Outcome of uncemented trapeziometacarpal prosthesis for treatment of thumb carpometacarpal joint arthritis

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

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

Dislocation in Single-Mobility Versus Dual-Mobility Trapezometacarpal Joint Prostheses

BACKGROUND

The purpose of this study was to analyze postoperative dislocation rates in single-mobility (Ivory) versus dual-mobility (Moovis) trapezometacarpal (TMC) joint prostheses. Second, we report complications requiring additional surgery in these 2 types of prostheses.

METHODS

We retrospectively obtained data of all patients receiving a TMC joint prothesis at our hospital between January 2015 and December 2020. We recorded the type of implant used (ie, single vs dual mobility; Ivory vs Moovis), and recorded dislocations and complications requiring additional surgery.

RESULTS

We recorded significantly more prosthetic dislocations in the single-mobility (Ivory) group (n = 6, 9.7%), compared with the dual-mobility (Moovis) group (n = 1, 1.4%). The most frequent complication requiring additional surgery was De Quervain tendinitis (n = 13, 9.6%).

CONCLUSIONS

This study shows that a dual-mobility TMC prosthesis has significantly less postoperative dislocations compared with its single-mobility counterpart. We identity De Quervain tendinitis as the most frequent complication requiring additional surgery.

Mid- and long-term clinical results of the Elektra and Moovis prosthesis for trapeziometacarpal joint replacement

BACKGROUND

Total joint arthroplasty as a surgical treatment option for trapeziometacarpal joint arthritis is recently revived. The aim of this study is to report on mid- and long-term results of the Elektra (single-mobility) and Moovis (dual-mobility) prosthesis for treatment of primary thumb carpometacarpal joint arthritis.

METHODS

In this retrospective, monocentric, descriptive cohort study, 31 prostheses were evaluated that were implanted by a single surgeon in 26 patients between 2009 and 2019. Indication for surgery was trapeziometacarpal joint osteoarthritis (Eaton/Littler Stage II and III). Clinical and radiological follow-up was performed at a minimum of 24 months. The postoperative assessment included range of motion, pain, strength as well as functional scores (DASH, MHQ). Implant survival and complications were the primary endpoints.

RESULTS

10 Elektra and 21 Moovis prostheses were implanted between 2009 and 2019 with a mean follow-up of 74.2 months in the Elektra and 41.4 months in the Moovis group. The average patients' age at surgery was 64 years. Postoperative pain levels (VAS 0-10) were below 2 at rest and under stress in both groups. Grip/pinch strength and range of motion showed results comparable to the contralateral hand. Opposition was excellent with an average Kapandji index of 9.6 in both groups. Elektra achieved slightly better functional scores in the DASH and MHQ score. Satisfaction was high in both groups, and 96% of the patients would recommend the procedure. Metacarpophalangeal hyperextension > 15° was seen in 3 patients per group preoperatively and was corrected to < 5° post-surgery. 3 Elektra prostheses were revised due to cup loosening and dislocation for cup and/or neck replacement or secondary trapeziectomy. 1 Moovis prosthesis was revised with an exchange of the neck to a larger size due to restricted movement. After the mean follow-up of 7.9 years in Elektra and 3.5 years in MOOVIS, cumulative survival was 68.6% vs. 95.2%, respectively.

CONCLUSIONS

In this mid- to long-term retrospective analysis, total joint arthroplasty in primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility and clinical function. Patient satisfaction is overall high. While revision due to cup loosening occurred more often in patients with single-mobility implants, no cases of dislocation or loosening of components were observed in the dual-mobility group.

TRIAL REGISTRATION

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of the Medical Faculty of Heidelberg University, reference number S-150/2020.

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.

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

Trapeziometacarpal prosthesis: an updated systematic review

The trapeziometacarpal prosthesis is mostly used in Europe to treat osteoarthritis of the basal joint of the thumb. Its supposed benefits are that it restores the length of the thumb, improves strength, function and mobility while reducing recovery time compared to other surgical treatments. However, previous reviews of the literature could not confirm these assumptions. This article provides an updated systematic review to help answer to these questions through a methodical statistical analysis and to quantify the two main complications, namely failure and deep infection. To achieve these aims, a selection of articles including implant case series was done in the Medline database based on specific criteria. Data about pain, function, strength, infection, and failure were compiled and a statistical analysis was performed. Results show a fast recovery in terms of pain and function but the positive effect on strength seems limited. The failure rate represented by the revision rate is high and the deep infection rate is fairly low. Randomized controlled studies are needed to obtain reliable data to compare the prosthesis to other surgical treatments.

Early Cup Loosening After Metal-on-Metal Total Joint Replacement of the Trapeziometacarpal Joint: A Retrieval Study

PURPOSE

To investigate the possible mechanisms behind early cup loosening in a metal-on-metal trapeziometacarpal joint replacement.

METHODS

The trapezia from 5 female patients were removed as part of a salvage procedure after a median of 22 months (range, 7-43 months) after implantation. Three osteoarthritic patients with symptomatic cup loosening and 2 with instability had a median age of 62 years (range, 59-65 years) at primary surgery. The trapezia with cups in situ were preserved and processed for histomorphometry. Studies with laser ablation inductively coupled plasma mass spectrometry and scanning electron microscopy with energy dispersive x-ray spectroscopy were also performed on 2 of the specimens.

RESULTS

In all 5 specimens, osteolytic lesions undermined the cups and were also seen at the cup edges, completely surrounding the loose cups. Large amounts of dark particular material were seen in the periprosthetic tissues, mostly internalized by macrophages. The presence of chrome and cobalt in these regions was confirmed. Four of the 5 cups showed marked or complete loss of hydroxyapatite.

CONCLUSIONS

We have found several possible explanations for the poor performance of this cup, including its cannulated design and metal-on-metal bearing. The changes seen are early and advanced, raising serious concerns about the implant and particularly the articulation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

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.

Current trends in the management of trapeziometacarpal arthritis

The purpose of this update is to report on a variety of topics related to trapeziometacarpal arthritis that have been recently investigated. The keyword trapeziometacarpal arthritis was utilized to query the PubMed database of the U.S. National Library of Medicine. From the resulting list, papers published from the beginning of April 2014 through the beginning of April 2017 were reviewed. The forty-five studies identified are reviewed here and referenced.

Preexisting Carpal and Carpometacarpal Osteoarthritis Has No Impact on Function after Distal Radius Fractures

Background  Functional outcomes of distal radius fractures vary widely regardless of treatment methods. Purpose  This study aims to verify whether preexisting carpal and carpometacarpal (CMC) osteoarthritis (OA) will negatively impact wrist functional outcome in patients with distal radius fractures. Patients and Methods  A retrospective case-control study was done using a prospective trauma database. Patients were matched 1:1 in two groups based on the presence of wrist or carpal arthritis (OA). The groups were matched for sex, follow-up, and treatment type. Patients were followed up for a minimum of 1 year and functional outcomes were assessed using validated scores. Results  A total of 61 patients were included. Mean age was 63 years (range: 20-85) and average follow-up was 26 months. There were 31 patients in the OA+ group and 30 in the OA- group. Forty-one patients were treated surgically and 20 nonoperatively. None of the patients in the OA- developed OA during follow-up. Both groups were comparable for sex, residual deformity, and follow-up. There was no significant difference for the visual analog scale, Short Form-12, Quick Disability Arm Shoulder Hand, and Patient-rated Wrist Evaluation, or for radiographic outcomes. Conclusion  Preexisting OA in the wrist or CMC does not seem to impact outcomes of distal radius fractures, regardless of treatment, age, or sex. Although this is a negative study, the results are important to help counsel patients with distal radius fractures. Further work must be done to identify other potential causes for negative outcomes. Level of Evidence  Level III, prognostic study.

Developments in trapezium Replacements

The purpose of this update is to report on a variety of topics related to trapezium implants that have been investigated during the past three years. The keyword trapezium implant was utilized to query the PubMed database of the U.S. National Library of Medicine. From the resulting list, papers published from the beginning of January 2012 through the beginning of April 2015 were reviewed. The twenty-three studies identified are reviewed here and referenced at the end of the review. Based on level of evidence criteria for therapeutic studies as adopted by the American Academy of Orthopedic Surgeons, the most frequent level of evidence for reviewed clinical studies was Level IV (13/19 studies), followed by Level III (4/19), and Levels II (1/19) and I (1/19).

Results of 115 Rubis II reverse thumb carpometacarpal joint prostheses with a mean follow-up of 10 years

The aim of this study was to assess the clinical and radiological results of the Rubis II thumb carpometacarpal joint reverse prosthesis, at a mean follow-up of 10 years. Between 1997 and 2008, 253 prostheses were implanted in 199 patients; 115 were reviewed. The survival after a mean of 10 years was 89%. At the last follow-up, 70% of prostheses were painless; the others reported moderate or intermittent pain. The satisfaction rate was 98%. The mean opposition was 9 on the Kapandji scale; the mean QuickDASH score was 30. Wrist, key and tip pinch strengths were comparable with the non-operated side. Of the 115 implants, one was radiologically loose (1%) and 15 had suffered dislocations (13%), 12 of which were caused by an injury. Eleven thumbs had revision surgery. This study confirms that the good clinical results of the Rubis II prosthesis are maintained in the medium and long term, and represents a useful alternative to trapeziectomy for selected patients.

LEVEL OF EVIDENCE

IV.

Total arthroplasty of basal thumb joint with Elektra prothesis: an in vitro analysis

The reported outcomes of the Elektra thumb carpo-metacarpal joint implant have been very variable. This study evaluates the influence of daily cyclic loads and the type of the screw-fit cup insertion technique in the trapezium, with and without prior threading, on the structural bone behaviour. The study was performed experimentally to predict initial implant stability and cortical bone strains. Computational models were developed to assess the structural cancellous bone behaviour. The use of Elektra implant considerably changed the bone strain behaviour compared with the intact joint. This may be associated with risks of cancellous bone fatigue failure due to overload, particularly in the trapezium. The joint load magnitude has a more important structural role than that of the screw-fit cup insertion technique. Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of this procedure.

LEVEL OF EVIDENCE

V.