The management of complications of small joint arthrodesis and arthroplasty

Salvage of failed proximal interphalangeal arthroplasty with vascularised toe joint transfer: Report of two cases

Failed implants of the proximal interphalangeal joint may result in bone and soft tissue deficits and joint instability with limited reliable options for reconstruction besides an arthrodesis procedure. The purpose of this report is to illustrate the use of vascularized second toe joint for salvage of failed, multi-operated proximal interphalangeal joint in two active patients. Pre-existing scars are used to define the approach and choice of donor site. Flow through anastomosis was performed on the finger digital artery. At final follow-up, the transplanted joints achieved 80-90 degrees of motion and the patients were able to return to their desired level of activities. The procedure is a good alternative for the fit patient wanting to achieve a stable finger with preservation of motion in catastrophic failure of prosthetic proximal interphalangeal joint arthroplasty.

The BioPro Thumb Carpometacarpal Hemiarthroplasty: Case Series and Surgical Technique

Thumb carpometacarpal (CMC) osteoarthritis is painful and debilitating. Here, we explore outcomes of a modular, press-fit thumb CMC hemiarthroplasty prosthesis (BioPro). This surgical option permits minimal bone resection, sparing the trapezium, hence allowing revision options if necessary. A retrospective review of all cases of the modular thumb CMC implants performed at one community US center between 2018 and 2021 were included and invited for email or telephone review. Electronic records were examined for demographics, patient outcomes, and morbidity. Eleven patients underwent 11 thumb CMC joint hemiarthroplasties, mean age was 64.8 years (SD: 7.68 y), with 6 females. Six received surgery on their dominant extremity. Two were manual workers (both in the medical field), 6 office-based, 2 retired, and 1 homemaker. The preoperative median pain score (Visual Analog Score) was 8/10 (range: 5 to 10), reducing to 1/10 (range: 1 to 10) ( P =0.000033) with a median follow-up of 23 months (range: 13 to 39 mo). In all, 8/11 patients reported they would recommend this surgery to friends and family and opt for the same surgery on their contralateral hand if necessary. One patient reported persistent pain a year postoperatively. On review, the head of the implant was placed too deep into the trapezium. Another center found that this patient had a postoperative trapezium fracture and underwent revision with implant removal and conversion to a suspension arthroplasty. At 12 months, 10/11 thumb CMC hemiarthroplasty showed good pain relief, function, and patient satisfaction. The BioPro has a low risk of subluxation and allows salvage options to remain available should failure occur.

Second Toe Osteochondral Bone Graft for Resurfacing the Articular Surface of the Proximal Phalanx Head of the Thumb: A Case Report

The most widely accepted surgical management of a traumatized interphalangeal joint of the thumb is arthrodesis. However, in certain situations, specific functional and vocational demands require preserved movement at this joint. In the present case report, we describe harvesting the second toe proximal phalanx head as an osteochondral bone graft to recontour the proximal aspect of the thumb interphalangeal joint. The post-operative hand therapy regimen is described resulting in a pain-free functional range of motion. We conclude that when a motivated, healthy patient has specific functional goals, osteochondral bone grafting from the toe is a viable technique to maintain a functional range of motion.

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.

Distal Interphalangeal Joint Arthroplasty: A Narrative Review

Background: Symptomatic distal interphalangeal (DIP) joint arthritis is frequently treated by arthrodesis, though DIP arthroplasty has been reported as a treatment option since 1977. This study reviews the current evidence on DIP joint arthroplasty for the treatment of arthritis refractory to non-operative management. Methods: A systematic search of PubMed, MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using the ROBINS-I tool. Results: The search yielded 55 records, of which six studies were included in the narrative review. All the included studies were of level IV evidence (case series or cohort studies). DIP arthroplasty was effective in relieving pain and reducing subsequent dysfunction. The average total arc of motion was 30°-40° but with an extension lag of 10°-15°. The overall complication rate was 15% with a re-operation rate of 8%. Joint instability (incidence of 2.5%) and infection (incidence of 2.1%) were the most common complications, while implant fracture was seen in 1% of cases. Joints that failed after DIP arthroplasty were salvaged by DIP arthrodesis. Conclusions: DIP arthroplasty is an effective treatment for painful arthritis but with a complication rate of 15%. Its main advantage over arthrodesis is the preservation of DIP motion. However, due to the limited high-quality evidence available, its use should be limited to circumstances where there is a desire or vocational need to maintain motion at the DIP joint. Level of Evidence: Level V (Therapeutic).

Distal Interphalangeal Joint Arthroplasty - A Systematic Review

Background: Arthritis of the distal interphalangeal joint (DIPJ) can result in significant functional limitations and pain. While arthrodesis is the most common surgical intervention, this can decrease grip strength and have other limitations. DIPJ arthroplasty may be an appealing alternative in select patient with this study aiming to review the outcomes of this procedure. Methods: A search was conducted according to PRISMA guidelines using PubMed, Embase and Ovid Medline from date of inception to April 2022. Relevant studies were included if they reported on complications and functional outcomes of DIPJ arthroplasty. Data was then extracted and analysed. Results: Seven studies were included including 171 patients with 269 digits. The mean age was 62.1 years, with 81% of the cohort being female. The indication for surgery was osteoarthritis in 97% of patients. Surgical approaches varied from dorsal transverse, dorsal T-incision, dorsal H-incision to radial incisions. A silicone implant was used in all patients. A total of 97.7% of patients were satisfied with their outcome, and pain improved or eliminated in all patients where it was reported. Joint stability was noted in 97.4% of cases. The mean preoperative DIPJ range of motion was 24° and improved to 36° post-operation. The mean preoperative extensor lag was 24° and reduced to 13° post operation. The rate of re-operation was 7.1%. Conclusions: DIPJ arthroplasty may be a viable alternative to arthrodesis in certain settings, providing high patient satisfaction, improvements in digital range of motion and relief of pain. However, the available literature is sparse, and limited by low-quality studies and heterogenous outcome reporting. Level of Evidence: Level III (Therapeutic).

Intramedullary Insetting of Silicone Implant for Lateral Stability in Distal Interphalangeal Joint Arthroplasty

Silicone implant arthroplasty is an alternative surgical intervention for painful and deformed osteoarthritis of the distal interphalangeal (DIP) joints. DIP joint stability is essential for hand function; however, it carries a potential risk of postoperative joint instability. To address this concern, an intramedullary implant insetting method was used to maintain joint stability by minimum resection of the head of the middle phalanx and preserving the collateral ligament. In the new method, the length of the bone excision was limited to maintain the lateral cortical bone with the insertion of the collateral ligament, and the medullary cavity of the middle phalanx was partially removed to intentionally set the hinge part of the silicone implant in the medullary canal. Between 20 digits of the conventional approach and 23 digits of the intramedullary insetting method, there were no significant differences in patient demographics (ie, age, affected hand, and finger), and clinical characteristics (ie, active DIP joint arc, DIP joint extension loss, grip strength, visual analog scale, and Quick Disabilities of the Arms, Shoulder and Hand questionnaire score) before and over 6 months after surgery. However, postoperative joint instability was significantly lower with the intramedullary insetting method, with a significantly shorter length of bone excision of the middle phalanx. This new approach is more beneficial than the conventional approach for preventing postoperative joint instability.

The Inlay Technique with Cortico-Cancellous Olecranon Bone Graft Used for Revision of Failed Distal Interphalangeal Joint Arthrodesis

Background and Objectives: Although distal interphalangeal (DIP) arthrodesis is an effective surgical method for end-stage osteoarthritis of the phalangeal joint, the nonunion rate of DIP arthrodesis has been reported to range from 15% to 20%. To this end, we devised an inlay technique with a cortico-cancellous olecranon bone graft for failed DIP arthrodesis. This study aimed to introduce the inlay bone grafting technique for failed arthrodesis of the DIP joint and demonstrate its advantages. Materials and Methods: We reviewed consecutive 19 digits (15 patients) who had undergone DIP revision arthrodesis using the technique at our institution between January 2010 and December 2020. The observed outcome measures were the bone union rate, and related complications. Bone union was evaluated using follow-up radiography. The quick Disabilities of the Arm, Shoulder and Hand (DASH), visual analog scale (VAS) for pain, and VAS for satisfaction assessed patient function and perceived clinical outcomes. Results: No major complications were observed at the recipient site. The average VAS for pain and satisfaction and DASH score improved from preoperatively to 6 months after surgery (both, p = 0.001). Conclusions: The inlay technique with cortico-cancellous olecranon bone grafts showed excellent bone union rates and functional scores with nonunion of the DIP joint. This technique may be an adequate surgical option for patients with confirmed nonunion of the DIP joint and persistent symptoms.

Severe Life-Threatening Sepsis Complicating Infected Thumb Carpometacarpal Arthroplasty

Thumb Carpometacarpal (CMC) total joint arthroplasty is commonly performed with increasing numbers worldwide. We present a case of Prosthetic Joint Infection (PJI) leading to severe septic shock and disseminated septic emboli 8 months following uneventful thumb CMC arthroplasty. Such extensive and life-threatening infection following thumb CMC arthroplasty has not been reported. Level of Evidence: Level V (Therapeutic).

Soft tissue interpositional arthroplasty as a treatment of proximal interphalangeal joint arthritis in resource-limited health care facility: A case report

Introduction

Treatment of choice for posttraumatic arthritis in proximal interphalangeal (PIP) joints has remained a controversial subject. There is a lack of consensus regarding the optimal approach and treatment options for PIP joint arthritis. In this study, we report our experience in management of PIP joint arthritis using soft-tissue interpositional arthroplasty.

Case presentation

A 12-year-old female, right-handed, complains of stiffness on the left ring finger. There was a flexion deformity accompanied by limitation on both active and passive flexion-extension range of motion (ROM) of the PIP joint. Soft tissue interpositional arthroplasty was then performed using middle phalanx periosteum as interpositional material. Postoperative follow-up showed improvement in both active and passive ROM of PIP joint, improvement in joint function, and a good pain relief. Overall, the patient was satisfied with the outcomes of the procedure.

Clinical discussion

Arthrodesis, implant arthroplasty, and interpositional arthroplasty are the treatments of choice for stiff fingers that are caused by bone problems. In this study, we report a case of PIP joint arthritis treated with interpositional arthroplasty. It was able to provide ROM improvement and good functional results. Periosteum is used as an interposition material because of its in-situ nature thereby reducing donor site related morbidity and postoperative complications. In addition, the use of the periosteum makes this procedure relatively inexpensive and makes it a suitable treatment of choice in limited resources areas.

Conclusion

Soft tissue interpositional arthroplasty shows promising results as a treatment option for arthritis of PIP joint, especially in limited resource areas.

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Interpositional arthroplasty provides good clinical outcomes for PIP joint arthritis.

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The use of periosteum as interposition material reduces morbidity and complications.

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Interpositional arthroplasty is a proper treatment option for limited resource area.

Nonunion and Reoperation Following Proximal Interphalangeal Joint Arthrodesis and Associated Patient Factors

BACKGROUND

Proximal interphalangeal joint (PIPJ) arthrodesis can provide reliable pain relief and restore hand function in patients with PIPJ arthritis. However, there is a paucity of literature on patient-specific preoperative risk factors that are associated with adverse outcomes after PIPJ arthrodeses. Therefore, the primary purpose of this study was to assess preoperative predictors of nonunion and reoperation after PIPJ arthrodesis.

METHODS

This study identified all patients who underwent PIPJ arthrodesis at a single community practice between 1987 and 2013. The final analysis included 415 PIPJs treated with arthrodesis. The mean follow-up was 1.3 years. Data on preoperative diagnosis, demographics, comorbidities, and operative techniques were recorded, as well as the occurrence of nonunions and reoperations. Logistic regression models were used to identify independent risk factors of nonunion and reoperation.

RESULTS

There were 40 nonunions (10%) and 62 reoperations (15%). Of the reoperations, there were 39 incidences of isolated hardware removal, 9 irrigation and debridement, 8 amputations, 5 revision arthrodeses, and 1 corrective osteotomy. The highest number of nonunions occurred in the traumatic diagnosis group (37%), followed by the rheumatoid group (23%) and the scleroderma group (15%). The highest number of reoperations occurred within the traumatic joint disorder group (40%), followed by the rheumatoid group (24%) and the scleroderma group (11%). Multivariate analysis revealed that male sex (P < .01) and hepatic disease (P = .03) were significant risk factors of nonunion. Male sex was also significantly associated with increased reoperation risk (P < .01).

CONCLUSION

Risks of nonunions and reoperations after PIPJ arthrodeses are low; however, these findings may guide clinicians and patients in the preoperative decision-making process and help with targeted postoperative surveillance to mitigate these risks.

Outcomes of Unconstrained Proximal Interphalangeal Joint Arthroplasty: A Systematic Review

Background: Unconstrained pyrocarbon and metal-on-polyethylene (MoP) proximal interphalangeal (PIP) joint arthroplasty is an increasingly popular alternative to silicone implants and arthrodesis. This systematic review appraises their outcomes. Methods: Thirty studies comprising 1,324 joints (813 pyrocarbon, 511 MoP) were included. Mean patient age was 59 years (38-78) and mean follow-up period was 54 months (12-118). Results: There were mean improvements of 4.5 points (2-6.9) in pain visual analogue score, 10.5° (-26 to 58) in range of motion (ROM), 3.1 kg (-4 to 7) in grip strength, 0.6 kg (-1.5 to 2) in pinch strength and 18 points (-3 to 29) in the disabilities of the arm, shoulder and hand score, with no significant differences between implant types. ROM gains deteriorated over time. Clinical complications were frequent (23%) and significantly more common with pyrocarbon, as were radiographic complications. However, most were mild-moderate and did not necessarily correlate with negative outcomes or dissatisfaction. Overall re-operation rate was 21%, and revision rate 11%, both more frequent with pyrocarbon. Most revisions were within 24 months, beyond which survival was maintained up to 10 years. Conclusions: Unconstrained PIP joint arthroplasty is effective in improving pain scores, active ROM, grip/pinch strength and patient-reported outcome measures, particularly in patients with osteoarthritis. Results are generally maintained at least to the medium term, although gains diminish in the longer term. Complication and early revision rates are high, particularly with pyrocarbon implants. Most patients express positive attitudes to arthroplasty, with significant improvements in patient-reported outcome measures for both pyrocarbon and MoP implants. Patients with post-traumatic and inflammatory arthropathy are generally less satisfied. There is currently insufficient data to recommend one implant type over another, although the early-to-medium term results of MoP implants are promising. Prospective surveillance via small joint registries is recommended. Level of Evidence: Level III (Therapeutic).

[Arthrodesis of the distal interphalangeal Joint - a literature Review]

This review addresses the arthrodesis of the distal interphalangeal joint of the finger and the interphalangeal joint of the thumb with focus on indications, approaches, preparation of the articular surfaces, the angle of arthrodesis, advances and disadvantages of each technique, and postoperative care.

Outcome of arthrodesis for severe recurrent proximal interphalangeal joint contractures in Dupuytren's disease

We report long-term outcomes of proximal interphalangeal joint arthrodesis for treatment of severe recurrent joint contractures secondary to Dupuytren's disease. The patients had at least two previous procedures for Dupuytren's contracture that involved the same joint, before undergoing joint fusion. Patient demographics, satisfaction, functional outcome, complications, revision and re-operation rates are reported. Eleven patients were included with a mean age of 64 years (range 53-73). The mean proximal interphalangeal joint contracture at presentation was 102° (range 80°-120°). None required revision surgery at a mean of 8 years and 9 months (range 9-199 months). All patients were able to perform their activities of daily living and would recommend this operation to family and friends. This series shows that proximal interphalangeal joint arthrodesis combined with needle fasciotomy or segmental fasciectomy provides a satisfactory salvage procedure in cases of severe recurrent Dupuytren's disease.Level of evidence: IV.

Functional Outcomes for Meniscal Allograft Interposition Arthroplasty of the Hand

Background

Osteochondral defects of the carpometacarpal (CMC), metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints often necessitate arthrodesis or arthroplasty. Meniscal allograft has been used for large joint resurfacing, but its application to smaller joints is less well understood. We propose its use for hand joint resurfacing as an off-the-shelf alternative to address osteochondral defects and restore articular function.

Methods

Thirty-one patients with osteoarthritis of the CMC, MCP, or PIP joints underwent arthroplasty with meniscal allograft. Patient demographics and operative information were recorded. Preoperative Disability of the Shoulder, Arm, and Hand, Wong Baker pain, grip and pinch strength, and range of motion were compared to postoperative scores at 6 weeks, 6 months, and 1 year.

Results

Twenty-three women and 8 men, mean age 62.8 years, underwent 39 joint reconstructions, including CMC (n = 26), thumb MP (n = 2), thumb IP (n = 2), digit MP (n = 2), and digit PIP (n = 7). At 1 year, mean Disability of the Shoulder, Arm, and Hand scores decreased from 41.3 to 15.6 (P < 0.001) and pain scores from 6.9 to 1.0 (P < 0.001). Grip strength increased from 38.1 to 42.9 (P = 0.017) and radial and palmar abduction from 43.1 to 49.2 (P = 0.039) and 43.7 to 51.6 (P = 0.098), respectively. There were no complications related to the meniscus.

Conclusions

Meniscal allograft represents an alternative to arthrodesis which obviates the need for a donor site and avoids many of the complications inherent to synthetic alternatives. Our early results demonstrate its successful use to reduce subjective pain and disability scores, improve objective strength measures, and maintain range of motion.

Results of proximal interphalangeal arthroplasty: border digits versus middle digits

This investigation assessed 106 consecutive primary proximal interphalangeal joint arthroplasties performed on border digits: 73 index or 33 little fingers. This was compared with 193 arthroplasties performed in non-border digits: 121 middle or 72 ring fingers. There were 20 proximal interphalangeal joint arthroplasties in the border digits that required revision surgery for pain and stiffness (10 digits), dislocation (six digits), implant fracture (one digit), and infection (three digits). Risk of revision surgery was not associated with border digit. The 5-year implant survival rate for the border digits was 81%. There was no significant difference in implant revision rate or joint dislocations between border and non-border digits. We conclude that proximal interphalangeal joint arthroplasties performed in border digits had similar pain relief, survivorship, complications, and reoperation rates compared with those performed in non-border digits.Level of evidence: IV.

Factors Influencing Bone Union in Finger Distal Interphalangeal and Thumb Interphalangeal Joint Arthrodesis

Background: Finger joint arthrodesis is a common operation which has many indications including acute trauma, post traumatic condition, osteoarthritis, and rheumatoid joint deformity. The objective of this study was to evaluate factors which may influence bone union in arthrodesis of the distal interphalangeal (DIP) joint of the fingers and interphalangeal (IP) joint of the thumb. Methods: A total of 310 arthrodesis (221 finger DIP and 89 thumb IP joint) were analysed retrospectively. We used variables related to the patient and to the operative technique in univariable and multivariable regression analysis. Outcome events were bone union within 90 days, established non-union, infection and re-operation. Results: Of the 310 operations 280 resulted in a favourable outcome while 30 resulted in bone non-union. In the univariable analysis the most important negative predictor variable for bone non-union was an operation done by other than hand surgery specialist (OR = 3.75, 95% CI = 1.727-8.140, p = 0.001), which also predicted the indication for re-operation (OR = 4.705, 95% CI = 1.563-14.163, p = 0.006). Because of insufficient event rate of bone non-union multivariable analysis was not possible for bone non-union. In the multivariable analysis rheumatoid arthritis had negative influence on bone union within 90 days (OR = 0.45, 95% CI = 0.219-0.925, p = 0.03) and none of the variables predicted infection. Conclusions: In our cohort finger DIP and thumb IP joint arthrodesis generally resulted in favourable outcome in terms of bony union regardless of the underlying medical condition or technical details of the surgical operation. Overall the results emphasize the importance of adequate surgical skill and practice even with a simple surgical operation.

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.

Failed Thumb Carpometacarpal Arthroplasty: Common Etiologies and Surgical Options for Revision

Carpometacarpal (CMC) arthroplasty surgery, although modifications have occurred over time, continues to be commonly performed and has provided patients with their desired pain relief and return of function. The complications of primary surgery, although relatively rare, can present in various clinical ways. An understanding of the underlying anatomy, pathology of coexisting conditions, and specific techniques used in the primary surgery is required to make the best recommendation for a patient with residual pain following primary CMC arthroplasty. The purpose of this review is to provide insights into the history of CMC arthroplasty and reasons for failure and to offer an algorithmic treatment approach for the clinical problem of persistent postoperative symptoms.

Salvaging a Failed Proximal Interphalangeal Joint Implant

Salvaging a failed proximal interphalangeal (PIP) joint implant arthroplasty remains a considerable technical and rehabilitation challenge. Experienced arthroplasty surgeons have reported 70% survival of revision PIP implants at 10 years with 25% of patients requiring subsequent revision surgery. At this time, there is no consensus surgical approach or implant proven superior for revision implant arthroplasty of the PIP joint. Secondary arthrodesis or amputation may be required to salvage the failed PIP implant arthroplasty with compromised bone stock or soft tissue envelopes that are inadequate for implant arthroplasty.

Proximal Interphalangeal Joint Fusion: Indications and Techniques

This article is an in-depth analysis of proximal interphalangeal joint arthrodesis indications and surgical techniques. There are a wide variety of indications for proximal interphalangeal joint arthrodesis with relatively few contraindications. Moreover, although there is a limited surgical approach, there is a wide breadth of modalities in which to obtain the arthrodesis, of which several are listed here. Proximal interphalangeal joint arthrodesis has been shown to have excellent outcomes and a high success rate.

Successful Arthroplasty Using Cadaveric Meniscus for Osteochondral Defects in the Wrist and Hand Joints

Background:

Osteochondral defects of the radiocarpal, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints often necessitate joint arthrodesis or mechanical arthroplasty, which has a limited lifespan. In severely arthritic wrist and finger joints, we propose a novel adjunct for joint salvage using cadaveric meniscus for joint resurfacing as an off-the-shelf alternative to address osteochondral defects and restore normal intraarticular contact stress.

Methods:

A total of 14 patients with osteochondral defects in 5 radiocapitate, 5 MCP, 3 PIP, and 1 carpometacarpal joints received cadaveric meniscus to facilitate arthroplasty. Patient demographic, perioperative pain, range of motion, and complications were examined.

Results:

Patients aged 17 to 73 years old (average, 54.6 years old) underwent joint reconstruction for scaphoid nonunion (n = 1), scaphoid-lunate advanced collapse (n = 4), or osteoarthritis of MCP/carpometacarpal (n = 6) or PIP (n = 3) joints. Successful arthroplasty with joint space preservation occurred in all joints. Patients had a significant reduction in average pain scale score (P < 0.01) and improved average range of active motion degrees of flexion (P < 0.01) and degrees of extension (P < 0.05). No complications resulted; only a revision tenolysis and capsulotomy were required for PIP and MCP arthroplasties. Postoperative films reveal preservation of arthroplasty joint space after an average 19.7-month follow-up (range, 8–54).

Conclusions:

We believe that meniscus is a viable joint salvage option or adjunct to preserve pain-free motion and avoid total joint arthrodesis. In this series of 14 patients, we demonstrate the successful use of cadaver meniscus in hand joint arthroplasty, such that it advantageously maintains a low metabolic demand, is biointegratable, and is surgically malleable.

Revision Ligament Reconstruction Tendon Interposition for Trapeziometacarpal Arthritis: A Case-Control Investigation

PURPOSE

To test the null hypothesis that there is no difference in patient-reported and objective outcomes of revision ligament reconstruction and tendon interposition (LRTI) compared with primary LRTI.

METHODS

This case-control investigation enrolled 10 patients who had undergone revision LRTI at a tertiary care center. All patients had previously undergone primary trapeziectomy with LRTI. Patients with a minimum of 2 years' follow-up were eligible. All patients completed an in-office study evaluation. Controls (treated only with primary LRTI) were matched from our practice to reach a 1:2 case-control ratio. Outcome measures included Michigan Hand Questionnaire (primary outcome), Quick-Disability of the Arm, Hand, and Shoulder (QuickDASH) questionnaire, visual analog scale (VAS) for pain and improvement, and physical examination. Statistical analyses were conducted to compare patient groups.

RESULTS

Patients who underwent revision LRTI reported significantly worse outcomes on all measured standardized questionnaires compared with primary patients. The Michigan Hand Questionnaire indicated worse overall outcomes (54 vs 79) as well as worse pain, appearance, and ability to complete activities of daily living. Compared with those who did not undergo revision LRTI, patients who did also reported more impairment (Quick-Disability of the Arm, Hand, and Shoulder, 47 vs 23), greater pain (VAS pain, 6.3 vs 1), and less improvement after surgery (VAS improvement, 2.7 vs 7.9). There was also a significantly higher rate of patient-reported depression in the revision LRTI group (50% vs 10% of patients treated with primary LRTI). We did not find a significant difference in objective outcomes of pinch strength, grip strength, and thumb palmar abduction between the 2 groups.

CONCLUSION

After revision LRTI, patient-reported outcomes indicate worse perceived function and greater pain than are expected following primary LRTI despite similar motion and strength. Revision surgery can be offered in the setting of persistent or recurrent symptoms, but patients should be counseled that improvement of symptoms is unpredictable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.