SURGICAL METHODS IN THE TREATMENT OF BASAL THUMB ARTHRITIS – FROM ARTHROSCOPY TO ARTHROPLASTY
The thumb has an extremely important role in the function of the hand. That function is enabled by a large range of motion of the thumb, dominantly in its basal joint, the first carpometacarpal joint (1 st CMC). Due to that large mobility, the thumb is more susceptible to injury, development of overuse syndromes, and degenerative changes. Osteoarthritis of the 1 st CMC joint is also known as basal thumb arthritis, trapeziometacarpal osteoarthritis and rhizarthrosis. After the knee, 1 st CMC is the second most common joint affected by osteoarthritis ( ). Women are more susceptible to develop basal thumb arthritis due to increased ligamentous laxity in postmenopausal period ( ). Genetic factors, age, obesity, overuse, intraarticular fractures and ligamentous injuries of 1 st CMC joint and systemic diseases such as rheumatoid arthritis also increase the risk of developing basal thumb arthritis ( - ). Although many patients experience pain relief with conservative treatment options, such as activity modification, nonsteroidal anti-inflammatory medications, splints or corticosteroid and hyaluronic acid injections, operative treatment is often needed. In this paper, we present a variety of surgical techniques available for the treatment of basal thumb arthritis, their advantages and drawbacks. 

The thumb rests in pronated position, flexed approximately 80° relative to the plane of the palm, which allows opposition towards the fingertips and more complex motions such as grasping. The radius of the first metacarpal base curvature is by 34% bigger than the one of the trapezoid, which allows a wider range of motion but may predispose to joint incongruity and instability ( ). This disproportion is more expressed in women who also have thinner trapezium cartilage ( , ). Because of bony instability of the 1 st CMC joint, 16 surrounding ligaments help stabilize it. The most important one is the volar oblique ligament (‘beak’ ligament) which acts as a pivot point and limits extreme range of motion, as well as the dorsal radial ligament ( ). It is postulated that pathologic ligamentous laxity because of chronic synovitis, overuse or injury of the beak ligament increases the risk of degenerative changes seen in the 1 st CMC joint of the thumb due to destabilization of the joint ( ). In the course of disease, ligaments that normally reinforce the ulnar side of the 1 st CMC joint (anterior oblique, ulnar collateral and intermetacarpal ligaments) become weak and partially ruptured due to chronic synovitis. These ligaments are no longer able to resist the prevailing, radially directed forces that naturally occur with a thumb pinch. Subsequently, the patient develops a deformity where the base of the first metacarpal slides radially, or dorsoradially relative to the trapezium ( ). In the area of high contact, shear stress forces can damage articular cartilage and cause progression towards osteoarthritis ( ). Compensatory hyperextension may occur in the metacarpophalangeal joint with dynamic collapse while pinching ( ). 

Patients often complain that activities requiring pinch grip such as opening jars, using a key or remote control cause severe pain in basal thumb joint. Stiffness, pain at rest, and joint deformity are usual indicators for late-stage disease. Point tenderness at the carpometacarpal joint and pain with axial compression of the thumb followed by circumduction (grind test) are pathognomonic signs for basal thumb arthritis ( ). Symptoms should be differentiated from first extensor compartment tenosynovitis (de Quervain disease), carpal tunnel syndrome, carpal fractures, osteoarthritis of nearby joints, Preiser disease, and stenosing tenosynovitis of the thumb flexor tendon. Standard radiographic evaluation that includes posteroanterior and lateral views of the hand have to be supplemented with two additional projections, true anteroposterior (Roberts) view and true lateral (Betts) view of the thumb, where the 1 st CMC joint is best visualized ( ). Magnetic resonance imaging (MRI) is helpful especially in early stages of the disease, as it shows cartilage wear, ligament injuries, synovitis, and loose bodies. In 1973, Eaton and Littler ( ) introduced a widely accepted radiographic staging system for thumb CMC arthritis ( ). 

A variety of surgical procedures are described in the literature for pain relief and improvement of hand function. The type of operation depends on patient age, functional demands, and stage of the disease. 

In early stages of the disease (Eaton stage 1 and 2), joint-preserving procedures are used. Their goal is to stabilize the CMC joint and reduce inflammatory process in order to slow progression of the disease and reduce its symptoms. Stabilization of 1 st CMC joint Eaton et al . ( ) describe the method in which half of the flexor carpi radialis tendon was proximally separated from the muscle and then passed through the volar to dorsal tunnel across the base of the first metacarpal bone, parallel to the trapeziometacarpal joint, in order to stabilize the 1 st CMC joint by reconstructing beak ligament ( ). The advantage of this technique is that trapezium is preserved, so the patients have good pinch and grip strength. Disadvantage of this procedure is that flexor carpi radialis tendon is used, which may be required for future treatment in case of disease progression. In early stages with dorsal subluxation of the 1 st CMC joint, simple imbrication of the dorsoradial capsule can provide joint stability ( ). Advantage of this procedure is that it is a much simpler procedure that does not require tendon grafts, but it may not be sufficient to support the 1 st CMC joint if volar beak ligament is insufficient. It can be used as an additional procedure for stabilizing the 1 st CMC joint. First metacarpal extension osteotomy First metacarpal extension osteotomy ( ) is performed one centimeter distal from the 1 st CMC joint ( ). A 20- to 30-degree bone wedge is removed from the radial side of the metacarpal bone. The site of osteotomy can be fixed with tension bend wires or with ‘T’-plate and screws or staples. The rationale of this operation is to move the load force from the damaged, volar part of the joint dorsally, thereby reducing pain and slowing progression of the disease. First CMC joint laxity is also decreased during pinch because more metacarpal flexion is needed, which causes tightening of the dorsal radial ligament ( ). Disadvantage is a higher percentage of infections and revision surgeries because of hardware removal, non-unions, tendon irritation, and tendon ruptures ( ). This procedure is not suitable for patients with fixed dorsal subluxation of the 1 st CMC joint, hyperlaxity and joint hyperextension. Arthroscopy for early basal thumb arthritis Arthroscopy of the basal thumb joint in early stages of osteoarthritis allows visualization of the entire joint and appropriate treatment ( ). Arthroscopic classification of 1 st CMC osteoarthritis was introduced by Badia ( ). In stage 1, cartilage damage and synovitis are treated with debridement and synovectomy, and removal of loose bodies ( , ). In the presence of dorsal subluxation, arthroscopic stabilization of the 1 st CMC joint is performed by electrothermal heating and shrinkage of volar ligaments and joint capsule with monopolar radiofrequency probe, followed by immobilization ( ). For stage 2, it is recommended to add first metacarpal extension osteotomy to arthroscopic procedure ( ). Advantages of arthroscopic procedures are a minimally invasive approach and less scar tissue, direct visualization and treatment of joint pathology. Disadvantages are inability to reconstruct 1 st CMC ligaments and danger of thermal injuries to the cartilage. 

st CMC joint Eaton et al . ( ) describe the method in which half of the flexor carpi radialis tendon was proximally separated from the muscle and then passed through the volar to dorsal tunnel across the base of the first metacarpal bone, parallel to the trapeziometacarpal joint, in order to stabilize the 1 st CMC joint by reconstructing beak ligament ( ). The advantage of this technique is that trapezium is preserved, so the patients have good pinch and grip strength. Disadvantage of this procedure is that flexor carpi radialis tendon is used, which may be required for future treatment in case of disease progression. In early stages with dorsal subluxation of the 1 st CMC joint, simple imbrication of the dorsoradial capsule can provide joint stability ( ). Advantage of this procedure is that it is a much simpler procedure that does not require tendon grafts, but it may not be sufficient to support the 1 st CMC joint if volar beak ligament is insufficient. It can be used as an additional procedure for stabilizing the 1 st CMC joint. 

First metacarpal extension osteotomy ( ) is performed one centimeter distal from the 1 st CMC joint ( ). A 20- to 30-degree bone wedge is removed from the radial side of the metacarpal bone. The site of osteotomy can be fixed with tension bend wires or with ‘T’-plate and screws or staples. The rationale of this operation is to move the load force from the damaged, volar part of the joint dorsally, thereby reducing pain and slowing progression of the disease. First CMC joint laxity is also decreased during pinch because more metacarpal flexion is needed, which causes tightening of the dorsal radial ligament ( ). Disadvantage is a higher percentage of infections and revision surgeries because of hardware removal, non-unions, tendon irritation, and tendon ruptures ( ). This procedure is not suitable for patients with fixed dorsal subluxation of the 1 st CMC joint, hyperlaxity and joint hyperextension. 

Arthroscopy of the basal thumb joint in early stages of osteoarthritis allows visualization of the entire joint and appropriate treatment ( ). Arthroscopic classification of 1 st CMC osteoarthritis was introduced by Badia ( ). In stage 1, cartilage damage and synovitis are treated with debridement and synovectomy, and removal of loose bodies ( , ). In the presence of dorsal subluxation, arthroscopic stabilization of the 1 st CMC joint is performed by electrothermal heating and shrinkage of volar ligaments and joint capsule with monopolar radiofrequency probe, followed by immobilization ( ). For stage 2, it is recommended to add first metacarpal extension osteotomy to arthroscopic procedure ( ). Advantages of arthroscopic procedures are a minimally invasive approach and less scar tissue, direct visualization and treatment of joint pathology. Disadvantages are inability to reconstruct 1 st CMC ligaments and danger of thermal injuries to the cartilage. 

st CMC Osteoarthritis – Joint Arthroplasty Procedures Progression of the disease (Eaton stage 3 and 4) leads to the development of significant degenerative changes, primarily on the trapezium, with loss of the cartilage cover and development of large osteophytes. Because of that, in later stages of basal thumb arthritis, partial or complete removal of the trapezium bone (trapeziectomy) combined with different joint stabilization procedures are the methods of choice. The main technical pearl, whether partial or complete removal of the trapezium is performed, is complete removal of osteophytes on the trapezium between the first and second metacarpal bone. That will enable reposition of the first metacarpal bone, eliminate pain, and improve function of the thumb. Hematoma distraction Good results with minimal complications shows a technique called ‘hematoma distraction’ ( ) ( ). After complete or partial trapeziectomy, metacarpal bone is fixed with Kirschner wire in a slightly overcorrected position, without tissue interposition or ligament reconstruction, in order to prevent proximal migration until hematoma is stiffened. Kuhns et al . ( ) report excellent results with this operative technique. Initially, this technique offers a pain-free and good range of thumb motion but subsidence and instability of first metacarpal can occur, and patient can start to feel pain and loose strength. Also, over time, cranial migration of metacarpal bone (subsidence) can cause impingement with the scaphoid. Interposition arthroplasty In order to prevent subsidence, in 1970, Froimson ( ) described a technique of tendon interposition following trapeziectomy ( ). Upon careful dissection and excision of the trapezium, the flexor carpi radialis tendon (FCR) was split and half of it was used as an interpositum in the place created by trapezial excision in order to prevent metacarpal migration. In similar manner, the abductor pollicis longus tendon (APL) can be used as interpositum. Due to increasing number of younger and highly active patients that need not only surgical treatment but also faster rehabilitation, various allogeneic materials such as silicon ( - ), polytetrafluorethylene (Gore-Tex) ( ), polyurethane (Artelon) ( ), acellular matrix (Graftjacket) ( ), and titanium ( ) were developed for interpositum because of their strength, but with time, instability of the implant and its wear resulted in inflammatory synovitis and reccurrence of pain ( ). Pyrolytic carbon implants are used as nonanatomic implants after partial or complete trapeziectomy ( ) ( ). It has elasticity comparable to cortical bone, and should be used in patients without subluxation of trapeziometacarpal joint and without scaphotrapeziotrapezoidal joint involvement ( ). Pyrocarbon implants provide good grip strength and range of motion, and can be used for revision procedures. The main problem concerning pyrocarbon is subluxation of the implant described in several studies, and need of revision ( ). Therefore, more long-term studies are still needed to evaluate this implant. Ligament reconstruction – suspensionplasty In 1986, Burton and Pellegrini ( ) described surgical technique that combined ligament reconstruction, similar to the technique of Eaton et. al ( ), and tendon interposition, similar to the technique of Froimson ( ). Half or whole tendon of flexor carpi radialis is harvested and then passed through the previously made hole in the base of metacarpal bone in order to reconstruct ligamentous complex ( ). The remaining tendon is interpositioned and sutured to the capsule between the scaphoid and first metacarpal bone. The goal of this procedure is to create suspension of the first metacarpal like a hammock that would stabilize the first metacarpal. Tomaino et al . ( ) report on excellent pain relief in 95% of operated patients during long-term follow up. There are several modifications of this technique reported, such as the use of interfering screw for fixation of the FCR tendon in the first metacarpal bone in order to achieve early mobilization and faster recovery ( ). This is the most popular procedure for treatment of 1 st CMC osteoarthritis and generally provides very good results but subsidence can still occur over time because of rupture or attrition of the FCR tendon. Tendon can also be injured intraoperatively, especially during removal of the trapezium, and it should be recognized during surgery. If tendon injury is not severe, it can be reinforced with suture, but if there is severe injury of the tendon, different procedure should be performed. However, it has been reported by some authors that the use of the FCR for basal thumb arthritis is associated with weakness in wrist flexion and torsion ( ). Because of that, Thompson ( ) has described the ‘suspensionplasty’ technique using a slip of the APL ( ). The idea was not to reconstruct volar beak ligament but to recreate the intermetacarpal ligament. After trapeziectomy, he used a distally based strip of the APL, made a tunnel in the base of the first and second metacarpal bone, and then suspended the base of the first metacarpal to the second metacarpal. The remaining tendon was used as an interposition. Reporting on 50 suspensionplasties over an 8-year period, using tendon interposition to fill the space of the trapezium, Thompson describes “generally excellent” outcomes, with pain reduction and improved mobility and strength ( ). Disadvantages of suspensionplasty techniques include possible injury to the superficial radial nerve and a cosmetically unappealing bump. Sigfusson and Lundborg ( ) modified Thompson’s technique so that it did not require bone tunnel in second metacarpal. They passed the APL tendon around the FCR tendon and sutured it back to itself on insertion on the first metacarpal. Weilby ( ) has published an alternative ‘suspensionplasty’ technique that also does not require bone tunnel creation at the base of the first metacarpal bone ( ). In this procedure, the trapezium is removed, after that approximately one third of the FCR tendon is harvested and mobilized to its insertion on the second metacarpal base. Subsequently, the harvested tendon graft is used as a sling to wind together the abductor pollicis longus tendon and the remaining two thirds of the FCR tendon as a suspension and interposition arthroplasty. Recently, suture-button suspensionplasty with mini Tight-Rope (Arthrex) was introduced and it is becoming more and more popular ( ) ( ). Suture-button system is made of sutures looped across two titanium buttons. After trapeziectomy and reposition of first metacarpal, bone tunnel is made through first and second metacarpal in oblique manner, from dorsoradial border of first metacarpal into proximal diaphysis of second metacarpal. Suture-button system is passed through that tunnel and buttons are placed on both metacarpals, and suture is tensioned and secured. Oblique position of the tunnel is thought to be better in preventing subsidence. Some authors place two suture-button systems to provide more secure stabilization of first metacarpal ( ). The advantage of this procedure is that it allows early mobilization and fast recovery because it does not need time to heal. It can also be good solution for revision cases. Drawbacks are some subsidence, cost of implant(s), and possible nerve injury and metacarpal fracture ( ). Arthroscopy for late basal thumb arthritis As technology continues to evolve, new advances in arthroscopy give us a possibility to achieve good strength of the thumb and pain reduction even in late stages of basal thumb arthritis. With camera control, hemitrapeziectomy can be done in a manner of producing contour of smooth flat surface by removing all osteophytes and loose bodies ( ). After that, thermal capsulodesis, with or without addition of Kirschner wire, can be done in order to stabilize the joint ( ). There is no published paper on arthroscopically done ligament reconstruction yet, but suspensionplasty, as mentioned before, can be achieved by the use of Mini Tight-Rope ( ). Finally, allogeneic or autogenous material can be placed as interpositum to avoid metacarpal subsidence. The advantage of this procedures is that capsule is intact and there are reduced chances of damage to radial sensory nerve branch. Disadvantage is that these procedures are technically demanding and could require longer operation time and use of fluoroscopy to confirm complete removal of osteophytes and adequate removal of trapezium. Prosthetic arthroplasty Total joint arthroplasty was also introduced as a method of treatment for basal thumb arthritis ( ). First total joint endoprosthesis was done back in 1979 by de la Caffiniere and Aucouturier ( ). Over time, more prosthetic implants have been developed. They all had very good short-term results, better than trapeziectomy and arthrodesis, but over time they showed poor survival rate and high loosening rate of 44% ( ). The main complications were hardware failure (including dislocation, subsidence and loosening of the components), persistent pain, neurologic damage, inflammation of the surrounding tissues, and peri-implant fractures. Among all, the most frequent is hardware failure because of the really small implant dimensions and thinness of the cortical bone of the joints involved. Although there are some studies that show good long-term results for certain types of prosthesis, with good strength and mobility of the thumb, literature review does not show that total arthroplasty is superior to trapeziectomy. Complications of prosthetic arthroplasty that are much higher and more difficult to manage and significant cost of implant are the drawbacks of this procedure ( ). Arthrodesis Trapeziectomy, whether it is a single or combined with any other described techniques, never provides enough strength for high-demanding patients. First CMC arthrodesis should be a reasonable procedure if strength is crucial ( ). It is to be noted that in arthrodesis, postoperative thumb function depends on increased mobility of surrounding joints to compensate for the lack of motion at the fused trapeziometacarpal joint. Because of that, in stage 4 of basal thumb arthritis where degenerative changes are extended to the surrounding joints, arthrodesis is contraindicated. Muller ( ) described technique in 1949. The thumb is fixed with screws or plate and screws in a position of 30-40° palmar abduction, 35° of radial abduction, 15° of pronation and 10° of extension. Surgery creates a pain-free, strong, stable thumb at the expense of full range of motion ( ). The possible complications are more postoperative infections and pseudarthrosis. Also, as in other arthrodesis, degenerative changes will in time spread to the surrounding joints, or hyperextension of MCP joint can develop ( ). The advantage of this procedure is that in exacerbation of disease, you can still perform simple trapeziectomy combined with other procedures mentioned above. 

Good results with minimal complications shows a technique called ‘hematoma distraction’ ( ) ( ). After complete or partial trapeziectomy, metacarpal bone is fixed with Kirschner wire in a slightly overcorrected position, without tissue interposition or ligament reconstruction, in order to prevent proximal migration until hematoma is stiffened. Kuhns et al . ( ) report excellent results with this operative technique. Initially, this technique offers a pain-free and good range of thumb motion but subsidence and instability of first metacarpal can occur, and patient can start to feel pain and loose strength. Also, over time, cranial migration of metacarpal bone (subsidence) can cause impingement with the scaphoid. 

In order to prevent subsidence, in 1970, Froimson ( ) described a technique of tendon interposition following trapeziectomy ( ). Upon careful dissection and excision of the trapezium, the flexor carpi radialis tendon (FCR) was split and half of it was used as an interpositum in the place created by trapezial excision in order to prevent metacarpal migration. In similar manner, the abductor pollicis longus tendon (APL) can be used as interpositum. Due to increasing number of younger and highly active patients that need not only surgical treatment but also faster rehabilitation, various allogeneic materials such as silicon ( - ), polytetrafluorethylene (Gore-Tex) ( ), polyurethane (Artelon) ( ), acellular matrix (Graftjacket) ( ), and titanium ( ) were developed for interpositum because of their strength, but with time, instability of the implant and its wear resulted in inflammatory synovitis and reccurrence of pain ( ). Pyrolytic carbon implants are used as nonanatomic implants after partial or complete trapeziectomy ( ) ( ). It has elasticity comparable to cortical bone, and should be used in patients without subluxation of trapeziometacarpal joint and without scaphotrapeziotrapezoidal joint involvement ( ). Pyrocarbon implants provide good grip strength and range of motion, and can be used for revision procedures. The main problem concerning pyrocarbon is subluxation of the implant described in several studies, and need of revision ( ). Therefore, more long-term studies are still needed to evaluate this implant. 

In 1986, Burton and Pellegrini ( ) described surgical technique that combined ligament reconstruction, similar to the technique of Eaton et. al ( ), and tendon interposition, similar to the technique of Froimson ( ). Half or whole tendon of flexor carpi radialis is harvested and then passed through the previously made hole in the base of metacarpal bone in order to reconstruct ligamentous complex ( ). The remaining tendon is interpositioned and sutured to the capsule between the scaphoid and first metacarpal bone. The goal of this procedure is to create suspension of the first metacarpal like a hammock that would stabilize the first metacarpal. Tomaino et al . ( ) report on excellent pain relief in 95% of operated patients during long-term follow up. There are several modifications of this technique reported, such as the use of interfering screw for fixation of the FCR tendon in the first metacarpal bone in order to achieve early mobilization and faster recovery ( ). This is the most popular procedure for treatment of 1 st CMC osteoarthritis and generally provides very good results but subsidence can still occur over time because of rupture or attrition of the FCR tendon. Tendon can also be injured intraoperatively, especially during removal of the trapezium, and it should be recognized during surgery. If tendon injury is not severe, it can be reinforced with suture, but if there is severe injury of the tendon, different procedure should be performed. However, it has been reported by some authors that the use of the FCR for basal thumb arthritis is associated with weakness in wrist flexion and torsion ( ). Because of that, Thompson ( ) has described the ‘suspensionplasty’ technique using a slip of the APL ( ). The idea was not to reconstruct volar beak ligament but to recreate the intermetacarpal ligament. After trapeziectomy, he used a distally based strip of the APL, made a tunnel in the base of the first and second metacarpal bone, and then suspended the base of the first metacarpal to the second metacarpal. The remaining tendon was used as an interposition. Reporting on 50 suspensionplasties over an 8-year period, using tendon interposition to fill the space of the trapezium, Thompson describes “generally excellent” outcomes, with pain reduction and improved mobility and strength ( ). Disadvantages of suspensionplasty techniques include possible injury to the superficial radial nerve and a cosmetically unappealing bump. Sigfusson and Lundborg ( ) modified Thompson’s technique so that it did not require bone tunnel in second metacarpal. They passed the APL tendon around the FCR tendon and sutured it back to itself on insertion on the first metacarpal. Weilby ( ) has published an alternative ‘suspensionplasty’ technique that also does not require bone tunnel creation at the base of the first metacarpal bone ( ). In this procedure, the trapezium is removed, after that approximately one third of the FCR tendon is harvested and mobilized to its insertion on the second metacarpal base. Subsequently, the harvested tendon graft is used as a sling to wind together the abductor pollicis longus tendon and the remaining two thirds of the FCR tendon as a suspension and interposition arthroplasty. Recently, suture-button suspensionplasty with mini Tight-Rope (Arthrex) was introduced and it is becoming more and more popular ( ) ( ). Suture-button system is made of sutures looped across two titanium buttons. After trapeziectomy and reposition of first metacarpal, bone tunnel is made through first and second metacarpal in oblique manner, from dorsoradial border of first metacarpal into proximal diaphysis of second metacarpal. Suture-button system is passed through that tunnel and buttons are placed on both metacarpals, and suture is tensioned and secured. Oblique position of the tunnel is thought to be better in preventing subsidence. Some authors place two suture-button systems to provide more secure stabilization of first metacarpal ( ). The advantage of this procedure is that it allows early mobilization and fast recovery because it does not need time to heal. It can also be good solution for revision cases. Drawbacks are some subsidence, cost of implant(s), and possible nerve injury and metacarpal fracture ( ). 

As technology continues to evolve, new advances in arthroscopy give us a possibility to achieve good strength of the thumb and pain reduction even in late stages of basal thumb arthritis. With camera control, hemitrapeziectomy can be done in a manner of producing contour of smooth flat surface by removing all osteophytes and loose bodies ( ). After that, thermal capsulodesis, with or without addition of Kirschner wire, can be done in order to stabilize the joint ( ). There is no published paper on arthroscopically done ligament reconstruction yet, but suspensionplasty, as mentioned before, can be achieved by the use of Mini Tight-Rope ( ). Finally, allogeneic or autogenous material can be placed as interpositum to avoid metacarpal subsidence. The advantage of this procedures is that capsule is intact and there are reduced chances of damage to radial sensory nerve branch. Disadvantage is that these procedures are technically demanding and could require longer operation time and use of fluoroscopy to confirm complete removal of osteophytes and adequate removal of trapezium. 

Total joint arthroplasty was also introduced as a method of treatment for basal thumb arthritis ( ). First total joint endoprosthesis was done back in 1979 by de la Caffiniere and Aucouturier ( ). Over time, more prosthetic implants have been developed. They all had very good short-term results, better than trapeziectomy and arthrodesis, but over time they showed poor survival rate and high loosening rate of 44% ( ). The main complications were hardware failure (including dislocation, subsidence and loosening of the components), persistent pain, neurologic damage, inflammation of the surrounding tissues, and peri-implant fractures. Among all, the most frequent is hardware failure because of the really small implant dimensions and thinness of the cortical bone of the joints involved. Although there are some studies that show good long-term results for certain types of prosthesis, with good strength and mobility of the thumb, literature review does not show that total arthroplasty is superior to trapeziectomy. Complications of prosthetic arthroplasty that are much higher and more difficult to manage and significant cost of implant are the drawbacks of this procedure ( ). 

Trapeziectomy, whether it is a single or combined with any other described techniques, never provides enough strength for high-demanding patients. First CMC arthrodesis should be a reasonable procedure if strength is crucial ( ). It is to be noted that in arthrodesis, postoperative thumb function depends on increased mobility of surrounding joints to compensate for the lack of motion at the fused trapeziometacarpal joint. Because of that, in stage 4 of basal thumb arthritis where degenerative changes are extended to the surrounding joints, arthrodesis is contraindicated. Muller ( ) described technique in 1949. The thumb is fixed with screws or plate and screws in a position of 30-40° palmar abduction, 35° of radial abduction, 15° of pronation and 10° of extension. Surgery creates a pain-free, strong, stable thumb at the expense of full range of motion ( ). The possible complications are more postoperative infections and pseudarthrosis. Also, as in other arthrodesis, degenerative changes will in time spread to the surrounding joints, or hyperextension of MCP joint can develop ( ). The advantage of this procedure is that in exacerbation of disease, you can still perform simple trapeziectomy combined with other procedures mentioned above. 

Adduction deformity of first metacarpal in advanced stages of disease can cause hyperextension and instability of the first metacarpophalangeal (1 st MCP) joint, ‘zigzag’ deformity of the thumb ( ). If this deformity is not corrected with treatment of the 1 st CMC joint, it will cause weak pinch of the thumb, and intercalated instability of first metacarpal which will regain adducted posture in order to stabilize 1 st MCP joint. That adducted posture will then put an excessive stress on 1 st CMC arthroplasty. For this reason, it is mandatory to treat hyperextension deformity of the 1 st MCP if it is greater than 30° ( ). It can be treated with volar plate capsulodesis or transfer of extensor pollicis brevis along with temporary transfixation of MCP joint with K wire in semiflexion ( , ). If the joint is grossly unstable or arthritic, MCP joint arthrodesis is the best solution. 

There are many different techniques for the treatment of 1 st CMC osteoarthritis to achieve the best possible functional results if conservative treatment fails. In early stages of the disease, ligament laxity or rupture and cartilage wear with synovitis are the main problem, and arthroscopy, metacarpal osteotomy and 1 st CMC stabilization are performed to address specific pathology. Late stages include severe degenerative changes with large osteophytes, especially in the first intermetacarpal space, and they need to be removed with partial or complete trapeziectomy. Additional procedure such as interposition arthroplasty, ligament reconstruction and suspensionplasty, is usually performed to achieve stability of the 1 st CMC joint and to prevent subsidence of first metacarpal. Total joint arthroplasty theoretically has the best predisposition to accomplish stable joint with good range of motion but more long-term studies are needed. First CMC arthrodesis is still preferred if the patient needs to be very active with high loads on his hands. The surgeon needs to be familiar with several different methods in order to provide appropriate treatment for each patient, and to be able to perform revision procedures or treat intraoperative complications. 

