Results of the cemented SR trapeziometacarpal prosthesis in the treatment of thumb carpometacarpal osteoarthritis

Total joint arthroplasty versus resection-interposition arthroplasty for thumb carpometacarpal arthritis: a randomized controlled trial

BACKGROUND AND PURPOSE

 Thumb carpometacarpal (TCMC) osteoarthritis is a common condition that causes pain and functional limitations. We compared the outcomes of 2 surgical procedures for TCMC osteoarthritis, the Epping resection-suspension arthroplasty and the double-mobility TCMC prosthesis, and focused on pain relief, functional outcomes, and patient quality of life.

PATIENTS AND METHODS

 Over a 7-year period a randomized controlled trial including 183 cases of TCMC osteoarthritis was conducted comparing a double mobility TCMC prosthesis (Moovis, Stryker, Kalamazoo, MI, USA) with the Epping resection-suspension arthroplasty. Pre- and postoperative examinations included the range of motion (ROM), SFMcGill score, visual analogue scale (VAS), the disabilities of the arm, shoulder and hand questionnaire (DASH), and the hospital anxiety and depression scale (HADS).

RESULTS

 At the 6-week postoperative follow-up, significant differences were found in VAS: Epping median 4.0 (interquartile range [IQR] 2.0-5.0) vs. TCMC prosthesis 2.0 (IQR 0.25-4.0), p = 0.03, effect size (area under the curve [AUC]) 0.64 (95% confidence interval [CI] 0.55-0.73), in DASH score: Epping 61 (IQR 43-75) vs. TCMC prosthesis 45 (IQR 29-57), p < 0.001, AUC 0.69 (CI 0.61- 0.78), and in radial abduction: Epping 55 (IQR 50-60) vs. TCMC prosthesis 62 (IQR 60-70), p = 0.001, AUC 0.70 (CI 0.61-0.79). No significant group differences were found at the 6- and 12-months follow-up. During the follow-up period, 3 of 82 prostheses had to be revised but there was no revision in the Epping group.

CONCLUSION

The double mobility TCMC prosthesis had superior outcomes compared with the Epping procedure at 6 weeks; however, there were no significant differences in outcomes at 6 months and 1 year postoperatively. The implant survival rate of 96% after 12 months was acceptable.

Arthroplasty in thumb trapeziometacarpal (CMC joint) osteoarthritis: An alternative to excision arthroplasty

Trapeziectomy for base of thumb arthritis is well established, but base of thumb arthroplasty offers potential advantages. The review covers the development of arthroplasty for the thumb from interposition arthroplasty to total joint replacement. It discusses contemporary prosthesis designs and results, including trapezial component geometry, bearing surfaces, and dual mobility.

Update on Thumb Basal Joint Arthritis Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance.

SUMMARY

Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

[A prospective Study about medium-term Results after autologous Fat Transplantation into arthritic CMC-I-joints]

PURPOSE

Prospective study to evaluate the midterm results after transfer of autologous fat into osteoarthritic CMC-I-joints.

PATIENTS AND METHODS

23 out of 27 patients (22 females and 5 men) with an average age of 59,8 (49-83) years with osteoarthritis of the CMC I joint were treated with a fat transfer into the damaged joints. The follow-up was 45,3 (39,3-50,9) months. 4 patients were excluded from the follow-up because of a resection arthroplasty in the meantime. Grip strength and pinch strength, DASH questionnaires and pain (VAS) were analysed.

RESULTS

The average pinch strength increased from preoperatively 3,7 kg to 5,1 kg postoperatively (p = .052). The average grip strength increased minimally from preoperatively 22,2 kg to 22,8 kg at follow-up (p = .506). The average DASH score improved significantly from preoperatively 50,8 to 29,6 postoperatively (p = 0,000). The average pain level decreased significantly from preoperatively 5,9 to 1,9 at follow up (p = .000). Patients with an advanced osteoarthritis of the CMC-I-joint had similar results as patients with a minor osteoarthritis.

CONCLUSION

The autologous fat transfer into the osteoarthritic CMC-I-joint showed in midterm follow-up good to very good clinical results regarding pinch strength, pain and DASH score. It is a safe minimal invasive promising alternative to accepted surgical therapies in the treatment of osteoarthritis of the CMC-I-joint.

Thumb CMCJ prosthetic total joint replacement: a systematic review

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

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

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

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

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

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

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

Joint replacement for trapeziometacarpal osteoarthritis: implants and outcomes

For thumb carpometacarpal osteoarthritis, trapeziectomy provides generally good results with reduction of pain and restoration of thumb mobility, but shortening of the thumb may at least in theory lead to reduction in grip and pinch strength. Furthermore, instability of the base of the first metacarpal and contact with the scaphoid may occur regardless of the several described techniques with ligament reconstruction and tendon interposition. Thus, for years alternatives to trapeziectomy have been explored and reported with disputable success. Often the road from idea to implantation in patients seems to have been short, and high complication rates and failure of new implant designs have been fairly common. This has led to the general impression that the implants do not provide sufficient benefits compared with simple trapeziectomy. More recent uncemented total joint replacement designs have shown rapid rehabilitation, reduction of pain, restoration of grip strength and movement, and much improved long-term implant survival. These factors may make total joint replacement a realistic alternative to trapeziectomy. Still, patient selection has to be improved, as the benefits may be small in the low activity elderly patient.

Trends in Trapeziometacarpal Implant Design: A Systematic Survey Based on Patents and Administrative Databases

Hand function is inseparably linked to the condition of the thumb. The trapeziometacarpal (TMC) joint that provides the different movements of opposition is one of the joints most affected by osteoarthritis, which causes an irreversible deformation of the bone. The ideal thumb carpometacarpal implant must restore range of movement, prevent complications, be biocompatible, and have good mechanical properties (ie, low wear, high corrosion resistance, and osteointegration properties where it is anchored in a bone). The integrity of the implant and the surrounding biological structures must be long-lasting and withstand constant stresses induced by the prosthesis. Three main types of implant systems for the thumb are currently clinically available; others are under investigation in human subjects. This systematic review is based on administrative databases, patents, the literature, and information from orthopedic companies. It provides a summary of strategies and design changes and an overview of the biomechanical characteristics of currently available carpometacarpal implants for treating osteoarthritis of the thumb.

Functional outcomes after surgery for thumb carpometacarpal joint arthritis

There are a number of possible assessments of functional outcomes for thumb carpometacarpal joint arthritis. The most important and easiest to measure is pain, but it is not the only material outcome. Functional scores for measuring the outcome of the treatment of thumb carpometacarpal joint arthritis have been recommended for some time, but are still not widely used even in published studies. It is also unclear which functional scores are the most valuable. Easily used scores, such as the Disabilities of the Arm Shoulder and Hand questionnaire, are freely available, but may not be sensitive enough to assess outcomes especially of thumb carpometacarpal joint arthroplasty. The optimal functional outcome measurement would be weighted for the individual patient. A minimum dataset needs to be defined in order to compare studies and derive meaningful data.

The effect of cup orientation on stability of trapeziometacarpal total joint arthroplasty: a biomechanical cadaver study

It has been suggested that the cup of a trapeziometacarpal total joint replacement should be positioned parallel with the proximal articular surface of the trapezium to align it with the centre of motion. This would diminish the chance of dislocation. The goal of this study was to test this idea biomechanically. A linked trapeziometacarpal prosthesis was implanted in seven cadaver hands and combined with three-dimensional printed trapezium cups in 17 different orientations. For every combination, stability of the prosthesis was assessed through its entire passive range of motion. Dorsal inclination of the cup relative to the proximal articular surface increased the risk of dislocation with thumb flexion and opposition. The risk of dislocation was also increased with lateral or medial inclination of the cup exceeding 20°. Our results demonstrate that cup orientation is an important factor in prosthetic joint stability. Cup placement parallel to the proximal articular surface is ideal.

Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review

PURPOSE

The purpose of the current review was to estimate failure rates of trapeziometacarpal (TMC) implants and compare against failure rates of nonimplant techniques for surgical treatment of TMC joint (basal thumb joint) arthritis.

METHODS

A systematic review was conducted to identify articles reporting on thumb implant arthroplasty and on nonimplant arthroplasty techniques for treatment of base of thumb arthritis in the English literature. The collected data were combined to calculate failure rates per 100 procedure-years. Failure was defined by the requirement for a secondary salvage procedure. The failure rates between different implant and nonimplant arthroplasty groups were compared directly and implants with higher than anticipated failure rates were identified.

RESULTS

One hundred twenty-five articles on implant arthroplasty and 33 articles on the outcome of nonimplant surgical arthroplasty of the TMC joint were included. The implant arthroplasty failure rates per 100 procedure-years were total joint replacement (2.4), hemiarthroplasty (2.5), interposition with partial trapezial resection (4.5), interposition with complete trapezial resection (1.7), and interposition with no trapezial resection (4.5). The nonimplant arthroplasty failure rates per 100 procedure-years were: trapeziectomy (0.49), joint fusion (0.52), and trapeziectomy with ligament reconstruction ± tendon interposition (0.23).

CONCLUSIONS

Several implant designs (arthroplasties) had high rates of failure due to aseptic loosening, dislocation, and persisting pain. Furthermore, some implants had higher than anticipated failure rates than other implants within each class. Overall, the failure rates of nonimplant techniques were lower than those of implant arthroplasty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Anatomic Pyrocarbon Hemiarthroplasty for Thumb Carpometacarpal Osteoarthritis in Patients under 65 Years: Mid Term Results

Background: To assess the midterm outcome of patients under 65 who underwent anatomic pyrocarbon hemiarthroplasty for thumb carpometacarpal (CMC) osteoarthritis.

Methods: A prospective analysis was performed of a consecutive series of active patients, less than 65 years of age, with symptomatic osteoarthritis who had undergone a CMC hemiarthroplasty using a stemmed metacarpal based, anatomic pyrolytic carbon resurfacing with an additional one third flexor carpi radialis (FCR) tendon transfer to maintain stability.

The Wrightington Hand Score, Disability Arm Shoulder and Hand (DASH) Score, and the Patient Rated Wrist Evaluation Score (PRWE) were utilised. Clinical data was obtained for grip strength, pinch strength, and range of motion.

Results: The MEAN age was 57.6 years. MEAN follow up was 6.5 years. All patients had improvement in pain, grip strength and function. There was no significant difference in grip and pinch strengths between the individual’s left and right hand. All patients stated that they would undergo the procedure again. There was one revision following a traumatic trapezium fracture. One patient underwent a neurolysis of a superficial radial nerve neuroma associated with an impinging trapezial osteophyte.

Conclusions: Active patients, under 65 years of age with Eaton-Littler stage III osteoarthritis of the thumb CMC joint who are treated with anatomic pyrolytic carbon resurfacing hemiarthroplasty and stabilisation may achieve sustained improvement in pain and hand function for up to 6.5 years.

Trapezium Bone Density-A Comparison of Measurements by DXA and CT

Bone density may influence the primary fixation of cementless implants, and poor bone density may increase the risk of implant failure. Before deciding on using total joint replacement as treatment in osteoarthritis of the trapeziometacarpal joint, it is valuable to determine the trapezium bone density. The aim of this study was to: (1) determine the correlation between measurements of bone mineral density of the trapezium obtained by dual-energy X-ray absorptiometry (DXA) scans by a circumference method and a new inner-ellipse method; and (2) to compare those to measurements of bone density obtained by computerized tomography (CT)-scans in Hounsfield units (HU). We included 71 hands from 59 patients with a mean age of 59 years (43–77). All patients had Eaton–Glickel stage II–IV trapeziometacarpal (TM) joint osteoarthritis, were under evaluation for trapeziometacarpal total joint replacement, and underwent DXA and CT wrist scans. There was an excellent correlation (r = 0.94) between DXA bone mineral density measures using the circumference and the inner-ellipse method. There was a moderate correlation between bone density measures obtained by DXA- and CT-scans with (r = 0.49) for the circumference method, and (r = 0.55) for the inner-ellipse method. DXA may be used in pre-operative evaluation of the trapezium bone quality, and the simpler DXA inner-ellipse measurement method can replace the DXA circumference method in estimation of bone density of the trapezium.

Implant Arthroplasty for Proximal Interphalangeal, Metacarpophalangeal, and Trapeziometacarpal Joint Degeneration

Arthritis of the hand can result from inflammatory arthritis, osteoarthritis (OA), or be posttraumatic and can cause pain and debilitation. Arthroplasty serves as 1 surgical option in the surgical management of arthritis and aims to create a pain-free joint with preservation of motion. Although implant arthroplasty of the proximal interphalangeal (PIP), metacarpophalangeal (MCP), and trapeziometacarpal (TMC) joints predictably produce pain relief and high satisfaction, it has historically suffered from high rates of complications. The hinged silicone prosthesis was 1 of the early implants and, in many cases, remains the gold standard. However, problems with deformity correction, implant fracture, and synovitis remain. Implants made of alternative materials such as metal-plastic and pyrocarbon have evolved; however, survivorship and reoperation rates remain a concern. This review details the evolution and current options available for small joint implant arthroplasty involving the MCP, PIP, and TMC joints.

Failure of an uncemented thumb carpometacarpal joint ceramic prosthesis

Thumb carpometacarpal joint replacement is associated with high rates of loosening and failure. We present our results for an uncemented ceramic-ceramic total joint prosthesis with a reverse ball-and-socket design and bioactive coating. Between 2008 and 2012, 29 prostheses were inserted into 28 patients (mean age 63 years) with advanced osteoarthritis. After a mean period of 33 months (range 9-62), 26 patients (27 implants) were available for follow-up. Six months postoperatively, 50% of the patients had radiological evidence of early loosening. Fifteen implants had been removed in 14 patients for aseptic loosening (13) or trapezium fracture (2). The 12 patients whose prosthesis was still in place had a mean visual analogue scale pain score of 1.9 (range 0-6) and a mean Disabilities of the Arm, Shoulder and Hand score of 23 (range 0-73.3). Eleven patients were satisfied with the procedure. The rate of early aseptic failure was unacceptably high.

LEVEL OF EVIDENCE

IV.

Pyrolytic Carbon Arthroplasty versus Suspensionplasty for Trapezial-Metacarpal Arthritis

Purpose This study aims to compare outcomes after pyrolytic carbon implant hemiarthroplasty (PH) versus Thompson suspensionplasty (TS) for trapezial-metacarpal (TM) arthritis. Patients and Methods There were 87 arthritic TM joints in 71 patients treated with PH (n = 47 joints, 37 patients) or TS (n = 40 joints, 34 patients). Patients had significantly longer follow-up in the TS group (86.9 months, 25th-75th percentile = 55.6-103.8) versus the PH group (38.4 months, 25th-75th percentile = 23.2-65.8, p < 0.001). Results PH patients maintained higher final grip strength (p = 0.03) and apposition pinch strength (p = 0.01) compared with TS patients. Nelson scores were significantly higher among patients undergoing PH (mean = 50.4, standard deviation [SD] = 24.5) compared with TS (mean = 36.8, SD = 12.5, p < 0.01). There was a significantly higher proportion of complications (p < 0.01), reoperations (p < 0.01), and joint revision surgery (p < 0.01) in patients undergoing PH compared with TS. Controlling for age and sex, there was a 72.8% lower risk of complications (p = 0.02), 87.7% lower risk of reoperations (p = 0.01), and 87.2% lower risk of joint revision surgery (p < 0.01) among patients undergoing TS compared with PH. There was a shorter time to first complication (p < 0.01), reoperation (p < 0.02), and joint revision (p < 0.01) in those undergoing PH compared with TS. Conclusion Both cohorts exhibited functional range of motion and pinch and grip strengths postoperatively, and those undergoing PH began with and maintained higher grip and pinch strength at final follow-up. Those undergoing PH had significantly increased risk of complications, reoperations, and joint revision surgery. Most complications in patients undergoing PH were related to suspected development of scaphotrapezotrapezoidal (STT) arthritis postoperatively. We thus recommend careful evaluation of possible STT arthritis when considering PH arthroplasty. Level of Evidence Level III.

WITHDRAWN: Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement). We did not find any studies that compared surgery with sham surgery or surgery with non-surgical interventions.Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery or to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Model-based roentgen stereophotogrammetric analysis of the surface replacement trapeziometacarpal total joint arthroplasty

The primary aim of this clinical and radiostereometric study was to study the migration pattern of the surface replacement trapeziometacarpal joint prosthesis (SR^TMTMC, Avanta^®, San Diego, CA). The secondary aims were to assess patient-related outcomes and prosthesis survival 5 years after surgery. Ten patients received the prosthesis. Radiostereometric radiographs were obtained 6 weeks, 6 months, 1 year and 5 years post-operatively and were analysed using model-based software. All patients completed DASH and Nelson Hospital scores at these follow-ups. Mean translations varied between 0.0 and 0.5 mm after 5 years. Rotation values could be calculated in six patients and mean rotations varied between -0.3 and 2.3°, although the precision of rotation values seems to be poor. The 5-year survival rate was 80%. Mean pre-operative DASH and Nelson Hospital scores were 53 (SD 14) and 51 (SD 13), respectively. Six months post-operatively, the DASH and Nelson Hospital scores had both significantly improved to 25 (SD 20) and 74 (SD 18) and remained high after 5 years. Implant stability was good 5 years post-operatively, and early migration did not predict implant failure in this study.

LEVEL OF EVIDENCE

IV.

Feasibility of model-based Roentgen Stereophotogrammetric Analysis to evaluate early migration of the trapeziometacarpal joint prosthesis

Background

The purpose of this study was to determine the feasibility of Roentgen Stereophotogrammetric Analysis (RSA) in total joint arthroplasty of the trapeziometacarpal (TMC) joint of the thumb.

Methods

In five cadaveric hands the TMC-joint was replaced by the Surface Replacement Trapeziometacarpal prosthesis (SR™ TMC prosthesis; Avanta, San Diego, CA) and tantalum beads of 0.8 mm were implanted for RSA. RSA radiographs in two directions were made in ten positions to calculate the measurement error. Migration values from zero are indicative for the measurement error. The number of detected markers was recorded.

Results

The accuracy analysis showed that for the translations the mean measurement error varied between 0.003 mm (SD 0.057) and 0.055 mm (SD 0.133). For the rotations values ranged from 0.034° (SD 1.759) to 0.502° (SD 1.617).

Conclusions

RSA analysis of the SR™ TMC prosthesis is feasible. The measurement error is good for the translations but high for the rotations. The latter is due to the close position of the markers relative to each other. Level of evidence III.

Thumb carpometacarpal joint total arthroplasty: a systematic review

Thumb carpometacarpal joint total arthroplasty has been undertaken for many years. The proponents believe the short-term outcomes are better than trapeziectomy and its variants, but the longer term complications are often higher. This systematic review of all peer reviewed articles on thumb carpometacarpal joint total arthroplasty for osteoarthritis shows that there are reports of many implants. Some are no longer available. The reported outcomes are very variable: for some there are good long-term outcomes to beyond 10 years ; for others there are unacceptably high early rates of failure. Overall the published evidence does not show that total arthroplasty is better than trapeziectomy and its variants yet there is a higher complication rate and significant extra cost of using an implant. Future research needs to compare total arthroplasty with trapeziectomy to assess short term results where the arthroplasties may be better, long-term outcomes and the healthcare and personal costs so that surgeons and patients can make fully informed choices about the treatment of symptomatic thumb carpometacarpal joint osteoarthritis.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. We excluded trials that compared non-surgical interventions with surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement).Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.We did not find any studies that compared any other combination of the other techniques mentioned above or any other techniques including a sham procedure.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery and we excluded studies that compared surgery to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Small joints replacement for hand osteoarthritis: a systematic review

INTRODUCTION

Small joints replacement is a valid treatment for moderate to severe osteoarthritis of the hand. Several design and materials are now available for prostethic procedures with very different clinical and functional outcomes.

SOURCES OF DATA

An online search was carried out using Medline, Cochrane and Google scholar online databases, searching for studies on small joints replacement in hand surgery.

AREAS OF AGREEMENT

Good functional and clinical outcomes can be achieved with silicone and pyrolitic carbon implants, either for trapeziometacarpal and metacarpophalangeal joints. In particular, the silicone spacer seems to be very effective for trapeziometacarpal osteoarthrosis, while the pyrolitic carbon total joint prosthesis produces excellent outcomes if used for metacarpophalangeal replacement. Major complications, such as persistent pain and implant loosening, have still a variable rate of occurrence.

AREAS OF CONTROVERSY

Heterogeneity in the methodology of the assessments in the studies reviewed and the implants and techniques involved makes it difficult to carry out a complete and effective comparative analysis of the data collected.

GROWING POINTS

Larger cohorts treated with the same implant should be investigated in better designed trials, to draw more clinically relevant conclusions from the evidences presented. Better methodology is also a goal to achieve, since the average Coleman Methodology Score measured for the articles included was 54.9 out of 100.

RESEARCH

More and better designed studies are needed to produce clear guidelines to define the better implant in terms of clinical outcomes, function and complications for trapeziometacarpal and metacarpophalangeal joints.

Partial trapeziectomy and pyrocarbon interpositional arthroplasty for trapeziometacarpal joint osteoarthritis: results after minimum 2 years of follow-up

A prospective study was undertaken to assess the outcomes of a series of patients treated using pyrocarbon implant arthroplasty after partial trapeziectomy for trapeziometacarpal joint osteoarthritis. We analysed the results of this procedure in 27 trapeziometacarpal joints of 25 patients. The mean follow-up interval was 34 months (range 26-52). The study showed that pyrocarbon interpositional arthroplasty provided excellent pain relief and high patient satisfaction. Overall function, according to disabilities of the arm, shoulder and hand (DASH) score, improved from 48 points preoperatively to 14 points at the last follow-up assessment. Key pinch strength recorded in the operated hands was comparable with the results obtained in the contralateral hand and in healthy individuals from the same population. No further operations were performed in the study group. Partial trapeziectomy with pyrocarbon arthroplasty may prove to be a successful option for the treatment of trapeziometacarpal joint osteoarthritis. Further long-term comparative studies are warranted.

Surgical treatment of trapeziometacarpal joint arthritis: a historical perspective

BACKGROUND

The trapeziometacarpal (TMC) joint's unique anatomy and biomechanics render it susceptible to degeneration. For 60 years, treatment of the painful joint has been surgical when nonoperative modalities have failed. Dozens of different operations have been proposed, including total or subtotal resection of the trapezium or resection and implant arthroplasty. Proponents initially report high levels of patient satisfaction, but longer-term reports sometimes fail to support initial good results. To date, no one procedure has been shown to be superior to another.

QUESTIONS/PURPOSES

This review sought to identify factors responsible for the development of many different procedures to treat the same pathology and factors influencing whether procedures remain in the armamentarium or are abandoned.

METHODS

I performed a nonsystematic historical review of English-language surgical journals using the key words "carpometacarpal arthritis", or "trapeziometacarpal arthritis", and "surgery" in combination with "history" using the PubMed database. In addition, bibliographies of pertinent articles were reviewed.

RESULTS

The factors that led to many surgical innovations appear to be primarily theoretical concerns about the shortcomings of previously described procedures, especially about proximal migration of the thumb metacarpal after trapezial resection. Longevity of a particular procedure seems to be related to simplicity of design, especially for prosthetic arthroplasty. The evolution of surgery for TMC joint arthritis both parallels and diverges from that in other joints. For example, for most degenerated joints (even many in the hand), treatment evolved from resection arthroplasty to implant arthroplasty. In contrast, for the TMC joint, the 60-year-old procedure of trapezial resection continues to be performed by a majority of surgeons; many modifications of that procedure have been offered, but none have shown better pain reduction or increased function over the original procedure. In parallel, many differently designed prosthetic total or hemijoint arthroplasties have been proposed and performed, again with as yet unconvincing evidence that this technology improves results over those obtained by simple resection arthroplasty.

CONCLUSIONS

Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. In the absence of evidence for the superiority of any one procedure, surgeons should consider using established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissue-engineered solutions are an important area of current research but have not yet reached the clinical trial stage.

Bone mineral density of the trapezium in osteoarthritic trapeziometacarpal joints

The aim of this study was to test the precision and reliability of measurements of the bone mineral density (BMD) of the trapezium in patients with osteoarthritic trapeziometacarpal joints using dual-energy X-ray absorptiometry scans and to assess whether there is an acceptable correlation between the BMD of the trapezium and that of the distal radius, for which normative data exist. We included 66 patients (52 women, 14 men) diagnosed with Eaton-Glickel stage II-IV osteoarthritis and a mean age of 59 years (range 40-77) in a prospective study. We found good intra- and inter-observer agreement of BMD measurements. Reliability was also good in repeated measurements. There was an indication of an increase in BMD with progression in the Eaton-Glickel stage. There was only a moderate correlation between the BMD of the trapezium and that of the radius.

A three-dimensional analysis of osteoarthritic changes in the thumb carpometacarpal joint

The purpose of this study is to gain a better understanding of the changes due to osteoarthritis (OA) occurring in the thumb carpometacarpal (CMC) joint by comparing quantitative geometrical measurements in computed tomography scans of healthy and pathological joints in various stages of OA. The measurements were (1) the subluxation of the metacarpal on the trapezium, (2) distance from the scaphoid centre to the metacarpal base, and (3) distance from the metacarpal base to the articulating surface of the trapezium. The three-dimensional position of three characteristic points on the metacarpal, trapezium, and scaphoid were detected in each of the 90 wrists we scanned. The distances between the points were compared by statistical analysis. With high accuracy, we have been able to confirm and quantify that subluxation occurs in the dorso-radial direction. A significant difference in trapezium height and joint space width was found between the OA and control groups. The results indicate how to restore the centre of rotation in surgical treatment of OA with total joint arthroplasty, but the clinical relevance of these findings has to be tested in further clinical studies.

Outcome comparison of primary trapeziectomy versus secondary trapeziectomy following failed total trapeziometacarpal joint replacement

PURPOSE

To compare the clinical outcome between secondary trapezial excision after failed total trapeziometacarpal joint replacement and primary trapeziectomy.

METHODS

Between October 2003 and July 2008, we performed 16 revision procedures in our institution because of failed trapeziometacarpal joint replacements. Of these patients, 15 were followed up. We compared clinical outcomes between this group and 15 patients treated with primary trapeziectomy in a matched-pair analysis. The matching criteria were sex, age, and time from surgery. The mean follow-up period was 48 months. We evaluated mobility (radial and palmar abduction, opposition, and Kapandji score), grip strength, and patient self-assessment (pain; satisfaction; Disabilities of the Arm, Shoulder, and Hand score; and activity restriction).

RESULTS

According to most of the clinical evaluation methods (range of motion and Kapandji score) and subjective assessments (pain; Disabilities of the Arm, Shoulder, and Hand), outcome did not differ considerably between the 2 study groups. In particular, the results of strength testing were not significantly different between groups.

CONCLUSIONS

The present study showed that the outcomes of secondary trapeziectomy after failed trapeziometacarpal joint replacement arthroplasty generally do not differ from the primary trapeziectomy results. Although it shows high revision rates in the literature, trapeziometacarpal total joint arthroplasty might be a treatment option. In the case of failure, the outcome of secondary trapeziectomy is comparable to that of primary trapeziectomy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Equally good fixation of cemented and uncemented cups in total trapeziometacarpal joint prostheses. A randomized clinical RSA study with 2-year follow-up

BACKGROUND AND PURPOSE

Cup failure is a recognized problem in total trapeziometacarpal (TM) joint prostheses; it may be related to poor fixation, which can be revealed by radiostereometric analysis (RSA). We compared the early implant migration of cemented trapezium cups to that of uncemented screw cups.

PATIENTS AND METHODS

In a prospective, parallel-group, randomized patient-blinded clinical trial, we included 32 hands in 28 patients (5 males) with a mean age of 58 (40-77) years and with Eaton stage-2 or -3 osteoarthritis of the trapeziometacarpal joint. Patients were randomized to surgery with a cemented DLC all-polyethylene cup (C) (n = 16) or an uncemented hydroxyapatite-coated chrome-cobalt Elektra screw cup (UC) (n = 16). Uncemented cups were inserted without threading of the bone. Stereoradiographs for evaluation of cup migration (primary effect size) and DASH and pain scores were obtained during 2 years of follow-up.

RESULTS

The 2-year total translation (TT) was similar (p = 0.2): 0.24 mm (SD 0.10) for the C (n = 11) and 0.19 mm (SD 0.16) for the UC (n = 11). Variances were similar (p = 0.4). Judged by RSA, 2 UC cups and 1 C cup became loose (TT > 1 mm). Both UC cups were found to be loose at revision. Grip strength, pain, and DASH scores were similar between groups at all measurement points.

INTERPRETATION

Early implant fixation and clinical outcome were equally good with both cup designs. This is the first clinical RSA study on trapezium cups, and the method appears to be clinically useful for detection of loose implants.

Computed tomography improves intra-observer reliability, but not the inter-observer reliability of the Eaton-Glickel classification

This study aimed to evaluate whether computed tomography improves the intra- and inter-observer reliability of the Eaton-Glickel classification of trapeziometacarpal joint osteoarthritis. The osteoarthritis of the trapeziometacarpal joint was evaluated with conventional radiographs and computed tomography by two hand surgeons, two registrars and one radiologist in 50 hands of 43 patients (12 male and 31 female) who had a median age of 60 years (46-80). Using plain radiographs, we found a mean intra-observer reliability of 0.54 (0.51-0.74), and the intra-observer reliability was improved to 0.76 (0.64-0.86) using computed tomography. Using plain radiographs, the mean inter-observer reliability was poor at 0.17 (0.04-0.51) and did not improve using computed tomography with a mean inter-observer reliability of 0.22 (0.02-0.38). In particular, the agreement in the distinction between Eaton-Glickel stage III and IV and the evaluation of the degenerative changes in the scaphotrapezio joint was low using computed tomography-scans. The detection of bone cysts on computed tomography was more precise than on plain radiographs.

Trapezium prosthetic arthroplasty (silicone, Artelon, metal, and pyrocarbon)

Trapezium prosthetic arthroplasty has been utilized to treat basal joint arthritis for nearly five decades in an attempt to mitigate some of the potential disadvantages of trapeziectomy while preserving range of motion. Implant arthroplasty seeks to preserve joint biomechanics, avoids metacarpal subsidence, and should provide immediate stability. These benefits may lead to improvements in strength, durability, and a decrease in metacarpophalangeal joint hyperextension which can occur subsequent to metacarpal shortening. First generation implants were primarily silicone trapezial spacers. While the use of these implants has been curtailed by their association with silicone synovitis, they still remain an option for low demand, rheumatoid patients. More recently developed synthetic spacers such as Artelon interposition arthroplasties have had results inferior to more established procedures including trapeziectomy. A variety of metal total joint prostheses have been developed and some of the more recent designs have shown good short-term outcomes. There are a number of different pyrocarbon implants that have become more recently available which range from trapezial substitution to non-anatomic hemiarthroplasty. Pyrocarbon arthroplasty offers a number theoretical advantages however early results have been mixed and further long term data is required.

[Isis(®) trapeziometacarpal prosthesis in basal thumb osteoarthritis: 30 months follow-up in 30 cases]

OBJECTIVES

The goal of our work was to evaluate the results of the Isis(®) trapeziometacarpal prosthesis.

METHODS

Our retrospective study included 26 patients, 30 prosthesis. The mean follow-up was 30 months. Preoperatively, the pain was 8.1 out of 10, the QuickDASH was 68.5 and the average Kapandji score was 7.8. The Dell's stage was 2.3. The prosthesis used was hybrid: the trapezial cup was cemented in 90% of cases, and the metacarpal stem was cementless.

RESULTS

Eighty-seven percent of patients were satisfied or very satisfied. At last follow-up, the pain was 3.4 out of 10, the QuickDASH was 37.8, and the average Kapandji score 9.1. The range of motion in flexion-extension and abduction-adduction were respectively 30.5° and 31.7±11°. The strength of the key-pinch, pulp-pinch and grasp averaged 75% of the contralateral side. On radiologic review, the rate of radiolucent lines was 20%, and the loosening or non-osteointegration rate 10%. No dislocation was noted. One surgical revision was necessary for symptomatic metacarpal non-osteointegration. The survival rate of the prosthesis was 93% at 42 months.

DISCUSSION

Clinical results are good. However, the rate of abnormal radiographic images (30%) at 30 months follow-up must incite caution. Although these prosthetic loosenings seem to be less symptomatic, a longer follow-up is necessary to assess the sustainability of clinical results and the future of these periprosthetic radiolucent lines. This led us to change our practice to using noncemented prostheses from now on.

Functional patterns of thumb key pinch and their influence on thumb strength and stability

Introduction

Trapeziometacarpal osteoarthritis (TMC OA) is a common condition frequently related to instability and hypermobility. Many factors are involved in the development of this degenerative process. Recent research suggests that the position of the metacarpophalangeal (MCP) joint may influence TMC joint contact wear patterns and subsequent development of OA. The aim of this study is to explore the alignment of the MCP joint of the thumb during lateral pinch in order to describe the naturally occurring alignment in a group of healthy volunteers without symptoms.

Methods

One hundred and nine participants were asked to apply a lateral pinch manoeuvre to a pinchmeter, while their thumbs were assessed. Passive hypermobility of the thumb MCP (MCP) joint was assessed, key pinch strength was measured, key pinch position was photographed and the angle of the joints during the assessment was measured.

Results

Four different functional pinch patterns were identified. The most frequent pattern seems to be MCP hyperextension described by Moulton as harmful for the TMC joint. The level of strength obtained did not correspond to the pinch pattern used, and hypermobility of the thumb MCP joint did not determine the position of the thumb during key pinch.

Conclusion

Four different thumb postures were identified during lateral pinch; however, these postures were not associated with any difference in pinch strength. We conclude that the more unstable and mechanically inefficient postures are compensated by functional capacity.

High frequency failure of the Moje thumb carpometacarpal joint arthroplasty

Arthroplasty is one of several options for treating symptomatic osteoarthritis of the thumb carpometacarpal joint. There are various hemi- and total arthroplasties available on the market. We report our experience of treating 12 patients with the Moje Acamo CMC1 prosthesis. We reviewed all the patients at a mean of 50 months postoperatively. All patients presented with loosening, migration or tilting of one or both implant components. Nine patients were symptomatic enough to warrant revision surgery with removal of the implant leaving a pseudarthrosis. At the last follow-up, five patients (42%) had already received revision surgery. All patients still possessing an implant showed progressive signs of implant loosening, although some of them had no symptoms. In order to assess their overall disadvantage compared with patients treated by primary trapeziectomy, the outcomes of these two groups were compared (matched pairs). The outcomes after revision surgery were comparable with those of primary trapeziectomy. We no longer use the Moje Acamo CMC1 implant and recommend that patients who have received this implant should be monitored carefully both clinically and radiologically.

Fixation of trapezial implants in a trapeziometacarpal total joint prosthesis tested in a model of porcine bone

High aseptic loosening rates have been reported in total joint prostheses of the carpometacarpal joint of the thumb, particularly in the trapezial component. The primary fixation of new implants may be tested in cadaver bones, but the anatomy of the pig is in many ways similar to that of the human, so we compared the central carpal bone from the forefoot of 6-month-old pigs, which has a saddle joint surface similar to the trapezium, to the trapezium in patients with carpometacarpal osteoarthritis. The mean (SD) bone mineral density of the 13 pig forefoot bones was 0.88 (0.12) g/cm(2) compared with 0.63 (0.16) g/cm(2) in the 31 human trapeziums. The measured size of the porcine bones was slightly larger than that of the human trapeziums. The similarity in form, size, and bone mineral density means that the central bone of the forefoot of 6-month-old pigs may be used for fixation tests in trapezial implants.

EARLY FUNCTIONAL IMPROVEMENT AFTER A MODIFIED LIGAMENT RECONSTRUCTION TENDON INTERPOSITION ARTHROPLASTY FOR THUMB BASAL JOINT ARTHRITIS

Many modifications to trapeziectomy have been proposed for the treatment of thumb basal joint arthritis. Their final outcomes have been discussed intensively, whereas functional changes in the early post-operative period have not been fully documented. The purpose of the present study is to evaluate an early functional change following our modified ligament reconstruction with tendon interposition (LRTI) arthroplasty. Nine patients (ten thumbs) were included in this study. Pain levels, strength, and mobility were assessed before and after surgery at intervals of two months. Pain level significantly improved at two months after surgery. Grip and pinch strengths had increased gradually after a temporal decrease at two-month follow-up, and were significantly stronger at six months after surgery. Palmar abduction improved significantly at six months after surgery, whereas opposition did not change significantly. A modified LRTI is an effective procedure in terms of early functional improvement of pain, strength, and mobility.

Primary cup fixation with different designs of trapeziometacarpal total joint trapezium components: a radiostereometric analysis in a pig bone model

High loosening rates of the trapezium components of trapeziometacarpal total joint prostheses have been reported. The purpose of this study was to compare the primary press fit fixation of two different, uncemented cup designs (MOTEC and Elektra) with the primary fixation of a cemented polyethylene cup (DLC) in a pig bone model. We did a push out test to measure the maximal load strength of the implants and a low-pressure cyclic loading test combined with radiostereometric analysis to measure the micromotion of the implants. There was no significant difference in fixation strength between the two uncemented screw cup designs or between the two uncemented screw cups and the cemented polyethylene cup. However, we found that threading of the bone before insertion of the Electra screw cup weakens the primary fixation strength of the implant. The results indicate that focus should be on the insertion technique as well as on the cup design of uncemented trapezium cup implants. Further studies of trapezium implant migration in a clinical setting are needed.

[Osteoarthritis of the trapeziometacarpal joint in men: different stakes. Results of three surgical techniques]

Basal thumb arthritis is less common in men, but the functional implication is different in this manual worker or active retired population. The objective was to analyse the results of three surgical procedure in an exclusively men's population. Twenty-eight patients (19 partial trapeziectomy with interposition of a chondrocostal autograft, seven total trapeziectomy and two prosthesis), with a mean age of 69 years old, were reviewed at a mean follow-up of 71 months. Mobility and pain were similar in the three populations. But the strength and Dash scores were better in the cartilage group. Radiologically the length of the thumb ray was greater in the cartilage group and no signs of loosening were observed in the prosthesis group. The surgery of reference in this population is the arthrodesis of the trapeziometacarpal joint. But the lack of mobility is disabling, the strength is questionable and painlessness varies due to high rates of non-union. Only one study compared four surgical procedures in an exclusively male population and total trapeziectomy seemed to give the best results. But this technique carries risk of shortening of the thumb ray. Even if the comparison is difficult, the association of partial trapeziectomy with interposition of costal cartilage graft seems to give better stability to the thumb column by preserving length as well as greater strength compared to total trapeziectomy. We advocate this procedure for basal thumb arthritis in men.

Failed total carpometacarpal joint prosthesis of the thumb: results after resection arthroplasty

Total joint prosthesis in carpometacarpal joint arthritis of the thumb often fails. Loosening of the implant is often treated by resection arthroplasty, and we reviewed 10 patients, mean age 54 years (range 47-63) who were treated by resection arthroplasty after a failed total joint prosthesis. The male:female ratio was 1:4 and the mean duration of observation 32 months (range 6-52). In three patients the revised implant was a MOJE uncemented carpometacarpal joint prosthesis and in seven patients an Elektra uncemented one. At follow-up grip strength was reduced to less than 90% of the other hand in eight of 10 patients, but the mean Disabilities of the arm, shoulder, and hand (DASH) scores, self-reported pinch-grip-related function, and pain were comparable with our earlier published results with the Elektra carpometacarpal total joint prosthesis.

Implant arthroplasty of the carpometacarpal joint of the thumb

Resection arthroplasty with or without ligament reconstruction for thumb trapeziometacarpal arthritis can be complicated by thumb shortening and pinch-strength weakness. Implant arthroplasties have been developed to limit loss of thumb length, improve strength, and limit postoperative convalescence. The ideal thumb carpometacarpal implant should be strong and stable, provide full range of motion, and prevent loosening. Unfortunately, no current prosthesis accomplishes all of these goals. Until the ideal implant is developed, clinical acumen must be used to determine appropriate patients and implants.

Trapeziometacarpal joint implants can be evaluated by roentgen stereophotogrammetric analysis

Both marker-based roentgen stereophotogrammetric analysis (RSA) and model-based RSA have been helpful evaluation tools in hip and knee arthroplasty. The purpose of this study was to test both model-based and marker-based RSA in the evaluation of total joint prostheses of the trapeziometacarpal joint. In a phantom study, the precision of marker-based RSA was tested with a cemented polyethylene cup and compared with the precision of model-based RSA in an uncemented Elektra screw cup. The precision of model-based RSA of the metacarpal stem was tested using an uncemented Elektra metacarpal stem. In a clinical study 11 patients had double stereo radiographs followed by RSA analysis. The precision of translation in both marker-based and model-based RSA was sufficient for clinical use, but rotation cannot be estimated with sufficient precision.

A cemented surface replacement prosthesis in the basal thumb joint

PURPOSE

The purpose of this study was to evaluate a cemented prosthesis (Avanta SR TMC prosthesis; Avanta Orthopaedics, San Diego, CA) of the basal thumb joint on the outcomes of range of motion, strength, pain, function, and loosening.

METHODS

Between July 2004 and December 2007, a total of 15 prostheses in 13 patients were implanted, with an average follow-up period of 36 months (range, 21-63 mo). Before and during the follow-up, the following scores were recorded: Kapandji-score (range of opposition), strength (hand dynamometer and pinch meter), pain (sequential occupational dexterity assessment [SODA], and Michigan Hand Outcomes Questionnaire [MHQ]) and function (9-hole peg test, SODA and MHQ). Radiographs taken before and after surgery were reviewed.

RESULTS

The measurements of range of opposition and strength did not show any significant postoperative improvement. Pain during activities (SODA) decreased significantly, and the function with both hands (SODA and MHQ) improved significantly after surgery. The review of pre- and postoperative radiographs did not show any signs of implant loosening after surgery. One failure and one nerve injury occurred.

CONCLUSIONS

In this group of patients, the Avanta SR TMC prosthesis provided statistically significant improvements in function with both hands and in pain during activity, but no significant change in range of motion, strength, or in function of the operated hand used alone. Prosthesis loosening was not detected.

The Artelon CMC spacer compared with tendon interposition arthroplasty

BACKGROUND AND PURPOSE

The Artelon CMC spacer is designed for surgical treatment of osteoarthritis (OA) in the carpometacarpal joint of the thumb (CMC-I). Good results using this degradable device were previously presented in a pilot study. We now present results from a larger randomized, controlled, multicenter study.

PATIENTS AND METHODS

109 patients (94 females) with a mean age of 60 (42-83) years, suffering from painful CMC OA, were included in the study at 7 centers in Sweden. The patients were randomized to Artelon CMC spacer (test, n = 72) or tendon arthroplasty (control, n = 37) at a ratio of 2:1. Perceived pain was recorded on a visual analog scale (VAS) before treatment and after 3, 6, and 12 months, when measuring maximal tripod pinch strength (primary outcome measure). In addition, range of motion, radiographic findings, and functional testing were recorded pre- and postoperatively.

RESULTS

Swelling and pain were more common in the test group and 6 implants were removed because of such symptoms. 5 of these patients did not receive antibiotics preoperatively according to the study protocol. In a per-protocol analysis, i.e. patients without signs of concomitant OA in the scaphoid-trapezium-trapezoid (STT) joint and those in the test group who received antibiotics, the mean difference in tripod pinch strength increase, adjusted for baseline, was 1.4 kg in favor of the test group (not statistically significant). Statistically significant pain relief was achieved in both groups, with perceived pain gradually decreasing during the follow-up period. In the intention-to-treat analysis but not in the per-protocol analysis, significantly better pain relief (VAS) was obtained in the control group. Patient-perceived disability evaluated by the DASH questionnaire improved in both groups.

INTERPRETATION

The Artelon CMC spacer did not show superior results compared to tendon interposition arthroplasty. Proper use of preoperative antibiotics and a thorough patient selection appear to be important for the results.

Surface replacement trapeziometacarpal joint arthroplasty--early results

This study reviews the results of Surface Replacement Trapeziometacarpal (SR TMC, Avanta, San Diego, CA) total joint arthroplasty. Fifty patients (62 joints) were included in the study. Forty-three patients (54 joints) were seen at final follow up. Seven patients (eight joints) were interviewed over the phone. Seven patients were revised to trapeziectomy and ligament reconstruction with tendon interposition, five for aseptic loosening and two for dislocation. At final follow up, the mean Quick DASH score was 30.4 and the Sollerman Score was 77.3. Radiological review of the surviving 55 joints showed subsidence of four trapezial components in asymptomatic patients. Cumulative survival rate was 91% at 3 years. Eighty-five percent of the patients were satisfied with the outcome of their treatment.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

This is an update of a Cochrane Review first published in 2005. Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To compare the effect of different surgical techniques in reducing pain and improving physical function, patient global assessment, range of motion and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, to investigate whether there was any improvement or deterioration in outcomes between the 12-month review and five year follow up.

SEARCH STRATEGY

We searched:(CENTRAL) (The Cochrane Library 2008, issue 1), MEDLINE (1950 to Dec 2008), CINAHL (1982 to Dec 2008), AMED (1985 to Dec 2008) and EMBASE (1974 to Dec 2008), and performed handsearching of conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Randomised or quasi-randomised trials where the intervention was surgery and pain, physical function, patient global assessment, range of motion or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse effects. We contacted trial authors for missing information.

MAIN RESULTS

We included nine studies involving 477 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint resurfacing, arthrodesis and joint replacement). Studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement for pain and physical function. The majority of studies included in this review had an unclear risk of bias which raises some doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment or range of motion. Of participants who underwent trapeziectomy with ligament reconstruction and tendon interposition, 22% had adverse effects (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1)) compared to 10% who underwent trapeziectomy. Trapeziectomy with ligament reconstruction and tendon interposition is therefore associated with 12% more adverse effects (RR = 2.21, 95% CI 1.18 to 4.15).

AUTHORS' CONCLUSIONS

Although it appears that no one procedure produces greater benefit in terms of pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy has fewer complications than trapeziectomy with LRTI.

Long-term durability of tendon arthroplasty with excision of the trapezium in stage 1 osteoarthritis of the thumb CMC joint

Basal joint arthritis of the thumb is commonly treated surgically. Although the results are good, there is still controversy regarding the treatment of young people with low radiographic stages of disease. Our purpose was to evaluate the durability of a tendon arthroplasty procedure in this population. Thirty patients aged 55 years or under, with early stage arthritis, were evaluated. Eight patients were available for long-term (average 86 months) follow-up. No deterioration in the strength and mobility of the operated thumbs in the long-term was found. There was a significant increase in tip pinch strength between short- and long-term follow-up evaluations. This study supports the durability of this surgery in younger patients, potentially reducing the need for multiple surgeries.

Elektra trapeziometacarpal prosthesis for treatment of osteoarthrosis of the basal joint of the thumb

The first reports about treating osteoarthrosis of the trapeziometacarpal (TMC) joint with the Elektra prosthesis were encouraging. Based on those, we operated on 17 hands in 16 patients with Eaton stage 3+4 osteoarthritis of the TMC joint using the Elektra hydroxyapatite-coated uncemented TMC prosthesis. There were 15 women and one man, mean age 54 years (range 40-70). At follow-up after 35 months (range 22-52), four patients had been reoperated on because of aseptic loosening of the screw cup with migration and progressive pain. Two other patients have been revised because the implant had to be removed for other reasons. At radiological follow-up in the 11 other patients, one cup had migrated and was clearly loose, leaving 10 implants with no sign of failure. Part of this mediocre result may be explained by the learning curve, but more studies are needed to confirm the excellent results obtained elsewhere with the Elektra prosthesis, and we advise others to monitor their results carefully when using this implant. Studies comparing joint replacement with resection arthroplasty are also needed.

Second generation GUEPAR total arthroplasty of the thumb basal joint: 50 months follow-up in 84 cases

BACKGROUND

Osteoarthritis of the thumb basal joint is the most common location for hand degenerative joint disease. First, carpometacarpal (CMC) joint arthroplasty is one treatment option. The purpose of this article is to present the outcome of the GUEPAR II prosthesis, a total trapeziometacarpal cemented implant of the retaining ball-and-socket design type. Numerous other advantageous features of this implant, second generation of an earlier version are explored.

HYPOTHESIS

Clinical and radiological results confirm the GUEPAR II trapeziometacarpal arthroplasty as a reliable and efficient evolution of earlier prosthetic designs.

MATERIALS AND METHODS

Eighty-four GUEPAR II prostheses were implanted to treat advanced and severely incapacitating first CMC osteoarthritis. The average follow-up time in this collaborative series (from 2 centers) was 50 months.

RESULTS

There were no intraoperative complications and no dislocations at the final follow-up evaluation, 92% of patients were satisfied or very satisfied with their results with objective improvement of their Kapandji score. Strength was closely comparable to the nonaffected side. Radiographic studies at the final follow-up evaluations did not show (except in one socket revision instance) signs of implant loosening. On occasion, non-progressive radiolucent lines were observed. More than 80% of the patients remained pain free.

CONCLUSIONS

In our series, GUEPAR II total joint arthroplasty of the thumb CMC joint has proven to be efficacious, improving motion, strength, and achieving a high degree of pain relief. Successful outcome appears in our experience contingent upon strict compliance with numerous surgical technique details. Current research focuses on improving bipolar fixation by developing press-fit cementless implants.

Early outcomes of pyrolytic carbon hemiarthroplasty for the treatment of trapezial-metacarpal arthritis

PURPOSE

Pyrolytic carbon implants have been successfully used in the treatment of osteoarthritis of the metacarpophalangeal and proximal interphalangeal joints. Recently, pyrolytic carbon hemiarthroplasties have been proposed for the treatment of osteoarthritis of the trapezial-metacarpal (TM) joint of the thumb. We wished to review our short-term outcomes for this device in the treatment of TM arthritis.

METHODS

Fifty-four arthritic TM joints in 49 patients, with a mean age of 59 years, were treated with use of a pyrolytic carbon hemiarthroplasty procedure. Underlying diagnoses included osteoarthritis in 44 thumbs, rheumatoid arthritis in 8 thumbs, psoriatic arthritis in 1 thumb, and juvenile rheumatoid arthritis in 1 thumb. The patients were followed up clinically as well as radiologically for an average of 22 months postoperatively.

RESULTS

The overall 22-month survival rate excluding scaphotrapezio-trapezoidal joint arthritis was 80% according to a Kaplan-Meier analysis. Ten metacarpal subluxations were observed. Seven of these cases were salvaged by increasing the depth of the trapezial cup. A total of 15 reoperations were required in this cohort. No complications were seen in the patients with inflammatory arthritis. Thirty-five patients were pain free at the latest follow-up, and 6 reported mild to occasional pain with repetitive activities. The overall satisfaction rate was 40 of 49 patients (81%). Grip strength recovered to 86% of that of the contralateral side. Apposition key and opposition pinch strength improved to 92% and 95%, respectively, of those of the contralateral hand.

CONCLUSIONS

Pyrolytic carbon thumb arthroplasty may prove to be an acceptable option for the treatment of TM, although a high complication rate was observed in this early cohort, with many cases of subluxation attributed to the creation of a too shallow trapezial cup. Further comparative studies are warranted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995-2005

There are numerous techniques for the surgical management of thumb carpometacarpal (CMC) joint arthritis. The four senior authors of this study employ three such techniques: trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition (LRTI). This study examines the three commonly utilized procedures at a single institution. This study examines the 10-year experience from 1995-2005 with a minimum 3-month follow-up. Disabilities of the arm, shoulder, and hand (DASH) scores, pre-and postoperative pinch strength, and operative time were examined. After approval from the institutional review board of our institution was obtained, all patients treated surgically by three of the senior authors were contacted via mail and phone. Each patient was asked to complete and return a DASH questionnaire. Of the 115 patients treated during that period, 60 participated in this study. Each patient's final postoperative pinch measurement was obtained from occupational therapy and clinic records. This pinch strength was compared to the preoperative pinch and contralateral pinch strength. Lastly, the total operative time for each procedure was obtained from the operative record. The only significant finding in this study was a shorter mean operative time with the trapeziectomy group (76.90 min) and osteochondral allograft group (90.45 min) when compared to the LRTI group (139.00 min; p = 0.001 and p = 0.001, respectively). We found no significant difference between groups in terms of DASH score and pinch strength. There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of the LRTI. This presents further evidence that potentially, "less is more" in the treatment of thumb CMC arthritis. We used a retrospective study design to evaluate potential differences between the three surgical techniques described above, therapeutic, levels III-IV.