Journal of Hand Surgery Global Online 2 (2020) 133e137 Contents lists available at ScienceDirect Journal of Hand Surgery Global Online journal homepage: www.JHSGO.org Original Research Partial Versus Total Trapeziectomy With Interposition Arthroplasty for Trapeziometacarpal Osteoarthritis Grade II to III Eaton-Littler: A Clinical Trial nchez-Flo Ricard Sa  , MD, * Ferran Fillat-Goma , MD, MSc, * Francesc Antoni Marcano-Ferna ndez, MD, PhD, * Alexandre Berenguer-Sa nchez, MD, * * * Pau Balcells-Nolla, MD, Pere Torner, MD, PhD * noma de Barcelona, Sabadell, Spain Orthopedic Department, Parc Taulí Hospital Universitari, Universitat Auto a r t i c l e i n f o Article history: Purpose: Total trapeziectomy is the most widely used technique to treat isolated thumb tra- Received for publication December 3, 2019 peziometacarpal joint osteoarthritis. However, this technique has been associated with proximal Accepted in revised form March 13, 2020 migration of the thumb metacarpal, which has led some physicians to consider partial trapeziectomy as a Available online April 15, 2020 valid alternative. The purpose of this study was to assess whether partial trapeziectomy improves final key pinch strength compared with total trapeziectomy. Key words: Methods: We randomized 34 patients with basal thumb osteoarthritis into 2 groups to undergo partial or Basal thumb arthritis total trapeziectomy with interposition arthroplasty. Key pinch strength at 12 months was the primary Ligamentoplasty Partial outcome measure. Other variables measured included trapezial space height, range of motion, grip Trapeziectomy strength, change in key pinch strength, patient-reported outcome measures, and pain. Results: No difference between groups was detected regarding final pinch strength, trapezial space height, grip strength, range of motion, change in pinch strength, patient-reported outcomes (Quick eDisabilities of the Arm, Shoulder, or Hand), or pain. Conclusions: We cannot conclude that partial trapeziectomy provides an advantage over total tra- peziectomy at 1 year after surgery. Although trapeziometacarpal space was substantially preserved in the partial trapeziectomy group at 12 months, this difference was not statistically or clinically significant. Type of study/level of evidence: Diagnostic III. Copyright © 2020, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Trapeziectomy was first described in 1947 by Gervis.1 Since Partial trapeziectomy (PT) was later introduced to preserve then, this method has been used as an effective treatment for tra- maximum thumb length.4 The aim of PT is to preserve healthy peziometacarpal osteoarthritis (TMOA) improving mobility and joints to maintain stability and strength and prevent first ray pain. Trapeziectomy has also been associated with a loss of thumb collapse. It is mainly indicated in patients without trapezioscaphoid strength resulting from proximal migration of the metacarpal.2 involvement. In 1986, Burton and Pellegrini3 described a new technique The purposes of this study were to assess whether PT improves consisting of ligament reconstruction and tendon interposition final key pinch strength compared with total trapeziectomy (TT) arthroplasty, which reduced proximal migration of the metacarpal. and to correlate the radiographic findings with patient outcomes. We hypothesized that PT would preserve final key pinch strength better than TT for basal thumb arthritis surgery. Declaration of interests: No benefits in any form have been received or will be received by the authors related directly or indirectly to the subject of this article. Materials and Methods Corresponding author: Francesc Antoni Marcano-Ferna ndez, MD, PhD, Or- thopedic Department, Parc Taulí Hospital Universitari, Institut d’Investigacio  i  Parc Taulí I3PT, Universitat Auto Innovacio noma de Barcelona, Sabadell, Spain. This study was conducted as a single-center, single-blinded, E-mail address: francescmarcanot@gmail.com (F.A. Marcano-Ferna ndez). randomized controlled trial at the Department of Hand and Wrist https://doi.org/10.1016/j.jhsg.2020.03.004 2589-5141/Copyright © 2020, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 134 nchez-Flo R. Sa  et al. / Journal of Hand Surgery Global Online 2 (2020) 133e137 Figure 1. Study flowchart. Surgery at our institution. A total of 34 patients were included between February 2014 and February 2015. The sample size was calculated with 2-tailed a ¼ 0.05 and (1-b) ¼ 0.80, considering as relevant a difference of 0.3 kg in final pinch strength using the same calibrated dynamometer each time. This difference was considered relevant based on a previous local pilot study and using a published paper with a similar population.5 Using these values, a sample size of 34 patients was calculated. Inclusion criteria were patients with isolated TMOA grade II to III (Eaton-Littler) with articular pain and loss of hand function. All patients provided written informed consent. Patients with TMOA grade IV (Eaton-Littler) and those with cognitive impairment and posttraumatic osteoarthritis were excluded, as well as those with hyperextension of the metacarpophalangeal joint. Figure 1 shows a study flowchart. Block randomization was accomplished by means of sequen- tially numbered sealed opaque envelopes. Allocation ratio was 1:1, and the allocation sequence was previously generated by an external analyst. The same physician performed all surgical procedures. Patients who consented to participate were randomly assigned to undergo PT or TT with suspension and interposition arthroplasty based on the Weilby technique.6 The incision was made on the radial edge of the first metacarpal, preserving the sensory branch of the radial nerve, and performing total or partial trapeziectomy, according to the randomized treatment previously assigned. Partial trapeziectomy was performed with the help of a saw and the distal 5 to 10 mm of the trapezium was resected, leaving enough space for the ligament suspension plasty. As shown in Figure 2, we harvested half of the flexor carpi radialis tendon and wove it in a figure-of-8 form around the insertion of the abductor pollicis longus tendon and a remaining strand of flexor carpi radialis. Fixation of the Figure 2. Harvested half of the flexor carpi radialis tendon woven in a figure-of-8 form tendon was done with a nonabsorbable suture and then pulled around the insertion of the abductor pollicis longus tendon and a remaining strand of together into the trapezial space. The thumb was then immobilized flexor carpi radialis. for 3 weeks with a thumb spica orthosis, followed by 3 months of physiotherapy until stabilization. Objective outcomes included trapezial space height, key pinch Outcomes were evaluated at different time points: before sur- strength, grip strength, and joint range of motion. Subjective out- gery at 3 and 12 months after surgery. Trapezial space height was comes were function and pain. evaluated only before surgery and 1 year after surgery. Trapezial nchez-Flo R. Sa  et al. / Journal of Hand Surgery Global Online 2 (2020) 133e137 135 Figure 3. Lateral x-ray view of the thumb metacarpal used to measure trapezial height, measured as the distance in millimeters between 2 parallel lines marked by the articular surface of the distal pole of the scaphoid and the thumb metacarpal base. space height was measured using calibrated x-rays. It was Student t test and Mann-Whitney U test were used to compare measured as the distance in millimeters between 2 parallel lines numerical variables between groups. Categorical data were marked by the articular surface of the distal pole of the scaphoid analyzed with chi-square. P < .05 was considered statistically and thumb metacarpal base in the lateral x-ray view. Two radiol- significant. ogists who were blinded to the functional outcome but not to the We conducted per-protocol data analysis. The study received method of treatment performed all radiographic measurements institutional review board approval and the protocol was registered (Fig. 3). at the US National Institutes of Health (clinicaltrials.gov) with the Key pinch and grip strength were assessed using a baseline identifier NCT02693600. The authors have adhered to Consolidated pinch gauge and grip dynamometer, respectively. In all cases, 3 Standards of Reporting Trials guidelines. measurements were made at each medical examination and the mean of the measurements was recorded. All recordings were Results performed with the same calibrated instruments. The main vari- able was final key pinch strength at 12 months; however, we also The study was completed in February 2017 after a sample size of analyzed the difference in pinch strength from baseline to 12 34 patients was obtained; surgery was performed with a minimum months and final grip strength at 12 months. Joint range of motion of 1-year follow-up. Seventeen patients were assigned to each was measured as thumb opposition evaluated using the Kapandji group. Two patients were lost to follow-up: one in the PT group score.7 owing to an unrelated death during follow-up and another in the TT To measure physical function and symptoms, a patient-reported group because a patient kept no subsequent appointments and did outcome (QuickeDisabilities of the Arm, Shoulder, and Hand not answer phone calls. Table 1 lists baseline characteristics of questionnaire [QuickDASH])8 was administered. In addition, the groups. degree of pain was assessed by a visual analog scale. One year after surgery, both groups improved in both pain and Collected data were processed by an independent analyst to subjective outcomes (QuickDASH), as shown in Tables 1 and 2. No ensure observer blinding of results. Patients’ characteristics were significant differences were observed between groups in the final expressed as the mean and SD or number and percentage. key pinch strength (TT: 3.6 kg, SD ¼ 1.9; PT: 3.6 kg, SD ¼ 3.1) at 12 136 nchez-Flo R. Sa  et al. / Journal of Hand Surgery Global Online 2 (2020) 133e137 Table 1 Table 2 Baseline Characteristics for TT and PT Groups Outcome Parameters for Variables Between TT and PT Groups at 12 Mo Follow-Up Variable Description Total (n ¼ 34) TT (n ¼ 17) PT (n ¼ 17) Variable Description TT (n ¼ 16) PT (n ¼ 16) P Value Age in years (SD) 60.5 (9.8) 61.0 (8.9) 60.5 (9.8) Mean trapezial space height, mm (SD) 6.6 (1.7) 9.3 (1.2) .091 Female, n (%) 28 (82.4) 15 (88.2) 13 (76.5) Mean key pinch, (SD) 3.6 (1.9) 3.6 (3.1) .568 Male, n (%) 6 (17.6) 2 (11.8) 4 (23.5) Mean D key pinch, kg (SD)* e0.5 (1.6) 0.6 (2.2) .126 L:R 10:24 4:13 6:11 Mean grip strength, kg (SD) 15.6 (7.8) 13.4 (6.3) .384 Dominant hand, n (%) 29 (85.3) 14 (82.5) 15 (88.2) Kapandji index (median [range]) 8 (6e10) 8 (5e10) .259 Eaton stage osteoarthritis II, n (%) 9 (27) 5 (29) 4 (25) Mean visual analog scale pain (SD) 2.6 (2.7) 2.3 (2.3) .328 Eaton stage osteoarthritis III, n (%) 24 (73) 12 (71) 12 (75) Mean QuickDASH (SD) 27.3 (9.4) 29.2 (10.8) .180 Mean visual analog scale pain (SD) 7 (1) 6.8 (1.0) 7.3 (1.8) * Change in key pinch strength (12 months after surgery strength minus baseline Mean QuickDASH (SD) 43 (8) 42.1 (6.5) 43.3 (8.7) strength). Mean key pinch strength, kg (SD) 3.6 (2.1) 4.1 (2.0) 3.1 (1.7) Mean grip strength, kg (SD) 11.6 (6.4) 13.5 (7.2) 9.8 (5.1) Mean trapezial space height, mm (SD) 10.8 (1.3) 11 (1.3) 10.5 (1.2) techniques, highlighting that although it would be feasible, the main challenges were follow-up visits and collecting data in sub- sequent appointments. months’ follow-up. However, the change observed in key pinch A biomechanical study in cadaveric models by Salas et al18 strength from baseline to the 12-month visit showed an improve- assessed trapezial space after TT and PT with capsular interposi- ment in the PT group ( D 0.5 kg; SD ¼ 1.6) and a deterioration in the tion (CI) and found that under lateral pinch load, PT CI resulted in TT group ( D e0.6 kg; SD ¼ 2.2), although this difference was not less proximal metacarpal subsidence and better maintenance of statistically significant (P ¼ .126). There was no difference in final thumb length than TT CI. trapezial space height (TT: mean ¼ 6.7 mm, SD ¼ 1.7 mm; PT: In the current study, a rapid improvement in subjective out- mean ¼ 9.3 mm, SD ¼ 1.2 mm; P ¼ .09). No other secondary vari- comes (pain and DASH score) was observed at 3 months, with ables showed differences at 12 months. further improvement at 1 year, in concordance with other studies.5,18e20 Discussion One year after surgery, no clear differences were observed in final grip strength or final key pinch strength between groups. The relationship between trapezial space height and key pinch Similarly to other studies,21,22 we found differences in the change of strength is currently debated. Some studies show that a decrease in key pinch strength from baseline to 1 year after surgery, with a trapezial space height has no relation to key pinch strength or small improvement in the PT group and a small deterioration in the subjective outcomes.9e12 In contrast, other authors found a rela- TT group. However, this difference was not statistically significant tionship among trapezial space height decrease, key pinch and was well within 1 SD of the mean value, but it may be strength,13 first metacarpal subluxation, and DASH score.14 Yet the important to consider for clinical decision-making and future relationship among partial trapeziectomy, a decrease in trapezial studies. space height, and key pinch strength has poorly been described. There were no complications or revision surgeries in this series Trumble et al14 showed a 21% decrease in trapezial space height during the first year of follow-up. A systematic review of failure with partial trapeziectomy with ligament reconstruction and rates associated with different techniques reported a 4.5% revision interposition with costochondral allograft and an improvement in rate for PT with interposition compared with a 0.23% for TT with key pinch strength compared with baseline. Menon4 found that key ligament interposition.23 However, the partial trapeziectomy group pinch strength and grip strength increased significantly after PT in that review included the use of implants and not ligament and interpositional arthroplasty but did not relate to tra- interposition, and we have not found another study showing a peziometacarpal space height. In a retrospective series of 33 pa- higher complication rate for PT. tients undergoing PT with suspension and interposition This study had limitations. The clinical examiner was not blin- tendinoplasty, Martinel et al15 found a decrease in tra- ded to the study protocol. We did not include patients with hy- peziometacarpal space of 2.54 mm at 5 years but did not assess perextension of the metacarpophalangeal joint of the thumb in the preoperative key pinch strength values. study, so we cannot assess the effect this may have had on clinical The results obtained in this randomized controlled trial outcomes.24 The follow-up assessment 1 year after surgery might comparing the evolution of patients with TMOA grade II to III be insufficient to evaluate the radiological and clinical evolution of (Eaton-Littler) who underwent PT or TT with suspension and both procedures in the long term.25 Interrater agreement between interposition arthroplasty showed a decrease in trapezial space radiologists for trapezial height measurement was not assessed, height in both groups, markedly lesser with PT (11.4%) than with TT which with the quality of the images might be a source of error.26 (39.4%). Nevertheless, this difference was not associated with a Although patients who were treated with a PT had a lower better functional outcome at 1 year after surgery. decrease in trapeziometacarpal space height compared with TT To the authors’ knowledge, few studies have compared the TT patients, this was not statistically significant, nor did it have a and PT techniques. A retrospective study performed by Park et al16 clinical advantage of PT over TT at 1 year after surgery. compared trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition and found no significant dif- ference among groups in terms of DASH score or key pinch References strength. Another retrospective study, by García-Mas et al,5 with a 1. Gervis WH. Excision of the trapezium for osteoarthritis of the trapezio- minimum follow-up of 3 years, reviewed 112 arthroligamento- metacarpal joint. J Bone Joint Surg Br. 1949;31(4):537e539. plasties performed to basal thumb arthritis Eaton grade II, III, and 2. Kvarnes L, Reikerås O. Osteoarthritis of the carpometacarpal joint of the thumb: IV, comparing 93 PT and 9 TT. The authors concluded that both an analysis of operative procedures. J Hand Surg Br. 1985;10(1):117e120. 3. Burton RI, Pellegrini VD. Surgical management of basal joint arthritis of the techniques resulted in similar outcomes. Thoma et al17 reported on thumb. Part II: ligament reconstruction with tendon interposition arthroplasty. the feasibility of performing a large-scale trial comparing both J Hand Surg Am. 1986;11(3):324e332. nchez-Flo R. Sa  et al. / Journal of Hand Surgery Global Online 2 (2020) 133e137 137 4. Menon J. Partial trapeziectomy and interpositional arthroplasty for tra- trapezometacarpal osteoarthritis: 5 years results [in French]. Chir Main. peziometacarpal osteoarthritis of the thumb. J Hand Surg Br. 1995;20(5): 2007;26(2):103e109. 700e706. 16. Park MJ, Lichtman G, Christian JB, et al. Surgical treatment of thumb carpo- 5. García-Mas R, Sole  Molins X. Partial trapeziectomy with ligament recon- metacarpal joint arthritis: a single institution experience from 1995-2005. structiondtendon interposition in thumb carpo-metacarpal osteoarthritis: a Hand (N Y). 2008;3(4):304e310. study of 112 cases. Chir Main. 2009;28(4):230e238. 17. Thoma A, Levis C, Patel P, Murphy J, Duku E. Partial versus total trapeziectomy 6. Nylen S, Juhlin LJ, Lugnegard H. Weilby tendon interposition arthroplasty for thumb arthroplasty: an expertise-based feasibility study. Plast Reconstr Surg osteoarthritis of the trapezial joints. J Hand Surg Br. 1987;12(1):68e72. Glob Open. 2018;6(3):e1705. 7. Kapandji A. Clinical test of apposition and counter-apposition of the thumb [in 18. Salas C, Mercer DM, O’Mahony G, Love J, LaBaze D, Moneim MS. Thumb French]. Ann Chir Main. 1986;5(1):67e73. metacarpal subsidence after partial trapeziectomy with capsular interposition 8. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, arthroplasty: a biomechanical study. Hand (N Y). 2016;11(4):444e449. shoulder and hand questionnaire (QuickDASH): validity and reliability 19. Lins RE, Gelberman RH, McKeown L, Katz JN, Kadiyala RK. Basal joint arthritis: based on responses within the full-length DASH. BMC Musculoskelet Disord. trapeziectomy with ligament reconstruction and tendon interposition arthro- 2006;7:44. plasty. J Hand Surg Am. 1996;21(2):202e209. 9. Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for 20. Vermeulen GM, Brink SM, Sluiter J, Elias SG, Hovius SER, Moojen TM. Ligament thumb basal joint osteoarthritis: a prospective, single-surgeon study including reconstruction arthroplasty for primary thumb carpometacarpal osteoarthritis outcomes measures. J Hand Surg Am. 2003;28(3):381e389. (Weilby technique): prospective cohort study. J Hand Surg Am. 2009;34(8): 10. Putnam MD, Meyer NJ, Baker D, Brehmer J, Carlson BD. Trapezium excision and 1393e1401. suture suspensionplasty (TESS) for the treatment of thumb carpometacarpal 21. Tomaino MM, Pellegrini VD, Burton RI. Arthroplasty of the basal joint of the arthritis. Tech Hand Up Extrem Surg. 2014;18(2):102e108. thumb: long-term follow-up after ligament reconstruction with tendon 11. Reissner L, Marks M, Schindele S, Herren DB. Comparison of clinical interposition. J Bone Joint Surg Am. 1995;77(3):346e355. outcome with radiological findings after trapeziectomy with ligament 22. Nylen S, Johnson A, Rosenquist AM. Trapeziectomy and ligament reconstruc- reconstruction and tendon interposition. J Hand Surg Eur Vol. 2016;41(3): tion for osteoarthrosis of the base of the thumb: a prospective study of 100 335e339. operations. J Hand Surg Br. 1993;18(5):616e619. 12. Downing ND, Davis TR. Trapezial space height after trapeziectomy: mechanism 23. Ganhewa AD, Wu R, Chae MP, et al. Failure rates of base of thumb arthritis of formation and benefits. J Hand Surg Am. 2001;26(5):862e868. surgery: a systematic review. J Hand Surg Am. 2019;44(9):728e741.e10. 13. De Smet L, Sioen W, Spaepen D, van Ransbeeck H. Treatment of basal joint 24. Brogan DM, van Hogezand RM, Babovic N, Carlsen B, Kakar S. The effect of arthritis of the thumb: trapeziectomy with or without tendon interposition/ metacarpophalangeal joint hyperextension on outcomes in the surgical treat- ligament reconstruction. Hand Surg. 2004;9(1):5e9. ment of carpometacarpal joint arthritis. J Wrist Surg. 2017;6(3):188e193. 14. Trumble TE, Rafijah G, Gilbert M, Allan CH, North E, McCallister WV. Thumb 25. Spekreijse KR, Vermeulen GM, Kedilioglu MA, et al. The effect of a bone tunnel trapeziometacarpal joint arthritis: partial trapeziectomy with ligament during ligament reconstruction for trapeziometacarpal osteoarthritis: a 5-year reconstruction and interposition costochondral allograft. J Hand Surg Am. follow-up. J Hand Surg Am. 2015;40(11):2214e2222. 2000;25(1):61e76. 26. Bhat M, Davis TRC, Bannerjee A. Trapezial space height measurement after 15. Martinel V, Mansat P, Mansat M, Rongie res M, Bonnevialle P. Partial tra- trapeziectomy: a comparison of the use of standard and stress radiographs. pezectomy with suspension and interposition tendinoplasty for J Hand Surg Am. 2003;28(3):390e396.