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Scaphotrapezoid arthritis: Prevalence in thumbs undergoing trapezium excision arthroplasty and efficacy of proximal trapezoid excision
Scaphotrapezoid Arthritis: Prevalence in Thumbs Undergoing Trapezium Excision Arthroplasty and Efficacy of Proximal Trapezoid Excision Matthew M. Tomaino, MD, Molly Vogt, PhD, Robert Weiser, PA-C, Pittsburgh, PA Between June 1995 and May 1998, 37 patients underwent trapezium excision arthroplasty. Preoperative radiographic assessment for scaphotrapezoid arthritis was performed. At the time of surgery intraoperative inspection of the scaphotrapezoid joint allowed calculation of the true prevalence of arthritis as well as sensitivity and specificity of the radiographic diagnosis. The true prevalence of scaphotrapezoid arthritis was 62%. The sensitivity of the radiographic diagnosis was 44% and the specificity was 86%. Comparison of surgical results in 23 patients who underwent both trapezium excision arthroplasty and proximal trapezoid excision, with 14 patients who underwent the former procedure, only showed that there was no morbidity associated with the latter. Because of the potential that scaphotrapezoid arthritis may cause residual symptoms following trapezium excision arthroplasty, and in light of the low sensitivity of radiographs, routine intraoperative assessment of the joint is recommended so that proximal trapezoid excision can be performed if degenerative change is present. (J Hand Surg 1999;24A: 1220 –1224. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Arthritis, scaphotrapezium, excision, arthroplasty.
Surgical treatment of painful degenerative arthritis at the carpometacarpal (CMC) joint of the thumb has been reported using a number of techniques, including excision arthroplasty,1 arthrodesis,2 resection arthroplasty with tendon interposition,3,4 and resection arthroplasty with ligament reconstruction.5,6 Because satisfactory outcome requires recognition of multiple From the Departments of Orthopaedic Surgery and Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, PA. Received for publication August 27, 1998; accepted in revised form May 25, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Matthew M. Tomaino, MD, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA 15213. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A06-0010$3.00/0
1220 The Journal of Hand Surgery
articular disease, radiographic evaluation of both thumb CMC and scaphotrapezial joints has become a routine part of preoperative evaluation. Indeed, the staging system described by Eaton et al7 emphasizes the importance of diagnosing scaphotrapezium arthritis (stage 4 disease) since hemitrapeziectomy alone will be complicated by residual pain. The staging system, however, does not address the scaphotrapezoid joint, yet North and Eaton8 identified scaphotrapezoid arthritis in 16 of 68 cadaver hands (24%). The potential for both over- and under-interpretation of pantrapezial arthritis based on x-ray alone has resulted in routine intraoperative assessment of the scaphotrapezial joint by most hand surgeons, particularly when electing between partial and complete trapezium excision. In the setting of thumb CMC
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1221
joint arthritis, however, similar attention to the scaphotrapezoid joint had not been emphasized until recently, when Irwin et al9 reported that untreated arthritis at the scaphotrapezoid joint resulted in incomplete pain relief following trapezium excision, ligament reconstruction, and tendon interposition in 1 patient. Secondary proximal trapezoid excision 6 months later provided complete pain relief. These investigators further reported that in 3 subsequent thumbs with scaphotrapezoid and thumb CMC joint arthritis, both trapezium excision arthroplasty and proximal trapezoid excision were performed, with excellent results. Our objectives in this study were 3-fold: to establish the prevalence of scaphotrapezoid arthritis in hands undergoing trapezium excision arthroplasty as treatment for thumb CMC joint arthritis, to determine the sensitivity and specificity of preoperative x-ray films, and to identify any morbidity associated with concomitant proximal trapezoid excision during trapezium excision arthroplasty when degenerative changes were noted during surgery at that joint.
Materials and Methods Between June 1995 and May 1998, ligament reconstruction tendon interposition arthroplasty was performed by a single surgeon (M.M.T.) using the technique described by Tomaino et al6 on 37 patients who presented with painful arthritis of the thumb CMC joint. The average age of the 6 men and 31 women was 60 years (range, 43– 80 years). Preoperative x-ray series, including posteroanterior stress and lateral and pronated anteroposterior (Robert’s) views, were obtained for each patient and evaluated for evidence of scaphotrapezoid joint space narrowing, subchondral sclerosis, or cyst formation. The scaphotrapezoid joint was inspected during surgery following trapezium excision by pulling on the index and long fingers to distract the articulation. When cartilage fibrillation, fissuring, or exposed subchondral bone was present, partial excision of the proximal trapezoid was performed so that with traction released from the fingers, there was no contact between trapezoid and scaphoid. This amounted to a resection equalling approximately 2 mm. Radiographic and intraoperative findings were compared to establish the prevalence of scaphotrapezoid arthritis by each method. The sensitivity and specificity of the preoperative x-rays in making the diagnosis were calculated using the surgeon’s intraoperative findings as the gold standard. The 95%
confidence interval was calculated using the formula W 5 = ((4Z2p(12p))/N), where W represents the width of the confidence interval. Clinical evaluation included subjective assessment of residual pain at the base of the thumb and in the region of the scaphotrapezoid joint and was also based on physical examination. We also measured pinch and grip strengths and compared them with preoperative values; we also compared the arthroplasty space measured between the base of the thumb metacarpal and the scaphoid using posteroanterior radiographs obtained 1 month following surgery and at the final follow-up visit. Before surgery we were unable to differentiate between pain at the thumb CMC and scaphotrapezium-trapezoidal joints. These patients complained of pain during palpation of both joints and during the crank and grind tests.6 The minimum follow-up period was 1 year; it averaged 18 months for patients who did not undergo proximal trapezoid excision and 15 months for patients who did. We used the unpaired t-test to evaluate whether postoperative differences in grip and pinch strengths between the 2 groups were statistically significant.
Results Our assessment of preoperative x-rays showed evidence of scaphotrapezoid arthritis in 12 hands and a normal joint space in 25 (Fig. 1), a prevalence of 32%. During surgery 23 scaphotrapezoid joints were found to be arthritic (fibrillation, fissuring, or exposed subchondral bone) and 14 were not, yielding a 62% prevalence of scaphotrapezoid arthritis (Table 1). The sensitivity of plain x-ray in establishing the diagnosis of scaphotrapezoid arthritis was 44% and specificity was 86% (Fig. 2) (Table 1). In the 23 hands with intraoperative evidence of scaphotrapezium arthritis, a 2-mm resection of the proximal trapezoid was performed. After surgery no patient expressed dissatisfaction with the status of their reconstruction or complained of pain at the base of the thumb. Physical examination demonstrated that every ligament reconstruction was intact and stable and revealed no palpable tenderness at the base of the thumb regardless of whether proximal trapezoid excision had been performed. Comparison of x-rays obtained at the final follow-up visit with those obtained 1 month following surgery showed no loss of arthroplasty space regardless of whether proximal trapezoid excision had been performed.
1222 Tomaino, Vogt, and Weiser / Scaphotrapezoid Arthritis
Figure 1. A posteroanterior stress view demonstrates scaphotrapezoid joint space narrowing (black arrow). Intraoperative assessment confirmed the presence of arthritis.
In the group of patients who underwent proximal trapezoid excision, preoperative and postoperative grip strengths averaged 18 and 24 kg, respectively, reflecting a 39% improvement. In the same group, preoperative and postoperative key pinch strengths averaged 4.5 and 5 kg, respectively, reflecting a 27%
Table 1. Sensitivity, Specificity, and Predictive Values for Diagnosis of Arthritis From Preoperative Radiographs Intraoperative Findings Radiographic Findings
Arthritis Present
Arthritis Absent
Total
Arthritis present Arthritis absent Total
10 13 23
2 12 14
12 25 37
Positive predictive value, 83% (10 of 12); negative predictive value, 48% (12 of 25).
increase. In the group of patients who underwent trapezium excision arthroplasty without proximal trapezoid excision, preoperative and postoperative grip strengths averaged 23 and 30 kg, respectively, reflecting a 36% increase. In the same group of patients, preoperative and postoperative key pinch strengths averaged 6 and 5.5 kg, respectively, reflecting a 50% decline. The differences in postoperative grip and pinch strengths between the 2 groups were not statistically significant. Large standard deviations were observed for pinch strength data; however, a trend was noted which suggested that an increased sample size might have resulted in a statistically significant improvement in the group with proximal trapezoid excision.
Discussion The importance of evaluating the scaphotrapezial joint during treatment of thumb CMC joint arthritis has become less of an issue since complete trapezium
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1223
Figure 2. A posteroanterior stress view demonstrates a normal scaphotrapezoid joint. Intraoperative assessment revealed degenerative changes.
excision has become more routine.6 By contrast, the scaphotrapezoid joint had been ignored during trapezium excision arthroplasty until Irwin et al9 reported incomplete pain relief secondary to unaddressed arthritis at that articulation in 1 patient. Based on favorable pain relief following proximal trapezoid excision, these investigators recommended that this procedure be performed during trapeziometacarpal arthroplasty if preoperative x-rays showed degenerative change. Their report was not intended to establish the risk that unaddressed scaphotrapezoid arthritis might become symptomatic if left untreated and their specific data did not allow such calculation. Rather, in light of the potential for incomplete pain relief, Irwin et al suggested that it was reasonable to assess the joint during surgery and to excise it if it was arthritic. Despite high levels of patient satisfaction after trapezium excision and ligament reconstruction,5,6 it is certainly possible that residual pain could be sec-
ondary to scaphotrapezoid arthritis. The 62% prevalence reported in this study is much higher than the 24% prevalence reported by North and Eaton,8 probably because their study evaluated a random sample of cadaver hands while our sample included only hands with thumb CMC joint disease. We have demonstrated that the preoperative x-ray alone is not overly helpful in assessing the scaphotrapezoid joint; sensitivity is very low, with less than half the cases detected. A relatively high positive predictive value, however, shows that if the x-rays are interpreted as positive for scaphotrapezoid arthritis, then it is likely present. The 95% confidence intervals of these measurements are relatively narrow and do not include 0, indicating that the findings are statistically significant. Based on these results, we recommend not only evaluation of preoperative x-rays, but also intraoperative inspection of the scaphotrapezoid joint during trapezium excision arthroplasty. Our strength data suggest that when proximal trap-
1224 Tomaino, Vogt, and Weiser / Scaphotrapezoid Arthritis
ezoid excision is combined with trapezium excision arthroplasty, insignificant differences in grip strength result. By contrast, our results suggest that this combined procedure may improve restoration of key pinch strength. We think these results should be viewed cautiously, however, in light of the relatively short follow-up period and the small number of patients. Tomaino et al6 have reported that key pinch strength returns more slowly over time than grip6; in that light, the 50% decrease in pinch strength that we observed at an average of 18 months after surgery in the group of patients who did not undergo proximal trapezoid excision is not particularly unusual. The modest improvement that we observed in patients who had proximal trapezoid excision combined with trapezium excision arthroplasty may reflect a weaker preoperative pinch strength, which may have resulted from increased pain secondary to the scaphotrapezoid arthritis itself. Irwin et al9 found the scaphotrapezoid joint to be symptomatic in only 3 of 80 ligament reconstruction tendon interposition patients after surgery. Therefore, the efficacy of proximal trapezoid excision during trapezium excision arthroplasty when scaphotrapezoid arthritis exists may be challenged in view of the fact that we did not specifically examine for scaphotrapezoid pain on preoperative physical examination. We must acknowledge that preoperative assessment of pain at the scaphotrapezoid joint (when CMC and/or scaphotrapezium arthritis is present) is rather difficult. Notwithstanding this limitation, the high prevalence of arthritis at this joint, the risk of persistent or future pain following trapezium excision arthroplasty when scaphotrapezoid arthritis is
not addressed, and the absence of morbidity in this study when proximal trapezoid excision was performed may justify routine intraoperative assessment of this joint and partial trapezoid excision arthritis is present.
References 1. Gervis WH. Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg 1949;31B: 537–539. 2. Carroll RE, Hill NA. Arthrodesis of the carpo-metacarpal joint of the thumb. J Bone Joint Surg 1973;55B:292–294. 3. Menon J, Schoene HR, Hohl JC. Trapeziometacarpal arthritis—results of tendon interpositional arthroplasty. J Hand Surg 1981;6:442– 446. 4. Menon J. Partial trapeziectomy and interpositional arthroplasty for trapeziometacarpal osteoarthritis of the thumb. J Hand Surg 1995;20B:700 –706. 5. Nylen S, Johnson A, Rosenquist AM. Trapeziectomy and ligament reconstruction for osteoarthrosis of the base of the thumb. A prospective study of 100 operations. J Hand Surg 1993;18B:616 – 619. 6. Tomaino MM, Pellegrini VD, Burton RI. Arthroplasty of the basal joint of the thumb: long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg 1995;77A:346 –355. 7. Eaton RG, Glickel SZ, Littler JW. Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb. J Hand Surg 1985;10A:645– 654. 8. North ER, Eaton RG. Degenerative joint disease of the trapezium: a comparative radiographic and anatomic study. J Hand Surg 1983;8:160 –167. 9. Irwin AS, Maffulli N, Chesney RB. Scapho-trapezoid arthritis: a cause of residual pain after arthroplasty of the trapezio-metacarpal joint. J Hand Surg 1995;20B:346 – 352.
Surgical treatment of painful degenerative arthritis at the carpometacarpal (CMC) joint of the thumb has been reported using a number of techniques, including excision arthroplasty,1 arthrodesis,2 resection arthroplasty with tendon interposition,3,4 and resection arthroplasty with ligament reconstruction.5,6 Because satisfactory outcome requires recognition of multiple From the Departments of Orthopaedic Surgery and Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, PA. Received for publication August 27, 1998; accepted in revised form May 25, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Matthew M. Tomaino, MD, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA 15213. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A06-0010$3.00/0
1220 The Journal of Hand Surgery
articular disease, radiographic evaluation of both thumb CMC and scaphotrapezial joints has become a routine part of preoperative evaluation. Indeed, the staging system described by Eaton et al7 emphasizes the importance of diagnosing scaphotrapezium arthritis (stage 4 disease) since hemitrapeziectomy alone will be complicated by residual pain. The staging system, however, does not address the scaphotrapezoid joint, yet North and Eaton8 identified scaphotrapezoid arthritis in 16 of 68 cadaver hands (24%). The potential for both over- and under-interpretation of pantrapezial arthritis based on x-ray alone has resulted in routine intraoperative assessment of the scaphotrapezial joint by most hand surgeons, particularly when electing between partial and complete trapezium excision. In the setting of thumb CMC
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1221
joint arthritis, however, similar attention to the scaphotrapezoid joint had not been emphasized until recently, when Irwin et al9 reported that untreated arthritis at the scaphotrapezoid joint resulted in incomplete pain relief following trapezium excision, ligament reconstruction, and tendon interposition in 1 patient. Secondary proximal trapezoid excision 6 months later provided complete pain relief. These investigators further reported that in 3 subsequent thumbs with scaphotrapezoid and thumb CMC joint arthritis, both trapezium excision arthroplasty and proximal trapezoid excision were performed, with excellent results. Our objectives in this study were 3-fold: to establish the prevalence of scaphotrapezoid arthritis in hands undergoing trapezium excision arthroplasty as treatment for thumb CMC joint arthritis, to determine the sensitivity and specificity of preoperative x-ray films, and to identify any morbidity associated with concomitant proximal trapezoid excision during trapezium excision arthroplasty when degenerative changes were noted during surgery at that joint.
Materials and Methods Between June 1995 and May 1998, ligament reconstruction tendon interposition arthroplasty was performed by a single surgeon (M.M.T.) using the technique described by Tomaino et al6 on 37 patients who presented with painful arthritis of the thumb CMC joint. The average age of the 6 men and 31 women was 60 years (range, 43– 80 years). Preoperative x-ray series, including posteroanterior stress and lateral and pronated anteroposterior (Robert’s) views, were obtained for each patient and evaluated for evidence of scaphotrapezoid joint space narrowing, subchondral sclerosis, or cyst formation. The scaphotrapezoid joint was inspected during surgery following trapezium excision by pulling on the index and long fingers to distract the articulation. When cartilage fibrillation, fissuring, or exposed subchondral bone was present, partial excision of the proximal trapezoid was performed so that with traction released from the fingers, there was no contact between trapezoid and scaphoid. This amounted to a resection equalling approximately 2 mm. Radiographic and intraoperative findings were compared to establish the prevalence of scaphotrapezoid arthritis by each method. The sensitivity and specificity of the preoperative x-rays in making the diagnosis were calculated using the surgeon’s intraoperative findings as the gold standard. The 95%
confidence interval was calculated using the formula W 5 = ((4Z2p(12p))/N), where W represents the width of the confidence interval. Clinical evaluation included subjective assessment of residual pain at the base of the thumb and in the region of the scaphotrapezoid joint and was also based on physical examination. We also measured pinch and grip strengths and compared them with preoperative values; we also compared the arthroplasty space measured between the base of the thumb metacarpal and the scaphoid using posteroanterior radiographs obtained 1 month following surgery and at the final follow-up visit. Before surgery we were unable to differentiate between pain at the thumb CMC and scaphotrapezium-trapezoidal joints. These patients complained of pain during palpation of both joints and during the crank and grind tests.6 The minimum follow-up period was 1 year; it averaged 18 months for patients who did not undergo proximal trapezoid excision and 15 months for patients who did. We used the unpaired t-test to evaluate whether postoperative differences in grip and pinch strengths between the 2 groups were statistically significant.
Results Our assessment of preoperative x-rays showed evidence of scaphotrapezoid arthritis in 12 hands and a normal joint space in 25 (Fig. 1), a prevalence of 32%. During surgery 23 scaphotrapezoid joints were found to be arthritic (fibrillation, fissuring, or exposed subchondral bone) and 14 were not, yielding a 62% prevalence of scaphotrapezoid arthritis (Table 1). The sensitivity of plain x-ray in establishing the diagnosis of scaphotrapezoid arthritis was 44% and specificity was 86% (Fig. 2) (Table 1). In the 23 hands with intraoperative evidence of scaphotrapezium arthritis, a 2-mm resection of the proximal trapezoid was performed. After surgery no patient expressed dissatisfaction with the status of their reconstruction or complained of pain at the base of the thumb. Physical examination demonstrated that every ligament reconstruction was intact and stable and revealed no palpable tenderness at the base of the thumb regardless of whether proximal trapezoid excision had been performed. Comparison of x-rays obtained at the final follow-up visit with those obtained 1 month following surgery showed no loss of arthroplasty space regardless of whether proximal trapezoid excision had been performed.
1222 Tomaino, Vogt, and Weiser / Scaphotrapezoid Arthritis
Figure 1. A posteroanterior stress view demonstrates scaphotrapezoid joint space narrowing (black arrow). Intraoperative assessment confirmed the presence of arthritis.
In the group of patients who underwent proximal trapezoid excision, preoperative and postoperative grip strengths averaged 18 and 24 kg, respectively, reflecting a 39% improvement. In the same group, preoperative and postoperative key pinch strengths averaged 4.5 and 5 kg, respectively, reflecting a 27%
Table 1. Sensitivity, Specificity, and Predictive Values for Diagnosis of Arthritis From Preoperative Radiographs Intraoperative Findings Radiographic Findings
Arthritis Present
Arthritis Absent
Total
Arthritis present Arthritis absent Total
10 13 23
2 12 14
12 25 37
Positive predictive value, 83% (10 of 12); negative predictive value, 48% (12 of 25).
increase. In the group of patients who underwent trapezium excision arthroplasty without proximal trapezoid excision, preoperative and postoperative grip strengths averaged 23 and 30 kg, respectively, reflecting a 36% increase. In the same group of patients, preoperative and postoperative key pinch strengths averaged 6 and 5.5 kg, respectively, reflecting a 50% decline. The differences in postoperative grip and pinch strengths between the 2 groups were not statistically significant. Large standard deviations were observed for pinch strength data; however, a trend was noted which suggested that an increased sample size might have resulted in a statistically significant improvement in the group with proximal trapezoid excision.
Discussion The importance of evaluating the scaphotrapezial joint during treatment of thumb CMC joint arthritis has become less of an issue since complete trapezium
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1223
Figure 2. A posteroanterior stress view demonstrates a normal scaphotrapezoid joint. Intraoperative assessment revealed degenerative changes.
excision has become more routine.6 By contrast, the scaphotrapezoid joint had been ignored during trapezium excision arthroplasty until Irwin et al9 reported incomplete pain relief secondary to unaddressed arthritis at that articulation in 1 patient. Based on favorable pain relief following proximal trapezoid excision, these investigators recommended that this procedure be performed during trapeziometacarpal arthroplasty if preoperative x-rays showed degenerative change. Their report was not intended to establish the risk that unaddressed scaphotrapezoid arthritis might become symptomatic if left untreated and their specific data did not allow such calculation. Rather, in light of the potential for incomplete pain relief, Irwin et al suggested that it was reasonable to assess the joint during surgery and to excise it if it was arthritic. Despite high levels of patient satisfaction after trapezium excision and ligament reconstruction,5,6 it is certainly possible that residual pain could be sec-
ondary to scaphotrapezoid arthritis. The 62% prevalence reported in this study is much higher than the 24% prevalence reported by North and Eaton,8 probably because their study evaluated a random sample of cadaver hands while our sample included only hands with thumb CMC joint disease. We have demonstrated that the preoperative x-ray alone is not overly helpful in assessing the scaphotrapezoid joint; sensitivity is very low, with less than half the cases detected. A relatively high positive predictive value, however, shows that if the x-rays are interpreted as positive for scaphotrapezoid arthritis, then it is likely present. The 95% confidence intervals of these measurements are relatively narrow and do not include 0, indicating that the findings are statistically significant. Based on these results, we recommend not only evaluation of preoperative x-rays, but also intraoperative inspection of the scaphotrapezoid joint during trapezium excision arthroplasty. Our strength data suggest that when proximal trap-
1224 Tomaino, Vogt, and Weiser / Scaphotrapezoid Arthritis
ezoid excision is combined with trapezium excision arthroplasty, insignificant differences in grip strength result. By contrast, our results suggest that this combined procedure may improve restoration of key pinch strength. We think these results should be viewed cautiously, however, in light of the relatively short follow-up period and the small number of patients. Tomaino et al6 have reported that key pinch strength returns more slowly over time than grip6; in that light, the 50% decrease in pinch strength that we observed at an average of 18 months after surgery in the group of patients who did not undergo proximal trapezoid excision is not particularly unusual. The modest improvement that we observed in patients who had proximal trapezoid excision combined with trapezium excision arthroplasty may reflect a weaker preoperative pinch strength, which may have resulted from increased pain secondary to the scaphotrapezoid arthritis itself. Irwin et al9 found the scaphotrapezoid joint to be symptomatic in only 3 of 80 ligament reconstruction tendon interposition patients after surgery. Therefore, the efficacy of proximal trapezoid excision during trapezium excision arthroplasty when scaphotrapezoid arthritis exists may be challenged in view of the fact that we did not specifically examine for scaphotrapezoid pain on preoperative physical examination. We must acknowledge that preoperative assessment of pain at the scaphotrapezoid joint (when CMC and/or scaphotrapezium arthritis is present) is rather difficult. Notwithstanding this limitation, the high prevalence of arthritis at this joint, the risk of persistent or future pain following trapezium excision arthroplasty when scaphotrapezoid arthritis is
not addressed, and the absence of morbidity in this study when proximal trapezoid excision was performed may justify routine intraoperative assessment of this joint and partial trapezoid excision arthritis is present.
References 1. Gervis WH. Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg 1949;31B: 537–539. 2. Carroll RE, Hill NA. Arthrodesis of the carpo-metacarpal joint of the thumb. J Bone Joint Surg 1973;55B:292–294. 3. Menon J, Schoene HR, Hohl JC. Trapeziometacarpal arthritis—results of tendon interpositional arthroplasty. J Hand Surg 1981;6:442– 446. 4. Menon J. Partial trapeziectomy and interpositional arthroplasty for trapeziometacarpal osteoarthritis of the thumb. J Hand Surg 1995;20B:700 –706. 5. Nylen S, Johnson A, Rosenquist AM. Trapeziectomy and ligament reconstruction for osteoarthrosis of the base of the thumb. A prospective study of 100 operations. J Hand Surg 1993;18B:616 – 619. 6. Tomaino MM, Pellegrini VD, Burton RI. Arthroplasty of the basal joint of the thumb: long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg 1995;77A:346 –355. 7. Eaton RG, Glickel SZ, Littler JW. Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb. J Hand Surg 1985;10A:645– 654. 8. North ER, Eaton RG. Degenerative joint disease of the trapezium: a comparative radiographic and anatomic study. J Hand Surg 1983;8:160 –167. 9. Irwin AS, Maffulli N, Chesney RB. Scapho-trapezoid arthritis: a cause of residual pain after arthroplasty of the trapezio-metacarpal joint. J Hand Surg 1995;20B:346 – 352.