ECRL Suspension as a Revision Procedure in Failed Resection Arthroplasty of the First Carpometacarpal (CMC-I) Joint

Abstract

Objective: Resection arthroplasty (RSA) is the standard procedure for first carpometacarpal (CMC-I) joint arthritis and gives excellent results in 95% of patients. There are several reasons explaining the 5% unsatisfying results. To the best of our knowledge, there is no report in the literature concerning revision procedures in failed RSA. The purpose of this retrospective study was to investigate the outcome after extensor carpi radialis longus (ECRL) suspension as a revision procedure in patients with persistent pain due to proximalization and bony impingement of the base of the first metacarpal and the base of the second metacarpal bone and/or the distal scaphoid. Methods: Between 2002 and 2013, 3429 patients with CMC-I arthritis underwent an RSA using the abductor pollicis longus (APL) tendon in our clinic. In the same period of time, we performed 128 revision procedures due to persistent pain following an RSA. Twenty-one of these patients with a mean age of 59 years (range, 51-70 years) demonstrated a proximalization and bony impingement. In these cases, we performed a revision suspension using half of the ECRL tendon. After an average follow-up of 4 years, 15 patients (13 female, 2 male) were available for a clinical and radiological follow-up examination, including range of motion (Kapandji-Score), grip and pinch strength, as well as several clinical tests (eg, grind test). Mayo Wrist Score (MWS) as well as DASH score and patient’s pain (visual analogue scale [VAS], 0-10) were evaluated. Standard radiographs of the wrist and the thumb in two planes were obtained. One of the 6 patients who could not be included in the follow up died, another refused follow-up due to total well-being and 4 patients moved and could not be located. Results: The time between RSA and revision averaged 2 years (range, 1-7 years). Clinical examination showed a positive grind test in 4 patients, and 11 patients remained free of pain. Eleven patients showed full opposition, and 4 patients showed mild restriction of opposition. The Kapandji score averaged 9.4 (range, 8-10), pinch strength averaged 76% of the opposite side. Postoperative MWS was 67, and DASH score was 39 points, whereas MWS was 37 preoperatively. Postoperative pain on VAS was 3 at rest and 5 with activity, whereas it was 8 at rest and 9 with activity previous to revision. Thirteen patients reported major improvement and 2 reported unchanged pain postoperatively. Fourteen patients were satisfied with the final result and would have the same procedure. Radiological evaluation showed a significant improvement in proximalization postoperatively. Twelve patients resumed the original employment, 10 of them performing heavy manual labor. Conclusion: These findings show that ECRL tendon suspension after previous RSA leads to a significant clinical improvement. The operation appears to be an effective revision procedure for patients with persistent pain due to proximalization of the first metacarpal bone and bony impingement following RSA.