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Reoperation Rate Following Thumb Basal Joint Arthroplasty: A Minimum Follow-Up Period of 5 Years

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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, 3.9–14.3 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.
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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, dened 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 modiable (repetitive use, manual labor, and trauma) and
nonmodiable (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 rst 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 benets 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 identied 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 rst thumb BJA were
included. Similarly, patients in which BJA was performed as a sec-
ondary operation (eg, after initial open reduction internal xation
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 Fishers
exact tests. All analyses were two-tailed, and signicance was set at
aPvalue of <.05.
Results
Study patients
A total of 686 primary thumb BJAs were performed in 637
patients by 14 board-certied 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 nally 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,
bromyalgia,
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 Supercial 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, Crohns 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 Ab, 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
Ab, atrial brillation; 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 signicant 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 gures 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, dened 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 gure 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
gure 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-
nicant 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 signicant reduction in pain and increase
in pinch/grip strength. Sadhu et al
24
report signicantly 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
rst revision, 2.3 years after index). Renfree et al
26
report that most
of their patients undergoing multiple revisions were satised 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%
Infecon/seroma Persistent pain/neuris Retained hardware Symptomac 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 identication 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 nd statistically signicant 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 identied 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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Purpose Thumb basal joint arthritis is a common degenerative condition of the hand that is often managed with thumb basal joint arthroplasty (BJA). This procedure generally results in a high level of patient satisfaction; however, the rate and cause of early unplanned reoperation after thumb BJA are not well-understood. Therefore, we performed a review to better understand the rate and cause of early reoperation. Methods A retrospective review of all thumb BJA cases performed at a single private academic center between 2014 and 2016 yielded 637 patients and 686 primary thumb BJAs with a minimum 1-year follow-up (mean, 2.4 years). Data collection included patient demographics, surgical technique and type of thumb BJA performed, time to reoperation, reason for early reoperation (within 2 years), and type of reoperation. Results Of 686 patients undergoing thumb BJAs, 10 had unplanned early reoperation (1.5%). Mean duration between the index procedure and reoperation was 5.2 months (range, 0.5–14.3 months). Of the 10 unplanned early reoperations, 4 thumbs in 4 patients required revision arthroplasties owing to persistent pain. Time to reoperation for revision arthroplasty was 9.6 months (range, 3.9–14.3 months). Three of 10 reoperations resulted from early infection, 2 from unplanned early removal of symptomatic K-wires, and one from radial sensory neuritis. Conclusions In this series of nearly 700 consecutive cases, we identified an unexpected early reoperation rate of 1.5%, with only a 0.6% reoperation rate specifically for painful subsidence requiring a revision arthroplasty. Mean time to revision was 9.6 months. These rates are lower than those published previously and should be considered by patients and surgeons when planning thumb BJA. Type of study/level of evidence Prognostic IV.
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Background and purpose — Revision surgery after trapeziometacarpal arthroplasty is sometimes required. Varying revision rates and outcomes have been reported in rather small patient series. Data on risk factors for revision surgery, on the final outcome of revision, and possible factors affecting the outcome of revision are also limited. We evaluated these factors in 50 patients. Patients and methods — From 1,142 trapeziometacarpal arthroplasties performed during a 10-year period, 50 patients with 65 revision surgeries were retrospectively identified and invited to participate in a follow-up study involving subjective, objective, and radiologic evaluation. The revision rate, risk factors for revision, and factors affecting the outcome of revision were analyzed. Results — The revision rate was 5%. Scaphometacarpal impingement was the most common reason for revision surgery. Patient age ≤ 55 years was a risk factor with a revision rate of 9% in this age group, whereas an operation on both thumbs during the follow-up period was a negative risk factor for revision surgery. There was no difference in revision risk between ligament reconstruction and tendon interposition with or without a bone tunnel. 9 patients had multiple revision procedures and their final outcome did not differ significantly from patients revised only once. Most of the patients felt subjectively that they had benefited from revision surgery and the subjective outcome measures (QuickDash and pain VAS) and the Conolly score were in the same range as previously described for revision trapeziometacarpal arthroplasty. Interpretation — Age ≤ 55 years is a risk factor for revision surgery. The type of primary surgery does not affect the risk of revision surgery and multiple revision procedures do not result in worse outcomes than cases revised only once. Mechanical pain caused by contact between the metacarpal and scaphoid is the most common indication for revision surgery. In general, patients seem to benefit from revision surgery for trapeziometacarpal osteoarthritis.
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The thumb basal joint is the second most common site of osteoarthritis in the hand, and osteoarthritis of this joint can contribute to painful movement and debilitating function. To achieve a high degree of prehensile and manipulative function, this highly mobile joint is constrained by both the saddle morphology of the trapezium and a stout complement of ligamentous constraints. The disease proceeds progressively with several wear patterns. Substantial new biomechanical and longitudinal clinical studies have changed some of the prevailing opinions on the process of serial degenerative changes. Diagnosis is made with a thorough clinical examination and radiographic staging, as described by Eaton and Littler. Thumb basal joint arthritis can be initially managed with medications, orthoses, and steroid injections; however, it frequently progresses despite these interventions. Surgical management commonly consists of trapeziectomy with or without interposition or suspension, arthroplasty with implant, volar ligament reconstruction, osteotomy, or arthrodesis; none of these techniques has been proved to be superior to the others.
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Purpose: We compare outcomes of revision surgery for trapeziometacarpal (TM) arthritis with outcomes for both primary and revision surgery for TM arthritis reported in the literature. We hypothesized that patients undergoing revision surgery for TM arthritis would demonstrate pain and functional outcome scores that were worse than those of patients undergoing primary TM surgery. Methods: A retrospective analysis of all patients undergoing revision TM surgery at a single institution from 1995 to 2015 was performed. Eighty-three patients (86 hands) met the inclusion criteria. Of these, 25 patients (27 hands) were available for follow-up via phone survey or clinical examination; 58 patients (59 hands) were available for chart review only. Patients available for phone survey or clinical examination were evaluated with the visual analog scale, Disabilities of the Arm, Shoulder, and Hand score, and the Conolly-Rath evaluation method. Patients available for clinical examination were also evaluated with grip strength, pinch strength, and radiographs. Results: Median follow-up was 8.5 years (range, 2.0-21.2 years). Twenty percent of patients experienced postoperative complications, most commonly pin problems (7%). Of the 27 hands available for interview or clinical examination, 15 were dominant and 12 were nondominant. The average visual analog scale was 28.2 (SD, 29.7). Disabilities of the Arm, Shoulder, and Hand scores averaged 32.0 (SD, 20.8). According to the Conolly and Rath criteria, 10 patients had a good outcome, 7 were fair, and 10 were poor. For the group of 13 patients who underwent physical examination, average adduction was 42° in the affected side versus 51° in the nonaffected side. Radial abduction was 58° in the affected side versus 65° in the nonaffected side. Palmar abduction was 53° versus 85° in each group, respectively. Tip finger pinch was 3.4 kg for the affected hand versus 4.0 kg for the nonaffected side. Key pinch was 4.7 and 5.5 kg, respectively. Grip strength was measured as 22.1 kg in the affected side versus 27.6 kg in the contralateral side when adjusted for dominance. Conclusions: In our study group, revision surgery for unsuccessful primary TM surgery demonstrated results inferior to those previously reported for primary surgery for TM arthritis but similar to prior studies of revision TM surgery. Revision surgery, however, can result in satisfactory long-term outcomes particularly when metacarpophalangeal joint pathology is addressed and complications are avoided. Type of study/level of evidence: Therapeutic IV.
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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.
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Purpose: To evaluate the outcome of revision surgery for failed thumb carpometacarpal (CMC) arthroplasty. Methods: We retrospectively analyzed 32 patients with failed thumb CMC arthroplasty. The primary reason for revision was pain caused by metacarpal subsidence. Revision surgery included soft tissue interposition and distraction pinning to address the metacarpal subsidence. Additional ligament reconstruction was performed in patients with thumb instability. Eight patients required additional metacarpophalangeal joint fusion for concomitant joint hyperextension. Eleven required additional partial excision of the trapezoid for concomitant scaphotrapezoidal joint arthritis. All patients were evaluated clinically and radiographically. Results: Mean follow-up was 57 months (range, 24-121 months). Pain levels evaluated by visual analog scale were significantly reduced in all patients after revision surgery. Mean grip strength and key pinch strength significantly increased. Twenty-seven patients achieved good functional results; those for 5 patients were fair. Conclusions: This study showed that revision surgery with distraction pinning and soft tissue interposition with or without ligament reconstruction was an effective treatment for failed CMC arthroplasty of the thumb. Type of study/level of evidence: Therapeutic IV.
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Purpose: Suture button suspensionplasty (SBS) has been used to treat thumb carpometacarpal joint osteoarthritis (CMC joint OA). Although promising short-term outcomes have been reported, no outcomes beyond 4 years have been published. The aim of this article is to report intermediate outcomes of SBS. Methods: We reviewed the charts of 14 patients who underwent 16 SBS procedures for symptomatic thumb CMC joint OA. We recorded demographic data, preoperative Eaton stage, length of follow-up, Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores, as well as pinch strength, grip strength, range of motion, and metacarpal subsidence. Operative time and postoperative complications were documented. Results: Average age was 64 years. There were 12 women and 2 men. Preoperative Eaton stages were III and IV in 8 thumbs each. Mean operative time was 93 minutes. Mean follow-up was 64 months with mean Quick-Disabilities of the Arm, Shoulder, and Hand score improvement of 58.2. Mean palmar and radial abduction were 105% and 97%, respectively, of the nonsurgical thumb. Kapandji scores for all operated thumbs were either 9 or 10. Pinch and grip strength were 107% and 102%, respectively, of the nonsurgical side. Mean trapezial space height was 71%. One patient underwent removal of a symptomatic implant and 2 patients had transient neuropraxia of the dorsal radial sensory nerve. Conclusions: Favorable outcomes (improvement in range of motion and pain relief) of SBS remain durable over time. Our results show that improvement in strength may also be expected over time when using SBS after trapeziectomy for the treatment of thumb CMC joint OA. Type of study/level of evidence: Therapeutic IV.
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Background: Trapeziometacarpal (TMC) arthritis is an expected part of ageing to which most patients adapt well. Patients who do not adapt to TMC arthritis may be offered operative treatment. The factors associated with reoperation after TMC arthroplasty are incompletely understood. The purpose of this study was to determine the rate of, the underlying reasons for, and the factors associated with unplanned reoperation after TMC arthroplasty. Methods: In this retrospective study, we included all adult patients who had TMC arthroplasty for TMC arthritis at 1 of 3 large urban area hospitals between January 2000 and December 2009. Variables were inserted into a multivariable Cox proportional hazards model to determine factors associated with unplanned reoperation, and the Kaplan-Meier curve was used to estimate and describe the probability of unplanned reoperation over time. Results: Among 458 TMC arthroplasties, 19 (4%) had an unplanned reoperation; 16 of 19 (84%) for persistent pain and two-thirds within the first year. The multivariate Cox regression analysis showed that unplanned reoperation was independently associated with younger age, surgeon inexperience, and index procedure type. Conclusions: Surgeons should be aware as well as patients should be informed that as many as 4% are offered or request a second surgery, usually for persistent pain and often within the 1-year window when additional improvement is anticipated.