Results of the cemented SR trapeziometacarpal prosthesis in the treatment of thumb carpometacarpal osteoarthritis

High loosening rate of the Moje Acamo prosthesis for treating osteoarthritis of the trapeziometacarpal joint

The Moje Acamo carpometacarpal (CMC) implant is an uncemented large ball-and-socket joint made of a ceramic material coated with a bioactive substance (Bioverit) for osseous fixation. Nine Moje Acamo CMC prostheses were implanted into nine patients with primary osteoarthritis of the thumb CMC joint. At 12 months, three implants had been revised because of progressing pain and osteolysis. In the remaining six patients, radiographs have shown progressive osteolysis around both implants in five patients. These poor results mean that we no longer perform this operation and we recommend close follow-up of all cases that have been performed.

[Revision of the ARPE prosthesis by the Jones procedure: a study of 6 cases and review of literature]

INTRODUCTION

The rate of failure of trapeziometacarpal prostheses increases with time for all types of prosthesis. Procedures for salvage are rarely detailed in the literature.

MATERIAL AND METHODS

In a series of 43 prosthesis ARPE between 1994 and 2001, 7 revisions (16%) were necessary. Six were treated by trapeziectomy and interposition of the palmaris longus tendon according to the technique of F.E. Jones. The average follow-up was 51 months (9-120). The study contained 5 women and 1 man, all reviewed by the author and the outcome assessed using an original questionnaire. The average age at the time of the revision was 62 years. The revision was necessary on average after 34 months (1 month to 10 years). All the procedures (implantations and revisions) were performed by the same surgeon.

RESULTS

The reason for the revision was loosening of the cup in 4 cases, excessive polyethylene wear in one case and premature dismantling for the last case. Ablation of the cup was straightforward but the extraction of the metacarpal side could still be difficult. For the revision, the Jones procedure did not present difficulties. Thumb function was satisfactory but force was slightly lower than on the opposite side. The scaphometacarpal height was always reduced (34,5% on average). Aesthetically, 2 patients were disappointed and preferred their thumb with prosthesis in place.

DISCUSSION AND CONCLUSION

Reports in the literature quote a revision rate of 15% after a follow-up of 4 years. Hence revisions will be more and more frequent in the future. Trapeziectomy with tendinous interposition is an excellent technique of revision because it is reliable medium-term and gives patient satisfaction in terms of thumb function. The results of this technique of revision should be compared with the same technique used as the primary procedure.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To investigate the effect of surgery in reducing pain and improving physical function, patient global assessment, range of motion, and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, it was the reviewers intention to investigate whether there was any improvement or deterioration in outcomes between the 12 months review and a 5 year follow-up.

SEARCH STRATEGY

We searched the the following databases in the Cochrane Library 2004, Issue 4: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE) as well as MEDLINE (1966-Dec 2004), CINAHL (1982-Dec 2004), AMED (1985-Dec 2004), and EMBASE (1974-Dec 2004). Database searches were supplemented by hand searching conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Studies were included if they were: randomised, quasi-randomised or controlled trials; intervention was surgery; and pain, physical function, patient global assessment, range of motion, or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two independent reviewers examined the identified studies according to the inclusion criteria. Included studies were assessed for methodological quality and then data, including adverse effects, was extracted and cross-checked. Authors were contacted to provide missing information.

MAIN RESULTS

Seven studies involving 384 participants were included. Studies of five surgical procedures were identified (trapeziectomy, trapeziectomy with interpositional arthroplasty, trapeziectomy with ligament reconstruction, trapeziectomy with ligament reconstruction and tendon interposition (LRTI), and joint replacement). All studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement across all stages of 27 to 57 mm on a 0-100 VAS scale for pain and 18-24 mm on a 0-100 VAS scale for physical function. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment, range of motion or strength. However, participants who underwent trapeziectomy had 16% fewer adverse effects (p=0<.001) than the other commonly-used procedures studied in this review; conversely, those who underwent trapeziectomy with ligament reconstruction and tendon interposition had 11% more (p=0.03) (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1).

AUTHORS' CONCLUSIONS

No one procedure produced greater strength than any other. Although this also appears to be the case for pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy is safer and has fewer complications than the other procedures studied in this review, and conversely trapeziectomy with LRTI has more.

Results from a degradable TMC joint Spacer (Artelon) compared with tendon arthroplasty

PURPOSE

A new spacer for the trapeziometacarpal joint (TMC) based on a biological and tissue-preserving concept for the treatment of TMC osteoarthritis (OA) has been evaluated. The purpose was to combine a spacing effect with stabilization of the TMC joint.

METHODS

Artelon (Artimplant AB, Sweden) TMC Spacer is synthesized of a degradable polyurethaneurea (Artelon), which has been shown to be biocompatible over time and currently is used in ligament augmentation procedures. Fibers of the polymer were woven into a T-shaped device in which the vertical portion separates the bone edges of the TMC joint and the horizontal portion stabilizes the joint. Fifteen patients with disabling pain and isolated TMC OA were included in the study. Ten patients received the spacer device and the remaining 5 (control group) were treated with a trapezium resection arthroplasty with abductor pollicis longus (APL) stabilization. The median ages of the 2 groups were 60 and 59 years, respectively. Pain, strength, stability, and range of motion were measured before and after surgery. Radiographic examination was performed in all patients before and after surgery. At follow-up evaluation 3 years after surgery an unbiased observer evaluated all patients. Biopsy specimens were obtained from 1 patient 6 months after surgery.

RESULTS

All patients were stable clinically without signs of synovitis. In both groups all patients were pain free. The median values for both key pinch and tripod pinch increased compared with before surgery in the spacer group but not in the APL group. The biopsy examinations showed incorporation of the device in the surface of the adjacent bone and the surrounding connective tissue. No signs of foreign-body reaction were seen.

CONCLUSIONS

This study showed significantly better pinch strength after Artelon TMC Spacer implantation into the TMC joint compared with APL arthroplasty.

Résultats à plus de cinq ans d'une série consécutive de 44 trapézectomies avec ligamentoplastie et interposition

BACKGROUND

Surgical management of trapeziometacarpal joint osteoarthritis remains controversial. There have been few long term studies of trapeziectomy combined with ligamentoplasty and interposition arthroplasty (TLIA). Our results are based on a five year minimum follow-up study.

METHODS

We carried out a study of 44 TLIA in 39 consecutive patients. A physical and radiological assessment was undertaken after on average of 6.9 years by a independent observer.

RESULTS

A durable physical improvement was obtained in 18 cases in less than six months and in five cases after more than one year. Thereafter there was no secondary deterioration. A standard pain measurement gave an average result of 1.4 on a ten point scale. Pain was independent of displacement of the first metacarpal bone but had a tendency to be greater where associated with scaphotrapezoidal joint osteoarthritis. Strength was improved in 36 cases. The patients were satisfied and considered their grip to be normal in 41 cases. These variables did not change over time.

DISCUSSION

TLIA give an excellent result in more than 90% of cases. This remains unchanged seven years after surgery. As opposed to prostheses, there is no secondary deterioration once healing is achieved. Algodystrophy is the main drawback.

CONCLUSION

In our opinion, TLIA remains the best available surgical treatment of trapeziometacarpal joint osteoarthristis.