Can We Really Say That No Patients Benefit from Ligament Reconstruction Tendon Interposition?

Abstract

Sir:FigureWe read with great interest the article entitled “Comparison of Trapeziectomy and Trapeziectomy with Ligament Reconstruction and Tendon Interposition: A Systematic Literature Review.”1 The article is clear and well designed, incorporating all of the major articles on this controversial topic in hand surgery. Although the authors conclude that “neither procedure produced greater benefit in terms of outcomes investigated,” this is still based on evidence without adequate power or sufficient follow-up. Indeed, patients were followed for an average of only 3 years in their comprehensive review. The insufficient power in assessing outcomes such as pain relief; Disabilities of the Arm, Shoulder and Hand questionnaire score; and grip strength are noted as limitations to the study in their discussion. Indeed, they have attempted to address and improve on the power in this study compared with previous reviews, but the data are still prone to a type II statistical error. These design flaws in the published literature make the surgeon reconsider whether it is the best option to perform trapeziectomy alone on such patients with basal thumb osteoarthritis. Although this is personal experience and more of a hypothesis that still needs to be addressed, we feel using a technique similar to an Eaton-Littler beak ligament reconstruction confers more stability to the thumb and addresses collapse in the long term. Importantly, it also allows the patient by means of the tenodesis effect to dynamically abduct and flex the thumb when the hand is placed into a prehensile position. One prospective study of 56 patients by De Smet et al. compared trapeziectomy with or without ligament reconstruction and tendon interposition; of significance, they noted that trapezial height was preserved much better in the ligament reconstruction and tendon interposition group, and the remaining trapezial height did correlate with key pinch force.2 Pelligrini3 identified that the degeneration of the anterior oblique ligament results in increased joint laxity and dorsal translation of the metacarpal on the trapezium when the thumb is in the position of lateral pinch. Ligament reconstruction and tendon interposition address anterior oblique reconstruction for carpometacarpal joint stability, whereas the tendon interposition addresses axial shortening.4 The volar beak ligament stabilizes the trapeziometacarpal joint; therefore, its reconstruction is important in reestablishing thumb stability.4 The senior author (R.J.) in our department harvests 50 percent of the flexor carpi radialis tendon, passing it through the base of the first metacarpal as a dynamic sling to stabilize the patient's thumb (Figs. 1 and 2).Fig. 1: The senior author's technique for ligament reconstruction and tendon interposition is shown. Fifty percent of the flexor carpi radialis tendon passes through the first metacarpal base, around the abductor pollicis brevis tendon, and back around the flexor carpi radialis tendon. Finally, the flexor carpi radialis tendon is anchored at the base of the first metacarpal.Fig. 2: A tendon interposition is finally constructed with the remaining flexor carpi radialis tendon.There is justification for performing trapeziectomy alone on elderly patients with fewer functional demands. However, there is a strong argument for ligament reconstruction and tendon interposition in the younger patient who remains active and at work. Longer term prospective studies with good follow-up comparing trapeziectomy with or without ligament reconstruction and tendon interposition are needed for more robust evidence. A large multicenter study is needed to compare trapeziectomy with or without ligament reconstruction and tendon interposition to determine which is superior, not just overall but in different patient groups. This question could not be answered in this review. We therefore believe it is more prudent to perform trapeziectomy with ligament reconstruction and tendon interposition to avoid the possibility of poor outcomes in the long term. Dariush Nikkhah, M.R.C.S. Jeremy Rodrigues, M.R.C.S. Plastic Surgery, Bradford Royal Infirmary Daniel B. Saleh, M.R.C.S. Plastic Surgery, Pinderfields General Royal Infirmary, Wakefield, United Kingdom Russell Jeffers, F.R.C.S. Bradford Royal Infirmary, Yorkshire, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.