Full Length Article

Journal of Hand Surgery

(European Volume)
Simple trapeziectomy versus 0(0) 1–5
! The Author(s) 2020
trapeziectomy with flexor carpi Article reuse guidelines:
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radialis suspension: a 17-year follow-up DOI: 10.1177/1753193420952966
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of a randomized blind trial

Adrian Brennan, Julia Blackburn, Jane Thomson and

Jeremy Field

Abstract
The purpose of this study was to investigate if there were any significant differences in the long-term out-
comes of patients who participated in a randomized trial of trapeziectomy alone compared with trapeziectomy
with ligament reconstruction and tendon interposition (LRTI). Sixty-five patients were invited for a follow-up
visit at a mean of 17 years (range 15–20) postoperatively. Twenty-eight patients attended, who had 34 oper-
ations, 14 trapeziectomy alone and 20 with LRTI. There were no statistically significant differences between
the two groups in terms of satisfaction with surgery or functional outcomes, with most measurements
showing minimal or no differences in means between the two groups. There was no difference in the
space between the metacarpal and scaphoid. Radial abduction was the only parameter that was significantly
greater in the patients with simple trapeziectomy (median 79 ) compared with trapeziectomy with LRTI
(median 71 ) (p ¼ 0.04). Even at 17 years there is no significant benefit of LRTI over trapeziectomy alone for
thumb carpometacarpal joint osteoarthritis.
Level of evidence: I

Keywords
Trapeziectomy, ligament reconstruction and tendon interposition, flexor carpi radialis suspension, long-term
outcomes

Date received: 21st May 2020; revised: 3rd July 2020; accepted: 5th August 2020

Introduction
Approximately one-third of postmenopausal women
have arthritis of the thumb carpometacarpal joint
(CMCJ), and one-third of these patients experience
pain at the base of their thumb (Armstrong et al.,
1994). The mainstay of surgical management for
first CMCJ arthritis is a simple trapeziectomy first
described by Gervis (1948) and this is the standard
by which any other treatments are measured.
Concerns about possible functional implications of
collapse of the metacarpal into the arthroplasty
space (Burton and Pellegrini, 1986) as well as the
potential for scaphometacarpal arthritis (Conolly
and Rath, 1993) led to the development of techniques
to try and prevent this.
The most popular method is ligament reconstruc-
tion and tendon interposition (LRTI) using half of
flexor carpi radialis (FCR) (Burton and Pellegrini,
1986; Wolf and Delaronde, 2012). However, a
number of randomized controlled trials (RCTs) have
shown that trapeziectomy alone is equivalent to tra-
peziectomy with ligament reconstruction and/or
tendon interposition in the short term (Belcher and
Nicholl, 2000; Davis et al., 1997, 2004; Davis and
Pace, 2009; Field and Buchanan, 2007; Gerwin
et al., 1997; Kriegs-Au et al., 2004) and the medium
Orthopaedic Department, Cheltenham General Hospital,
Cheltenham, UK
Corresponding Author:
Julia Blackburn, Orthopaedic Department, Cheltenham Hospital,
Cheltenham GL53 7AN, UK.
Email: jlrkblackburn@doctors.org.uk
Twitter: @jlrkblackburn
2 Journal of Hand Surgery (Eur) 0(0)
term (Gangopadhyay et al., 2012; Salem and Davis,
2012).
In 2007, we published a single centre randomized
single blind trial of simple trapeziectomy alone com-
pared with trapeziectomy and FCR suspension for
Eaton and Glickel Grade III or IV (Eaton and Glickel,
1987) arthritis of the thumb CMCJ that also showed
no significant difference in outcomes at 1 year (Field
and Buchanan, 2007). The aim of this study was to
examine the same group of patients clinically and
radiologically between 15 and 20 years after their
surgery to see if there was still no difference with
and without an LRTI.
Methods
All patients provided written consent for their data to
be used and the institutional review board approved
the study. In our previous study (Field and Buchanan,
2007), 65 patients with osteoarthritis of the CMCJ of
the thumb were recruited into the single-blind ran-
domized trial. Sealed envelopes with computer-gen-
erated randomized numbers were used to allocate
patients to trapeziectomy alone or LRTI (Field and
Buchanan, 2007). For bilateral procedures, each
side was randomized separately. Details of the meth-
odology and procedures are detailed in our previous
publication (Field and Buchanan, 2007).
All patients from our previous study were invited
to participate in this long-term follow-up study. If
they agreed, they were telephoned to arrange a con-
venient time to attend the hospital for a clinical and
radiological assessment.
Assessments
Patients were asked to complete a visual analogue
scale (VAS) for satisfaction with the outcome of their
procedure, rated on a scale from 0 (most dissatisfied)
to 100 (most satisfied). They also completed the short
version of the Disabilities of the Arm, Shoulder and
Hand Score (QuickDASH) at their appointment
(Beaton et al., 2005).
Measurements were made by an independent
senior hand therapist (JT), who was blinded to the
type of operation. Range of movement was measured
using a goniometer. Extension and palmar abduction
were measured using the angle between the thumb
and index finger metacarpal. A Kapandji score of
between 1 and 10 (Kapandji, 1986) was used to
assess the level of thumb opposition. The first web
space span was measured using the distance
between the nailbed angles of the thumb and index
finger in maximal radial abduction. Grip, key and tip
pinch strengths were recorded with a Jamar
dynamometer. A grind test (Merritt et al., 2010) was
recorded as positive if the test was painful and nega-
tive if the test was not.
Plain radiographs were taken and the scaphome-
tacarpal distance was measured on the anteropos-
terior radiograph as previously described (Field and
Buchanan, 2007). The reproducibility of this method
was confirmed in the original study.
Statistical analysis
A Kolmogorov–Smirnov test was used to test the nor-
mality of the data. Normally distributed data was
expressed as mean and SD. If not normally distributed,
median and interquartile range (IQR) was used. For all
continuous, parametric data we used a paired t-test to
compare differences between the two groups. To com-
pare continuous, non-parametric data we used a Mann–
Whitney U test, and for categorical data, a Chi-squared
test. P-values of less than 0.05 were considered signifi-
cant. We did not proceed to calculation of the power of
these statistical analyses as the means of those vari-
ables in two groups of patients without significant dif-
ferences were found equal or of minimal differences.
Results
Of the 65 patients who participated in our original
study, we were able to follow-up 28 patients (43%).
Six patients had died, and 31 patients were either
uncontactable or declined to participate. These 28
patients had 34 operations (as six had bilateral pro-
cedures), with 14 simple trapeziectomies and 20
having had a trapeziectomy with LRTI. The mean
age of the patients was 76 years (range 67–86), and
there were 22 women and six men. The mean length
of follow-up was 17.5 years (range 15–20). There
were no differences in demographic characteristics
between the two groups (Table 1).
Our patients reported excellent outcomes follow-
ing surgery, with median satisfaction scores of 100
for both groups (Table 2). QuickDASH scores were
low for both groups, indicating excellent function,
and there was no statistically significant difference
between them (p ¼ 0.23).
Both groups had good range of movement, with no
significant differences between groups for thumb
abduction, opposition (Kapandji score) and first web
space span, with minimal difference in the mean
values of these measurements between two groups
of patients. However, the range of thumb radial
abduction (extension) was significantly greater for
patients who underwent trapeziectomy alone
(median 79 ) compared with trapeziectomy with LRTI
(median 71 ) (p ¼ 0.04).). There were no significant
Brennan et al. 3

Table 1. Demographic characteristics of the two groups.

Trapeziectomy alone Trapeziectomy þ LRTI

Variable (N ¼ 14) (N ¼ 20) p-value

Sex (male:female) 3:11 5:15

Age (years) 75 (6) 79 (5) 0.06
Dominant:non-dominant:missing 6:5:3 7:11:2
Duration of follow-up (years) 17 (1.5) 17.5 (1.5) 0.77
Data expressed as number or mean (SD).
LRTI: ligament reconstruction and tendon interposition.

Table 2. Outcomes for the two groups.

Variable Trapeziectomy alone Trapeziectomy þ LRTI p-value

Abduction (degrees) 78 (8) 74 (8) 0.17

Extension (degrees) 79 (71–90)a 71 (66–76)a 0.04
Kapandji score (0–10) 10 (8–10)a 10 (9.25–10)a 0.06
First web space span (cm) 14 (1.3) 13 (1.8) 0.32
Grip strength (kg) 12 (7–20)a 15.5 (11–20)a 0.29
Key pinch strength (kg) 4 (2–6)a 4 (3–6)a 0.93
Tip pinch strength (kg) 4 (2) 4 (2) 0.39
QuickDASH (0–100) 5 (0–23)a 9 (5–21)a 0.23
VAS satisfaction (0–100) 100 (95–100)a 100 (96–100)a 0.72
Scaphometacarpal distance (mm) 4 (1) 4 (1.5) 0.88
Grind test (frequency) 1/14 1/20
Data expressed as mean (SD) or median (IQR).
a
Median (IQR).
LRTI: ligament reconstruction and tendon interposition; VAS: visual analogue scale.

differences in grip strength (p ¼ 0.29), key pinch
strength (p ¼ 0.93) or tip pinch strength (p ¼ 0.39)
between the two groups; the mean strength data
were equal or had minimal differences between the
two groups of patients (Table 2). Only two patients had
a positive grind test, one in each group (Table 2). There
was no significant difference in scaphometacarpal
distance measured on plain radiographs at the 17-
year follow-up for the two groups (p ¼ 0.88) (Table 2).
Discussion
It was very gratifying that patients reported such
excellent satisfaction scores with both trapeziectomy
alone and trapeziectomy with LRTI at a mean of 17.5
years follow-up. It is thus clear that this operation
(with or without an LRTI) works really well in the
long term and it may be that we should stop looking
for alternative and more expensive treatments for
this common debilitating condition.
Proponents of thumb CMCJ replacement believe
that strength of thumb function may be better
maintained, but this is not clear from the existing
literature. We do know that thumb length has no
relation to pinch strength (Downing and Davis,
2001). Our study shows that strength is well main-
tained following trapeziectomy at a mean follow-up
of 17.5 years. We would agree with the systematic
review of CMCJ replacements (Huang et al., 2015)
in concluding that replacement arthroplasties
would need to be significantly better than trapeziect-
omy to justify their use.
The obvious limitation of this study is that we were
only able to assess less than half of our original
cohort of patients. However, our initial study was a
prospective RCT that would reduce bias and analysis
of our remaining participants showed no statistically
significant differences in demographic characteris-
tics between the two groups. Other retrospective
long-term follow-up studies have also struggled
with loss to follow-up. A non-randomized study of
120 patients who underwent trapeziectomy with or
without LRTI was only able to assess 54 patients at
an average of 13 years postoperatively (range 10–22
4 Journal of Hand Surgery (Eur) 0(0)
years), but found good clinical outcomes for both
groups (Pomares et al., 2016). This loss to follow-
up does increase the risk of Type II error. Previous
prospective randomized studies have concluded that
as most operations produce 70%–90% good results,
large numbers of patients must be recruited to
detect significant differences, if they exist, between
treatment options (Davis et al., 1997).
The range of movement of the thumb was no dif-
ferent at 12 months follow-up (Field and Buchanan,
2007). At a mean follow-up of 17 years there was found
to be a difference in radial abduction (extension)
favouring the simple trapeziectomy group. However,
both groups had an excellent median range of move-
ment of more than 70 , and the difference of 8
between groups is unlikely to be clinically significant.
At between 15 and 20 years we found no difference
in the gap between the metacarpal and scaphoid
(p ¼ 0.88). In our original article, at 12 months
follow-up there was still a difference in ‘the gap’,
but the difference was reducing with time (p ¼ 0.001
at 3 months to p ¼ 0.05 at 12 months) (Field and
Buchanan, 2007). We also found no cases of scapho-
metacarpal osteoarthritis, perhaps dispelling the
fears of earlier authors (Conolly and Rath, 1993).
The ‘gap’ has been rather a hand surgical obsession
over the years, with the thought that the shortening
of the thumb reduces pinch strength. This was dis-
proved by Downing and Davis (2001) and certainly is
not the case at long-term follow-up so perhaps dis-
persing a myth.
Davis et al. (1997) first indicated that the outcomes
were the same whether a simple trapeziectomy was
performed or whether it was supplemented by a
tendon interposition or an FCR suspension. Good sci-
ence must stand up to repeated studies and Belcher
and Nichol (2000) did just that, finding no difference
with an abductor pollicis brevis suspension. The con-
clusion drawn was that the suspension was not
necessary, but this meant surgeons were justified
in performing either operation. Further repletion by
Field and Buchanan (2007) drew the same conclu-
sions, but because there was an increased complica-
tion rate with LRTI it was suggested that
trapeziectomy alone was safer. More recent studies
have confirmed the former conclusion and this
medium-term follow-up also concludes that the sus-
pension is not necessary. A RCT of 174 thumbs
(Gangopadhyay et al., 2012), at a median of 6 years
postoperatively (range 5–18 years), found no differ-
ence in pain relief or grip strength between patients
who had received simple trapeziectomy or FCR LRTI.
A further RCT of 114 thumbs at a median 6 years
follow-up (range 4–7 years) found no differences in
outcomes between patients with trapeziectomy alone
or with LRTI and temporary Kirschner wire insertion
(Salem and Davis, 2012).
As other RCTs of trapeziectomy with or without
LRTI have shown no difference in short- to
medium-term outcomes (Davis et al., 1997; Gerwin
et al., 1997; Kriegs-Au et al., 2004) but a higher com-
plication rate (Field and Buchanan, 2007) with LRTI,
this study adds that there are no benefits of LRTI over
trapeziectomy alone for thumb CMCJ osteoarthritis
at over 17 years following surgery. Although the
LRTI is a technically challenging and perhaps surgi-
cally entertaining addition to the operation, it is not
necessary and it may not be justified.
Declaration of conflicting interests The authors
declare no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
Ethical approval The institutional review board approved
the study (17/LO/1259).
Informed consent All patients provided written consent
for their data to be used.
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