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• W4252610085 abstract "We thank Dr. Burton for his interest in our article. We agree that more comparative studies of different treatment options are required to allow the readers of this journal and others to decide what is best for the patient. We note that Dr. Burton's “best procedure,” the “100% LRTI,” is costly because it has a lengthy operating time (2 hours). This makes it even more important to ensure that the additional demands on health resources result in a better functional outcome than cheaper alternatives. Prolonged complex procedures do not necessarily have added value and need to be justified by studies similar to ours.We interpret Dr Burton's letter as indicating that he no longer recommends the technique of trapeziectomy and flexor carpi radialis (FCR) ligament reconstruction described in his classic 1986 report.1Burton R.I. Pellegrini Jr, V.D. Surgical management of basal joint arthritis of the thumb Part II. Ligament reconstruction with tendon interposition arthroplasty.J Hand Surg. 1986; 11: 324-332PubMed Scopus (505) Google Scholar This is because only 50% of the FCR tendon was used, a Kirschner wire was passed from the thumb metacarpal through the arthroplasty space into the scaphoid (see Fig. 3 in Burton and Pellegrini), no drill holes were placed in the scaphoid for secure attachment of the capsule, and the deep capsule adjacent to the old FCR bed was not tightly closed. We are surprised that this technique may no longer be recommended, because a 9-year follow-up of the cases reported in the 1986 article concluded that “ligament reconstruction-tendon interposition [LRTI] arthroplasty provided a stable and functional reconstruction of the thumb, resulting in excellent relief of pain and a significant increase in strength for as long as eleven years after the procedure.”2Tomaino M.M. Pellegrini Jr, V.D. Burton R.I. Arthroplasty of the basal joint of the thumb Long-term follow-up after ligament reconstruction with tendon interposition.J Bone Joint Surg. 1995; 77A: 346-355Google Scholar Furthermore, that 9-year follow-up demonstrated that the “50% FCR LRTIs” were biomechanically functioning well, because there was excellent maintenance of the arthroplasty space (only a 13% loss) and little metacarpal subluxation (11%). It would thus seem that 50% of the FCR is sufficient to produce and maintain an arthroplasty space, presumably as the result of the creation of a robust ligament, because the space created by excision of the trapezium is much larger than the volume of FCR tendon available for tendon interposition.Recruitment to our study3Gangopadhyay S. McKenna H. Burke F.D. Davis T.R.C. Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition.J Hand Surg. 2012; 37A: 411-417Google Scholar occurred in 1992 through 2001, and thus our study was well advanced before the publication of Dr. Burton's description of the revised “100% FCR LRTI” technique in 1997 and 1998. We are confident our LRTI procedures were performed according to the criteria described by Burton and Pellegrini,1Burton R.I. Pellegrini Jr, V.D. Surgical management of basal joint arthritis of the thumb Part II. Ligament reconstruction with tendon interposition arthroplasty.J Hand Surg. 1986; 11: 324-332PubMed Scopus (505) Google Scholar because Dr Burton's coauthor visited Nottingham in 1991 and demonstrated the procedure on 1 of our patients, who had an excellent result. In all of our cases, the thumb base was placed at the level of the index carpometacarpal joint, the thumb metacarpal was immobilized in the appropriate position with appropriate tightness of the LRTI, and the lateral capsule was closed as tightly as possible. All the thumbs were splinted for 6 weeks, and patients were then shown a series of exercises. Only those who struggled attended formal physiotherapy.We observe that many different ligament reconstructions and many different tendon interpositions have been described. Furthermore, some who used to favor the 50% and 100% FCR LRTIs now use alternatives and have observed no differences in their outcomes.4Tomaino M.M. Suspensionplasty for basal joint arthritis: why and how.Hand Clin. 2006; 22: 171-175Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar It is likely that few surgeons perform precisely identical procedures; however, the 1 thing most procedures incorporate is excision of the trapezium. We thank Dr. Burton for his interest in our article. We agree that more comparative studies of different treatment options are required to allow the readers of this journal and others to decide what is best for the patient. We note that Dr. Burton's “best procedure,” the “100% LRTI,” is costly because it has a lengthy operating time (2 hours). This makes it even more important to ensure that the additional demands on health resources result in a better functional outcome than cheaper alternatives. Prolonged complex procedures do not necessarily have added value and need to be justified by studies similar to ours. We interpret Dr Burton's letter as indicating that he no longer recommends the technique of trapeziectomy and flexor carpi radialis (FCR) ligament reconstruction described in his classic 1986 report.1Burton R.I. Pellegrini Jr, V.D. Surgical management of basal joint arthritis of the thumb Part II. Ligament reconstruction with tendon interposition arthroplasty.J Hand Surg. 1986; 11: 324-332PubMed Scopus (505) Google Scholar This is because only 50% of the FCR tendon was used, a Kirschner wire was passed from the thumb metacarpal through the arthroplasty space into the scaphoid (see Fig. 3 in Burton and Pellegrini), no drill holes were placed in the scaphoid for secure attachment of the capsule, and the deep capsule adjacent to the old FCR bed was not tightly closed. We are surprised that this technique may no longer be recommended, because a 9-year follow-up of the cases reported in the 1986 article concluded that “ligament reconstruction-tendon interposition [LRTI] arthroplasty provided a stable and functional reconstruction of the thumb, resulting in excellent relief of pain and a significant increase in strength for as long as eleven years after the procedure.”2Tomaino M.M. Pellegrini Jr, V.D. Burton R.I. Arthroplasty of the basal joint of the thumb Long-term follow-up after ligament reconstruction with tendon interposition.J Bone Joint Surg. 1995; 77A: 346-355Google Scholar Furthermore, that 9-year follow-up demonstrated that the “50% FCR LRTIs” were biomechanically functioning well, because there was excellent maintenance of the arthroplasty space (only a 13% loss) and little metacarpal subluxation (11%). It would thus seem that 50% of the FCR is sufficient to produce and maintain an arthroplasty space, presumably as the result of the creation of a robust ligament, because the space created by excision of the trapezium is much larger than the volume of FCR tendon available for tendon interposition. Recruitment to our study3Gangopadhyay S. McKenna H. Burke F.D. Davis T.R.C. Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition.J Hand Surg. 2012; 37A: 411-417Google Scholar occurred in 1992 through 2001, and thus our study was well advanced before the publication of Dr. Burton's description of the revised “100% FCR LRTI” technique in 1997 and 1998. We are confident our LRTI procedures were performed according to the criteria described by Burton and Pellegrini,1Burton R.I. Pellegrini Jr, V.D. Surgical management of basal joint arthritis of the thumb Part II. Ligament reconstruction with tendon interposition arthroplasty.J Hand Surg. 1986; 11: 324-332PubMed Scopus (505) Google Scholar because Dr Burton's coauthor visited Nottingham in 1991 and demonstrated the procedure on 1 of our patients, who had an excellent result. In all of our cases, the thumb base was placed at the level of the index carpometacarpal joint, the thumb metacarpal was immobilized in the appropriate position with appropriate tightness of the LRTI, and the lateral capsule was closed as tightly as possible. All the thumbs were splinted for 6 weeks, and patients were then shown a series of exercises. Only those who struggled attended formal physiotherapy. We observe that many different ligament reconstructions and many different tendon interpositions have been described. Furthermore, some who used to favor the 50% and 100% FCR LRTIs now use alternatives and have observed no differences in their outcomes.4Tomaino M.M. Suspensionplasty for basal joint arthritis: why and how.Hand Clin. 2006; 22: 171-175Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar It is likely that few surgeons perform precisely identical procedures; however, the 1 thing most procedures incorporate is excision of the trapezium. Basal Joint Surgical AlternativesJournal of Hand SurgeryVol. 37Issue 8PreviewThis letter is written on behalf of patients who might not receive optimal treatment because of the well-intentioned but flawed study by authors Gangopadhyay and associates.1 That study was an attempt to compare the ligament reconstruction tendon interposition (LRTI) procedure results with those of simple trapezial excision and of trapezial excision with ligament reconstruction. My concern is that what the authors allege to be the LRTI is in fact not the LRTI procedure as described. After I carefully read the article, I concluded that the results of the study were predictable, as in essence the authors were comparing trapezial excision with trapezial excision. Full-Text PDF" @default.
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• W4252610085 title "In Reply" @default.
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