Trapeziectomy with Ligament Reconstruction and Tendon Interposition (LRTI)

History:  This is a 55-year-old, ambidextrous female who runs her own company.  She has had 10 years of pain in her right thumb base.  The pain has been getting worse over the past 1 year.  She has intermittent symptoms, lasting about 2 or 3 weeks at a time.  She has increased pain with grasping, such as opening jars.  Her symptoms are also interfering with her work.  She is a previous smoker, who quit in 1983.  Previous treatments include:

  • Thumb spica brace
  • Steroid injections


Right thumb:  Skin is intact.  There is squaring at the thumb base, also called a “shoulder sign.”  There is a bony prominence on the trapezium.  She has an adduction contracture, but no significant metacarpophalangeal joint hyperextension.  She has tenderness at the carpometacarpal joint with a positive grind test.

Lateral, oblique  and Robert’s views of her right thumb are shown.  She has marked narrowing of the carpometacarpal joint with bone-on-bone contact.  The subchondral bone is sclerotic and there is a small subchondral cyst radially in the trapezium.  She has large osteophytes, >2mm in size.  There is minimal subluxation.  The scaphotrapeziotrapezoid joint does not appear involved.  She is Eaton stage 3 (osteophytes >2mm with no STT joint involvement).

Tests:  Preoperative evaluation was normal.

Options:  She has activity limiting symptoms and has already had a trial of injections and bracing.  While hand therapy, anti-inflammatory medications, heat, ice, and creams and rubs can help with symptoms, she has poor symptom control with bracing and injections and is at a point where surgery can be helpful.  Surgical possibilities include:

  • Simple trapeziectomy—Most surgeons do not choose this option because of a concern that the thumb will settle, however, it can be just as effective as other procedures.
  • Trapeziectomy and ligament reconstruction—This requires a small, but well-anchored tendon graft, typically using all or part of the flexor carpi radialis tendon.
  • Trapeziectomy and tendon interposition arthroplasty—This may use any of a number of tendon grafts that is rolled and placed into the space where the bone was removed.
  • Trapeziectomy with ligament reconstruction and tendon interposition (LRTI)—This is arguably the most common procedure performed, repositioning and suspending the thumb.
  • Implant arthroplasty—Most of these devices are experimental.  Some implants, such as Orthosphere and Swanson silicone spacers, have had disastrous failures.
  • Artelon spacer—This bioabsorbable material is designed to spare bone in lower grades of arthritis.  Early experience suggests good results, but some have reported inflammatory reactions to the material.
  • Arthroscopy with hemiresection and interposition—This is being done in lower grades of arthritis.  Early results are promising.  It is technically challenging to get an arthoscope in this small joint.
  • Consideration can also be made for releasing the adduction contracture and correcting the metacarpophalangeal joint hyperextension, but she has minimal secondary deformity.

Treatment:  She underwent a ligament reconstruction and tendon interposition (LRTI).  She was in a splint until suture removal at about 10 days after surgery.  She then wore a cast for an additional 4 weeks.  She was transitioned to a brace and started hand therapy about 6 weeks after surgery.

Lateral, oblique and Robert’s views of her right thumb are shown.  There are a few specks of trapezium visible in the soft tissues.  There is a wide space between the scaphoid and thumb metacarpal, indicating a good soft tissue suspension of the thumb.

Outcome:  3 months after surgery, she was back to full duties at work and her pain was much improved compared to before surgery.  She was quite pleased with her results.

Share this page:
  • Print
  • Facebook
  • Twitter
  • LinkedIn
  • Digg
  • StumbleUpon
  • Google Bookmarks