Total Arthroplasty Versus Trapeziectomy With Ligamentoplasty for Trapeziometacarpal Osteoarthritis: 5-year Outcomes

Trapeziometacarpal (TMC) osteoarthritis is the most prevalent osteoarthritis of the upper limb. It is one of the most disabling conditions. Currently, the most suitable surgical technique is debated. Trapeziectomy with ligamentoplasty continues to be the gold standard; however, results for function, esthetics, and quality of life have not been optimal. For this reason, surgeons have continued to refine and develop various surgical techniques, among which total arthroplasty is increasingly emerging as a major alternative, but it has not yet demonstrated superiority and its durability is still in doubt.

At a minimum follow-up time of 5 years, do patients with total basilar thumb arthroplasty, compared with patients with trapeziectomy and ligament reconstruction, have (1) better pain as measured by a VAS scale, (2) lower disability as measured by the DASH, and (3) better tip pinch strength and functional range?

This was a prospective study conducted in a specialized hand surgery unit within a tertiary-level referral hospital located in an urban area, with 54 patients diagnosed with TMC osteoarthritis administratively assigned to two different surgeons. Between February 2018 and June 2018, we treated 54 patients for TMC osteoarthritis. Of those, we considered as potentially eligible patients who met the following inclusion criteria: TMC osteoarthritis classified as Eaton-Littler Type III or IV, good bone quality, persistent pain lasting for > 6 months, and failure to respond to conservative treatment. The study was designed as a parallel group study in which patients treated by one surgeon were treated with total arthroplasty and patients treated by the other study surgeon were treated with trapeziectomy with ligamentoplasty. Patients were administratively assigned to their groups, and the surgeons were comparably experienced and performed similar surgical volumes. A total of 27 patients were treated with total arthroplasty, and 27 patients were treated with trapeziectomy with ligamentoplasty. One patient in the total arthroplasty group was lost to follow-up after the intervention for personal reasons unrelated to the study or the disorder. For this reason, that patient was excluded from the study. Finally, among the 26 patients who underwent arthroplasty at the end of the follow-up period, 96% (25) were women, and the mean ± SD age was 59 ± 8 years. Four percent (1) of patients were lost to follow-up before 5 years. Of the 27 patients who received ligament reconstruction and tendon interposition, 96% (26) were women with a mean ± SD age of 59 ± 7 years. A total of 0% (0) were lost to follow-up before 5 years. This left 96% (26) of patients in the total arthroplasty group and 100% (27) in the tendon interposition arthroplasty group, respectively. The mean ± SD follow-up time for all patients was 78 ± 4 months. The mean follow-up time for patients who received total arthroplasty was 78 ± 4 months, and it was 77 ± 3 months for those who received trapeziectomy with ligamentoplasty. The minimum follow-up period for inclusion was 5 years (60 months). Patients in the two treatment groups did not differ in terms of age, sex, dominant hand surgery, functional work requirement, concomitant disorder, radiographic characteristics, and Eaton-Littler stage, but a higher percentage of patients in the total arthroplasty group had carpal tunnel syndrome at the time of presentation (58% [15 of 26] versus 30% [8 of 27]; p = 0.04). Pain was assessed using a VAS ranging from 0 (pain free) to 10 (maximum pain), with a clinically significant change defined as 0.7 to 0.9. Functionality was evaluated using the DASH questionnaire, with a minimum clinically important difference (MCID) of 10.83. Secondary outcomes included mobility, measured through radial abduction and retropulsion of the thumb using a goniometer, and thumb opposition assessed by the Kapandji index, which scores opposition on a scale of 0 to 10. Grip strength was measured with a pinch gauge, averaging three measurements, with an MCID of 0.33 kg.

At 5 years, patients who had total arthroplasty had less pain compared to patients with trapeziectomy with ligament reconstruction (VAS 1.3 ± 0.7 versus 3.0 ± 0.9, mean difference 1.7 [95% confidence interval (CI) 1.3 to 2.1]; p < 0.001). Patients who had total arthroplasty had lower scores for upper extremity disability at 5 years (DASH 11 ± 9 versus 28 ± 12, mean difference -17 [95% CI -22 to -12]; p < 0.001). There was no clinically important difference between the groups in terms of tip pinch strength as measured in kg (3.7 ± 0.6 versus 3.2 ± 0.6, mean difference 0.4 [95% CI 0.1 to 0.8]; p = 0.01). Regarding mobility, we found differences between the total arthroplasty group and the trapeziectomy with ligamentoplasty group at 5 years of follow-up (Kapandji score 9.9 ± 0.4 versus 8.5 ± 0.6, mean difference 1.4 [95% CI 1.0 to 1.8]; p < 0.001).

In light of these findings, surgeons should consider total arthroplasty as a first-line therapeutic option for patients with advanced TMC arthritis, especially those with significant pain and persistent functional limitations. While both treatments offer benefits, total arthroplasty provides superior pain relief and greater improvement in functional disability. Future studies should focus on the long-term durability of total arthroplasty compared to trapeziectomy with ligamentoplasty, with follow-up visits extending beyond 10 to 20 years to assess implant longevity and potential late complications.Level of Evidence Level II, therapeutic study.