i An update to this article is included at the end

Weilby Technique for Interpositional

Arthroplasty of Thumb Carpometacarpal Joint
Kristofer S. Matullo, MD, and Shawn Yeazel, MD

Thumb interposition is an accepted technique for the treatment of stage 2-4 arthritis of the
trapeziometacarpal joint of the thumb. With the usage of the Weilby suspension technique, the
flexor carpi radialis is used to suspend the thumb metacarpal using an intertendinous weave
rather than bony tunnels. This method allows early range of motion and decreased splint
usage, maximizing outcomes, and recovery.
Oper Tech Orthop 28:29-34 C 2018 Elsevier Inc. All rights reserved.

KEYWORDS interposition, basal joint arthritis, CMC arthritis, Weilby

Introduction tendon to ensure stability at the base of the thumb.3,4 This

tendon is woven between the remaining, intact FCR and the

A lthough thumb carpometacarpal joint arthritis is one of

the most common types of arthritis in elderly patients,
treatment options have been varied throughout the decades.
abductor pollicis longus tendon (APL) at the base of the thumb
metacarpal after trapezial excision. The goal of the operation is
to give the patient a stable joint, free of pain, and with
Surgical procedures have included trapeziectomy, hematoma reasonable mobility and strength, while being capable of
arthroplasty, suspensionplasty, ligament reconstruction, and revision is there are complications. The technique allows more
tendon interposition, as well as artificial joint arthroplasty. accelerated range of motion, and in the authors experience, less
Although some techniques have provided consistent pain pain than bone tunnel formation.
relief, others, such as silicone arthroplasty have fallen by the
wayside.
The treatment of carpometacarpal arthritis of the thumb Surgical Technique
with the concept of trapezial excision was first described by
Gervis in 1949, but tendon interposition was not originally After the patient is correctly identified, the patient is brought
used with this technique.1 The lack of tissue interposition was into the operating room and placed on the operative table in
hypothesized to lead to weakening of the thumb and an supine position, while either general or regional or sedation
inability to prevent collapse of the first metacarpal bone toward anesthesia is induced, depending on surgeon preference. A
the scaphoid.2 In an attempt to solve these problems, the usage well-padded pneumatic tourniquet is placed on the operative
of bony tunnels was developed. Weilby published an alter- extremity, and the limb is prepped and draped in a normal,
native technique that did not require the creation of bone sterile, and orthopedic fashion. Preoperative intravenous anti-
tunnels, instead the trapezium was removed and a plication of biotics are provided and a surgical time out is performed
tendon was interposed into the gap. Although the abductor according to institutional policy.
pollicis longus was used originally to fill the gap, the technique After the performance of a time out, an Esmarch bandage is
was modified to use of a strip of the flexor carpi radialis (FCR) used to exsanguinate the wound, and the tourniquet is inflated.
A curvilinear incision is made at the junction of the glabrous
and nonglabrous skin, extending from the proximal one-third
St. Luke’s University Health Network, Bethlehem, PA. of the thumb metacarpal to the level of the (FCR) tendon
Conflict of interest: K.S.M. is a paid consultant for DePuy Synthes and Integra (Fig. 1). Care is taken to protect the superficial neurovascular
Life Sciences. There are no conflicts pertaining to this article.
Address reprint requests to Kristofer S. Matullo, MD, Division of Hand Surgery, structures. As dissection proceeds, one must identify the
Temple University, St. Luke’s University Hospital, 801 Ostrum St, superficial sensory branches of the radial nerve at the radial
Bethlehem, PA 18015. E-mail: [Link]@[Link] border of the incision and the superficial branch of the radial

[Link] 29
1048-6666//& 2018 Elsevier Inc. All rights reserved.
30 K.S. Matullo and S. Yeazel

Figure 1 Skin incision marked extending from the base of the

metacarpal toward the FCR tendon. (Color version of the figure
available online.) Figure 5 The APL tendon is identified and dissected free with care
taken to avoid the superficial sensory branches of the radial nerve.
(Color version of the figure available online.)

artery, which may cross the operative field at the level of the
FCR tendon. The superficial branch of the radial artery may be
preserved or ligated according to location and surgeon
preference (Fig. 2).
The radial junction of the thenar muscles and APL tendon is
identified. With care to preserve the tendon insertion, the
thenar muscles are elevated from radial to ulnar, stopping at
the trapezial tunnel and FCR tendon (Fig. 3). The FCR sheath
is opened to the level of the trapezial ridge (Fig. 4). A
Figure 2 After elevation of the skin and subcutaneous tissues, the radial capsulotomy of the trapeziometacarpal joint is now made,
artery is visualized at the ulnar border of the incision. (Color version of and a synovectomy is performed. The APL tendon is now
the figure available online.)
further dissected on both the radial and ulnar sides of its
insertion on the thumb metacarpal (Fig. 5). Care must be taken
on the ulnar aspect of the tendon to avoid damage to the deep
branch of the radial artery, found proximoulnarly at the level of
the scaphoid.
Starting at the radial border of the trapezium, a straight
rongeur is placed directly superficial to the FCR tendon and

Figure 3 Elevation of the thenar muscles from radial to ulnar. (Color

version of the figure available online.)

Figure 4 The FCR sheath is identified and incised, revealing the FCR Figure 6 A joystick is inserted in the trapezium for easier excision.
tendon. (Color version of the figure available online.) (Color version of the figure available online.)
Interpositional arthroplasty 31

Figure 7 The trapezium is removed. (A) The trapezium after removal. (B) The space created after removal of the trapezium.

deep to the trapezial ridge. The trapezial ridge is removed from Carroll tendon retriever (Fig. 9). The harvested FCR tendon is
proximal to distal, with care taken to protect the FCR tendon at dissected completely to the level of the index metacarpal
its base. The scaphotrapezial joint is now able to be identified. insertion (Fig. 10). At this time, the FCR sheath is closed to
With insertion of a Kirschner wire into the trapezium to act as a prevent future subluxation of the remaining, intact FCR
joystick, the trapezium is dissected free of all soft tissue tendon (Fig. 11). Care must be taken at this time, as the
constraints, and may be removed as a single unit or piecemeal superficial sensory branch of the median nerve is present at the
according to preference (Figs. 6 and 7). Care must be taken ulnar border of the FCR sheath.
during this step to protect the FCR tendon ulnarly, the APL The thumb is positioned in 30° of palmar and radial
tendon radially, and the radial artery in the deep radial border abduction. The harvested half of the FCR tendon is passed
of the wound. through the middle of the APL tendon at the base of the
A second incision is made approximately 6-8 cm proximally thumb metacarpal (Fig. 12). This weave is secured with 3-0
over the FCR tendon (Fig. 8). The ulnar one-half of the FCR nonabsorbable braded suture. The remainder of the FCR is
tendon is harvested and delivered distally with the use of a

Figure 8 A second incision is made overlying the FCR tendon in the

forearm. Figure 9 The ulnar one-half of the FCR tendon is harvested.
32 K.S. Matullo and S. Yeazel

10 days after surgery, the operative dressings and sutures are

removed. The patient is placed into a removable thumb spica
neoprene splint and started in hand therapy. Therapy at this
time should focus on range of motion, including opposition
and abduction as well as edema control and scar desensitiza-
tion. A 1 pound weight restriction is maintained during this
time. Six weeks postoperatively, the neoprene splint is
transitioned to an as needed basis and progressive strengthen-
ing up to 10 pounds is started with therapy. Three months
postoperatively, all activities are permitted with the removal of
restrictions.
Figure 10 The graft is mobilized to its insertion at the base of the index
metacarpal. (Color version of the figure available online.)
Complications
passed in a figure of 8 fashion around the intact FCR at the Complications of the surgical procedure can be divided into
base of wound and the APL proximally until the graft is intraoperative and postoperative categories. Intraoperatively,
completely used (Fig. 13). A 3-0 sutures are used to secure this care must be taken to protect the superficial sensory branches
weave. Care must be taken during this step to avoid of the radial nerve and the palmar cutaneous branch of the
wrapping the graft around the extensor pollicis brevis tendon, median nerve. Iatrogenic injury to these structures may cause
located just dorsal to the APL at this level. A tenodesis of the postoperative numbness or a painful neuroma. Damage to the
extensor pollicis brevis to the APL can be completed now if radial artery may cause bleeding or cold intolerance. In the case
desired. of patients with incompetent ulnar artery flow to the hand,
The wounds are irrigated with sterile saline solution, damage to the radial artery may have a more ominous
the capsule at the base of the thumb metacarpal is closed, outcome.
and the surgical wounds are sutured according to surgeon Postoperatively, the most common complications include
preference. The author prefers 3-0 Vicryl and 4-0 Prolene. The scar sensitivity, stiffness, de Quervain tenosynovitis, FCR
surgical site is covered with nonadherent dressing, gauze, tendon rupture, infection, and subsidence of the metacarpal.
webroll, and a forearm-based thumb spica splint maintaining Although these complications are rare, identification is critical
the thumb in 30° of palmar and radial abduction while to patient success. Stiffness and scar sensitivity are best treated
allowing unrestricted finger and thumb interphalangeal joint with formal therapy and a dedicated home program to work
motion. on motion and desensitization, respectively. De Quervain
tenosynovitis, can be treated with extended bracing, cortico-
steroid injections (if greater than 3 months from the time of
Postoperative Management surgery) or surgical release. FCR tendon rupture is typically
encountered if more than one-half of the FCR tendon is
The patient is instructed to maintain strict elevation of the
harvested during the surgical procedure or with early exuber-
fingers and wrist for the first 24-48 hours. Digital, elbow, and
ant activity by the patient. Symptomatic care and bracing yields
shoulder motion is encouraged to prevent stiffness. Ice is used
pain relief, with a gradual resumption of activities when pain
for the first 48 hours to help prevent swelling. Approximately,
free.
More significant complications consist of infection or painful
subsidence of the metacarpal. Superficial infection can be
treated with oral antibiotics, whereas deep infection must be
operatively treated with debridement and possible resuspen-
sion using a slip of APL or extensor carpi radialis longus
tendon.

Outcomes
One of the earlier described results utilizing the Weilby
technique was in 1987 by Nylen et al. In their series of 89
cases, satisfactory results were obtained in 73% of patients with
72% being pain free. Contractures of the thumb were relieved
in 51% of patients, and 73% of patients returned to work at an
Figure 11 Closure of the FCR sheath prevents subluxation of the FCR average of 4 months after surgery. Complications included
after tendon wrap and suspension. (Color version of the figure edema (2 patients), carpal tunnel (3 patients), trigger thumb
available online.) (1 patient), and reflex sympathetic dystrophy (5 patients).3
Interpositional arthroplasty 33

A B

Figure 12 The FCR is passed through the APL at the thumb metacarpal base. (A) The tendon weaver is passed through the
APL at the metacarpal base. (B) The FCR tendon is woven through the APL. (C) The FCR is secured with a braided
nonabsorbable suture.

Weilby later described his technique in 1988 describing his In 2009, Vermeulen et al, performed a prospective study
results in 100 patients. Totally, 85% of patients were pain free, examining 20 thumbs in 19 patients treated with a Weilby
while complications consisted of radial nerve lesions (3 interposition arthroplasty using preoperative and post-
patients), de Quervain tenosynovitis (7 patients), and APL operative outcomes measurements. Patients had no significant
rupture (2 patients).4 change in interphalangeal or metacarpophalangeal joint

A B

Figure 13 The FCR is woven around the APL and intact FCR tendon. (A) Passing the graft around the FCR. (B) Passing the
graft around the APL. (C) Finished weave.
34 K.S. Matullo and S. Yeazel

motion, however thumb palmar abduction and opposition 2. Burton RI, Pellegrini VD Jr: Surgical management of basal joint arthritis of
the thumb. Part II. Ligament reconstruction with tendon interposition
improved from preoperative values. Pinch and grip strength
arthroplasty. J Hand Surg Am 11:324-332, 1986
increased by final follow up with an improvement in post- 3. Nylen S, Juhlin LJ, Lugnegard H: Weilby tendon interposition arthroplasty
operative disabilities of the arm, shoulder and hand scores and for osteoarthritis of the trapezial joints. J Hand Surg Br 12:68-72, 1987
a satisfaction rate of 89%.5 4. Weilby A: Tendon interposition arthroplasty of the first carpo-metacarpal
joint. J Hand Surg Br 13:421-425, 1988
5. Vermeulen GM, Brink SM, Sluiter J, et al: Ligament reconstruction
References arthroplasty for primary thumb carpometacarpal osteoarthritis (weilby
1. Gervis WH: Excision of the trapezium for osteoarthritis of the trapezio- technique): Prospective cohort study. J Hand Surg Am 34:1393-1401,
metacarpal joint. J Bone Joint Surg Br 31B:537-539, 1949 2009
 Update
Operative Techniques in Orthopaedics
Volume 28, Issue 3, September 2018, Page 175

DOI: [Link]
Corrigendum to: Weilby Technique for
Interpositional Arthroplasty of Thumb
Carpometacarpal Joint
Operative Techniques in Orthopaedics,
Volume 28 (2018) pg 29-34
Kristofer S. Matullo, MD, and Shawn Yeazell, MD

The authors regret to inform a misspelling of Dr. Yeazell's last name. It should be listed as “Yeazell” and not “Yeazel.”
The authors would like to apologise for any inconvenience caused.
DOI of original article: [Link]
Kristofer S. Matullo, MD

St. Lukes University Health Network, Bethlehem, PA.

E-mail: [Link]@[Link]

[Link] 175
1048-6666/© 2018 Elsevier Inc. All rights reserved.