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Original Research
Reoperation Rate Following Thumb Basal Joint Arthroplasty: A
Minimum Follow-Up Period of 5 Years
Adam N. Fano, MD,
*
Jack G. Graham, MD,
*
Jonathan Dang, BS,
y
Alexis Kasper, BS,
z
Asif M. Ilyas, MD, MBA
*
,
y
,
z
*
Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
y
Drexel University College of Medicine, Philadelphia, PA
z
Rothman Orthopaedic Institute, Philadelphia, PA
article info
Article history:
Received for publication December 14, 2023
Accepted in revised form December 24,
2023
Available online February 8, 2024
Key words:
Arthroplasty
Basal joint
Carpometacarpal
Reoperation
Thumb
Purpose: Thumb basal joint arthroplasty (BJA) performed for thumb basal joint arthritis is associated with
high patient satisfaction. However, complications requiring reoperation occur, with a previously reported
early reoperation rate (within 2 years) of 1.5%. The purpose of this study was to determine the risk of and
reasons for reoperation in the intermediate term, defined as within 5 years of the index surgery.
Methods: All cases of primary thumb BJA performed from 2014 to 2016 at a single private academic
center were reviewed. For cases requiring reoperation, data regarding index surgical technique, reason
for reoperation, time to reoperation, and reoperation technique were collected. Risk of reoperation
(return to the operating room for any reason) and risk of revision arthroplasty (revision surgery for
symptomatic subsidence or instability) within 5 years of the index surgery were calculated.
Results: A total of 686 primary thumb BJAs were performed in 637 patients. Risk of reoperation for any
reason was 2.0% (14/686), and risk of revision arthroplasty for symptomatic subsidence or instability was
0.6% (4/686) within 5 years of surgery. The mean time between the index surgery and reoperation was
10.3 months (range, 16 days to 4.6 years) for all cases; however, for revision arthroplasty, the mean time
was 9.6 months (range, 3.9e14.3 months).
Conclusions: The intermediate term (5 years minimum) rate of reoperation following thumb BJA for any
reason was 2%, with only approximately one-fourth of reoperation cases requiring revision arthroplasty
for symptomatic subsidence or instability. These data may provide useful information in the counseling
of patients considering thumb BJA surgery.
Type of study/level of evidence: Prognostic IV.
Copyright ©2024, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Osteoarthritis of the thumb basal joint is among the most
common degenerative conditions of the hand and has been re-
ported to affect up to 91% of those >80 years of age.
1e3
There are
both modifiable (repetitive use, manual labor, and trauma) and
nonmodifiable (increasing age, female sex,
4
and ligamentous laxity;
eg, as seen in EhlerseDanlos syndrome) risk factors for develop-
ment of thumb basal joint arthritis.
1,2,5e7
Despite the cause, pa-
tients may suffer from activity-related pain, weakness with pinch/
grasp, and up to a 50% impairment in the affected upper extrem-
ity.
1,8
Given the impact of advanced disease, surgical intervention is
often pursued in the form of thumb basal joint arthroplasty (BJA),
also known as thumb or first carpometacarpal arthroplasty.
There are a number of surgical techniques employed to perform
thumb BJA, most including a combination of trapeziectomy and
some form of suspensionplasty to support the thumb meta-
carpal.
9e11
Regardless of technique, outcomes are generally
good.
12e16
However, complications requiring reoperation do occur,
and given its elective nature, reoperation risk following this pro-
cedure is of interest.
17
Previous studies have reported a revision risk
ranging from 2.9% to 5%, but the evidence is scarce.
18e22
A retro-
spective study performed at our center by Graham et al
22
was
published in 2019, reporting an early reoperation rate (within 2
years) of 1.5% and an early revision rate of 0.6%.
Declaration of interests: No benefits in any form have been received or will be
received related directly to this article.
Corresponding author: Asif M. Ilyas, MD, MBA, Department of Orthopaedic
Surgery, Rothman Orthopaedic Institute, 925 Chestnut Street, Philadelphia, PA
19107.
E-mail address: Asif.ilyas@rothmanortho.com (A.M. Ilyas).
Contents lists available at ScienceDirect
Journal of Hand Surgery Global Online
journal homepage: www.JHSGO.org
https://doi.org/10.1016/j.jhsg.2023.12.013
2589-5141/Copyright ©2024, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Hand Surgery Global Online 6 (2024) 268e272
Given the variability in reported risk and limited available data,
the purpose of this study was to extend the investigation presented
by Graham et al
22
to the intermediate term to determine the risk of
and reasons for reoperation within 5 years of the index surgery. It
was hypothesized that the risk of reoperation within 5 years of the
index surgery would be less than 5%.
Materials and Methods
Study design and setting
Institutional review board approval was secured. The study
was organized as a retrospective study including all patients un-
dergoing primary thumb BJA from January 2014 to December 2016
(a 3-year period) at a single private academic center.
Study patients
Patients with a diagnosis of thumb basal joint arthritis who
underwent primary thumb BJA from 2014 to 2016 were included in
this study. Patients were identified using current procedural ter-
minology codes 25447 (interposition arthroplasty, intercarpal or
carpometacarpal joints) or 25210 (carpectomy; one bone). Patients
who had undergone thumb BJA surgery prior to 2014 were
excluded, and only patients undergoing their first thumb BJA were
included. Similarly, patients in which BJA was performed as a sec-
ondary operation (eg, after initial open reduction internal fixation
for fracture) were excluded. Index thumb BJA surgical techniques
included ligament reconstruction and tendon interposition (LRTI),
trapeziectomy with suture-button suspensionplasty (SBS) using the
Mini TightRope (Arthrex, Inc), trapeziectomy with pinning, and
trapeziectomy without pinning.
Data collection and analysis
Baseline demographic information was collected for each pa-
tient, including age, sex, laterality, diagnosis, and comorbidities.
The medical record was reviewed with attention paid to reopera-
tion following the index procedure. For cases requiring reoperation,
data on index surgical technique, reason for reoperation, time to
reoperation, and reoperation technique were collected. Risk of
reoperation (return to the operating room for any reason) and risk
of revision arthroplasty (revision surgery for symptomatic subsi-
dence or instability) within 5 years of the index surgery were
calculated. Categorical variables were compared using Fisher’s
exact tests. All analyses were two-tailed, and significance was set at
aPvalue of <.05.
Results
Study patients
A total of 686 primary thumb BJAs were performed in 637
patients by 14 board-certified hand surgeons (A.M.I.) over the 3-
year study period, of which 494 (72%) were performed in
women and 192 (28%) in men, with a total mean age at time of
index surgery of 61.5 ±9.6 years (range, 33e83 years) (Ta ble 1).
The thumb BJA technique consisted of trapeziectomy with LRTI in
515 (75.1%), trapeziectomy with SBS in 119 (17.3%), trapeziectomy
with pinning in 35 (5.1%), and trapeziectomy without pinning in
17 (2.5%) (Fig. 1). The mean duration between the index surgery
and electronic medical record review was 7.9 ±0.9 years (range,
6.4e9.7 years).
Risk of reoperation
A total of 14 of 686 (2.0%) primary thumb BJAs underwent
reoperation within 5 years of the index surgery (Table 2). The mean
duration between the index surgery and reoperation for any reason
was 10.3 months (range, 16 days to 4.6 years).
Of the 14 cases undergoing reoperation,four (0.6% of total; 4/686)
underwent revision surgery for painful subsidence. Two patients
underwent index LRTI and were treated with revision to an SBS
construct. One patient underwent index trapeziectomy with
pinning and was treated with revision to an SBS construct. Finally,
one underwent index SBS and was treated with revision SBS. Mean
duration between the index surgery and revision arthroplasty for
painful subsidence was 9.6 months (range, 3.9e14.3 months).
Among the other 10 cases requiring reoperation, three cases
(21.4%) were complicated by infection/seroma requiring irrigation
and debridement (and in one case, removal of hardware with
revision SBS), three cases (21.4%) were complicated by persistent
pain/neuritis requiring neurolysis, two cases (14.3%) were compli-
cated by retained hardware following trapeziectomy with pinning
requiring unplanned removal of hardware, and finally two cases
(14.3%) developed symptomatic cysts at the BJA surgical site
requiring cyst excision (Fig. 2). The mean duration between the
Table 1
Demographics, Reoperations, and Revisions by Index Surgical Technique
Index Technique Joints, n (%) Age (y), Mean (Range) Female, n (%) Reoperations, n (%) Revisions, n (%)
LRTI 515 (75.1) 62.5 (33e83) 372 (72) 7 (1.4%) 2 (0.4)
SBS 119 (17.3) 61.0 (43e80) 90 (76) 4 (3.4%) 1 (0.8)
Trapeziectomy with pinning 35 (5.1) 59.8 (44e78) 29 (83) 3 (8.6%) 1 (2.9)
Trapeziectomy without pinning 17 (2.5) 62.8 (53e71) 3 (18) 0 (0%) 0 (0)
Total 686 (100) 61.5 (33e83) 494 (72) 14 (2.0%) 4 (0.6)
.
75.10%
17.30%
5.10% 2.50%
LRTI SBS Trapeziectomy with pinning Trapeziectomy without pinning
Figure 1. Index surgical technique.
A.N. Fano et al. / Journal of Hand Surgery Global Online 6 (2024) 268e272 269
Table 2
Joints Undergoing Reoperation Following Thumb BJA
Patient ID Age (y) Sex Laterality Diagnosis Comorbidities Index Technique MCP Procedures Reason for Reoperation Time to
Reoperation (mo)
Reoperation
Technique
1 47 F L CMC OA, Eaton III PE, HTN, HLD,
fibromyalgia,
previous smoker
LRTI None Painful subsidence 12.9 Conversion to SBS
2 64 F L CMC OA, Eaton IV HTN, smoker Trapeziectomy with
pinning
None Painful subsidence 3.9 Conversion to SBS
3 61 M R CMC OA, end stage CKD, HTN, anxiety,
depression, smoker
LRTI None Superficial infection 0.5 I&D
4 55 F R CMC OA, end stage HTN, OSA, depression,
previous smoker
SBS None Seroma 4.2 I&D, removal of
hardware,
revision SBS
5 68 F R CMC OA, severe Osteoporosis LRTI None Painful subsidence 7.1 Conversion to SBS
6 65 F L CMC OA, Eaton III SLE, Crohn’s disease LRTI None Infection 1.1 I&D
7 78 M L CMC OA, advanced HTN, HLD, OSA,
previous smoker
Trapeziectomy with
pinning
None Retained symptomatic pin 1.8 Removal of
hardware
8 70 F L CMC OA, end stage Asthma, HLD,
depression
Trapeziectomy with
pinning
None Retained symptomatic pin 1.8 Removal of
hardware
9 61 M L CMC OA, advanced Anxiety LRTI None Radial sensory neuritis 3.9 Radial sensory
neurolysis
10 53 F L CMC OA, Eaton III HLD, anxiety,
depression, smoker
SBS None Painful subsidence 14.3 Revision SBS
11 65 F R CMC OA, advanced CHF, HTN, osteoporosis,
smoker
LRTI None Ganglion cyst at surgical site 3.7 Excision of cyst
12 76 F L CMC OA, advanced Afib, hypothyroidism,
HTN, HLD, osteoporosis
SBS None Cyst near surgical site 4.6 Excision of cyst
13 69 F L CMC OA, advanced Heart disease, HTN,
HLD, OSA, depression
SBS Capsulodesis Persistent pain 55.6 Revision SBS
14 60 F R CMC OA, end stage HLD LRTI None Persistent pain 28.8 Revision LRTI,
radial sensory
neurolysis
Afib, atrial fibrillation; CHF, congestive heart failure; CKD, chronic kidney disease; CMC OA, carpometacarpal osteoarthritis; F, female; HLD, hyperlipidemia; HTN, hypertension; I&D¼irrigation and debridement; L, left; LRTI,
ligament reconstruction tendon interposition; M, male; MCP, metacarpophalangeal; OSA, obstructive sleep apnea; PE, pulmonary embolism; R, right; SBS, suture button suspension; SLE, systemic lupus erythematosus.
A.N. Fano et al. / Journal of Hand Surgery Global Online 6 (2024) 268e272270
index surgery and reoperation for a nonrevision arthroplasty
reason was 10.6 months (range, 16 days to 4.6 years).
Risk of reoperation for any reason was 1.4% (7/515) following
LRTI, 3.4% (4/119) following SBS, 8.6% (3/35) following tra-
peziectomy with pinning, and 0% (0/17) following trapeziectomy
without pinning. Joints undergoing trapeziectomy with pinning
had an increased risk of reoperation when compared to LRTI (8.6%
vs 1.4%; P¼.02); however, no statistically significant differences
were found when comparing each of the other groups (LRTI vs SBS,
LRTI vs trapeziectomy without pinning, SBS vs trapeziectomy with
pinning, SBS vs trapeziectomy without pinning, and trapeziectomy
with pinning vs trapeziectomy without pinning; P>.05).
The risk of revision arthroplasty for painful subsidence was 0.4%
(2/515) following LRTI, 0.8% (1/119) following SBS, 2.9% (1/35)
following trapeziectomy with pinning, and 0% (0/17) following
trapeziectomy without pinning.
The risk of reoperation for a nonrevision arthroplasty reason
was 1.0% (5/515) following LRTI, 2.5% (3/119) following SBS, 5.7%
(2/35) following trapeziectomy with pinning, and 0% (0/17)
following trapeziectomy without pinning.
Discussion
Osteoarthritis of the thumb basal joint is a common ailment of
the hand and can lead to substantial impairment.
1,2,8
Surgical
intervention in the form of thumb BJA is effective in reducing pain
and restoring function with generally high patient satisfaction.
12e16
Although uncommon, there are instances in which a reoperation or
revision BJA may be indicated.
17
The literature is scarce regarding
the risk of revision, and reported figures range from 0.6% to 5%.
18e22
The purpose of this study was to expand upon an investigation into
early (within 2 years) reoperation risk published by Graham et al
22
in 2019 from this center, to determine the risk of and reasons for
reoperation at the intermediate term, defined as within 5 years of
index surgery.
The risk of reoperation within 5 years of the index surgery was
found to be 2%, while the risk of revision arthroplasty was found to be
0.6%. The risk of reoperation was expectedly higher than that re-
ported by Graham et al
22
in 2019 (1.5% reoperation risk) owing to an
increase in time to follow-up but still notably lower than other
published reports.
18e22
Megerle et al
18
reported a revisionrisk of 2.9%
at a mean of 2.7 years after the index surgery. Wilkens et al
19
differentiated between revision and reoperation, reporting a revi-
sion risk of 2.8% within 5 years and a reoperation risk of 4%. Cooney
et al
20
report a 3.8% revision risk, but this figure is questionable as
calculating risk from their data set seems to yield a risk of 2.8%, not
3.8%. Mattila et al
21
also investigated the revision risk and report a
figure of 5%. Ourcohort is unique in that we analyzedpatients treated
by 14 surgeons, which includes an inherent variability in preference
and technique,which may increase the generalizabilityof our results.
Ligament reconstruction and tendon interposition was by far
the most commonly employed technique for index surgery (75%).
This was followed by SBS (17.3%), trapeziectomy with pinning
(5.1%), and trapeziectomy without pinning (2.5%). The breakdown
of surgical techniques is variable between studies (eg, Mattila
et al
21
and Cooney et al
20
did not have cases of SBS in their cohorts),
which limits the comparison. The risk of reoperation was found to
be higher following trapeziectomy with pinning (8.6%) when
compared directly to LRTI (1.4%). In the 2019 study, Graham et al
22
found an increased risk of reoperation following trapeziectomy
with pinning when compared to both LRTI and SBS (P<.01);
however, only the former comparison remained statistically sig-
nificant in this current expanded follow-up study. Interestingly,
Wilkens et al
19
found that partial or complete trapeziectomy with
interposition alone was associated with an increased risk of reop-
eration when compared to partial or complete trapeziectomy with
interposition and ligament reconstruction or suspensionplasty.
Four joints in our cohort underwent reoperation in the form of
revision arthroplasty secondary to painful subsidence: two under-
went index LRTI and were treated with revision to an SBS construct;
one underwent index trapeziectomy with pinning and was treated
with revision to an SBS construct; and one underwent index SBS
and was treated with revision SBS. Two joints that underwent in-
dex LRTI were complicated by infection requiring irrigation and
debridement. In one case treated with index SBS, seroma devel-
oped, and this was addressed with irrigation and debridement,
removal of hardware, and revision SBS. Two joints treated with
index LRTI were complicated by persistent pain; one was treated
with simple neurolysis for presumed radial sensory neuritis, and
the second underwent revision LRTI þneurolysis. One joint treated
with index SBS and simultaneous capsulodesis of the ipsilateral
metacarpophalangeal joint was complicated by persistent pain and
ultimately treated with revision SBS. Two joints that underwent
index trapeziectomy with pinning experienced retained hardware
(pin) after attempted pull in the outpatient setting, necessitating
reoperation for hardware removal. Finally, two joints, one index
LRTI and one index SBS, developed cysts near the BJA surgical site
and underwent reoperation for cyst excision.
Papatheodorou et al
23
investigated 32 cases of failed BJA, most
secondary to painful subsidence; they found that revision with
distraction pinning and soft tissue interposition ±ligament
reconstruction resulted in significant reduction in pain and increase
in pinch/grip strength. Sadhu et al
24
report significantly worse
patient-reported outcomes in patients undergoing revision LRTI
compared to patients undergoing primary LRTI. This conclusion is
corroborated by Munns et al,
25
reporting that results are expectedly
inferior following revision arthroplasty when compared to primary
arthroplasty; however, they state that revision arthroplasty can still
result in satisfactory long-term outcomes. Renfree et al
26
investi-
gate the salvage of failed BJA in 12 patients and note that multiple
procedures owing to recurrent complications were common with
an average of 4.5 per patient. Of note, one patient in our cohort
treated with index LRTI and revision to SBS construct for painful
subsidence (1.1 years after index) experienced recurrent painful
subsidence and underwent a second revision arthroplasty in the
form of partial trapezoidectomy and revision SBS (1.2 years after
first revision, 2.3 years after index). Renfree et al
26
report that most
of their patients undergoing multiple revisions were satisfied with
their pain relief and function at an average follow-up of 5 years.
This study has several limitations. First, follow-up is limited to
the information contained within our electronic medical record. It
21.40%
21.40%
14.30%
14.30%
Infecon/seroma Persistent pain/neuris Retained hardware Symptomac cyst
Figure 2. Reasons for reoperation (excluding those undergoing revision arthroplasty
secondary to painful subsidence).
A.N. Fano et al. / Journal of Hand Surgery Global Online 6 (2024) 268e272 271
is possible that there is a fraction of our cohort that had sought care
elsewhere either for a revision surgery or for routine follow-up that
was not captured, limiting the ability to review the most up-to-date
and accurate information. Second, reliance on current procedural
terminology codes for identification of our cohort leaves the pos-
sibility of missing patients during the initial query if coding errors
existed. Finally, given the infrequency of a positive event (reoper-
ation) in this data set, all statistical analyses performed are limited
and likely underpowered to find statistically significant differences
if true differences indeed exist (ie, these analyses are prone to type
II error).
In conclusion, following the prior study in which Graham et al
22
reported an early (within 2 years) reoperation and revision risk
following thumb BJA, an expanded investigation to 5 years after
surgery identified a reoperation rate of 2% with a revision risk of
0.6% for instability or painful subsidence. This information adds to
the existing literature and may provide surgeons with a useful
framework to guide shared decision making with patients consid-
ering thumb BJA for symptomatic arthritis.
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