Failed Thumb Carpometacarpal Arthroplasty: Common Etiologies and Surgical Options for Revision
2018; Elsevier BV; Volume: 43; Issue: 9 Linguagem: Inglês
10.1016/j.jhsa.2018.03.052
ISSN1531-6564
AutoresDaniel E. Hess, Patricia Drace, Michael J. Franco, A. Bobby Chhabra,
Tópico(s)Dupuytren's Contracture and Treatments
ResumoCarpometacarpal (CMC) arthroplasty surgery, although modifications have occurred over time, continues to be commonly performed and has provided patients with their desired pain relief and return of function. The complications of primary surgery, although relatively rare, can present in various clinical ways. An understanding of the underlying anatomy, pathology of coexisting conditions, and specific techniques used in the primary surgery is required to make the best recommendation for a patient with residual pain following primary CMC arthroplasty. The purpose of this review is to provide insights into the history of CMC arthroplasty and reasons for failure and to offer an algorithmic treatment approach for the clinical problem of persistent postoperative symptoms. Carpometacarpal (CMC) arthroplasty surgery, although modifications have occurred over time, continues to be commonly performed and has provided patients with their desired pain relief and return of function. The complications of primary surgery, although relatively rare, can present in various clinical ways. An understanding of the underlying anatomy, pathology of coexisting conditions, and specific techniques used in the primary surgery is required to make the best recommendation for a patient with residual pain following primary CMC arthroplasty. The purpose of this review is to provide insights into the history of CMC arthroplasty and reasons for failure and to offer an algorithmic treatment approach for the clinical problem of persistent postoperative symptoms. CME Information and DisclosuresThe Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details.The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.Statement of Need: This CME activity was developed by the JHS editors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care.Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.Provider Information can be found at https://www.assh.org/About-ASSH/Contact-Us.Technical Requirements for the Online Examination can be found at https://www.jhandsurg.org/cme/home.Privacy Policy can be found at http://www.assh.org/About-ASSH/Policies/ASSH-Policies.ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities.Disclosures for this ArticleEditorsDavid Netscher, MD, has no relevant conflicts of interest to disclose.AuthorsAll authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.PlannersDavid Netscher, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.Learning ObjectivesUpon completion of this CME activity, the learner should achieve an understanding of:•Clinical assessment of the patient who presents with an unfavorable result following thumb carpometacarpal (CMC) arthroplasty•Analysis for the reasons for failure of the initial arthroplasty procedure•Revision surgical options for the unfavorable result following thumb CMC arthroplasty•Expected outcomes for revision surgery following thumb CMC arthroplastyDeadline: Each examination purchased in 2018 must be completed by January 31, 2019, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.Copyright © 2018 by the American Society for Surgery of the Hand. All rights reserved. The Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced. Statement of Need: This CME activity was developed by the JHS editors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval. Provider Information can be found at https://www.assh.org/About-ASSH/Contact-Us. Technical Requirements for the Online Examination can be found at https://www.jhandsurg.org/cme/home. Privacy Policy can be found at http://www.assh.org/About-ASSH/Policies/ASSH-Policies. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. David Netscher, MD, has no relevant conflicts of interest to disclose. All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. David Netscher, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Upon completion of this CME activity, the learner should achieve an understanding of:•Clinical assessment of the patient who presents with an unfavorable result following thumb carpometacarpal (CMC) arthroplasty•Analysis for the reasons for failure of the initial arthroplasty procedure•Revision surgical options for the unfavorable result following thumb CMC arthroplasty•Expected outcomes for revision surgery following thumb CMC arthroplasty Deadline: Each examination purchased in 2018 must be completed by January 31, 2019, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour. Copyright © 2018 by the American Society for Surgery of the Hand. All rights reserved. Considering the importance in routine daily activities of the basal thumb joint, it is not surprising that degenerative conditions have long engaged the attention of hand surgeons. The most appropriate and effective surgical intervention remains somewhat controversial. Simple trapeziectomy was first described by Gervis in 1949 for monoarticular osteoarthritis but not for rheumatoid arthritis or polyarthritis. The 1973 Gervis and Wells paper1Gervis W.H. Wells T. A review of excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint after twenty-five years.J Bone Joint Surg Br. 1973; 55: 56-57Crossref PubMed Google Scholar reported on 25 years of data for simple trapeziectomy and the results were “satisfactory without exception” and reported “pain-free” responses from all patients. However, concerns about shortening of the thumb metacarpal into the trapezial space following excision led to the introduction of ligament stabilization and interposition procedures. To combat subsidence, some suggested leaving the trapezium in place and simply stabilizing the joint with reportedly good results.2Barron O.A. Eaton R.G. Save the trapezium: double interposition arthroplasty for the treatment of stage IV disease of the basal joint.J Hand Surg Am. 1998; 23: 196-204Abstract Full Text PDF PubMed Scopus (70) Google Scholar In the early 1970s, prosthetic implants began to be used with mixed results,3de la Caffiniere J.Y. Aucouturier P. Trapezio-metacarpal arthroplasty by total prosthesis.Hand. 1979; 11: 41-46Crossref PubMed Scopus (121) Google Scholar and this has subsequently been followed by use of biological implants. The rate of carpometacarpal (CMC) arthroplasties that require revision is largely unknown. Complications and unsatisfactory results are only briefly mentioned in the broader context of mostly good to excellent outcomes, regardless of surgical procedure. Cooney et al4Cooney W.P. Leddy T.P. Larson D.R. Revision of thumb trapeziometacarpal arthroplasty.J Hand Surg Am. 2006; 31: 219-227Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar retrospectively evaluated over 600 cases of CMC arthroplasties over a 12-year period, reporting that 2.5% went on to require revision procedures. Another large institutional review cited a similar revision rate of 2.9%.5Megerle K. Grouls S. Germann G. Kloeters O. Hellmich S. Revision surgery after trapeziometacarpal arthroplasty.Arch Orthop Trauma Surg. 2011; 131: 205-210Crossref PubMed Scopus (35) Google Scholar The overall literature on failures and revision procedures, however, is deficient. Certain surgical risks may occur with any of the CMC arthroplasty procedures. These include neuroma, complex regional pain syndrome (CRPS), infection, untreated metacarpophalangeal (MCP) joint hyperlaxity and/or arthritis, and untreated peritrapezial or other midcarpal arthritis.6Mitchell S.A. Meals R.A. Reoperative Hand Surgery. Springer, New York2012Google Scholar During a standard surgical approach to the first CMC joint, the superficial sensory radial nerve (SSRN) is typically found superficial to the extensor pollicis brevis tendon, providing sensation to the dorsum of the thumb, and is the most common nerve to be injured.5Megerle K. Grouls S. Germann G. Kloeters O. Hellmich S. Revision surgery after trapeziometacarpal arthroplasty.Arch Orthop Trauma Surg. 2011; 131: 205-210Crossref PubMed Scopus (35) Google Scholar Failure to identify or recognize an injury to the nerve can lead to a painful neuroma. CRPS may result with or without a nerve injury and is characterized by autonomic sensory dysfunction and chronic pain. Infection is a rare complication, but a hypothetical concern when using synthetic implants.7Satteson E.S. Langford M.A. Li Z. The management of complications of small joint arthrodesis and arthroplasty.Hand Clin. 2015; 31: 243-266Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Failure to address MCP joint hyperlaxity may lead to weakness and instability of the thumb. Lastly, recalcitrant mechanical pain can continue if the treating surgeon fails to address concomitant scaphotrapeziotrapezoidal or other coexisting midcarpal arthritis.6Mitchell S.A. Meals R.A. Reoperative Hand Surgery. Springer, New York2012Google Scholar Each of the common arthroplasty procedures performed has risks for specific complications. Ligament reconstruction tendon interposition (LRTI) with trapeziectomy procedures can result in graft extrusion or mechanical failure of the suspension.7Satteson E.S. Langford M.A. Li Z. The management of complications of small joint arthrodesis and arthroplasty.Hand Clin. 2015; 31: 243-266Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar This can lead to subsidence of the metacarpal vertically or dorsoradial migration, on the scaphoid, or impingement with the adjacent trapezoid leading to mechanical pain.6Mitchell S.A. Meals R.A. Reoperative Hand Surgery. Springer, New York2012Google Scholar Incomplete trapeziectomy is relatively common complication when planning a full excision of the trapezium. Conversely, a shell of deep trapezium that is nonarticular, but nonetheless seen radiographically, may not be the cause of postoperative pain. Utilizing the flexor carpi radialis tendon (FCR), as many procedures do, may play a role in development of scapholunate instability. The FCR has been described as a dynamic stabilizer of the scaphoid, and redirection of that tendon at the carpal level could lead to dorsal intercalated segment instability deformity.8Salvà-Coll G. Garcia-Elias M. Llusá-Pérez M. Rodríguez-Baeza A. The role of the flexor carpi radialis muscle in scapholunate instability.J Hand Surg Am. 2011; 36: 31-36Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Only using half of the FCR may reduce this potential risk. Complications of CMC arthrodesis include nonunion and prominent hardware.7Satteson E.S. Langford M.A. Li Z. The management of complications of small joint arthrodesis and arthroplasty.Hand Clin. 2015; 31: 243-266Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Nonunion rates have been reported as high as 16%,9Hartigan B.J. Stern P.J. Kiefhaber T.R. Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition.J Bone Joint Surg Am. 2001; 83-A: 1470-1478Crossref PubMed Scopus (134) Google Scholar varying with the type of fixation and the use of bone graft. Implant arthroplasty can be complicated by aseptic loosening, dislocation or subluxation, hardware complication, or foreign body reactions.6Mitchell S.A. Meals R.A. Reoperative Hand Surgery. Springer, New York2012Google Scholar Loosening is the most commonly encountered problem with synthetic implants, with some studies approaching 50% loosening rates, but not all of those cases were symptomatic or required revision.10van Cappelle H.G. Elzenga P. van Horn J.R. Long-term results and loosening analysis of de la Caffinière replacements of the trapeziometacarpal joint.J Hand Surg Am. 1999; 24: 476-482Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Diagnostic accuracy and patient selection are imperative for successful revision surgery. Not all of the previously mentioned complications warrant surgical intervention, and distinguishing those not appropriate for revision surgery is important. Mechanical (vs neurological) etiologies are typically the best indications for revision procedures. It is important to relay to the patient what is a typical postoperative course for a primary surgery. Surgical intervention is generally not recommended (short of catastrophic failure) within the first 6 months following the initial procedure. Radiographs tend to exaggerate the amount of subsidence and impingement and should be interpreted with caution in the early postoperative period. Refractory pain for 3 to 6 months after surgery should be treated with reassurance and activity modification. Pain or symptoms that last beyond 6 months, however, are an indication for further investigation. In addition to radiographs, diagnostic injections in various carpal articulations can help identify the true source of the pain. If multiple injections are being considered, it is important to separate them by time to allow for a more specific diagnosis. Mechanical etiologies often present in the postoperative patient as a deep pain, grinding, or feeling of instability with pinch or grip.6Mitchell S.A. Meals R.A. Reoperative Hand Surgery. Springer, New York2012Google Scholar Mechanical etiologies include nonunion after arthrodesis, impingement, implant loosening, or failure to adequately treat instability or arthritis. Treatment of subsidence of the metacarpal base after a trapeziectomy with or without any sort of interposition or suspension is controversial. Thumb metacarpal subsidence does not appear to directly correlate with pinch strength or patient satisfaction.116th ed. Green’s Operative Hand Surgery. Vol. 1. Elsevier/Churchill Livingstone, Philadelphia2011Google Scholar Subsidence alone is often asymptomatic and not an indication for revision. Subsidence can, however, be a harbinger of failure of the suspension or interposition, and close monitoring for symptoms of impingement is needed. Impingement can also result from overconstraint, which presents as an abduction contracture and an inability of the palm and thumb to lie flat. Residual symptomatic pinch or pinch/grasp weakness (especially with larger objects) can be a result of failure to correct a hyperextension/adduction deformity of the MCP joint that classically coexists with CMC arthritis. Hyperextension of the MCP joint should be evaluated before surgery and addressed at the same time as the CMC arthroplasty, but failure to address or correct hyperextension of greater than 10° can be a source of pain and weakness.12Armbruster E.J. Tan V. Carpometacarpal joint disease: addressing the metacarpophalangeal joint deformity.Hand Clin. 2008; 24 (vii): 295-299Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar A variety of surgical procedures are available to correct MCP joint hypermobility including volar capsulodesis, extensor pollicis brevis tenodesis, temporary K-wire fixation, and arthrodesis. When arthrodesis is warranted—typically for deformities greater than 40°, fixed deformities, or significant MCP arthritis—the goal is to fuse the joint in 15° to 25° of flexion, neutral radial/ulnar deviation, and slight pronation.13Blank J. Feldon P. Thumb metacarpophalangeal joint stabilization during carpometacarpal joint surgery.Atlas Hand Clin. 1997; 2: 217-225Google Scholar Variation from the ideal arthrodesis position can lead to poor outcomes. Coexisting peritrapezial arthritis can cause residual pain in the postoperative CMC arthroplasty patient. This can be noted before surgery on radiographs or on physical examination with crepitus and pain with axial load through the thumb but should be verified during surgery. It is common to find arthritis between the trapezoid and the scaphoid when evaluating during surgery because this joint may not be adequately or reliably visualized with standard wrist radiographs. Neurogenic pain is a feared outcome for most operative hand surgeons; it is typically diffuse, often poorly defined by the patient, and difficult to treat. Patients often describe a burning pain and are hypersensitive to touch. Injuries to the sensory nerves in the operative field, such as the SSRN and the lateral antebrachial cutaneous nerve of the forearm, are the more common complications reported after surgery. Other potential neurogenic etiologies are hypersensitive surgical scar and CRPS. The author’s (A.B.C.) preferred treatment depends on both the underlying cause for failure as well as the prior surgical technique used. Because of the spectrum of procedures available for primary CMC arthroplasty, it is impossible to recommend a single option for revision procedures. In evaluation of the patient, we review prior surgeries so that we can determine options for revision procedures and which options may be most beneficial to the patient. The patient is clinically tested for carpal tunnel syndrome. If positive, an EMG/nerve conduction velocity study is ordered before surgery to address all potential sources for pain and residual or recurrent symptoms. We clinically assess for MCP joint hyperextension, hypermobility, or degenerative changes to determine if this is a cause for patient symptoms. Radiographs may aid in diagnosis of scaphotrapezoidal arthritis, MCP joint arthrosis, proximal migration, or impingement of the first metacarpal on the scaphoid. Be prepared to be flexible with intraoperative decisions at the time of revision surgery because plans may change based on findings. Approach revision surgery with caution and advise the patient on the potential for additional surgeries. Always include a discussion of expectations for pain reduction and return to prior activities. Neuroma and nerve-related issues after CMC arthroplasty are most commonly related to the SSRN owing to its close proximity to the surgical site. These should be managed nonoperatively for at least 6 months following the initial procedure with a combination of therapy and pain management including desensitization and neuromodulating medications to minimize hypersensitivity and pain. Importantly, the role of CRPS as a pain generator should not be overlooked and surgery should be avoided in patients with symptoms of active CRPS (unless there is an associated neuroma). Symptoms of acute CRPS include pain, swelling, warmth, erythema, decreased range of motion/joint stiffness (in other digits as well), and hyperhidrosis. Subacute symptoms can be present for 3 to 12 months and these include pain, skin dryness and atrophy, cyanosis, and joint stiffness. Patients can also have osteopenia as a radiographic finding at this stage. As CRPS becomes chronic, joint contracture may occur, although patients tend to have less pain. In refractory cases of CMC arthroplasty failure due to neurogenic causes, surgical exploration of the affected nerve (usually SSRN) can be considered with nerve exploration and neurolysis from any surrounding scar or inflammatory tissue. If a neuroma is encountered, we recommend resection of the neuroma with graft or conduit interposition to prevent recurrent neuroma. Another option is to bury the neuroma end in an adjacent muscle belly away from the skin. The ST arthritis should be recognized and addressed at the time of the first procedure by direct and radiographic examination (Fig. 1). If not addressed at that time, it can be a cause of ongoing pain and debility after CMC arthroplasty. For patients who remain symptomatic following CMC arthroplasty, a hemitrapezoidectomy with interposition is performed. An osteotome is used to remove the proximal portion of the trapezoid that articulates with the scaphoid and an interpositional graft (we prefer FCR tendon slip, if available) is placed. A microsuture-anchor can be placed into the trapezoid to tie the graft in place. Residual osteophytes on or near the metacarpal base can also cause pain and symptoms with grip, especially if there is instability of the LRTI and proximal migration of the metacarpal. In this case, resection of osteophytes is recommended along with suspension of the metacarpal with a suspension suture anchor, as described in cases of instability and impingement. The author’s (A.B.C.) preferred technique for failed LRTI, trapeziectomy with/without soft tissue interposition, and implant arthroplasty with proximal impingement of the metacarpal on the scaphoid (Fig. 2) is revision to LRTI with FCR tendon autograft, as originally described by Burton and Pellegrini.14Burton 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 Am. 1986; 11: 324-332Abstract Full Text PDF PubMed Scopus (510) Google Scholar Specific revision recommendations include use of the patient's prior incision as part of our approach with a curve in the proximal edge of the incision along the proximal volar wrist crease if harvesting the FCR tendon for the procedure. The branches of the SSRN are often encased in scar and difficult to dissect. Once the base of the first metacarpal and the CMC joint are exposed, additional assessment of the underlying cause for revision surgery is undertaken. Any residual scar or prior interpositional debris remaining in the trapezial fossa is carefully removed. The first metacarpal stability is assessed for pistoning and proximal impingement with the aid of fluoroscopic imaging. The first metacarpal base should remain stable and aligned with the base of the second metacarpal. The preferred tendon for primary and revision LRTI is the FCR.15Eaton R.G. Littler J.W. Ligament reconstruction for the painful thumb carpometacarpal joint.J Bone Joint Surg Am. 1973; 55: 1655-1666Crossref PubMed Scopus (672) Google Scholar However, if this tendon has been used in prior procedures or compromised, several other tendons can be used as an option for revision including the abductor pollicis longus, extensor carpi radialis longus (ECRL), or extensor carpi radialis brevis. We use a distally based slip of the abductor pollicis longus passed through the first metacarpal base from volar and radial to dorsal and ulnar and then sew the tendon back onto itself or sew to the extensor carpi radialis brevis at the base of the second metacarpal. The ECRL may also be used by harvesting a distally based slip and routing the tendon volarly between the second and the third metacarpals, through the abductor pollicis longus insertion, and then sewn back upon itself. Select an alternate tendon from that used in the first procedure for suspensionplasty or use a tightrope suture between the first and the second metacarpal if no tendon is available. A tightrope can also be used as an adjunct for suspension if instability persists after revision LRTI. These tendons can be harvested in their entirety or as a partial slip. If the FCR tendon has already been used, attenuated from ST arthrosis, or torn, we consider the use of an alternate tendon for LRTI. Jones et al16Jones D.B. Rhee P.C. Shin A.Y. Kakar S. Salvage options for flexor carpi radialis tendon disruption during ligament reconstruction and tendon interposition or suspension arthroplasty of the trapeziometacarpal joint.J Hand Surg Am. 2013; 38: 1806-1811Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar described a number of salvage techniques when the FCR tendon is attenuated or torn. A distally based partial-thickness strip of the FCR can be threaded through the base of the first metacarpal in cases of simple attenuation, thereby creating an LRTI-like sling. If the FCR is absent or completely torn, a slip of the ECRL or abductor pollicis longus may be harvested and used as described in the previous paragraph. If the first metacarpal is hypermobile after LRTI or if tendon options are limited, we then proceed with tightrope suture suspensionplasty of the first metacarpal to the second metacarpal (Fig. 3). The Mini TightRope (Arthrex, Naples, FL) supports and maintains the thumb and index metacarpals in proper relationship, while allowing for healing and scar tissue formation in the trapezial space with 74% maintenance of trapezial height at 2-year follow-up in primary CMC arthroplasty.17Yao J. Song Y. Suture-button suspensionplasty for thumb carpometacarpal arthritis: a minimum 2-year follow-up.J Hand Surg Am. 2013; 38: 1161-1165Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar The Arthrex technique guide is followed for use of the Mini-Tightrope. A C-arm fluoroscopic imaging is used to confirm wire placement across the first and second metacarpal bases in the anteroposterior and lateral positions prior to passing the suture for the tightrope. Button placement, reduction of the first metacarpal to the second metacarpal, and motion can be checked via fluoroscopic imaging prior to tying all knots to ensure that there is no proximal impingement with the tightrope in place. If the patient has more than 10° of hyperextension at the MCP joint but less than 30° of hyperextension, one may consider volar capsulodesis or soft tissue procedures to address the hyperextension in primary procedures. However, we do not recommend this in revision situations. Our preferred method to address both arthritis and hypermobility issues with the MCP joint is arthrodesis of the MCP joint (Fig. 3). We use a 2.0-mm plate-screw construct to obtain compression across the MCP joint once the joint surfaces have been appropriately prepared and all articular cartilage has been removed. The MCP joint is fused in 15° of flexion for optimal functional grasp and power grip. If all soft tissue options have been exhausted, for failed suspensionplasty revision (Fig. 4), or for failed implant/tightrope situations, we consider fusion of the first metacarpal base to the second metacarpal base with internal fixation and bone graft. This salvage technique was initially described for treatment of the flail thumb associated with poliomyelitis in order to improve thumb position for opposition.18Shah A. Ellis R.D. Thumb-index metacarpal arthrodesis for stabilization of the flail thumb.J Hand Surg Am. 1994; 19: 453-454Abstract Full Text PDF PubMed Scopus (3) Google Scholar In this situation, we utilize the patient's previous incision to identify the bases of first and second metacarpals. We then elevate a portion of ECRL from the second MCP base and expose cancellous bone with a bur and rongeurs. We use a 2.0-mm locking T-plate in compression mode along with bone allograft or autograft (Fig. 5).Figure 5A Posteroanterior and B lateral radiographs of a first to second metacarpal arthrodesis procedure using a 2.0-mm locking T-plate in compression mode.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We do not use silicone or other implants for revision CMC arthroplasty surgery because they have not shown acceptable outcomes in the literature (Fig. 6). We do not use distraction hematoma techniques for revision situations without a tightrope for long-term fixation. In anticipation of revision CMC arthroplasty surgery, it is important to counsel the patient regarding expectations and the potential for more than 1 subsequent surgery. Renfree and Dell19Renfree K.J. Dell P.C. Functional outcome following salvage of failed trapeziometacarpal joint arthroplasty.J Hand Surg Br. 2002; 27: 96-100Crossref PubMed Scopus (33) Google Scholar reported an average of 4.5 operations during a 5-year follow-up of patients in their failed CMC arthroplasty study. Many patients (27%) had complications related to SSRN. At the end of follow-up in this study, despite necessity for multiple surgeries, 9 of 12 patients were satisfied with improved pain and function. They noted especially poor outcomes with attempted fusion of the first metacarpal to the scaphoid with 100% (7 of 7) of these attempts resulting in failure, likely owing to shortening of the first ray. Cooney et al4Cooney W.P. Leddy T.P. Larson D.R. Revision of thumb trapeziometacarpal arthroplasty.J Hand Surg Am. 2006; 31: 219-227Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar reported on revision surgery for failed CMC arthroplasty including 15 patients who underwent 17 revision procedures. Their revisions were performed mainly with ligamentous reconstruction and/or soft tissue interposition procedures following a variety of initial procedures. Good or satisfactory results were noted in 13 of 17 procedures. Two fair and 2 poor results were associated with neurogenic pain related to SSRN neuritis and CRPS. Megerle et al5Megerle K. Grouls S. Germann G. Kloeters O. Hellmich S. Revision surgery after trapeziometacarpal arthroplasty.Arch Orthop Trauma Surg. 2011; 131: 205-210Crossref PubMed Scopus (35) Google Scholar reported 2 good, 5 fair, and 5 poor results after 19 procedures related to metacarpal impingement, ST arthritis, and SSRN neuropathy. Conolly and Rath20Conolly W.B. Rath S. Revision procedures for complications of surgery for osteoarthritis of the carpometacarpal joint of the thumb.J Hand Surg Br. 1993; 18: 533-539Crossref PubMed Scopus (82) Google Scholar noted similar outcomes with 5 of 17 poor results after revision procedures following a variety of primary procedures. Although limited case series exist, these data show positive outcomes after revision CMC arthroplasty surgery with about 70% of patients showing improvement in symptoms and/or function.4Cooney W.P. Leddy T.P. Larson D.R. Revision of thumb trapeziometacarpal arthroplasty.J Hand Surg Am. 2006; 31: 219-227Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 19Renfree K.J. Dell P.C. Functional outcome following salvage of failed trapeziometacarpal joint arthroplasty.J Hand Surg Br. 2002; 27: 96-100Crossref PubMed Scopus (33) Google Scholar, 20Conolly W.B. Rath S. Revision procedures for complications of surgery for osteoarthritis of the carpometacarpal joint of the thumb.J Hand Surg Br. 1993; 18: 533-539Crossref PubMed Scopus (82) Google Scholar Whereas feasible surgical options exist, our recommendation is to proceed cautiously with revision surgery after detailed discussion with patients regarding potential need for additional surgeries with the real potential for ongoing complications in the future. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlODI4ZWNhYWJlYTY3MjM1ZDhjNjcxZTRlMzY4MjQ3OCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NjY3ODM4fQ.BfcmFiyAaQjv6OYCkCOZeHUGnawZwUeN2lPcngFDmBt0cUkBEHWJhQJs9J0WodzWUzSI938O7whkmlEZM72ZcDDAQfHxZXZqTt8GtfNCeTXO_63o7i9vWHw3nD5e0Xlv28KK8mR51h2DWFAEvE8k1cvbE_fVY6eePVAqzRwhXYnwXsNLomuhYgs6Xz7n3U2Veu5uN_LQOw868CYrnlSjlqAZpdzLCX29TUxPDQcFuEoTjEJPLGmYqf5UdZE7m1hTcXnhn1ueZQhPlsoOOaeOTul96W9BOQfcgRSQ33J-xYfZ_5b4EHDkPO-MUxHbSoB4_8_qpA7xKgUxEBnf_h5_XA Download .mp4 (28.28 MB) Help with .mp4 files Video AThis is a long video at over 17 minutes, but nonetheless is very useful. It analyzes the causes for the relatively uncommon failure following thumb CMC arthroplasty. It also describes a variety of treatment options. Viewed in conjunction with the printed article, the 2 enhance and augment each other. Journal CME QuestionsJournal of Hand SurgeryVol. 43Issue 9Preview Full-Text PDF
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