Article published online: 2020-09-17

Original Article 233

Lessons Learned: Trapeziectomy and Suture

Suspension Arthroplasty for Thumb Carpometacarpal
Osteoarthritis
Ashley L. Pistorio1  John B. Moore2

1 Department of Plastic Surgery, UNLV School of Medicine, Address for correspondence Ashley L. Pistorio, MD, Department of
Las Vegas, Nevada, United States Plastic Surgery, UNLV School of Medicine, 1701 Charleston Boulevard,
2 Premier Plastic Surgery, The University of Kansas Medical Center, Suite 490, Las Vegas, NV 89102, United States
Kansas, United States (e-mail: Ashley.Pistorio@unlv.edu).

J Hand Microsurg 2022;14:233–239.

Abstract
Keywords
► carpometacarpal
► ligament
reconstruction and
tendon interposition
► mini tight rope
fixation
► thumb arthritis
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In this study, we describe refinements of an accepted technique made by a single
surgeon for trapeziectomy and suture suspension arthroplasty for thumb carpometa-
carpal (CMC) osteoarthritis after 220 cases over 4 years. Results are derived from
77 patients who underwent treatment using this technique comparing postoperative
results with preoperative assessment and had sufficient data for inclusion. The surgi-
cal technique is described, including tips and modifications to avoid known possible
complications. All patients in this study had advanced Eaton stage III or IV osteoarthri-
tis. Grip strength and key pinch showed statistically significant improvement, and the
improvement in palmar pinch approached significance. Pain scores were significantly
decreased with over 50% of the patients rating their pain at 0 postoperatively. The
overall complication rate was very low, and improvements in technique were made to
mitigate future occurrence. This surgical technique for the treatment of thumb CMC
arthritis achieved pain relief and recreated ligamentous support of the base of the first
metacarpal to resist proximal migration after trapeziectomy, providing an increase in
grip strength and key pinch with return of range of motion early in the postoperative
period. Refinements on this technique through a large volume single surgeon experi-
ence provide technical tips for optimizing outcomes.

Introduction enters phase 3. What is often missing in this evolution are

Most surgeons find the promise of new procedures exciting
and intriguing, especially when treating a pathology that
is common, inhibits function, and is progressive such as
osteoarthritis (OA). New techniques and devices, decreased
cost, shorter operative times, faster recoveries, fewer com-
plications, and more durable results are all fundamental
goals. New procedures generally go through three life cycle
phases. In phase 1, the procedure is introduced and initial
instructions given to encourage some early adopters. Phase 2
includes published series of various sizes presenting results
and a list of complications encountered. If the new procedure
survives 5 to 10 years of successful trials, it may become part
of the surgical armamentarium and “standard of care” and
more detailed instructions by the early adopters on the finer
points of the surgery as well as the pre- and postoperative
care that can make the difference between a satisfying suc-
cess and a disappointing failure.
OA at the base of the thumb causes significant pain and
disability, especially with actions requiring pinch, and can
be demonstrated clinically using the axial grind test which
localizes pathology to the area of the trapezial carpometa-
carpal (CMC) and scaphotrapezial trapezoid joints.1 The
thumb CMC joint is the most common site for surgical
reconstruction indicated by OA in the upper extremity.2 The
thumb CMC joint is a saddle joint formed by articulation of
the first metacarpal of the thumb and the trapezium. The

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234 Arthroplasty for Thumb CMC Osteoarthritis  Pistorio, Moore
biconcave-convex nature of the joint allows motion in three
planes: flexion-extension, adduction-abduction, and axial
rotation. This joint is stabilized by multiple ligaments includ-
ing the anterior oblique (beak) ligament, laxity of which is a
major contributor to the development of OA. Laxity of the
beak ligament leads to cartilage loss through increased stress
loads and results in impingement and pain.3 Classification of
thumb CMC OA can be attained using the radiographic stag-
ing system developed by Eaton et al4 (►Table 1). Thumb CMC
OA generally affects up to 11% of men and 33% of women
in their fifth and sixth decade of life. In patients older than
75 years, there has been shown to be radiographic evidence
of CMC OA in up to 25% of men and 40% of women.2 There has
been speculation that the increased incidence of the condi-
tion in postmenopausal women is due to a hormonal predis-
position.5 A large study out of Finland showed that obesity is
a strong determinant of thumb CMC OA in both sexes.6
Hand function before and after interventions for thumb
CMC OA has been reported using physical measurements
and patient-reported questionnaires.7-9 Objective data col-
lected using physical measurements can demonstrate grip
and pinch strength as well as range of motion, and provide
more reliable comparison between pretreatment, posttreat-
ment, multiple treatment groups, and possibly across differ-
ent studies.
Treatment options for thumb CMC OA include nonsurgi-
cal options such as splinting, activity modification, the use
of nonsteroidal anti-inflammatory medications, and steroid
injections. These options are more effective in earlier stage
CMC OA as shown by Day et al,10 where intraarticular steroid
injections provided relief in 80% of Eaton stage I patients at
18 months, but only provided relief in 25% of Eaton stage IV
patients in the same time frame. Surgical treatments—gener-
ally reserved for patients with Eaton stage II or higher—have
historically included osteotomy, trapeziectomy, prosthetic
interpositional implants with or without trapeziectomy,
hematoma distraction arthroplasty, ligament reconstruction
with or without tendon interposition, and trapeziectomy
with suture suspension arthroplasty. The ligament recon-
struction tendon interposition (LRTI) procedure, originally
described by Burton and Pellegrini,11 is usually reserved for
mild-to-moderate CMC OA. This procedure, which usually
utilizes the radial portion of the flexor carpi radialis (FCR)
Table 1  Eaton classification of thumb carpometacarpal
arthritis
Eaton Radiographic findings
stage
I Joint widening due to effusion, <33% metacarpal
subluxation
II CMC joint sclerosis, <2 mm osteophytes, joint
narrowing, >33% metacarpal subluxation
III Debris and osteophytes within the CMC joint
>2 mm, severe narrowing
IV Pan trapezial arthritis including STT joint
Abbreviations: CMC, carpometacarpal; STT, scaphotrapeziotrapezoidal.
Journal of Hand and Microsurgery  Vol. 14  No. 3/2022  © 2020. Society of Indian Hand Surgery & Microsurgeons.
tendon, has three main principles described by Tomaino
et al12 including removal of abnormal bony surface via a
partial or complete trapeziectomy, reconstruction of the lig-
ament to stabilize the joint, and shortening of the metacar-
pal to prevent bony impingement. It is generally considered
to be the gold standard against, which other treatments are
compared.13-15 There are potential disadvantages to this pro-
cedure, however. First, the sacrifice of part or all of the FCR
tendon has hypothetical negative kinematic consequences13
as well as a secondary donor site adding to postoperative
pain.14 No studies of the LRTI procedure have measured wrist
flexion strength; the main parameter one would expect to be
impacted by FCR sacrifice. The devascularized tendon graft
may not be reliable to provide the early strong support to
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prevent metacarpal migration.14,16
The senior author has worked to refine the thumb CMC
arthroplasty described by Taghinia et al17 with the goal of
increased suture strength and vertical restriction to limit
metacarpal migration over time.16 The aims of this study
were to further assess results of the modified technique over
a larger patient number, and to provide a detailed description
of the technique with “tips and tricks” used to maximize out-
comes and minimize problems.
Materials and Methods
Data were prospectively collected for all patients surgically
treated as previously described18 (n = 250). Inclusion crite-
ria were subjects who underwent trapeziectomy with suture
suspension thumb CMC joint arthroplasty who had ade-
quate pre- and postoperative measures available for analysis.
Factors recorded included gender, age, dominant handed-
ness, operative side, grip strength in kilograms, key pinch
in kilograms, palmar pinch in kilograms, three-jaw pinch in
kilograms, thumb abduction in degrees, follow-up period,
and pain score. Any patient with incomplete data or who
were lost to follow-up were excluded. For inclusive analysis,
a total of 77 procedures (38 left and 39 right) on 73 patients
met final criteria. Patients were observed for an aver-
age of 11.5 months postoperatively (median = 12 months,
minimum = 1.5 months, maximum = 24 months). Grip
strength, key pinch, palmar pinch, three-jaw pinch, and
active thumb radial abduction were measured pre- and post-
operatively using a standard hand pinch gauge, dynamom-
eter, and goniometer based on recommendations published
by the American Society of Hand Therapists.19 Pre- and post-
operative pain was tracked using a standard scale of 0 to 10,
with 0 being no pain and 10 being the worst pain ever expe-
rienced. We used a paired t-test to compare pre- and post-
operative results to a significance level of p <0.05. This study
was approved by our institutional review board (University
of Kansas Medical Center).
Key steps of the procedure include:
• After inflation of a tourniquet, make a 3.5-cm incision
centered over the thumb CMC joint at the glabrous border.
Small vessels are controlled using bipolar electrocautery.
Dissect with tenotomy scissors to reveal the main trunks
 Arthroplasty for Thumb CMC Osteoarthritis  Pistorio, Moore 235

of the radial sensory nerve proximally within the incision
and follow them distally as they branch; sweep them in a
dorsal or volar direction to prevent injury.
• Make a fascial incision where the abductor pollicis ten-
don meets the abductor pollicis brevis muscle and deepen
down to the metacarpal periosteum, saving a flap of
abductor pollicis brevis (APB) muscle. Creation of this flap
prevents palpability and clears a 1-cm space for suture
button placement. Note that the metacarpal shape is tri-
angular and care should be taken where the suture anchor
plate is placed so that there is significant bone stock for
fixation, and the ridge of the metacarpal can overhang the
anchor button to combine with the APB muscle flap to
prevent palpability (►Fig. 1A, arrow).
a rongeur to remove any remaining bone fragments or
alternatively; a scalpel can be used if the bone is soft and
the ligaments are strong. Never forget the beak of the tra-
pezium which can extend 1 to 2 cm distally between the
bases of the first and second metacarpals.
• Remove any remaining abnormal synovium, degenerative
ligament, and small bone fragments. Repair the FCR ten-
don if inadvertently injured.
• Check the scaphotrapeziotrapezoidal (STT) joint surface
for any abnormalities and consider an interpositional
arthroplasty if sparse cartilage (we use dermal allograft).
• Make a 1.5-cm incision at the ulnar base of the second
metacarpal as far proximal as possible. There is always a
radial nerve branch just to the ulnar side of the incision

• Identify the trapeziometacarpal (CMC) joint.
• Identify and protect the radial artery, which will be easily
seen on top of the trapezium between the first and second
extensor compartments.
• Elevate the capsule from the trapezium (we prefer a
15C scalpel with a round handle) and rongeur the CMC
joint space to remove any osteophytes, free bodies, and
synovitis.
• Identify the scaphotrapezial joint and divide the dorsal
retaining ligament.
• Identify and protect the FCR tendon on the volar side of
the trapezium.
• Remove the trapezium in its entirety using a combination
of an oscillating power saw, osteotome, rongeur, and scal-
pel. The first saw cut is dorsal to volar, parallel to the course
of the FCR tendon, at a 45-degree angle three-quarters
of the way through the trapezium. An 8-mm osteotome
twisted in the groove completes the cut while protecting
the underlying FCR tendon from laceration. The second
cut is transverse over the entire length of the trapezium
three-quarters of the way through the bone just short of
the trapezoid and then finished with an osteotome. Use
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that must be identified and protected.
• Make a subperiosteal pocket with a freer elevator on the
ulnar side of the second metacarpal, lifting an interos-
seous muscle flap to prevent palpability of the second
suture button.
• At this point, the surgeon has the choice of passing the
suture guidewire either of two directions: first to second
metacarpal or vice versa. We have tried both and find
the track in the first-to-second direction more reliable.
One also has the choice of which metacarpal to place the
suture knot against and we feel that it can be more effec-
tively hidden against the thumb metacarpal base.
• Place the surgeon’s thumb at the base of the first (push-
ing distally to open up the trapezial space) and index fin-
ger at the second metacarpal ulnar side pocket and drive
the 1.1-mm guidewire, which tapers down to a 0.86-mm
wire with a Nitinol loop at the distal end, from the first
metacarpal toward the second metacarpal using your pre-
defined metacarpal targets. We recommend liberal use
of tissue protectors. Do not grab the narrower part of the
guidewire with the driver or it will break. Pull the wire
through until a loss of resistance is felt. This correlates to

Fig. 1  Placement of suture button anchors. (A) Suture button shown in its preferred position (red arrow) on the radial side of the first meta-
carpal base just volar to the ridge, and the target spot is visualized on the proximal second metacarpal. Inset bottom right shows enlarged
view. (B) The suture button anchor is visualized in its preferred position (red arrow) on the ulnar side of the second metacarpal. Inset bottom
left shows enlarged view.

Journal of Hand and Microsurgery  Vol. 14  No. 3/2022  © 2020. Society of Indian Hand Surgery & Microsurgeons.
236 Arthroplasty for Thumb CMC Osteoarthritis  Pistorio, Moore
the small part of the guidewire being the only portion that
remains within the bone.
• We prefer the knot on the side of the first metacarpal, so
we use a passing suture through the guidewire looped
end from the first metacarpal and out at the second
metacarpal, and then pass back after attaching thread-
ing the button to be seated on the second metacarpal.
The authors find that approximately 2 cm FiberWire
length is ideal to perform suture passing successfully.
Assure that the suture button is seated well on the sec-
ond metacarpal and apply the other suture button at
the free ends on the first metacarpal side (see ►Fig.  1
for suture button positioning, arrows indicate button
location). Tie a single square knot down then check the
seating against the first metacarpal without interposi-
tion of any soft tissue.
• Visualize the space between the scaphoid and first meta-
carpal within the operative site. Apply an axial load
to assure this space does not collapse. Tension can be
adjusted on the suture suspension as needed. Bring the
thumb out to 90 degrees abduction to assure there has not
been overtightening.
• Once proper seating of suture buttons and appropriate
tension is confirmed, tie four square knots, and cut to a
3-mm tail length.
• Close the muscle and fascia over the plates on both sites
using a 4–0 Monocryl suture. Close the incisions as
preferred.
• A wrist block of all three nerves is performed using rop-
ivacaine for postoperative analgesia. Skipping the ulnar
nerve results in residual pain from the deep branch.
• The patient is placed in a thumb spica splint for 5 days
total. After 5 days, the patient is seen in the office and
skin sutures removed. Patients are placed in a removable
Table 2  Patient demographics and follow-up time
Mean
Subject age at surgery (y) 62.1
Maximum follow-up (mo) 11.6
Hand dominance Left = 36, Right = 38
% Dominant side surgery 55%
Table 3  Comparison of pre- and postoperative averages (standard error of the mean)
Preoperative
Grip Strength (kg) 19.9 (1.7)
Key Pinch (kg) 4.8 (0.6)
Palmar Pinch (kg) 3.3 (0.5)
3-Jaw Pinch (kg) 4.2 (0.6)
Thumb abduction (degrees) 58.2 (1.0)
Pain score 6.3 (0.2)
Journal of Hand and Microsurgery  Vol. 14  No. 3/2022  © 2020. Society of Indian Hand Surgery & Microsurgeons.
thermoplastic hand-based thumb splint for comfort. The
total splinting time is 3 weeks. Thumb motion and grip
strengthening is begun at 5 days and pinch strengthening
at 3 weeks. Postoperative X-rays are obtained at 3, 6, and
12 months.
Results
We have evaluated and treated 250 patients for thumb CMC
arthritis over the course of 4 years as we refined our pre-
ferred technique. Of those patients, data from 77 thumb CMC
arthroplasties on 73 patients (36 left-sided and 38 right-
sided; 55% on the dominant side) using the suture suspen-
sion technique were included in this study (►Table 2). There
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were improvements in all variables measured although
not all were statistically significant (►Table  3). Significant
improvements were seen in average grip strength (22.9 vs.
19.9 kg, p < 0.01), key pinch (5.4 vs. 4.8 kg, p < 0.01), and pain
score (1.3 vs. 6.3, p < 0.01), while improvement in palmar
pinch approached significance (3.7 vs. 3.3 kg, p = 0.07). For
41 of the 73 (56%) of the patients, pain was rated at 0 after
surgery at the 6-month follow-up. Solving for an average grip
strength difference of 4 kg and a common standard deviation
of 10, and assuming an α of 0.05, the post hoc power was 94%.
Postoperative X-rays were compared at 3, 6, and
12 months postoperatively as feasible based on individual
follow-up period, with 38 patients meeting the 12-month
criteria included in this study (see ►Fig.  2 for exemplar
radiographs). All but three of the 38 patients showed
acceptable radiographic position of the thumb metacarpal
base without proximal migration, or subsidence, of the first
metacarpal at 12 months postoperatively, all due to surgeon
error. During reoperation for patients that had unacceptable
findings, the suspension suture had pulled through the volar
Median Range
61 41–85
12 1.5–24
Postoperative p-Value
22.9 (1.74) <0.01
5.4 (0.5) <0.01
3.7 (0.4) 0.07
4.3 (0.4) 0.76
59.7 (0.9) 0.14
1.3 (0.2) <0.01
 Arthroplasty for Thumb CMC Osteoarthritis  Pistorio, Moore 237

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Fig. 2  Postoperative radiographs following suture suspension arthroplasty. PA (A) and lateral (B) radiographs taken after suture suspension
arthroplasty show button anchor placement and positioning of the suspension. Note the small articular facet at the base of the second meta-
carpal in the PA view can be a source of pain if the first metacarpal is suspended too distally. PA, posterior approach.

cortex of the thumb metacarpal secondary to inadequate Table 4  Complication rates after 250 cases performed
bone stock/placing the button too close to the radial cortex. Total number of
The other was secondary to tying the suspension too loosely. subjects (rate %)
These patients had suture button replacement in the cen-
Hematoma 0 (0)
tral metacarpal and were resuspended without issue. This
Seroma 0 (0)
is why the technique was modified to assure starting loca-
tion just volar to the metacarpal ridge as depicted (►Fig. 1A, Infection 0 (0)
arrow). The ideal goal is to have the thumb metacarpal base Wound dehiscence 0 (0)
5 mm proximal to the second metacarpal. Exact anatomic Keloid/hypertrophic scar 0 (0)
alignment has led to an excessively tight cable that inter- Neuroma 0 (0)
feres with maximal abduction and can cause pain between Suture button breakage 0 (0)
the bases of the two metacarpals. This was exemplified by
Cable breakage 0 (0)
two of our postoperative cases in which patients developed
erosive arthritis between hidden osteophytes at the base of Palpable button 0 (0)
the thumb metacarpal and the small trapezial-metacarpal CRPS 0 (0)
facet at the radial base of the second metacarpal. Loss of abduction 1 (0.4)
Complications of the procedure in our hands (►Table 4), Unrecognized osteophytes 2 (0.8)
while not included in the 73 patients analyzed for this study, Fractures 3 (1.2)
included the two patients who developed painful arthral-
Subsidence 3 (1.2)
gia between the base of the thumb metacarpal and a small
Clicking 2 (0.8)
articular facet at the radial base of the second metacarpal
and the three patients who had loss of suspension, two Reoperation 7 (2.8)
due to the suture pulling through inadequate bone stock of Abbreviation: CRPS, complex regional pain syndrome.
the first metacarpal as noted above and one due to tying
the suspension too loosely. In two patients, there were
osteophytes at the ulnar base of the first metacarpal with first metacarpal base is kept at the level of the distal trap-
ongoing pain requiring reoperation to resect the metacar- ezoid. Three second metacarpal fractures occurred in three
pal base osteophyte, placement of dermal interpositional different patients. One was early in adoption of the tech-
autograft, and resuspension. There was only one case of nique when a larger drill was used and this healed with the
loss of abduction due to tying the cable too tightly. There use of a splint without need for reoperation. The two others
were two cases of clicking when the first metacarpal base occurred due to multiple passages of the guidewire, cre-
was distracted to match the facet at the radial base of the ating a dotted-line osteotomy which eventually gave with
second metacarpal, which was resolved by assuring that the minimal trauma. One of these patients felt the bone break

Journal of Hand and Microsurgery  Vol. 14  No. 3/2022  © 2020. Society of Indian Hand Surgery & Microsurgeons.
238 Arthroplasty for Thumb CMC Osteoarthritis  Pistorio, Moore
and one was asymptomatic and picked up on postop X-ray.
Both healed with 1 month of splinting and no reoperation.
Complication rate was 11/250 (0.04%) and overall decreased
as refinements were made, with no complications in the
final 24 months of this study.
Discussion
Endeavors to ascertain the best surgical treatment of symp-
tomatic thumb CMC joint OA have fallen short of realiza-
tion. In one randomized study of 174 thumbs that compared
outcomes at a minimum of 5 years for hematoma distrac-
tion arthroplasty, LRTI, and trapeziectomy with tendon
interposition, no difference in pain, tip pinch, key pinch,
and grip strength was observed.20 In general, suture sus-
pension arthroplasty is similar to hematoma distraction
arthroplasty except the thumb metacarpal is suspended by
a suture instead of a Kirschner wire allowing hematoma to
fill the trapeziectomy space and formation of scar tissue over
time. Suture suspension arthroplasty allows early thumb
range of motion and therapy, 5 to 7 days postoperatively. The
lack implanted K-wires for 4 to 6 weeks, such as in hema-
toma-distraction arthroplasty, mitigates potential compli-
cations like pin site infection and pin migration. There is
decreased operative time and less dissection compared with
LRTI, decreasing potential pain. Additionally, sparing of the
FCR tendon allows early range of motion and maintains nat-
ural wrist kinematics.
In our study, we found that patients treated with tra-
peziectomy and suture suspension arthroplasty had
increased thumb strength and partial or complete reso-
lution of pain associated with thumb CMC arthritis. The
thumb trapeziometacarpal joint undergoes considerable
compressive forces during pinch.21 Thumb metacarpal
proximal migration after trapeziectomy creates a biome-
chanical disadvantage, potentially resulting in weakness of
thumb pinch strength and pain at the MC scaphoid artic-
ulation.20,22-24 Methods to prevent this proximal migra-
tion, including suture suspension arthroplasty. In a recent
study on revision CMC arthroplasty for persistent pain and
functional deficit, reasons for failure were likely MCP joint
hyperextension, scaphotrapezoid joint arthritis, or metacar-
pal subsidence.25 Offering a distinct advantage in preventing
the need for revisions, the construct created with suture
suspension arthroplasty prevents metacarpal subsidence as
well as MCP hyperextension, as well as the ability to treat
any scaphotrapezoid arthritis.
The use of the Mini TightRope system for suture suspen-
sion arthroplasty carries benefits and disadvantages. It cre-
ates a simple and reliable system with a stronger construct
that avoids sacrifice of a tendon and allows early range
of motion. The trajectory does not recreate the posterior
oblique ligament, and there is a known risk of overtightening.
There is a risk of metacarpal fracture and of suture migration
or failure. Having experienced some of these complications
firsthand, we feel that they can be largely avoided with care-
ful maneuvers as discussed in this study.
Journal of Hand and Microsurgery  Vol. 14  No. 3/2022  © 2020. Society of Indian Hand Surgery & Microsurgeons.
This study has limitations due to its nature as a cohort
study with pre- and postintervention measurements with
no control group or direct comparison with outcomes from
another technique. In the practice of the primary surgeon and
his hand therapist, measures such as disabilities of the arm,
shoulder and hand (DASH) are not typically used unless spe-
cifically requested and were not available for these subjects.
The DASH and Patient Reported Outcomes Measurement
Information System (PROMIS) are all long multiitem self-re-
ported questionnaires that we have found have poor response
rates and are less meaningful to most surgeons who routinely
measure motion, pinch/grip strength, and pain relief in their
postoperative patients. The Kapandji’s score for thumb oppo-
sition was not measured, but radial abduction—functionally
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important for grasping large objects—was measured and
changes were not found to reach a level of significance. Other
measurements taken did show improved strength with spe-
cific motions and pain score, and one can presume this would
also result in an improved DASH score.
Also, due to the nature of this study and subjects, follow-up
did not always meet the minimum preferred of 12 months
for the final functional testing, pain score, and radiographs.
In general, all subjects followed-up in the very early postop-
erative period, and most at 3 and 6 months but were some-
times lost to follow-up after that. Several subjects did return
for later postoperative follow-up after 12 to 24 months.
Results are from a single surgeon and surgical techniques
have a known learning curve for reproducibility. There has
been clinical success using the suture suspension technique
with the Arthrex Mini TightRope system at different insti-
tutions, and the authors point out details of their particu-
lar method including small modifications felt to improve
outcomes in our hands. Another limitation of this study is
that our study group was not matched with a control group
using another technique. The use of standardized objective
measurements allows for comparison to previous studies in
other patient populations. There is also an added advantage
in our study that pre- and postoperative measurements were
performed in a standardized fashion, allowing for direct com-
parison of improvements due to the surgery instead of com-
paring surgical side with nonsurgical side.
Conflict of Interest
None declared.
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