14 Management of Complications of Thumb CMC Surgery: Trapeziectomy, Arthrodesis, and Total Joint Arthroplasty

Filip Stockmans

Abstract

Thumb carpometacarpal joint surgery is the most commonly performed joint surgery in the hand. Clinically, the predominant complaint is pain. Once conservative treatment no longer controls the symptoms, surgery can offer a solution. Trapeziectomy with or without ligamentoplasty is by far the most common procedure. Reported complication rates are around 5% but it is not clear if this is the true complication rate. The main reason for revision surgery after trapeziectomy is ongoing or recurrent pain followed by functional impairment due to metacarpal instability and/or collapse. Removal of bony remnants of the trapezium, if present, and revision ligamentoplasty is the preferred treatment. In selected cases, fusion of the first and second metacarpal base can be considered as ultimate salvage procedure. Trapeziometacarpal fusion is mostly preferred for young, high demand patients. The main complications are nonunion and soft tissue irritation due to the dorsal hardware. Meticulous surgical technique is mandatory when performing this procedure with special attention to bone preparation, the use of bone grafts, and correct use of fixation material. Hardware removal after complete bony healing can be indicated in case of persistent soft tissue irritation. Total joint arthroplasty is not universally accepted. Current implants have 10-year joint survival rates around 90%. The majority of problems are related to the cup positioning and cup fixation. Cup revision can be performed but is not always feasible. Trapeziectomy combined with a ligamentoplasty is a good salvage option with good clinical outcome.

Branches of dorsal sensory radial nerve (DSRN) and lateral antebrachial cutaneous nerve (LACN) are at risk during surgical exposure of the TMC joint. The nerve branches are deep to the superficial venous system and should be visualized and protected during surgical approach. Injury can be caused by transection, excessive traction, or coagulation. This risk is even more important whenever revision surgery is undertaken on the TMC joint. The reported symptoms by the patient are variable from hypoesthesia over dysesthesia to hyperesthesia. Neuroma formation is probably the most feared complication. Initial treatment should be conservative with physiotherapy, pain management including neuromodulating medication, and desensitization. Referral to a pain specialist should be considered for these patients to optimize nonsurgical treatment. Surgical exploration is only considered if the symptoms persist for at least 6 months.1 Surgery consists of neurolysis of the sensory branches from the surrounding scar. In case of neuroma formation, excision of the neuroma can be considered in combination with nerve grafting or nerve conduit. Many other treatment options are available.²

14.3 Trapeziectomy with and without Ligamentoplasty

Trapeziectomy was already proposed by Gervis in 19493 as a treatment option for osteoarthritis of the TMC joint. The ligamentoplasty has been added to the procedure since there was concern about the subsidence of the metacarpal into the empty space after resection of the trapezium. The reported failure rate of these procedures is under 5%^4,5; it is not clear if this is the true failure rate since these data are retrieved from retrospective studies. Although the complication rate is low, one needs to realize that multiple revision surgeries are frequent within this group.⁴ The main complications are incomplete trapeziectomy, symptomatic scaphotrapezoid arthritis, and problematic subsidence of the thumb metacarpal.

14.3.1 Incomplete Trapeziectomy

It is not uncommon to see residual shells of trapezium on postoperative radiographs after piecemeal resection of the trapezium. Although not all residual trapezium will be problematic, those located at the metacarpal base between the first and second metacarpal will be problematic. Often, they represent a remnant of the typical medial intermetacarpal osteophyte. Resection is recommended and is usually associated with suspension of the metacarpal.¹

14.3.2 Scaphotrapezoid Arthritis

Unaddressed scaphotrapezoid arthritis has been recognized as a cause of residual pain after trapeziectomy.⁶ Although systematic hemiresection of the proximal pole of the trapezoid is recommended by some authors, others question systematic resection.⁷ One of the reasons to be cautious about systematic resection of the proximal trapezoid is related to midcarpal instability, as in resection of the distal pole of the scaphoid there is a theoretical concern regarding the stability of the proximal carpal row. A recent cadaver study demonstrated that up to 4-mm resection of proximal trapezoid has a negligible effect upon lunocapitate and scapholunate stability.⁸ Most authors recommend interposition of a tendinous slip into the dead space after partial trapezoid resection.⁹

14.3.3 Problematic Subsidence of the Thumb Metacarpal

Some subsidence is expected after trapeziectomy.¹⁰ Only when subsidence causes instability of the metacarpal base or impingement onto the distal pole of the scaphoid it becomes a reason for revision surgery. Whenever there is a problem with the stability of the first metacarpal base after trapeziectomy, ligamentoplasty should be the first option. The preferred tendon is the flexor carpi radialis (FCR). Most authors prefer to use only half the FCR tendon since the FCR is considered to be an important secondary stabilizer of the scaphoid and the loop of the distally based tendon slip around the remaining FCR tendon adds a dynamic component to the ligamentoplasty during grip. In case the FCR tendon has been used, ruptured, or compromised during the previous surgery, a slip of the abductor pollicis longus or extensor carpi radialis longus or brevis can be used.¹¹ The surgical procedure remains similar to the conventional ligamentoplasty with a metacarpal bone tunnel, and the distally based tendon slip is looped around its remaining half to add the dynamic component to the reconstruction. More recently a suture button device has been introduced as a less invasive alternative for tendon harvesting.¹² Careful technique is mandatory when using these devices since poor technique can lead to overtightening of the suspension resulting in stiffness and painful contact between the base of the first and second metacarpal. Also fracturing of the second metacarpal has been reported and is related to multiple drilling of the bone tunnel or suboptimal positioning of the suture bottom device.¹³ In case of major instability or failed revision soft tissue suspension arthroplasty, bony fusion between the base of the first and second metacarpal can be considered. The technique has been described for paralytic conditions but can be used as a last resort in these cases.¹⁴ Patients need to be informed about the fixed abducted/opposed position of the intermetacarpal fusion which implies that the hand can’t be flattened out anymore. The use of bone graft between the base of the first and second metacarpal is necessary and rigid fixation with locking plates is preferred.¹⁵

14.4 Trapeziometacarpal Arthrodesis

In the case of carpometacarpal arthrodesis, the most common problems encountered are nonunion, hardware irritation, malposition, and scapho-trapezio-trapezoidal (STT) arthritis.

14.4.1 Nonunion

In the case of carpometacarpal arthrodesis, the most common problem is related to achieving bony union with reported nonunion rates between 0 and 58%.^16,17 In an effort to achieve more stable fixation, different techniques were used. Currently dorsal locking plates are preferred. However, these plates are not always well tolerated and the dorsal approach is associated with irritation of the dorsal sensory branch of the radial nerve.¹⁸

Initial surgical technique used K-wires with or without tension banding. Since K-wires cannot reliably achieve compression, tension banding was added to provide both compression and increased stability.^19,20

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