What does a right thumb trapeziectomy with ligament reconstruction and tendon interposition (LRTI) involve?

Right Thumb Trapeziectomy with LRTI: Procedure Overview

A right thumb trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is a surgical procedure for severe thumb base osteoarthritis that involves removing the trapezium bone and reconstructing the joint space using a tendon graft—however, based on current evidence, this combined approach offers no advantage over simple trapeziectomy alone and causes significantly more complications.

What the Procedure Involves

Surgical Steps

The traditional LRTI procedure consists of three components:

1. Trapeziectomy: Complete or partial removal of the trapezium bone at the base of the thumb
2. Ligament Reconstruction: Using a harvested tendon (typically the flexor carpi radialis) to create a new ligament support system
3. Tendon Interposition: Placing tendon material into the space left by the removed trapezium to prevent the thumb metacarpal from collapsing proximally

Technical Variations

Modern modifications include 1, 2:

• Partial trapeziectomy (distal-half only) rather than complete removal
• Using the entire flexor carpi radialis tendon harvested from the forearm
• Interference screw fixation through a bone tunnel in the first metacarpal
• Rolling the remaining tendon into a ball to fill the trapezial space

Critical Evidence Against LRTI

The Guideline Recommendation

EULAR guidelines explicitly recommend AGAINST the combined LRTI approach 3. Based on systematic reviews including seven RCTs with 383 patients, the evidence shows:

• No pain relief advantage: Effect size = -0.17 (95% CI -0.57 to 0.24) compared to trapeziectomy alone
• No functional improvement: Effect size = 0.03 (95% CI -0.37 to 0.44) compared to trapeziectomy alone
• Significantly more complications: RR = 2.12 (95% CI 1.24 to 3.60) compared to simple trapeziectomy

Specific Complications of LRTI

The combined procedure causes 3:

• Tendon rupture or adhesion
• Scar tenderness
• Sensory changes and neurological complications
• Joint instability
• Complex regional pain syndrome

Most Recent Cochrane Evidence

The 2026 Cochrane review confirms that trapeziectomy with LRTI may make little to no difference compared to trapeziectomy alone in pain (MD -2.80 mm), physical function (SMD 0.01), or adverse events (RR 1.89) 4.

When Surgery Is Indicated

Surgery should be considered for 3, 5:

• Severe thumb base osteoarthritis (typically Eaton stage III or IV)
• Marked pain and/or disability affecting quality of life
• Failed conservative management including:
  • Education and ergonomic training
  • Hand exercises and strengthening
  • Thumb orthoses (first-line for thumb base OA)
  • Topical NSAIDs (preferred over systemic)
  • Oral NSAIDs for limited duration

The Better Alternative

Simple trapeziectomy alone is the evidence-based choice 3. It provides:

• Equivalent pain relief and functional outcomes
• Significantly fewer complications
• Shorter operative time
• Faster rehabilitation

Other Surgical Options to Consider

The 2019 EULAR guidelines recommend 5:

• Trapeziectomy for thumb base OA (without LRTI)
• Arthrodesis for interphalangeal OA
• Arthroplasty for interphalangeal OA

Recent evidence suggests arthrodesis may avoid carpal alignment changes that occur with trapeziectomy 6, 7, though both procedures provide comparable clinical outcomes.

Common Pitfalls to Avoid

1. Don't assume "more is better": The combined LRTI procedure intuitively seems superior but evidence proves otherwise
2. Don't ignore the complication profile: A 2.12-fold increase in complications is clinically significant
3. Don't skip conservative management: Surgery is only for refractory cases after conservative treatment failure 5
4. Don't use intra-articular corticosteroids routinely: Evidence shows no benefit beyond one month for thumb base OA 3

Expected Outcomes

Regardless of technique, patients can expect 1, 2, 8:

• Significant pain reduction (VAS improvement of 5+ points)
• Improved grip and pinch strength
• Better functional scores (DASH improvement of 20-30 points)
• Return to daily activities within 2-3 weeks for most patients
• Maintenance of trapezial space height when adequate interposition is achieved

The key difference is that simple trapeziectomy achieves these outcomes with half the complication risk compared to the combined LRTI approach.