Davis 2004 - JHS - Trapeziectomy techniques review

Summary

This article reports the results of a randomized controlled trial comparing three surgical treatments for osteoarthritis of the trapeziometacarpal joint of the thumb. The three treatments compared were:

1) simple excision of the trapezium (T),

2) excision of the trapezium with palmaris longus tendon interposition (T+PL), and

3) excision of the trapezium with ligament reconstruction and flexor carpi radialis tendon interposition (T+LRTI).

The study included 183 thumbs in 162 patients (21 had bilateral procedures). The majority were women in their late 50s. The three groups were similar in terms of age, hand dominance, work status, grade of osteoarthritis, and additional procedures performed. During each surgery, a K-wire was inserted across the trapeziometacarpal joint and retained for 4 weeks. All patients wore a thumb spica cast for 6 weeks postoperatively.

Pain levels, range of motion, pinch strength, grip strength, and subjective assessments of pain, stiffness and weakness were evaluated before and at 3 months and 1 year after surgery. Radiographs were obtained to assess joint stability.

The results showed no significant differences between the three procedures in terms of pain relief, range of motion, pinch or grip strength at 3 months or 1 year. At 1 year, over 80% of patients in each group had good pain relief and improved pinch strength. Thumb opposition was well preserved in all groups. There were no cases of joint instability or painful subluxation of the pseudarthrosis.

Complications were evenly distributed between groups. Eleven patients developed reflex sympathetic dystrophy, though only 3 had persistent symptoms at 1 year. Several patients had scar tenderness or numbness from radial nerve injury. No painful neuromas were identified.

In conclusion, this randomized trial found no significant differences in outcomes between simple trapeziectomy, trapeziectomy with palmaris longus tendon interposition, and trapeziectomy with ligament reconstruction and FCR tendon interposition, in both the early postoperative period and at 1 year. Over 80% of patients in all groups experienced good pain relief and improved pinch strength. Neither tendon interposition nor ligament reconstruction provided additional measurable clinical benefit. The authors suggest excision of the trapezium is likely the critical component of surgical treatment for trapeziometacarpal arthritis. Longer follow-up is needed to determine if ligament reconstruction or tendon interposition helps prevent late complications like joint instability.