DEFINITION

The trapeziometacarpal joint of the thumb is frequently affected by osteoarthritis, second in frequency only to the distal interphalangeal joint, but often more disabling due to pain and weakness of grip and pinch strength.

The choice of surgical management for symptomatic thumb carpometacarpal (CMC) joint arthrosis varies according to patient age, medical comorbidities, functional demands, and radiographic staging.

Arthrodesis of the CMC joint was initially described by Muller13 in 1949. Despite the popularity of arthroplasty at this joint, arthrodesis can also provide excellent functional outcomes.

Arthrodesis is ideal for the younger patient with moderate to advanced thumb CMC degeneration (arthritic or posttraumatic) who anticipates higher load pinch and grip requirements.9

 

 

ANATOMY

 

The thumb CMC joint is a biconcave-convex (saddle) joint, permitting motion in three planes: flexion-extension, abduction-adduction, and pronation-supination. These multiplanar motions allow for power grip, power pinch, opposition, and delicate precision pinch.

 

Provided minimal osseous constraints, ligamentous structures are largely responsible for stabilizing the thumb CMC joint.

 

Sixteen ligaments have been described around the thumb CMC joint.

 

 

Seven are primary stabilizers of the thumb CMC joint:

 

 

 

Superficial anterior oblique ligament (sAOL) and deep anterior oblique ligament (dAOL) Dorsoradial

 

 

 

 

Posterior oblique Ulnar collateral Intermetacarpal Dorsal intermetacarpal

 

The remainder stabilize the trapezium, providing a stable foundation for the thumb.2

 

PATHOGENESIS

 

The pathogenesis of CMC joint arthrosis is multifactorial, involving biochemical,16 biomechanical, and genetic influences.

 

Osteoarthritis of the thumb CMC joint occurs more commonly in females compared to males.

 

Arthritic degeneration begins on the palmar aspect of the thumb metacarpal and trapezium. This may be secondary to compression in this area during pinch.

 

The dorsal ligament complex (dorsoradial and posterior oblique ligaments) is the thickest, strongest, and most important ligament stabilizing the thumb CMC joint. It prevents both the thumb metacarpal volar beak from disengaging from the volar recess in the trapezium as well as dorsal subluxation of the metacarpal base during power grip or pinch. Although the anterior (palmar) oblique ligament, or so-called beak ligament, was thought to be the most important stabilizing ligament of the thumb, multiple studies have suggested the dorsal ligament

complex is the most critical stabilizer.3,19,22 The volar beak ligament is completely lax in opposition and taut only in the hitchhiker position.

 

Arthritis begins secondary to the compressive, rotational shear forces during power pinch and grip in the volar recess of the trapezium near to the volar beak of the metacarpal. After many years, the volar beak begins to

wear down and instability develops during the screw-home-torque rotation seen in opposition.7 With progression of disease, osteophytes develop and eburnation progresses throughout the entire joint surface.

 

Osteoarthrosis can also develop from disruption of the articular cartilage. Any fracture involving the articular surfaces (most commonly the base of the thumb metacarpal) will predispose to, or accelerate the development of, arthrosis. This is the result of direct cartilage injury at the time of the accident or over time secondary to articular incongruity or articular surface irregularity.

 

 

Anatomic restoration of the joint surface can minimize this progression but not eliminate it completely.

 

NATURAL HISTORY

 

Arthrosis of the thumb CMC joint begins along the palmar aspect of the metacarpal secondary to the compressive rotational shear and dorsal subluxating forces during pinch and grip. These forces can approach

164 kg during power grasp at the CMC joint.4

 

The entire base of the metacarpal and the distal trapezium experience eburnation of the cartilage, which progresses to develop osteophytes.

 

As arthritis progresses, the thumb metacarpal subluxates dorsally and radially. The metacarpal adducts and flexes resulting in compensatory metacarpophalangeal (MCP) joint hyperextension. This hyperextension effectively brings the thumb pulp out of the palm to allow for grasp.

 

In fulminant arthritis, the entire surface of the trapezium becomes involved, resulting in degeneration between the proximal trapezium and the distal scaphoid.

 

Arthrosis can involve all the trapezial articulations as well as the scaphotrapezoidal joint.15,21

 

 

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PATIENT HISTORY AND PHYSICAL FINDINGS

 

Thumb CMC joint arthrosis will often present with pain at the base of the metacarpal.

 

 

The pain will be exacerbated with activities that load the thumb metacarpal base, such as turning a doorknob, twisting a lid off a jar, or turning a key.

 

Pain at rest may or may not be present.

 

This classic deep-seated pain at the base of the thenar muscles must be distinguished from de Quervain tendonitis, tendonitis of the flexor carpi radialis, radioscaphoid degeneration, and trigger thumb.

 

Symptoms do not always correlate with the clinical or radiographic appearance. A patient may have advanced clinical and radiographic disease with minimal symptoms. Conversely, a patient may have significant symptoms with minimal radiographic changes and no clinical deformity.

 

Physical examination of the patient with advanced disease reveals deformity.

 

 

The thumb metacarpal base subluxates in a dorsal direction and the metacarpal becomes fixed in adduction and flexion. This manifests as a metacarpal prominence at the CMC joint with decreased ability to abduct the thumb away from the palm.

 

In an effort to compensate for this limitation, the MCP joint will often hyperextend, creating a zigzag deformity.

 

Asking the patient to place one finger on the point that is most symptomatic helps localize the point of maximal tenderness to the CMC joint or another area.

 

CMC grind test: Reproduction of symptoms while axially loading the thumb and circumducting the thumb metacarpal confirms the CMC joint as a site of disease.

 

Finkelstein maneuver: Maximal tenderness over the radial styloid during ulnar deviation of the hand with a thumb in the fist suggests that de Quervain tendonitis may be a greater source of symptoms.

 

Phalen test: Reproduction of symptoms during wrist flexion indicates carpal tunnel syndrome as a more likely etiology.

 

Carpal tunnel compression test (Durkan test): Reproduction of symptoms with compression over the carpal tunnel indicates carpal tunnel syndrome as a more likely etiology of symptoms.

 

Trigger evaluation: Reproduction of pain, triggering, or locking of the thumb at the interphalangeal joint with activity flexion indicates trigger thumb as an etiology.

 

Allen test: The radial and ulnar arteries are compressed and the hand is exsanguinated. The ulnar artery is released and the circulation of the hand is assessed. The process is repeated, releasing the radial artery while the ulnar artery is occluded. Surgical procedures often involve mobilization of the radial artery in the snuffbox. Damage to this artery will require reconstruction if the ulnar artery cannot compensate.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Plain radiographs are the imaging modality of choice for evaluation of thumb CMC joint arthrosis (FIG 1).

 

 

These include posteroanterior, pronated anteroposterior (AP) (Robert view), lateral, and Bett views.

 

 

Eaton and Littler6 have described a radiographic staging system that is commonly used.

 

 

Stage I: normal-appearing or widened joint space secondary to synovitis

 

 

 

FIG 1 • Posteroanterior (PA) radiograph of wrist showing osteoarthritis of the thumb CMC joint.

 

 

 

Stage II: joint space narrowing and osteophyte formation smaller than 2 mm Stage III: joint space narrowing with osteophytes larger than 2 mm

 

Stage IV: stage III appearance with the addition of narrowing or osteophytes in the scaphotrapezial joint

 

The scaphotrapezoid joint is not specifically addressed in this system and may be difficult to assess radiographically, but this joint should always be assessed at the time of surgery because it may be a source of

continued pain.21

 

 

DIFFERENTIAL DIAGNOSIS

Thumb CMC arthrosis De Quervain disease

Trigger thumb or stenosing tenosynovitis

 

Flexor carpi radialis tendonitis

Scaphoid pathology (fracture, nonunion, avascular necrosis) Radioscaphoid arthrosis

Scaphotrapeziotrapezoid (STT) arthrosis Carpal tunnel syndrome

Intramuscular (thenar) processes, such as vascular or tumor etiologies

 

 

NONOPERATIVE MANAGEMENT

 

Most patients with symptomatic thumb CMC joint arthrosis benefit from a trial of conservative therapy, which may include rest, oral anti-inflammatory medication, intra-articular corticosteroid injection, thenar isometric

strengthening exercises, and splinting.1

 

 

Forty percent of patients can have significant and sustained relief of pain with steroid injection and splinting for

 

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3 weeks regardless of radiographic staging. If separated by Eaton's staging, over 80% with stage I can have sustained relief for over 18 months compared to approximately 33% with stage II or III or less than 25% with

stage IV.5

 

Although nonoperative treatment does not eliminate the problem or alter the underlying disease process, it often reduces symptoms and may either negate the need for surgery or at least allow for delay of surgical intervention. During this time, patients are reassured that continued activity is not expected to change the disease course and that despite radiographic progression, the arthritic pain may at times improve over time.

 

SURGICAL MANAGEMENT

 

The indication for surgical intervention for symptomatic thumb basilar joint arthrosis is pain and weakness not sufficiently responsive to conservative treatments.

 

There are multiple procedures used to treat symptomatic CMC thumb arthritis, none of which have proven superiority.

 

The ideal patients for thumb CMC arthrodesis are younger, active patients who need to maintain power grip and pinch and regularly place high force demand on their thumb. These are typically younger manual laborers with stage II or III disease. However, arthrodesis can provide symptomatic relief in older patients with stage II or III disease.

 

The condition of joints around the thumb CMC joint should be considered, as pathology may relatively contraindicate CMC arthrodesis.

 

 

STT arthritis also contraindicates thumb CMC arthrodesis as the patient would be expected to experience continued symptoms from this joint postoperatively.9

 

Thumb MCP hyperextension or arthrosis may require MCP arthrodesis which would markedly limit the thumb if the CMC joint is also fused.9

Preoperative Planning

 

The patient should be made aware of the decreased mobility, inability to flatten the palm on the table (index

MCP joint typically 1 to 2 cm off table when attempting to flatten palm), potential difficulty in placing the hand in tight confined spaces, and possible difficulty placing the hand in a glove.9

 

Patients also should understand the risks of nonunion, prolonged postoperative casting, potential for hardware complications, and potential for developing degenerative changes at adjacent joints.

 

Positioning

 

The procedure is performed under regional or general anesthesia with the use of a pneumatic tourniquet on either the proximal forearm or upper arm.

 

The patient is supine with the arm extended on an arm board.

 

Approach

 

We prefer a dorsal incision be oriented in a longitudinal fashion, along the ulnar aspect of the first dorsal compartment tendons.

 

Alternatively, the procedure can be performed through a Wagner-type incision, along the junction of the glabrous and dorsal skin, or through a dorsal incision.

 

TECHNIQUE

• Thumb Carpometacarpal (Trapeziometacarpal) Arthrodesis

Incision and Dissection

 

Make a dorsal longitudinal incision along the ulnar aspect of the first dorsal compartment tendons using a knife and then dissect once into subcutaneous tissue with tenotomy scissors (TECH FIG 1A).

 

Identify and protect sensory branches of the radial nerve and the lateral antebrachial cutaneous nerve in the subcutaneous tissue (TECH FIG 1B).

 

Identify the interval between the first dorsal compartment tendons and the EPL tendon.

 

 

 

TECH FIG 1 • A. Dorsal longitudinal incision along the ulnar aspect of the first dorsal compartment. B. Surgical incision with identification of the radial sensory nerve. C. Dorsal branch of radial artery is mobilized and protected by retracting it dorsally and proximally.

 

 

The first dorsal compartment is released.

 

Identify the dorsal branch of the radial artery deep to the abductor pollicis longus and extensor pollicis brevis tendons running in a dorsal and ulnar direction. Carefully mobilize and protect it by retracting it dorsally throughout the remainder of the case (TECH FIG 1C). The radial artery courses directly over the STT joint.

 

Identify the base of the thumb metacarpal, and complete a longitudinal capsulotomy to expose the base of the metacarpal, the entire trapezium, and the distal aspect of the scaphoid.

 

 

Fluoroscopy is used to confirm the location of the CMC joint if necessary.

 

Preparation of the Joint

 

Inspect the STT joints.

 

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If there is evidence of arthrosis, consideration is given to alternative procedures such as trapeziectomy and possible ligament interposition.

 

Inspect the CMC joint (TECH FIG 2A).

 

By releasing the surrounding capsular attachments radially and ulnarly, the base of the metacarpal can be flexed to allow better access to the joint.

 

Use a rongeur to remove osteophytes (TECH FIG 2B), any remaining articular cartilage, and subchondral sclerotic bone to get down to healthy cancellous bone at the base of the thumb metacarpal.

 

Shape the metacarpal base in a convex fashion to match the trapezium (TECH FIG 2C).

 

 

 

TECH FIG 2 • A. Exposure of the thumb CMC joint (probe is in the scaphotrapezial joint). B. Débridement

of thumb metacarpal with a rongeur. C. Thumb metacarpal base fully débrided. D. View of the CMC joint while trapezium is being débrided with a rongeur. E. Trapezium is fully débrided in preparation for arthrodesis.

 

 

Decorticate the distal aspect of the trapezium in a similar fashion (TECH FIG 2D,E).

 

Use a water-cooled burr to perform final contouring of the concave surface of the trapezium.

 

Per surgeon preference, the articular surfaces can also be prepared as parallel flat surfaces with a water-cooled oscillating saw.

Distal Radius Bone Graft Harvest

 

Distal radius autograft is harvested to pack into the arthrodesis site.

 

Extend the dorsal incision proximal to Lister tubercle and bluntly spread through the subcutaneous tissues to expose the extensor retinaculum.

 

Incise the retinaculum sharply over the radial edge of Lister tubercle to expose the tubercle's surface within the second extensor compartment.

 

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Use a curette as a hand drill (spin with compressive force applied by hand) into the radial border of Lister tubercle. This provides access to the medullary canal through an area of thin cortex. Cancellous bone graft is harvested.

Positioning and Fixation

 

The position for arthrodesis should allow the pulp of the thumb to rest against the radial distal aspect of the index middle phalanx when the hand is resting with slight wrist extension.

 

The exact angles to accomplish this position are debated, but in general, there should be about 30 to 45 degrees of palmar abduction and adequate pronation to direct the thumb pulp space toward the index finger.

 

Once positioned, provisionally stabilize the CMC joint with a single 0.045 Kirschner wire. This allows for clinical assessment of position and fluoroscopic evaluation.

 

A six- to eight-hole plate (two rows of screws) is applied across the CMC joint (TECH FIG 3A), and sequentially, two holes in trapezium are drilled and screws placed (TECH FIG 3B).

 

Cortical or locking screws can be used based on bony purchase and plate apposition on the trapezium.

 

Care should be taken to ensure that screws in the trapezium do not violate the articular surfaces of the scaphoid, trapezoid, or index metacarpal.

 

While maintaining reduction and manual compression of the thumb metacarpal against the trapezium and plate, the remaining four to six holes are drilled and cortical screws placed (TECH FIG 3C).

 

 

 

TECH FIG 3 • A. A six-hole plate is applied across the CMC joint. B. Two screws have been placed through the plate into the trapezium. C. Plate being applied onto the thumb CMC. D. Distal radius bone graft being packed into the CMC joint.

 

 

Distal radius bone graft is then packed into the fusion site (TECH FIG 3D).

 

At this time, final assessment of clinical alignment and fluoroscopic evaluation (position, bony contact, hardware placement/screw length) are performed (see FIG 2A,B).

 

Irrigate the wound lightly with saline. Close the capsule with a nonabsorbable suture (3-0 Ethibond), repeat irrigation, and deflate the tourniquet to confirm hemostasis as the radial artery and venae comitantes are within the operative field. Close the skin with 4-0 nylon horizontal mattress sutures.

 

If mild thumb MCP joint hyperextension is noted at this juncture, pin the MCP joint in 20 degrees of flexion with a single 0.045 Kirschner wire or consider a volar capsulodesis. In our experience, correction of the fixed flexion and adduction of the thumb metacarpal often improves MCP position with pinch so that operative intervention at the MCP joint is infrequent.

 

Apply soft sterile dressings and a well-padded short-arm thumb spica splint.

Fixation Options

 

Although we prefer plate fixation, single or multiple smooth Kirschner wires, tension band wiring, cerclage wiring, staples, compression screws, and other types of plate and screw constructs have all been used

with documented success.9

 

Conflicting reports of union rates are reported when comparing Kirschner wires to more rigid fixation devices such as plates and screws.8,11

 

 

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PEARLS AND PITFALLS

Surgical

approach

• Take care to protect the cutaneous branches of the radial sensory nerve and

  the lateral antebrachial cutaneous nerve throughout the entire procedure.

• Protect the radial artery coursing over the STT joint.

Intraoperative ▪ Carefully inspect the STT joints, as arthritic involvement will preclude success

joint with CMC arthrodesis. inspection

Judicious use ▪ Make sure there is good apposition of the bony surfaces before closure. Distal

of bone graft radius autograft is ideal to fill any voids.

Radial

sensory nerve injury

• If there is inadvertent injury to the radial sensory nerve and this is recognized, it

should be repaired with fine epineurial suture.

Radial artery

injury

• If there is inadvertent injury to the radial artery, it should be temporarily clipped

with temporary vascular clamps. After the arthrodesis is completed and the capsule is closed, the tourniquet is deflated. If there is good perfusion to all the digits, the artery can be ligated. If the perfusion is inadequate, microvascular repair must be accomplished.

Nonunion or

malunion

• Inadequate preparation of joint surfaces may lead to nonunion.

• Improper positioning of thumb metacarpal on the trapezium may lead to malunion.

 

 

POSTOPERATIVE CARE

 

The patient is seen in the office at 7 to 14 days to check the wound. Sutures are removed and radiographs obtained. If fixation is secure, a well-molded short-arm thumb spica cast is applied and the patient is encouraged to continue active digital motion. The thumb interphalangeal joint can be left free.

 

The patient is seen at 4 to 6weeks postoperatively for reassessment with cast removal and repeat x-rays. The patient is placed in a removable Orthoplast thumb spica splint and immobilized for 2 to 4 more weeks. Active and active-assisted thumb motion are initiated.

 

Usually, radiographic evidence of fusion will be seen by 6 to 8 weeks after surgery (FIG 2). Removable bracing is used until radiographic fusion. Then, the patient is allowed to begin strengthening exercises and gradually progress toward unrestricted activities.

 

Final photos of motion from a patient 2 months and 9 days postoperative are shown in FIG 3A-D.

 

 

 

FIG 2 • A,B. AP (A) and lateral (B) fluoroscopic images demonstrating application of plate and screws across thumb CMC joint.

 

 

OUTCOMES

The outcomes of trapeziometacarpal arthrodesis are generally good, with predictable pain relief and patient satisfaction.

Forseth and Stern8 compared the complication rate with Kirschner wire fixation (n = 59) to that with plates (minicondylar blade or T plate, n = 26) and screws over an average follow-up of 40 months. They found similar nonunion rates (<10% in their small series), but there were higher rates of secondary procedures and lower patient satisfaction in the plate and screw group.

Hartigan et al11 retrospectively reviewed patients who had arthrodesis and compared them to those having trapezial excision and ligament reconstruction with an average follow-up of 69 months.There were no significant differences in pain, function, patient satisfaction, or grip strength. The arthrodesis group had greater lateral pinch and chuck pinch but more difficulty with opposition and the ability to flatten the hand, all of which were statistically significant.

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The arthrodesis group also had a higher complication rate, most of which was attributable to nonunion. There was a 16% nonunion rate using Kirschner wires or tension band, but this rate decreased to 6% after they switched to using a minicondylar plate. Interestingly, all patients with nonunion had improvement in their pain, were able to return to their previous job, and were very satisfied with their outcomes.

 

 

 

FIG 3 • A-D. Final photos of motion 2 months and 9 days postoperatively after thumb CMC joint arthrodesis with plate and screw fixation. The right side is the operative side. A. At rest. B. Radial abduction. C. Opposition. D. Fist.

 

 

Hartigan et al's11 data contrasts with Mureau et al14 who found less subjective improvement with arthrodesis in comparison to arthroplasty and no significant differences in pinch or grip strength. They also found a higher incidence of complications in the arthrodesis group. However, fixation was performed using crossed Kirschner wires with or without iliac crest autograft. In another series, when arthrodesis was performed using a three- to four-hole AO miniplate with cortical screws, no differences in outcomes were found and less complications were found in the arthrodesis group compared to a resection-

interposition arthroplasty group.18

 

Considering the body of available literature, no consensus exists as to the optimal surgical treatment for thumb CMC arthrosis.10,11,17,18,20 Although complications and reoperations have been found to be more frequent following CMC arthrodesis, this has not been proven to affect the overall outcome.11,20

 

Two systematic reviews did not show any difference in either subjective or objective outcome measures between all surgical procedures for thumb CMC arthrosis but did comment that high level randomized

trials comparing arthrodesis to other surgical procedures are needed to fully assess this question.12,23

 

COMPLICATIONS

Complications from thumb CMC arthrodesis are generally related to nonunion or hardware problems, including malposition (screws in the trapeziotrapezoid joint), prominence and tendon irritation, and rupture.

 

The patient should be made aware of the possible need for secondary procedures to address such complications.

 

 

REFERENCES

1. Berggren M, Joost-Davidsson A, Lindstrand J, et al. Reduction in the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven year prospective study. Scand J Plast Reconstr Surg Hand Surg 2001;35:415-417.

    

    

2. Bettinger PC, Linscheid RL, Berger RA, et al. An anatomical study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J Hand Surg Am 1999;24(4):786-798.

    

    

3. Bettinger PC, Smutz WP, Linscheid RL, et al. Material properties of the trapezial and trapeziometacarpal ligaments. J Hand Surg Am 2000;25(6):1085-1095.

    

    

4. Cooney WP III, Chao EY. Biomechanical analysis of static forces in the thumb during hand function. J Bone Joint Surg Am 1977;59(1):27-36.

    

    

5. Day CS, Gelberman R, Patel AA, et al. Basal joint osteoarthritis of the thumb: a prospective trial of steroid injection and splinting. J Hand Surg Am 2004;29(2):247-251.

    

    

6. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am 1973;55(8):1655-1666.

    

    

7. Edmunds JO. Current concepts of the anatomy of the thumb trapeziometacarpal joint. J Hand Surg Am 2011;36(1):170-182.

    

    

8. Forseth MJ, Stern PJ. Complications of trapeziometacarpal arthrodesis using plate and screw fixation. J Hand Surg Am 2003;28(2):342-345.

    

    

9. Goldfarb CA, Stern PJ. Indications and techniques for thumb carpometacarpal arthrodesis. Tech Hand Up Extrem Surg 2002;6(4): 178-184.

    

    

10. Hart R, Janecek M, Siska V, et al. Interposition suspension arthroplasty according to Epping versus arthrodesis for trapeziometacarpal osteoarthritis. Eur Surg 2006;38(6):433-438.

     

     

11. Hartigan BJ, Stern PJ, Kiefhaber TR. Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition. J Bone Joint Surg Am 2001;83-A(10):1470-1478.

     

     

12. Martou G, Veltri K, Thoma A. Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb: a systematic review. Plast Reconstr Surg 2004;114(2):421-432.

     

     

13. Muller GM. Arthrodesis of the trapeziometacarpal joint for osteoarthritis. J Bone Joint Surg Br 1949;31B(4):540-542.

     

     

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14. Mureau MA, Rademaker RP, Verhaar JA, et al. Tendon interposition arthroplasty versus arthrodesis for the treatment of trapeziometacarpal arthritis: a prospective comparative follow-up study. J Hand Surg Am 2001;26(5):869-876.

     

     

15. North ER, Eaton RG. Degenerative arthritis of the trapezium: a comparative roentgenologic and anatomic study. J Hand Surg Am 1983; 8(2):160-166.

     

     

16. Pellegrini VD Jr, Smith RL, Ku CW. Pathobiology of articular cartilage in trapeziometacarpal osteoarthritis. I. Regional biochemical analysis. J Hand Surg Am 1994;19(1):70-85.

     

     

17. Raven E, Kerkhoffs G, Rutten S, et al. Long term results of surgical intervention for osteoarthritis of the trapeziometacarpal joint. Int Orthop 2007;31(4):547-554.

     

     

18. Schröder J, Kerkhoffs GM, Voerman HJ, et al. Surgical treatment of basal joint disease of the thumb: comparison between resection-interposition arthroplasty and trapezio-metacarpal arthrodesis. Arch Orthop Trauma Surg 2002;122(1):35-38.

     

     

19. Strauch RJ, Behrman MJ, Rosenwasser MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J Hand Surg Am 1992;19(1):93-98.

     

     

20. Taylor EJ, Desari K, D'Arcy JC, et al. A comparison of fusion, trapeziectomy, and silastic replacement for the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg Br 2005;30(1):45-49.

     

     

21. Tomaino MM, Vogt M, Weiser R. Scaphotrapezoid arthritis: prevalence in thumbs undergoing trapezium excision arthroplasty and efficacy of proximal trapezoid excision. J Hand Surg Am 1999;24(6):1220-1224.

     

     

22. Van Brenk B, Richards RR, Mackay MB, et al. A biomechanical assessment of ligaments preventing dorsoradial subluxation of the trapeziometacarpal joint. J Hand Surg Am 1998;23(4):607-611.

     

     

23. Vermeulen GM, Slijper H, Feitz R, et al. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am 2011;36(1):157-169.