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Biomechanical Comparison of Suture-Button Suspensionplasty and LRTI for Basilar Thumb Arthritis

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Abstract and Figures

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.
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HAND
2016, Vol. 11(4) 438 –443
© American Association for
Hand Surgery 2016
DOI: 10.1177/1558944716643119
hand.sagepub.com
Surgery Article
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-
tomy alone.20
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
rehabilitation protocols.
643119HANXXX10.1177/1558944716643119HANDDesai et al
research-article2016
1Vanderbilt University, Nashville, TN, USA
2University of Missouri, Columbia, MO, USA
3Duke University, Durham, NC, USA
Corresponding Author:
Mihir J. Desai, Department of Orthopaedics, Vanderbilt University, 1215
21st Ave S., MCE S. Tower Suite 3200, Nashville, TN 37232-8828, USA.
Email: Mihir.j.desai@vanderbilt.edu
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
Abstract
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
reconstruction.
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.
Results
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.
Discussion
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
suspensionplasty.
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
trapeziectomy.37
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
complications.
Acknowledgment
Specimens and implants were provided by Arthrex (Naples,
Florida).
Ethical Approval
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
subjects.
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
article.
Funding
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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... Osteoarthritis-related defects of the finger joint can be repaired with temporary replacements, such as implants [1][2][3][4][5], permanent arthrodesis, and vascularized joint grafts like joint flaps or articular flaps [6][7][8][9][10][11]. Among these methods, the best one is believed to be the permanent substitution through an autogenous vascularized joint transfer utilizing the proximal interphalangeal joint of the second toe [6][7][8][9][10][11]. ...
... While most patients experience only minor symptoms, some develop severe pain, weakness, and instability in their thumb, severely impairing their hand function. Treatment consists primarily of removal of the diseased trapezium and stabilization of the metacarpal base [4,5]. Surgery may be an option in the case of advanced disease. ...
... However, no technique has demonstrated a superior outcome to trapeziectomy yet. Newer treatment options such as ideal prosthetic implants and carpometacarpal arthroplasty are now being used [4,5]. ...
... Although SBS has gained popularity, there is a lack of evidence and of comparative studies advocating either LRTI or SBS. Only comparative biomechanical studies in cadaver models were found [5,6,32,33]. ...
... Patients in the SBS group were able to return sooner to their usual activities and showed less decrease in Trapezial Space Ratio at end of follow-up. We believe that these results are explained by the hypothesis suggested by biomechanical studies that revealed a greater initial load-bearing profile and maintenance of trapezial space following serial loading in cadaver models, and by first dorsal interosseous muscle atrophy due to prolonged immobilization and FCR harvesting [33,40]. ...
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The purpose of the present study was to compare the results of patients operated with trapeziectomy and ligament reconstruction and tendon interposition (LRTI) using flexor carpi radialis tendon versus trapeziectomy followed by suspension of the first metacarpal to the second metacarpal using a Mini TightRope® suture button (suture button suspension: SBS). A single-center prospective randomized controlled trial was performed, comparing 37 patients with SBS and 39 with LRTI. All surgeries were performed by the same fellowship-trained hand surgeon. Patients were assessed by an independent observer at 40 months’ follow-up. Pre- and postoperative strength, trapezial space ratio (TSR), range of motion, QuickDASH and visual analogue pain score were recorded. Both procedures improved functional parameters of pain, key strength, tip strength and grip strength while maintaining range of motion, without significant differences. In the SBS group, TSR decreased by 17%, compared to 28% in the LRTI group. The mean operative time was shorter in SBS (63 vs 91 minutes; p < 0.0001), as was immobilization time (2 vs 6 weeks; p < 0.0001), and patients resumed normal activity sooner (10 vs 12 week; p = 0.0138) and required less physical therapy (19.3 vs 13.1 weeks; p < 0.0001). We believe that our results are related to the hypothesis suggested by biomechanical studies that revealed better initial load bearing profile and maintenance of trapezial space following serial loading in cadaver models.
... resistance and less metacarpal subsidence when compared with LRTI with or without the use of a biotenodesis interference screws. 10 Although the potential advantages of interference screw suspensionplasty have been established in animal studies, there are no mid-or long-term outcome studies in vivo, and further investigation of this technique is warranted. ...
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Many approaches to CMC arthroplasty have been described for treatment of advanced arthritis, yet there is no consensus on the “best” operation. Implantable hardware is increasingly utilized for metacarpal suspension, but few hardware-mediated complications have been documented. Here we present the case of a 69-year-old man with insidious-onset median neuropathy following ligament reconstruction and tendon interposition for CMC arthritis, utilizing interference screw fixation. After surgery, the patient developed median neuropathy, and his physical examination and MRI demonstrated a mass in the volar wrist. Operative exploration revealed an interference screw that was lodged immediately volar to the transverse carpal ligament, causing median nerve compression. Median neurolysis and screw removal led to symptom resolution. Carpal tunnel syndrome is an unreported complication of interference screw use during thumb CMC arthroplasty, and should be considered in patients with postoperative median neuropathy following ligament reconstruction and tendon interposition.
... Joint dislocation and collapse can easily occur after surgery. Some scholars have also proposed non-plugging therapies such as total trapezium excision with button plate suspension of the rst metacarpal bone 11 and autograft tendon transposition with joint ligament reconstruction 12 . However, the rst carpometacarpal joint would be in poor stability as its subsidence and dorsal intercalated segment instability (DISI) would appear as a disability of the distal portion of the scaphoid after total trapezium excision 13,14 . ...
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Background: The purpose of this study was to analyze the clinical efficacy of allogeneic tendon ball tamponade with the proximal joint surface of trapezium preservation for the treatment of patients with first carpometacarpal arthritis in patients in Eaton stage Ⅱ and Ⅲ. Methods: Data of 16 patients with first carpometacarpal arthritis who were treated with allogeneic tendon ball tamponade with the proximal joint surface of trapezium preservation from April 2016 to June 2021 were retrospectively analyzed. The subsidence rate of the first carpometacarpal joint was evaluated based on the height of the joint space and its index according to three-dimensional computed tomography (3D-CT). Visual analogue scale (VAS) score, disabilities of the arm, shoulder, and hand (DASH) score, grip strength and pinch force pre- and post-operatively were analyzed. The data were analyzed by t-test or one-way analysis of variance (ANOVA) followed by Tukey’s post hoc test for multiple comparisons. Results: All participants were followed up for at least 8 months. After the surgery, the VAS and DASH scores were significantly lower than those before surgery. The pinch strength and grip strength significantly increased. No significant difference was found in the carpometacarpal height index at the final follow-up, indicating that the first metacarpal had no obvious collapse after surgery. Conclusion: Allogeneic tendon tamponade with the proximal joint surface of trapezium preservation is effective for the first carpometacarpal joint arthritis in patients with Eaton stages Ⅱ and Ⅲ. The therapeutic effect of this modified operation was satisfactory for alleviating pain and reducing the collapse rate of the first metacarpal.
Article
The suture button (SB) suspension technique has become popular in the treatment of thumb basal joint arthritis, as it works as an internal mean for metacarpal stabilization, demonstrating good results with improvement in function and strength. The aim of our study is to describe a new transosseous suture suspensionplasty technique using a simple Ethibond #2 suture as a substitute for the suture button and to report the postoperative clinical outcomes. In this study, we included a total of 14 patients with 2 years follow-up. We evaluated patients with the use of the Disabilities of the Arm, Shoulder and Hand questionnaire, the Visual Analog Scale, the Kapandji test, and the key pinch strength. Patients treated with transosseous suture suspensionplasty demonstrated clinical improvement at an average follow-up of 24 months. No complications were noted immediately after the procedure or during the 2-year follow-up period.
Article
Purpose The purpose of this cadaveric biomechanical experiment was to evaluate the effects of suture button suspensionplasty of the first carpometacarpal joint on thumb biomechanics and thumb position compared with an intact, arthritic specimen. Methods Six tendons in 8 cadaver hands were loaded to simulate 6 activities of daily living and passively moved through a circumduction motion. Proximal migration of the base of the first metacarpal was measured using optical motion sensors in the intact hand, after trapeziectomy, and following insertion of a suture button suspensionplasty with nominal tightening (approximately 4.5 N) and with firm tightening (approximately 44.5 N). Results Removal of the trapezium caused a significant increase in the proximal migration of the first metacarpal during a simulated jar grasp, opposition, flexion, extension, and abduction (average, 9.5 mm) compared with its location with the thumb in the intact, neutral position (average, 3.8 mm). Firm tightening of the tightrope caused a near elimination of the proximal migration of the first metacarpal (average, 0.7 mm). In all 6 static loading cases with the trapezium removed, firm tightening caused a significantly smaller migration than in the absence of tightening. Conclusions This biomechanical cadaver study supports the hypothesis that trapeziectomy results in proximal migration of the first metacarpal. Suture suspensionplasty mitigates against this migration while maintaining normal motion of the first metacarpal compared with the intact state. Firm tightening of the suture does not adversely affect the first metacarpal’s mobility and further decreases proximal migration. However, firm tightening may cause impingement between the first and second metacarpals. Clinical relevance Suture button suspensionplasty can be used in addition to trapeziectomy in the treatment of basal joint arthritis, and may diminish the need for ligament reconstruction or temporary K-wire insertion.
Article
Several surgical procedures have been described to treat thumb carpometacarpal osteoarthritis, including suture button suspensionplasty and ligament reconstruction and tendon interposition. To date, no single procedure has demonstrated clinical superiority. Suture button suspensionplasty has achieved favorable outcomes at 5 years in primary cases, but has not been validated in revision surgery. In this study, it was evaluated for revision of failed thumb carpometacarpal osteoarthritis surgery, and outcomes were compared to ligament reconstruction and tendon interposition outcomes. A retrospective chart review identified patients who underwent suture button suspensionplasty or ligament reconstruction and tendon interposition after failure of previous thumb carpometacarpal osteoarthritis surgery since 2010. Eighteen patients were included, with nine patients in each group. Eighteen patients had mean final follow-up of 35 months. There were two complications in the ligament reconstruction and tendon interposition group and none in the suture button suspensionplasty group. No patients required additional surgery. The suture button suspensionplasty group had an average visual analogue scale pain score improvement of 2.9, compared to 2.4 in the ligament reconstruction and tendon interposition group. Average final Quick Disabilities of the Arms, Shoulder and Hand questionnaire score was 15.1 in the suture button suspensionplasty group, compared to 22.6 in the ligament reconstruction and tendon interposition group. Mean operative time of 86.3 minutes in the suture button suspensionplasty group was significantly shorter than the 121-minute mean in the ligament reconstruction and tendon interposition group. Suture button suspensionplasty is an effective treatment option for revision of previous thumb carpometacarpal osteoarthritis surgery, with outcomes comparable to revision using ligament reconstruction and tendon interposition, and the added benefit of shorter operative times and early mobilization. Clinical question/level of evidence: Therapeutic, III.
Article
The trapeziometacarpal joint is the site that most commonly develops arthritis in the hand. Although optimal treatment requires careful consideration of history, physical examination, radiographs, and functional goals, many patients ultimately undergo surgical intervention. Several described techniques and approaches are highlighted in this article, especially pertaining to carpometacarpal arthroplasty with ligament reconstruction and tendon interposition. The rationale, benefit, and evidence for each approach are discussed and the author's preferred technique is described.
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Background The purpose of this study was to help understand national practice patterns in carpometacarpal (CMC) arthroplasty and how they have evolved with evidence-based recommendations over the past 15 years. Methods The American Board of Plastic Surgery (ABPS) started collecting practice data on primary CMC joint arthroplasty in 2006 as a portion of its continuous certification (CC) process. Data on primary CMC arthroplasty from May 2006 through December 2013 were reviewed and compared to those from January 2014 to March 2020. National practice trends observed in these data were evaluated. Comprehensive evidence-based medicine reviews published in 2008, 2011, 2013, and 2017 were reviewed alongside the CC data. Results In all, 570 primary CMC joint arthroplasty cases were included from May 2006 to March 2020. The average age at the time of repair was 62 years and the patient population was predominantly female (79%). Most cases were done under general anesthesia (69%), and there was an increase in the use of regional anesthesia with nerve block when our 2 cohorts were compared (27% vs 37%; P = .020). A trapezium excision with flexor carpi radialis tendon ligament reconstruction was the most popular technique (72%) and an increase in the use of simple trapeziectomy was observed (6% vs 14%; P = .001). One-third of patients did not receive any form of deep vein thrombosis prophylaxis. Conclusions The ABPS CC data provide a databank that allows for direct observation of national practice trends and sheds light on potential avenues for improvement in patient care.
Article
To our knowledge, no study has directly measured the loads in the trapeziometacarpal joint during an isometric key pinch. The aim of this study was to measure the load acting on the trapeziometacarpal joint for increasingly greater key pinch forces (0.5 kg to 1.5 kg). We performed a cadaver study using 10 fresh-frozen, unembalmed adult forearms and hands (5 right and 5 left). Thumb pinch was simulated by loading the main actuator tendons involved in the key pinch grip (i.e., adductor pollicis, flexor pollicis longus, extensor pollicis longus, extensor pollicis brevis and abductor pollicis longus tendons). Measurements were made inside the joint using a force-sensing resistor sensor (Tekscan® FlexiForce™ force sensor). All specimens were tested twice in a row in the same condition. The median load values recorded in the trapeziometacarpal joint were 1.9 kg (IQR 2.2–1.5), 3 kg (IQR 3.4–2.7) and 4.1 kg (IQR 4.4–3.9) during 0.5 kg, 1 kg, and 1.5 kg key pinch, respectively. For each specimen, similar load values were observed during both loading trials. Our findings indicate that the loads measured directly in the trapeziometacarpal joint during a simple key pinch are materially lower than those estimated in biomechanical models of the thumb (generally greater than 10 kg for 1 kg of applied force) probably due to intersubject variability. This pilot study will serve as a basis for further studies, for example, comparing biomechanical thumb models and experimental measurements under the same set-up conditions.
Article
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Background Basilar thumb arthritis, or first carpometacarpal arthritis, is a common condition, predominantly affecting women. Surgical treatment of this condition is highly varied. One common method consists of trapezium excision and a concomitant procedure for treatment of the “floating” thumb metacarpal. That procedures vary suggests that no method has an “outcome” advantage over another. However, the frequency of side effects is higher in more complex procedures. Question/Purposes We speculated that in vitro testing might identify a potential outcome difference that has been difficult to measure in vivo. Since the more complex procedure to treat this condition has a higher frequency of clinical side effects, we hoped to determine its functional value compared with less complex procedures. Methods A two-degrees-of-freedom biomechanical cadaver study examined simulated pinch strength and metacarpal subsidence during pinch. Three methods were compared with each other and against the normal pretreatment state: trapezial excision alone; trapezial excision and suture suspensionplasty (TESS); and trapezial excision followed by a ligament reconstruction using one-half of the flexor carpi radialis and tendon interposition (LRTI). Results After TESS, the loaded mean height of the arthroplasty space was 1.20 cm. This was statistically less than the pretreatment height of 1.50 cm (P < 0.05). However, the height maintained after LRTI (1.00 cm) was also statistically less than pretreatment state (P < 0.05) and less than TESS (P < 0.05). Trapezial excision alone was least successful at maintaining height. In contrast, the mean key pinch measured after treatment could not be predicted by treatment employed. Conclusions In summary, the tested technique of TESS appears to be biomechanically sound as related to maintenance of first metacarpal height. In in vitro testing it is superior to excision alone and at least equal to the ligament reconstruction method tested. Analysis of our data shows that 96% of the overall height (distance) maintained post excision is explained by surgical state. Clinical Relevance Trapezial height is preserved using support schemes in a laboratory setting. In the in vivo postsurgical state, clinical intrinsic muscle function may be superior when support is used compared with trapeziectomy alone.
Article
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Background The safety and the effects of different trajectories on thumb motion of suture-button suspensionplasty post-trapeziectomy are not known. Methods In a cadaveric model, thumb range of motion, trapeziectomy space height, and distance between the device and nerve to the first dorsal interosseous muscle (first DI) were measured for proximal and distal trajectory groups. Proximal trajectory was defined as a suture button angle directed from the thumb metacarpal to the second metacarpal at a trajectory less than 60° from the horizontal; distal trajectory was defined as a suture button angle directed from the thumb metacarpal to the second metacarpal at a trajectory of greater than 60° from the horizontal (Fig. 1). Results There were no significant differences in range of motion and trapeziectomy space height between both groups. The device was significantly further away from the nerve to the first DI in the proximal trajectory group compared to the distal trajectory group, but was still safely away from the nerve in both groups (greater than 1 cm). Conclusions These results suggest that the device placement in either a proximal or distal location on the second metacarpal will yield similar results regarding safety and thumb range of motion.
Article
We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Metacarpal osteotomy was equally successful in relieving symptoms of those with early (grade 2) and moderate (grade 3) degenerative changes. This simple procedure provides lasting pain relief, corrects adduction contracture and restores grip and pinch strength, giving good results with few complications.
Article
Despite the numerous techniques available to treat thumb carpometacarpal arthrtis, studies show no long-term differences in outcomes among these techniques. However, simple trapeziectomy has been gaining popularity because of its low propensity for complications and relatively short intraoperative procedural time. Current approaches to trapeziectomy use Kirschner wire fixation to prevent subsidence. Unfortunately, this fixation method requires at least 4 weeks of immobilization of the thumb. We describe a novel technique involving suture-button (SB) suspensionplasty (Mini TightRope, Arthrex, Naples, FL) that allows for earlier mobilization of the thumb and faster overall recovery. This method uses a SB device that suspends the thumb ray after arthroscopic hemitrapeziectomy or full trapeziectomy. Preliminary results are promising, but further studies must be conducted to confirm the safety and efficacy of this SB suspensionplasty technique.
Article
To evaluate the efficacy of the technique of dual Mini TightRope suspensionplasty for treatment of trapeziometacarpal joint arthritis. We conducted a retrospective study investigating the use of a dual Mini TightRope suspensionplasty technique from 2010 to 2013 at a single institution. We identified 11 patients (12 thumbs). Grip and pinch strength, thumb range of motion, and complications were reviewed. The trapezial space ratio was measured from the preoperative, postoperative, and follow-up radiographs. All patients completed the Disabilities of Arm, Shoulder, and Hand survey, Patient-Rated Wrist Evaluation, and the Michigan Hand Outcome Questionnaire at the latest follow-up. Dual Mini TightRope suspensionplasty resulted in reduced pain levels, increased grip and pinch strength, and preserved range of motion. Radiographs demonstrated maintenance of trapezial space height at an average of 17 months (range, 10-26 mo). There were no cases of impingement or fracture of the first and second metacarpal bases. Dual Mini TightRope suspensionplasty for the management of trapeziometacarpal joint arthritis yielded satisfactory results with improvement in strength and function. Therapeutic IV. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Article
Purpose: To retrospectively review the results at a minimum of 2 years of suture-button plasty with partial or full trapeziectomy and suture-button suspensionplasty. Methods: We evaluated 21 patients who received suture-button suspensionplasty at least 2 years after surgery. We measured postoperative pinch strength, grip strength, range of motion, and metacarpal height. All patients also completed the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire. Results: At an average follow-up of 2.8 ± 0.7 years, the mean Quick Disabilities of the Arm, Shoulder, and Hand score was 10 ± 9. Pinch and grip strengths were 86% and 89% of the contralateral limb, respectively. Average first trapezial height was 74% of the contralateral trapezial height. There were no major complications. Conclusions: The favorable results of the suture-button suspensionplasty procedure confirm its usefulness in treating thumb carpometacarpal arthritis with minimal risk of complications, ineffective fixation, or loss of function. Subjective and objective outcomes measures are similar to previously described techniques. The benefit of this technique results from the implanted nature of the suspensionplasty elements that require no time to heal, so rehabilitation is begun as early as 10 days postoperatively. Type of study/level of evidence: Therapeutic IV.
Article
Trapeziectomy has been regaining popularity in treatment of thumb carpometacarpal (CMC). Current approaches to trapeziectomy use Kirschner wire fixation to prevent subsidence of the thumb metacarpal into the newly created trapeziectomy space. This fixation method requires at least 4 weeks of strict immobilization of the thumb. A technique using a suture-button device to suspend the thumb allows for earlier mobilization of the thumb and potentially leads to a faster overall recovery. Preliminary results are promising, but further studies must be conducted to confirm the long-term efficacy of this suture-button suspensionplasty.
Article
Trapeziectomy, by itself or combined with ligament reconstruction/interposition arthroplasty, is commonly performed for advanced trapezial-metacarpal arthritis. Several methods and materials, both autogenous and artificial, are commonly used for ligament reconstruction and interposition arthroplasty. Harvesting autologous tendons adds to operative time and could increase potential surgical complications. Using an artificial material would, in theory, avoid some of these problems. However, this approach is not without its problems. We present a case of index metacarpal fracture after using the Arthrex Mini TightRope (Arthrex, Naples, FL) suture button fixation of the thumb and index metacarpals after complete trapeziectomy.
Article
Suture-button fixation for tibiofibular syndesmosis injuries is a relatively new surgical technique thought to provide semirigid dynamic stabilization. However, adequate information is still not available and there are controversies as to whether it provides enough fixation for syndesmosis injuries. Optimally directed suture-button fixation brings physiologic dynamic stabilization of the ankle syndesmosis. Controlled laboratory study. Stabilization of the ankle syndesmosis fixed by a suture-button construct was examined using 6 normal fresh-frozen cadaver legs. After initial tests of intact and injured models, suture-button fixation and screw surgical techniques were performed sequentially for each specimen, with single suture-button fixation, double suture-button fixation, anatomic suture-button fixation, and metal screw. Anterior and medial traction forces, as well as external rotation force, were applied to the tibia; the diastasis of the syndesmosis and the rotational angle of the fibula related to the tibia were measured using a magnetic tracking system. Each traction and rotation force significantly increased the diastasis and fibular rotational angles in the created injury models. With single fixation, the diastases increased significantly compared with the intact model with an anterior traction force (P < .001), a medial traction force (P = .005), and an external rotation force (P = .015). The fibular rotational angles increased significantly with a medial traction force (P = .005) and an external rotation force (P < .001). With double fixation, the diastases increased significantly with a medial traction force (P = .004) and an external rotation force (P = .012). The fibular rotational angles increased significantly with a medial traction force (P = .035) and an external rotation force (P = .002). With anatomic fixation, there were no significant differences compared with the intact model. With the metal screw, the diastases decreased significantly with an external rotation force (P = .037). Neither single nor double fixation for syndesmosis injuries provided multidirectionally stabilizing syndesmosis. Anatomic fixation directed from the posterior cortex of the fibula to the anterolateral edge of the tibia allowed dynamic stabilization of intact cadaver specimens. The metal screw provided very rigid fixation. Optimal direction of the suture button can provide adequate stabilization of the ankle and could benefit athletes with syndesmosis injuries.