2016, Vol. 11(4) 438 –443
© American Association for
Hand Surgery 2016
Osteoarthritis (OA) at the base of the thumb can cause
severe pain, weakness, and deformity and can result in
marked disability.14 The unique anatomy of the thumb car-
pometacarpal (CMC) joint predisposes it to degenerative
arthritis.5,27 Specifically, the degree of weakening of the
palmar beak ligament has been correlated with degenerative
processes in the joint and is the target of ligament recon-
struction for symptomatic arthritis.7
Degenerative OA at the thumb CMC joint is treated ini-
tially with activity modification, splinting, medication, and
intra-articular corticosteroid injections.34 For advanced dis-
ease, or when nonoperative treatments have failed, surgical
intervention can be considered. Surgical options include
volar ligament reconstruction,11 first metacarpal osteot-
omy,13 CMC joint arthrodesis,12 total joint arthroplasty,1
and trapeziectomy with or without ligament reconstruction
and tendon interposition (LRTI).3,9 Comparative studies
have shown no significant long-term difference in outcomes
among these techniques,18,29-31 aside from a lower compli-
cation rate30,31 and shorter operative time with trapeziec-
The use of a suture-button suspensionplasty (SBS) with
trapeziectomy has grown in popularity.6,24,35,36 Advocates of
this technique cite safety, ease of use, early mobilization,
and good early results.35,36 However, it is not known how
effectively the SBS withstands metacarpal subsidence
under loaded conditions. The purpose of this study was to
biomechanically compare the more widely adopted LRTI
procedure with SBS using a cadaveric model. We hypothe-
size that the SBS will result in a biomechanically stronger
construct with immediate loading. Demonstration of an
enhanced ability to withstand early active pinch while pre-
venting metacarpal subsidence may support early motion
643119HANXXX10.1177/1558944716643119HANDDesai et al
1Vanderbilt University, Nashville, TN, USA
2University of Missouri, Columbia, MO, USA
3Duke University, Durham, NC, USA
Mihir J. Desai, Department of Orthopaedics, Vanderbilt University, 1215
21st Ave S., MCE S. Tower Suite 3200, Nashville, TN 37232-8828, USA.
Biomechanical Comparison of
Suture-Button Suspensionplasty and
LRTI for Basilar Thumb Arthritis
Mihir J. Desai1, David M. Brogan2, Marc J. Richard3,
Suhail K. Mithani3, Fraser J. Leversedge3, and David S. Ruch3
Background: The purpose of this study was to compare the initial biomechanical strength of trapeziectomy and suture-
button suspensionplasty (SBS) with ligament reconstruction and tendon interposition (LRTI) for thumb carpometacarpal
(CMC) arthritis in a cadaveric model. Methods: Eight matched pairs of below-elbow cadaveric arms were used for this
study. Each specimen was randomly assigned to either receive a trapeziectomy and LRTI (LRTI group) or trapeziectomy
and SBS (SBS group). Using previously described and validated testing protocols, physiological key pinch was simulated. The
thumb metacarpal was then incrementally loaded from 5 to 20 lbs, using 5-lb increments. Metacarpal subsidence during
physiological key pinch and incremental loading was determined using radiographic measurements of trapezial space height.
Results: The average pretesting trapezial space height did not differ significantly between the LRTI (11.9 mm) and SBS
(13.7 mm) groups. After simulated physiological key pinch, the SBS group had significantly greater average trapezial space
height compared with the LRTI group (8.0 mm vs 5.5 mm). For each incremental metacarpal load from 5 to 20 lbs, the SBS
group had significantly greater average trapezial space height than the LRTI group. Conclusions: In a cadaveric model, SBS
demonstrates greater resistance to metacarpal subsidence with immediate loading compared with LRTI.
Keywords: suture-button suspensionplasty, basilar thumb arthritis, Mini TightRope
Desai et al 439
Materials and Methods
We obtained institutional review board approval for this
study and used 8 matched pairs of fresh-frozen below-
elbow cadaver arms in this study. All specimens were exam-
ined and found to have no history of any prior basilar thumb
or wrist procedures. The specimens were prepared as
described by Luria et al.17 The extensor pollicis longus
(EPL), extensor pollicis brevis (EPB), flexor pollicis longus
(FPL), and the adductor pollicis (AP) tendons were pre-
pared as the muscle-tendon units given their role in simulat-
ing key pinch.4 A 2.0 FiberWire suture (Arthrex, Naples,
Florida) was placed in each tendon using a Krackow stitch
to facilitate loading (Figure 1).
One specimen in each matched pair was randomly
assigned to either the LRTI or SBS group. Each LRTI was
performed using the technique described by Burton and
Pellegrini.3 The SBS group underwent a trapeziectomy and
SBS using the Mini TightRope (Arthrex) as described by
Cox et al.6
Each specimen was then mounted using a clamp holding
the proximal radius and ulna. We used previously described
and validated testing protocols to simulate key pinch of
approximately 32 N.4,17,22,23 Load was applied using fishing
line and weights attached to the sutures in each muscle-ten-
don unit (EPL: 2.5 lbs; EPB: 2.5 lbs; AP: 2.5 lbs; FPL: 5 lbs;
total: 12.5 lbs) as described by Putnam et al to generate
pinch (Figure 2).23
After simulation of key pinch, the first metacarpal was
axially loaded in an incremental fashion utilizing a 2.0-mm
Steinman pin placed through its middle third from dorsal to
volar. Increasing weight was sequentially added to the pin
in 5-lb increments, to a maximum load of 20 lbs, with the
goal to maximally load the metacarpal and axially stress the
We obtained 30° supinated anteroposterior C-arm
images in the following scenarios: (1) intact trapezium
with simulated key-pinch load applied, (2) postoperatively
with no load applied, (3) postoperatively with simulated
key-pinch load applied, and (4) postoperatively with sim-
ulated axial loading of the metacarpal at 5-lb increments
to a maximum of 20 lbs (Figure 3). The trapezial space
height was measured for each image and used to quantify
metacarpal subsidence as described by Downing and
Davis.8 Using open source digital software (Image J,
NIH), trapezial space height was measured from an
orthogonal line from the long axis of the scaphoid at the
distal articular surface and a parallel line that bisected the
proximal first metacarpal articular surface at the midline
(Figure 3).2 The trapezial space height was independently
measured twice and averaged for each testing state. The
percent decrease in trapezial space height from the pre-
loaded state was also calculated for each load. Statistical
analysis was performed using a paired t test.
Five male and 3 female matched-pair below-elbow speci-
mens were tested. The age of the cadavers ranged from 36
to 72 years, with an average age of 56 years.
The average native trapezial space height was similar
between the LRTI and SBS groups (14.6 mm vs 14.7 mm,
Figure 1. Illustration of muscle-tendon units involved in
simulating key pinch.
Source. Illustration adapted from Luria et al.17
Note. A 2.0 FiberWire (Arthrex, Naples, Florida) was Krackow stitched
through the FPL, EPB, EPL, and AP tendons. To ensure an adequate
line of pull, the suture through the AP was routed subcutaneously and
passed over a k-wire placed into the hamate to act as a pulley. Fishing
line was used to attach weight to the FiberWire suture to load the
muscle-tendon units with a line of pull in the direction of the arrows.
A total of 6 k-wires were used to stabilize the hand and wrist. These
were placed across the radiocarpal (not pictured) and ulnocarpal (not
pictured) articulations to prevent wrist flexion/extension, proximal to
the distal radioulnar joint (not pictured) to prevent rotation, across the
index and long metacarpophalangeal joints with joints positioned at 90°
of flexion to resist pinch, and into the hamate to act as a pulley for our
AP line of pull. An additional 2 k-wires were placed parallel into the
scaphoid and first metacarpal to gauge thumb rotation under load as
described by Luria et al.17 We discontinued the use of these k-wires, as
the measurement of rotation was too subjective and unreliable. EPL =
extensor pollicis longus; AP = adductor pollicis; EPB = extensor pollicis
brevis; APL = abducor pollicis longus; FPL = flexor pollicis longus; FCR =
flexor carpi radialis; k-wire = Kirschner wire.
440 HAND 11(4)
P = .9.). Following trapeziectomy and either intervention,
the unloaded average trapezial space height did not signifi-
cantly differ between the LRTI and SBS group (11.9 mm vs
13.7 mm, P = .4).
During simulated physiological key pinch, metacarpal
subsidence was evident in each specimen. The SBS group
maintained a significantly greater average trapezial space
height (8.0 mm) compared with the LRTI group (5.5 mm,
P = .04; Table 1).
Following incremental loading of the metacarpal, the
SBS group maintained significantly greater average trape-
zial space height than the LRTI at each weight increment.
For both groups, the percent change in the trapezial height
increased linearly as the weight increased (Figure 4).
Failure was noted in 1 specimen in the SBS group at the
20-lb metacarpal loading increment. The knot failed at the
suture button overlying the index metacarpal. No other fail-
ures were noted.
This experiment showed that SBS was biomechanically stron-
ger in resisting metacarpal subsidence under immediate load-
ing as compared with the standard LRTI in a cadaveric model.
This finding was evident both under physiological loading for
key pinch and incremental axial metacarpal loading.
A variety of surgical techniques have been described for
the treatment of basilar thumb OA. Pain relief, stability,
mobility, and strength remain the primary goals of treat-
ment. Since the original description nearly 30 years ago,
Burton and Pellegrini’s LRTI remains the most widely
used procedure for CMC arthritis.29 The technique requires
harvesting the flexor carpi radialis (FCR) tendon and weav-
ing it through a bone tunnel at the base of the thumb meta-
carpal to recreate the volar beak ligament. In theory, this
reconstruction maintains the trapezial space height after
resection of the trapezium thereby improving thumb
strength. However, compared with trapeziectomy alone,
trapeziectomy with LRTI does not demonstrate any superi-
ority.18,31 In addition, adverse events such as scar tender-
ness, tendon adhesion or rupture, sensory changes, or
complex regional pain syndrome type 1 have been reported
to occur in 22% of patients after LRTI compared with 10%
of patients after trapeziectomy only.30,31
Furthermore, there is controversy as to the sequelae of
harvesting the FCR. Naidu et al examined the effects of har-
vesting the entire FCR tendon and used the contralateral
Figure 2. Line drawing depicting the experimental apparatus.
Note. The specimen was held by a tabletop clamp. Weights are
suspended from a fishing line clipped to the 2.0 FiberWire (Arthrex,
Naples, Florida) through the muscle-tendon units.
Figure 3. Radiograph of specimen under testing of key pinch.
Note. The radiopaque marker is a quarter taped to the specimen and
is used as measurement reference. The trapezial space height was
measured for each image and used to quantify metacarpal subsidence as
described by Downing and Davis.8 Using open source digital software
(Image J, NIH), trapezial space height was measured from an orthogonal
line from the long axis of the scaphoid at the distal articular surface and
a parallel line that bisected the proximal first metacarpal articular surface
at the midline.2
Table 1. Average Trapezial Space Height (mm) for Both
Groups Preoperatively and Postoperatively During Testing of
Simulated Key Pinch.
Group Preop loaded Postop unloaded Postop loaded
LRTI group 14.6 11.9 5.5
SBS group 14.8 13.7 8
P = .9 P = .4 P = .04
Note. Preop = preoperatively; Postop = postoperatively; LRTI =
ligament reconstruction and tendon interposition; SBS = suture-button
Desai et al 441
extremity as the control.19 These authors found that the con-
trol extremity had 2.5 times greater wrist flexion fatigue
resistance than that of the surgically treated side. They also
found that the surgical side showed a significantly lower
wrist flexion-to-extension peak torque ratio than that of the
control extremity. Other studies have reported no secondary
deficits after FCR harvest.26,28
SBS was initially described to replace Kirschner wire
(k-wire) stabilization of the thumb metacarpal following
arthroscopic trapeziectomy.6 The authors cited the need for
a buried implant to allow earlier mobilization and avoid pin
site infections as percutaneous k-wires remain in place for a
minimum of 4 weeks. Using a cadaveric model of lateral
pinch, Yao et al showed similar metacarpal stability with
both SBS and percutaneous k-wire insertion after
Complications of the suture-button device used in the
foot and ankle have been reported in the orthopedic litera-
ture. Inadequate fixation and foreign-body reactions from
the suture-button placement have been reported.10,16,25,32
Fracture of the index metacarpal has also been reported fol-
lowing SBS.15,36 Since those reports, the Arthrex second-
generation Mini TightRope kit includes a 1.1-mm guidewire
to drill the metacarpal instead of the 2.7-mm drill used in
the earlier systems. Since the change to a guidewire from
the larger drill, no fractures have been reported.36
In a series of 21 patients with a minimum of 2-year fol-
low-up, Yao et al reported favorable results of SBS.36 Their
postoperative protocol allowed therapist-directed range of
motion exercises 10 days after surgery. The authors reported
that subjective and objective outcome measures were simi-
lar to previously described techniques, including LRTI.
Two complications were reported in a single patient: com-
plex regional pain syndrome and index metacarpal fracture
3 months postoperatively, both of which resolved by 10
months. The fracture occurred prior to the implementation
of the second-generation Mini TightRope system.
Some authors have expanded the use of SBS to include 2
Mini TightRopes. A series of 11 patients (12 thumbs) dem-
onstrated satisfactory pain reduction, grip strength, and pre-
served range of motion.21 Trapezial space height was
maintained from preoperative levels at an average of 17
months postoperatively. They reported no cases of fracture,
but 3 patients had dysesthesias and 1 developed complex
regional pain syndrome.
Overall, the long-term clinical effect of postoperative
metacarpal subsidence is thought to be minimal. Yang and
Weiland reported that despite a 32% decrease in trapezial
space height, patients still had a 17% improvement in pinch
and grip strength.33 However, the theorized ability of the
SBS to withstand metacarpal subsidence is cited by advo-
cates of this technique.34 Authors report that with increased
resistance to subsidence, an early motion protocol can be
used.34 The results of this study showed that SBS is biome-
chanically superior to the LRTI procedure in withstanding
metacarpal subsidence in simulated physiological pinch and
incremental metacarpal loading immediately following the
procedure supporting an early motion protocol. In addition,
Figure 4. Comparison of the average change in trapezial space height between the LRTI and SBS groups after simulated pinch and
incrementally increasing axial loads to the first metacarpal.
Note. A higher percentage indicates a greater loss of trapezial space height and collapse of the first ray. LRTI = ligament reconstruction and tendon
interposition; SBS = suture-button suspensionplasty.
*Statistical significance, P < .05.
442 HAND 11(4)
the trapezial space height decreased in a linear fashion as
the metacarpal was incrementally loaded in both groups.
Clinical studies have shown that SBS is a safe and effec-
tive technique for the treatment of basilar thumb arthritis.21,36
To date, there are no long-term data to support one surgical
option over the other (or any surgical options for basilar
thumb arthritis). The authors of these clinical series have
adopted an early mobilization protocol, with range of motion
starting as early as 10 days and the goal of earlier recovery.
The results of this study would support the early mobiliza-
tion protocol due to the biomechanical strength of SBS.
The overall cost differences of the 2 procedures should
also be considered. Although this is not a study of cost anal-
ysis, the SBS does require the purchase and additional cost
of an implantable device. However, by not having to harvest
the FCR tendon for an LRTI, the overall operating room
(OR) time may be shortened, thus decreasing OR costs.
There are limitations to this study. A validated physio-
logical key-pinch testing protocol was used along with a
novel (but unvalidated) method of incrementally loading
the metacarpal to force subsidence. While testing, it was
noted that metacarpal rotation was not controlled at the
heavier loads. The effect of this rotation is uncertain.
Furthermore, scar tissue is likely to augment the resistance
of metacarpal subsidence following an LRTI procedure and
cannot be tested in a biomechanical setting.
In addition, an initial attempt was made to assess the 2
procedures’ effect on metacarpal rotation during pinch at
physiological loads. Using the protocol of Luria et al, 2 par-
allel k-wires were placed into the metacarpal and scaphoid
and relative angular displacement after load application was
assessed in an attempt to gauge rotation.17 This method was
incredibly subjective, and the measurements were poorly
replicated. Therefore, this portion of the study was aban-
doned during testing. To properly assess rotation, more pre-
cise methods of measurement are necessary.
SBS merits continued clinical studies with long-term
follow-up to fully understand its potential uses and
Specimens and implants were provided by Arthrex (Naples,
This study was approved by our institutional review board.
Statement of Human and Animal Rights
This article does not contain any studies with human or animal
Statement of Informed Consent
No individual participants were included in the study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Funding was provided by Arthrex (Naples, Florida) with the pro-
vision of cadaver specimens and equipment to conduct this study.
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