Complications of small joint arthroplasty

Management of Index Finger Metacarpophalangeal Joint Arthritis

Metacarpophalangeal joint arthritis of the index finger is a debilitating disease often caused by osteoarthritis or inflammatory arthritides such as rheumatoid arthritis. Treatment options include nonsurgical management with nonsteroidal anti-inflammatory drugs, splinting, occupational therapy, corticosteroid injections, and disease-modifying antirheumatic drugs. Operative management options include arthrodesis and arthroplasty, which can be further broken down into silicone implants and 2 component resurfacing implants. The article summarizes the current literature for each of the treatment options for metacarpophalangeal joint arthritis of the index finger.

Registration of finger implants in the Dutch arthroplasty registry (LROI)

Finger arthroplasty is commonly used to treat pain in the finger joints due to osteoarthritis or rheumatoid arthritis. Despite the procedure having existed for a relatively long time, it is still unknown which characteristics influence implant survival. The Dutch Arthroplasty Registry (LROI) is one of the 4 registries worldwide registering finger arthroplasties. This study aimed to investigate impact factors for implant survival regarding finger joint arthroplasty and assess registration completeness using the national healthcare claims database to compare. A total of 951 primary arthroplasties and 84 revision arthroplasties of the finger joints were registered. A higher likelihood of primary and revision surgery was found in female patients. The third and fourth proximal interphalangeal (PIP) joints were the most frequently operated in primary surgery; however, the metacarpophalangeal (MCP) joints were the most frequently revised joints. Silicone implants were used in most cases and evenly throughout all digits. Suboptimal registration completeness was shown for plastic surgeons with just 35.5%-37.4% of all surgeries registered. Although orthopedic surgeons do not perform most surgeries on the hand, they registered 76.5%-78.2% of surgeries. No statistical analyses were justified, considering the low completeness and limited follow-up. Female gender and PIP joint disease are possible risk factors for primary arthroplasty. MCP arthroplasties showed higher revision rates. However, participation rates and, therefore, data completeness were not optimal. To optimize participation, improving ease of registration should be explored. Furthermore, we urge readers who deal with joint implants to register their surgeries in the LROI database because only optimal registration completeness leads to high-quality data.

Surface wear of PyroCarbon implant in metacarpophalangeal joint arthroplasty without radiographic abnormality: A case report

CASE

A 54-year-old male with osteoarthritis of the right long finger metacarpophalangeal joint underwent PyroCarbon joint arthroplasty. Seven years later the patient presented for metacarpophalangeal joint swelling and pain. The workup was benign, without signs of implant complication or osseous abnormality. He underwent washout and two-stage revision, where gross implant wear and debris not demonstrated by radiograph were found. He then returned to the operating room for reimplantation of a PyroCarbon implant.

CONCLUSION

This case demonstrates a novel presentation of aseptic PyroCarbon implant failure in the hand without radiographic abnormality that can alter operative management by reducing operating room returns.

Metacarpophalangeal Joint Pyrocarbon Arthroplasty for Osteoarthritis: An Analysis of 44 Arthroplasties

PURPOSE

The objective of this study was to analyze postoperative outcomes in a group of patients who underwent metacarpophalangeal (MCP) arthroplasty using a pyrocarbon prosthesis for noninflammatory arthritis.

METHODS

An analysis of 44 MCP joint arthroplasties in 30 patients with >2 years of follow-up over a 12-year period was reviewed. The mean age was 63 years. The primary operative indication was pain and stiffness from osteoarthritis refractory to nonsurgical management.

RESULTS

At a mean follow-up of 6 ± 3 years, 8 (18%) joints underwent reoperation, including 5 (11%) that underwent revision arthroplasty. The 2- and 5-year rates for survival free of revision arthroplasty were 95% and 93%, respectively. One (2%) operation was complicated by intraoperative fracture. Postoperative complications occurred in 8 (18%) fingers and included ligament/tendon rupture (n = 3) and instability (n = 2). There was significant postoperative improvement in pain levels, MCP arc of motion, pinch strength, and grip strength. At a mean 5 years of radiographic follow-up, 7% had progressive implant instability because of grade 3 or greater loosening. No joints experienced implant instability from progressive subsidence.

CONCLUSIONS

Metacarpophalangeal arthroplasty using a pyrocarbon implant for osteoarthritis demonstrates an 7% revision rate at 5 years after surgery. Complications lead to reoperation in 1 of 5 arthroplasties. Radiographic evidence of implant instability was uncommon. Overall, patients experienced predictable pain relief and improvements in their range of motion and pinch strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Development of novel hybrid 3D-printed degradable artificial joints incorporating electrospun pharmaceutical- and growth factor-loaded nanofibers for small joint reconstruction

Small joint reconstruction remains challenging and can lead to prosthesis-related complications, mainly due to the suboptimal performance of the silicone materials used and adverse host reactions. In this study, we developed hybrid artificial joints using three-dimensional printing (3D printing) for polycaprolactone (PCL) and incorporated electrospun nanofibers loaded with drugs and biomolecules for small joint reconstruction. We evaluated the mechanical properties of the degradable joints and the drug discharge patterns of the nanofibers. Empirical data revealed that the 3D-printed PCL joints exhibited good mechanical and fatigue properties. The drug-eluting nanofibers sustainedly released teicoplanin, ceftazidime, and ketorolac in vitro for over 30, 19, and 30 days, respectively. Furthermore, the nanofibers released high levels of bone morphogenetic protein-2 and connective tissue growth factors for over 30 days. An in vivo animal test demonstrated that nanofiber-loaded joints released high concentrations of antibiotics and analgesics in a rabbit model for 28 days. The animals in the drug-loaded degradable joint group showed greater activity counts than those in the surgery-only group. The experimental data suggest that degradable joints with sustained release of drugs and biomolecules may be utilized in small joint arthroplasty.

Proximal Interphalangeal Joint Arthroplasty for Fracture

Proximal interphalangeal joint arthroplasties can be performed in the setting of acute comminuted fracture, chronic fracture presentations, and posttraumatic arthritis. These surgeries provide excellent pain relief and patient satisfaction but patients should be cautioned not to expect an improvement in motion postoperatively. Despite high rates of minor complications and radiographic loosening, these implants have good rates of long-term survival with most revisions occurring in the early postoperative period. They provide viable alternatives to arthrodesis, osteotomy and amputation in the appropriate patient.

Managing Difficult Problems in Small Joint Arthroplasty: Challenges, Complications, and Revisions

Small joint arthroplasty of the hand has been an established means of joint preservation and pain relief for over a half a century. Despite this, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint arthroplasty has not achieved the long-term success seen with hip and knee arthroplasty. Problems following MCP, PIP, and carpometacarpal (CMC) joint arthroplasty can include intraoperative fracture, postoperative dislocation, recurrent pain, limitation of motion, and instability. The hand surgeon needs to be prepared for these problems and their management. This article addresses the management of the most common complications seen following MCP, PIP, and CMC arthroplasty.

Is a Vascularized Interphalangeal Unicondylar Transfer Worth the Efforts? Surgical Technique and Clinical Application

Interphalangeal joints (IPJ) play a key role in hand function for performing activities of daily living and are frequently involved in complicated injuries resulting in significant functional limitations such as secondary arthritis and stiffness being the most challenging. In adult patients with more than 5 mm bone loss of the proximal articular surface who request a functional interphalangeal joint with minimal pain a vascularized joint transfer is a treatment choice. A unicondylar loss more than 5 mm wide in a 22-year-old carpenter is reported and illustrates our experience with a vascularized unicondylar transfer showing the advantages compared to the "classic" total joint transfer or distal interphalangeal (DIP) joint arthrodesis. By using this technique at the 12-month follow-up, we achieved no donor site complications, a good graft alignment, a good joint congruity, complete bone healing and a normal vascular patency with no signs of bone malunion or resorption of the graft.

Outcome of the MatOrtho arthroplasty for PIP osteoarthritis with a minimum follow-up of two years

The aim of this study is to report the early results of the MatOrtho arthroplasty, a newer generation resurfacing implant of the proximal interphalangeal joint. We performed a prospective cohort review of all MatOrtho arthroplasties implanted between 12/2013 and 05/2018 by a single surgeon at a single institution because of primary osteoarthritis, with a minimum follow-up of two years. Patient demographics, diagnosis, implant revision and other surgical interventions were recorded. Subjective and objective outcomes were evaluated, including range of motion, Patient Reported Outcome Measures and radiographic assessment. A total of 34 implants were inserted in 25 patients. Two implants were lost to follow-up. Pain scores improved significantly (mean VAS pre- op 7, mean VAS post-op 1, p < 0.05). Active range of motion improved in 83% (25/30) of joints, with a mean improvement of the total arc of motion of 25 degrees. On radiographic assessment, no signs of circumferential lucency or subsidence were observed. Additional surgery was necessary for three out of 32 implants, including implant removal in two cases. 93.75% (30/32) implants survived after a mean follow-up of 33 months. Our results confirm that at least at short term follow up, the MatOrtho PIP arthroplasty can be a successful procedure with high patient satisfaction and functional improvement.

Reconstruction of the thumb interphalangeal joint from the second toe proximal interphalangeal joint combined with artificial dermis covering: A case report

RATIONALE

Thumb function is one of the most fundamental components of hand function, and a vast majority of hand functions are derived from thumb motion. Injury of the thumb interphalangeal joint has a tremendous impact on the function of the thumb, and damage to the thumb interphalangeal joint (IPJ) caused by trauma is usually accompanied by dislocation of the surrounding skin; therefore, it is particularly important to restore the thumb anatomy and skin coverage.

PATIENT CONCERNS

A 41-year-old woman presented with IPJ disfigurement accompanied by a local skin defect caused by machine compression of her right thumb. Restoring the appearance and function of the thumb is key to this operation.

DIAGNOSES

Open fracture of the right thumb.

INTERVENTIONS

After detailed preoperative and radiographic evaluation, the appearance and function of the thumb were reconstructed by IPJ grafting and artificial dermis covering.

OUTCOMES

At 4 months' follow-up, the patient's visual analogue score was 0, no complications (eg, osteomyelitis, osteolysis, osteoarthritis, and nonunion of the artificial dermis) were observed, and the range of motion of the thumb IPJ returned to 60% of that of the healthy side.

LESSONS

The innovative application of the second toe proximal IPJ flap combined with double-layer artificial dermis covering to reconstruct the thumb IPJ defect not only solves the problem of skin defects in the recipient area after transplantation in previous cases but also restores the beauty of the recipient area, making it easier for patients to accept this surgical program.

The Long-term Results of Proximal Interphalangeal Joint Arthroplasty of the Osteoarthritic Index Finger

Background: Arthroplasty of the proximal interphalangeal (PIP) joint is a widely performed procedure for patients with osteoarthritis. Its use in the index finger is often discouraged due to concerns over implant longevity and stability secondary to coronal forces this digit is exposed to during pinch. Methods: We analyzed 47 consecutive index finger silastic interposition arthroplasties, performed through a dorsal approach, at a mean follow-up of 5.15 years. Results: Only 2 patients had ulnar deviation greater than 15°. The reoperation rate was 12.8%, with only 1 finger requiring arthrodesis. The mean Visual Analog Scale score was 1.1; and of the whole series, only 1 patient would retrospectively have preferred a fusion. Conclusions: Our series shows that excellent functional results and patient satisfaction can be gained using silastic PIP joint arthroplasty in the index finger. We would advocate offering this procedure, especially in lower demand patients as an alternative to arthrodesis, with the benefit of providing good pain relief while preserving movement.

Proximal interphalangeal joint arthroplasty with the Tactys® prosthesis: Clinical and radiological outcomes at a mean 3.1 years' follow-up

Preliminary results with the Tactys® modular gliding prosthesis for proximal interphalangeal joint (PIPJ) replacement were encouraging, with notable improvement in clinical and functional scores at 1 and 2 years' follow-up. However, a recent study found a trend for deterioration over time. We wanted to check this by analyzing medium-term outcomes. Sixty-four arthroplasties were performed in 48 patients in single facility between January 2015 and January 2020. Clinical, functional, and radiographic outcomes were analyzed at short- and medium-term follow-up for 15 of these arthroplasties. Mean follow-up of the 48 patients was 3.1 years. Pain significantly decreased on the numeric rating scale (p < 0.01) and the functional QuickDASH score improved from 67.3 to 55.9 (p < 0.01). Grip and pinch strengths were lower in the operated than in the contralateral hand (p = 0.04 and p = 0.6, respectively). PIPJ active range of motion (ROM) in flexion/extension improved from 44° to 49.4° (p = 0.17). 70% of the 48 patients were satisfied. Fifteen arthroplasties were analyzed at 17 and 61 months' follow-up. Pain relief continued. ROM decreased from 57° to 46° (p < 0.05) and the functional QuickDASH score deteriorated from 25.8 to 54.7 (p < 0.01). Both grip and pinch strength increased, with a significant difference in pinch (p = 0.003). The main complication was swan-neck deformity (46%), with a mean 11 months' onset. Our results confirmed the deterioration trend observed over time in the functional results of the Tactys® prosthesis despite, good patient satisfaction. LEVEL OF EVIDENCE: 4.

Silicone and Pyrocarbon Artificial Finger Joints

Artificial finger joint design has been developed through different stages through the past. PIP (proximal interphalangeal) and MCP (metacarpophalangeal) artificial finger joints have come to replace the amputation and arthrodesis options; although, these artificial joints are still facing challenges related to reactive tissues, reduced range of motion, and flexion and extension deficits. Swanson silicone artificial finger joints are still common due to the physician's preferability of silicone with the dorsal approach during operation. Nevertheless, other artificial finger joints such as the pyrocarbon implant arthroplasty have also drawn the interests of practitioners. Artificial finger joint has been classified under three major categories which are constrained, unconstrained, and linked design. There are also challenges such as concerns of infections and articular cartilage necrosis associated with attempted retention of vascularity. In addition, one of the main challenges facing the silicone artificial finger joints is the fracture occurring at the distal stem with the hinge. The aim of this paper is to review the different artificial finger joints in one paper as there are few old review papers about them. Further studies need to be done to develop the design and materials of the pyrocarbon and silicone implants to increase the range of motion associated with them and the fatigue life of the silicone implants.

Interpositional Arthroplasty Using Mammary Capsule for Finger Joints: A Novel Technique

Degenerative osteoarthritis frequently affects the hands, altering the movements; surgical therapy includes arthrodesis and arthroplasty. We report the case of a female patient who presented arthrosis in the hands, severe on the proximal interphalangeal (PIP) joints, initially in her right index finger, and subsequently in the index and middle left fingers. At first, she received treatment in the PIP joint of the right index finger with a silicone implant; later on, she presented fracture of it and required replacement 8 years later. In the PIP joints of index and middle left fingers, treatment was made with interposition arthroplasty by mammary implant capsule. We present the postoperative progression of the silicone versus mammary capsule interposition arthroplasty. It is remarkable that, over time, articular function of the intervened joints with capsular arthroplasty remained stable with good motion, while range of motion in other fingers was reduced as a consequence of osteoarthritis. The frequency of patients presenting simultaneously with mammary capsule contracture and osteoarthritis is low, but this novel technique is nonetheless worthwhile to take into consideration.

National Prevalence of Complications and Cost of Small Joint Arthroplasty for Hand Osteoarthritis and Post-Traumatic Arthritis

PURPOSE

Osteoarthritis (OA) of the hand is commonly treated using implant arthroplasty. Despite the increasing prevalence of hand OA, population-based evidence regarding the complication profile and associated cost for patients undergoing proximal interphalangeal (PIP) joint and metacarpophalangeal (MCP) joint arthroplasty are lacking. Therefore, we aimed to evaluate the complication profiles and variation in cost of care for patients undergoing PIP and MCP joint arthroplasty.

METHODS

We analyzed insurance claims from 2009 to 2016 using the Truven MarketScan Databases for adult patients undergoing a PIP and MCP joint arthroplasty following OA or post-traumatic arthritis diagnosis. Multivariable logistic regression was performed to investigate the association of patient-level factors and complications at 2 years after surgery. Cumulative direct cost, defined as the cost of the index surgery and 2-year postoperative episode, and patient-level characteristics were examined.

RESULTS

We analyzed a total of 2,859 patients who underwent MCP joint arthroplasty (36%) or PIP joint arthroplasty (64%). On average, these procedures have a 35% complication rate. However, patients undergoing PIP joint arthroplasty were more likely to suffer a prosthetic fracture than patients undergoing MCP joint arthroplasty (3.4% vs 1.5%, respectively). Each complication resulted in an additional cost of $1,076.

CONCLUSIONS

This nationwide analysis provides a population estimate of the complication profile and associated costs of MCP and PIP joint arthroplasty for hand OA and post-traumatic arthritis. Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Finger joint denervation in hand osteoarthritis: Indications, surgical techniques and outcomes. A systematic review of published cases

In cases of osteoarthritis with preserved motion, joint denervation can be an effective alternative to arthroplasty or arthrodesis to reduce joint-related pain. Although denervation is a standardized procedure for wrist osteoarthritis, it is used sparingly for finger joints. We conducted a systematic review to summarize reported cases of finger joint denervation in hand osteoarthritis with a specific focus on surgical procedures and postoperative outcomes. PubMed, Cochrane and Science Direct databases were searched from 1998 to 2019 and 13 relevant articles were selected. Three hundred and twenty-five denervations were conducted on 291 patients. Distal interphalangeal (DIP) joint denervation was performed through a dorsal approach; 83% of patients were satisfied with the surgery and complications occurred in 58%. Proximal interphalangeal (PIP) joint denervation was performed through a palmar approach; 90% of patients were satisfied with the surgery; complications were observed in 14%. Good results were observed in 95% of patients who underwent metacarpophalangeal (MCP) joint denervation; complications were observed in 26%; denervation was carried out with dorsal and palmar approaches in all cases. Denervation of the trapeziometacarpal (TMC) joint was achieved through the Wagner approach (61%), multiple incisions (26%), or dorsal approach (13%); satisfaction rate was 91%, with a 6% complication rate. Finger joint denervation in hand osteoarthritis is a simple and effective procedure, providing satisfactory pain relief. Good results are reported in all studies, especially for PIP and TMC joint denervation. Further investigations should be conducted on DIP and MCP joint denervation.

The proximal interphalangeal joint: arthritis and deformity

Finger joints are of the most common site of osteoarthritis and include the DIP, PIP and the thumb saddle joint.

Joint arthroplasty provides the best functional outcome for painful destroyed PIP joints, including the index finger.

Adequate bone stock and functional tendons are required for a successful PIP joint replacement

Fixed swan-neck and boutonnière deformity are better served with PIP arthrodesis rather than arthroplasty.

Silicone implants are the gold standard in terms of implant choice. Newer two-component joints may have potential to correct lateral deformities and improve lateral stability.

Different surgical approaches are used for PIP joint implant arthroplasty according to the needs and the experience of the surgeon.

Post-operative rehabilitation is as critical as the surgical procedure. Early protected motion is a treatment goal.

Revision and exchange PIP arthroplasty may successfully be used to treat chronic pain, but will not correct deformity.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180042

Hand and wrist joint procedures in patients with scleroderma: a systematic review

We aimed to examine if joint procedures in hands and wrists of patients with scleroderma could be performed without major morbidity and conducted a systematic review of the literature to assess this hypothesis. Studies were identified in four different databases; soft tissue procedures in scleroderma patients were excluded, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Seven studies out of an initial total of 203 articles were included. One-hundred and twelve scleroderma patients with a total of 402 joint procedures in the hand and wrist were identified. A low complication incidence, comparable with that of non-sclerodermic population, in terms of infection, wound healing problems, and nonunion was reported in all studies. The application of joint procedures in scleroderma hands and wrists seems to be associated with low morbidity.

Revision Metacarpophalangeal Arthroplasty: A Longitudinal Study of 128 Cases

PURPOSE

The objective was to examine outcomes associated with a large cohort of revision metacarpophalangeal (MCP) arthroplasties.

METHODS

A review of 128 revision MCP arthroplasties performed in 64 patients was performed. The mean age at surgery was 62 years. Fifty nonconstrained (31 pyrocarbon and 19 surface-replacing arthroplasty) and 78 constrained silicone implants were used for revisions.

RESULTS

At a follow-up of 6 years (2 to 16), 20 (16%) implants required a secondary revision surgery. The 5- and 10-year survival rates were 81% and 79%, respectively. Postoperative dislocation occurred in 17 (13%) MCP joints. Subgroup analysis demonstrated a 5-year survival rate of 67% in surface-replacing arthroplasties, compared with 83% for both pyrocarbon and silicone implants (hazard ratio, 2.60; P = 0.09). Clinical improvements in pain and MCP range of motion were noted in most patients postoperatively.

CONCLUSIONS

Revision MCP arthroplasty is a challenging procedure with one in five patients requiring a revision procedure at 5 years and a relatively high rate of postoperative dislocations. However, most patients who did not undergo a secondary revision surgery experienced improvements in pain and range of motion. Worse outcomes are seen in patients with a history of MCP dislocations.

LEVEL OF EVIDENCE

Level IV.

Biomechanical analysis of metacarpophalangeal joint arthroplasty with metal-polyethylene implant: An in-vitro study

BACKGROUND

The most common implant options for the metacarpophalangeal joint arthroplasty include silicone, pyrocarbon and metal-polyethylene. A systematic review of outcomes of silicone and pyrocarbon implants was conducted; however, a similar exercise for metal-polyethylene implants revealed a scarcity of published results and lack of long-term follow-up studies. The aim of the present work is to test the hypothesis that the magnitude of metacarpophalangeal joint cyclic loads generates stress and strain behaviour, which leads to long-term reduced risk of metal-polyethylene component loosening.

METHODS

This study was performed using synthetic metacarpals and proximal phalanges to experimentally predict the cortex strain behaviour for both intact and implanted states. Finite element models were developed to assess the structural behaviour of cancellous-bone and metal-polyethylene components; these models were validated by comparing cortex strains predictions against the measurements.

FINDINGS

Cortex strains in the implanted metacarpophalangeal joint presented a significant reduction in relation to the intact joint; the exception was the dorsal side of the phalanx, which presents a significant strain increase. Cancellous-bone at proximal dorsal region of phalanx reveals a three to fourfold strain increase as compared to the intact condition. Interpretation The use of metal-polyethylene implant changes the strain behaviour of the metacarpophalangeal joint yielding the risk of cancellous-bone fatigue failure due to overload in proximal phalanx; this risk is more important than the risk of bone-resorption due to the strain-shielding effect. By limiting the loads magnitude over the joint after arthroplasty, it may contribute to the prevention of implant loosening.

Complications, reoperations and revisions after proximal interphalangeal joint arthroplasty: a systematic review and meta-analysis

This systematic review and meta-analysis investigates the prevalence of complications, reoperations (surgeries without implant modifications) and revisions (surgeries with implant modifications) after proximal interphalangeal joint arthroplasty with pyrocarbon, metal-polyethylene and silicone implants. Thirty-four articles investigating 1868 proximal interphalangeal joints were included. Implant-related complications were associated with 14%, 10% and 11% of the pyrocarbon, metal-polyethylene and silicone implants, respectively, yet these rates were not significantly different from one another. Silicone implants showed more finger deviations (3%) and instabilities (2%) compared with the other implants. Reoperations were fewer for silicone arthroplasties (1%) compared with pyrocarbon (7%) and metal-polyethylene implants (10%). The revision rates of 4%, 3% and 2% were similar for pyrocarbon, metal-polyethylene and silicone implants. Our results indicate that silicone implants remain a valuable option for the treatment of stable proximal interphalangeal joints. Surface replacing implants might be better to correct unstable or deviated proximal interphalangeal joints, although they are associated with a higher risk of reoperations.

Outcomes Following Acute Metacarpophalangeal Joint Arthroplasty Dislocation: An Analysis of 37 Cases

PURPOSE

There remains a paucity of information regarding the treatment outcomes of dislocation after metacarpophalangeal (MCP) joint arthroplasty. The purpose of this study was to assess the outcomes of surgical and nonsurgical treatment modalities of MCP arthroplasty dislocations.

METHODS

Of 816 MCP joint arthroplasties over a 14-year period, there were 37 (4%) acute MCP joint dislocations that required intervention by a health care professional. Implants involved included 28 nonconstrained implants including pyrocarbon (n = 17) and surface replacement arthroplasty (n = 11), and 9 silicone implants. The analysis included the treatment of dislocations after primary (n = 30) and revision (n = 7) MCP joint arthroplasty. Dislocation was defined as clinical and radiographic evidence of MCP joint prosthetic acute dislocation diagnosed and treated by a fellowship trained hand surgeon.

RESULTS

Etiologies underlying the dislocations included implant fracture (n = 6), component loosening (n = 2), and soft tissue deficiency (n = 29). Of the 37 dislocations, treatments included 14 nonsurgical (closed reduction, orthosis fabrication) all of which ultimately failed. Surgically, including some of the failed prior procedures, 18 soft tissue stabilization procedures and 21 revision arthroplasties were performed, with 6 that had failed soft tissue stabilization. The soft tissue stabilization procedures had a 28% success rate in achieving a stable MCP joint. Revision arthroplasty had a 71% success rate. Subgroup analysis showed an 86% success rate for silicone revisions and a 43% success rate with nonconstrained revisions, with 80% and 36% 5-year survival free of instability, for the 2 types of implants, respectively.

CONCLUSIONS

The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Biomechanical evaluation of pyrocarbon proximal interphalangeal joint arthroplasty: An in-vitro analysis

BACKGROUND

Pyrocarbon proximal interphalangeal joint arthroplasty provided patients with excellent pain relief and joint motion, however, overall implant complications have been very variable, with some good outcomes at short-medium-term follow-up and some bad outcomes at longer-term follow-up. Implant loosening with migration, dislocation and implant fracture were the main reported clinical complications. The aim of the present work was to test the hypothesis that the magnitude proximal interphalangeal joint cyclic loads in daily hand functions generates stress-strain behaviour which may be associated with a risk of pyrocarbon component loosening in the long-term.

METHODS

This study was performed using synthetic proximal and middle phalanges to experimentally predict the cortex strain behaviour and implant stability considering different load conditions for both intact and implanted states. Finite element models were developed to assess the structural behaviour of cancellous-bone and pyrocarbon components, these models were validated against experimentally measured cortex strains.

FINDINGS

Cortex strains showed a significant increase at dorsal side and reduction at palmar side between intact and implanted states. Cancellous-bone adjacent to the condylar implant base components suffers a two to threefold strain increase, comparing with the intact condition.

INTERPRETATION

The use of pyrocarbon implant changes the biomechanical behaviour of the joint phalanges and is associated with a potential risk of support cancellous-bone suffer fatigue failure in mid to long term due to the strain increase for cyclic loads in the range of daily hand activities, this risk is more prominent than the risk of bone resorption due to strain-shielding effect.

Current European Practice in the Treatment of Proximal Interphalangeal Joint Arthritis

There are increasing numbers of proximal interphalangeal (PIP) arthroplasties performed in Europe. Meanwhile, most surgeons prefer arthroplasty over arthrodesis. Silastic arthroplasties remain the most widely used implants. The main disadvantage of the Silastic implants is the limited stability they provide. Correction of pre-existing deformation is difficult. Soft tissue handling and postoperative scarring have an influence on the results of PIP arthroplasty. Different surgical approaches are possible. The most popular approach in Europe is dorsal. Different surface replacement implants are on the market in Europe. The main advantage of these implants is the lateral stability provided through their more anatomic form.

Pyrocarbon Proximal Interphalangeal Joint Arthroplasty: Minimum Five-Year Follow-Up

PURPOSE

To report the outcomes, complications, and survivorship of pyrocarbon proximal interphalangeal joint arthroplasty at a minimum of 5-year follow-up.

METHODS

A review of 97 implants in 72 consecutive patients from our joint arthroplasty database was undertaken. Patient demographics, complications, further surgery, and implant revision were recorded. Objective outcome was assessed by grip strength, range of motion, and radiological assessment of alignment, loosening, and subsidence. Subjective outcome was assessed by Patient Evaluation Measure; Quick Disabilities of the Arm, Shoulder, and Hand score; and visual analog scores (0, best; 10, worst) for appearance, satisfaction, and pain.

RESULTS

Diagnosis was osteoarthritis in 60 joints, rheumatoid arthritis in 12 joints, psoriatic arthritis in 11 joints, and trauma in 14 joints. The average follow-up was 118 months (range, 60-164 months). The mean arc of motion was 35° (range, 0° to 90°). There was no difference in grip strength between operated and nonoperated side. Of the 97 implants, 36 required additional surgery, of which 14 were revised and 22 required reconstruction around a retained implant. The average Patient Evaluation Measure and Quick Disabilities of the Arm, Shoulder and Hand scores were 33 (range, 10-69) and 35 (range, 0-93), respectively. Mean visual analog scores for pain, satisfaction, and appearance were 2 (range, 0-8), 7 (0-10), and 8 (0-10), respectively. All implants had a lucent line with nearly all classified as either Herren grade 2 or 3. Progressive loosening was seen in 48% of implants. Implant survival as assessed by Kaplan-Meier was 85% at both 5 and 10 years.

CONCLUSIONS

Good pain relief and maintenance of preoperative arc of motion was achieved with no major deterioration over time. Most implant revisions were performed within 24 months of the index procedure. Currently progressive loosening was not translated into revision surgery. Implant revision rate was higher than with other prostheses.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Intraoperative periprosthetic fractures associated with metacarpophalangeal joint arthroplasty

PURPOSE

To assess the incidence of and identify risk factors for intraoperative periprosthetic fractures during primary and revision metacarpophalangeal (MCP) joint arthroplasty.

METHODS

Through our institutional Joint Registry Database, we identified 818 MCP joint arthroplasties performed in 285 patients from 1998 to 2012, including 690 primary arthroplasties and 128 revision arthroplasties. Primary diagnoses included inflammatory arthritis (667), osteoarthritis (75), and posttraumatic arthritis (76). Periprosthetic fractures were identified through review of medical records.

RESULTS

Intraoperative periprosthetic fractures occurred in 23 (3%) fingers (21 patients), including 19 primary and 4 revision arthroplasties. Twelve fractures required stabilization, 4 required only bone grafting, and 1 required both. The fractures occurred during broaching (12), implantation (10), or prior implant removal (1). Diabetes mellitus (DM), younger age, pyrocarbon implant insertion, and cementless fixation increased risk for intraoperative fracture. In particular, DM and the use of pyrocarbon implants significantly increased fracture risk. At 4 years (range, 1.3-10.2 y) average follow-up, no patient with intraoperative fracture had developed a subsequent fracture compared with 3 postoperative fractures in patients without intraoperative fractures. All fractures had healed by the time of the last follow-up. The 2- and 5-year implant survival rates were 96% and 80% in those with intraoperative fractures, respectively, which was not significantly different from those without an intraoperative fracture. When comparing patients with an intraoperative fracture with those without, there was an increased risk of postoperative MCP joint instability defined as implant dislocation. Patients with intraoperative fractures still had noteworthy improvements in their postoperative pain levels and pinch strengths.

CONCLUSIONS

Intraoperative fractures occurred in 3% of MCP joint arthroplasties, including 3% of primary and 3% of revision arthroplasties. Increased risk for fracture was associated with the use of pyrocarbon implants, cementless fixation, and DM. Although these fractures did not appear to adversely affect implant survival, they were associated with increased risk of postoperative instability.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

A modular surface gliding implant (CapFlex-PIP) for proximal interphalangeal joint osteoarthritis: a prospective case series

PURPOSE

To evaluate the one-year postoperative clinical and patient-rated outcomes in patients receiving proximal interphalangeal (PIP) joint arthroplasty with a modular surface gliding implant, CapFlex-PIP.

METHODS

10 patients each with primary osteoarthritis of a single PIP joint were assessed preoperatively (baseline), at 6 weeks, and 3, 6, and 12 months after CapFlex-PIP arthroplasty for lateral stability and range of motion of the affected digit. In addition, patients rated their pain using a numeric rating scale and function and overall assessment of their treatment and condition using the quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Patient Evaluation Measure (PEM) questionnaires, respectively.

RESULTS

The mean baseline active mobility of the affected PIP joint increased from 42° to 51° by one year, although this change was not significant. Patients reported reduced pain at one year, which was statistically significant. There was also a significant improvement between baseline and one-year QuickDASH (43 points vs 15 points, respectively) and PEM scores (51 vs 25 points, respectively). Absent or low lateral instability was observed in 9 joints at follow-up. All implants remained intact over the one-year postoperative period and there was no migration, osteolysis, or implant fracture. After study completion, 2 patients underwent tenolysis.

CONCLUSIONS

Patients experienced a significant reduction in pain and a trend towards increased mobility. All implants showed complete osteointegration without evidence of radiological migration. Lateral stability improved.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Advances in small joint arthroplasty of the hand

Substantial effort has been directed at the development of small joint prostheses for the hand. Despite advances in prosthetic joint design, outcomes have been relatively unchanged over the past 60 years. Pain relief and range of motion achieved after surgery have yet to mirror the success of large joint arthroplasty. Innovations in biotechnology and stem cell applications for damaged joint surfaces may someday make prostheses obsolete. The purpose of this review is to describe the current status, ongoing advances, and future of small joint arthroplasty of the hand.

First metacarpal resurfacing with polyvinyl alcohol implant in osteoarthritis: preliminary study

Osteoarthritis of first carpometacarpal (CMC) joint is a condition that is frequently encountered in hand surgery. If conservative treatment fails, several surgical procedures are available ranging from arthroscopic debridement to total joint arthroplasty. This study focuses on a new resurfacing technique for the base of the first metacarpal using a polyvinyl alcohol hydrogel implant. Our preliminary study found good clinical outcomes and no inflammatory reaction after a follow-up of 30 months. However prospective studies with a longer follow-up and more patient are needed to confirm these results.

Revision arthroplasty for failed silicone proximal interphalangeal joint arthroplasty: indications and 8-year results

PURPOSE

To evaluate the indications for revision of silicone proximal interphalangeal joint arthroplasties, to analyze the results of revision surgery, and to determine which specific patient concerns were most successfully addressed by revision surgery.

METHODS

This study combined a cross-sectional evaluation of the patients' condition after revision surgery and a retrospective chart review. All patients who had revision surgery of their PIP silicone arthroplasty in our clinic between 1999 and 2009 were invited for clinical follow-up. We reviewed their medical records, took radiographs, and recorded the active flexion and extension, pain, and patient satisfaction.

RESULTS

Thirty-four revisions in 27 patients were performed, and we were able to examine 20 patients with 24 arthroplasties clinically. The average follow-up was 4.3 years after revision and 8.3 years following primary surgery. The main indications for revision surgery were pain and restricted active range of motion, with or without implant breakage, predominantly in the index and middle fingers. Patients were fairly satisfied with the outcome of the revision surgery and reported only mild residual pain. Patients whose indication for revision was a restricted active range of motion increased active flexion from 33° before the revision to 71° following the operation. Patients who required revision for a large ulnar deviation deformity (mean, 33°) still had a residual deviation of 15° at follow-up.

CONCLUSIONS

Revision surgery after failed silicone proximal interphalangeal joint arthroplasty was most successful in patients with severe postoperative stiffness. Pain was relieved, and patients were fairly satisfied with the results of the revision. Ulnar deviation could not be corrected completely.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surgical treatment of degenerative osteoarthritis of the fingers

Degenerative osteoarthritis of the long fingers is rare and surgical management is often necessary if there is joint pain, however this indication should not only be based on radiographic imaging. The specific anatomical problems of the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are described. The surgical approach for each joint is described as well as functional management, in particular that of the extensor apparatus. Mobility should always be preserved for the MCP, arthroplasties are recommended for the PIP except for the index, and arthrodesis for the DIP. The different and most frequently used implants are described as well as the indications and expected results. The indications are discussed in relation to the limited results in the literature as well as the preferences of a panel of French hand surgeons.

Proximal interphalangeal joint replacement in patients with arthritis of the hand: a meta-analysis

We systematically reviewed all the evidence published in the English language on proximal interphalangeal joint (PIPJ) replacement, to determine its effectiveness on the function of the hand and the associated post-operative complications. Original studies were selected if they reported clinical outcome with a minimum of one year's follow-up. Quality was assessed using the Cowley systematic review criteria modified for finger-joint replacements. Of 319 articles identified, only five were adequately reported according to our quality criteria; there were no randomised controlled trials. PIPJ replacements had a substantial effect size on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1) and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach was most successful. Post-operative loosening occurred in 10% (95% CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon replacements. Post-operative complications occurred in 27.8% (95% CI 20 to 37). We conclude that the effectiveness of PIPJ replacement has not been established. Small observational case studies and short-term follow-up, together with insufficient reporting of patient data, functional outcomes and complications, limit the value of current evidence. We recommend that a defined core set of patients, surgical and outcome data for this intervention be routinely and systematically collected within the framework of a joint registry.

Medium-term outcomes of pyrocarbon arthroplasty of the proximal interphalangeal joint

We evaluated the outcome of pyrocarbon arthroplasty for proximal interphalangeal joint osteoarthritis in 18 arthroplasties carried out by a single surgeon using the Ascension prosthesis (Ascension Orthopedics Inc., Austin, Texas) in 15 patients after a mean of 6.2 years. Significant and maintained improvements in pain scores at rest and on active movements were achieved for surviving implants, and the range of motion was comparable with preoperative measurements. The radiographs, which were evaluated for evidence of ongoing migration and potential failure, were of concern in 10 out of 18 joints. Two patients required implant removal.

Distal interphalangeal joint arthrodesis with a headless compression screw: morphometric and functional analyses

INTRODUCTION

We performed radiologic measurement of the distal and middle phalanges in volunteers to determine the size of a headless compression screw suitable for distal interphalangeal (DIP) joint arthrodesis in Korean subjects and report on clinical results using an acutrak fusion screw.

MATERIALS AND METHODS

Radiologic measurements on the distal and middle phalanx were performed to determine the optimal size of screw. Five hundred fingers from 50 adult Koreans without any abnormality on plain radiographs were selected and anteroposterior and lateral radiographs were obtained for measurements. For the distal phalanx, the narrowest diameter of the cortical bone was measured to determine the minimal diameter of the screw that would not penetrate the cortex. For the middle phalanx, the narrowest diameter of the medullary canal was measured to determine the appropriate size of the screw for fixation. Between May 2004 and December 2007, there were 23 fingers in 22 patients (6 male, 16 female) that had finger DIP joint or thumb IP joint arthrodesis performed with the acutrak fusion screws. At the final follow up, time to union, complications, clinical fusion angle, pinch power, visual analogue score (VAS) for pain and the Korean version of the disabilities of the arm, shoulder and hand (DASH) questionnaire were assessed.

RESULTS

In the distal phalanx, the narrowest diameter of the cortex was 2.64 ± 0.51 mm for the little finger. In the middle phalanx, the narrowest diameter of the medullary canal was 1.83 ± 0.50 mm for the little finger and 4.17 ± 0.68 for the thumb. The mean time to union was 10 weeks (range 8-12). The mean clinical fusion angle of the DIP joint was 11.9° (range 0-20). The VAS pain score was 0.4 (range 0-3). Pinch power was 75% of the normal side. The average Korean DASH score was 5 points (range 0-8). We experienced one intraoperative fixation failure for thumb IP joint arthrodesis caused by a wide medullary canal of the proximal phalanx.

CONCLUSION

The acutrak fusion screw was a feasible and adequate tool for DIP arthrodesis, particularly in Koreans. However, meticulous attention to technique was important to avoid complications in some little fingers. If preoperative radiographs suggest the thumb has a wide medullary canal, alternate methods of fixation should be considered.

Reoperations following proximal interphalangeal joint nonconstrained arthroplasties

PURPOSE

To retrospectively analyze the reasons for reoperations following primary nonconstrained proximal interphalangeal (PIP) joint arthroplasty and review clinical outcomes in this group of patients with 1 or more reoperations.

METHODS

Between 2001 and 2009, 294 nonconstrained (203 pyrocarbon and 91 metal-plastic) PIP joint replacements were performed in our institution. A total of 76 fingers (59 patients) required reoperation (50 pyrocarbon and 26 metal-plastic). There were 40 women and 19 men with an average age of 51 years (range, 19-83 y). Primary diagnoses included osteoarthritis in 35, posttraumatic arthritis in 24, and inflammatory arthritis in 17 patients. There were 21 index, 27 middle, 18 ring, and 10 small fingers. The average number of reoperations per PIP joint was 1.6 (range, 1-4). A total of 45 joints had 1 reoperation, 19 had 2, 11 had 3, and 1 had 4.

RESULTS

Extensor mechanism dysfunction was the most common reason for reoperation; it involved 51 of 76 fingers and was associated with Chamay or tendon-reflecting surgical approaches. Additional etiologies included component loosening in 17, collateral ligament failure in 10, and volar plate contracture in 8 cases. Inflammatory arthritis was associated with collateral ligament failure. Six fingers were eventually amputated, 9 had PIP joint arthrodeses, and 2 had resection arthroplasties. The arthrodesis and amputation rates correlated with the increased number of reoperations per finger. Clinically, most patients had no or mild pain at the most recent follow-up, and the PIP joint range-of-motion was not significantly different from preoperative values. Pain levels improved with longer follow-up.

CONCLUSIONS

Reoperations following primary nonconstrained PIP joint arthroplasties are common. Extensor mechanism dysfunction was the most common reason for reoperation. The average reoperation rate was 1.6, and arthrodesis and amputation are associated with an increasing number of operations. Overall clinical outcomes demonstrated no significant change in range of motion, and most patients had mild or no pain.