Dissatisfaction After Trapezial-Metacarpal Arthroplasty Benjamin M. Braun, BA, Zhongyu Li, MD, PhD, Ethan R. Wiesler, MD THE PATIENT A 47-year-old right-handed male obstetrics/gynecology surgeon reports 18 months of pain at the base of both thumbs. The patient underwent staged trapeziectomy of both hands with ligament reconstruction and tendon interposition (LRTI) using the entire flexor carpi radialis tendon for trapezial-metacarpal (TMC) arthritis 6 months prior by another surgeon (Fig. 1). He rates his current pain as 10 out of 10 on the left and is notes that he cannot touch his thumb to his little finger owing to pain. He also has significant pain on the right with limited grasp. THE QUESTION What is the best treatment for continued pain after TMC arthroplasty? CURRENT OPINIONS Simple trapeziectomy was the original option for TMC arthroplasty1,2 until surgeons treating the approximately 20% of patients that were unsatisfied with trapeziectomy theorized that the ongoing pain was due to instability of the thumb metacarpal. New procedures were developed using tendon grafts to stabilize the metacarpal and various materials interposed tissue to fill the void created by partial or total resection of the trapezium,3,4 Unfortunately, between 10% and 20% of patients remain unsatisfied with TMC arthroplasty.5 The optimal management of continued pain after TMC arthroplasty is unclear. From the Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC. Received for publication July 17, 2013; accepted in revised form December 31, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Ethan R. Wiesler, MD, Medical Center Blvd., Winston-Salem, NC 27157; e-mail: [email protected]. 0363-5023/14/3905-0025$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.12.030

THE EVIDENCE Sodha et al6 and Becker et al7 demonstrated that TMC arthrosis is an expected part of human aging in both sexes. In the larger and more recent study, the radiographs of 2,321 patients aged 31 and older treated for a distal radius fracture demonstrated TMC arthritis in 100% of women 91 years and older, and 93% of men 81 years and older.7 Women develop arthrosis earlier than men but sex alone was not a risk factor for the development of TMC arthrosis. The authors noted that only 3 patients in this large cohort had radiographic evidence of TMC arthroplasty, suggesting that patients are largely able to adapt to TMC arthritis without surgical intervention.7 A Cochrane review found that no one arthroplasty procedure was superior to another in regards to functional outcome, range of motion, or pain. Simple trapeziectomy was associated with a lower rate of complications than procedures that use tendon grafts for ligament reconstruction or interposition.4 Subsidence of the metacarpal that settles into the trapezial void does not correlate with symptoms or function after TMC arthroplasty.8 One study of the radiographs of 15 patients happy with the results of LRTI, 21% sustained loss of the initial postoperative trapeziectomy void at rest and an additional 10.5% subsidence with key pinch. The patients had an average increase of 17% in their key pinch grip compared with their preoperative measurement. In Cooney et al’s paper,9 15 of 654 (2.3%) patients requested a second surgery after TMC arthroplasty. In another review,10 16 of 343 (4.7%) patients requested a second surgery. Renfree and Dell11 noted that, among 15 patients who had revision TMCl arthroplasty—6 of whom underwent LRTI as their primary procedure—an average of 3 additional procedures were performed before the patient was satisfied with the result. Mergerle et al10 evaluated 12 patients who had surgery subsequent to the index TMC arthroplasty: 6 underwent a repeat arthroplasty (1 for resection of residual fragments of trapezium alone), 2 had a thumb

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to surgeon unrelated to differences in pathophysiology. Although there is evidence that dissatisfaction after TMC arthroplasty leads to multiple subsequent surgeries with difficulty obtaining satisfaction—similar to the so-called “failed back” in spine surgery—the psychosocial aspects common to such problems are uncommonly addressed by hand surgeons. Furthermore, there is not a clear relationship between pathophysiology (eg, metacarpal subsidence) and symptoms and disability. DIRECTIONS FOR FUTURE RESEARCH Given that TMC is an expected part of human aging, there may be important differences between the average patient who adapts to these changes and the subset of patients electing surgical management. If patients who choose surgery are less adaptive, they may be predisposed to dissatisfaction with surgery even if that surgery achieves its goals without adverse events. This line of thinking merits additional research. A large prospective cohort study of patients undergoing TMC arthroplasty of various types could determine factors associated with dissatisfaction among demographic, pathophysiological, technical, and psychosocial factors. Prospective randomized clinical trials comparing different operative interventions and operative with nonoperative treatment of dissatisfaction after TMC arthroplasty would help determine which treatments are helpful. Learning from the analogy of the so-called “failed back,” a study of screening and treatment of symptoms of depression and ineffective coping strategies prior to TMC arthroplasty in the ideal, but definitely when there is dissatisfaction with TMC arthroplasty seems wise.

FIGURE 1: Patient presentation after failed index LRTI. Note the bone tunnel at the base of the thumb metacarpal and proximal subsidence of the thumb.

metacarpaletoeindex metacarpal arthrodesis, 2 had complete wrist denervation, and 1 each underwent neurolysis of the sensory branch of the radial nerve and flexor carpi radialis tenolysis. All 7 patients who had repeat arthroplasty or arthrodesis had subsequent procedures such as first dorsal compartment release or carpal tunnel release before they were satisfied. Two of the other 5 patients also requested additional surgery.

OUR CURRENT CONCEPTS FOR THIS PATIENT Although this patient is remarkably young to have undergone bilateral TMC arthroplasty and reports disproportionate 10 out of 10 pain in his thumb, we believe that a technical deficiency such as a dorsal dislocation of the interposition material is likely and could account for these symptoms. We are also confident that a repeat TMC arthroplasty using alternative autograft tissue (abductor pollicis longus, extensor carpi radialis brevis) augmented by a Tightrope while at the same time looking for associated nerve injury is the best treatment option. In the unlikely event that the aforementioned procedure should fail to alleviate the pain, we would offer him a costochondral or similar bone graft for rigid stability of the TMC joint or possible arthrodesis to the index

SHORTCOMINGS OF THE EVIDENCE Given that TMC arthroplasty is one of the most common hand surgeries performed in the United States and that the reported rate of satisfaction is about 80% to 90%, there should be a large population of dissatisfied patients to study.5,12 The fact remains, however, that current data regarding revision TMC arthroplasty surgery consist of case reports, small case series, and surgical technique papers with a various techniques and results. In studies to date, the definition of success is varied and usually applied from the surgeon’s perspective. The decision for additional surgery is subjective and the rates of revision surgery vary substantially from surgeon J Hand Surg Am.

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metacarpal or a newer option of trapezium replacement with a titanium prosthesis. Some might perceive this patient’s young age, bilateral surgery, 10 out of 10 pain, dissatisfaction with surgery, and willingness to undergo more surgery so soon after the first as indicators of psychological distress or ineffective coping strategies, but we choose to ignore these concerns because the patient reports a desire to return to productive livelihood and function.

4. Wajon A, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2009;4:CD004631. 5. Forthman CL. Management of advanced trapeziometacarpal arthrosis. J Hand Surg Am. 2009;34(2):331e334. 6. Sodha S, Ring D, Zurakowski D, Jupiter JB. Prevalence of osteoarthrosis of the trapeziometacarpal joint. J Bone Joint Surg Am. 2005;87(12):2614e2618. 7. Becker SJ, Briet JP, Hageman MG, Ring D. Death, taxes, and trapeziometacarpal arthrosis. Clin Orthop Relat Res. 2013;471(12): 3738e3744. 8. Yang SS, Weiland AJ. First metacarpal subsidence during pinch after ligament reconstruction and tendon interposition basal joint arthroplasty of the thumb. J Hand Surg Am. 1998;23(5):879e883. 9. Cooney WP, Leddy TP, Larson DR. Revision of thumb trapeziometacarpal arthroplasty. J Hand Surg Am. 2006;31(2):219e227. 10. Megerle K, Grouls S, Germann G, Kloeters O, Hellmich S. Revision surgery after trapeziometacarpal arthroplasty. Arch Orthop Trauma Surg. 2011;131(2):205e210. 11. Renfree KJ, Dell PC. Functional outcome following salvage of failed trapeziometacarpal joint arthroplasty. J Hand Surg Br. 2002;27(1): 96e100. 12. Tomaino MM, Pellegrini VD, Burton RI. Arthroplasty of the basal joint of the thumb. Long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am. 1995;77(3):346e355.

REFERENCES 1. Gervis WH, 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(1):56e57. 2. Gervis WH. Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg Br. 1949;31(4):537e539. illust.] 3. Burton RI, Pellegrini VD. Surgical management of basal joint arthritis of the thumb. Ligament reconstruction with tendon interposition arthroplasty. J Hand Surg Am. 1986;11(3):324e332.

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DISSATISFACTION AFTER TRAPEZIAL-METACARPAL ARTHROPLASTY

Dissatisfaction after trapezial-metacarpal arthroplasty.

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