Current Status of Metacarpophalangeal Arthroplasty and Basilar Joint Arthroplasty of The Thumb

Reconstruction of a metacarpal head defect due to bite injury: two case reports

We present two rare cases of acute osteomyelitis after bite injury that were reconstructed with a third metacarpal base osteoarticular flap and a vascularised medial femoral trochlea osteocartilaginous flap. The outcomes show that a vascularised osteoarticular flap is a good treatment option for a metacarpal head defect.

Bone loss in the hand

Traumatic bone loss in hand surgery is challenging for the patient as well as the doctor. Whereas the patient is threatened with a possible amputation or severe disability, the hand surgeon focuses on reconstruction, restoration of the function, bony union, and appearance of the injured hand. Both are confronted with a long-standing and staged treatment coupled with a high risk of complications. This review encompasses the classifications and treatment options of bone loss in hands. The optimal treatment is still prevention of the trauma itself.

Ligament reconstruction and tendon interposition arthroplasty of the trapeziometacarpal joint with the use of the full thickness of the flexor carpi radialis tendon

We analyzed the outcomes of the ligament reconstruction and tendon interposition arthroplasty of the trapeziometacarpal joint with use of the full thickness of the flexor carpi radialis. We reviewed 19 patients, with 23 thumbs at mean follow-up of 59 ± 15 months. According to Dell classification, 11 thumbs were grade 2, and 12 thumbs were grade 3.The preoperative VAS pain score was 7 ± 0.9 and thumb web space was 23 ± 2.4°. The preoperative grip strength was 13 ± 0.7 kg, tip pinch strength was 2.8 ± 0.5 kg and lateral pinch strength was 4 ± 0.9 kg. None of the thumbs could touch the palmar crease of the little finger. The final outcome was 0.9 ± 1.4 for VAS, 19 ± 1 kg for grip strength, 4.5 ± 0.3 kg for tip pinch strength, 5.6 ± 0.5 kg for lateral pinch strength and 38 ± 2.4° for thumb web space. Mobility of the thumbs was improved; 19 thumbs could touch the base of the fifth finger, and five thumbs could touch the crease of the proximal interphalangeal joint. We compared the operated side with the healthy one in 15 patients, the grip strengths were 82% of the contralateral side, tip pinch strengths 78%, and lateral pinch strengths as 75%. According to our series, this surgical technique relieves pain and provides stability and mobility of the thumb.

The use of a third metacarpal base osteoarticular flap for treatment of metacarpophalangeal joint traumatic defects

PURPOSE

To describe the use of a pedicled osteoarticular flap harvested from the base of the third metacarpal for the treatment of traumatic defects of the metacarpophalangeal (MCP) joints.

METHODS

From February 2006 to January 2008, we included in the study 15 patients with posttraumatic defects of the MCP joints. The mean age of the patients was 35 years. The injured MCP joints were located in the thumb (n = 6) and index (n = 4), middle (n = 4), and ring fingers (n = 1). Of the 15 patients, 10 presented with acute injuries and 5 with old injuries. At follow-up, we assessed active motion and pinch strength and compared all measurements with those from the opposite hand. In patients with old MCP joint injuries, we also compared preoperative and postoperative motion and pinch strength. We assessed hand function using the Disabilities of the Arm, Shoulder, and Hand questionnaire.

RESULTS

At the final follow-up (mean, 28 mo), the mean motion arc of the reconstructed MCP joints and the opposite joints was 46° and 91°, respectively, and the mean pinch strength of the injured and opposite sides was 5.4 and 7.1 kg, respectively. For the 5 patients with old injuries to the fingers, the mean preoperative and postoperative motion arc was 2° and 43°, and the mean preoperative and postoperative pinch strength was 1.6 and 5.3 kg, respectively. The mean Disabilities of the Arm, Shoulder, and Hand score of the entire patient series was 9, whereas the mean preoperative and postoperative scores of the 5 patients with old injuries were 44 and 17, respectively.

CONCLUSIONS

The use of a pedicled osteoarticular flap harvested from the base of the third metacarpal is a reliable technique for the treatment of traumatic defects of the MCP joints.

The rheumatoid thumb

Rheumatoid arthritis of the thumb is a common source of disability. Obtaining an understanding of the underlying biologic and physical manifestations of rheumatoid arthritis is essential in the choice of treatment of the disease. In the early stages of the disease, conservative and less invasive measures can be used. In the more advanced stages, arthrodesis and arthroplasty are often used. Isolated interphalangeal involvement is best managed with arthrodesis. Metacarpophalangeal involvement in low-demand patients can be treated with arthroplasty, whereas arthrodesis can be used in more active patients. Patients who have carpometacarpal joint damage are best treated with trapezium resection arthroplasty.

Reconstruction of the rheumatoid thumb

Thumb deformities are common manifestations of rheumatoid arthritis and represent a significant source of disability. A clear understanding of the pathophysiology of the disease is essential in directing treatment. Differential diagnosis for flexible deformities includes soft-tissue imbalances as well as tendon ruptures. In its early stages, thumb involvement can be treated nonsurgically or with soft-tissue reconstruction. With more advanced disease, arthrodesis and arthroplasty often are required. Isolated interphalangeal involvement is best addressed with arthrodesis. Metacarpophalangeal involvement can be treated with arthroplasty in low-demand patients or with arthrodesis in more active patients. Trapezium resection arthroplasty provides excellent relief for patients with carpometacarpal joint destruction.

Thumb metacarpophalangeal arthritis: arthroplasty or fusion?

The human thumb assumes 50% of the workload of the human hand, and is therefore the most important digit. As such, the thumb has a propensity for the development of osteoarthritis. Moreover, the thumb is also often diseased, in anywhere from 68% to 80%of patients who have rheumatoid arthritis. Much attention over the years has been given to the carpalmetacarpal joint of the thumb, whereas the metacarpophalangeal (MP) joint of the thumb remains largely unstudied. The purpose of this article is to review the etiology of thumb MP joint arthritis, and discuss the different treatment options of this condition.

Experimental investigation of finger dynamics before and after metacarpophalangeal joint arthroplasty

PURPOSE

The purpose of this study was to quantify the changes in the arc of digital flexion before and after metacarpophalangeal (MCP) silicone arthroplasty with a 30 degrees preflexed design.

METHODS

Index, middle, and ring fingers of 4 fresh-frozen cadaver hands were used. Each hand was attached (palmar side up) to a custom test apparatus. The tendon was drawn by a small winch-type servomotor. Micropotentiometers that were attached to the centers of rotation of the MCP, distal interphalangeal, and proximal interphalangeal joints measured angular displacement before and after MCP arthroplasty as a function of tendon excursion. The data were analyzed comparing the angle of flexion initiation and the angular displacement as a function of tendon excursion before and after joint arthroplasty.

RESULTS

There were no statistical differences in the angles of the MCP joints at rest, the order of initiation of joint flexion, and the overall degree of flexion between the unoperated fingers and the fingers that had surgery. There was, however, a trend toward delay in flexion initiation, an increase in the MCP angle at rest, and a decrease in torque after implant arthroplasty.

CONCLUSIONS

The decrease in initiation of flexion of the MCP joint, although not statistically significant, probably was related to the 30 degrees of preflexion built into the implant. We also noted a trend of decreased flexion at the MCP joint and increased flexion at the proximal interphalangeal and distal interphalangeal joints. This trend may be advantageous in the reconstruction of hands that initially have an MCP joint flexion deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

to come.

Results following trapeziometacarpal arthroplasty of the thumb

A retrospective follow-up study was performed on patients with degenerative joint disease (DJD) who underwent trapeziometacarpal arthroplasty of the thumb with 3-week immobilization and without the use of K-wire fixation. Pre- and post-operative pain, activities of daily living (ADLs), grip strength, and pinch strength were compared. Data were collected on 25 hands in 23 patients, 7 hands with full trapezium resections and 18 with hemi-trapezium resections. The median age was 60 years, with a range of 39 to 73 years, and the median follow-up period was 1 year 11 months, with a range of 3 months to 11 years. Grip and pinch strength were measured pre- and postoperatively. Pain was assessed on a visual analog scale (VAS), and ADLs were assessed by means of a 15-item survey. Both pain and ADLs were evaluated postoperatively with recall of preoperative status. Following surgery, all thumbs were immobilized in a static splint for 3 weeks and then allowed progressive use. Median improvements in hemi-trapezium resections included grip, 22.5 lb; pinch, 4.7 lb; and ADLs, 33%. Pain was reduced a median of 7.0 cm on the VAS. Median improvements in full trapezium resection included grip, 29.5 lb; pinch, 0 lb; ADLs, 60%; and pain reduction, 8 cm on the VAS. This follow-up study suggests that satisfactory results can be achieved in pain reduction, strength, and ADLs with an immobilization period of only 3 weeks and without the use of K-wires following carpometacarpal (CMC) arthroplasty.

Long-term results of cemented Steffee arthroplasty of the thumb metacarpophalangeal joint

A retrospective evaluation of the Steffee metacarpophalangeal (MCP) thumb joint prostheses was performed to determine the long-term outcome and survivorship of the prosthesis. Fifty-four primary thumb arthroplasties (49 patients) were performed for pain, weakness, or instability involving the thumb MCP joint secondary to arthritis. Underlying etiology included rheumatoid (49 thumbs), psoriatic (1 thumb), scleroderma (2 thumbs), and degenerative (2 thumbs) arthritis. Thirty-one thumbs had concomitant interphalangeal joint instability and underwent interphalangeal joint fusions. At an average follow-up period of 57 months, the average motion of the MCP joint was 21 degrees (range, 0 degrees to 40 degrees ), with a significant improvement in position and stability. Thumb axis length was maintained or increased in 98%. Although there was not a consistent long-term improvement in grip or pinch strength, 87% of the patients reported subjective improvement in strength and function as a result of surgery. Pain was relieved in all thumbs with preoperative pain. Complications included a periprosthetic fracture, 2 late infections, and 1 gross loosening of the implant. The survivorship of the implant was 93% survivorship at 5 years and 89% survivorship at 10 years, with only 4 failures in 54 thumbs. The Steffee thumb MCP arthroplasty resulted in excellent long-term survivorship, patient satisfaction, and functional outcome.