstruction. At 8 weeks unrestricted
thumb motion is allowed and the splint is discontinued.
Follow-up Evaluations
Evaluation Using Outcomes Instrument. The
disability of arm, shoulder, and hand (DASH) questionnaire19,20 was used to determine the patient’s
Figure 2. The attachment of the abductor pollicis longus
onto the base of the thumb metacarpal is split longitudinally along with the capsule of the TM joint that is
elevated as radial and ulnar flaps.
testing of the allograft also must be negative. The
allograft cartilage can be easily carved with a scalpel
into the shape of a life saver (a disk with a central
hole) with a diameter matching that of the resected
trapezial surface (Fig. 6). It is helpful to leave the
allograft life saver attached to the rib cartilage to use
as a handle when performing a trial reduction.
Twenty-two– gauge stainless steel wires are doubled over and used to pass the tendon through the
cartilage and the bone (Fig. 7). The tendon is sequentially passed through the trapezium, the allograft
cartilage, and the base of the thumb metacarpal (Fig.
8). The tendon is placed under tension to ensure the
stability of the TM joint. The FCR tendon graft is
then sutured back onto itself and the capsule is closed
with nonabsorbable sutures (Fig. 9).
Figure 3. An oscillating saw is used to remove the distal
articular surface of the trapezium.
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 65
Figure 4. (A) Holes are drilled through the trapezium, allograft cartilage, and base of the thumb metacarpal. (B) The initial
concept of the costochondral allograft spacer is demonstrated in this drawing by Littler. (Reproduced with permission from
Steven Z. Glickel, MD.)
66 Trumble et al / Thumb Trapeziometacarpal Joint Arthritis
Figure 5. A costochondral allograft measuring approximately 1.0 ⫻ 2.0 ⫻ 4.0 cm.
perception of their most recent postoperative functional status. Forty-six thumbs in 41 patients were
evaluated with the self-administered survey at a
mean of 42 months after surgery (range, 24 – 88
months). Pain, stiffness, and weakness were ranked
on a numerical rating scale from 1 (none) to 5 (extreme). Activities assessed in the DASH questionnaire included opening a jar, writing, turning a key,
preparing meals, opening doors, placing objects over
the head, etc, and were ranked on a numerical rating
scale from 1 (no difficulty) to 5 (unable to perform).
Employment status was evaluated by the ability of
the patients to return to their prior occupation with or
without job modifications. The patients’ confidence
with the use of their hands was assessed with 5
numerical rating scales in response to the statement,
Figure 6. The costochondral allograft is carved with a scalpel to match the shape of the space between the distal surface
of the trapezium and the base of the thumb metacarpal. A hole (approximately 3.2 mm) is drilled in the center of the graft.
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 67
41 patients at a mean of 42 months (range, 24 – 88
months). Grip strength and lateral pinch strength
were determined for both hands using a Jamar dynamometer (Asimov Engineering, Los Angeles, CA)
and a pinch meter (Therapeutic Instruments, Clifton,
NJ). The web space angle was measured bilaterally
as the maximal radial and palmar abduction between
the thumb metacarpal and the index metacarpal. Because of the differences in the size of the hands, the
absolute space measurement from the tip of the
thumb pulp to the radial aspect of the proximal
interphalangeal joint was not used. Preoperative
measurements were available in 36 thumbs of 33
patients at the time of the final follow-up evaluation.
Using a modification of the classification of basal
joint arthritis described by Eaton and Glickel,21 the
severity of arthritis was staged according to preoperative radiographic appearance. All thumbs had
stage III arthritis without evidence of arthritis at the
scaphotrapezio-trapezoidal joints (Fig. 10). Patients
with stage IV arthritis (pantrapezial arthritis) were
treated with a different surgical approach that in-
Figure 7. A 22-gauge malleable wire is folded in half to
pass the distally based strip of half of the FCR tendon
through the drill hole in the palmar surface of the trapezium, the allograft cartilage, and the radial surface of the
thumb metacarpal.
“I feel less capable, less confident, or less useful
because of my arm, shoulder, or hand problem.” The
patients’ overall satisfaction with surgery, their relief
of preoperative pain, and their ability to perform
activities of daily living were assessed using a similar questionnaire. Because of the format of the
questionnaires, lower scores on the DASH and
satisfaction questionnaires indicated better functional
outcomes. The patients were also questioned as to
whether they would choose to undergo surgery again
under the same circumstances.
Objective Follow-up Evaluation. Postoperative
physical evaluation was performed in 46 thumbs of
Figure 8. The strip of the FCR is threaded through the
trapezium, the carved allograft cartilage, and the base of
the thumb metacarpal (MCI).
68 Trumble et al / Thumb Trapeziometacarpal Joint Arthritis
nique reported by Lins et al.11 The measurement is
defined by the distance from the distal end of the
thumb metacarpal to the proximal surface of the
trapezium (Fig. 11). Lines were extended along the
edges of the proximal articular surface of the trapezium and the distal edge and subchondral bone of the
metacarpal. At the midpoint a perpendicular line was
extended between these 2 lines to define the TM
height. To minimize the variability of the trapezium
to metacarpal height due to the differences in the
magnification of the radiographs, the thumb proximal phalanx was used as a comparative standard.
Figure 9. After the strip of the FCR is brought out
through the base of the thumb metacarpal, it is folded back
onto itself and sutured under tension using nonabsorbable
sutures.
cluded resection of the entire trapezium. Patients
with stage III arthritis had radiographic evidence of
destruction of the TM joint with complete loss of the
joint space and/or sclerosis and cystic changes in the
subchondral bone on either side of the joint.
To measure how well the space between the thumb
metacarpal and the proximal half of the trapezium
was maintained, preoperative and postoperative
thumb metacarpal to trapezial (TM) distances were
calculated (Fig. 11). The TM distance is more reproducible than measurements from the distal edge of
the scaphoid to the base of the thumb metacarpal
because of the irregular shape of the arthritic thumb
metacarpal base. The TM distance is determined
from measurements taken from posteroanterior radiographs of the thumb using the radiographic tech-
Figure 10. All the patients had Eaton stage III osteoarthritis with loss of the TM joint space along with sclerosis
and cyst formation on either side of the joint space; however, the scaphotrapezial joint space was spared.
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 69
height to the average proximal phalangeal height for
all the patients. All radiographic distances were measured to the nearest 0.5 mm.
Kadiyala et al22 showed that similar measurements
of the thumb basal joint using a ratio involving the
proximal phalanx demonstrated satisfactory interobserver reliability in the study of both normal radiographs and radiographs of patients with basal joint
arthritis. Subluxation of the thumb TM joint was
measured by drawing a line connecting the superior
and inferior edges on the ulnar border of the trapezium and a line parallel to this incorporating the
ulnar margin of the thumb metacarpal (Fig. 12, distance A). The relative subluxation of the thumb was
determined as the ratio of distance A divided by the
width of the articular surface of the base of the thumb
metacarpal (distance B). The graft height was measured in the initial postoperative radiographs and
then at the final follow-up visit. The height of the
graft was reported as the average of the medial and
lateral margins of the graft normalized by multiplying the average by the ratio of the proximal phalangeal height to the average phalangeal height
(Fig. 13).
Data Analysis
Statistical analysis was performed using the Abacus concepts, Stat View II software program (Abacus
Concepts, Inc, Berkeley, CA). Paired t-tests were
used to compare preoperative and postoperative values for trapezium to metacarpal (TM) height as well
as grip and pinch strengths. Spearman correlation
coefficients (r) were used to analyze relationships
between trapezium to metacarpal height, grip and
pinch strength, thumb motion, and the parameters
determined in the DASH questionnaire.
Figure 11. The TM distance is defined as the distance
from the distal end of the thumb metacarpal to the proximal surface of the trapezium.
Outcome Analysis
The proximal phalanx height was determined by
identifying the midpoint of a tangential line drawn
across the superior edge of the proximal phalanx
condyles to a point along the inferior subchondral
surface of the base of the proximal phalanx in a
manner similar to that used to outline the base of the
metacarpal (Fig. 11). The trapezium to metacarpal
(TM) height was normalized by multiplying the trapezium to metacarpal height of the individual radiograph by the ratio of the patient’s proximal phalanx
The findings from the outcome analysis were divided into primary outcomes, including relief of
pain, patient satisfaction, and patient confidence. We
assumed that the residual pain was due to the TM
joint because the preoperative and postoperative radiographs of the scaphotrapezium-trapezoid articulation did not demonstrate degenerative changes
except in 1 patient. The radiographic findings correlated with our inspection of the scaphotrapezio-trapezoidal joint during surgery.
Secondary outcomes were categorized as qualitative and quantitative. Secondary qualitative out-
Results
70 Trumble et al / Thumb Trapeziometacarpal Joint Arthritis
to determine whether there was a correlation between
proximal metacarpal migration and patient satisfaction or performance. Grip and pinch strength were
additionally compared with primary and secondary
qualitative outcomes.
Figure 12. Subluxation of the thumb TM joint was measured by drawing a line connecting the superior and inferior edges on the ulnar border of the trapezium and a line
parallel to this incorporating the ulnar margin of the thumb
metacarpal (distance A). The relative subluxation of the
thumb was determined as the ratio of distance A divided
by the width of the articular surface of the base of the
thumb metacarpal (distance B).
comes included subjective reports of problems with
activities of daily living and the ability to return to
work or sports activities. Secondary quantitative outcomes included the results of objective measurements of grip, pinch strength, and abduction of the
thumb.
Outcomes were then compared with the TM height
Figure 13. The height of the graft was reported as the
average of the medial and lateral margins of the graft
normalized by multiplying the average by the ratio of the
proximal phalangeal height to the average phalangeal
height.
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 71
Table 1. Secondary Qualitative Outcomes
Feature
Contralateral
Before Surgery
After Surgery
p Value*
Grip strength (kgf)
Pinch strength (kgf)
Palmar abduction
Radial abduction
MCP joint motion
IP joint
TM distance (mm)
Subluxation
22.0 ⫾ 5.9
5.5 ⫾ 1.1
52° ⫾ 8°
52° ⫾ 10°
61° ⫾ 18°
79° ⫾ 17°
NA
NA
16.0 ⫾ 5.2
3.4 ⫾ 1.4
45° ⫾ 8°
48° ⫾ 7°
59° ⫾ 24°
78° ⫾ 21°
5.0 ⫾ 4.0
0.21 ⫾ .11
21.0 ⫾ 6.8
4.6 ⫾ 1.5
50° ⫾ 9°
50° ⫾ 9°
58° ⫾ 21°
74° ⫾ 15°
50.6 ⫾ 4.5
0.16 ⫾ .13
⬍.01
⬍.01
⬍.05
⬎.05
⬎.05
⬎.05
⬍.01
⬍.05
MCP, metacarpophalangeal; IP, interphalangeal; NA, not applicable.
*Comparison of preoperation values with postoperative values.
Primary Outcomes
Pain. The average postoperative pain severity was
1.7 ⫾ 1.0 on a scale of 1 to 5. Seven patients (17%)
indicated some pain with work or heavy activities
(level 2). Eight patients (20%) indicated that they
had pain even with light activities or activities of
daily living (level 3 or 4). The average score on the
outcome questionnaire for sleep difficulty was 1.3 ⫾
0.5, indicating that the average difficulty with sleep
was considered mild. Compared with their preoperative state, 38 patients (92%) felt the severity of pain
had improved or resolved.
Satisfaction and Confidence. The mean score for
loss of confidence was 1.8 ⫾ 1.2. In 8 hands (7
patients) there were reports of substantial loss of
confidence (score of 4 or 5). In many cases, patients
indicated that they did not feel confident holding
objects and that they frequently dropped heavy objects. Thirty-eight patients (92%) were satisfied with
their operations and would undergo surgery again if
faced with the same situation.
Secondary Outcomes
Qualitative. The patients demonstrated very little
difficulty with light activities, such as writing, turning a key, or preparing a meal, with DASH questionnaire scores of 1.4 ⫾ 0.7, 2.2 ⫾ 01.7, and 1.9 ⫾ 1.0,
respectively. They did not score as well for more
difficult activities, however, such as opening a jar
(DASH score 2.7 ⫾ 1.5), pushing open a heavy door
(DASH score 2.2 ⫾ 1.3), or carrying an object
heavier than 10 pounds (DASH score 2.3 ⫾ 1.2)
compared with any of the light activities (p ⬍ .01)
(Table 1). Patients scored 1.7 ⫾ 0.8 for weakness
and 1.6 ⫾ 0.8 for stiffness, indicating that these were
only mild problems for the majority of the patients.
Recreational activities requiring an impact (ie, golf,
tennis) resulted in higher scores, indicating more
difficulty for patients who scored these activities
(DASH score 2.1 ⫾ 1.0) compared with any of the
recreational activities with free movement (ie, swimming, card playing; DASH score 1.6 ⫾ 0.9; p ⬍ .01).
Patients noted that symptoms related to their thumbs
had only a mild effect on their social activities, with
a score of 1.7 ⫾ 1.0.
All 17 of the patients who were employed returned
to work, although 7 modified or changed their jobs
on their return. Fourteen of the patients returning to
work (82%) reported pain responses of 1 or 2, indicating minimal pain at work. Two patients reported a
pain level of 3; 1 patient reported a pain response of
4 and requires the use of a brace while at work.
Quantitative. Significant improvements were noted
in grip and pinch strength. Preoperative grip strength
averaged 16.0 ⫾ 5.2 kgf compared with 21.0 ⫾ 6.8 kgf
after surgery (p ⬍ .01; Table 1). Postoperative grip
strength was not significantly different from the grip
strength of the contralateral side (22.0 ⫾ 5.9 kgf). Pinch
strength averaged 3.4 ⫾ 1.4 kgf before surgery compared with 4.6 ⫾ 1.5 kgf after surgery (p ⬍ .01), but
this was still less than the pinch strength of the contralateral side, which averaged 5.5 ⫾ 1.1 kgf (p ⬍ .05).
Thumb palmar abduction averaged 45° ⫾ 8° before
surgery; this increased to 50° ⫾ 9° after surgery (p ⬍
.05). The thumb palmar abduction on the contralateral
side for the patients with unilateral surgery was slightly
greater than on the operated hand (52° ⫾ 8°), although
we detected no statistically significant difference. The
thumb radial abduction averaged 48° ⫾ 7° before surgery and increased to 50° ⫾ 9° after surgery. This was
not a significant improvement, however; the results
after surgery remained lower than the contralateral side,
which maintained 52° ⫾ 10° of motion. The motion of
the thumb metacarpophalangeal joint motion decreased
72 Trumble et al / Thumb Trapeziometacarpal Joint Arthritis
from 59° ⫾ 24° before surgery to 58° ⫾ 21° after
surgery, but this was not a significant change. The
thumb interphalangeal motion did not significantly
change after surgery (74° ⫾ 15°) compared with before
surgery (78° ⫾ 21°).
Radiographic Evaluation
Only 1 patient demonstrated evidence of scaphotrapezium-trapezoid arthritis at the follow-up examination. The preoperative TM height averaged
53.1 ⫾ 4.0 mm. In the initial postoperative radiographs (obtained within 6 months of surgery) the TM
height averaged 53.8 ⫾ 5.2 mm (Table 1). On the
final follow-up examination the radiographs of the
normalized TM height averaged 50.6 ⫾ 4.5 mm, for
an average loss of 2.5 ⫾ 1.5 mm on the final postoperative radiographs and 3.2 ⫾ 1.7 mm from the
initial postoperative radiographs because the graft
was thicker than the segment of bone removed from
the trapezium. This corresponded to a decrease in the
graft height from 7.1 ⫾ 1.8 mm to 3.8 ⫾ 1.4 mm (a
46% decrease). The average height of the trapezium
was 12 mm before surgery. The 2.5-mm decrease in
the TM space corresponded to a 21% decrease in the
space once occupied by the trapezium. In 15 patients
there were radiographs available approximately 1
year following the surgery. The normalized TM
height in these patients averaged 50.0 ⫾ 4.7 mm,
indicating that most of the loss of height of the
allograft cartilage had occurred within the first year.
The subluxation of the TM joint decreased from
0.21 ⫾ 0.11 before surgery to 0.16 ⫾ 0.13 after
surgery (p ⬍ .05).
Intergroup Analysis
Postoperative pinch and grip strength correlated
directly with overall satisfaction (r ⫽ .413 and .526,
respectively) and inversely with pain severity (r ⫽
⫺.258 and ⫺.215, respectively) and loss of confidence (r ⫽ ⫺.363 and ⫺.561, respectively). Grip and
pinch strength also correlated inversely with activities requiring strength such as jar opening (r ⫽
⫺.510 and ⫺.532, respectively) and recreational
sports with impact (r ⫽ ⫺.351 and ⫺.447, respectively). Comparison of the loss in the TM height to
the qualitative and quantitative clinical outcomes
revealed that there was a significant inverse correlation between the overall DASH score and the maintenance of the trapezium to metacarpal (TM) height
(r ⫽ ⫺.516). The responses to specific questions that
required greater strength (ie, cutting with a knife
[r ⫽ ⫺.412] and doing heavy household chores [r ⫽
⫺.564]) demonstrated stronger inverse correlation
than less strenuous activities (ie, changing light bulbs
[r ⫽ ⫺.326] and placing objects on a shelf [r ⫽
⫺.353]) (Table 2). The overall DASH score also
decreased with decreasing TM subluxation (r ⫽
.537). Pain with work activities (r ⫽ .425) and pain
with activities of daily living (r ⫽ .483) also decreased with decreasing subluxation of the TM joint.
Outcome assessments by the DASH, satisfaction,
and pain questionnaires as well as quantitative measurements of grip and pinch strength and thumb
motion did not demonstrate a significant correlation
between age, gender, and hand dominance. There
were no significant differences between the patients
included in the study and patients who were excluded
or lost to follow-up evaluation with respect to age,
gender, hand dominance, and radiographic parameters.
Complications
One patient in this series developed recurrent pain
of the basal joint 72 months after the initial surgery.
Radiographs demonstrated collapse of the joint space
with bone on bone contact and stage IV arthritis
involving the scaphotrapezial joint.21 The patient
was treated with a revision arthroplasty, including
resection of the entire trapezium, reconstruction with
a silicone rubber implant, and ligament reconstruction using the remaining half of the FCR tendon,
which was woven through the abductor pollicis longus tendon to stabilize the implant. The silicone
rubber implant was chosen because the space remaining after the resection of the entire trapezium
was too large to be filled in by allograft cartilage.
The most recent grip strength averaged 15 kgf (before surgery, 13 kgf) and pinch strength averaged 5
kgf (before surgery, 3 kgf). One patient who was
subsequently lost to follow-up evaluation had fractured the interposition allograft cartilage following a
fall and had recurrence of subluxation and pain. This
patient was treated with arthrodesis of the thumb TM
joint. At last report, the patient was doing well with
a solid arthrodesis 9 months after the second surgery.
Discussion
The major strategies in motion-preserving treatments for arthritis of the thumb TM joint have included simple excision of the trapezium,1,2,5,6 trapeziectomy and interposition (ie, silicone rubber,
tendon graft),3,14,23–25 ligament reconstruction,13,26
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 73
Table 2. Responses to Specific Questions on the DASH Questionnaire
Score (%)
Outcome Category
1 (No
Difficulty)
2 (Mild
Difficulty)
3 (Moderate
Difficulty)
4 (Severe
Difficulty)
5
(Unable)
Open a jar
Writing
Turning a key
Prepare a meal
Push a heavy door
Place an object on a shelf
Heavy household chore
Yard work
Make a bed
Carry a bag or briefcase
Carry an object heavier than 10 pounds
Change a light bulb
Wash hair
Wash back
Pull on a sweater
Cut food with a knife
Light recreational activity
Recreational activity with impact
Recreational activity with free movement
Managed transportation
Sexual activity
Hand interfere with social activities
Limited work activity
Severity of pain
Hand pain with specific activity
Tingling
Weakness
Stiffness
Sleep difficulty
Loss of confidence
13 (29)
29 (64)
39 (87)
20 (44)
18 (40)
28 (62)
21 (47)
20 (44)
22 (49)
22 (49)
15 (33)
27 (60)
24 (53)
23 (51)
43 (96)
19 (42)
31 (69)
15 (33)
29 (64)
29 (64)
29 (64)
27 (60)
39 (87)
27 (60)
26 (58)
41 (91)
22 (49)
28 (62)
33 (73)
27 (60)
10 (22)
12 (27)
5 (11)
15 (33)
11 (24)
3 (7)
7 (16)
11 (24)
14 (31)
12 (27)
14 (31)
14 (31)
16 (36)
14 (31)
1 (2)
15 (33)
12 (27)
16 (36)
9 (20)
8 (18)
15 (33)
10 (22)
5 (11)
8 (18)
9 (20)
0
14 (31)
9 (20)
0
7 (16)
4 (9)
0
0
7 (16)
5 (11)
8 (18)
10 (22)
4 (9)
0
8 (18)
6 (13)
0
4 (9)
5 (11)
0
5 (11)
1 (2)
8 (18)
5 (11)
4 (9)
0
3 (7)
0
5 (11)
8 (18)
4 (9)
8 (18)
0
12 (27)
3 (7)
12 (27)
4 (9)
0
2 (4)
9 (20)
6 (13)
7 (16)
10 (22)
9 (20)
3 (7)
9 (20)
4 (9)
1 (2)
3 (7)
0
5 (11)
1 (2)
6 (13)
2 (4)
4 (9)
1 (2)
5 (11)
0
5 (11)
2 (4)
0
1 (2)
8 (18)
0
8 (18)
6 (13)
0
1 (2)
2 (2)
2 (4)
0
0
0
0
0
1 (2)
0
0
0
1 (2)
1 (2)
0
0
0
0
0
0
1 (2)
0
0
0
0
0
0
0
and ligament reconstruction with interposition.7,12,27,28
The rationale behind the ligament reconstruction is to
recreate the palmar oblique ligament after the trapezium has been removed.13 The stabilizing effect of
the TM joint capsule and the ligaments is well documented.26,29 Although portions of the capsule restrain axial rotation, the palmar oblique (beak) ligament is the primary stabilizer in pronation during
activities such as lateral pinch.10,30 Instability of the
palmar oblique ligament in anatomic specimens has
been shown to correlate with a predictable pattern of
biochemical breakdown of the articular cartilage,
especially in the palmar regions of the TM joint.10,29
There are theoretical advantages to reconstructing
the palmar oblique ligament, but no study has compared ligament reconstruction with or without interposition materials with simple trapeziectomy or trapeziectomy with the use of interposition materials.
Even though silicone rubber implants demonstrated
early success,24,31,32 findings of silicone synovitis
prompted a switch from the use of silicone rubber
implants to tendon interposition grafts.17,18,25
The value of ligament reconstruction arthroplasties
appears to be the ability to prevent proximal migration of the thumb metacarpal with the resultant instability and pain due to compression of the metacarpal against the scaphoid. At a 2-year follow-up
evaluation Burton and Pellegrini9 used stress radiographs to demonstrate a proximal thumb migration of
11% compared with the immediate postoperative
radiographs. At a 9.4-year follow-up examination of
the same group of patients, similar stress radiographs
produced a 13% decrease in arthroplasty height.12
Using the same technique as Burton and Pellegrini9
and Tomaino et al,12 Lins et al11 demonstrated a 33%
reduction in the trapezial space when radiographs
before and after arthroplasty were compared. The
results of the current study differ significantly from
these procedures because only a partial trapeziectomy is required. Using this technique there was a
74 Trumble et al / Thumb Trapeziometacarpal Joint Arthritis
0.7-mm increase in the TM distance in the initial
postoperative radiographs compared with the preoperative radiographs. Although a 47% loss in height of
the implant occurred, the net loss in the trapezial
space was only 22%. The greater loss of trapezial
space in the report by Lins et al11 compared with the
results of Tomaino et al12 suggests that the ligament
reconstruction may have a variable effect on preventing proximal migration of the thumb metacarpal.
This evidence suggests that the costochondral allograft arthroplasty with only partial resection of the
trapezium prevents proximal migration of the thumb
metacarpal with a shorter period of immobilization
compared with other techniques for treating basal
joint arthritis of the thumb. Furthermore, no temporary internal fixation is required with this technique
because of the stability provided by the allograft
spacer combined with the tendon weave.
We acknowledge that this technique using a tenodesis of the FCR tendon through a bone tunnel in the
trapezium, a drill hole in the cartilage interposition
allograft, and a drill hole in the thumb metacarpal
does not reconstruct the biomechanical alignment
provided by the palmar oblique ligament. However,
no studies have actually confirmed that the ligament
reconstruction and tendon interposition can recreate
the stability of the palmar oblique ligament. Based
on the facts that only 22% of the initial trapezial
height is lost at the final follow-up examination and
that subluxation averaged only 16% after surgery
compared with 21% before surgery, it appears that
this technique offers sufficient stability to prevent
proximal thumb metacarpal migration despite the
lack of reconstruction of the palmar oblique ligament.
Similar to the findings noted in previous studies,
the clinical data in this outcomes analysis demonstrate a high degree of patient satisfaction, with 38 of
the 41 patients (92%) willing to undergo the procedure again. In 34 patients (82%) there was no pain
restricting work activities. In 39 patients (95%) there
was no pain with activities of daily living.
In a long-term follow-up evaluation of the ligament reconstruction and tendon interposition technique, Tomaino et al12 demonstrated a 10-kgf (93%)
increase in grip strength and a 0.4-kgf (34%) improvement in pinch strength. Using identical surgical
techniques, Lins et al11 noted a 5.9-kgf increase in
grip strength (50%) and a 1.4-kgf increase in pinch
strength (42%). In our study, grip strength improved
from 16 kgf before surgery to 21 kgf after surgery
(31% increase) and pinch strength improved from
3.4 kgf before surgery to 4.6 kgf after surgery (35%
increase). Similar to the data reported by Lins et al11
using measurements of the absolute distance between
the thumb and the index finger proximal interphalangeal joint, the patients in this study had improved
thumb abduction measured as angular motion. Improvements in grip and pinch strength and thumb
motion noted by the patients in this study were
similar to those noted by Lins et al,11 who had a
43-month average follow-up period compared with
the 42-month average follow-up period in this study.
The follow-up period in the study of Tomaino et al12
averaged 108 months.
In contrast to the study of Lins et al,11 this study
demonstrated that the ability to maintain the trapezial
space after surgery was associated with better patient
outcome as assessed by the DASH questionnaire.
Improvements in postoperative grip and pinch
strength not only correlated with better outcome
scores on the DASH questionnaire, but also with
maintenance of the trapezial space, as evidenced by
the TM height and decreased subluxation of the
metacarpal in relationship to the trapezium. This
evidence suggests the need to clarify the issue of
technique-dependent trapezial collapse, which at
present is unresolved. In their 1998 report introducing a double interposition arthoplasty technique for
the treatment of stage IV arthritis in which the trapezium is maintained, Barron and Eaton32A reported
an 8% collapse of the basal joint under axial load but
did not report subluxation, thereby preventing a
meaningful comparison. The differences may reflect
the differences in the biomechanics of a partial trapezial resection arthroplasty compared with a complete trapezial resection arthroplasty, as reported by
Lins et al11 and Tomaino et al.12
Certain limitations regarding this retrospective
study are acknowledged. Our measurements of the
preoperative functional status and patient expectations by postoperative questionnaire rely on patients’
ability to recall information years after surgery,
which may influence subjective outcomes measurements. Ideally, the patients should have completed
the questionnaires before surgery and at the final
follow-up visit, but no validated outcome tools were
available when the patients had their surgeries performed.19,33 The strength of this study should be
acknowledged as well. It provides comprehensive
assessment of both objective and subjective outcomes. It has become well established that questionnaires can elicit reliable and valid information regarding patient status.19,33,34 Patient-centered
The Journal of Hand Surgery / Vol. 25A No. 1 January 2000 75
outcome assessments may be the most important
operative outcome.34,35 The DASH questionnaire
was chosen because it is an outcome tool that is
directed to the upper extremity without specifically
focusing on a single condition, such as carpal tunnel
syndrome.19,33 The DASH questionnaire has been
validated as an outcome tool. Other validated outcome tools, such as the SF-36, provide excellent
general information regarding the patient’s wellbeing but do not focus on the specific hand functions
involving grip strength, pinch strength, or dexterity.20 The collection of both subjective and objective data was particularly helpful in pointing out
persistent limitations in function with such routine
activities as jar opening, yard work, etc, with a
procedure generally reported to provide excellent
results involving many different techniques for arthroplasty of the basal joint of the thumb. These
functional data from the patient questionnaires point
to the need for improved techniques for the treatment
of basal joint arthritis of the thumb to allow the
patients to perform a wider variety of activities without pain.
The advantage of the allograft cartilage interposition arthroplasty with the FCR tenodesis is the ability
to provide a very stable reconstruction of the TM
joint of the thumb without requiring pin fixation. In
our experience, which includes performing over 40
basal joint surgeries with the ligament reconstruction
and tendon interposition procedure as described by
Burton and Pellegrini,9,13 irritation from the pin was
a common problem. The allograft interposition
avoids the problems of pin irritation and the need for
any additional bracing after the first 8 weeks after
surgery. The procedure does not reconstruct the palmar oblique ligament, but the data presented by Lins
et al11 indicate that the ligament reconstruction and
tendon interposition procedure may not fully reconstruct the ligament or prevent proximal migration of
the thumb metacarpal. Our data suggest that there is
high patient satisfaction and improved objective
measurements of grip and pinch strength and thumb
abduction with this technique of basal joint arthroplasty. Costochondral allograft interposition arthroplasty with tenodesis of the FCR is a safe and effective treatment method for treating patients with
isolated TM arthritis. The patients have a shorter
period of postoperative immobilization compared
with patients undergoing the ligament reconstruction
and tendon interposition technique and they do not
require temporary K-wire fixation. The correlation
between the TM distance and TM subluxation and
the function outcome suggest the need to develop
treatments that maintain the stability and height of
the TM articulation.
There are very little data regarding the effect of
long-term cartilage allograft implants. There are no
reports involving implanted costochondral allografts.
There are reports of transplanted meniscal cartilage.36,37 In these reports the allografts were transplanted to replace the damaged menisci in the knee;
the integrity of the meniscus was maintained at follow-up examination. The transplanted menisci appeared to decrease the rate of joint degeneration
compared with control joints without a meniscus.
The role of the menisci was clearly different from the
costochondral allograft used in this study. These
reports only provide short-term follow-up information. The lack of an inflamatory response is encouraging but longer-term follow-up studies are necessary.
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