Appendix 3
Metacarpal Osteotomy
The metacarpal extension osteotomy procedure was first reported by Wilson [11] in 1973 as a
treatment for osteoarthritis (OA). The outcomes of eight patients (age range, 54–67 years) were
assessed at a followup of 6 months to 9 years. The author reported all patients were “entirely
relieved of pain and entirely satisfied.” No other outcome measures were reported.
In 1983, Wilson and Bossley [12] published the results of 23 osteotomies in a group of 21
patients (average age, 48 years; range, 38–67 years). At an average followup of 12 years, “all had
lasting relief” of pain and only three patients were not completely relieved of pain. All patients
“consider they have full function of the thumb.”
In 1991, Molitor et al. [6] reported the retrospective results of 12 osteotomies in 11 patients
(average age, 64.5 years; range, 53–85 years) and the prospective results of five patients (average
age, 63.4 years; range, 49–77 years). All patients were either pain free or had improved pain
scores. In the prospective group, grip strength increased for all patients postoperatively. The
length of followup was not reported.
In 1992, Futami et al. [3] reported the results of 12 thumbs in 10 patients (average age, 58 years;
range, 51–68 years). They performed an abduction opposition osteotomy, which is a
modification of the Wilson extension osteotomy. Outcomes were graded as satisfactory if
patients had increased pinch strength, returned to work, and had increased ROM and were
otherwise graded as unsatisfactory. At an average followup of 4 years, 10 of the 12 thumbs were
satisfactory. Futami et al. [2] reported on the same series of patients later, with the addition of
two more thumbs. No followup timing was given in the second series, and there appeared to be
no additional followup on the original 10 patients.
In 1996, Pellegrini et al. [8] investigated the biomechanical basis of metacarpal osteotomy in 20
fresh-frozen specimens. Ten joints were nonarthritic, five had moderate arthritis (palmar only),
and five had end-stage OA (diffuse eburnation). Specimens were placed in flexion, extension,
and lateral pinch, and joint contact pressures were recorded with pressure-sensitive film. This
was repeated after extension metacarpal osteotomy. The authors found the primary contact area
migrated in a dorsal direction in the nonarthritic and moderately arthritic groups, while no
change was detected in the end-stage arthritic group. The authors concluded the biomechanical
basis of extension osteotomy is unloading of the palmar compartment of the trapeziometacarpal
(TMC) joint.
In 1998, Hobby et al. [4] reported the results of 41 thumbs in 33 patients who presented with
mild or moderate disease. Average followup was 6.8 years, with 80% of patients reporting either
no pain or discomfort only with heavy use.
In 2000, Tomaino [10] reported the results of 12 patients (average age, 38 years; range, 24–51
years) with Eaton Stage I disease treated with extension osteotomy. At an average followup of
2.1 years, eight patients were very satisfied, three satisfied, and one dissatisfied. Pain score on
average decreased from 5 to 1, and grip and pinch strength increased on average 8.5 and 3 kg,
respectively. The author noted stability of the TMC joint was improved after osteotomy.
In 2003, Shrivastava et al. [9] simulated extension osteotomy in seven fresh-frozen specimens
(average age, 27 years). They reported, in the position of lateral pinch, extension osteotomy
reduced joint laxity in all directions, especially dorsal volar (40% reduction), and concluded the
benefits of metacarpal extension osteotomy may be due to reduced joint laxity. The mechanism
of this increased stability was believed to result from tightening of the dorsal ligaments in the
position of lateral pinch, due to the osteotomy.
In 2006, Koff et al. [5] compared joint stability and contact areas after permutations of
metacarpal extension osteotomy (10° and 15°) and Eaton-Littler type ligament reconstruction
(total, volar, dorsoradial). Ligament reconstruction procedures were performed with plastic
sheathed steel cables to prevent viscoelastic creep. They reported both 15° osteotomy and EatonLittler reconstruction reduced laxity in all directions, but osteotomy additionally shifted contact
area dorsally while ligament reconstruction did not. The authors concluded osteotomy may have
a “theoretical advantage” compared to ligament reconstruction in joints with more volar articular
wear.
In 2007, Badia and Khanchandani [1] reported their technique of combined arthroscopic
synovectomy, thermal capsulorraphy, and metacarpal dorsoradial osteotomy for Eaton Stage II
basal joint arthritis. The authors treated 43 patients with this technique and reported “satisfactory
results in terms of pain relief, stability, and pinch strength,” but no further outcome details were
provided.
In 2008, Parker et al. [7] reported the outcomes of eight patients treated with extension
osteotomy, with an average followup of 9 years. Three patients had Eaton Stage I disease, three
Stage II, and two Stage III. Lateral pinch, oppositional pinch, and grip were measured at 5, 3,
and 19 kg (129%, 103%, 108% contralateral), respectively, although these did not reflect
statistically significant changes. Six of eight patients had “excellent” outcomes as defined by
pain and functional limitations.
References
1. Badia A, Khanchandani P. Treatment of early basal joint arthritis using a combined
arthroscopic debridement and metacarpal osteotomy. Tech Hand Up Extrem Surg.
2007;11:168-173.
2. Futami T, Kobayashi A, Ukita T, Fujita T. Abduction-opposition wedge osteotomy of the
base of the first metacarpal for thumb basal joint arthritis. Tech Hand Up Extrem Surg.
1998;2:110-114.
3. Futami T, Nakamura K, Shimajiri I. Osteotomy for trapeziometacarpal arthrosis: 4 (1–6) year
follow-up of 12 cases. Acta Orthop Scand. 1992;63:462-464.
4. Hobby JL, Lyall HA, Meggitt BF. First metacarpal osteotomy for trapeziometacarpal
osteoarthritis. J Bone Joint Surg Br. 1998;80:508-512.
5. Koff MF, Shrivastava N, Gardner TR, Rosenwasser MP, Mow VC, Strauch RJ. An in vitro
analysis of ligament reconstruction or extension osteotomy on trapeziometacarpal joint
stability and contact area. J Hand Surg Am. 2006;31:429-439.
6. Molitor PJ, Emery RJ, Meggitt BF. First metacarpal osteotomy for carpo-metacarpal
osteoarthritis. J Hand Surg Br. 1991;16:424-427.
7. Parker WL, Linscheid RL, Amadio PC. Long-term outcomes of first metacarpal extension
osteotomy in the treatment of carpal-metacarpal osteoarthritis. J Hand Surg Am.
2008;33:1737-1743.
8. Pellegrini VD Jr, Parentis M, Judkins A, Olmstead J, Olcott C. Extension metacarpal
osteotomy in the treatment of trapeziometacarpal osteoarthritis: a biomechanical study. J
Hand Surg Am. 1996;21:16-23.
9. Shrivastava N, Koff MF, Abbot AE, Mow VC, Rosenwasser MP, Strauch RJ. Simulated
extension osteotomy of the thumb metacarpal reduces carpometacarpal joint laxity in lateral
pinch. J Hand Surg Am. 2003;28:733-738.
10. Tomaino MM. Treatment of Eaton Stage I trapeziometacarpal disease with thumb metacarpal
extension osteotomy. J Hand Surg Am. 2000;25:1100-1106.
11. Wilson JN. Basal osteotomy of the first metacarpal in the treatment of arthritis of the
carpometacarpal joint of the thumb. Br J Surg. 1973;60:854-858.
12. Wilson JN, Bossley CJ. Osteotomy in the treatment of osteoarthritis of the first
carpometacarpal joint. J Bone Joint Surg Br. 1983;65:179-181.