Advances in the Surgical Treatment of Basal Thumb Arthritis and Instability

Advances in the Surgical Treatment of Basal
Thumb Arthritis and Instability
Suture Button Suspensionplasty Using the Instratek CMC Cable FIX
A Case Report
Andrew K. Lee, M.D., Mark Khorsandi, D.O., Jackson Ombaba, M.D., Randolph Lopez, M.D.,
Baher Maximos, M.D.
The treatment for painful basal thumb osteoar-
thritis has been the focus of many hand surgeons
due to the condition’s relatively common incidence
and debilitating symptoms. Disagreement still
exists today about which surgical treatment is
optimal; however, trapezium excision and various
types of ligamentous reconstruction (i.e., LRTI)
seems to be the preferred treatment option. In the
advancing field of minimally invasive surgery, many
surgeons are interested in faster and less intrusive
ways to obtain their desired results. This paper
describes the procedure and the outcome of a
patient who had undergone a trapezium excision
and ligament reconstruction using the CMC Cable
FIX™ (Instratek Inc.®, Houston, TX) which is a
minimally invasive inter-metacarpal suture button
suspensionplasty system.
joint, sclerosis of the subchondral bone with osteophyte formation and mild radial subluxation of the
1st metacarpal base (Figure 1). The 1st web space
angle was 24 degrees. A diagnosis of osteoarthritis,
Eaton stage III, was assessed. Her persisting symptoms despite conservative management indicated
that a trapeziectomy and ligament reconstruction
were warranted. We discussed with the patient the
option of using the CMC Cable FIX ™ for ligament
reconstruction, and she agreed to proceed.
L.H. is a 59-year-old female who had been
complaining of left thumb pain for about one year.
She had difficulty opening doors, turning a key to
start her car, and buttoning shirts. The physical
examination revealed swelling and tenderness at the
thumb CMC joint, and a positive grind test was
confirmed. The patient had thumb abduction of 28
degrees and demonstrated a grip and pinch strength
of 28.7 lbs. and 7.3 lbs., respectively. The preoperative DASH score* was 37.5. The radiograph
demonstrated narrowing of the trapeziometacarpal
Figure 1
Preoperative Radiograph
nder tourniquet control, we first performed a
standard open trapeziectomy. The entry point for
the guide wire was then assessed by palpating the
base of the 2nd metacarpal (Figure 2). A 7-mm
incision was then made at the dorsal ulnar base. We
carried out blunt dissection with Littler scissors to
identify the extensor tendon, which was retracted.
The dorsal ulnar cortex of the 2nd metacarpal was
then exposed.
The tip of the supplied 1.3-mm k-wire was placed
at the ulnar side of the proximal metaphysis and at
the center of the metacarpal with respect to the
sagittal plane. Pinning in the direction of the 2nd
metacarpal to the 1st metacarpal was performed.
(This facilitates a central drill hole placement at the
2nd metacarpal). The position of the k-wire was
confirmed with the C-arm radiographs and under
direct vision (Figure 3). The base of the thumb was
then held in a reduced position, and the k-wire was
drilled to the midpoint of the 1st metacarpal base.
(Ideally, the exit point should be about 5 mm to 1
cm volar to the metacarpal ridge, where the thenar
muscles begin, so that the round button can be
buried underneath the thenar muscles. This would
help avoid any implant tenderness). In the AP
plane, the wire was aimed at the base of the thumb
metacarpal approximately 5 to 10 mm distal to the
joint surface. The k-wire was passed radially outside
the skin about 3 cm. Good positioning of the
k-wire was confirmed by fluoroscopy in both AP
and lateral views. A 7-mm incision was made at the
exit point on the k-wire and blunt dissection was
performed to expose the radial cortex of the 1st
metacarpal. Reaming was then performed utilizing
the 2.7 cannulated drill bit from the 2nd metacarpal to the 1st metacarpal under fluoroscopic control
(Figure 4). With the cannulated drill bit in place,
the k-wire was removed and the tip of the guide
wire suture assembly was inserted through the
cannulated drill bit so that the tip was well ulnar to
the 2nd metacarpal (Figure 5).
Figure 2
Palpating the base of the 2nd metacarpal for dorsal ulnar
entry point of the guidewire
Figure 3
Radiograph confirmation of the k-wire position
The drill bit was then retrograded ulnarly, leaving
the implant assembly within the bone tunnels. The
guide wire suture assembly was gently pulled
through both bone tunnels, exiting ulnarly of the
Figure 4
Overdrilling the k-wire leaving the drill bit in position
metacarpal until the 2-hole round plate was seated
on the 1st metacarpal cortex. Holding the oblong
plate with a hemostat and guide wire with a hand,
the oblong plate was detached from the guide wire
(Figure 6). The guide wire was set aside for disposal.
The two strands of suture were tensioned gradually
until the oblong plate was firmly attached to the
2nd metacarpal cortex. (This is best accomplished
by pulling each strand independently in small increments until the oblong plate is seated firmly against
the cortex of the 2nd metacarpal, deep to the extensor tendon). Good positioning of the round and
oblong plates was confirmed. While the thumb was
held in an abducted and reduced position, 3
surgeon’s knots were tied (Figure 7). (This
technique avoids over-tightening of the cable,
which can result in loss of thumb abduction and
impingement of the two metacarpals). The sutures
were then cut and buried. The wounds were
irrigated and then closed with 5-0 nylon simple
sutures. A sterile dressing and a protective thumb
spica splint were then applied. The additional time
required for the CMC Cable FIX™ procedure was 9
Figure 5
Inserting implant guidewire into cannulated drill bit
he patient returned to our office for the first
postoperative follow-up at 10 days. We removed
the sutures and started occupational therapy in
order to initiate early range-of-motion and scar
management. A thumb spica splint was used
off-and-on for the patient’s comfort. At the 4-week
follow-up, she was using the hand quite well without significant pain. The patient returned to work
at 2 weeks post-op. At the 8-week follow-up, she
had improved her DASH score to 20 and by 12
weeks, her grip and pinch strength normalized to
29 lbs. and 7.9 lbs., respectively. By 20 weeks, her
grip and pinch strength improved to 32 lbs. and 9.8
lbs., respectively, with a DASH-score of 4. The
thumb abduction improved to 44 degrees. The
radiographic examination at the 20-week follow-up
showed a 1st webspace angle of 36 degrees with no
evidence of subsidence of the 1st metacarpal or
instability (Figure 8). Her Basal Joint Arthroplasty
Outcome Survey (BJAOS) score** was 16 out of 16
at 20-week follow-up.
Figure 6
Detaching oblong plate from the guidewire
Figure 7
Fixation of CMC Cable FIX with ulnar knot position
require intervention (¹). The main cause of disease is
thought to be attenuation of the palmar beak
ligament, which is one of the primary basal thumb
stabilizers, resulting in increased metacarpal translation and shear force on the trapezium articular
surface (²). Non-operative treatment is considered
first; however, surgical intervention is often needed.
The principal surgical intervention includes various
types of arthroplasty and in some cases arthrodesis
for younger active patients and those patient populations requiring a strong grip for activities (¹,³). A
number of implants have been devised for thumb
joint arthroplasty, including silicone and metallic
implants, but they are plagued by numerous
complications, including subluxation, subsidence,
implant wear, and several other reported complications in the literature (4,5). Although various surgical
techniques are employed based on the surgeon’s
training, expertise, and preferences, none has been
proved to be superior to the others (6).
Figure 8
Post Operative Radiograph
The traditional trapezium excision arthroplasty
with ligament reconstruction, tendon interposition
(LRTI), has been a seemingly standard procedure
for advanced-stage osteoarthritis (7). This procedure
seeks to recreate the anterior oblique ligament and
the intermetacarpal ligament, which are important
stabilizers of the thumb. The importance of a
primary stabilizer and the weakness and instability
after trapeziectomy alone have led to the recommendation of ligament reconstruction in both
early- and late-stage osteoarthritis (8,9,¹0). Although
the need for ligament reconstruction has been questioned (¹¹,¹²), a recent ASSH survey showed 68% of
the hand surgeons still feel that ligament reconstruction is important and have included it in their
protocol (¹³).
Table 1. Preoperative and Postoperative
Physical & Radiographic
Follow Up
Follow Up
Thumb Abduction
28 deg
35 deg
44 deg
Grip Strength
28.7 lbs
29 lbs
32 lbs
Pinch Strength
7.3 lbs
7.9 lbs
9.8 lbs
24 deg
30 deg
36 deg
DASH Score
1st Web Space Angle
CMC Cable FIX achieves the goal as the stablizing
component of traditional ligamentous reconstruction. However, this minimally invasive procedure
with a brief learning curve recreates the critical
anatomical stabilizing component without the
many complex procedures and potential long-term
complications of the traditional LRTI (Table 2).
Basal thumb arthritis can be very debilitating,
because it may cause severe pain during the activities of daily living. It is the second most common
joint affected in the hand and the most common to
The advantages of this system compared to traditional LRTI include that it avoids the need for an
Table 2. Advantages of the CMC Cable FIX Compared to LRTI
Minimally invasive (Percutaneous)
Require multiple incisions
Less OR time (Avg. 11 min.)
Longer operative time
No need for immobilization
Postoperative immobilization
No donor site morbidity or scarring
Sacrifice a functioning tendon
No altered biomechanics of the wrist
Altered biomechanics of the wrist
Brief learning curve
Technically challenging
Possibly faster recovery
Higher complication rate
autograft harvest, which can alter the wrist
mechanics, and that it can be performed percutaneously. The CMC Cable FIX can be combined with
any type of trapezium arthroplasty, such as total or
partial trapeziectomy, with or without interpositional graft, and open or arthroscopic trapeziectomies. Another advantage is the reduced operative
time (9 minutes in this case) compared to LRTI,
which is typically an additional 30 minutes (¹4).
This minimally invasive CMC Cable FIX proce-
dure may provide improved outcomes by achieving
anatomical correction of basal thumb instability
without the complex procedures and potential
complications of traditional LRTI. This procedure
can reduce operative time and morbidity, and may
facilitate a quicker recovery than the traditional basal
thumb ligamentous reconstruction techniques. We
plan to conduct a randomized comparative study to
confirm these results.
This patient had the early range-of-motion protocol at 2 weeks since there was no need to immobilize the thumb for tendon or tendon-to-bone
healing. The thumb abduction improved from 28
degrees to 35 degrees at 12 weeks. She regained grip
and pinch strength from 27.3 lbs. to 29 lbs. and 7.3
lbs. to 7.9 lbs. at 12 weeks and further improved to
32 lbs. and 9.8 lbs at 20 weeks, respectively. Her
functional capability was improved as reflected on
her DASH score (from 37.5 to 20 at 12 weeks and
4 at 20 weeks). She demonstrated a relatively early
return to work of 2 weeks. The patient was very
pleased with the outcome shown by the maximum
basal joint arthroplasty survey score.
* DASH stands for Disability of the Arm, Shoulder and
Hand. It is a 30-item, self-report questionnaire designed to
measure physical function and symptoms. A score of 0 is
normal and 100 is complete disability.
** BJAOS score is a patient satisfaction scoring system. 0 is
total dissatisfaction and 16 is complete satisfaction.
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