Maïa® trapeziometacarpal joint arthroplasty: Survival and clinical outcomes at 5 years' follow-up

Outcomes of dual-mobility trapeziometacarpal arthroplasties: a systematic review

This systematic review reports the clinical, patient-reported, radiographic outcomes, complications and survivorship of dual-mobility trapeziometacarpal (TMC) joint arthroplasties including the MAÏA®, Moovis® and Touch® prostheses. Thirteen studies were included and outcomes reported for 1421 such arthroplasties. Overall, improvements in strength, range of motion, pain, function and satisfaction were demonstrated with a complication incidence of 13%. The risk of dislocation was 0.6%. The follow-up period was not long enough to draw conclusions about the long-term survival of the implants. Also, due to the low quality of the evidence, it was not possible to conclude that dual-mobility TMC arthroplasty was superior to trapeziectomy. This review highlights the need for Level I evidence with adequate long-term follow-up for TMC joint arthroplasty.

Management of the capsule in trapeziometacarpal joint implant arthroplasty: resection versus repair

We compared the effects of capsule resection versus capsule suturing in patients treated with a dual-mobility trapeziometacarpal joint prosthesis. We included 131 patients with capsular resection and 57 patients with repair. The mean scores for pain and the brief Michigan Hand Outcomes Questionnaire were similar between the groups preoperatively and at 6 weeks and 1 year postoperatively. Mean key pinch strength was also similar in both groups before surgery and at 1 year, but higher in the capsular resection than in the suture group at 6 weeks. The incidence of complications reported throughout the 1-year postoperative period was not significantly different between the groups. One implant in the capsular resection group was revised for reasons most likely unrelated to capsule management. We conclude that the capsule can be safely resected during trapeziometacarpal joint implant arthroplasty.Level of evidence: III.

Immobilization, rehabilitation and complications classification after thumb trapeziometacarpal total joint arthroplasty. A scoping review

The best way of immobilization as well as effectiveness of rehabilitation for trapeziometacarpal total joint arthroplasty is unknown. We aimed to identify and describe the available evidence, practice variation and knowledge gaps. The literature was searched without restrictions. 123 studies were included, reporting 21 types of prosthesis. Reported immobilization types were cast (23%), splint (18%), compression bandage (10%), or combinations (26%). In 19%, immobilization time and type was not reported. Supervised rehabilitation (22%), self-rehabilitation (11%), functional use (11%), or customized rehabilitation (16%) were the rehabilitation forms reported. In 28% rehabilitation type was not described. Two (2%) studies used complication classifications, but time to complication was not described in 53 (43%). Multiple evidence gaps exist; lacking studies comparing types of immobilization protocols as well as rehabilitation regimens after trapeziometacarpal total joint arthroplasty. Currently there is no scientific evidence for any postoperative regime. This means that decision-making is based on clinical experience rather than evidence, explaining the wide practice variation.

De Quervain's tendinitis after trapeziometacarpal arthroplasty

OBJECTIVES

De Quervain's tendinitis is frequently observed after placement of a trapeziometacarpal prosthesis. The aim of this study was to investigate the relationship between De Quervain's tendinitis, osteoarthritis of the thumb and placement of a trapeziometacarpal prosthesis. The second aim was a critical analysis of the literature in search of a cause for this postoperative event after arthroplasty or trapeziectomy.

METHODS

We reviewed a series of 331 trapeziometacarpal prostheses.

RESULTS

There were no differences in thumb column length, gender, type of neck (straight or angled), or surgical approach between patients who developed De Quervain's tendinitis and those who did not. However, the frequency of De Quervain's tendinitis was much higher after arthroplasty than trapeziectomy.

CONCLUSIONS

We believe that the preoperative frequency of De Quervain's tendinitis in trapeziometacarpal osteoarthritis is underestimated, being part of a more general pain symptomatology. More precise and specific examination is needed for a better preoperative diagnosis. Trapeziometacarpal osteoarthritis should be considered within a more global framework of peri-trapeziometacarpal pathology, including the trapeziometacarpal and triscaphoid levels, the articular ligaments and the abductor pollicis longus, extensor pollicis brevis, flexor pollicis longus, and flexor carpi radialis tendons.

[Base-of-thumb osteoarthritis: aspects to be considered with the indication of trapeziectomy and CMC I prosthesis]

Base-of-thumb osteoarthritis is the most frequent osteoarthritis of the hand requiring surgical treatment, although conservative treatment options should be exhausted before surgery. If the wear process progresses with continuing pain-related loss of thumb function, thus leading to a loss of function of the whole hand, surgical treatment is indicated. In 1947, Gervis published results after trapeziectomy and heralded the development of a multitude of different surgical procedures. The long time needed for rehabilitation is a major problem of trapeziectomy with or without tendon interposition and/or suspension. After the implementation of the first CMC I prosthesis by De la Caffiniere 50 years ago, a rapid development took place, leading to the current modular bipolar implants. Especially in the German-speaking world, there is still some scepticism regarding these prostheses, which is why this review aims to illuminate both surgical procedures with a special focus placed on the aspects of indication.

[Current Trends in the Implantation of the Touch Prosthesis at the Thumb Carpometacarpal Joint: Results of the 1st German-Speaking User Meeting]

The introduction of the new generation of thumb carpometacarpal (CMC I) joint implants for the treatment of CMC I osteoarthritis has significantly broadened the scope of hand surgery in recent years. However, the technical demands of the procedure and the many details that need to be considered require appropriate training and a learning curve. To share experiences with the Touch CMC I prosthesis, we held the first German-speaking CMC I joint prosthetics user meeting in Zurich. After some basic introductory lectures on biomechanics and the principles of prosthetic fitting of the CMC I joint, the various challenges associated with CMC I joint prosthetics were discussed in interactive expert panels. Subsequently, cases were discussed in small groups under expert guidance and the respective conclusions were discussed in plenary. The main results of this symposium are summarised in this manuscript.

Proposed Radiographic Parameters to Optimize Clinical Outcomes in Trapezio-Metacarpal Prosthesis Placement Using CT Imaging, with 1-Year Follow-Up

PURPOSE

Addressing trapezio-metacarpal (TMC) osteoarthritis often involves considering TMC joint replacement. Utilizing TMC prostheses offers advantages such as preserving the thumb length and more accurately replicating the thumb's range of motion (ROM). TMC prostheses have an intrinsic risk of dislocation and aseptic loosening. Analyzing pre- and postoperative imaging can mitigate complications and improve prosthetic placement, providing insights into both successes and potential challenges, refining overall clinical outcomes.

MATERIALS AND METHODS

We conducted a prospective analysis of 30 patients with severe TMC arthritis treated with a Touch© (Kerimedical, Geneva, Switzerland) prosthesis in 2021-2023: X-ray and CT protocols were developed to analyze A) the correct prosthesis placement and B) its correlation with clinical outcomes (VAS, Kapandji and QuickDASH scores) by performing Spearman correlation analysis.

RESULTS

The average differences in trapezium height and M1-M2 ratio pre- and post-surgery were, respectively, 1.8 mm (SD ± 1.7; p < 0.001) and 0.04 mm (SD ± 0.04; p = 0.017). Pre-to-postoperative M1 axis length increased by an average of 2.98 mm (SD ± 3.84; p = 0.017). Trapezial cup sinking, indicated by the trapezium index, measured 4.6 mm (SD ± 1.2). The metacarpal index averaged at 11.3 mm (SD ± 3.3). The distance between the centers of the trapezium distal surface and the prosthesis cup was 2.23 mm (SD ± 1.4). The Spearman correlation analysis gave the following results: negative correlations were highlighted between postoperative VAS scores and the M1/M2 ratio and residual trapezium height (correlation coefficient: -0.7, p = 0.03 and -0.064, p = 0.03, respectively) at 6 months; a negative correlation was found at the 3-month mark between QuickDASH and the trapezium residual height (correlation coefficient: -0.07, p = 0.01); and a positive correlation was found for the trapezium index at 1 month (correlation coefficient: 0.07, p = 0.03) and 3 months (p = 0.04) using the Kapandji score. Similarly, we found a positive correlation between the distance between the prosthesis and trapezium centers and QuickDASH score at 1 and 3 months (correlation coefficient: 0.066, p = 0.03; correlation coefficient: 0.07, p = 0.05, respectively) and a positive correlation between prosthesis axis and the residual first metacarpal angle with QuickDASH score at 3 months (correlation coefficient: 0.07, p = 0.02).

CONCLUSIONS

Pre- and postoperative systematic imaging analysis should become a method for predicting complications and guiding recovery in TMC prosthesis: CT imaging could provide us with radiographical landmarks that are intrinsically linked to clinical outcomes. Further research is necessary to fuel a protocol for the correct intraoperative TMC prosthesis implantation.

Trapeziectomy versus Maïa Prosthesis in Trapeziometacarpal Osteoarthritis

Background  Osteoarthritis at the base of the thumb is the most frequent osteoarthritis of the hand. Trapeziectomy in a broad variety of surgical methods have been proposed to achieve pain reduction and improvement of thumb function. A well-known disadvantage is the long recovery time. Arthroplasty of the thumb carpometacarpal joint is a competing new method for this indication with different revision and complication rates reported. Purposes  The aim of this study is to assess whether there are significant differences in outcome during the first 12 months and time return to work after either, implant of a Maïa joint prosthesis, or trapeziectomy with tendon interposition after Weilby. Patients and Methods  This clinical follow-up study compares the efficacy of total basal joint replacement using the Maïa prosthesis with tendon interposition arthroplasty in 59 thumbs. Clinical, functional, and radiological results at preoperative, 3-, 6-, and 12-month postoperative are presented. Results  We found a significant shorter return to work in the prosthesis group with 4.5 compared with 8.6 weeks. In addition to a significant difference in pain reduction with a better Mayo wrist score in the Maïa group after 3 months. The scores are closer after 6 months and nearly match after 12 months. Measurement of the pinch grip showed a parallel course. A radiological loosening of the cup in two patients was detected after 12 months. Conclusion  Implantation of Maïa prosthesis enables a significant shorter recovery but is associated with the risk of loosening and higher costs. Level of Evidence  Level IV, case-control study.

Scaphometacarpal arthroplasty with a TOUCH® prosthesis: feasibility and biomechanical impact in a cadaver model

In this cadaveric study, we compared the performance of the TOUCH® dual mobility trapeziometacarpal prosthesis implanted sequentially in the trapeziometacarpal joint and scaphometacarpal joint. Intraprosthetic mobility, implant dislocation, intraprosthetic impingement and the effect on scaphoid position were evaluated in six hands using radiographic measurements. The standard necks of 6-10 mm were used for trapeziometacarpal arthroplasty. Scaphometacarpal arthroplasty after trapeziectomy was technically feasible but required specially designed prosthetic necks 12-26 mm in length. Compared to trapeziometacarpal arthroplasty, scaphometacarpal arthroplasty increased the intraprosthetic mobility by 7%-39%. While no complications occurred with trapeziometacarpal arthroplasty, there were two instances of implant dislocation and seven instances of intraprosthetic impingement with scaphometacarpal arthroplasty. Unlike trapeziometacarpal arthroplasty, scaphometacarpal arthroplasty altered scaphoid position by translating it in an ulnar and proximal direction relative to the radius.

Contribution to the study of stresses in the thumb column during key pinch grip

OBJECTIVES

The aim of this study was to calculate the stress acting on the trapeziometacarpal joint during an key pinch grip.

METHOD

We used profile X-rays of the thumb to measure the various bony and muscle lever arms. We assessed the angles of action of the muscular elements involved in the thumb column. Based on this data, we established a two-dimensional geometric model that enabled us to determine the forces at each joint level, as a function of stresses and muscular contributions. We were also able to calculate the participation of the different muscle groups in obtaining a balanced situation.

RESULTS

Our results, as a function of the degree of flexion of the interphalangeal and metacarpophalangeal joints, show a multiplying factor of 2.9-3.19 in relation to the key pinch grip force.

DISCUSSION

Previous studies modelling a key pinch grip are showed multiplying factors from 6 to 13 in relation to the key pinch grip force. They are not compatible with the characteristics of the polyethylene used for trapeziometacarpal prostheses, whereas numerous articles in the literature show survival rates that are more or less comparable to those of total hip prostheses. These studies required an excessive number of assumptions, which could lead to error. Our results are compatible with the results of trapeziometacarpal prosthesis and with those of a recent study measuring intra-articular trapeziometacarpal pressure in a cadaveric model. Our model allows us to test different configurations of the thumb spine depending on the degree of flexion of the interphalangeal and metacarpophalangeal joints.

A review of wear debris in thumb base joint implants

AIM

Polymers and metals, such as polyethylene (PE) and cobalt chrome (CoCr), are common materials used in thumb-based joint implants, also known as CMC (Carpometacarpal) arthroplasty. The purpose of this review was to investigate the reported failure modes related to wear debris from these type of materials in CMC implants. The impact of wear debris on clinical outcomes of CMC implants was also examined. Potential adverse wear conditions and inflammatory particle characteristics were also considered.

METHOD

A literature search was performed using PRISMA guidelines and 55 studies were reviewed including 49 cohort studies and 6 case studies. Of the 55 studies, 38/55 (69%) focused on metal-on-polyethylene devices, followed by metal-on-metal (35%), and metal-on-bone (4%).

RESULTS

The summarized data was used to determine the frequency of failure modes potentially related to wear debris from metals and/or polymers. The most commonly reported incidents potentially relating to debris were implant loosening (7.1%), osteolysis (1.2%) and metallosis (0.6%). Interestingly the reported mechanisms behind osteolysis and loosening greatly varied. Inflammatory reactions, while rare, were generally attributed to metallic debris from metal-on-metal devices. Mechanisms of adverse wear conditions included implant malpositioning, over-tensioning, high loading for active patients, third-body debris, and polyethylene wear-through. No specific examination of debris particle characterization was found, pointing to a gap in the literature.

CONCLUSION

This review underscores the types of failure modes associated with wear debris in CMC implants. It was found that failure rates and adverse wear conditions of CMC implants of any design are low and the exact relationship between wear debris and implant incidences, such as osteolysis and loosening remains uncertain. The authors note that further research and specific characterization is required to understand the relationship between debris and implant failure.

Failure Rate and Early Complications of Thumb Carpometacarpal Joint Replacement-A Multicenter Retrospective Study of Two Modern Implant Designs

Joint replacement arthroplasty for the treatment of thumb osteoarthritis is gaining popularity as recent studies have demonstrated better pinch and grip strength and faster rehabilitation. Our aim was to identify early complications in modern implant designs using a multicenter study. A total of 381 patients who underwent thumb carpometacarpal replacement surgery in six participating hospitals were enrolled. The complications included were fractures, dislocations, infections, tendon and nerve injuries, and complex regional pain syndrome. Major complications were defined as a failure to implant the prosthesis, revision surgery to remove the implant, and any other need for further surgical intervention. The secondary outcomes were any other complications treated non-surgically and the timing of the complications. Eleven procedures failed, and these patients were treated with trapeziectomies. Twelve other patients required repeat surgical interventions. Minor adverse events occurred in 25.4% of the cases, and transient irritation of the superficial radial nerve and De Quervain tendinopathy were the most prevalent complications. Although this cohort depicted the learning curves of multiple surgeons, our study demonstrated low short-term failure rates. An inability to achieve primary stability of the cup in the trapezium was the leading cause of failure. Dislocations and other major complications with modern implants were very few.

Superior bone fixation of conical compared with hemispherical trapezial cup design: an experimental radiostereometry study

PURPOSE

The most used cup designs for trapeziometacarpal (TMC) arthroplasty are of hemispherical and conical geometrical shape. Using a validated pig bone model, we compared the bone fixation using radiostereometry (RSA).

METHODS

Twenty saddle-shaped pig forefoot bones were prepared with insertion of bone markers and reaming. Hemispherical Type T cups (Beznoska, Kladno, Czech Republic) (N = 10) and conical Moovis cups (Stryker, Pusignan, France) (N = 10) of 9-mm diameter were inserted press-fit. The bones were fixed in cement blocks for stability, and the cups were loaded in a motorized test stand. First, a low-pressure cyclic load test (0-150N) with 130 compression cycles was performed. Next, a push-in test of progressive loads with 50N increments (range: 150-900N) was applied until a visual change in cup position appeared. Cup migration was evaluated with RSA after every new load application. Cup failure was defined as total translation > 0.5 mm between two load applications.

RESULTS

Both cup types tolerated a compression load of 450 N without failure. Beyond this load level, the total translation cup migration of mean 0.20 mm (95% CI 0.11; 0.30) for the Type T group was higher than mean 0.10 mm (95% CI 0.06; 0.15) of the Moovis group (p = 0.046). The Hazard ratio for failure was 0.52 (95% CI 0.12; 2.17) (p = 0.37), indicating that the risk of failure was two-fold higher in the Type T group.

CONCLUSION

We conclude that conical TMC cups have superior fixation as compared to hemispherical cups above a loading level of 450 N, which correspond to a 3.8 kg tip-pinch. In a clinical perspective, based on the fixation strength of both cup types, it seems safe to allow light-load activities of daily living such as buttoning a shirt and using a key shortly after surgery and until sufficient osseointegration is achieved.

Targeted partial arthroscopic trapeziectomy with temporary distraction: a retrospective study with 5-year follow-up

Targeted partial arthroscopic trapeziectomy with temporary distraction is a minimally invasive treatment for trapeziometacarpal osteoarthritis. We performed a retrospective single centre study from March 2011 to May 2022 and included patients with at least 5 years of follow-up. A failure was defined as a patient requiring a second procedure. Of the 28 patients with at least 5 years of follow-up, 23 were reviewed. Five of the 23 patients underwent revision surgery with a 5-year survival rate of 78%. There was a significant improvement in pain and the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score. There were three postoperative complications, one with complex regional pain syndrome, and two with hyperesthesia in the distribution of the sensory branch of the radial nerve. Targeted partial arthroscopic trapeziectomy with temporary distraction is a feasible temporary solution for early stage trapeziometacarpal joint osteoarthritis. However, there remains a 20% risk of failure.Level of evidence: IV.

Wide-Awake Local Anesthesia No Tourniquet for Rhizarthrosis Surgery: Technique and Experience for 16 Consecutive Cases

Since it was described, wide-awake local anaesthesia no tourniquet (WALANT) has gained popularity. Our department has started using WALANT for hand surgery with increasing complexity. We present our results with WALANT rhizarthrosis surgery, including prosthetic replacement, trapeziectomy with suture button suspensionplasty and revision surgery. A retrospective review of all rhizarthrosis procedures under WALANT was performed from April 2021 to July 2022. We included patients who fulfilled inclusion criteria and had adequate imaging and clinical follow-up. A satisfaction survey was performed by telephone. Surgical time, complications, conversion to conventional anesthesia, pain, anxiety and global satisfaction were recorded. Tumescent anesthesia is performed 20-25 minutes before surgery, and is performed in four or five strategic locations that allow adequate anesthesia and vasoconstriction for the procedure to be comfortably carried out. We observed a series of 16 sequential surgeries involving 14 patients. All were female with a mean age of 65 years. Fourteen cases were performed due to primary rhizarthrosis, eight trapeziectomies with suture button suspensionplasty, six prosthetic replacements, and two revision surgeries. One patient needed to be converted to conventional anaesthesia due to anxiety during the procedure. Mean procedure time was 73 minutes. There were no WALANT-related complications. Mean patient-reported satisfaction with the anesthetic technique was a 9 (on a scale from 1 to 10) and 100% of patients would choose to undergo surgery with WALANT anesthesia for a future procedure. We find it useful to actively engage the patients during surgery to keep them comfortable and also help the surgeons assess stability and functional results. After wound closure, the hand is shown to the patient and he performs various tasks. There is somewhat of a learning curve for rhizarthrosis surgery under WALANT; patient comfort can be achieved through an adequate anesthetic technique and reassurance before and during surgery. We recommend that the first few cases be done in the presence of an anesthesiologist and a fasting patient in case there is a need to convert to conventional anesthesia. Wide awake rhizarthrosis surgery, even revision surgery, is safe and pain-free. Patient-reported satisfaction is also high. The authors find that including patient participation in their own surgery might be promising for post-op rehabilitation. There are limitations in this study such as the absence of a control conventional anesthesia group, the satisfaction questionnaire was not done immediately post-operatively, as such, a memory bias cannot be excluded, and it is not yet validated for the Portuguese population.

Dual mobility prosthesis for trapeziometacarpal osteoarthritis: results from a prospective study of 55 prostheses

This prospective study evaluated outcomes after trapeziometacarpal joint replacement with a dual mobility prosthesis (Touch®) in 55 thumbs (52 patients) with a mean follow-up of 25 months (range 12-36). Pre- and postoperative assessments included pain, range of motion, the Kapandji index, pinch- and grip strength, as well as functional scores and radiological parameters. Mean preoperative metacarpophalangeal joint hyperextension of 19° (range 15°-28°) showed a significant correction after 1 year with a mean value of 2° (range 0°-5°). Mean Quick Disabilities of the Hand, Shoulder and Arm score was 14 (range 6-28), and Michigan Hand Questionnaire 82 (range 67-92). No revisions due to infection, loosening, dislocation or material failure occurred during follow-up. The dual mobility trapeziometacarpal joint prosthesis was a reliable treatment option to decrease pain, improve motion, strength and pre-existing metacarpophalangeal joint hyperextension at short-term follow-up.Level of evidence: IV.

Primary trapeziectomy with Regjoint(TM), a poly-L/D-lactide spacer, a two-year follow-up study with new radiological assessment tool

The aim of this retrospective study was to evaluate the potential bony erosion and the clinical and radiological results of primary trapeziectomy with RegjointTM interposition, in patients with peritrapezial arthritis. Data were recorded on twenty patients over a period of two years (January 2015-December 2016). On average 24 months, patients were reconvened for a post-operative evaluation (subjective evaluation of pain, function and patient satisfaction; clinical evaluation with strength and mobility measures; post-operative X-rays). On X-rays, 2 criteria were evaluated: the bony erosion and the shortening of the thumb column (trapezium+metacarpal height measure, ratio between first and second metacarpal bones, a new radiological assessment tool based on a trapezoid relationship gradation). In most patients, surgery relieved pain and offered good functional results, according to the Quick Disabilities of the Arm, Shoulder and Hand scale. Following surgery, our patients showed a subjective improvement, both in terms of pain and functional results. For plain X-ray, only 3 patients showed an osteolytic lesion (maximum of 2.8 millimeters) on the first metacarpal base. A statistically significant reduction in the thumb column height was generally observed on follow-up X-rays. However, all of these radiologic changes were present without any clinical impact. We show that the RegjointTM spacer is an available alternative in the surgical treatment of peritrapezial arthritis. We did not highlight any significant associated complications, no important adverse tissue reaction or bone erosion, no pain or functional disorder. Type of study/level of evidence Therapeutic IV.

The ISIS® prosthesis in 77 cases of trapeziometacarpal arthritis: outcomes and survival at a minimum follow-up of 5 years

The aim of this study was to determine the clinical and radiographic outcomes and survivorship of the ISIS® (Evolutis™, Briennon, France) trapeziometacarpal prosthesis at a minimum follow-up of 5 years. Of the 77 implants (66 patients) reviewed at a mean follow-up of 107.5 months, pain and function had improved significantly. Fourteen cups (19%) and three stems (4%) appeared to have loosened on radiographs. Loosening occurred more often with cemented cups than screwed cups (p = 0.0342). In five cases, the prosthesis was removed and revised by trapeziectomy and interposition: four were cemented cups (three loosening, one trapezium fracture) and one was a loosened metacarpal stem. A single case of dislocation occurred during the follow-up period. The survival rate was 94% (95% CI: 85 to 97). The ISIS® prosthesis is a reliable implant for treating disabling thumb basal joint arthritis, with a low complication rate and long-lasting clinical and functional improvements. Using a screwed trapezial cup instead of a cemented one appears to prevent loosening and the need for surgical revision.Level of evidence: IV.

Long-term survival analysis of 191 MAÏA® prostheses for trapeziometacarpal arthritis

Surgery for trapeziometacarpal osteoarthritis after failure of medical treatment remains controversial. The aim of this study was to determine the long-term results of the MAÏA® trapeziometacarpal prosthesis (Lépine, Genay, France). This was a retrospective clinical and radiographic study of 191 MAÏA® trapeziometacarpal prostheses implanted between 2001 and 2016 from a single centre. The survival rate of the implants at the final follow-up of 12 years (range 17 days to 140 months) was 88%. Median pain score was 1/10. The median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 20. The rate of major complications was 9% (5% dislocations and 4% loosening) with all dislocations needing revision surgery. The risk of prosthetic dislocation was highest during the first 3 years, most often related to malposition of the trapezium implant. The MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis. Level of evidence: IV.

Total joint replacement for osteoarthritis of the carpometacarpal joint of the thumb: why and how?

Total joint replacement has certain advantages over other surgical treatment methods for osteoarthritis of the thumb carpometacarpal joint, including restoration of thumb length and alignment, good cosmetical result, fast recovery of hand function and prevention of iatrogenic complications at neighbouring joints. Disadvantages include the technical difficulty to perform this surgery and a possible higher complication rate. A meticulous surgical technique is mandatory. Combined with a cementless and modular ball-in-socket implant with a metal-on-polyethylene friction couple, a 10-year survival rate higher than 90% can be expected. Revision surgery is possible with implant exchange or conversion to trapeziectomy.

Thumb Carpometacarpal Implant Arthroplasty

Thumb carpometacarpal implant arthroplasty aims to preserve thumb length and motion and to provide pain relief and functional recovery after a short postoperative time. For several decades, implant arthroplasty has been performed with total trapeziometacarpal joint prosthesis using the concept of "ball-and-socket" joint. More recently, pyrocarbon implants used as hemiarthroplasty or interposition arthroplasty have been proposed. Whatever the type of arthroplasty used, the surgical technique must be precise and may require a learning curve. Implant arthroplasty has proven that in the medium and long-term, it may be considered as a valid and reliable alternative to trapeziectomy.

Results of treatment of trapeziometacarpal osteoarthritis with trapeziectomy and tendon allograft interposition

The aim of the study was to evaluate the results of treatment of osteoarthritis of the carpometacarpal joint of the thumb with tendon allograft interposition. Fifty-three patients (61 hands), 13 men and 40 women, were operated on at a mean age of 61 years. A partial trapeziectomy with tendon interposition was performed in 19 hands and with suspension arthroplasty in 24. Seventeen thumbs underwent a total trapeziectomy with suspension arthroplasty. Patients were evaluated at a mean follow-up of 4 years. In 34 patients (41 hands), a mean disability of arm, shoulder and hand score of 19 was found and a mean visual analogue scale for pain of 1.3. The satisfaction rate was 83 %. Revision operations were performed in 8 out of 61 hands. Four of those thumbs had been operated on previously or did not have primary osteoarthritis. No revisions were needed after partial trapeziectomy and tendon allograft interposition with suspension arthroplasty. In conclusion, tendon allograft interposition can be considered as one of the treatment options for osteoarthritis of the carpometacarpal joint of the thumb.

Dual mobility trapeziometacarpal prosthesis: a prospective study of 107 cases with a follow-up of more than 3 years

We report the results of a prospective study using a dual mobility trapeziometacarpal prosthesis (Touch®) in 107 patients with a minimum follow-up of 3 years. One-hundred and two patients (95%) were very satisfied or satisfied with the functional outcomes and the mean pain intensity in visual analogue scale decreased from 7.4 to 0.8 (p < 0.001). Thumb opposition (Kapandji score) index increased from an average of 8.0 to 9.4, while the mean QuickDASH score improved from 38 preoperatively to 20 at follow-up (p < 0.01). Key-pinch strength improved from 3.5 kg (range 0.5-9.5) to 5.5 kg (range 3.0-11.5). There was a 4.6% rate of complications, including cup loosening and wear of polyethylene, which required revision, but no cases of prosthetic dislocation were seen. Applying the dual mobility principle to trapeziometacarpal arthroplasty may significatively improve the stability of these prostheses. Radiolucent zones around the components of the prostheses are not systematic predictors of future loosening.Level of evidence: IV.

Revision of failed trapeziometacarpal prothesis by CMI pyrocarbon implant: Retrospective study of 28 patients with a mean follow-up of 7.5 years

INTRODUCTION

There is no consensus on the best salvage option after a failed trapeziometacarpal prothesis. Conserving the trapezium and inserting a pyrocarbon hemiarthroplasty implant will prevent thumb shortening and preserve the thumb's motion. The aim of this study was to evaluate the clinical and radiological outcomes in the medium term of trapeziometacarpal prothesis revisions done using the CMI pyrocarbon implant.

PATIENTS AND METHODS

This was a retrospective study of 28 patients with a mean age of 63.5 years. The mean time to revision was 6.1 years after the initial arthroplasty. The dominant side was operated in 70% of patients. The surgery consisted of removing the existing prosthesis, reconstructing the trapezium with a bone graft, and inserting the CMI pyrocarbon implant. The review consisted of a functional assessment (visual analog scale for pain, QuickDASH score, patient satisfaction), physical assessment (Kapandji, grip strength, key pinch strength, tip pinch strength) and radiological assessment (complications, radiolucent lines, scaphometacarpal height, implant centering, bone remodeling).

RESULTS

At a mean follow-up of 7.5 years, no further surgical revisions were needed. The mean QuickDASH score was 1.1 and the mean QuickDASH was 13%. Twenty-five patients (89%) were satisfied with the outcome. The Kapandji score improved significantly from 7.5 to 9.5 on average. Grip strength improved significantly from 16.7kg to 21.5kg on average. The mean postoperative key pinch strength was 93% of the contralateral side. The mean postoperative tip pinch strength was 88% of the contralateral side. There were no fractures or dislocations visible on the radiographs. However, there was bone remodeling in the trapezium related to the pyrocarbon implant's indentation that was well tolerated by patients in the medium term.

CONCLUSION

For revision of failed trapeziometacarpal prothesis, inserting the CMI pyrocarbon implant combined with trapezium reconstruction appears to be a good alternative to the more commonly used trapeziectomy procedure. Reconstructing the trapezium and inserting this hemiarthroplasty implant preserves the thumb's projection, length, and stability. The functional improvement experienced by patients makes this a relevant treatment option.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Partial arthroscopic trapeziectomy and stabilisation by ligamentoplasty: Outcomes in patients younger than 60years

BACKGROUND

Thumb carpometacarpal joint (TCMJ) osteoarthritis is the fourth leading cause of referral to elective hand surgery. None of the available techniques has proved superior over the others. Some techniques carry unacceptable risks for younger patients, such as loss of strength and shortening of the thumb column after total trapeziectomy, or wear and loosening after total arthroplasty. Our objective was to assess outcomes after partial arthroscopic trapeziectomy (PAT) combined with suspensionplasty using the abductor pollicis longus (APL) tendon in patients younger than 60years of age.

HYPOTHESIS

PAT combined with suspensionplasty using the APL tendon in patients younger than 60years would restore strength in the medium-term without further surgery.

MATERIAL AND METHODS

We retrospectively included consecutive patients operated between 2007 and 2017, in a single centre, and aged less than 60years. All patients had isolated TCMJ osteoarthritis stage 1 to 3 according to Eaton and Glickel classification that remained symptomatic despite optimal conservative treatment. We collected pain intensity, range of motion, strength, the Nelson Hospital Score (NHS), and the Patient-Rated Wrist Evaluation (PRWE) score. Radiographs were reviewed.

RESULTS

We included 27 patients, of whom 6 had surgery on both thumbs, yielding 33 thumbs for the analysis. Mean follow-up was 64.7months (range: 10.6-136.5months). Pain intensity, grip strength, and key-pinch strength were significantly improved (p<0.001), with no difference between men and women. No differences were found for the Kapandji score (p=0.2) or TCMJ hyperextension (p=0.06). At last follow-up, the mean NHS was 83.2±19.4 and the mean PRWE was 15.4±17.9. Mean sick leave duration was 5.4weeks (range: 1-24weeks). Only 2 patients, both in manual jobs, were unable to return to work. The radiographs at last follow-up showed the development of moderate TCMJ narrowing in 14 patients and evidence of scapho-trapezio-trapezoid (STT) osteoarthritis in 10 patients. No patient experienced complex regional pain syndrome or injury to the sensory branch of the radial nerve. A single patient required further surgery for persistent pain.

DISCUSSION

Patients younger than 60years who are treated with this minimally invasive technique are likely to experience sustained improvements in both strength and pain intensity. Total trapeziectomy and pyrocarbon implant has also been evaluated in younger patients, who experienced pain relief and strength gains but had lower levels of satisfaction and developed complications inherent in the implants. The short time off work and low morbidity make our technique a procedure of choice in younger patients. To build on this study, a comparison of PAT and arthroplasty would be of interest.

LEVEL OF EVIDENCE

IV.

Assessment of trapezial prosthetic cup migration: A biomechanical study

We performed a biomechanical study using 60 Sawbones® rigid foam blocks of two simulated densities (osteoporotic, n = 30 and non-osteoporotic, n = 30) and 10 cadaveric trapezium bones from fresh-frozen, unembalmed adult cadaver hands to assess the trapezial prosthetic cup migration with progressively greater compression loads (10-40 kg). Two cups from the Touch® prosthesis were compared: 9-mm conical cup and 9-mm spherical cup. Uniaxial compression tests were carried out using an MTS Criterion® Series 40 Electromechanical Testing System. Cup migration was measured in millimeters (mm) at 10, 20, and 40 kg of compression load. Median cup migration values were similar in the cadaveric trapezium bones and Sawbones® non-osteoporotic blocks, and higher in the Sawbones® osteoporotic blocks. In the cadaveric trapezium bones and the Sawbones® non-osteoporotic blocks, migration values were less than or equal to 0.1 mm for 10 and 20 kg loads; it was 0.2 mm for 40 kg load. In the Sawbones® osteoporotic blocks, migration values were less than or equal to 0.3 mm for 10 and 20 kg loads; it was 0.4-0.5 mm for 40 kg load. There was no significant difference between the two cup shapes in both cadaveric trapezium bones and Sawbones® non-osteoporotic blocks. In Sawbones® osteoporotic blocks, the largest difference between the two cup shapes was 0.1 mm for loads up to 40 kg, which corresponded to our measurement accuracy. Our findings indicate that the trapezial component of total trapeziometacarpal joint arthroplasty undergoes very weak migration for axial compression loads up to 40 kg, presumably below the threshold of clinical relevance. The cup shape did not have an obvious influence; however, low bone mineral density may result in greater cup migration.

Comparison of two radiographic landmarks for centering the trapezial component in total trapeziometacarpal arthroplasty

We performed a retrospective review of standard anteroposterior and lateral radiographs of the thumb in 80 patients, to compare two radiographic landmarks, in terms of mediolateral bone support, for centering the trapezial component in total joint arthroplasty. On anteroposterior view, we identified the distal articular surface of the trapezium and trapezium width, and defined the two midpoints as radiographic landmarks for positioning a 9-mm trapezial cup. Mean trapezium width was significantly greater than the distal articular surface of the trapezium, and the midpoints did not match. Thus, after positioning simulated 9-mm prosthetic cups centered on each landmark, the residual radial bone distance was significantly greater using the landmark based on trapezium width. The mean value was 33% greater with this landmark, and the minimum value was 2.1 mm, compared to 0.2 mm using the landmark based on the distal articular surface. Our study thus suggested that the midpoint of the trapezium width is the more relevant radiographic landmark for centering the trapezial prosthetic cup in total joint arthroplasty, by preserving better bone stock on the radial side without depleting the ulnar side. On an intraoperative anteroposterior fluoroscopic view, this landmark could be used to check cup positioning.

Thumb CMCJ prosthetic total joint replacement: a systematic review

Thumb carpometacarpal joint (CMCJ) arthritis is a common and painful condition. Thumb CMCJ prosthetic replacement aims to restore thumb biomechanics and improve pain and function. Early reviews demonstrated a lack of high-quality studies, but more recently a significant number of higher-quality studies have been published. This review provides a concise and systematic overview of the evidence to date.

A systematic review of several databases was conducted according to PRISMA guidelines. Studies evaluating the outcomes of thumb CMCJ prosthetic total joint replacement were included. Data extracted included patient-reported outcome measures (PROMs), pain scores, range of motion, strength, survival rates and complications.

A total of 56 studies met all inclusion criteria and were analysed. There was one randomized controlled trial, three prospective comparative cohort studies, five retrospective comparative cohort studies, and 47 descriptive cohort studies. The reported studies included 2731 patients with 3048 thumb total CMCJ prosthetic joint replacements. Follow up ranged from 12 months to 13.1 years.

In general, good results were demonstrated, with improvements in PROMs, pain scores and strength. Failure rates ranged from 2.6% to 19.9% depending upon implant studied. Comparative studies demonstrated promising results for replacement when compared to resection arthroplasty, with modest improvements in PROMs but at a cost of increased rates of complications.

Studies reporting outcomes in thumb CMCJ prosthetic total joint replacement are increasing in both number and quality. Failure, in terms of loosening and dislocation, remains a concern, although in the medium-term follow up for modern implants this issue appears to be lower when compared to their predecessors.

Functional outcomes also look promising compared to resection arthroplasty, but further high-quality studies utilizing a standardized resection arthroplasty technique and modern implants, together with standardized core outcome sets, will be of value.

Cite this article: EFORT Open Rev 2021;6:316-330. DOI: 10.1302/2058-5241.6.200152

Can we decrease the duration of basal thumb joint distraction for early osteoarthritis from 8 to 6 weeks? Study protocol for a non-inferiority randomized controlled trial

BACKGROUND

To our knowledge, to date, 52 patients with thumb carpometacarpal osteoarthritis (CMC1 OA) were treated with joint distraction. So far, most patients experienced improved physical function and less pain. After 2 years, only 1 patient proceeded to trapeziectomy. This study assesses if we can safely lower the distraction duration from 8 to 6 weeks for CMC1 joint distraction, maintaining the improvement in physical function and pain.

METHODS

This is a monocenter randomized controlled non-inferiority trial that includes patients younger than 65 years of age with ongoing symptoms of CMC1 OA and an established indication for surgery. All patients will be treated with CMC1 joint distraction. The primary outcome is to assess whether 6 weeks of joint distraction is not inferior to 8 weeks in terms of physical function at 1 year after surgery. Secondary outcomes will identify differences between groups at 1 year in pain intensity, patient satisfaction, hand health status, adverse event rates, treatment failure, differences in thumb strength and range of motion, and radiographic changes.

DISCUSSION

If safe, the duration of basal thumb joint distraction can be reduced to 6 weeks, reducing patient burden. Because this is a relatively new treatment, this trial will provide greater knowledge of potential adverse events. This knowledge allows for more informed decision making for patients considering CMC1 distraction treatment. Future studies can directly compare joint distraction to other treatments of CMC1 joint arthritis like splinting and trapeziectomy.

TRIAL REGISTRATION

Central Committee on Research Involving Human Subjects (CCMO), NL68225.100.18; registered on 9 August 2019. Medical Research Ethics Committees United (MEC-U), R19.003; registered on 9 August 2019. Netherlands Trial Register, NL8016 ; registered on 15 September 2019.

Two-year results of the Moovis trapeziometacarpal joint arthroplasty with focus on early complications

In this prospective study, we aimed to analyse the early results of 200 consecutive total trapeziometacarpal joint arthroplasties using the Moovis cup, a new generation, dual-mobility, uncemented conical cup, with special focus on early complications. At the 24-month follow-up, we found clinically relevant improvement of function and comfort. Among intraoperative complications were nine intraoperative trapezial fractures, which were treated by screw osteosynthesis; prolonged immobilization; and conversion to cemented cup fixation or primary or secondary trapeziectomy. One was left untreated as the loose cup did not cause notable symptoms. There were three implants with polyethylene wear and two with liner dislocation. We conclude that early outcomes of this new-generation implant are favourable, but its surgery is challenging and associated with important intraoperative and early postoperative complications related to the learning curve. Attentive reaming of the trapezium and careful cup impaction are crucial steps to avoid trapezial fracture and early cup failure. Level of evidence: II.

Autologous chondrocyte transplantation in the treatment of thumb CMC joint osteoarthritis

Degenerative thumb carpometacarpal (CMC) joint osteoarthritis is a common disease in women starting at 40-50 years of age. Nevertheless, synovitis and initial cartilage damage start earlier, and then degenerative arthritis develops leading to joint narrowing with progressive exposure of subchondral bone, subluxation, osteophyte formation and joint deformity that can impact the surrounding joints. The aim of this study was to evaluate the outcome of patients treated with autologous chondrocyte transplantation at the thumb CMC joint at early stages. A prospective study on 10 cases of thumb CMC osteoarthritis in 8 patients was done. The thumbs were stage Eaton II (2 cases) and III (8 cases) and were treated by CMC arthroplasty with the implant of autologous chondrocytes by an open or arthroscopic technique. Two patients were treated bilaterally. Preoperatively all patients had persistent pain resistant to various kinds of nonoperative treatments for at least 1 year. Mean preoperative pinch strength was 3.7 Kg pain on VAS was 8, DASH was 55. All patients had limited abduction and flexion at the end range. Ethics committee approval was obtained for this study. Fragments of 3-4 mm of cartilage were harvested by arthroscopy or by an open technique from the wrist or elbow joint. Cartilage cells were sent to the laboratory to be grown on a collagenous biphasic matrix (MACI/Novocart®). After 3 weeks, the chondrocyte augmented scaffold was ready to be implanted in the thumb CMC joint, or frozen for a second operation later. All patients were females aged 42-67 years (mean 52 years). The dominant hand was treated in 6 cases. In 7 cases, the patients were operated with an open technique and in three cases by arthroscopy. Partial trapezium resection and dorsoradial ligament reconstruction was added to stabilize the CMC joint in most cases. Patients were seen in person at 1, 3, and 6, months, 1 year, 2 years, and 5 years after the initial surgery. Patients (nine thumbs) were then reviewed at a mean follow up 8 years (range 4.4-11 years); pain on VAS, Mayo, DASH and PRWE scores were evaluated at follow-up. One patient was lost to follow-up after 2 years. Of those nine hands, seven had an excellent result according to Mayo score, one had a good result. One thumb CMC joint was still painful and was reoperated and converted to arthroplasty after 4.4 years. All patients regained full range of motion. Mean pinch strength increased to 6.25 ± 1.3 Kg, mean DASH score was 7.3 ± 6.7; pain on VAS was 1.0 ± 1.5; these data were statistically significant compared to preoperative values (p < 0.01). Grip strength also increased in all cases, but this was not statistically significant. PRWE was 7.7 ± 6.4. No complications occurred postoperatively. The results obtained are encouraging since the implanted cartilage has lasted a mean of 8 years and up to 11 years. Biological tissue engineering techniques are being developed and could be a new solution to restore normal cartilage in young patients to postpone more aggressive surgical procedures until an older age. In cases of CMC joint instability, a ligament stabilization procedure was added to avoid subsequent damage to the implanted neocartilage. A longer follow-up and a greater number of cases are necessary to definitively establish the usefulness of this procedure, which has the advantage of being completely biological but the disadvantage of being costly.

Revision procedures after trapeziometacarpal surgery

Surgical treatment of thumb basal joint arthritis generally yields good and excellent results. In case of failure, the surgeon will propose an appropriate solution to the patient, one that can be performed easily. Each technique has its own complications: shortening with trapeziometacarpal pain following trapeziectomy, loosening and instability following total arthroplasty, instability for some implants. 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 in mind when determining the best possible surgical technique initially. The different surgical solutions are exposed here. Prosthetic replacement is preferred in case of loosening when it is technically possible in order to preserve the thumb's length. A conversion to trapeziectomy with or without interposition (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.

Trapeziometacarpal total joint arthroplasty: The effect of capsular release on range of motion

It has been suggested that trapeziometacarpal total joint arthroplasty be combined with complete release of the joint capsule to prevent ligament tethering and implant dislocation. Our goal was to evaluate the consequences of capsular release on range of motion. Trapeziometacarpal joint motion was measured with a 3D motion tracking system in seven fresh frozen human cadaver hands before and after capsular release and total joint arthroplasty with subsequently longer neck lengths. Relative to the native trapeziometacarpal joint with intact joint capsule, mean flexion-extension was significantly increased after the arthroplasty with released capsule and lengthening up to 6 mm. Mean abduction-adduction did not increase significantly. Total joint replacement combined with capsular release increases the trapeziometacarpal joint's range of motion, but not beyond the limits of most trapeziometacarpal implant designs. Lengthening of the implant neck progressively decreases the excess motion.

Tendon versus Pyrocarbon Interpositional Arthroplasty in the Treatment of Trapeziometacarpal Osteoarthritis

Background

Trapeziometacarpal (TMC) arthritis is treated with surgery when nonsurgical treatment fails. The best surgical option for improving pain relief, functional outcomes, and postoperative complications remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between trapezium excision with ligament reconstruction and tendon interposition (LRTI) and pyrolytic carbon interpositional arthroplasty.

Methods

From March 2009 to August 2014, 37 patients (39 wrists) with Eaton-Littler stage II or III TMC arthritis underwent complete trapezium excision with LRTI (Group L, n=19) or pyrolytic interpositional arthroplasty (Group P, n=20). Visual analog scale (VAS) pain scores; grip and pinch strength; Kapandji scores to quantify thumb opposition; and Disabilities of Arm, Shoulder, and Hand (DASH) scores were used to compare clinical outcomes between the two groups. Radiographic changes (metacarpal shortening, subluxation, and radiolucency) were evaluated on the radiographs of thumb basal joints.

Results

There were no differences in patient demographics, Eaton-Littler stage, preoperative outcome measures, or the duration of follow-up between the two groups. At the last follow-up, VAS pain scores, pinch and grip strengths, Kapandji scores, and DASH scores were significantly improved in both groups compared with preoperative scores. All follow-up measurements were similar between the two groups except pinch strength, which was 1.8 kg higher in Group P (p<0.001). Proximal metacarpal migration did not differ significantly between the groups. Periprosthetic lucency more than 1 mm was observed in 7 of 20 (35%) thumbs. Complication rates were similar between the two groups.

Conclusions

All subjective and objective outcomes were similar following LRTI and pyrolytic interpositional arthroplasty in patients with TMC arthritis, except pinch strength, which was more improved following pyrolytic interpositional arthroplasty. Longer follow-up is required to test adverse effects of high rates of periprosthetic lucency and prosthetic subluxation on clinical outcomes after PyroDisk interpositional arthroplasty.