The technique of ligament suspension after trapeziectomy described in this paper by Scheker and Boland represents considerable sophistication of the original concept of “ligament reconstruction—tendon interposition” (LRTI) described by Burton and Pellegrini [1]. The elaboration of the routing of the tendon slip of FCR is ingenious, and has the purpose of providing more direct ligamentous control of the metacarpal base to prevent both dorsal subluxation and proximal migration of the metacarpal, and a cushion between the first and second metacarpal bases. There is no doubt that the procedure is technically more demanding. After more than 200 operations it is not surprising that a master-surgeon such as Dr Scheker makes the operation appear simple, but any surgeon planning to embark on this procedure in preference to more simple versions of the operation should be prepared for some difficulty in matching Dr Scheker’s expertise, and his results. It would certainly be advisable for a less experienced surgeon to observe the operation in the hands of an experienced exponent. Dr Scheker’s results, taken together with the large size of the series, are impressive, and compare well with those reported by Tomaino et al. [2] in a small series, although the latter noted some fall in power over 9 years compared to 6, and there is some confusion in their paper about the preoperative and postoperative key pinch measurements which make direct comparison difficult. The opposite approach to Dr Scheker’s is to simplify rather than elaborate the reconstruction, and Davis et al. [3] have shown no difference between their results with or without LRTI. Long-term results are not yet available. The results in terms of pain relief are not obviously different from Scheker and Boland’s, although the methods of evaluation are not easily comparable. Davis et al. showed much less improvement in strength, so the precise method of soft tissue reconstruction may be the important factor. In particular, Davis et al. question the importance of preventing proximal migration of the metacarpal, and there may be grounds to speculate on the ability of a ligament reconstruction, however strong to start with, to prevent gradual migration over the long term. All series of trapeziectomy will have a small proportion of disappointing results, and for some the reason may be amenable to prevention; persistent scaphotrapezoid arthritis can be anticipated by joint excision, and first metacarpal adduction deformity avoided by maintaining control of a hypermobile first MP joint, either with a temporary k-wire during the period of splintage, or by MP fusion. Any surgeon who feels that he or she can master Scheker and Boland’s technique can be confident that the results will be among the best achievable, but those planning to change from a method that works for them should be aware of the increased complexity and technical demands of this operation.