Commentary & Perspective

Commentary & Perspective on
"Ligament Reconstruction with or without Tendon Interposition to Treat Primary Thumb Carpometacarpal Osteoarthritis"
by Gabriele Kriegs-Au, MD, et al.

Commentary & Perspective by
Donald C. Ferlic, MD*, Denver, Colorado

Painful osteoarthritis of the basal thumb joint is commonly seen by hand surgeons and frequently requires surgery. The surgical techniques for basal thumb osteoarthritis have progressed during the past fifty years from arthrodesis and trapeziectomy to various types of arthroplasties.

First, there was ligament reconstruction of the apical ligament, as described by Eaton and Littler in 1973, without excision of the trapezium¹. Next came the introduction of silicone implants for use with advanced arthritis or for when there were pantrapezial changes. The problems with this technique included silicone wear and instability, the latter of which could be controlled with an extensive tendon capsular reinforcement or reconstruction of the apical ligament through a fenestration in the implant.

After some time, silicone lost favor, and ligament reconstruction with tendon interposition arthroplasty that made use of one half of the flexor carpi radialis with resection of the distal half of the trapezium or the entire trapezium was popularized by Burton and Pellegrini in 1986². They found that patients did better than those in whom a silicone arthroplasty was performed and that subluxation and migration were less. After this report, the trend has been for most hand surgeons to perform this operation or some modification of it, and there have been numerous publications and presentations on the outcome of this procedure, usually with quite satisfactory results. So why belabor the issue?

In this study, Kriegs-Au et al. have presented a well-documented study comparing the results of apical ligament reconstruction alone or with tendon interposition for basal thumb osteoarthritis. They found, as did Gerwin et al³, that it was not necessary to perform the interposition as long as the apical ligament was reconstructed. They found that patients who had undergone interposition did somewhat better than those who did not. Although both of these reports are based on limited numbers of patients, it seems that they have a common theme, which is that it is not necessary to add the tendon interposition.

But to compound the question, Davis et al.⁴ reported equal results with trapeziectomy alone or combined with tissue interposition and/or ligament reconstruction.

So what is the surgeon to do?

The message seems to be that ligament reconstruction will produce better results with trapeziectomy. Anything else may be superfluous.

*The author did not receive grants or outside funding in support of research or preparation of this manuscript. The author did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973;55:1655-66.
2. Burton RI, Pellegrini VD Jr. Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty. J Hand Surg [Am]. 1986;11:324-32.
3. Gerwin M, Griffith A, Weiland AJ, Hotchkiss RN, McCormack RR. Ligament reconstruction basal joint arthroplasty without tendon interposition. Clin Orthop. 1997;342:42-5.
4. Davis TR, Brady O, Barton NJ, Lunn PG, Burke FD. Trapeziectomy alone, with tendon interposition or with ligament reconstruction? J Hand Surg [Br]. 1997;22:689-94.