Ligament reconstruction tendon interposition arthroplasty for basal joint arthritis. Rationale, current technique, and clinical outcome.

The literature unequivocally supports the LRTI arthroplasty. Indeed, thumb stability, pain relief, and improvements in strength are the expected outcomes. Although some investigators believe that ligament reconstruction is not necessary, trapezium excision alone, or in combination with facial or tendon interposition, is less likely to provide long-term stability or restore satisfactory pinch and grip strength. Some hand surgeons may be apprehensive about harvesting the entire width of the FCR tendon because of fear that wrist function may be impaired or that a larger bony channel in the metacarpal might result in fracture. In that light, Coleman and the author recently reported the results of a prospective evaluation that rather convincingly showed there was no morbidity accompanying harvest of the entire FCR tendon, from the standpoint of wrist strength or endurance. Furthermore, technical modification by which the end of the FCR is tapered or trimmed obviates the need for an excessively large bony channel through the metacarpal. Preliminary pin fixation of the metacarpal, with its base suspended at the level of the index CMC joint, in the fisted position, is still recommended to allow accurate tensioning of the new ligament, and protection in the early postoperative period. Proximal migration of only 13% at an average of 9 years after surgery may very well reflect the value of this particular practice. In conclusion, attention to technical detail and compliance with the postoperative therapy program, in the author's opinion, are intricately related to the favorable outcomes he has observed during 5 years of seeing Burton perform the LRTI arthroplasty and more than 6 years of performing the procedure in his own practice.