Up till now, many different techniques have been used for the treatmentof 1st carpometacarpal (cmc) joint arthritis. Here we present a new combination of well- known techniques and surgical approaches that gave excellent results in a five year follow up.

Surgical techniques used for the treatment of 1st cmc joint arthritis include 1st cmc joint arthrodesis [1],1st metacarpal osteotomy [2],excisionof the trapezium with tendon interposition (known as the anchovy procedure) [3], excisionof the trapezium with ligamentreconstruction, tendon interposition (LRTI) [4], hematoma distraction arthroplasty (HDA) [5] and implant replacement [6].

We present a combination of hematoma distraction technique with interposition of a spacer from the distal part of the flexor carpi radial is tendon. Furthermore, the surgical approach used is a combination of Wagner approach for treatment of fractures of the base of the first metacarpal (Bennet etc.) [7] with the Trance FCR approach to the distal radius [8]. The former gives an excellent and more or less safe view for excision of the trapezium while the latter is equally efficient for lifting a small part of the distal flexor carpi radialis tendon. As an alternative, the longitudinal part of the incision can be replaced by a smaller one, positioned more centrally on the palmar surface of the wrist so that a Palmaris longustendon graft can be taken and used as a spacer instead of the FCR tendon. Both incisions can be used for simultaneous carpal tunnel decompression if needed.

During a time period of 12 years 20 patients suffering of 1st cmc joint arthritis have been treated with the technique we present. The mean follow-up time was 5 years (3-6).There were 13 women and 5 men (2 bilateral operations) all of them above their 40th year of age (40-82) All of them had an excellent pain relief and an improvement of their grasping ability of about 40%. This was below the healthy hand, but all patients were satisfied. Traumatic neuroma of a small branch of the radial nerve in one patient, was the only complication met and was treated by surgical exploration and cauterization. The stumps were then embedded in the radius.

Surgical Technique and Follow Up

Under general anesthesia and an arm tourniquet the upper limb is prepped and draped. A curved skin incision around the base of the first metacarpal is extended proximally on the line of the tendon of the flexorcarpi radials (Figure1).

Attention is then given to preserve the sensory radial nerve and it branches that may need to be carefully dissected. The longitudinal part of the incision is deepened through the fcr and the radial artery is usually not met (figure 2).

The trapezium is then excised-most of the times in one piece (Figure 3)

Taking care that the distal part of the fcr remains intact. The 1st metacarpal is then distracted and stabilized to the second one with a k-wire. Appropriate metacarpal distraction is verified with the c-arm (Figure 4).

and attention is then turned back to the fcr tendon. A longitudinal stripe of about 1/3 of the tendon’s width and 1/3 of its length is removed under direct vision, turned into a small ball with the use of an absorbable suture and put into the gap produced by the trapezium excision (Figure 5).

Finally, skin is closed and the hand put in a thumb spicapopsplint. Sutures are removed two, whereas the pin and spica six weeks postoperatively. A careful physiotherapy program is then commenced and the hand left

The method that we present offers an effective and safe approach for treatment of the first carpometacarpal jointarthritis of the hand.Low rate of complicationsand adequate pain relief,with improved graspingability of the hand, confirm its usefulness and we therefore propose it.