JBJS | Thumb Carpometacarpal Osteoarthritis: Arthrodesis Compared with Ligament Reconstruction and Tendon Interposition

The Journal of Bone & Joint Surgery, Volume 83, Issue 10

Scientific Article | October 01, 2001

Thumb Carpometacarpal Osteoarthritis: Arthrodesis Compared with Ligament Reconstruction and Tendon Interposition

Brian J. Hartigan, MD; Peter J. Stern, MD; Thomas R. Kiefhaber, MD

Investigation performed at Hand Surgery Specialists and the Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
Brian J. Hartigan, MD
Northwestern Center for Orthopedics, 676 North St. Clair Street, Suite 450, Chicago, IL 60611. E-mail address: bjhartigan@hotmail.com

Peter J. Stern, MD
Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, P.O. Box 670212, Cincinnati, OH 45267

Thomas R. Kiefhaber, MD
Hand Surgery Specialists, 2800 Winslow Avenue, Suite 401, Cincinnati, OH 45206

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They 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 authors are affiliated or associated.

A video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our CD-ROM (call 781-449-9780, ext. 140, to order).

The Journal of Bone & Joint Surgery. 2001; 83:1470-1478

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Abstract

Background: There has been considerable controversy regarding the procedure of choice for treatment of any given stage of osteoarthritis of the thumb carpometacarpal joint. This study was designed to directly compare the clinical results of two common surgical procedures for this condition, trapeziometacarpal arthrodesis and trapezial excision with ligament reconstruction and tendon interposition, in similar patient populations.

Methods: Between 1988 and 1998, 109 patients (141 thumbs) who were less than sixty years old were treated with one of the two procedures. In a retrospective review, forty-two patients (fifty-eight thumbs) treated with arthrodesis completed an outcome questionnaire and twenty-nine patients (forty-four thumbs) treated with arthrodesis completed the questionnaire and were examined. In the group treated with trapezial excision with ligament reconstruction and tendon interposition, thirty-nine patients (forty-nine thumbs) completed the questionnaire and thirty patients (thirty-eight thumbs) completed the questionnaire and were examined. The average duration of follow-up was sixty-nine months. The groups were similar with regard to age, gender, hand dominance, and duration of follow-up.

Results: Subjective evaluation of pain, function, and satisfaction demonstrated no significant difference between the two groups, with >90% of patients satisfied following either procedure. Although grip strength did not differ between the groups, the arthrodesis group had significantly stronger lateral pinch (p < 0.001) and chuck pinch (p < 0.01). The group treated with ligament reconstruction and tendon interposition had a better range of motion with regard to opposition (p < 0.05) and the ability to flatten the hand (p < 0.0001). There was a higher complication rate in the arthrodesis group, with nonunion of the fusion site accounting for the majority of the complications. However, despite a persistent nonunion in six thumbs, those thumbs and the thumbs in which union was obtained did not differ with regard to pain; all of the patients with nonunion had improvement in their pain status compared with preoperatively, and all were very satisfied with the outcome. Peritrapezial arthritis developed in nine patients (fourteen thumbs). This finding was not related to age and did not affect overall pain, function, or satisfaction.

Conclusions: Although traditionally arthrodesis and ligament reconstruction and tendon interposition have been indicated in two different patient populations, we compared them in a homogeneous group and found that the two procedures had similar results with regard to pain, function, and satisfaction despite minimal differences in strength and motion. Although complications were more frequent following arthrodesis, most did not affect the overall outcome.

Figures in this Article

Introduction

Osteoarthritis of the thumb carpometacarpal joint is a common condition that affects approximately 16% to 25% of postmenopausal women and causes pain, swelling, instability, deformity, and loss of motion^1,2. Numerous procedures have been described for the treatment of advanced arthritis of the thumb carpometacarpal joint. These include ligament reconstruction³, metacarpal osteotomy⁴, total joint arthroplasty^5,6, silicone arthroplasty⁷, carpometacarpal arthrodesis⁸, and trapezial excision with or without ligament reconstruction and soft-tissue interposition^9-11. Two of the more common procedures are carpometacarpal arthrodesis and trapezial excision with ligament reconstruction and tendon interposition. Both procedures provide excellent pain relief and high patient satisfaction; however, traditionally arthrodesis has been reserved for the treatment of posttraumatic arthritis in high-demand, younger patients and ligament reconstruction and tendon interposition has been used for elderly patients with lower demands^12-14.

Amadio and De Silva¹⁵ compared the results of sixteen arthrodeses, seven tendon interposition arthroplasties without ligament reconstruction, twelve arthroplasties with cement, and twelve silicone arthroplasties in men with osteoarthritis. They found "little overall difference" between the results of arthrodesis and arthroplasty, although specific conclusions could not be made because of limited data and the inclusion of several different techniques. In 1993, Conolly and Lanzetta¹³ compared the results of sixteen arthrodeses, fifteen trapezial excisions and soft-tissue arthroplasties, and eighty-seven silicone arthroplasties. Arthrodesis was used only for isolated trapeziometacarpal arthritis in patients who performed heavy labor and were less than fifty years old. Soft-tissue arthroplasty was used for older, low-demand patients. In a limited evaluation, they found a good result after 68% of the arthrodeses and 80% of the soft-tissue arthroplasties.

We have routinely used both procedures for the treatment of primary osteoarthritis of the thumb carpometacarpal joint regardless of the patient’s age. This study was designed to directly compare the clinical results of these two procedures for the treatment of primary osteoarthritis in younger patients.

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Fig. 1:: Summary of the patients’ subjective evaluation of their ability to perform six common activities of daily living.

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Fig. 2-A:: Figs. 2-A through 2-E A forty-one-year-old woman who underwent bilateral trapeziometacarpal arthrodesis because of thumb carpometacarpal arthritis. Fig. 2-A Preoperative radiographs.

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Fig. 2-B:: Postoperative radiographs of the left (Fig. 2-B) and right (Fig. 2-C) thumbs, made at nineteen and twenty years, respectively, demonstrating scaphotrapezial joint-space narrowing and subchondral cyst formation consistent with degenerative changes.

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Fig. 2-C:: Postoperative radiographs of the left (Fig. 2-B) and right (Fig. 2-C) thumbs, made at nineteen and twenty years, respectively, demonstrating scaphotrapezial joint-space narrowing and subchondral cyst formation consistent with degenerative changes.

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Fig. 2-D:: Despite the radiographic appearance, the patient had radial abduction (Fig. 2-D) and opposition (Fig. 2-E) bilaterally, had only occasional pain, and was able to perform all activities of daily living without difficulty.

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Fig. 2-E:: Despite the radiographic appearance, the patient had radial abduction (Fig. 2-D) and opposition (Fig. 2-E) bilaterally, had only occasional pain, and was able to perform all activities of daily living without difficulty.

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TABLE I: Subjective Postoperative Results

*The values are given as the number of patients, with the percentage in parentheses. †On a scale of 0 (no pain) to 10 (severe pain).

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
No. of patients	42	39
No. of thumbs	58	49
Pain
Frequency*
Never	13 (31%)	16 (41%)
Occasional	23 (55%)	18 (46%)
Frequent	?5 (12%)	?5 (13%)
Constant	?1 (2%)	?0 (0%)
Mean visual analog score†	?3.1	?2.1
Compared with preop. level*
Substantially improved	34 (81%)	33 (85%)
Improved	?7 (17%)	?3 (8%)
Same	?0 (0%)	?3 (8%)
Worse	?1 (2%)	?0 (0%)
Satisfaction*
Very satisfied	33 (79%)	35 (90%)
Satisfied	?8 (19%)	?1 (3%)
Dissatisfied	?0 (0%)	?3 (8%)
Very dissatisfied	?1 (2%)	?0 (0%)

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TABLE I: Subjective Postoperative Results

*The values are given as the number of patients, with the percentage in parentheses. †On a scale of 0 (no pain) to 10 (severe pain).

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
No. of patients	42	39
No. of thumbs	58	49
Pain
Frequency*
Never	13 (31%)	16 (41%)
Occasional	23 (55%)	18 (46%)
Frequent	?5 (12%)	?5 (13%)
Constant	?1 (2%)	?0 (0%)
Mean visual analog score†	?3.1	?2.1
Compared with preop. level*
Substantially improved	34 (81%)	33 (85%)
Improved	?7 (17%)	?3 (8%)
Same	?0 (0%)	?3 (8%)
Worse	?1 (2%)	?0 (0%)
Satisfaction*
Very satisfied	33 (79%)	35 (90%)
Satisfied	?8 (19%)	?1 (3%)
Dissatisfied	?0 (0%)	?3 (8%)
Very dissatisfied	?1 (2%)	?0 (0%)

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TABLE II: Objective Postoperative Results

*Smallest possible distance from the flexion crease of the thumb interphalangeal joint to the distal palmar crease directly over the metacarpophalangeal joint of the small finger. †Largest possible distance from the flexion crease of the thumb interphalangeal joint to the distal palmar crease directly over the metacarpophalangeal joint of the long finger.

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
Average grip strength (kg)	25	25
Average lateral-pinch strength (kg)	?6	?5
Average tip-pinch strength (kg)	?5	?4
Average chuck-pinch strength (kg)	?6	?5
Average total arc of metacarpophalangeal motion (deg)	65	57
Average total arc of interphalangeal motion (deg)	73	75
Average palmar abduction (deg)	42	47
Average radial abduction (deg)	45	48
Average adduction* (cm)	?2.4	?2.4
Average opposition† (cm)	?5.0	?5.4
Able to touch thumb tip to small finger metacarpal (no.)	30/44 (68%)	28/38 (74%)
Able to flatten hand (no.)	29/44 (66%)	38/38 (100%)

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TABLE II: Objective Postoperative Results

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
Average grip strength (kg)	25	25
Average lateral-pinch strength (kg)	?6	?5
Average tip-pinch strength (kg)	?5	?4
Average chuck-pinch strength (kg)	?6	?5
Average total arc of metacarpophalangeal motion (deg)	65	57
Average total arc of interphalangeal motion (deg)	73	75
Average palmar abduction (deg)	42	47
Average radial abduction (deg)	45	48
Average adduction* (cm)	?2.4	?2.4
Average opposition† (cm)	?5.0	?5.4
Able to touch thumb tip to small finger metacarpal (no.)	30/44 (68%)	28/38 (74%)
Able to flatten hand (no.)	29/44 (66%)	38/38 (100%)

Materials and Methods

Patients who had undergone either trapeziometacarpal arthrodesis or trapezial excision with ligament reconstruction and tendon interposition for the treatment of primary osteoarthritis of the thumb carpometacarpal joint, were less than sixty years old at the time of treatment, and had been followed for a minimum of two years were included in the study. We identified 109 patients (141 thumbs) treated between 1988 and 1998 who met these criteria. All charts were reviewed retrospectively to determine demographic data, previous treatment, operative details, concomitant procedures, postoperative course, and complications. An attempt was made to contact each of these patients. One patient had died and twenty-seven patients could not be located despite the use of information from the medical records, telephone operator, and the Internet. The remaining eighty-one patients (107 thumbs) were contacted and completed a questionnaire to assess pain, function, ability to return to work, and satisfaction (see Appendix). Twenty-two patients were not available for personal examination. The remaining fifty-nine patients (eighty-two thumbs) were personally evaluated by one of us (B.J.H.) at an average of sixty-nine months (range, twenty-six to 252 months) postoperatively. The demographics for the two subsets of patients were similar (see Appendix).

All patients presented with pain and weakness in the thumb that interfered with normal daily activities. Surgical management was considered only after failure of nonoperative management. The choice of procedure was based on the preference of each of the three surgeons performing the operations. None of the patients had had previous surgery on the affected thumb.

Arthrodesis Group

Of the fifty-five patients (seventy-three thumbs) who had been identified as having had the arthrodesis, forty-two patients (fifty-eight thumbs) completed the questionnaire and twenty-nine patients (forty-four thumbs) were personally examined at an average of seventy-three months (range, twenty-seven to 252 months) after the arthrodesis. Of those who completed the questionnaire, five were male and thirty-seven were female, and their average age was fifty-one years (range, forty-one to fifty-nine years) at the time of the surgery. The procedure was performed in thirty dominant extremities and twenty-eight nondominant extremities. Seventeen patients had a bilateral procedure. Seven patients were laborers, and two were involved in a Workers’ Compensation claim. Preoperatively, eleven thumbs had stage-II disease and forty-seven had stage-III disease according to the radiographic classification described by Eaton and Glickel¹⁶.

Arthrodesis was performed through either a volar or a dorsal approach to the trapeziometacarpal joint. With the joint distracted by traction on the thumb, the articular cartilage and the subchondral bone on the opposing surfaces of the trapezium and the base of the thumb metacarpal were removed. The denuded surfaces were then coapted, and they were supplemented with distal radial bone graft in forty-four of the fifty-eight thumbs. The position for the arthrodesis was such that the distal phalanx of the thumb rested on the middle phalanx of the index finger of a fully clenched fist, as described by Leach and Bolton^12,17. Fixation was performed with multiple Kirschner pins (forty thumbs), tension band fixation (two), or a 2.0-mm minicondylar blade plate (Synthes USA, Paoli, Pennsylvania) (sixteen). Postoperative immobilization consisted of a forearm-based thumb spica splint that was worn for six weeks. If Kirschner pins had been used, they were removed at six weeks, regardless of the radiographic appearance.

Group Treated with Ligament Reconstruction and Tendon Interposition

Of the fifty-four patients (sixty-eight thumbs) treated with ligament reconstruction and tendon interposition, thirty-nine patients (forty-nine thumbs) completed the questionnaire and thirty patients (thirty-eight thumbs) were personally evaluated at an average of sixty-three months (range, twenty-six to 108 months) postoperatively. Of those who completed the questionnaire, three were male and thirty-six were female, and their average age was fifty-two years (range, forty-three to fifty-nine years) at the time of the surgery. The procedure was performed in twenty-three dominant extremities and twenty-six nondominant extremities, and eleven patients had a bilateral procedure. Seven patients were laborers, and five were involved in a Workers’ Compensation claim or litigation. Preoperatively, according to the radiographic classification described by Eaton and Glickel¹⁶, ten thumbs had stage-II disease; thirty-five, stage-III; and four, stage-IV.

The operative procedure is similar to that described by Tomaino et al.¹⁸, which is an evolution of the original procedure described by Burton and Pellegrini⁹. The trapeziometacarpal joint was exposed through either a dorsal or a volar approach, with care taken not to injure the superficial sensory nerves or the radial artery. The entire trapezium was excised. The entire flexor carpi radialis tendon was harvested proximally in the forearm, with its insertion left intact on the base of the second metacarpal to provide a more substantial ligament for reconstruction and creation of an interposition arthroplasty^18,19. The free end was then routed through a drill-hole in the base of the thumb metacarpal and sutured to itself. The remaining tendon was folded back on itself and held with suture, creating an "anchovy." This interposition material was placed into the space formerly occupied by the trapezium, and the capsule was closed over it. Postoperatively, a thumb spica splint was worn for three to six weeks.

Follow-up Evaluations

All patients were examined independent of the operating surgeon. Grip and pinch strength and range of motion were assessed bilaterally. Standardization of these data was difficult since preoperative data were missing in some cases. Comparison with the contralateral side is also unreliable in this patient population because bilateral disease is frequently present¹⁸, and a considerable number of patients had had a bilateral procedure. Therefore, since the two groups were similar with regard to age, occupation, and gender, the raw data were compared directly.

Grip strength was quantified with use of a Jamar dynamometer (Asimow Engineering, Los Angeles, California) set in the second position. A pinch meter was used to determine lateral-pinch, tip-pinch, and chuck-pinch strength. Tests were administered as described by Mathiowetz et al.²⁰. Flexion and extension of the interphalangeal and metacarpophalangeal joints were determined. Palmar abduction and radial abduction of the carpometacarpal joint were measured according to the angle between the thumb and index metacarpals with the thumb maximally abducted in the sagittal and coronal planes, respectively. Opposition and adduction measurements were based on those used for the American Medical Association impairment rating²¹. Opposition was measured as the largest possible distance from the flexion crease of the thumb interphalangeal joint to the distal palmar crease directly over the metacarpophalangeal joint of the long finger. Adduction was measured as the smallest possible distance from the flexion crease of the thumb interphalangeal joint to the distal palmar crease over the metacarpophalangeal joint of the small finger. The ability to touch the thumb tip to the bases of the ring and small digits and the ability to place the hand flat on a table were assessed as well.

Posteroanterior, lateral, and Betts²² radiographs were made for all fifty-nine patients seen at the time of follow-up. In the arthrodesis group, fusion was determined by the presence of trabecular bridging on all views. The follow-up radiographs were also compared with preoperative images to look for evidence of peritrapezial arthritis.

Statistical testing for significance was performed with the unpaired t test for continuous variables and the chi-square test for categorical variables. The level of significance was set at p £ 0.05.

Results

With the numbers available, no significant difference could be detected between the groups with regard to age, gender, or hand dominance. There were more bilateral procedures in the arthrodesis group (p = 0.0184). The duration of follow-up, which was seventy-five months (range, twenty-six to 252 months) for the patients treated with arthrodesis and sixty-three months (range, twenty-six to 109 months) for those treated with ligament reconstruction and tendon interposition, also did not differ significantly between the groups.

The results with regard to the frequency and level of pain (as indicated on a visual analog scale) and how the pain status at the time of follow-up compared with that before the surgery are summarized in Table I. There were no significant differences between the groups with regard to any assessment of pain.

Function was evaluated subjectively by having the patient rate his or her ability to perform six different activities: turning a doorknob, opening the door of an automobile, opening a tight jar, buttoning clothes, turning a key, and lifting a gallon (3.8 L) of milk. Each activity was rated on a scale from 1 to 5, with 1 indicating no difficulty and 5 indicating an inability to perform the task. The results are summarized in Figure 1. There was no significant difference between the two groups with regard to any of the activities. The majority of the patients were able to perform each activity with no or only mild difficulty, except for opening a tight jar, which was done with mild-to-moderate difficulty.

The ability to return to the same job and the time until the patient returned to work were similar between the two groups despite the fact that more patients treated with ligament reconstruction and tendon interposition were involved in a Worker’s Compensation claim. Thirty-seven of the forty-two patients in the arthrodesis group returned to the same job, at an average of five weeks (range, two to twelve weeks). Of the five who did not return, only two felt that they were unable to return because of the surgery; the other three left their job by choice. Thirty-seven of thirty-nine patients treated with ligament reconstruction and tendon interposition returned to work, at an average of five weeks (range, one to twelve weeks). The remaining two patients felt that they were unable to return to the same job because of the surgery.

The patients in the two groups were equally satisfied, with forty-one (98%) of the forty-two patients satisfied following arthrodesis and thirty-six (92%) of the thirty-nine patients satisfied following ligament reconstruction and tendon interposition. There was no significant difference between the groups (Table I). The only "very dissatisfied" patient had undergone arthrodesis. She had a solid union but stated that she had constant pain (rated as 6 of 10) and believed that her current level of pain was worse than it had been before the surgery. Despite these symptoms, she was able to return to work after four weeks, and at the time of follow-up at sixty-eight months she was working at the same job that she had held preoperatively.

Comparisons of average grip, lateral-pinch, tip-pinch, and chuck-pinch strengths are summarized in Table II. There was no significant difference between groups with regard to grip or tip-pinch strength. The arthrodesis group did have a significantly stronger lateral pinch (p < 0.001) and chuck pinch (p < 0.01).

While there was no difference between groups with regard to motion of the interphalangeal joint, the patients managed with arthrodesis had significantly more motion of the metacarpophalangeal joint (p = 0.04) (Table II). Although motion of the carpometacarpal joint with regard to radial and palmar abduction, adduction, and the ability to touch the thumb tip to the base of the small finger was slightly better in the group treated with ligament reconstruction and tendon interposition, it was not significantly better. Opposition was significantly greater in the group managed with the ligament reconstruction and tendon interposition (p < 0.05). Additionally, the patients in that group were more consistently able to flatten the hand, with this ability being noted after all thirty-eight procedures in this group but after only twenty-nine (66%) of the forty-four arthrodeses (p < 0.0001).

Nonunion occurred after nine (16%) of the fifty-eight arthrodeses but after only one (6%) of the sixteen fusions stabilized with a minicondylar plate. Three patients underwent revision arthrodesis with a minicondylar plate and autogenous bone graft and obtained solid union. Six patients had persistent nonunion, but at the time of follow-up they had either no pain or only occasional pain, with an average level of 1.3 of 10. All felt that the pain was substantially decreased compared with preoperatively and all were very satisfied with the outcome. Functionally, they had very little difficulty with activities of daily living, with results similar to those for the other patients in the study, regardless of the type of procedure. All were able to return to work postoperatively. At an average of eighty-eight months postoperatively, four were employed at the same job as they had been preoperatively and two had retired.

At the time of follow-up, the radiographs of the patients who had had an arthrodesis were evaluated for evidence of peritrapezial degenerative changes. After an average duration of follow-up of eighty-six months, arthritis had developed in nine patients (fourteen thumbs) (see Appendix and Figs. 2-A, 2-B, 2-C, 2-D, and 2-E). This arthritis typically involved the scaphotrapezial articulation, although in some cases it also involved other trapezial articulations. Despite an average level of pain of 2.6 of 10, all patients had a significant decrease in pain compared with the preoperative level and all were satisfied with the outcome. Eight were able to return to work postoperatively. At the time of follow-up, five were working at the same job as they had been preoperatively, three had retired, and one had changed jobs after the surgery.

Fifteen complications were seen in thirteen patients who had undergone arthrodesis. The majority (nine) of these complications were nonunions. There was one deep infection requiring incision and drainage, and there were two superficial infections, which were successfully treated with oral antibiotics. In one patient, transient pain and paresthesias developed in the distribution of the superficial sensory branch of the radial nerve; this lasted for six weeks. Two patients required removal of a symptomatic fixation device. Six patients had a complication after ligament reconstruction and tendon interposition. Persistent pain lasting more than three months was the most prevalent complication and was seen in four patients. None of these patients required further treatment, and the pain eventually resolved in all four. A superficial infection was seen in one patient and was treated with oral antibiotics. Reflex sympathetic dystrophy developed in another patient, who continued to have pain at the time of follow-up.

Discussion

Uncertainty remains regarding the best choice of procedure for any given stage of osteoarthritis of the thumb carpometacarpal joint^23,24. Few investigators have directly compared the results of the different procedures. In addition, review of the results of the various procedures is confusing because of a wide range of reported assessments^25,26. Despite this controversy, ligament reconstruction and tendon interposition is often considered the procedure of choice for thumb carpometacarpal arthritis. It has evolved from simple trapeziectomy as originally described by Gervis¹¹ in 1949, with the addition of soft-tissue interposition by Froimson¹⁰ in 1970 and finally the addition of ligament reconstruction by Burton and Pellegrini⁹ in 1986. In its current form, ligament reconstruction and tendon interposition has yielded favorable results with regard to pain, function, and satisfaction in both short-term and long-term follow-up studies^9,18. It has consistently been included in the few studies comparing the various options for surgical treatment of carpometacarpal arthritis and has been preferred when compared with silicone implant replacement arthroplasty^9,24,27 and the Ashworth-Blatt interposition implant arthroplasty²⁴.

Arthrodesis of the trapeziometacarpal joint has also been shown to have good results with regard to pain relief and functional improvement, with overall satisfaction approaching 100%^12,17,28-34. It also has had favorable results in long-term studies^28,29. Yet, traditionally it has been reserved for posttraumatic arthritis in young patients. This approach was recommended by Carroll²⁸ in 1987 on the basis of a single case of progression of peritrapezial arthritis in a sixty-year-old patient. Arthrodesis has also been criticized for resulting in limited motion, an inability to flatten the hand, a need for postoperative immobilization, and a risk of nonunion.

In this study, we used both subjective and objective criteria to directly compare the outcomes of arthrodesis and ligament reconstruction and tendon interposition for the treatment of nontraumatic arthritis in similar groups of patients. Subjectively, the two groups were remarkably similar. Pain was decreased in 98% of the patients treated with arthrodesis and in 92% of those treated with ligament reconstruction and tendon interposition, with 86% and 87% of the patients, respectively, reporting that they never or only occasionally had pain at an average of more than five years after the operation. Overall satisfaction was >90% in both groups.

Despite the conclusions by Dhar et al.²³ and by Eiken and Carstam³⁵ that arthrodesis limits hand function and results in clumsiness and impaired precision handling, we found no significant difference between the groups with regard to the subjective evaluation of their ability to perform activities of daily living. Other studies have also shown arthrodesis to have a minimal effect on activities^12,17,31,34. Additionally, return to work was not significantly affected by the choice of procedure, with approximately 90% of the patients in each group able to return to their previous occupation at an average of five weeks.

In reports supporting the use of ligament reconstruction and tendon interposition, limited motion is often mentioned as a criticism of trapeziometacarpal arthrodesis^18,23,24. Yet, several studies have shown that thumb mobility is not dramatically altered by trapeziometacarpal arthrodesis^8,12,17,34. Our study supports this conclusion as we found little difference between the procedures with regard to thumb mobility. It is generally believed that the loss of motion of the trapeziometacarpal joint is made up for by increased motion at the scaphotrapezial joint and by hyperextension of the metacarpophalangeal joint, although the concept of hyperextension of the metacarpophalangeal joint has been disputed^12,34. In our study, patients with an arthrodesis did have significantly more motion of the metacarpophalangeal joint and slightly lower values for the typical measurements of carpometacarpal motion (radial and palmar abduction, adduction, and opposition). We also found that that group had significantly less thumb extension as measured by the ability to place the hand flat, perhaps as a result of the position of fusion in 35° to 40° of palmar abduction. However, the inability to place the hand flat was rarely noticed by the patients and did not affect their overall satisfaction.

One of the other major concerns about arthrodesis is the potential for nonunion. Our nonunion rate of 16% is comparable with the overall rate of 13% as reported by Bamberger et al.¹². This rate was significantly lower after the arthrodeses performed with the minicondylar plate, as opposed to multiple Kirschner wires or a tension band, and we now prefer the minicondylar plate for fixation. Despite a persistent nonunion in six of our patients, pain was minimal, all six patients were able to return to their previous job, and all were very satisfied with the outcome. This finding is in agreement with those of other reports that indicate that nonunions may be asymptomatic^12,30,36. Clough et al.³⁰ reported 100% satisfaction in spite of a 50% nonunion rate after Herbert screw fixation. Mattsson³⁶ reported that the fusion site failed to unite after nine of nineteen arthrodeses with cerclage-wire fixation but only one patient had pain.

A second noteworthy criticism of arthrodesis is the potential predisposition to arthritis at adjacent joints. Because of this, pantrapezial arthritis is often considered a contraindication to trapeziometacarpal arthrodesis^8,28,37. We did not perform arthrodesis for stage-IV disease and therefore we cannot comment on this concern.

In recent years, ligament reconstruction and tendon interposition has increasingly become the procedure of choice for osteoarthritis of the thumb carpometacarpal joint, while arthrodesis has continued to be recommended primarily for young patients with posttraumatic arthritis. We found the two procedures to have comparable outcomes when assessed with objective criteria, except for a slight increase in pinch strength following arthrodesis and a slight increase in carpometacarpal motion following ligament reconstruction and tendon interposition. Despite these differences, the subjective outcomes were similar, with a high level of satisfaction following both procedures. Although the rate of complications was higher following arthrodesis, many of the complications were minimally symptomatic.

Appendix

Tables showing the assessment questionnaire, patient demographics, and data on patients with peritrapezial arthritis following arthrodesis are available with the electronic versions of this article, on our web site (www.jbjs.org) and on our CD-ROM (call 781-449-9780, ext. 140, to order).

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Fig. 1:: Summary of the patients’ subjective evaluation of their ability to perform six common activities of daily living.

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Fig. 2-A:: Figs. 2-A through 2-E A forty-one-year-old woman who underwent bilateral trapeziometacarpal arthrodesis because of thumb carpometacarpal arthritis. Fig. 2-A Preoperative radiographs.

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TABLE I: Subjective Postoperative Results

*The values are given as the number of patients, with the percentage in parentheses. †On a scale of 0 (no pain) to 10 (severe pain).

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
No. of patients	42	39
No. of thumbs	58	49
Pain
Frequency*
Never	13 (31%)	16 (41%)
Occasional	23 (55%)	18 (46%)
Frequent	?5 (12%)	?5 (13%)
Constant	?1 (2%)	?0 (0%)
Mean visual analog score†	?3.1	?2.1
Compared with preop. level*
Substantially improved	34 (81%)	33 (85%)
Improved	?7 (17%)	?3 (8%)
Same	?0 (0%)	?3 (8%)
Worse	?1 (2%)	?0 (0%)
Satisfaction*
Very satisfied	33 (79%)	35 (90%)
Satisfied	?8 (19%)	?1 (3%)
Dissatisfied	?0 (0%)	?3 (8%)
Very dissatisfied	?1 (2%)	?0 (0%)

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TABLE I: Subjective Postoperative Results

*The values are given as the number of patients, with the percentage in parentheses. †On a scale of 0 (no pain) to 10 (severe pain).

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
No. of patients	42	39
No. of thumbs	58	49
Pain
Frequency*
Never	13 (31%)	16 (41%)
Occasional	23 (55%)	18 (46%)
Frequent	?5 (12%)	?5 (13%)
Constant	?1 (2%)	?0 (0%)
Mean visual analog score†	?3.1	?2.1
Compared with preop. level*
Substantially improved	34 (81%)	33 (85%)
Improved	?7 (17%)	?3 (8%)
Same	?0 (0%)	?3 (8%)
Worse	?1 (2%)	?0 (0%)
Satisfaction*
Very satisfied	33 (79%)	35 (90%)
Satisfied	?8 (19%)	?1 (3%)
Dissatisfied	?0 (0%)	?3 (8%)
Very dissatisfied	?1 (2%)	?0 (0%)

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TABLE II: Objective Postoperative Results

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
Average grip strength (kg)	25	25
Average lateral-pinch strength (kg)	?6	?5
Average tip-pinch strength (kg)	?5	?4
Average chuck-pinch strength (kg)	?6	?5
Average total arc of metacarpophalangeal motion (deg)	65	57
Average total arc of interphalangeal motion (deg)	73	75
Average palmar abduction (deg)	42	47
Average radial abduction (deg)	45	48
Average adduction* (cm)	?2.4	?2.4
Average opposition† (cm)	?5.0	?5.4
Able to touch thumb tip to small finger metacarpal (no.)	30/44 (68%)	28/38 (74%)
Able to flatten hand (no.)	29/44 (66%)	38/38 (100%)

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TABLE II: Objective Postoperative Results

	Arthrodesis	Ligament Reconstruction and Tendon Interposition
Average grip strength (kg)	25	25
Average lateral-pinch strength (kg)	?6	?5
Average tip-pinch strength (kg)	?5	?4
Average chuck-pinch strength (kg)	?6	?5
Average total arc of metacarpophalangeal motion (deg)	65	57
Average total arc of interphalangeal motion (deg)	73	75
Average palmar abduction (deg)	42	47
Average radial abduction (deg)	45	48
Average adduction* (cm)	?2.4	?2.4
Average opposition† (cm)	?5.0	?5.4
Able to touch thumb tip to small finger metacarpal (no.)	30/44 (68%)	28/38 (74%)
Able to flatten hand (no.)	29/44 (66%)	38/38 (100%)