Trapeziectomy Versus Trapeziectomy With Ligament Reconstruction And Tendon Interposition For Trapeziometacarpal Osteoarthritis: A Systematic Review And Meta-analysis
Brian Chin, MD, Cameron Leveille, BSc, Bram Rochwerg, MD MSc, Sophocles Voineskos, MD MSc.
McMaster University, Hamilton, ON, Canada.
Adults with trapeziometacarpal osteoarthritis of the thumb suffer from pain and loss of function. Among many surgical options available, trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is most often performed. Previous meta-analyses have drawn uncertain conclusions on the benefits of LRTI compared to simple trapeziectomy based on low quality evidence. The objective of this study is to determine if trapeziectomy with LRTI improves pain and function compared to a simple trapeziectomy, and evaluate the quality of evidence using the GRADE framework.
We searched the following database up to 19 February 2019: MEDLINE (1946 to February 2019), EMBASE (1974 to February 2019), CENTRAL (to February 2019), WHO ICTRP (to February 2019), and ClinicalTrials.gov (to February 2019). Randomized controlled trials comparing trapeziectomy and trapeziectomy with LRTI were selected for analysis. Two review authors independently screened and included studies, assessed risk of bias and extracted data. Authors of registered but unpublished trials were contacted. Data were pooled as standardized mean difference (SMD) using random-effects models. The SMD was converted to validated instruments such as VAS and DASH using weighted standard deviations to improve interpretation of results. The quality of evidence was evaluated using GRADE.
This review includes 6 randomized controlled trials with 504 patients (mean age 59 [range: 44 to 79), 89% female) comparing trapeziectomy to trapeziectomy with LRTI. Most studies were at high risk of bias for patient-reported outcomes due to lack of participant blinding. There is moderate quality evidence that trapeziectomy with LRTI likely results in little to no difference in pain or physical function when compared to trapeziectomy alone. The mean pain score measured by the Visual Analog Scale (0 to 100mm, 0=no pain) was 0mm higher (95% CI: 5.35 lower or 5.12 higher) in the trapeziectomy with LRTI group which excludes a clinically important difference in context of a minimally important difference of 10mm. The mean physical function measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire (0 to 100-points, 0=full function) was 0.95 points higher (95% CI: 4.04 lower or 6.19 higher) in the trapeziectomy with LRTI group which also excludes a clinically important difference in context of a minimally important difference of 10 points. There is low quality evidence that trapeziectomy with LRTI may increase complications (relative risk 2.23, 95% CI 1.32 to 4.07). The absolute effect is an increase of 91 complications per 1,000 patients undergoing trapeziectomy with LRTI (95% CI: 22 to 211 more complications).
Under the GRADE framework, there was low quality evidence in previous meta-analyses comparing outcomes between trapeziectomy with or without LRTI. This updated meta-analysis including the most recent studies shows there is now moderate quality evidence that trapeziectomy with LRTI results in little to no difference in pain or function. There may be increased risk of complications in trapeziectomy with LRTI but the certainty of evidence remains low for this outcome.
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