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Hand & Upper Limb

1st CMC Arthroplasty — Trapeziectomy & LRTI

Complete surgical technique guide for 1st CMC (basal thumb) arthroplasty including trapeziectomy alone vs LRTI/suspensionplasty, Eaton-Littler staging, FCR harvest, radial artery protection, and adductor contracture release — FRCS/FRACS/EBOT exam preparation

Core Procedure
intermediate
By OrthoVellum Medical Education Team

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High-yield overview

Basal thumb CMC osteoarthritis | Eaton-Littler Stage II–IV | Intermediate

Epidemiology and Pathophysiology

Global Epidemiology

  • 1st CMC OA is the second most common joint affected by OA in the hand (after DIP joints)
  • Affects approximately 15% of post-menopausal women radiographically; symptomatic disease in approximately 5–7%
  • Female:male ratio approximately 10:1 — oestrogen deficiency implicated in ligamentous laxity
  • Bilateral in 50–70% of symptomatic patients
  • Peak presentation: 5th–7th decades

Pathophysiology Sequence

  1. Ligamentous laxity (especially anterior oblique ligament / beak ligament) — early Stage I
  2. Metacarpal subluxation dorsally and radially from pull of APL on the unstable base
  3. Articular cartilage damage from abnormal contact stresses at subluxed joint — Stages II–III
  4. Osteophyte formation and subchondral sclerosis — progresses to Stage III
  5. Adductor contracture: as metacarpal migrates dorsally, adductor pollicis shortens; patient loses thumb span and develops fixed adduction deformity
  6. Compensatory MCP hyperextension: CMC adduction deformity causes MCP to hyperextend to maintain pinch — the classic Z-deformity of the thumb
  7. Stage IV: Arthritis spreads to adjacent STT joint (scapho-trapezio-trapezoidal)

Clinical Pearl

Examiner Question: "Describe the Z-deformity of the thumb in CMC OA."

Model Answer: "The Z-deformity describes the characteristic thumb posture in advanced CMC OA. It consists of: (1) Adduction deformity at the CMC joint — the metacarpal migrates dorsally and radially into adduction as the anterior oblique ligament fails; and (2) Compensatory MCP hyperextension — the patient hyperextends the MCP to maintain a flat pinch grip despite the CMC adduction. On examination the thumb appears shortened and adducted at the base, with the MCP in hyperextension. The adductor pollicis is contracted. Management of the Z-deformity requires: trapeziectomy (addresses CMC), adductor release (addresses contracture), and if MCP hyperextension is greater than 20–30° at surgery — MCP stabilisation (volar capsulodesis or sesamoid-to-metacarpal fusion) to prevent continued hyperextension."

Surgical Imaging

Eaton-Littler classification of thumb CMC osteoarthritis
Radiograph of advanced thumb carpometacarpal osteoarthritis: trapeziometacarpal joint-space narrowing, subchondral sclerosis, osteophytes and radial subluxation of the metacarpal base — the changes that define higher Eaton–Littler stages.Credit: AI-generated medical image · OrthoVellum
Trapeziectomy with ligament reconstruction and tendon interposition
Trapeziectomy with LRTI: the trapezium is excised, an FCR slip is passed through a metacarpal bone tunnel as a sling, and rolled tendon fills the void. The radial artery in the snuffbox is at risk.Credit: AI-generated medical image · OrthoVellum
Radiographs of thumb basal joint osteoarthritis
Radiographic series of thumb carpometacarpal osteoarthritis before and after surgical management.Credit: via Open-i (NIH), CC BY
Intra-operative trapeziectomy exposure
Intra-operative exposure of the thumb basal joint during trapeziectomy, with the trapezium delivered before excision.Credit: via Open-i (NIH), CC BY

Critical Danger Structures and Exam Traps

Eaton-Littler Staging

Stage I: Synovitis, normal joint space. Stage II: Mild joint space narrowing, subluxation, osteophytes less than 2mm. Stage III: Severe narrowing/subluxation/sclerosis, osteophytes greater than 2mm. Stage IV: Pantrapezial disease (STT joint also involved). All stages II–IV are surgical candidates if conservative treatment fails.

Trapeziectomy vs LRTI — RCT Evidence

Davis 2004 (PMID 15576217) randomised 183 thumbs to trapeziectomy alone vs trapeziectomy + PL interposition vs trapeziectomy + FCR LRTI and found no difference in pain, grip or key-pinch at 1 year. Gangopadhyay 2012 (PMID 22305824) reviewed the same cohort at a minimum of 5 years (median 6, range 5–18) with the same equivalence. LRTI adds operative time and FCR donor morbidity without benefit, and the Cochrane review (PMID 25702783) found a trend to more adverse events with LRTI. Trapeziectomy alone is now the preferred technique in most high-volume units worldwide.

Radial Artery at Risk

The radial artery passes through the anatomical snuffbox between the APL/EPB (anterior wall) and EPL (posterior wall), then dives deep between the two heads of the first dorsal interosseous. It passes directly over the trapezium in the surgical field. Must identify and mobilise the radial artery before trapezium removal to avoid arterial injury or inadvertent ligation.

FCR Harvest Technique

In LRTI, harvest half the width of FCR through a separate 2cm incision 6–8cm proximal to the wrist crease. Leave distal attachment intact. The tendon slip is passed through a bone tunnel in the thumb metacarpal base, looped back, sutured to itself to act as the suspensory ligament. The remaining FCR is folded into an anchovy and placed in the trapezial void to fill dead space and cushion the metacarpal.

Adductor Contracture Correction

In advanced disease (Stage III–IV), adductor pollicis tightness causes a fixed adduction deformity. This must be assessed preoperatively and released at the time of trapeziectomy. Release via the volar interval: divide the adductor pollicis fascia at its first metacarpal origin. Failure to release leaves the patient unable to fully abduct the thumb despite a technically perfect trapeziectomy.

Scaphometacarpal Impingement

After trapeziectomy the thumb metacarpal can subside proximally onto the scaphoid, causing scaphometacarpal impingement. This risk is the stated rationale for LRTI (the suspensory ligament maintains metacarpal height). However, the RCT evidence does not show this translates into worse functional outcomes. If LRTI not done, a thumb spica post-op for 4–6 weeks limits early subsidence.

Mnemonic

E-A-T-O-NEATON — Staging the Basal Thumb

Hook:EATON staging is the universal language for CMC OA. Stage I = injection/splint. Stages II–IV = trapeziectomy. Stage IV (pantrapezial) does NOT change surgical plan — trapeziectomy still works.

Mnemonic

L-R-T-ILRTI — Procedure Steps

Hook:LRTI = four key steps in order. The TUNNEL and INTERPOSITION are what distinguishes LRTI from simple trapeziectomy. Remember: evidence shows trapeziectomy alone = equivalent outcome.

Indications for Surgery

Surgical management is indicated when conservative measures have failed after 3–6 months:

  • Eaton-Littler Stage II–IV basal thumb arthritis (primary indication)
  • Pain with pinch and grip activities, pain at rest in advanced disease
  • Loss of span (adduction deformity from adductor contracture)
  • Functional impairment limiting daily activities, work, or hobbies
  • Failed splinting (thumb spica), activity modification, and corticosteroid injection

Conservative Treatment (Before Surgery)

ModalityEvidenceComment
Thumb spica splintGrade BThermoplastic CMC splint; reduces pain in 60–80%
Corticosteroid injectionGrade BShort-term relief 3–6 months; 2–3 injections acceptable
Hyaluronic acid injectionGrade CSome benefit; not superior to corticosteroid
Physiotherapy / joint protectionGrade CActivity modification, strengthening
NSAIDsGrade BSymptomatic relief

Surgical Options: Evidence Comparison

Trapeziectomy Alone vs LRTI vs Alternatives

Clinical Pearl

Examiner Classic: "The evidence shows trapeziectomy alone is equivalent to LRTI. Why do many surgeons still perform LRTI?"

Model Answer: "The evidence is clear — Davis 2004 (PMID 15576217) randomised 183 thumbs to trapeziectomy alone, trapeziectomy with palmaris longus interposition, or FCR LRTI and found no difference at 1 year; Gangopadhyay 2012 (PMID 22305824) followed the same cohort to a minimum of 5 years (median 6, range 5–18) with the same result. Neither pain, pinch strength, grip strength nor patient-reported outcomes differ between groups, and the Cochrane review (PMID 25702783) actually found a trend to MORE adverse events with LRTI. Despite this, some surgeons persist with LRTI on the theoretical rationale that the suspensory ligament prevents metacarpal proximal migration and scaphometacarpal impingement. Radiographic subsidence is broadly similar between techniques and has not translated into functional benefit. The current evidence-based recommendation is trapeziectomy alone — simpler, shorter, fewer complications, and no FCR donor morbidity, with no proven clinical disadvantage."


Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 58-year-old active grandmother with bilateral CMC arthritis presents with dominant right thumb pain, Eaton-Littler Stage III. She asks which operation gives the best result — trapeziectomy alone or LRTI. What do you tell her, and what do you recommend?"

PRACTICAL APPROACH
I would explain that this is a well-studied question with high-quality evidence to guide her decision. The Nottingham randomised controlled trial reported by Davis 2004 (PMID 15576217) at 1 year and by Gangopadhyay 2012 (PMID 22305824) at a minimum of 5 years (median 6, range 5–18) randomised thumbs to trapeziectomy alone, trapeziectomy with tendon interposition, or LRTI and found equivalent results for pain relief, grip strength, pinch strength and patient satisfaction, with no difference persisting in the long term. The Cochrane review (PMID 25702783) reached the same conclusion and noted a trend to more adverse events with LRTI. LRTI does not improve outcomes compared to simple trapeziectomy. On this basis, I recommend trapeziectomy alone as it is a simpler, shorter procedure, avoids harvesting half of her FCR tendon (which can cause wrist weakness), and produces the same functional result. I would explain that after removing the trapezium, the thumb metacarpal will gradually sit slightly higher (proximal migration) into the space — this fills with scar tissue and acts as a natural buffer. The overwhelming majority of patients are satisfied. I would also counsel her about the 4–6 week splinting period, the 3–4 month recovery to full function, and the excellent long-term prognosis.
CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"During trapeziectomy (piecemeal removal), you encounter significant arterial bleeding from the anatomical snuffbox area. What do you do, and how could this have been prevented?"

PRACTICAL APPROACH
This is a serious intraoperative complication suggesting injury to the radial artery or a significant branch. My immediate management: apply direct pressure to control bleeding, call for assistance (senior colleague, vascular surgery availability if needed), ensure tourniquet is inflated (if not already), and improve exposure with additional lighting and loupes. I would carefully identify the bleeding point. The radial artery passes over the trapezium in the snuffbox between APL/EPB and EPL — it is the most likely source. If a branch is divided, primary ligation of the small crossing branch is usually safe. If the main radial artery trunk is injured: primary repair with 7-0 or 8-0 prolene is required; if the defect is too large, a vein graft (cephalic vein) may be needed. I would check thumb perfusion after repair with pulse oximetry on the thumb. Prevention: the critical preventive step is to identify and tag the radial artery with a vessel loop before attempting trapezium removal. Removing the trapezium piecemeal rather than en-bloc minimises the force required and reduces the chance of inadvertent arterial traction. Loupe magnification is essential.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"At 4 months post-trapeziectomy + LRTI, a patient complains the thumb 'drops' into flexion at the IP joint on reaching and she cannot extend it fully. What has happened and how do you manage it?"

PRACTICAL APPROACH
This presentation suggests proximal migration of the thumb metacarpal with scaphometacarpal impingement — but actually the more likely diagnosis here given the LRTI context is that the FCR sling has been set at incorrect tension, or the FCR anchoring has failed. However, the specific complaint of IP joint flexion without full extension raises a different concern: iatrogenic damage to EPL or EPB during the procedure, or if this was an LRTI with the FCR passed through a dorsal metacarpal tunnel, there may be tethering. More likely: the IP flexion deformity with inability to fully extend the thumb IP suggests injury to the EPL tendon, or the suspensory sling is too tight and tethering metacarpal extension is pulling the IP joint into flexion. Management: assess clinically — is this a tendon injury (tendon rupture, test EPL by asking to lift thumb off a flat surface) or mechanical tethering? XR to assess metacarpal position and hardware. If EPL rupture is suspected, explore and repair or consider EIP-to-EPL transfer. If tethering from LRTI sling: return to theatre, release/revise the FCR loop tension. Set new tension with thumb fully extended at neutral wrist.

1st CMC Arthroplasty (Trapeziectomy ± LRTI) — Exam Summary

Clinical summary

Key Evidence

Excision of the trapezium for osteoarthritis: a study of the benefit of ligament reconstruction or tendon interposition

Level I
Davis TR, Brady O, Dias JJ • J Hand Surg Am
Clinical Implication: In the short term there is no benefit to adding tendon interposition or ligament reconstruction to a simple trapeziectomy — the foundational RCT underpinning trapeziectomy alone.
Verify on PubMed (PMID 15576217)

Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and LRTI

Level I
Gangopadhyay S, McKenna H, Burke FD, Davis TR • J Hand Surg Am
Clinical Implication: The equivalence of trapeziectomy alone and LRTI is durable to nearly two decades — LRTI confers no long-term functional advantage.
Verify on PubMed (PMID 22305824)

Surgery for thumb (trapeziometacarpal joint) osteoarthritis (Cochrane systematic review)

Level I
Wajon A, Vinycomb T, Carr E, Edmunds I, Ada L • Cochrane Database Syst Rev
Clinical Implication: The highest level of synthesised evidence shows no added benefit and a possible harm from LRTI — supporting trapeziectomy alone as the default.
Verify on PubMed (PMID 25702783)

Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review

Level II
Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW • J Hand Surg Am
Clinical Implication: Reinforces equivalence across techniques and flags the higher complication burden of LRTI and arthrodesis.
Verify on PubMed (PMID 21193136)

Interposition arthroplasty versus dual-cup mobility prosthesis for trapeziometacarpal osteoarthritis: a prospective randomized study

Level I
Guzzini M, Arioli L, Annibaldi A, Pecchia S, Latini F, Ferretti A • Hand (N Y)
Clinical Implication: Modern dual-mobility implants give faster early recovery than interposition, but longer-term survivorship data are still maturing, so trapeziectomy remains the durable benchmark.
Verify on PubMed (PMID 37482747)

References

  1. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973;55(8):1655–1666. PMID: 4804988

  2. Davis TR, Brady O, Dias JJ. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition. J Hand Surg Am. 2004;29(6):1069–1077. PMID: 15576217 · doi:10.1016/j.jhsa.2004.06.017

  3. Gangopadhyay S, McKenna H, Burke FD, Davis TR. Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition. J Hand Surg Am. 2012;37(3):411–417. PMID: 22305824 · doi:10.1016/j.jhsa.2011.11.027

  4. Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am. 2011;36(1):157–169. PMID: 21193136 · doi:10.1016/j.jhsa.2010.10.028

  5. Wajon A, Vinycomb T, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2015;2015(2):CD004631. PMID: 25702783 · doi:10.1002/14651858.CD004631.pub4

  6. Guzzini M, Arioli L, Annibaldi A, Pecchia S, Latini F, Ferretti A. Interposition arthroplasty versus dual cup mobility prosthesis in treatment of trapeziometacarpal joint osteoarthritis: a prospective randomized study. Hand (N Y). 2024;19(8):1260–1268. PMID: 37482747 · doi:10.1177/15589447231185584

  7. Tomaino MM. Ligament reconstruction tendon interposition arthroplasty for basal joint arthritis: rationale, current technique, and clinical outcome. Hand Clin. 2001;17(2):207–221.