Optimizing Carpometacarpal Arthroplasty Of The Thumb: A Prospective Clinical Trial Comparing Suture Suspension To Ligament Reconstruction And Tendon Interposition
Debra A. Bourne, MD1, Ian Chow, MD2, Dann Laudermilch, MD2, Benjamin Schilling, BS3, Wesley Sivak, MD, PhD2, William Hagberg, MD4, Marshall Balk, MD4, Glenn Buterbaugh, MD4, Joseph Imbriglia, MD4, John Fowler, MD2.
1University of Kentucky, Lexington, KY, USA, 2University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 3University of Pittsburgh, Pittsburgh, PA, USA, 4Wexford Hand and UpperEx Center, Pittsburgh, PA, USA.
Background: Thumb carpometacarpal (CMC) arthritis is the most common arthritis of the hand and thumb CMC arthroplasty is the most commonly performed surgical reconstruction for arthritis in the upper extremity. The most common technique is the ligament reconstruction and tendon interposition (LRTI) where, following trapeziectomy, the flexor carpi radialis (FCR) tendon is passed through a bone tunnel at the base of the first metacarpal to reconstruct the palmar oblique ligament and prevent collapse, with the remaining tendon used to fill the space vacated by the trapezium. In 2009 DelSignore published the suture suspension technique in which, after trapeziectomy, the FCR is sutured to the abductor pollicis longus to create a sling under the first metacarpal to correct subluxation and maintain the joint space. The purpose of this study is to compare outcomes between to the two techniques and determine if one is superior.
Methods: Following IRB approval, 38 consecutive patients undergoing CMC arthroplasty for basilar thumb osteoarthritis were enrolled by four senior, fellowship trained surgeons; two of whom prefer the LRTI technique and two who routinely perform suture suspension arthroplasty. Outcome measures were recorded including: first metacarpal subsidence measured on radiographs, thumb range of motion, pinch and grip strength, functionality assessed through the Disability of Arm, Shoulder and Hand (DASH) and Michigan Hand Questionnaires (MHQ), and pain measured on a 10-point Visual Analog Scale (VAS).
Results: Both techniques are effective at reducing pain with a decrease from baseline to 6-weeks post-procedure of 5.5±1.8 to 3.1±1.9 (p=0.030) in the LRTI group and 5.8±2.1 to 2.2±2.8 (p<0.001) in the suture suspension group. The suture suspension technique resulted in greater thumb abduction at 6-weeks compared to LRTI (61.3°±12.7° versus 39.5°±16.9°, p=0.018). LRTI resulted in more limited opposition at 6-weeks post-procedure (p=0.002). There was no significant difference in thumb extension, grip or pinch strength. Both techniques improved functionality from baseline to 6-weeks post-operative based on the MHQ (LRTI 47.3±8.2 to 53.8±9.9, p=0.037; suture suspension 46.9±6.9 to 57.0±11.7, p=0.012). There was significant radiographic subsidence in both groups with 32.4%±3.9% for suture suspension and 55.3%±6.0% for LRTI at 2-weeks post-operative (p<0.001), however, subsidence was significantly less for suture suspension compared to LRTI (p=0.005).
Conclusions: LRTI and suture suspension arthroplasty techniques are equally effective for improving pain and functionality. Both techniques are subject to some subsidence of the first metacarpal. The suture suspension technique has less restriction of abduction and opposition in the early post-operative period as well as less radiographic subsidence of the first metacarpal.
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