Surgery for thumb (trapeziometacarpal joint) osteoarthritis
Abstract
Background
Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.
Objectives
To investigate the effect of surgery in reducing pain and improving physical function, patient global assessment, range of motion, and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, it was the reviewers intention to investigate whether there was any improvement or deterioration in outcomes between the 12 months review and a 5 year follow‐up.
Search methods
We searched the the following databases in the Cochrane Library 2004, Issue 4: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE) as well as MEDLINE (1966‐Dec 2004), CINAHL (1982‐Dec 2004), AMED (1985‐Dec 2004), and EMBASE (1974‐Dec 2004). Database searches were supplemented by hand searching conference proceedings and reference lists from reviews and papers.
Selection criteria
Studies were included if they were: randomised, quasi‐randomised or controlled trials; intervention was surgery; and pain, physical function, patient global assessment, range of motion, or strength was measured as an outcome.
Data collection and analysis
Two independent reviewers examined the identified studies according to the inclusion criteria. Included studies were assessed for methodological quality and then data, including adverse effects, was extracted and cross‐checked. Authors were contacted to provide missing information.
Main results
Seven studies involving 384 participants were included. Studies of five surgical procedures were identified (trapeziectomy, trapeziectomy with interpositional arthroplasty, trapeziectomy with ligament reconstruction, trapeziectomy with ligament reconstruction and tendon interposition (LRTI), and joint replacement). All studies reported results of a mixed group of participants with Stage II‐IV osteoarthritis, with a range of improvement across all stages of 27 to 57 mm on a 0‐100 VAS scale for pain and 18‐24 mm on a 0‐100 VAS scale for physical function. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment, range of motion or strength. However, participants who underwent trapeziectomy had 16% fewer adverse effects (p=0<.001) than the other commonly‐used procedures studied in this review; conversely, those who underwent trapeziectomy with ligament reconstruction and tendon interposition had 11% more (p=0.03) (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1).
Authors' conclusions
No one procedure produced greater strength than any other. Although this also appears to be the case for pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy is safer and has fewer complications than the other procedures studied in this review, and conversely trapeziectomy with LRTI has more.
PICOs
Plain language summary
Surgery for osteoarthritis of the thumb
Does surgery for osteoarthritis of the thumb help and is it safe?
Seven studies of high quality were reviewed and provide the best evidence we have today. The studies tested over 380 people with osteoarthritis at the base of the thumb at all stages (or severity) of the disease. Five different types of surgery were compared and the benefits and harms of the surgeries were measured after 1 to 5 years.
What is osteoarthritis of the thumb and why surgery?
Osteoarthritis (OA) at the base of the thumb (or trapeziometacarpal joint) causes pain, stiffness and weakness in the thumb. This can affect how well the thumb moves, how strong a person's grip is, and how well a person can do routine things at home or at work. Splints, exercises and drugs can be used to relieve pain and stiffness. But for some people, these treatments are not enough to help and surgery may be an option.
There are many types of surgery for the base of the thumb. The simplest surgery is a 'trapeziectomy'. Other surgeries use this simple approach but will also work on ligaments and tendons at the thumb or replace the thumb joint.
What did the studies show?
Overall, the majority of people felt satisfied with the surgery. All types of surgery decreased pain, increased range of motion and pinch strength, and improved function of the thumb.
Pain decreased by about 27 to 57 points on a 0‐100 scale.
Function in the thumb improved by about 18 to 24 points on a scale of 0‐100.
Unfortunately, there is not enough evidence to prove that one surgery is better than the other. However, it appears that pain, function, range of motion and overall well‐being probably improve about the same amount for each type of surgery. There is enough evidence to prove that strength improves the same amount, no matter which type of surgery.
How safe is thumb surgery?
Harms that can occur after surgery include pain, redness, scar tenderness, tendon adhesion or rupture , cut nerves, reduced sensation and loss of function in the thumb.
The simplest type of surgery, the trapeziectomy, caused fewer harms than a trapeziectomy with ligament reconstruction and tendon interposition or trapeziectomy with interpositional arthroplasty.
30 harmful events may occur with trapeziectomy with ligament reconstruction and tendon interposition or trapeziectomy with interpositional arthroplasty.
14 harmful events may occur with trapeziectomy.
This means 16 fewer harms may occur with trapeziectomy.
The trapeziectomy with ligament reconstruction and tendon interposition caused more harms than trapeziectomy, trapeziectomy with interpositional arthroplasty and trapeziectomy with ligament reconstruction.
What is the bottom line?
The level of quality of the evidence is 'silver'. Surgery for osteoarthritis of the thumb improves pain, function, range of motion, and strength in the thumb and enhances well‐being. One surgery does not appear to be better than the other.
Unless there are strong reasons not to do so, the simplest type of surgery, the trapeziectomy, should be used since it causes less harm. Also, the trapeziectomy with ligament reconstruction and tendon interposition should be avoided since it causes more harm.
