CMC Arthroplasty for Treatment of the Painful and Arthritic Thumb: A Review of Surgical Treatment Options with Preferred Technique

Abstract

Arthritis of the first carpometacarpal joint is a prevalent and often disabling condition for many older adults. The diagnosis is typically established through a comprehensive patient history, physical examination, and confirmatory radiographs. Nonsurgical management with splinting and anti-inflammatory medication has demonstrated effectiveness. Several surgical options have proven effectiveness for those who fail nonsurgical management. Surgical options include silicone implantation, resection arthroplasty, tendon interposition, ligament reconstruction, denervation, and joint implant arthroplasty. In the following review, we will elaborate upon the array of therapeutic approaches, culminating in the delineation of our preferred method.

The first carpometacarpal (CMC) joint is an intricate saddle joint consisting of the articulation between the trapezium and the first metacarpal. Its unique saddle-shaped configuration confers considerable mobility while sacrificing stability. The interaction of this joint with adjacent carpals is characterized by the axial forces exerted through the thumb during compression, highlighting its critical function in the mechanics of grip and manipulation.¹

Given the vital role of the thumb in a variety of functions, the thumb CMC joint endures repeated stress in its three primary planes of movement: abduction–adduction, flexion–extension, and flexion–extension.² Although the exact etiology remains unclear, it is hypothesized that atraumatic arthritis begins as laxity of the ligamentous stabilizers of the first CMC joint, particularly the anterior oblique (volar beak) ligament and the dorsoradial ligament.³ The resulting instability leads to synovitis and progressive cartilage wear, which eventually progresses to degenerative changes such as joint space narrowing, osteophyte formation, ligament attenuation, and eventual dorsal radial subluxation of the first metacarpal base (Table 1).^3,4 The loss of the volar beak ligament results in dorsal translation and articular contact as observed in patients with confirmed osteoarthritis of the CMC joint.³ Over time, patients may develop compensatory metacarpophalangeal hyperextension, amplifying dysfunction while diminishing pinch strength and range of motion.³

Table 1.

Eaton and Littler Classification for Arthritis of the First CMC Joint

Stage	Radiographic Features
1	Normal or subtle joint space widening.
2	Joint space narrowing, with osteophytes, loose bodies <2 mm.
3	Advanced joint space narrowing, with osteophytes, loose bodies >2 mm.
4	Stage 3 with progressive STT arthritis.

Women are more commonly affected than men, and the typical age of onset is between 50 and 70 years of age. Patients typically present with a gradual onset of pain at the base of the thumb. The discomfort is typically exacerbated with use, considerably limiting a patient’s ability to engage in routine daily activities that load the CMC joint, such as opening a jar or turning a key.⁵ Activities requiring thumb opposition, such as writing or carrying objects between the thumb and fingers, often cause pain and activity avoidance. Over time, there is a progression from pain and weakened pinch strength to stiffness and cramping, even when at rest.

Although most patients are older women, there is also a younger subset of patients in their 20s and 30s who experience first CMC joint arthritis. This subset of patients describes symptoms resulting from joint laxity and synovitis of the trapeziometacarpal joint. These younger patients usually do not have overly impressive radiographic findings. Irrespective of the patient's age, pain is often alleviated by nonsurgical management such as rest, immobilization, and analgesics.

Physical examination frequently reveals a dorsoradial prominence at the base of the thumb which is often referred to as a shoulder deformity.⁶ This finding is indicative of dorsoradial subluxation of the thumb metacarpal base secondary to volar oblique ligamentous laxity and the pull of the adductor pollicis muscle.⁷ As arthritis advances, patients may develop a first webspace contracture because of CMC joint stiffness and intrinsic thenar muscle atrophy.⁶ The trapeziometacarpal joint is typically tender to palpation. The “CMC grind” test, in which the thumb metacarpal base is axially loaded and translated against the trapezium, is pathognomonic for first CMC joint arthritis.⁸ A positive test reproduces pain at the base of the thumb and also generates a palpable grinding sensation. Stability of the joint is assessed by stabilizing the thumb metacarpophalangeal and interphalangeal joints and translating the thumb metacarpal in various directions.

Radiographs are used to confirm the diagnosis and determine the severity of joint changes. Standard anteroposterior, lateral, and oblique views are often sufficient. A stress view of the joint, achieved through a 30° posteroanterior view centered on the thumbs while the patient presses their thumb tips together, helps gage the degree of joint space loss and subluxation of the trapeziometacarpal joint. Lastly, Betts and Roberts views offer true lateral and anteroposterior assessments, respectively, and are useful for obtaining detailed information about the trapeziometacarpal joint space. It is important to correlate the clinical and physical examination with radiographic findings. Many patients with radiographic evidence of first CMC joint arthritis do not exhibit clinical symptoms.⁹ Although less common, there are also patients who have notable symptoms but a relatively preserved joint.

The differential diagnosis for pain at the base of the thumb includes DeQuervain tenosynovitis, scaphotrapezial-trapezoid arthritis, scaphoid pathology, and inflammatory disease, such as autoimmune, crystal-induced inflammatory arthridities like gout and pseudogout. Two major classification systems exist for CMC arthritis, each offering distinct approaches to staging this condition. The first system, proposed by Burton³, combines clinical signs, patient symptoms, and radiographic findings (Table 2). In stage I, thumb CMC joint findings include patient reported pain, a positive grind test, and demonstrable ligamentous laxity, usually evident through dorsoradial subluxation. Stage II findings include increased instability, additional subluxation, and radiographically apparent degenerative changes. In Stage III, the degeneration extends to encompass the scaphotrapezial joint, while Stage IV can either be stage II or III in addition to metacarpophalangeal joint arthritis. Burton’s classification relies on a combination of subjective symptoms and objective radiographic signs.

Table 2.

Burton Classification for CMC Arthritis

Stage	Clinical and Radiographic Features
1	Pain, ligamentous laxity with dorsoradial subluxation and positive CMC grind test.
2	Instability with chronic subluxation, radiographic degenerative changes.
3	Involvement of the STT joint.
4	Stage 2 or 3 with inclusion of the MCP of the first digit.

The Eaton classification (Table 1) relies solely on radiographic findings.^3,4 stage I is defined as a normal to slightly widened trapeziometacarpal joint because of ligamentous laxity or effusion while maintaining normal articular contours with up to one-third subluxation. Stage II is characterized by narrowing of the trapeziometacarpal joint and the presence of osteophytes or loose bodies measuring less than 2 mm in diameter. In Eaton Stage III, the trapeziometacarpal joint space is further narrowed, with the emergence of subchondral cysts, sclerosis, osteophytes, or loose bodies measuring 2 mm or more in diameter, and subluxation encompassing more than one-third of the joint space. Stage IV involves degeneration extending into the scaphotrapezial joint. The Eaton classification is radiographically based.

Nonsurgical Options

It is reasonable to initially offer nonsurgical treatment options regardless of stage of disease. Initial management options include describing activity modifications, supporting the joint with bracing during activities with hand based or wrist based thumb spica, and nonsteroidal anti-inflammatory drugs. If the patient experiences symptomatic improvement during this time, they can gradually transition away from the splint. Some patients have opted for use of novel, though largely unproven, treatments such as cannabidiol oil and curcumin, dietary interventions with omega-3 fatty acids, topical agents like capsaicin, and alternative methods such as acupuncture and thermal therapy. These options offer a spectrum of nonsurgical approaches to manage pain and inflammation, although their effectiveness can vary. Lastly, corticosteroid injections can augment the previously mentioned nonsurgical treatments. However, corticosteroids have been shown to have cytotoxic effects to cartilage in vitro; thus, we reserve steroid injections for the advanced Eaton stages of arthritis where the cartilage is already demonstrating notable erosive changes.

It is worth noting that the primary objective of nonsurgical management is not the complete elimination of all pain and discomfort. Rather, the goal is to enhance the patient's ability to engage in daily activities and enhance their overall quality of life while avoiding surgical intervention. In our practice, we believe that the best bracing is the bracing that the patient can wear while doing their respective activities of daily living. For this reason, we educate the patient on the different forms of hand based, wrist based, and custom splint offerings, and advise the patient to use numerous braces for their different activities of daily living. If activity modification does not yield satisfactory results, intra-articular injections into the CMC joint may be offered to alleviate pain. Corticosteroid injections are typically performed, despite demonstrating similar effectiveness to alternative treatments such as hyaluronic acid injections.¹⁰ Corticosteroids result in relief of symptoms at 1–6 months following injection, with diminishing returns after initial treatment. Randomized controlled trials of hyaluronic acid injections have shown relief beyond 6 months, despite slower onset and increased cost relative to corticosteroid injections.¹¹ The accuracy of the CMC injection can be enhanced with ultrasound or fluoroscopic guidance. Alternatively, other forms of nonsurgical management include exercise therapy and custom orthosis application. The rate of conversion from nonsurgical management to first CMC osteoarthritis surgery is roughly 22% to 33%, with the majority occurring within the first year.^12,13

Surgical Indications

Indications for surgery in first CMC joint arthritis include persistent pain, reduced function, joint instability, and the absence of relief from nonsurgical management. A US survey of 1,122 hand surgeons demonstrates wide variety in the rate of surgical management of first CMC joint arthritis, with an average of 1.9 (interquartile range 0–9.1; range 0–66) trapeziometacarpal surgeries per year.¹⁴ The most common procedure performed was interposition arthroplasty; however, multiple surgical techniques for first CMC joint arthritis have been described to manage its symptoms.15, 16, 17

Gervis¹⁷ initially described trapezium resection. Subsequently, resection with reconstruction of the trapeziometacarpal ligament was suggested. Recently, CMC suspensionplasty has become popularized as well as novel implant arthroplasty.^15,18 In younger, higher demand individuals, arthrodesis of the first CMC joint has been considered. However, with the success rates of various arthroplasty techniques, arthrodesis has diminished in popularity and is primarily reserved for instances of post-traumatic or rheumatoid arthritis limited solely to the first CMC joint.

A range of thumb CMC arthroplasty techniques have been demonstrated. The described options include partial or complete trapeziectomy, either arthroscopic or open; utilization of prosthetic implants; and ligament interposition and reconstructions.^15,17,18 These methods are typically recommended for stage II or more advanced disease when nonsurgical management has proven ineffective. A 2024 American Society for Surgery of the Hand survey demonstrates that trapeziectomy + ligament reconstruction tendon interposition (LRTI) is the most commonly performed procedure (40.5%), followed by trapeziectomy + suspensionplasty (28.2%).¹⁹ According to survey respondents, familiarity and exposure to procedure during fellowship were among the most commonly cited reasons for performing trapeziectomy + LRTI. Hence, the choice of surgical reconstruction is largely based on surgeon preference, with consideration of patient likelihood to benefit from procedure.

Trapeziectomy with suspension arthroplasty without interposition

Trapeziectomy with suture suspensionplasty is a technique that uses a suture support to stabilize the thumb metacarpal to maintain proper length and power by preventing postoperative metacarpal subsidence.^20,21 The use of sutures preserves the natural biomechanics of the joint while avoiding the need for traditional fixation. By securing the stitch between the abductor pollicis longus (APL) and flexor carpi radialis (FCR) tendons following trapeziectomy, the CMC joint biomechanics are preserved through thumb height preservation while simultaneously preventing proximal migration the thumb metacarpal. This innovative approach minimizes the risk of complications associated with hardware, such as loosening, migration, or pin track infection. Trapeziectomy with suture suspension aims to provide patients with an effective and less painful option, along with a quicker recovery and improved long-term outcomes. Caggiari et al²² and Delsignore et al²³ concluded that trapeziectomy with suture suspensionplasty had shorter operating time and lower cost when compared to tendon suspension procedures. A study by Shonuga et al²⁴ compared 53 patients with LRTI and 59 patients with suture suspensionplasty without interposition. Their comparison demonstrated that suture suspensionplasty had subsidence rates and patient reported outcome measures that were at least equivalent to LRTI, along with comparable rates of complications. Yaffe et al²⁵ looked at a single surgeon’s experience with trapeziectomy and FCR suspension without tendon interposition and demonstrated consistent results up to 7.6 years for clinical, functional, and radiographic outcomes. In a cohort of 57 patients aged 55 years or less, suture suspensionplasty offered similar postoperative pain relief and increased grip strength with fewer complications relative to trapeziectomy with LRTI, demonstrating its utility in the management of early onset CMC arthritis.²⁶ Minor and major complications of suture suspensionplasty occur at rates of 2% and 4%, respectively, and include neuritis or neuroma, infection, wound dehiscence, tendon rupture, and reflex sympathetic dystrophy (Table 3).24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42

Table 3.

Overview of Surgical Techniques For First CMC Arthritis

Surgery	Indications	Outcomes	Complications
Trapeziectomy with suspension arthroplasty without interposition	•Symptomatic advanced CMC arthritis •Absence of relief from nonsurgical management •Preservation of CMC anatomy •Early onset (<55) first CMC arthritis26	•Shorter operating and tourniquet time than LRTI27 •Comparable short-medium term outcomes24 and superior long-term patient reported outcomes25 •Similar patient reported satisfaction + increased grip strength in early onset CMC arthritis26	•Lower or comparable complication rates compared to LRTI25 •Fewer complications in younger patients26 •Include but not limited to neuritis, neuroma, infection, and tendon rupture28
Trapeziectomy with ligament reconstruction and interposition arthroplasty	•Symptomatic advanced CMC arthritis •Absence of relief from nonsurgical management •Preservation of thumb mobility desired	•Favorable patient outcomes with pain relief, functionality, and satisfaction29,30 •High long-term patient satisfaction reported with both FCR and APL techniques31,32 •Addition of LRTI has not been shown to improve outcomes30	•Relatively well-tolerated with low complication rates, although first metacarpal subsidence may necessitate revision surgery33 •Include nerve dysfunction, FCR "pulling" sensation, and scar tenderness33
Joint arthroplasty	•Symptomatic advanced CMC arthritis •Desire to preserve motion and avoid trapeziectomy or fusion •Older, lower-demand patients34	•May improve pinch/grip strength, pain relief, and joint function compared to trapeziectomy35,36 •Select implants show promising short- to mid-term stability and motion improvement37	•Higher revision rates than trapeziectomy (loosening, dislocation, implant wear)37 •Potential implant failure or need for conversion to LRTI34 •Silicone implants associated with late wear and synovitis34
CMC arthrodesis	•Younger, high-demand patients with advanced CMC arthritis38 •Chronic instability or failed prior CMC surgery38	•Provides stable, pain-free thumb with increased strength •High satisfaction in appropriately selected patients •Can improve pinch force and grip stability	•Complications are related to loss of CMC joint motion •Nonunion rate ∼7% (often asymptomatic)39 •Risk of adjacent joint arthritis (STT, MCP) over time39
CMC denervation	•Younger patients wishing to avoid trapeziectomy or fusion40	•Short operative time41 •Similar grip, key pinch, and pinch strength to trapeziectomy at short- to mid-term follow-up41 •Faster return to activities with similar patient reported outcomes41 •Significant pain relief reported in most series42	•More data needed to establish long-term durability •Radial nerve paresthesias42 •Patchy hypoesthesia around surgical site42 •Wound infection risk42

Trapeziectomy with ligament reconstruction and interposition arthroplasty

Prior to suture suspensionplasty, trapeziectomy with interposition arthroplasty was described. The surgery also employed the removal of the trapezium with the addition of replacing the trapezium with a space occupying component such as the FCR tendon or APL to mitigate the loss of joint space caused by surgical bone removal.43, 44, 45, 46 Eaton and Littler⁴⁷ first described the procedure in 1973 using the radial portion of the FCR that was redirected through a sagittal directed bone tunnel at the base of the metacarpal. Their described procedure was later modified by Burton and Pelligrini to include an interposition tendon arthroplasty.⁴³

With the traditionally described LRTI, a segment of the FCR tendon is harvested and split distally to its insertion. The radial half of the FCR tendon, harvested at the muscle–tendon junction, is used for ligament reconstruction. This tendon is threaded through a tunnel at the metacarpal base from deep to superficial or ulnarly to radially. The tendon is then tensioned with the thumb in traction and abduction. After which, it is secured to the lateral periosteum and itself to reconstruct the volar oblique ligament. The remaining tendon is inserted into the void created by the excised trapezium, similar to a “rolled up anchovy”. The technique of ligament reconstruction with tendon interposition not only removes pain-generating bone-on-bone surfaces but also recreates the pathologically lax volar beak ligament and fills the void created by trapeziectomy, aiming to reduce subsidence.²⁹ Patients have reported favorable outcomes in terms of pain relief, function, and satisfaction, with 84% of patients experiencing no pain or restrictions 1 year after surgery. However, the addition of LRTI has not demonstrated therapeutic benefit over trapeziectomy alone, questioning its clinical utility (Table 3).24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42

A similar approach for ligament reconstruction and interpositional arthroplasty has been described that instead employs the APL for both ligamentous repair and as an interpositional graft in the void created by trapeziectomy. Avisar et al³¹ published 15-year outcome data with trapeziectomy and APL interposition arthroplasty. That group found similar grip and pinch strength to the contralateral, nonoperated hand, and confirmed that this technique can provide high quality outcomes.³²

Brunelli⁴⁸ introduced a technique that uses the APL to recreate the volar beak ligament, thereby addressing one of the primary deforming forces of the first metacarpal base and correcting the pathologic laxity of the volar beak ligament. The approach involves transecting the APL tendon 6 cm proximal to its insertion and exposing the first metacarpal base. A tunnel is carefully drilled from the first metacarpal base toward the second, through which the APL tendon is threaded and fastened to prevent dislocation during flexion–extension and abduction movements. Results from this approach have been positive, with most patients reporting satisfaction and experiencing minimal postoperative pain (Table 3).24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42

In addition to the previously described techniques, various alternative techniques for FCR tendon interposition following trapeziectomy have been detailed, including methods that employ the entire tendon to augment the material available for filling the resulting void. Naidu et al³² reported outcomes on 39 patients that underwent a complete harvest of the FCR tendon. Their outcomes showed an improvement in Disabilities of the Arm, Shoulder and Hand scores, grip strength, and pinch strength.³² However, the contralateral extremity exhibited superior fatigue resistance with flexion resistance, and the flexion/extension torque ratio decreased on the operative side.³² Conversely, techniques that incorporate only a portion of the FCR are designed to strike an equilibrium between the quantity of tendon used and the conservation of wrist functionality. Despite the theoretical advantages of LRTI, superior outcomes to trapeziectomy alone are not apparent throughout the literature.³⁰

Although trapeziectomy and LRTI is a relatively well-tolerated procedure, complications may arise secondary to first metacarpal subsidence against the scaphoid or trapezoid. This results in debilitating pain that necessitates revision surgery, with a revision rate as high as 4.7% reported.³³ A common complication is superficial radial nerve dysfunction resulting in paresthesias, most likely secondary to inadequate identification and protection of capsular branches. Other complications include palmar cutaneous branch of median nerve dysfunction, complex regional pain syndrome, scar tenderness, and FCR pulling.³³

Joint arthroplasty

Initial studies with titanium implants or titanium and polyethylene prosthesis have shown promise.^49,50 Silicone implants previously used for thumb CMC implant arthroplasty have fallen out of favor because of long-term complications such as implant wear and silicone synovitis caused by particles ≤15 μm. The wear typically occurs around 2 years after surgery because of shear and compression forces. More recently, studies evaluating alternative implants, like the Orthosphere and Swanson titanium condylar implants (Wright Medical Technology), have demonstrated varied outcomes, including subsidence, pain, and weakness in select cases. Others necessitated revisions to ligament reconstruction and tendon interposition, whereas some showed stability and improvement in motion and strength in others. Additionally, positive results have been reported in elderly patients undergoing ball and socket CMC arthroplasty.³⁴

Surgical solutions to reproduce thumb CMC joint function with prosthetic implants aim to provide patients with pain relief and improved pinch and grip strength, along with improved joint function.^35,36 Raj et al³⁷ completed a systematic review and meta-analysis looking at trapeziectomy versus joint replacement for first CMC joint arthritis. Their investigation found that joint replacement may result in better function (key pinch, Quick Disabilities of the Arm, Shoulder and Hand, visual analog scale), but at the expense of higher complication and revision rates, particularly loosening and dislocation.³⁷ The authors concluded that both procedures have benefits and drawbacks and that educating patients on the outcomes of both options are vital in selecting the appropriate procedure.³⁷

Arthrodesis

Thumb CMC joint fusion can be a successful procedure for patients experiencing pain, chronic instability, or younger patients with advanced CMC arthritic changes.³⁸ Although a thumb CMC fusion option offers benefits such as a stable thumb, enhanced strength, and pain relief, it comes with drawbacks such as the potential for degeneration of adjacent scaphotrapezium-trapezoid (STT) or metacarpophalangeal (MCP) joints, a surgical nonunion rate of 7%, and an extended period of postoperative immobilization lasting up to 3 months.³⁹ Moreover, patients undergoing fusion have difficulties in full thumb mobility and may encounter challenges in positioning their hand flat or accessing pockets.

The preferred fusion position is the thumb key pinch, characterized by a pronated thumb with the pulp resting on the radial aspect of the index-middle phalanx. This position involves 30° to 40° of palmar abduction and 10° to 20° of radial abduction and extension. The surgical exposure uses the interval between the APL and abductor pollicis brevis tendons, which allows for exposure and removal of any remaining cartilage within the thumb CMC joint. Various fixation methods, such as K-wires, plates, screws, condylar blade plates, and headless compression screws, can be employed.42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 A study by Fulton and Stern⁵¹ involving 49 patients using K-wire fixation reported a 7% nonunion rate, with most nonunions being asymptomatic. At the 7-year follow-up, the average pain score was 1.5 on a scale of 0 to 10. However, seven patients developed adjacent joint arthritis, three at the scaphotrapezial joint, and four at the trapezial-index metacarpal articulation.⁵¹

CMC denervation

Over the last several years, denervation has gained in popularity.^42,52 The procedure involves exposure of the thumb CMC capsule with gentle dissection to allow for separation of sensory nerve branches, including the dorsoradial and dorsoulnar branches, as well as the terminal branch of the lateral antebrachial cutaneous nerve and branches from the palmar cutaneous branch of the median nerve.⁵³ Electrothemal cauterization is used for nerve destruction. Following denervation, additional procedures may be warranted, including retracting the APL tendon to complete a CMC joint synovectomy or osteophyte excision, followed by postoperative immobilization. Ebelin⁵⁴ described his technique for division of the most volar slip of the APL to lessen joint reactive forces across the CMC joint. Although data are limited, a prospective comparative study of CMC denervation versus trapeziectomy found that patients undergoing CMC denervation were, on average, 10 years younger, and both groups achieved similar functional improvements.⁴⁰ Frost et al⁴¹ compared 2-year outcomes of denervation to trapeziectomy with LRTI and found that denervation had shorter operative times with similar grip, key, and pinch strengths, as well as comparable patient reported outcomes with a faster return to activities as compared to trapeziectomy with LRTI.

In a recent review of first CMC joint denervations by Rezzadeh et al,⁴² data from six anatomic studies and nine clinical studies were analyzed. The findings revealed encouraging results, with patients generally experiencing improvements in pinch strength, grip strength, and Kapandji scores.⁴² Notably, most studies reported significant pain relief as well.⁴² However, it is crucial to appreciate that in the study population of 169 patients undergoing denervation, 20 patients experienced radial nerve paresthesias, nine experienced patchy hypoesthesia around the surgical site, and three patients experienced postoperative wound infections.⁴² This review underscores the necessity for further clinical studies incorporating extended follow-up periods and control groups. Such studies are essential for a more comprehensive understanding of the long-term effectiveness and durability of CMC denervation as a treatment for first CMC arthritis.

Our Preferred Technique

The authors all consider trapeziectomy with suture suspensionplasty technique to combine the benefits of existing techniques while maintaining a low complication profile. The technique uses a single 3 cm incision and requires minimal fluoroscopy, thus decreasing the risk of infection. Suture suspensionplasty provides a suture sling to decrease proximal metacarpal subsidence. In addition, the technique preserves the first CMC tendon anatomy, which if harvested may preclude the use of future tendon transfers. In a direct surgeon comparison of suture suspensionplasty to trapeziectomy + LRTI, the former benefited from shorter surgical and tourniquet times.²⁷ Although complications such as neuritis or neuroma, infection, and tendon rupture may arise, careful protection of the superficial radial nerve, FCR, and flexor pollicis longus tendons minimizes risk.²⁸ Given its safety and easy reproducibility, the technique offers several advantages with a reduced risk profile from a physician and patient perspective.

A roughly 3 cm longitudinal incision over the dorsum of the thumb CMC joint is used (Fig. 1). Early identification and protection of the branches of the superficial radial nerve is paramount during dissection. Dissecting scissors are used to expose the first compartment, which often exhibits thickening, and subsequently, it is meticulously released. The APL and extensor pollicis brevis (EPB) tendons are gently retracted (Fig. 2). A self-retaining retractor is then employed to maintain this exposure, thereby safeguarding the nerve, and allowing unencumbered access to the joint, mitigating the risk to neurovascular structures.

Figure 1.

Illustration depicting incision site over the first CMC capsule.

Figure 2.

Illustration depicting the APL and EPB tendons after incision and dissection.

The CMC capsule is incised to provide for exposure thickly to allow for capsular repair. The entire trapezium is identified and excised with sharp dissection, a McGlamry elevator, rongeur, or osteotomes. Special care is exercised to protect the FCR and flexor pollicis longus tendons. Complete removal of the trapezium is confirmed through inspection and fluoroscopy.

Once the trapezium has been fully removed, the suspensionplasty procedure is executed using the FiberLock system (Arthrex), with an added augmentation in the form of a slip from the APL tendon, if necessary. To begin, the midline of the base of the second metacarpal is pinpointed, and an obliquely oriented bicortical guidewire is inserted. The drill guide is subsequently positioned over the guidewire and securely attached to the base of the second metacarpal (Fig. 3). The drilling process is then conducted on the second metacarpal, with utmost care taken not to dislodge the drill guide. The FiberTak anchor is then introduced through the drill guide, requiring a gentle tap from a mallet to pass through the far cortex. The proper deployment of the anchor may be confirmed via fluoroscopy. Once the anchor is securely set, the guide is then gently removed.

Figure 3.

Illustration depicting drill guide insertion into base of second metacarpal.

Our attention is then redirected to the first metacarpal, where a guidewire is introduced into the radial aspect of its base. A drill is subsequently inserted over the guidewire and carefully removed. The two sutures are then draped over the saddle of the first metacarpal base. The 3.5 mm Swivelock anchor (Arthrex) is then inserted, ensuring the capture of both strands of the suture. Lastly, the wound is methodically irrigated and closed in a layered fashion with particular attention to the capsule, which augments the structural support, and avoids the sensory branches of the radial nerve.

A thumb spica splint is applied after surgery, and patients are discharged with appropriate pain medication, including 5 mg oxycodone and/or 800 mg ibuprofen. The first phase of therapy consists of splint maintenance along with passive finger and elbow exercises. At 2 weeks after surgery, the surgical splint is replaced with a rigid custom thumb brace that positions the thumb metacarpophalangeal joint in 30° of flexion and slight abduction to ensure capsular healing. During the second phase of therapy, passive abduction and extension of the first CMC joint are encouraged, while flexion, adduction, and thumb opposition are avoided to protect the capsular repair. At 6 weeks after surgery, the patient transitions to the third phase of therapy, which includes active thumb palmar abduction, opposition, circumduction, and light functional activities. At 10 weeks after surgery, the fourth phase begins, focusing on progressive strengthening and active thenar adduction and pinch. The custom splint is discontinued at 12 weeks after surgery. With continued strengthening, patients may gradually resume work and daily activities, using a soft thumb spica splint as needed.

Conclusion

First CMC joint arthritis is a common problem that all hand surgeons will encounter frequently during their career. Various surgical techniques, ranging from denervation to simple trapeziectomy to implant arthroplasty, have been proposed to address basilar thumb arthritis, all of which have shown satisfying results with varying complication profiles. Degeneration or laxity of the volar beak ligament is implicated in the development of first CMC joint arthritis, leading to joint subluxation, synovitis, pain, and eventually radiographic evidence of joint degeneration. It is our conviction that an effective surgical approach must not only alleviate the pain resulting from bone-on-bone contact, but also restore the proper tension in the volar beak ligament. Trapeziectomy with LRTI is among the operative methods that meet these criteria. Our preferred surgical procedure favors complete trapezium removal, employing a suture suspensionplasty between the first and second metacarpals to stabilize the reconstructed CMC joint, obviating the need for postoperative pin fixation and lessening postoperative immobilization while simultaneously using a single incision, preserving the normal tendinous anatomy, and preventing subsidence. Our approach ensures direct access to the trapezium, protecting critical structures like the radial artery and superficial radial nerve, providing surgeons with a safe and unhindered working environment.

Overall, there is no clear superiority among the surgical procedures when it comes to pain relief, physical function, patient reported outcomes, range of motion, or strength (Table 3).24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 However, the limited availability of high quality studies on certain techniques, including more minimally invasive techniques such as denervation, calls for further investigation into long-term outcomes. Additionally, the focus should shift toward developing more sensitive outcome measures to better assess hand function after CMC arthroplasty, making this tool valuable for hand surgeons and hand specialists managing this prevalent arthritic condition.

Conflicts of Interest

No benefits in any form have been received or will be received related directly to this article.