Surgery for thumb (trapeziometacarpal joint) osteoarthritis

Anne Wajon; Toby Vinycomb; Emma Carr; Ian Edmunds; Louise Ada

doi:10.1002/14651858.CD004631.pub4

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Forest plot of comparison: 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus Trapeziectomy (T), outcome: 1.1 Pain ‐ 100 mm VAS (post‐intervention).

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Figure 4

Forest plot of comparison: 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), outcome: 1.2 Pain ‐ number of participants with resting pain.

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Figure 5

Forest plot of comparison: 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), outcome: 1.11 Adverse events ‐ number of participants with adverse events (post‐intervention).

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Figure 6

Forest plot of comparison: 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), outcome: 1.9 Strength ‐ lateral (key) pinch strength (kg).

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Analysis 1.1

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 1 Pain ‐ 100 mm VAS.

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Analysis 1.2

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 2 Pain ‐ number of participants with resting pain.

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Analysis 1.3

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 3 Physical function ‐ 0‐100 with '0' = no disability.

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Analysis 1.4

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 4 Adverse events ‐ number of participants with adverse events.

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Analysis 1.5

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 5 Trapeziometacarpal joint imaging ‐ SMD at rest (mm).

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Analysis 1.6

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 6 Range of motion ‐ palmar abduction (cm).

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Analysis 1.7

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 7 Range of motion ‐ palmar abduction (degrees).

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Analysis 1.8

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 8 Strength ‐ tip pinch strength (kg).

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Analysis 1.9

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 9 Strength ‐ lateral (key) pinch strength (kg).

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Analysis 1.10

Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 10 Strength ‐ grip strength (kg).

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Analysis 2.1

Comparison 2 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR), Outcome 1 Pain ‐ number of participants with frequent or constant pain.

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Analysis 2.2

Comparison 2 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR), Outcome 2 Physical function ‐ number of participants with moderate difficulty with daily function.

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Analysis 2.3

Comparison 2 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR), Outcome 3 Physical function ‐ Buck Gramcko score (number of participants with good‐excellent total score).

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Analysis 2.4

Comparison 2 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR), Outcome 4 Adverse events ‐ number of participants with adverse events.

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Analysis 2.5

Comparison 2 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR), Outcome 5 Trapeziometacarpal joint imaging ‐ SMD at rest (mm).

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Analysis 2.6

Comparison 2 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR), Outcome 6 Range of motion ‐ palmar abduction (degrees).

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Analysis 2.7

Comparison 2 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR), Outcome 7 Strength ‐ lateral (key) pinch strength (kg).

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Analysis 4.1

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 1 Pain ‐ 100 mm VAS during key pinch.

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Analysis 4.2

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 2 Pain ‐ 100 mm VAS during tripod pinch.

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Analysis 4.3

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 3 Adverse events ‐ mild to moderate swelling.

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Analysis 4.4

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 4 Treatment failure ‐ reoperation due to pain.

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Analysis 4.5

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 5 Range of motion ‐ palmar abduction (degrees).

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Analysis 4.6

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 6 Strength ‐ lateral (key) pinch strength (kg).

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Analysis 4.7

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 7 Strength ‐ pinch (tripod) strength (kg).

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Analysis 4.8

Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 8 Strength ‐ grip strength (kg).

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Analysis 5.1

Comparison 5 Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson), Outcome 1 Pain ‐ 100 mm VAS.

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Analysis 5.2

Comparison 5 Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson), Outcome 2 Adverse events ‐ number of participants with adverse events.

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Analysis 5.3

Comparison 5 Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson), Outcome 3 Trapeziometacarpal joint imaging ‐ SMD at rest (mm).

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Analysis 5.4

Comparison 5 Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson), Outcome 4 Range of motion ‐ palmar abduction (degrees).

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Analysis 5.5

Comparison 5 Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson), Outcome 5 Strength ‐ lateral (key) pinch strength (kp/cm²).

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Summary of findings for the main comparison. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T)

Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T)
Patient or population: Patients with thumb (trapeziometacarpal joint) osteoarthritis Settings: Hospital Intervention: Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) Comparison: Trapeziectomy (T)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Trapeziectomy (T)	Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI)
Pain 100mm VAS . Scale from: 0 to 100. Follow‐up: 3 to 54 months	The mean pain in the control groups was 26 mm	The mean pain in the intervention groups was 2.8 lower (9.8 lower to 4.2 higher)		162 (3 studies)	⊕⊕⊝⊝ low^1,2,3,4	Absolute change ‐3% (‐10% to 4%); Relative change ‐4% (‐13% to 6%)⁵.
Physical function DASH Score. Scale from: 0 to 100. Follow‐up: 7 to 97 months	The mean physical function in the control groups was 31 points	The mean physical function in the intervention groups was 0.01 standard deviations higher (0.30 lower to 0.32 higher) This translates to an absolute mean increase of 0.03 (‐0.83 to 0.88) points compared to control using a 0 to 100 point scale⁷		211 (3 studies)	⊕⊕⊝⊝ low^1,2,4,6	SMD 0.01 (‐0.30 to 0.32); Absolute change 0.03% (‐0.83% to 0.88%); Relative change 0.05% (‐1.56% to 1.66%)⁷.
Quality of life ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Global assessment ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Adverse events Complications reported Follow‐up: 7 to 54 months	Moderate		RR 1.81 (0.96 to 3.73)	328 (4 studies)	⊕⊕⊝⊝ low^1,3,4,6,8	Absolute change of 5% (‐1% to 11%)<BR/>Relative change 89% (‐4% to 273%)
	10 per 100	19 per 100 (10 to 39)	RR 1.81 (0.96 to 3.73)	328 (4 studies)	⊕⊕⊝⊝ low^1,3,4,6,8
Treatment failure ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Trapeziometacarpal joint imaging Scapho‐metacarpal distance Follow‐up: 7 to 29 months	The mean trapeziometacarpal joint imaging in the control groups was 2.3 mm	The mean trapeziometacarpal joint imaging in the intervention groups was 0.1 lower (0.81 lower to 0.61 higher)		42 (1 study)	⊕⊕⊝⊝ low^1,4	Absolute and relative change cannot be calculated⁹.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Belcher 2000: Unclear performance bias; unclear detection bias; unclear attrition bias; unclear reporting bias. ²De Smet 2004: Unclear selection bias; unclear performance bias; unclear detection bias; unclear attrition bias; unclear reporting bias. ³Field 2007: Unclear selection bias; unclear performance bias; unclear detection bias; unclear reporting bias. ⁴ Less than 300 total participants (imprecision). ⁵ Relative change calculated using the mean from control group in Field 2007 (mean 76 mm). ⁶Salem 2012: Unclear selection bias; unclear performance bias; high risk of selection bias; unclear reporting bias. ⁷ Absolute and relative change calculated using the mean and SD from the control group in Salem 2012 (DASH score, mean 53 points; SD 2.75 points). ⁸Gangopadhyay 2012: Unclear performance bias; unclear reporting bias. ⁹ Absolute change cannot be calculated as there is no scale for trapeziometacarpal joint space imaging. Relative change cannot be calculated as there is no baseline mean in any control groups as this space is created during the surgery.

Summary of findings for the main comparison. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T)

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Summary of findings 2. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR)

Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR)
Patient or population: Patients with thumb (trapeziometacarpal joint) osteoarthritis Settings: Hospital Intervention: Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) Comparison: Trapeziectomy and ligament reconstruction (T and LR)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Trapeziectomy and ligament reconstruction (T and LR)	Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI)
Pain ‐ not measured	See comment	See comment	Not estimable	—	See comment	Participant‐reported pain relief of 50% or greater or VAS pain scores not reported in any study.
Physical function Buck‐Gramcko score: Number with good‐excellent total score Follow‐up: 15 to 120 months	Moderate		RR 0.82 (0.63 to 1.06)	31 (1 study)	⊕⊕⊝⊝ low^1,2	Absolute change of ‐19% (‐40% to 2%); Relative decrease 18% (‐35% to 27%).
	100 per 100	82 per 100 (63 to 100)
Quality of life ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Global assessment ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Adverse events Complications reported Follow‐up: 15 to 120 months	Moderate		RR 1.41 (0.27 to 7.28)	31 (1 study)	⊕⊕⊝⊝ low^1,2	Absolute change 5% (‐20% to 31%); Relative change 41% (‐73% to 628%).
	13 per 100	19 per 100 (4 to 97)
Treatment failure ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Trapeziometacarpal joint imaging Scapho‐metacarpal distance Follow‐up: mean 23 months	The mean trapeziometacarpal joint imaging in the control groups was 5.2 mm	The mean trapeziometacarpal joint imaging in the intervention groups was 0.7 lower (1.9 lower to 0.5 higher)		20 (1 study)	⊕⊕⊝⊝ low^2,3	Absolute and relative change cannot be calculated⁴.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Kriegs‐Au 2004: Unclear selection bias; unclear performance bias; unclear detection bias, unclear reporting bias. ² Less than 300 total participants (imprecision). ³Gerwin 1997: Unclear selection bias; unclear performance bias; unclear detection bias; unclear attrition bias; unclear reporting bias. ⁴ Absolute change cannot be calculated as there is no scale for trapeziometacarpal joint space imaging. Relative change cannot be calculated as there is no baseline mean in any control groups as this space is created during the surgery.

Summary of findings 2. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR)

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Summary of findings 3. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and interpositional arthroplasty (T and IA)

Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and interpositional arthroplasty (T and IA)
Patient or population: Patients with thumb (trapeziometacarpal joint) osteoarthritis Settings: Hospital Intervention: Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) Comparison: Trapeziectomy and interpositional arthroplasty (T and IA)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Trapeziectomy and interpositional arthroplasty (T and IA)	Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI)
Pain ‐ not measured	See comment	See comment	Not estimable	—	See comment	Participant‐reported pain relief of 50% or greater or VAS pain scores not reported in any study.
Physical function ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Quality of life ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Global assessment ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Adverse events complications reported Follow‐up: 5 to 18 years	Moderate		RR 1.36 (0.48 to 3.88)	100 (1 study)	⊕⊕⊕⊝ moderate^1,2	Absolute change of 4% (‐9% to 17%); Relative change 36% (‐52% to 288%).
	24 per 100	32 per 100 (11 to 92)	RR 1.36 (0.48 to 3.88)	100 (1 study)	⊕⊕⊕⊝ moderate^1,2
Treatment failure ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Trapeziometacarpal joint imaging ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Gangopadhyay 2012: Unclear performance bias; unclear reporting bias. ² Less than 300 total participants (imprecision).

Summary of findings 3. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and interpositional arthroplasty (T and IA)

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Summary of findings 4. Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon joint resurfacing

Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon joint resurfacing
Patient or population: Patients with thumb (trapeziometacarpal joint) osteoarthritis Settings: Hospital Intervention: Trapeziectomy with interpositional arthroplasty (IA) Comparison: Artelon joint resurfacing
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Artelon joint resurfacing	Trapeziectomy with interpositional arthroplasty (IA)
Pain 100mm VAS. Scale from: 1 to 100. Follow‐up: 3 years	The mean pain in the control groups was 21.2 mm	The mean pain in the intervention groups was 3.2 lower (23.8 lower to 17.3 higher)		77 (2 studies¹)	⊕⊝⊝⊝ very low^2,3	Absolute change ‐3% (‐24% to 17%); Relative change ‐7% (‐53% to 38%).
Physical function ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Quality of life ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Global assessment ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Adverse events Mild to moderate swelling Follow‐up: 1 year	33 per 100	3 per 100 (0 to 20)	RR 0.09 (0.01 to 0.61)	98 (1 study)	⊕⊝⊝⊝ very low^3,4	Absolute change ‐30% (‐18% to ‐43%); Relative change ‐81% (‐99% to ‐49%); Number needed to benefit 4 (4 to 7).
Treatment failure Reoperation due to pain Follow‐up: 1 year	10 per 100	1 per 100 (0 to 22)	RR 0.14 (0.01 to 2.36)	98 (1 study)	⊕⊝⊝⊝ very low^3,4	Absolute change ‐10% (‐1% to ‐18%); Relative change ‐86% (‐99% to ‐136%).
Trapeziometacarpal joint imaging ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Nilsson 2005: Controlled, prospective pilot study. ²Nilsson 2005: High risk selection bias; unclear performance bias; unclear detection bias; high risk reporting bias. ³ Less than 300 total participants (imprecision). ⁴Nilsson 2010: Unclear selection bias; unclear performance bias; unclear detection bias; high risk attrition bias; unclear reporting bias.

Summary of findings 4. Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon joint resurfacing

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Summary of findings 5. Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziometacarpal joint replacement (Swanson)

Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziometacarpal joint replacement (Swanson)
Patient or population: Patients with thumb (trapeziometacarpal joint) osteoarthritis Settings: Hospital Intervention: Trapeziectomy with interpositional arthroplasty (T and IA) Comparison: Trapeziometacarpal joint replacement (Swanson)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Trapeziometacarpal joint replacement (Swanson)	Trapeziectomy with interpositional arthroplasty (T and IA)
Pain 100mm VAS. Scale from: 0 to 100. Follow‐up: 22 to 66 months	The mean pain in the control groups was 9.0 mm	The mean pain in the intervention groups was 5.0 higher (7.4 lower to 17.4 higher)		26 (1 study)	⊕⊕⊝⊝ low^1,2	Absolute change 5% (‐7.4% to 17%); Relative change 8% (‐12% to 27%).
Physical function ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Quality of life ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Global assessment ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Adverse events Complications reported Follow‐up: 22 to 66 months	Moderate		RR 0.2 (0.01 to 3.8)	26 (1 study)	⊕⊕⊝⊝ low^1,2	Absolute change ‐15% (‐82% to 7%); Relative change ‐80% (‐99% to 280%).
	15 per 100	3 per 100 (0 to 59)	RR 0.2 (0.01 to 3.8)	26 (1 study)	⊕⊕⊝⊝ low^1,2
Treatment failure ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Trapeziometacarpal joint imaging ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Tagil 2002: Unclear selection bias; unclear performance bias; high risk detection bias; unclear reporting bias. ² Less than 300 total participants (imprecision).

Summary of findings 5. Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziometacarpal joint replacement (Swanson)

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Summary of findings 6. Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziectomy (T)

Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziectomy (T)
Patient or population: Patients with thumb (trapeziometacarpal joint) osteoarthritis Settings: Hospital Intervention: Trapeziectomy with interpositional arthroplasty (T and IA) Comparison: Trapeziectomy (T)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Trapeziectomy (T)	Trapeziectomy with interpositional arthroplasty (T and IA)
Pain ‐ not measured	See comment	See comment	Not estimable	—	See comment	Participant‐reported pain relief of 50% or greater or VAS pain scores not reported in any study.
Physical function ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Quality of life ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Global assessment ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Adverse events Complications reported Follow‐up: 5 to 18 years	Moderate		RR 1.44 (0.41 to 5.05)	99 (1 study)	⊕⊕⊕⊝ moderate^1,2	Absolute change 3% (‐8% to 15%); Relative change 44% (‐59% to 405%).
	14 per 100	21 per 100 (6 to 73)	RR 1.44 (0.41 to 5.05)	99 (1 study)	⊕⊕⊕⊝ moderate^1,2
Treatment failure ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
Trapeziometacarpal joint imaging ‐ not measured	See comment	See comment	Not estimable	—	See comment	Not reported in any study.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Gangopadhyay 2012: Unclear performance bias; unclear reporting bias. ² Less than 300 total participants (imprecision).

Summary of findings 6. Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziectomy (T)

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Table 1. Adverse events of trapeziectomy and LRTI versus trapeziectomy

Study	Group	Tendon rupture/adhesion	Scar tenderness or infection	Recurrent pain	Sensory change	Cut PCMN	Neuroma	Instability	De Quervain's Disease	CRPS (type 1)
Belcher 2000	Trapeziectomy (n = 19)	—	—	1	—	—	1	—	—	—
Belcher 2000	Trapeziectomy and LRTI (n = 23)	1	—	2	1		1	1	—	—
De Smet 2004	Trapeziectomy (n = 21)	—	—	—	—	—	—	1	—	—
De Smet 2004	Trapeziectomy and LRTI (n = 34)	—	—	—	—	—	—	—	—	—
Field 2007	Trapeziectomy (n = 32)	—	2	—	1	—	—	—	—	1
Field 2007	Trapeziectomy and LRTI (n = 33)	6	1	—	1	—	—	—	—	4
Gangopadhyay 2012	Trapeziectomy (n = 53)	—	—	—	2	2	—	—	—	—
Gangopadhyay 2012	Trapeziectomy and LRTI (n = 54)	2	2	—	2	2	—	—	—	—
Salem 2012	Trapeziectomy (n = 21)	—	—	—	—	3	—	—	1	1
Salem 2012	Trapeziectomy and LRTI (n = 27)	1	1	—	4	—	—	—	1	—
Cut PCMN = cut palmar cutaneous branch of median nerve; CRPS = Complex Regional Pain Syndrome.

Table 1. Adverse events of trapeziectomy and LRTI versus trapeziectomy

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Table 2. Adverse effects of trapeziectomy and LRTI versus LR

Study	Group	CRPS (type 1)
Kriegs‐Au 2004	Trapeziectomy and LRTI (n = 16)	1
Kriegs‐Au 2004	Trapeziectomy and LR (n = 15)	—
Cut PCMN = cut palmar cutaneous branch of median nerve; CRPS = Complex Regional Pain Syndrome.

Table 2. Adverse effects of trapeziectomy and LRTI versus LR

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Table 3. Adverse effects of trapeziectomy and LRTI versus IA

Study	Group	Tendon rupture/adhesion	Scar tenderness	Sensory change	Cut PCMN
Gangopadhyay 2012	Trapeziectomy and IA (n = 46)	1	—	2	2
Gangopadhyay 2012	Trapeziectomy and LRTI (n = 54)	2	2	2	2
Cut PCMN = cut palmar cutaneous branch of median nerve CRPS = Complex Regional Pain Syndrome

Table 3. Adverse effects of trapeziectomy and LRTI versus IA

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Table 4. Adverse events of trapeziectomy and IA versus Artelon implant

Study	Group	Mild to moderate swelling	Re‐operation due to pain
Nilsson 2010	Trapeziectomy and IA (n = 35)	1	1
Nilsson 2010	Artelon implant (n = 63)	—	6

Table 4. Adverse events of trapeziectomy and IA versus Artelon implant

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Table 5. Adverse events of trapeziectomy and LRTI versus Swanson joint replacement

Study	Group	Instability	CRPS (type 1)
Tagil 2002	Swanson (n = 13)	2	—
Tagil 2002	Trapeziectomy and IA (n = 13)	—	—
Cut PCMN = cut palmar cutaneous branch of median nerve CRPS = Complex Regional Pain Syndrome

Table 5. Adverse events of trapeziectomy and LRTI versus Swanson joint replacement

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Table 6. Adverse events of trapeziectomy and IA versus trapeziectomy

Study	Group	Tendon rupture/adhesion	Sensory change	Cut PCMN
Gangopadhyay 2012	Trapeziectomy (n = 53)	—	2	2
Gangopadhyay 2012	Trapeziectomy and IA (n = 46)	1	2	2
Cut PCMN = cut palmar cutaneous branch of median nerve; CRPS = Complex Regional Pain Syndrome.

Table 6. Adverse events of trapeziectomy and IA versus trapeziectomy

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Comparison 1. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain ‐ 100 mm VAS Show forest plot	3	162	Mean Difference (IV, Random, 95% CI)	‐2.80 [‐9.82, 4.21]

2 Pain ‐ number of participants with resting pain Show forest plot	2	224	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.31, 4.54]

3 Physical function ‐ 0‐100 with '0' = no disability Show forest plot	3	211	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.30, 0.32]

4 Adverse events ‐ number of participants with adverse events Show forest plot	4	328	Risk Ratio (M‐H, Random, 95% CI)	1.89 [0.96, 3.73]

5 Trapeziometacarpal joint imaging ‐ SMD at rest (mm) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

6 Range of motion ‐ palmar abduction (cm) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

7 Range of motion ‐ palmar abduction (degrees) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

8 Strength ‐ tip pinch strength (kg) Show forest plot	2	213	Mean Difference (IV, Random, 95% CI)	0.13 [‐0.26, 0.52]

9 Strength ‐ lateral (key) pinch strength (kg) Show forest plot	4	325	Mean Difference (IV, Random, 95% CI)	0.11 [‐0.18, 0.41]

10 Strength ‐ grip strength (kg) Show forest plot	2	213	Mean Difference (IV, Random, 95% CI)	0.59 [‐3.12, 4.29]

Comparison 1. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T)

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Comparison 2. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain ‐ number of participants with frequent or constant pain Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Physical function ‐ number of participants with moderate difficulty with daily function Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Physical function ‐ Buck Gramcko score (number of participants with good‐excellent total score) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Adverse events ‐ number of participants with adverse events Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Trapeziometacarpal joint imaging ‐ SMD at rest (mm) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

6 Range of motion ‐ palmar abduction (degrees) Show forest plot	2	51	Mean Difference (IV, Random, 95% CI)	‐1.03 [‐7.81, 5.75]

7 Strength ‐ lateral (key) pinch strength (kg) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 2. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and ligament reconstruction (T and LR)

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Comparison 3. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and interpositional arthroplasty (T and IA)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain ‐ number of participants with resting pain	0		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2 Adverse events ‐ Number of participants with adverse events	0		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
3 Strength ‐ tip pinch strength (kg)	0		Mean Difference (IV, Random, 95% CI)	Totals not selected
4 Strength ‐ lateral (key) pinch strength (kg)	0		Mean Difference (IV, Random, 95% CI)	Totals not selected
5 Strength ‐ grip strength (kg)	0		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 3. Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy and interpositional arthroplasty (T and IA)

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Comparison 4. Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain ‐ 100 mm VAS during key pinch Show forest plot	2	77	Mean Difference (IV, Random, 95% CI)	‐3.24 [‐23.77, 17.29]

2 Pain ‐ 100 mm VAS during tripod pinch Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3 Adverse events ‐ mild to moderate swelling Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Treatment failure ‐ reoperation due to pain Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Range of motion ‐ palmar abduction (degrees) Show forest plot	2	113	Mean Difference (IV, Random, 95% CI)	‐4.13 [‐11.16, 2.91]

6 Strength ‐ lateral (key) pinch strength (kg) Show forest plot	2	113	Mean Difference (IV, Random, 95% CI)	‐1.09 [‐2.40, 0.22]

7 Strength ‐ pinch (tripod) strength (kg) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

8 Strength ‐ grip strength (kg) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 4. Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant

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Comparison 5. Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain ‐ 100 mm VAS Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2 Adverse events ‐ number of participants with adverse events Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Trapeziometacarpal joint imaging ‐ SMD at rest (mm) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

4 Range of motion ‐ palmar abduction (degrees) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

5 Strength ‐ lateral (key) pinch strength (kp/cm²) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 5. Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson)

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Comparison 6. Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziectomy (T)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain ‐ number of participants with resting pain	0		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2 Adverse events ‐ number of participants with adverse events	0		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
3 Strength ‐ lateral pinch strength (kg)	0		Mean Difference (IV, Random, 95% CI)	Totals not selected
4 Strength ‐ tip pinch strength (kg)	0		Mean Difference (IV, Random, 95% CI)	Totals not selected
5 Strength ‐ grip strength (kg)	0		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 6. Trapeziectomy with interpositional arthroplasty (T and IA) versus trapeziectomy (T)

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