Clinical and radiologic outcomes of partial trapeziectomy and suture button suspensionplasty for the treatment of thumb carpometacarpal joint arthritis: a study with a minimum 2-year follow-up

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Arch Hand Microsurg. 2025;30(1):22-28

Publication date (electronic) : 2025 February 12

doi : https://doi.org/10.12790/ahm.24.0055

Yeongyoon Koh, Seul Gi Park, Jae Jun Nam, Jong Woong Park, In Cheul Choi

Department of Orthopaedic Surgery, Korea University Anam Hospital, Seoul, Korea

Corresponding author: In Cheul Choi Department of Orthopaedic Surgery, Korea University Anam Hospital, 73 Goryeodae-ro, Seongbuk-gu, Seoul 02841, Korea Tel: +82-2-920-5924 Fax: +82-2-924-2471 E-mail: indolldr@korea.ac.kr

Received 2024 October 30; Revised 2024 November 8; Accepted 2024 November 14.

Abstract

Introduction

The thumb carpometacarpal (CMC) joint has a wide range of motion but is inherently unstable, making it the second most common site of arthritis in the hand after the interphalangeal joints. This condition affects 25% to 40% of postmenopausal women and is the most frequently surgically treated joint in the upper extremity [1].

The progression of thumb CMC joint arthritis is primarily staged based on radiographic findings according to the Eaton and Littler classification [2]. Surgical intervention is considered when symptoms persist despite conservative management. In stage I, anterior ligament reconstruction (LR) or osteotomy may be performed, while in stage II and beyond, various surgical techniques are available. However, long-term outcomes among these techniques reportedly show no significant differences [3,4].

Among the surgical methods, trapeziectomy with LR, using either the flexor carpi radialis (FCR) or abductor pollicis longus (APL) tendons, has shown comparable surgical outcomes [5]. However, LR is technically challenging, as it not only requires sacrificing the FCR and APL tendons but also necessitates Kirschner wire (K-wire) fixation. Prolonged K-wire fixation has been criticized for its potential to reduce joint range of motion, increase the risk of infection, and present technical challenges, prompting the development of alternative approaches. One alternative is suture suspensionplasty using the APL and FCR tendons. In this technique, a suture is placed through the insertion of the APL tendon at the base of the first metacarpal and then through the FCR tendon distally, near its insertion on the second metacarpal, before being weaved back through both tendons. This method offers advantages such as shorter surgical time and the elimination of the need for implants or tendon grafts [6].

This method was further refined into trapeziectomy with suture button suspension, introduced by Yao and Song [7] in 2013, which demonstrated excellent outcomes in terms of pain relief and functional recovery, including grip and pinch power, over a 2-year period.

This study aims to analyze the 2-year follow-up results of partial trapeziectomy with suture button suspension based on previously reported short-term outcomes [8], evaluate its effectiveness in the treatment of thumb CMC arthritis, and provide evidence for its future clinical application.

Methods

2. Surgical methods

All surgeries were performed under brachial plexus block anesthesia by a single experienced hand surgeon (ICC) at a single academic institution (Korea University Anam Hospital). Under C-arm fluoroscopic guidance, a 2 to 3 cm skin incision was made on the palmar side of the APL tendon at the thumb CMC joint area. The CMC joint capsule was incised, and a 3 to 5 mm portion of the distal trapezium was resected parallel to the articular surface (partial trapeziectomy) (Fig. 1A). Temporary pin fixation was performed from the first metacarpal to the second metacarpal to maintain the appropriate position of the thumb (Fig. 1B). A 4-inch elastic bandage was maintained in the first web space from the insertion of the first guide pin until the suture tension was adequately adjusted to ensure proper thumb positioning (Fig. 1C).

Fig. 1.

(A) Skin incision is carried out over the thumb basal joint, and then only the distal “horns” of the trapezial saddle and any peripheral osteophytes are resected. (B) Kirschner wire (K-wire) was introduced through the first and second metacarpal bone as a proper positioning of the thumb. (C) To maintain proper suture tension and ensure appropriate placement of the suture anchor from the initial insertion of the first guide pin until the desired tension is achieved, a 4-inch elastic bandage was maintained in the first glenoid space. (D, E) The 1st generation TightRope (Arthrex, Naples, FL, USA), which used a 2.7-mm K-wire, could potentially cause fractures in the 2nd metacarpal bone. Therefore, the 2nd generation TightRope (MiniTightRope; Arthrex), with a reduced drill diameter, was developed. (F) Postoperative X-ray, using 2nd generation TightRope.

The authors initially used the first-generation Mini TightRope (Arthrex). However, due to the risk of second metacarpal fractures when using a 2.7-mm drill bit, a modified technique involving the creation of a bone tunnel with a 1.2-mm K-wire was adopted. Subsequently, the second-generation TightRope (Mini TightRope) with a 1.2 tapered K-wire instead of a drill was developed, allowing for safer surgical procedures (Fig. 1D, 1E) [9]. To ensure the proper positioning of the thumb, a 4-inch elastic bandage was maintained in the first web space from the insertion of the first guide pin until the suture was tightened to the appropriate tension. Care was taken to avoid over-tightening, which could cause impingement between the first and second metacarpals. Following the initial suture knot, a ballottement test was conducted to verify the appropriate tension, after which the remaining knots were secured.

RESULTS

Of the 17 patients included in the study, 16 were female and one was male. The surgery was performed on the dominant hand in nine cases and on the nondominant hand in eight cases. The mean age of the patients was 63.2 years (range, 56–70 years), and the average duration of conservative treatment before surgery was 12.4±7.0 months. According to the Eaton and Littler classification, six patients were classified as stage II, and 11 patients were classified as stage III.

The types of suture buttons used included nine cases with the first-generation Mini TightRope, three cases with the second-generation Mini TightRope, and five cases in which an 8-shaped suture button was created by cutting a 4-hole mini plate in half.

At the 2-year follow-up, significant improvements were observed in clinical outcomes: pain scores decreased from 7.1±1.4 to 3.7±1.2 (p<0.001), Quick DASH scores improved from 50.2±14.3 to 28.3±6.6 (p<0.001), grip strength increased from 62.6%±19.4% to 86.1%±19.4% (p<0.001), pinch strength increased from 69.6%±21.8% to 82.7%±14.5% (p=0.015), and thumb joint range of motion improved from 85.3±9.8% to 98.3±2.65% (p=0.013), all showing statistically significant changes (Table 1).

Table 1.

Clinical outcomes over 2 years after partial trapeziectomy and suture button suspensionplasty

Radiological evaluation of the TSR showed a significant decrease at 6 months postoperatively, with preoperative values averaging 0.45±0.06 and 6-month postoperative values at 0.37±0.07 (p<0.01). However, the TSR showed no significant change from 6-month postoperative to final follow-up values at 0.37±0.06 (p=0.722) (Table 2).

Table 2.

Trapezial space ratio after partial trapeziectomy and suture button suspensionplasty preoperatively, at 6 months, and at the final follow-up

Postoperative complications included one case of second metacarpal tunnel fracture at 6 weeks after surgery, which was treated with cast immobilization for 4 weeks. After cast immobilization, fracture union was observed, and functional outcomes showed significant improvement from preoperative to postoperative assessments. A case with hardware irritation at the second metacarpal button fixation necessitated removal 1 year postoperatively. This patient also showed clinical improvement at the last follow-up. Another case with FCR tendon rupture was treated conservatively. Clinical outcomes were satisfactory.

1. Case example

The patient is a 60-year-old female patient who presented with progressive pain, swelling, and crepitus to the base of the left thumb of her nondominant hand; with significant functional deficit due to pain for the past 12 months. On physical examination, she showed positive shear and grind tests along with tenderness to palpation directly over the thumb CMC joint. Initial plain radiogram of the patient showed narrowing of the CMC joint with sclerotic change, along with small osteophytes, indicating Eaton stage II arthritis (Fig. 2A). Preoperative functional scores showed VAS 6, Quick DASH 45, pinch strength 77.8% (as compared to contralateral), grip strength 81.3% (as compared to contralateral), and thumb range of motion of 90%. Preoperative TSR was 0.38.

Fig. 2.

(A) Preoperative X-ray of the patient’s left hand, showing Eaton stage II carpometacarpal arthritis. (B) Postoperative X-ray at 6 months, showing a decrease in trapezial space ratio (TSR) from preoperative X-ray. (C) Postoperative X-ray at 24 months, showing no progressive decrease in TSR from X-ray taken at 6 months.

As indicated, the patient underwent partial trapeziectomy and suture button suspensionplasty. At the last follow-up at postoperative 24 months, the patient’s pain and functional scores improved significantly (VAS, 1; Quick DASH, 27.5; pinch strength, 91.2%; grip strength, 88.9%; thumb range of motion, 95%) (Fig. 3). At 6-month (Fig. 2B) and at 24-month follow-up (Fig. 2C), the patient’s TSR was 0.36 and 0.37. There were no significant differences in the TSR values at the three indicated time points of follow-up.

Fig. 3.

Clinical photographs showing the thumb's range of motion. The images demonstrate full thumb motion comparable to the contralateral side at the final follow-up.

The patient eventually returned to normal daily activities of living with minimal pain and great functional outcomes.

Discussion

Thumb basal joint arthritis is one of the most common degenerative joint conditions in the hand, with a wide range of pain and disability severity. The prevalence of thumb basal joint arthritis is higher in women than in men [9], consistent with the predominance of female patients in our study. There are various treatment options for thumb basal joint arthritis. Giesen et al. [10] reported satisfactory outcomes in terms of Kapandji scores, pinch strength, and pain relief after surgical nerve ablation in early-stage arthritis patients, but not in those with Eaton and Littler classification grade IV disease. Arthrodesis is a widely used surgical treatment that has been shown to improve DASH scores and pinch strength across multiple studies, although it does not provide statistically superior outcomes compared to anterior LR [3,11,12]. Additionally, partial trapeziectomy with suspensionplasty is another frequently employed surgical technique, offering the benefit of preventing radial displacement of the thumb CMC joint and proximal migration of the first metacarpal, thus enhancing joint stability [13]. Various methods of suspensionplasty have been described, including those using the APL tendon and the TightRope system. The TightRope technique has the advantage of eliminating the need for prolonged K-wire fixation, thereby reducing the risks of restricted joint mobility and infection compared to traditional surgical approaches.

On a technical note, one of the reasons why total trapeziectomy was performed in previous operative techniques such as ligament reconstruction and tendon interposition (LRTI) was because of the surgical room required to perform the surgery. TightRope system allows percutaneous insertion of the rope under C-arm guidance, which does not necessitate a lot of room for ligament passage or interposition in techniques such as LRTI.

Yao and Song [7] reported improved DASH scores with no significant complications in a 2-year follow-up of 21 cases using the TightRope system. At the 5-year follow-up in this study, significant improvements were observed in pain scores, Quick DASH, grip strength, thumb joint range of motion, and pinch strength [14].

Another 10-week follow-up case report demonstrated significant pain reduction, although no significant changes were observed in Quick DASH, pinch strength, grip strength, or range of motion [8].

Downing et al. [15] reported a significant reduction in the TSR at the 1-year follow-up, with similar results across all surgical methods, including simple trapeziectomy, trapeziectomy with palmaris longus tendon interposition, and LR with trapeziectomy. TSR in this study also showed a significant reduction over time at the postoperative 6-month follow-up; however, this reduction was not substantial enough to induce additional arthritis in adjacent joints. Notably, the TSR did not progress from the 6-month postoperative mark to the last follow-up.

We believe that performing a partial trapeziectomy avoids the need to sacrifice unaffected joints and has the advantage of preserving the scaphotrapeziotrapezoid joint.

Postoperative complications included one case of second metacarpal tunnel fracture 6 weeks after surgery, which was treated with cast immobilization for 4 weeks. This is due to the larger drill diameter used in the first-generation TightRope system. To address this, a second-generation TightRope (Mini TightRope) with a 1.2 tapered K-wire instead of a drill was developed and is currently in use internationally, demonstrating favorable outcomes in clinical studies [9] This second-generation TightRope has been introduced in Korea and was used in the final three cases of this study. A case with hardware irritation at the second metacarpal button fixation necessitated removal 1 year postoperatively. The button is irritated due to its position at the dorsal surface of the 2nd metacarpal. After button removal, the patient showed satisfactory functional outcome as well as radiologic outcome without much subsidence seen on TSR at the last follow-up. We assume that the role of the TightRope button diminishes after about a year with fibrotic adhesion of the rope within the osseous tunnel. Another complication encountered was a rupture of the FCR tendon, which was managed conservatively and demonstrated satisfactory clinical outcomes at the final follow-up, as an injured FCR is known to result in minimal functional deficit. The rupture was attributed to excessive saw depth during the partial trapeziectomy. To minimize this risk, we limited the use of the saw to only a portion of the procedure and used an osteotome at the deep portion of trapezium to prevent FCR rupture.

The limitations of this study include the small sample size and the variation in surgical instruments used, despite the consistent application of the TightRope technique. Future studies should standardize surgical instruments to minimize statistical bias and ensure robust statistical power through continuous data collection and the inclusion of additional cases.

Conclusion

Partial trapeziectomy followed by suture button suspensionplasty for thumb basal joint arthritis showed significant clinical improvement in short-term follow-up [8], and satisfactory clinical outcomes were maintained at the 2-year follow-up. This technique allows for early mobilization, resulting in less restriction of the joint range of motion. Radiologically, the TSR decreased at the last follow-up in comparison to at preoperative but over the 2-year follow-up period, showed no significant progression in subsidence. Compared to other surgical methods, partial trapeziectomy with suture button suspensionplasty offers advantages such as simplicity, and reduced invasiveness for those who present with relatively early CMC arthritis.

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