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Mateusz Gładysz

Thumb-base joint replacement and trapeziectomy

· MD · FEBOPRAS · FEBHS

Thumb-base arthritis is wear of the saddle joint between the trapezium and the first metacarpal.

Last clinically reviewed

1. Indications

  • Pain at the base of the thumb from trapeziometacarpal osteoarthritis that limits daily activities despite non-operative care. The British guideline places surgery after self-management, a splint and, where used, an injection have failed1. No trial has compared surgery with continued non-operative care2.
  • Joint replacement: disease confined to the trapeziometacarpal joint — Eaton–Littler stages II and III3 — with enough trapezial height and bone stock to hold a press-fit cup. It suits patients who want an early return of pinch strength and thumb length. In a series of 130 dual-mobility replacements the estimated 2-year survival was 96 per cent, and its authors recommend the operation as the standard procedure for isolated trapeziometacarpal arthritis4.
  • Trapeziectomy: arthritis that also involves the scaphotrapeziotrapezoid joint (pantrapezial disease) and failure of an implant56; also a trapezium too small or too soft to hold a cup, and patients who prefer an operation without an implant.
  • Metacarpophalangeal hyperextension of the thumb is not in itself a reason for a second procedure: after joint replacement, hyperextension of more than 20° corrected to about 9° without any operation on the metacarpophalangeal joint7.

2. Contraindications

  • Active infection of the hand or wrist.
  • For joint replacement: arthritis of the (stage IV) is outside the labelled indication of the implant and is a case-by-case decision, because pain from that joint may persist after the replacement. Trapeziectomy is the usual choice when that joint is involved5.
  • For joint replacement: a trapezium too low or too osteoporotic to hold a press-fit cup. Central placement and parallel alignment of the cup are crucial for its stability8.
  • For joint replacement, a relative caution: polyethylene liner fractures have been reported, mostly in active men with a high key pinch9.
  • Arthrodesis remains an alternative to discuss, but in a trial against trapeziectomy with a tendon sling it caused more complications and the trial was stopped early; its authors do not recommend routine arthrodesis with plate and screws in women aged 40 or more with stage II or III disease10.

3. Relevant anatomy

The trapezium articulates distally with the first metacarpal in a saddle-shaped joint and proximally with the scaphoid and trapezoid. Sixteen ligaments stabilise the trapezium and the trapeziometacarpal joint; the dorsoradial and deep anterior oblique (beak) ligaments play the main stabilising role, and the deep anterior oblique ligament may act as a pivot that allows the metacarpal to pronate during palmar abduction11. Resorption of the anterior beak of the metacarpal weakens the anterior oblique ligament; the metacarpal then flexes and subluxes dorsoradially, and compensatory hyperextension of the metacarpophalangeal joint produces the zigzag deformity12.
Two structures are at risk in a dorsoradial approach. The arteries of the joint arise from the radial artery and the princeps pollicis artery, and the richest arterial network lies on the dorsoradial surface of the joint13. Branches of the were at risk at every arthroscopic approach to the joint in a cadaver study14, and they lie in the field of the open dorsoradial approach.

4. Patient positioning

Supine, with the arm on a hand table and the forearm pronated so that the thumb is uppermost. The operation is done under a given by an anaesthetist, with an upper-arm tourniquet at 250 mmHg. An image intensifier is positioned and draped before the incision; implant sizes are templated on the pre-operative radiograph of the trapeziometacarpal joint. Cefazolin 2 g is given intravenously and completed before the tourniquet is inflated (3 g at 120 kg or more; clindamycin in β-lactam anaphylaxis), as a single dose. Venous thromboembolism prophylaxis is mechanical only, because this is a day-case upper-limb operation with immediate mobilisation.

5. Approach

A dorsoradial longitudinal incision, 4 to 5 cm long, is centred on the trapeziometacarpal joint in line with the extensor pollicis brevis tendon. Branches of the superficial radial nerve are identified, mobilised and protected throughout; the radial artery is identified proximally over the trapezium and retracted. The interval between abductor pollicis longus and extensor pollicis brevis is developed, preserving the abductor pollicis longus insertion.

6. Key steps

  1. 1. Capsulectomy and release of the joint

    The capsule is opened longitudinally and excised completely. In a comparison of 131 resections with 57 repairs during dual-mobility arthroplasty, pain, hand function and complications at 1 year did not differ, and the authors concluded that the capsule can be safely resected15. The joint is then released circumferentially: the intermetacarpal ligament, the anterior beak of the metacarpal base and every marginal osteophyte, particularly those between the thumb and index metacarpals12. The scaphotrapeziotrapezoid joint is inspected.

  2. 2. Metacarpal preparation

    The metacarpal base is delivered by flexing and adducting the thumb. The articular surface is cut with an oscillating saw through the cutting guide, perpendicular to the metacarpal axis, removing no more than 5 mm. The canal is opened centrally in the axis of the shaft and broached in sequence until the broach is stable to rotation.

  3. 3. Trapezial guidewire and reaming

    The centre of the distal articular surface of the trapezium is found at the intersection of its dorsopalmar and radioulnar diameters. A guidewire is placed there, perpendicular to the proximal articular surface of the trapezium in both the lateral and the dorsopalmar plane, and its position is checked on the image intensifier before any reaming; in one series both revisions for cup dislocation followed misplacement of the cup16. Cannulated reaming then preserves the subchondral bone of the scaphotrapeziotrapezoid surface and leaves the trapezial walls intact.

  4. 4. Cup implantation

    The definitive cup is impacted press-fit, centred on the distal trapezial surface and parallel to its proximal articular surface, and its seating is confirmed on the image intensifier. Central placement and parallel alignment are crucial for cup stability and for preventing dislocation; if a cup tilts or seats off-centre, computer-simulation work suggests revision to a larger cup, deeper in cancellous bone or with bone graft — suggestions not yet confirmed in anatomical specimens8.

  5. 5. Trial reduction and neck selection

    Trial necks are tested with the trial stem. The neck is chosen on tension — about half to one head diameter of subluxation under longitudinal traction — with full flexion, extension, abduction, adduction, opposition and retropulsion free of neck-on-cup impingement and no subluxation on axial compression. In a computer and cadaver study, impingement in extension occurred with the offset neck once the cup was tilted 15° anteriorly but only at 30° with the straight neck; the authors recommend a straight neck when the cup is tilted 15° or more anteriorly17.

  6. 6. Definitive implants and imaging

    The definitive stem is impacted in the axis of the canal and the definitive neck, with its pre-assembled polyethylene liner, is seated on the dried taper. After reduction, range of motion, stability and the absence of impingement are confirmed again, and posteroanterior and lateral images are saved: cup centred and parallel to the proximal trapezial surface, stem in the metacarpal axis, joint reduced, no fracture. Implant sizes and lot numbers are recorded from the labels, never from memory.

  7. 7. Trapeziectomy, as described in the published trials

    Trapeziectomy is the alternative operation and the salvage for a failed implant, which can be exchanged or converted to a trapeziectomy6; in a multicentre series the 11 failed replacements were treated by trapeziectomy18. At the same operation, a trapeziectomy is also the bail-out when the trapezium cracks or will not hold the cup securely; a crack in a trapezium that still holds the cup is managed with a longer period of immobilisation instead. The trapezium is excised completely. In a long-term randomised trial, 174 thumbs had simple trapeziectomy, trapeziectomy with palmaris longus interposition, or ligament reconstruction and tendon interposition with half of the flexor carpi radialis; all had a K-wire across the void for 4 weeks and a thumb spica for 6 weeks, and the outcomes of the three operations did not differ at a median of 6 years19. The 2026 Cochrane review found low-certainty evidence that adding makes little or no difference to pain, function or adverse events compared with trapeziectomy alone2.

7. Closure

After joint replacement the tourniquet is released and haemostasis secured with bipolar diathermy; the wound is irrigated. The capsule and deep layers are not closed and no drain is used. The skin is closed with a 4-0 Monocryl subcuticular suture (3-0 for thicker skin) and Steri-Strips, so there are no sutures to remove. A non-adherent dressing, wool and crepe, and a well-padded thumb spica plaster back-slab in palmar abduction with the interphalangeal joint free complete the operation.

8. Aftercare

After joint replacement:
  • day case; elevation for 48 hours; finger and interphalangeal joint movement from day 1;
  • paracetamol and an anti-inflammatory regularly for 5 to 7 days, with a short course of tramadol if needed;
  • the back-slab stays until the hand-therapy review at 3 to 5 days, then a removable thermoplastic thumb orthosis is worn to 4 weeks;
  • active thumb movement and opposition out of the orthosis from day 5, avoiding axial traction and forced retropulsion;
  • no forceful pinch, lifting over 1 kg or heavy manual loading for 6 weeks; pinch and grip loading from 6 weeks after satisfactory radiographs;
  • wound check and Steri-Strip removal at 10 to 14 days;
  • driving from 4 weeks; desk work at 2 to 3 weeks; manual work at 6 to 8 weeks;
  • radiographs at 6 weeks, 1 year and 5 years for implant surveillance; clinic review at 2 weeks, 6 weeks, 3 months and 1 year.
There is no comparative evidence for any regimen after joint replacement: a scoping review of 123 studies found wide variation in immobilisation and rehabilitation and no study comparing protocols20. After trapeziectomy, early mobilisation was as safe and effective as 6 weeks in a rigid orthosis in a randomised trial21, and after ligament reconstruction and tendon interposition a longer immobilisation protocol gave no better function, strength or satisfaction than early mobilisation22.

9. Complications

Joint replacement
  • Overall: in a systematic review of 1,421 dual-mobility arthroplasties, complications occurred in 13 per cent and dislocation in 0.6 per cent; follow-up was too short to judge long-term survival23.
  • Survival and revision: the estimated 2-year implant survival was 96 per cent in 130 patients, revisions being for dislocation, loosening or impingement4; in another series 4 of 88 (4.5 per cent) were revised, two for cup dislocation after misplacement and two for impingement16. In 107 implants followed for more than 3 years, complications were 4.6 per cent, including cup loosening and polyethylene wear, with no dislocation24.
  • First extensor compartment (De Quervain-type) tenosynovitis: 6 of 101 patients at 2 years in one series4 and 4.4 per cent in another, unrelated to thumb lengthening25. One group, finding a high rate, suggests opening the first extensor compartment while positioning the prosthesis26.
  • Trigger thumb: 5 of 101 patients4.
  • Polyethylene liner fracture: 17 cases reported, mostly in active men with a high key pinch, treated by head and liner exchange or trapeziectomy9.
  • Learning curve: proficiency was reached after 33 to 40 cases, although outcomes before that point were not worse27.
  • Early complications: in 381 replacements with two modern implant designs, minor adverse events occurred in 25.4 per cent, most often transient irritation of the superficial radial nerve and De Quervain tendinopathy; failure to achieve primary stability of the cup was the leading cause of failure18.
  • In a systematic review of all implant and non-implant techniques, total joint replacements needed a salvage operation at about 2.4 per 100 procedure-years, against 0.49 for trapeziectomy28.
Trapeziectomy

10. Evidence

Two randomised trials compared dual-mobility replacement with trapeziectomy. In the first, of 62 women, replacement was not superior on the Michigan Hand Outcomes Questionnaire at 1 year but gave better strength and range of motion30; at 5 years the hand-function score still did not differ, while , satisfaction and willingness to repeat the operation favoured replacement31. In a second trial of 147 thumbs against trapeziectomy with tendon interposition, the replacement group improved faster, particularly in strength and range of motion5. A network meta-analysis of 21 trials found similar pain relief, with pinch about 0.9 kg stronger after replacement and no long-term data32. In a pooled analysis, pinch strength returned to its pre-operative level about 1.5 months after replacement against about 6 months after trapeziectomy, from low-quality studies, and the difference was not statistically significant33. In a cost-effectiveness study, working patients returned to work after 52 days on average after replacement against 84 days after resection-suspension-interposition arthroplasty34.
For trapeziectomy, the long-term randomised trial and the Cochrane review support the simple operation: tendon interposition or ligament reconstruction adds no lasting benefit192. Pain relief after trapeziectomy was good in 78 per cent at a median of 6 years19.
The main gap is long-term survival of modern dual-mobility implants: one prospective series follows 61 implants for a mean of 6.5 years (5 to 8.8)35, and across implant designs failure rates ranged from about 3 to 20 per cent, lower for modern implants than for their predecessors36. In patients who had one operation on each hand, 10 of 14 would choose the implant again37.
For patients — plain-language summary
Arthritis at the base of the thumb can be treated with an operation when splints, exercises and injections no longer help. There are two main choices. A joint replacement fits a small ball-and-socket implant into the joint. It is done as a day case with the arm numbed by an injection. You wear a plaster for 3 to 5 days and then a removable splint to 4 weeks, start moving the thumb at day 5, and avoid heavy pinching and lifting for 6 weeks. Driving is usually possible from 4 weeks, and manual work from 6 to 8 weeks. A trapeziectomy removes the small worn bone instead. Recovery of strength is slower, but there is no implant that could wear or loosen. Both operations relieve pain in most people. In a randomised trial, people with a replacement had a stronger pinch and were more satisfied at 5 years, but long-term results for the newest implants are not yet available. Your surgeon will discuss which suits your hand, your work and your wishes.

References

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  34. Marks M, Mathis K, Schindele S, Herren DB. Cost-Effectiveness of Trapeziometacarpal Dual Mobility Implant Arthroplasty Compared to Resection Arthroplasty. J Hand Surg Am. 2026;51(9):946-955. PubMed DOI
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  37. Nietlispach V, Marks M, Imhof J, Pudic T, Herren DB. Which would you choose again? Comparison of trapeziometacarpal implant versus resection arthroplasty in the same patient. J Hand Surg Eur Vol. 2024;50(2):178-183. PubMed DOI