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Available online at

ScienceDirect
www.sciencedirect.com

Recent advance

Revision procedures after trapeziometacarpal surgery

Techniques de révision après chirurgie trapézo-métacarpienne
Pascal Ledoux *
Clinique du Parc, 48 bis, rue Henri Barbusse, 59880 Saint-Saulve, France

A R T I C L E I N F O A B S T R A C T

Article history: Surgical treatment of thumb basal joint arthritis generally yields good and excellent results. In case of
Received 31 March 2020 failure, the surgeon will propose an appropriate solution to the patient, one that can be performed easily.
Received in revised form 14 August 2020 Each technique has its own complications: shortening with trapeziometacarpal pain following
Accepted 15 August 2020
trapeziectomy, loosening and instability following total arthroplasty, instability for some implants.
Available online xxx
There are also intolerances such as allergies to nickel, foreign body reactions to silicone and
inflammatory reactions to some synthetic ligament implants. It is important to bear these complications
Keywords:
in mind when determining the best possible surgical technique initially. The different surgical solutions
Thumb basal joint arthritis
Revision
are exposed here. Prosthetic replacement is preferred in case of loosening when it is technically possible
Trapeziectomy in order to preserve the thumb’s length. A conversion to trapeziectomy with or without interposition
Prosthesis (implant or ligament reconstruction) will be carried out in the other cases. In case of trapeziectomy
failure, solutions are more difficult to find. In the current state of things, it seems that implant or
biological tissue interposition is the best solution.
C 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.

R É S U M É

Mots-clés: Les techniques chirurgicales utilisées dans la rhizarthrose donnent une majorité de bons et excellents
Rhizarthrose résultats. En cas d’échec, il est important de pouvoir proposer au patient une solution de reprise aisée pour
Trapézectomie le chirurgien et satisfaisante pour le patient. Chaque technique a ses complications particulières :
Reprise collapsus avec contact douloureux de l’espace scapho-métacarpien pour les trapézectomies, descelle-
Prothèse ments et instabilités pour les prothèses, instabilité pour les implants. Il existe également des intolérances à
certains matériaux: allergies au nickel, réaction à corps étranger pour le silicone et réactions
inflammatoire pour certains implants ligamentaires synthétiques. Il faut connaitre ces complications,
afin de choisir la meilleure technique lors du premier geste. Les différentes solutions chirurgicales de
reprise sont décrites. Pour conserver la longueur de la colonne du pouce, on privilégie le remplacement
prothétique pour les descellements lorsque c’est techniquement possible. Une conversion en
trapézectomie avec ou sans interposition (implant ou ligamentoplastie) est réalisée dans les autres
cas. Pour les échecs de trapézectomie, les solutions techniques sont plus difficiles à trouver. Dans l’état
actuel des choses, il semble que l’interposition par implant ou tissu biologique soit la meilleure solution.
C 2021 SFCM. Publié par Elsevier Masson SAS. Tous droits réservés.

Introduction
Surgical treatment of trapeziometacarpal osteoarthritis has
become increasingly common over the last 10 years. The annual
number of trapeziometacarpal joint replacements in Belgium
* Corresponding author.
E-mail address: pascal.ledoux@skynet.be (P. Ledoux).
increased from 555 in 2006 to 2156 in 2015 and, over the same
period, the number of trapeziectomy procedures increased from
500 to 1124 (Belgian healthcare system data). This can be
explained by the public’s and medical community’s increased
awareness of the surgical potential, but also by the greater
functional demand expressed by our patients. The increase in the
number of total joint replacements reflects the improvements
made to the implants since the first model was proposed by de la
Caffinière [1]. Presently, patients undergo surgery at a younger age

https://doi.org/10.1016/j.hansur.2020.08.010
2468-1229/ C 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.

Please cite this article as: P. Ledoux, Revision procedures after trapeziometacarpal surgery, Hand Surg Rehab, https://doi.org/10.1016/
j.hansur.2020.08.010
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due to severely incapacitating thumb basal joint arthritis, while
this was not proposed at that age in the past. In the author’s
practice over the last 10 years, 41% of our patients were less than
60 years of age and 19% less than 55 years.
A foreseeable consequence of that trend is the need to treat an
increasing number of deteriorations of the initial result due to
symptomatic loosening and implant dislocations, and due to
painful contact between the metacarpal base and distal extremity
of the scaphoid after trapeziectomy. First, in case of persistent pain,
a regional pathology (tenosynovitis, osteophytes, MCP arthritis,
STT arthritis, etc.) must be ruled out before considering revision
surgery.
We reviewed the literature to summarize the different
possibilities of surgical revision after trapeziometacarpal surgery
and report our own experience.
Revision after trapeziometacarpal arthroplasty
The two main reasons for revision are prosthetic loosening and
recurrent dislocations. Less frequently, a defect of early bone
fixation of the cup is observed; sometimes it is secondary to either
an intraoperative fracture of the trapezium or to a bone burn
during trapezium preparation with a motorized drill.
Dislocation may occur early due to incorrect cup positioning,
due to the persistence or insufficient resection of a medial
osteophyte, or due to shortening of the thumb column secondary
to excessive bone resection, which is evaluated by the ratio M1/M2
[2]. But in most cases, despite correct implantation, the early
dislocation is linked to the small diameter of the head (4 mm) and
to the lack of scar tissue needed to ensure implant cohesion.
Hyperlaxity is a rare cause of early and recurrent dislocations. Late
dislocations are related to either wear or deformation of the
polyethylene component or to ossifications that ultimately induce
a cam effect.
Loosening results from the combination of a stress deviation
effect induced by the prosthesis and the migration of polyethylene
wear debris between the implant and host bone promoted by the
decalcification induced by the stress shielding. The polyethylene
debris stimulates a granulomatous reaction that gradually induces
implant loosening. When pain and functional impairment recur,
the question of surgical revision arises.
Early revisions
In case of early dislocation, a reduction under fluoroscopy is
performed and the mobility of the joint implant is tested. If the
dislocation recurs during mobilization, it is necessary to look for a
cam effect related to bone contact between the base of the first
metacarpal and a medial or anterior osteophyte of the trapezium
and to carry out additional bone resection. In case of contact with
the anterior metacarpal beak, the latter must be resected. A cam
effect can also be due to incorrect cup orientation, which leads to
contact between the cup and the neck as shown by Brauns et al.
[3]. In this case, the cup must be removed and replaced with a new
cup in the correct orientation. In case of excessive thumb
shortening, a longer neck is needed. When there is no mechanical
explanation for the dislocation, the implant must be replaced by a
dual mobility model because the increased diameter of the head
drastically decreases the risk of dislocation.
The defect of early bone fixation of the cup must be treated by
cup removal, manual curettage of the bone cavity and placement of
a new cup on a bed of cancellous bone graft taken from the distal
radius. A plaster cast must be worn by the patient for at least
6 weeks to ensure integration of the bone grafts.
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Implant replacement
Like total hip arthroplasty, we have performed total trapezio-
metacarpal implant revisions [4].
Surgical technique
An incision is made on the dorsal side of the trapeziometacarpal
joint, midway between the EPL and EPB tendons. The subcutaneous
tissues are generally inflamed and often are black in color due to
metallic wear debris. The EPB and EPL must be dissected. A
retractor is used to protect the sensory branches of the superficial
branch of the radial nerve on radial and ulnar sides as well as the
radial artery on the ulnar side. These inflamed tissues must be
resected as carefully and as completely as possible, in order to
expose the prosthetic joint. The implant is then dislocated. Doing
so often requires varying amounts of periprosthetic fibrous tissue
resection to separate the head from the cup. The neck must then be
disconnected from the metacarpal stem, which often remains
attached at its distal part. If the metacarpal stem remains firmly
attached, a powered spindle is inserted between the metacarpal
and implant to weaken the attachment. A thin, narrow osteotome
is then introduced between the implant and the metacarpal, and
the implant is completely released from the bone by lightly tapping
with a hammer, while rotating around the implant. This procedure
is delicate due to the risk of fracturing the metacarpal, which
would then require tension band wiring if the subsequent repair
proved to be unstable.
If the implant is cemented, the cement must be completely
removed. If necessary, the metacarpal can be opened on its dorsal
side by making a cortical flap to remove the stem [5]. Before the
implant is replaced, a cerclage wire must be placed around the
metacarpal.
Once the metacarpal stem has been extracted, samples are
collected from the metacarpal cavity for microbiology analysis and
very careful curettage and rinsing of the marrow cavity is
performed to remove all inflammatory interposition tissues and
the metal and polyethylene debris that it contains.
Removal of the trapezial cup is generally easier. Careful
curettage of all inflammatory interposition tissue in the trapezial
cavity must also be performed.
Cancellous bone grafts are then harvested, generally from the
distal radial epiphysis via a dorsal longitudinal incision in the axis
of Lister’s tubercle. These cancellous bone grafts are placed in the
proximal half of the metacarpal, which generally constitutes the
site of greatest bone loss. The new stem therefore sits on a bed of
bone graft that become compacted when the implant is impacted.
The remaining bone grafts are placed in the trapezial cavity and are
also compacted when the new cup is impacted. This maneuver is
generally sufficient to ensure adequate stability of the cup (Fig. 1).
The trapezium or the trapezium base may be fractured during
cup removal, with intrusion of the cup into the scaphotrapezial
space. If this fracture is not too large, the trapezium can be
reconstructed with a cortico-cancellous bone graft to reconstitute
the defective part of the trapezial cortical bone. This cortico-
cancellous graft is taken at the distal radial epiphysis, where the
cortical bone is thin. In that case, temporary pinning of the first and
second metacarpals for 6 weeks is necessary to immobilize the first
web space in the open position and to protect the cup from the
axial stresses transmitted by the metacarpal stem.
In all cases, a plaster cast must be worn by the patient for at
least 6 weeks to ensure integration of the bone grafts.
Outcomes
We reviewed 32 trapeziometacarpal joint revisions [6] with
an average follow-up of 40 months. In 29 cases, the implant was
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Fig. 1. Revision of failed trapezio-metacarpal prosthesis by implant replacement. A: lossening of the implant after 11 years, B: placement of a new implant on a bed of bone
graft (from the radial styloid) after 13 months, C after 8 years, D after 10 years, E after 14 years.

replaced and in 3 cases, conversion to trapeziectomy was
necessary. Twenty-one patients reported no pain. Loss of
thumb retropulsion was observed in 12 cases, but all patients
were able to place the hand flat on a surface. Mean strength (key
pinch) was 4.5 kg on the operated side and 5.2 kg on the
contralateral side.
Trapeziectomy
Various authors have proposed trapeziectomy in the event of
implant loosening or recurrent dislocations. According to Lenoir
et al. [7] and Kaszap et al. [8], the clinical results of secondary
trapeziectomy are the same as those of primary trapeziectomy.
In the event of conversion to trapeziectomy, the metacarpal
stem may be left in place providing that it does not overlap the
metacarpal bone margin and that any periprosthetic bone lysis is
not too pronounced. We do not perform ligament reconstruction in
this scenario; we place a suture in the remaining scar tissues to
interpose them between the scaphoid and metacarpal base.
Kaszap et al. [8] perform a ligament reconstruction at the base
of the first metacarpal according to the technique of Epping and
Noack in case of total trapeziectomy and metacarpal instability.
Apard et al. [9] propose a trapeziectomy and interposition of the
palmaris longus tendon based on the technique described by F.E.
Jones. Ardouin et al. [10] propose the interposition of a
corticocancellous graft taken at the iliac crest for large bone

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defects. This technique compensates for the loss of thumb column
length. The bone graft is stabilized in the residual metacarpal by
using crossed 1.5 mm K-wires and completed with a flexor carpi
radialis (FCR) interposition between the graft and the distal pole of
the scaphoid and an extensor carpi radialis longus (ECRL) ligament
reconstruction if necessary.
Interposition
The aims of interposition are to avoid bone-to-bone contact, to
maintain the thumb length, to preserve strength, and to limit
hyperextension of the metacarpophalangeal (MCP) joint.
Pyrocarbon implant interposition has been proposed by several
authors. Pequignot et al. [11] reported 22 cases of pyrocarbon Pi2
interposition after trapeziometacarpal prosthesis removal. If a
total or partial trapeziectomy is indicated, the Pi2 implant can be
interposed with or without metacarpal medullary shaft bone-
grafting with good clinical results and preservation of thumb
length. Dunaud et al. [12], after having performed trapeziectomy
with interposition and ligament reconstruction, used a pyrocarbon
implant consisting in an intra-metacarpal stem terminating in a
hemisphere articulating with the remaining trapezium. They
reported on a small series of 5 cases, with 4 good results. If a
sufficient portion of the trapezium can be preserved or recon-
structed with a bone graft, revision can be done with the CMI
pyrocarbon implant. Bovet and Tiemdo [13] reviewed 15 cases of
total arthroplasty revisions with CMI pyrocarbon implants. The
results related to pain were good (14 pain-free thumbs). Mobility
and strength were satisfactory with 70%–80% of the contralateral
values (Fig. 2). Bellemère [14], in a recent exhaustive review of
pyrocarbon implants, recommended using that type of interposi-
tion after removing total joint arthroplasty implants.
Revision after trapeziectomy
With regard to trapeziectomy, the failures are mainly related to
proximalization of the first metacarpal [15–19], which may result
in painful contact with the distal end of the scaphoid and
Fig. 2. Failed trapeziectomy (painful contact between the scaphoid and the base of the first metacarpal) (A). Revision with a Pyrocarbon CMI 1implant (B) (courtesy of Jean
Louis Bovet).
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sometimes the trapezoid. Ascension of the first metacarpal
decreases the length of the thumb column, which tends to
exacerbate MCP hyperextension. Moreover, shortening of the
thumb column contributes to loss of strength due to relaxation of
the thenar musculature and sometimes causes a Z deformity of the
thumb.
In trapeziectomy revisions, the general principle is to avoid
contact between the base of the metacarpal and the scaphoid, by
using an interposition and if possible, to restore thumb length to
avoid MCP hyperextension.
The absence of the trapezium renders revision using total joint
replacement implants very difficult. Chiche et al. [20] published a
series of 10 patients with cup implantation in the distal pole of the
scaphoid, among which six cases were done for failed trapeziec-
tomy. The functional results at the mid-term (mean follow-up
34 months) were good with only one revision for non-osteointe-
gration of the cup after 3 months. Those implantations require the
use of long necks, which increase the stresses on the cup, which
may give rise to impaired resistance over time (Fig. 3). Valenti et al.
[21] proposed using costochondral autografts as a salvage
procedure after failed total joint replacement followed by failed
trapeziectomy in one case with good pain relief. This technique
was later used by Guardia et al. [22] who reviewed 20 trapeziec-
tomies, of which 17 for STT impingement. In all cases, debridement
of the initial tendinoplasty and excision of the osteophytes were
conducted. In 7 cases, a costal cartilage graft was implanted and in
3 cases, a pyrocarbon implant was used. In 8 cases, a new
tendinoplasty and in 2 cases, M1-M2 arthrodesis were carried out.
The satisfaction rate for the revisions was only 40%; the dissatisfied
patients complained of residual pain and lack of strength.
Bellemere [14], in a general review of pyrocarbon implants,
proposed using CMI and Pi2 implants to salvage a failed
trapeziectomy when there is a sufficient space between the
scaphoid and metacarpal. The Nugrip implant can be used when
there is sufficient residual trapezium (after partial trapeziectomy)
or by reaming of a cavity in the scaphoid base. If there is an
irreducible collapse, interposition of the thinner Pyrocardan
implant is a simple and effective solution [11,23].
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Fig. 3. Implantation of the cup in the scaphoid for a trapeziectomy revision.
Umarji et al. [24] reported 10 cases of trapeziectomy revision
using a Silastic interpositional finger joint implant with the large
stem in the metacarpal and the small stem in the scaphoid. The
patients were operated an average of 34 months after the primary
surgery. According to the authors, all patients had improved.
Fig. 4. Failed trapeziectomy (A). Transverse osteotomy of the metacarpal base, arthrodesis of the M1 base and M2 base, implantation of the cup in the metacarpal base and
implantation of the stem in the distal part of the metacarpal (B). Failed arthrodesis and fusion of the base and the diaphysis of the first metacarpal (C).
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However, no strength and mobility values were reported. The
review was performed at an average of 53 months and no
complications were reported.
Conolly et al. [25] proposed the fusion of the first and second
metacarpal with bone graft from the iliac crest, after failed
trapeziectomy or failed silicone arthroplasty; the clinical result
was poor.
Goorens et al. [26] reported a case of trapeziectomy revision
using an inverted prosthesis (stem in the scaphoid and cup in the
metacarpal base) which proved to be painful and was replaced by
an Ebony prosthesis filling the trapezial cavity. The implant
dislocated after 6 months and subsequently, scaphometacarpal
arthrodesis with interposition of an iliac graft was carried out
(Fig. 5).
We performed a transverse osteotomy of the base of the first
metacarpal in 4 cases. The cup was implanted in the metacarpal
base and the stem was implanted in the distal residual metacarpal.
Arthrodesis of the metacarpal base and the trapezoid or the base of
the second metacarpal was also conducted. The four cases were
failures due to non-union of the arthrodesis. In one case, the base
consolidated with the residual metacarpal and thus surrounded
the implant (Fig. 4). Therefore, this technique should be
abandoned.
Discussion
Trapeziometacarpal arthritis is a common pathology. The
demand for a functional solution has been growing steadily for
about 30 years. Moreover, increasingly younger patients are asking
for treatment. Several surgical techniques exist, each with short,
medium or long-term disadvantages. We must therefore consider
the surgical treatment of thumb basal joint arthritis not as a one-
off procedure, but one that falls in the context of a continuum of
treatments for arthritis in this location.
There is a consensus on the need to maintain the length of the
thumb column to preserve strength and avoid a ‘‘Z’’ deformity.
Initially, we prefer the procedures that spare the most bone,
maintain the two components of the joint (trapezium and
metacarpal) and maintain the length of the thumb column.
Robles-Molina et al. [27] compared the results of an articulated
implant that maintains the length of the thumb, with those of
ligament reconstruction and tendon interposition (LRTI) using the
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Fig. 5. Revision of failed trapeziectomy with a reversed trapeziometacarpal prosthesis (A). First column arthrodesis with iliac bone graft (B) (courtesy of Goorens and Goubau
[26]).
Burton-Pellegrini technique. They concluded that the functional
results (strength and mobility) were better in the implant group
and that the MCP hyperextension seemed to be prevented in the
implant group but increased during the follow-up period in the
LRTI group. So it is essential to focus on techniques that retain or
restore thumb length.
Implant loosening in the context of total hip replacement is a
well-known complication. Revision of loosened hip implants is
subject to well-defined procedures and yields satisfactory results.
That strategy may be transposed to trapeziometacarpal implants
with equally satisfactory results. This enables potential intervention
on younger patients who would previously not have been eligible.
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In a short-term prospective comparative study, Jager et al. [18]
concluded that trapeziometacarpal arthroplasty yields better
outcomes than trapeziectomy with interposition. Robles-Molina
et al. [27] did a comparative study (follow up 4.8 years) and
concluded that articulated implants yield better clinical results but
with a higher complication rate than trapeziectomy.
Published series of trapeziometacarpal arthroplasty show
survival rates near 90% at 5 or 10 years [28–33]. The most
important reasons for revision are dislocation, tendinitis and
painful peri-articular ossifications. Early dislocations are more
frequent when a large capsular release is done [32], but they can
often be reduced percutaneously.
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Fig. 6. Therapeutic strategy of revision after early prosthesis failure.

Fig. 7. Therapeutic strategy after late prosthesis failure.

The literature about trapeziectomy complications is incom-

plete, probably because surgical solutions are limited and difficult
to implement. The study by Guardia et al. [23] reported
20 trapeziectomy revisions over a 14-year period, treated by
costochondral autograft in 7 cases, new tendon interposition or
ligament reconstruction in 8 cases, pyrocarbon implant interposi-
tion in 3 cases and arthrodesis between the first and the second
metacarpal in 2 cases.
Using implants in a manner that differs from a manufacturer’s
recommendations [20,24,26] should done cautiously, but in our
opinion, this strategy is valid in cases where there is no other
satisfactory solution.
Under those conditions, all the options remain open when the Fig. 8. Therapeutic strategy after failure of trapeziectomy.

question of revision arises. The options for revision vary depending

on the context. For early revisions of arthroplasty (Fig. 6),
conservation of the implant is preferable to maintain the length
of the thumb column and a stable fulcrum between the trapezium
and metacarpal. The mechanical causes of dislocation need to be
ruled out: residual osteophytes that must be removed, and
defective cup orientation that must be corrected. In the other
cases, the advent of dual mobility implants with a head diameter of
7 mm has led to a drastic reduction in the risk of early dislocation
(i.e., dislocation before formation of scar tissue ensuring implant
cohesion).
For late arthroplasty revisions (Fig. 7), the quality of the
trapezium is the essential factor for defining the revision strategy.
If the trapezium is usable, it is preferable to replace the implant
with a new articulated prosthesis in order to maintain the length of
the thumb column. If the trapezium is not usable, a pyrocarbon
spacer implant may be inserted or trapeziectomy may be
conducted.
Trapeziectomy revisions (Fig. 8) may be carried out using a
pyrocarbon interposition implant, costal or bone graft interposi-
tion; another option is intermetacarpal or scaphometacarpal
arthrodesis.

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Conclusion
Trapeziometacarpal prostheses continue to intimidate some
surgeons due to the risk of prosthetic loosening. The complications
associated with trapeziectomy are very rarely addressed in the
literature. Trapeziometacarpal implants, like hip or knee replace-
ment implants, have a limited lifetime. In the case of hip and knee
replacements, this is not a controversial subject. It is perfectly
possible, as is the case for hip replacements, to replace the implant
or convert to trapeziectomy with or without an interposition
implant without any loss of opportunity relative to first-line
trapeziectomy.
Human and animal rights
The authors declare that the work described has not involved
experimentation on humans or animals.
Informed consent and patient details
The authors declare that this report does not contain any personal
information that could lead to the identification of the patient(s) and/or
volunteers.
Funding
This work did not receive any grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Disclosure of interest
The authors declare the following financial or personal relationships that could be
viewed as influencing the work reported in this paper:
Author contributions
All authors attest that they meet the current International Committee of
Medical Journal Editors (ICMJE) criteria for Authorship.
Disclosure of interest
The author receives royalties from Kerimedical1.
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