MCP arthrodesis using an intramedullary interlocking device

Biomechanical Comparison of 5 Different Fixation Constructs in a Trapeziometacarpal Joint Arthrodesis Model

PURPOSE

Trapeziometacarpal joint (TMC) arthrodesis has a high rate of nonunion. This biomechanical analysis sought to determine the stiffness of 5 fixation methods in a TMC joint arthrodesis model.

METHODS

Five fixation constructs were tested in a validated porcine model: crossed 1.1-mm K-wires, crossed 1.6-mm K-wires, crossed headless compression screws (HCSs), compression plating (CP), and locked compression plating (LCP). The cantilever bending stiffness was measured in abduction, adduction, flexion, and extension. Samples were loaded to failure in extension, and the mode of failure was examined.

RESULTS

The crossed HCSs performed consistently well in all tests. Loading to failure resulted in screw pullout. In abduction and adduction, HCS and 1.6-mm K-wires were significantly stiffer than the other constructs. The mean load to failure in extension was similar in the HCS, CP, and LCP groups (304 N/mm, 311 N/mm, and 293 N/mm, respectively). There were no differences between CP and LCP in any biomechanical tests, and the mode of failure was through plate bending. The crossed 1.1-mm K-wires performed poorly in all tests.

CONCLUSIONS

Crossed HCS displayed the greatest overall stability. Standard plating in compression mode and LCP had a similar biomechanical performance.

CLINICAL RELEVANCE

The ideal construct stiffness required for the successful union after TMC joint arthrodesis is unknown, but HCS has the best overall biomechanical performance and, therefore, might be considered the best choice for this clinical setting.

Outcomes of Thumb Metacarpophalangeal Joint Arthrodesis Using the XMCP Intramedullary Interlocking Device

Purpose

The intramedullary interlocking device for metacarpophalangeal (MCP) joint arthrodesis (XMCP, Extremity Medical, Parsippany, NJ) has been shown to promote union at a precise angle, provide strong fixation without the need for prolonged immobilization, and lower the incidence of hardware irritation and revision surgery. In this study, we evaluated the clinical outcomes of patients undergoing MCP joint arthrodesis with the XMCP system using a retrospective chart review, patient reported outcomes, and radiographic analysis.

Methods

A retrospective chart review and phone survey was conducted on 57 patients (58 cases) from a single institution between 2017 and 2022. The primary outcome was patient satisfaction, including pre- and postoperative Numeric Rating Scale (NRS) pain scores, Disabilities of Arm Shoulder and Hand (QuickDASH) outcomes, perceived grip strength, and willingness to undergo the procedure again. Secondary outcomes included the need for revision procedures, successful fusion of arthrodesis, and postoperative complications.

Results

Of the 57 patients who underwent MCP joint arthrodesis of the thumb using the XMCP fusion device, a total of 43 (75%) completed the phone survey. The average age of patients was 67 years with an average clinical follow-up of 9 months (range 1-65 months). Patients who participated in the phone survey questionnaire had an average QuickDASH score of 24.7 ± 20.5. Average perceived NRS scores were 6.2 ± 3.5 and 1.2 ± 2.1 before and after surgery, respectively. Average perceived grip strength of patients was 3 ± 1.3 out of 5. When evaluating for concurrent procedures, there was no statistically significant difference in pre- or postoperative NRS scores. In total, 38 (88%) patients were satisfied with the procedure, and 39 (91%) patients would undergo the procedure again.

Conclusion

Metacarpophalangeal joint arthrodesis of the thumb with the intramedullary fusion device is reproducible, allows for immediate use without immobilization, has a low number of complications, and provides improved function and pain relief.

Level of Evidence

Therapeutic III.

Primary Arthrodesis of Non-thumb Metacarpophalangeal Joints of the Hand: Clinical and Patient-Reported Outcomes

BACKGROUND

Metacarpophalangeal (MCP) joint arthritis is common secondary to a variety of inflammatory, degenerative, and traumatic causes. Although MCP arthroplasty is more common for the second to fifth digits, primary arthrodesis can be used for high-demand patients with arthritis or unsalvageable fractures of the MCP joint. There has been limited recent studies on the outcomes of these patients.

METHODS

A retrospective review of 38 fingers in 27 patients with primary arthrodesis from 1990 to 2020 was conducted. The major outcomes were complications, reoperations, radiographic union, and time to union. Patient-reported outcomes including the Michigan Hand Outcomes Questionnaire and a questionnaire specific to the operative MCP joint were collected.

RESULTS

Rate of radiographic union was 84% including revisions. The average time to union was 3.6 months. Rates of complications, reoperation, and amputation were 26%, 16%, and 7%, respectively. Arthrodesis as part of emergent trauma reconstruction was significantly more likely to result in reoperation (50% vs 7%) and complication (63% vs 17%) than chronic arthritis. Patient-reported outcomes were fair to good with improvement in pain (79%), function (66%), and appearance (40%). Sixty-six percent (66%) of patients were satisfied with their surgery, and 73% would repeat the surgery.

CONCLUSION

Arthrodesis for unsalvageable MCP fractures was associated with higher rates of reoperation and complication than inflammatory or degenerative arthritis. Excluding emergent trauma, MCP fusion was reliable with a reoperation rate of 7% and a modest complication rate of 17%. Patients rated reasonable levels of satisfaction and willingness to repeat the procedure despite complications.

Long-term Outcomes of Silastic Arthroplasty of the Thumb Metacarpophalangeal Joint

Background: Silastic metacarpophalangeal arthroplasty (SMPA) has proven to be a durable option for end-stage arthritis in the non-thumb digits, while fusion has been the mainstay procedure for the thumb metacarpophalangeal joint (MP). Few studies exist to comment on the viability of thumb MP arthroplasty. This study reports both survival and objective outcomes following SMPA of the thumb. Methods: In an institutional review board-approved retrospective study, we identified 18 patients who underwent thumb SMPA at a tertiary academic center by 3 board-certified hand surgeons. Primary outcome measures were implant survival and post-operative complications. Secondary outcomes measures were quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) scores, brief Michigan Hand Questionnaire (bMHQ), and postoperative pain as rated by the numerical rating scale. Results: Mean quickDASH and bMHQ scores at final follow-up were 35.6 and 70.6, respectively. The most common short-term complication was clinical deformity, followed by instability. The sole long-term complication was an implant dislocation in a previously asymptomatic patient. All patients reported reduction in pain. Three patients were indicated for revision surgery, 2 for persistent instability, and 1 for implant dislocation. Primary survivorship was 83% at mean follow-up of 5.8 years. Conclusions: Thumb SMPA is a viable option for end-stage arthritis. Pain relief in our series was unanimous. Among those that reported persistent symptoms or required revision, a majority had one or more key preoperative risk factors for failure as currently reported in literature. Larger, prospective series are needed to prove superior longevity and functional outcomes of thumb SMPA versus fusion.

Thumb Metacarpophalangeal Joint Arthritis

Arthritis of the thumb metacarpophalangeal joint can be debilitating whether in isolation or in conjunction with degenerative disease at the adjacent joints. Despite its crucial role in fluid and dexterous motion of the thumb axis, little is known about the isolated incidence of pathology at this joint. Etiologies include primary, posttraumatic, and inflammatory arthritis. For early, isolated degenerative disease, arthroscopic synovectomy has been shown to yield satisfactory results. For more advanced disease, fusion is the benchmark. The literature suggests that increased flexion angles may mitigate development of trapeziometacarpal arthritis. In case of advanced arthropathy of the entire thumb axis, arthroplasty is a viable option to reduce pain, preserve motion, and thus limit progression of adjacent joint disease. Special considerations should be given to the rheumatoid thumb because a select combination of treatments for each deformity is thought to best address the unique pathomechanics.

Union Rates and Complications After Thumb Metacarpophalangeal Fusion

Background: Fusion of the thumb metacarpophalangeal joint (MPJ) can be performed using tension band wiring (TBW) or plate and screw (PS) fixation. This study evaluated results and complications using these techniques. Methods: A retrospective review of patients who underwent thumb MPJ fusion at our institution from 2010 to 2016 was performed. Patients with >1 year follow-up were included. Demographic information, indication for fusion, time to fusion, and complications were collected. Final radiographs were examined and alignment measured. Results: There were 56 thumbs in 53 patients (42 women and 11 men) including 12 TBW and 44 PS. The mean age was 60.9 years, and follow-up was 32.4 months. Twenty-eight of 44 plates were nonlocking, and 16 were locking. Of the locking plates, 7 of 26 used all locking screws, and 9 of 26 had a combination of locked and nonlocked screws. The mean flexion angle for TBW was 16.5° and PS was 12.8°. The mean coronal angle for TBW patients was 4.0° ulnar and PS was 2.5° ulnar. The overall union rate was 95%. There were 12 complications, 9 in the PS group. The TBW complications were painful hardware requiring removal. Eight complications in the PS group occurred in patients with locked plates. Five of the delayed or nonunions occurred in patients with locked plates and 4 of these were in plates with all screws locked. Conclusion: Complications using PS or TBW are not infrequent. Alignment with both techniques is similar, but use of locked plates specifically increases the rate of delayed or nonunions. We do not recommend routine use of locked plates for fusion of the thumb MPJ.

[Dorsal plate arthrodesis of the thumb metacarpophalangeal joint]

OBJECTIVE

Elimination of pain or instability by arthrodesis of the thumb joint in functional position by dorsal plateosteosynthesis.

INDICATIONS

Painful primary or secondary arthrosis of the thumb, nonreconstructable ulnar, radial or palmar instability, posttraumatic dislocation, defect injuries, bone tumors in the region of the thumb metacarpophalangeal joint.

CONTRAINDICATIONS

Local infection of the thumb metacarpophalangeal joint area.

SURGICAL TECHNIQUE

Dorsal approach to the thumb metacarpophalangeal (MP) joint, splitting of the extensor aponeurosis between the extensor pollicis longus and extensor pollicis brevis tendon. Opening of the anterior capsule and separation of the collateral ligaments, open up the joint, narrow concave and convex joint surface resections, adjustment of the arthrodesis position in 10-20° flexion and K‑wire transfixation, dorsal plateosteosynthesis, fine adjustment of the flexion, axis and pronation position. Closure of the capsule and the periosteal gliding tissue over the plate, reconstruction of the extensor aponeurosis.

POSTOPERATIVE MANAGEMENT

Splint for 3 weeks. Full load after 6-8 weeks.

RESULTS

The dorsal plate arthrodesis of the thumb MP joint is a reliable surgical method with very good functional results.

Current trends in the management of trapeziometacarpal arthritis

The purpose of this update is to report on a variety of topics related to trapeziometacarpal arthritis that have been recently investigated. The keyword trapeziometacarpal arthritis was utilized to query the PubMed database of the U.S. National Library of Medicine. From the resulting list, papers published from the beginning of April 2014 through the beginning of April 2017 were reviewed. The forty-five studies identified are reviewed here and referenced.

Arthrodesis of the proximal interphalangeal joint of the 4th and 5th finger using an interlocking screw device to treat severe recurrence of Dupuytren's disease

OBJECTIVE

To assess the radiological and functional outcome of arthrodesis of the 4th and 5th finger using the APEX™ (Extremity Medical, Parsippany,NJ)intermedullary interlocking screw system in patients with severe recurrence of Dupuytren's disease.

MATERIAL AND METHOD

The DASH questionnaire and the VAS scale were used to assess the clinical outcomes. The angle of arthrodesis, fusion time and implant fixation were evaluated on x-rays. The patients were monitored for complications during surgery and the follow-up period.

RESULTS

The sample comprised 6 patients. Mean follow up was 19.6 months. All of the patients presented clinical and radiological evidence of fusion at 8 weeks, with fusion angles of 30° (3) and 45° (3). There were no complications and none of the implants had to be removed. The functional outcomes in these patients were poor.

CONCLUSION

The system offers a reliable method for IPJ arthrodesis at a precise angle. It promotes stable fixation that does not require prolonged immobilisation. It can be used together with other procedures on the hand with severe recurrence of DD. The functional outcomes for this group of patients using this device were poor.

Metacarpophalangeal joint of the thumb arthrodesis using intramedullary interlocking screws XMCP™

The study objective was to assess the results of a thumb metacarpophalangeal joint (MCPJ) arthrodesis using intramedullary interlocking screws at 25°, XMCP ™ (Extremity Medical, Parsippany, NJ). Radiographs evaluated the angle of arthrodesis, time of fusion and fixation of the implant. Clinical and functional outcomes were assessed using the DASH questionnaire and the VAS scale. Any complications found during surgery or the follow-up period were noted. We studied 9 patients. The mean follow-up was 27.6 months. Patients showed clinical and radiological evidence of fusion in an average of 8 weeks, the angle of fusion was 25°. There were no complications and no implant had to be removed. The XMCP™ system provides a reliable method for MCPJ arthrodesis for several indications and can be used with other procedures in the complex hand.

Metacarpophalangeal Joint Arthrodesis of the Thumb - Minimum of Eight Months Follow-up

Background:

Disorders of the thumb metacarpophalangeal (MCP) joint can lead to significant loss of function and pain. Thumb MCP arthrodesis following traumatic injuries is inadequately described and recent studies have questioned the outcome of this treatment.

Purpose:

The purpose of this study was to report outcome and disability following thumb MCP joint arthrodesis in the treatment of chronic instability after traumatic injuries.

Methods:

A retrospective review of 26 patients operated on with MCP joint arthrodesis, median follow-up 42 months (8-104months). Subjective outcome was assessed using the disabilities of the Arm, Shoulder, and Hand-questionnaire (DASH). In addition, patient satisfaction, pain, stiffness, and impairment of activities of daily living were assessed on a Visual Analogue Scale (VAS) followed by a question stating whether they would undergo the same procedure again.

Results:

Two patients (7.7%) needed re-operation due to nonunion. Four patients (15.4%) needed hardware removal. Median DASH-score was 18 (25-75% range 6-47), with lower DASH scores being better. Scores were significantly worse in gender and age matched individuals (p<0.05). Median VAS for pain was 3.7 (range 0-8). More than 50% of patients reported mild, moderate or severe pain, but all patients reported that they were willing to undergo the same procedure again.

Conclusion:

Our data suggest, that patients with post-traumatic thumb injuries managed with thumb MCP joint arthrodesis perform worse than gender and age matched individuals. Many lived with pain, but all reported that they were willing to undergo the same procedure again. We suggest that the disability scale by the National Board of Industrial Injuries should be reconsidered for patients operated on with thumb MCP arthrodesis.

The management of complications of small joint arthrodesis and arthroplasty

Arthrodesis and arthroplasty are surgical options used for the management of pain, stiffness, deformity, and instability related to arthritis and traumatic injury of the small joints of the hand. Arthrodesis and arthroplasty come with a risk of postoperative infection. Superficial soft tissue infections can often be managed with oral antibiotics alone. Deep infections and osteomyelitis frequently require removal of hardware in addition to antibiotics and may require surgical revision once the infection is cleared. Selection of the most appropriate revision technique depends on the underlying cause of the initial failure, patients' functional and outcome needs, and surgeon preference.