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Meta-Analysis
. 2015 Feb 23;2015(2):CD004631.
doi: 10.1002/14651858.CD004631.pub4.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

Anne Wajon  1 , Toby Vinycomb, Emma Carr, Ian Edmunds, Louise Ada
Affiliations
Meta-Analysis

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

Anne Wajon et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

Objectives: To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

Search methods: We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. We excluded trials that compared non-surgical interventions with surgery.

Data collection and analysis: We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

Main results: We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement).Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.We did not find any studies that compared any other combination of the other techniques mentioned above or any other techniques including a sham procedure.

Authors' conclusions: We did not identify any studies that compared surgery to sham surgery and we excluded studies that compared surgery to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

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Conflict of interest statement

We have no known conflicts of interest.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 3
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).
Figure 4
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.
Figure 5
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).
Figure 6
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).
Analysis 1.1
Analysis 1.1
Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 1 Pain ‐ 100 mm VAS.
Analysis 1.2
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.
Analysis 1.3
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.
Analysis 1.4
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.
Analysis 1.5
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).
Analysis 1.6
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).
Analysis 1.7
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).
Analysis 1.8
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).
Analysis 1.9
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).
Analysis 1.10
Analysis 1.10
Comparison 1 Trapeziectomy with ligament reconstruction and tendon interposition (T and LRTI) versus trapeziectomy (T), Outcome 10 Strength ‐ grip strength (kg).
Analysis 2.1
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.
Analysis 2.2
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.
Analysis 2.3
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).
Analysis 2.4
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.
Analysis 2.5
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).
Analysis 2.6
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).
Analysis 2.7
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).
Analysis 4.1
Analysis 4.1
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 1 Pain ‐ 100 mm VAS during key pinch.
Analysis 4.2
Analysis 4.2
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 2 Pain ‐ 100 mm VAS during tripod pinch.
Analysis 4.3
Analysis 4.3
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 3 Adverse events ‐ mild to moderate swelling.
Analysis 4.4
Analysis 4.4
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 4 Treatment failure ‐ reoperation due to pain.
Analysis 4.5
Analysis 4.5
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 5 Range of motion ‐ palmar abduction (degrees).
Analysis 4.6
Analysis 4.6
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 6 Strength ‐ lateral (key) pinch strength (kg).
Analysis 4.7
Analysis 4.7
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 7 Strength ‐ pinch (tripod) strength (kg).
Analysis 4.8
Analysis 4.8
Comparison 4 Trapeziectomy with interpositional arthroplasty (T and IA) versus Artelon implant, Outcome 8 Strength ‐ grip strength (kg).
Analysis 5.1
Analysis 5.1
Comparison 5 Trapeziectomy with interpositional arthroplasty (T and IA) versus Trapeziometacarpal joint replacement (Swanson), Outcome 1 Pain ‐ 100 mm VAS.
Analysis 5.2
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.
Analysis 5.3
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).
Analysis 5.4
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).
Analysis 5.5
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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References

References to studies included in this review

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References to other published versions of this review

    1. Wajon A, Ada L, Edmunds I. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database of Systematic Reviews 2005, Issue 4. [DOI: 10.1002/14651858.CD004631.pub2] - DOI - PubMed
    1. Wajon A, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD004631.pub3] - DOI - PubMed