See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/6654426 Total Joint Arthroplasty in the Treatment of Advanced Stages of Thumb Carpometacarpal Joint Osteoarthritis Article in The Journal Of Hand Surgery · January 2007 Impact Factor: 1.67 · DOI: 10.1016/j.jhsa.2006.08.008 · Source: PubMed CITATIONS 65 READS 155 2 authors: Alejandro Badia Badia Hand to Shoulder Center, Miami, FL … 47 PUBLICATIONS 608 CITATIONS SEE PROFILE Senthil Nathan Sambandam 31 PUBLICATIONS 187 CITATIONS SEE PROFILE All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately. Available from: Alejandro Badia Retrieved on: 20 May 2016
he trapeziometacarpal joint has an exclusiveanatomic design that allows arcs of motion in3 different planes (abduction–adduction, flex-
on–extension, axial rotation) to place the thumb in areaxial position to resist axial loads.1 These variableositions of load may explain why it is common forhis joint to develop osteoarthritis (OA) even whenther small joints in the vicinity remain uninvolved.2
t has been shown that there is a strong correlationetween basal joint laxity (specifically volar ligamentnstability) and the evolution of early degenerativehanges. These alterations lead to pain, weakness,
nd adduction deformity.3 m
Restoration of thumb function with a painfree,table, and mobile joint with preserved strength arehe main goals of treatment of painful arthritis of thehumb.2 Many surgical methods have been proposedo achieve these goals. Procedures such as ligamenteconstruction,4–12 ligament reconstruction and ten-on interposition,7,8,13–20 tendon interposition with-ut ligament reconstruction,7,14,21–31 and simple tra-ezial excision7,8,32–35 all are associated with someoss of thumb length and hence pinch strength. Theole of metacarpal osteotomy is not clearly estab-ished.6,36–41 Arthrodesis is associated with loss of
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eighboring joints.29,42–48 Silicone implant arthro-lasty was proposed as an alternative but is associ-ted with instability, silicone wear, synovitis, pros-hesis fracture, and prosthesis subluxation.35,49–64
Total joint arthroplasty was first described by de laaffiniere and Aucouturier.65 This procedure applies
he concept of total hip replacement to creating aermanent swivel within the base of the thumb thatbviates the need for ligament reconstruction, re-laces the joint surface with a mechanical bearingurface for frictionless movement, and provides sta-ility for strong pinch and grasp.66
Various implant designs are available on the mar-et for total joint arthroplasty of the thumb.36,65–85
he de la Caffiniere implant is the mostidely used and most extensively studied
mplant65,69,70,73–76,78,80 – 83 Appendix 1 can beiewed at the Journal’s Web site, http://www.handsurg.org). De la Caffiniere first reported hiswn experience with this implant in 197965 andater in 1991.75 GUEPAR is another implant thatas been reported in the French67,85,86 and Ger-an84 literature (Appendix 2 can be viewed at the
ournal’s Web site, http://www.jhandsurg.org).ven though surgeons in different parts of theorld continue to use other implants (Appendix 3
an be viewed at the Journal’s Web site, http://ww.jhandsurg.org), the indications and long-
erm outcomes of those implants are not reportedrequently and hence are not adequately estab-ished.
The Braun-Cutter prosthesis (SBI/Avanta Or-hopaedics, San Diego, CA) is a commonly usedmplant for total joint arthroplasty.36,71,72 In histudy71 in 1982, Braun reported his experience in2 patients with 29 involved thumbs. Three yearsater, he reported his experience with 50 patients.36
hese are the only 2 reports regarding the Braunrosthesis, both from its designer. The implantesign, cementing techniques, and surgical tech-iques, however, have changed considerably in theast 20 years. Therefore, the purpose of this articles to report our experience with the Braun-Cutterrapeziometacarpal joint prosthesis and its out-ome in the treatment of stage III and select casesf stage IV OA of the thumb carpometacarpalCMC) joint.
aterials and Methodsotal joint arthroplasty of the trapeziometacarpal
oint was performed on 26 thumbs in 25 patients (24
omen, 1 man) to treat advanced basal joint OA of h
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he thumb between 1998 and 2003 (Table 1). Allatients were initially treated conservatively withonsteroidal anti-inflammatory medications, splint-ng, and steroid injections for a minimum of 6 to 12eeks. Surgical treatment was considered in thoseatients for whom the conservative treatment hadailed and who continued to have severe pain, loss ofinch strength, and lack of thumb motion that limitedheir activities of daily living.
Before surgery, we measured pain using a visualnalog scale, movement using a goniometer, griptrength using a dynamometer (Jamar Digital Handynamometer; Therapeutic Equipment Corp.,lifton, NJ), and pinch strength using a pinch gauge
Preston pinch gauge; JA Preston, New York, NY).adiographic assessment was performed according
o the Eaton-Littler method. Patients with Eatontage III trapeziometacarpal arthritis87 and selectedtage IV patients with clinically painless mildcaphotrapezial joint involvement were included inhis study. Patients with clinically painful scaphotra-ezial joints and those who had advanced radiologicsteoarthritic changes in the scaphotrapezial jointere excluded from having total joint arthroplasty of
he thumb CMC joint. We also excluded patientsho were younger than 60 years old or whose jobs
nvolved strenuous manual work, because we be-ieved that more active patients are not good candi-ates for implant arthroplasty.
emographicshe average patient age was 71 years; there were 24omen and 1 man. There was 1 bilateral case. The
ight thumb was involved in 17 patients and the leftn 9. The dominant hand was involved in 22 casesnd the nondominant in 4. None of the patients had
Table 1. Patient Demographics
Characteristic Value
Number of patients 25Number of thumbs 26Average age, y 71M:F ratio 24:1Dominant:nondominant hand
ratio 22:3Average duration of symptoms, y 3Average follow-up period, mo 46Average surgery time, min 45Preoperative pain (no. of patients)
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lained of diffuse pain about the thumb basal jointvisual analog scale score, 8–9/10) and decreasedateral pinch strength and grip strength. One patientad severe loss of the first web space. Patients expe-ienced symptoms an average of 3 years (range,–4 y) before surgery. Positive physical findingsncluded a grind test in all patients. Consistent pre-perative radiographic findings were dorsal metacar-al subluxation, the presence of prominent marginalsteophytes on the ulnar border of the distal trape-ium, joint space narrowing, cystic changes, andclerotic bone (Fig. 1). No patients had severe flat-ening or loss of trapezial height of the trapezium,hich would preclude the use of a CMC implant.Based on radiographic staging, 21 thumbs showed
vidence of Eaton stage III OA and 5 of stage IV OA.
igure 1. Radiographic study from the left thumb of a 67-ear-old woman showing complete loss of trapeziometacar-al joint space, subluxation, osteophytes, and subchondralysts. Total cemented arthroplasty was performed in thisatient.
dditional procedures performed at the time of CMC c
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rthroplasty included endoscopic carpal tunnel re-ease (8 patients), volar capsulodesis of the firstetacarpophalangeal joint (4 patients), first extensor
ompartment release (6 patients), and first web space-plasty (1 patient). The average follow-up time was9 months (range, 26–68 mo). During the follow-upisits, pain (visual analog scale), motion, pinch andrip strengths, and x-ray appearances of the individ-al patients were personally evaluated. No patientas lost to follow-up study.
hesis was implanted in this series by using a boneement technique. A 3-cm, longitudinal, lazy-Sncision is performed over the dorsal aspect of thease of the thumb. Branches of the superficialensory radial nerve are identified and protected.urther dissection is performed between the exten-or pollicis longus and extensor pollicis brevisendons isolating and protecting the dorsal branchf the radial artery. The dorsal capsule of therapeziometacarpal joint is opened longitudinallyith a proximal-based flap. The periosteum and
he dorsal capsule are reflected proximally as aingle flap to be repaired later. A sagittal saw issed to remove the proximal 6- to 8-mm base ofhe thumb metacarpal. The adductor pollicis iseleased if required to allow abduction of thehumb metacarpal away from the palm. At thisoint, longitudinal traction and flexion are appliedo better expose the trapezial surface. A rongeur issed to remove the marginal osteophytes and flat-en the joint surface of the trapezium. With imag-ng, the center of the trapezium is identified with amall burr. The center hole is then enlarged toreate a deep channel within the trapezium wherehe polyethylene cup will be cemented. For thehumb metacarpal, a guide is used to open thentramedullary canal, which is broached with aurr to allow for an ample cement mantle. Therapezial cup is first cemented in the trapeziumFig. 2) with care taken to impact the cementeneath the subcortical bone. Once the cup haseen inserted and the cement cured, the thumbetacarpal component is inserted with bone ce-ent (Fig. 3). Because this stem is collarless, it is
mportant to maintain adequate neck length (torevent subsidence) until the bone cement hasured. Care is taken so that the stem neck does notmpinge on the edge of the trapezium. Once the
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n the trapezium. Stability and circumferentialotion are assessed to ensure no impingement on
he implant (Fig.4). The proximal-based capsule–eriosteum flap is closed with absorbable suture.uring the procedure, intraoperative fluoroscopy
s performed to check proper alignment and place-ent of the prosthesis (Fig.5).We close the skin and the subcutaneous tissue
ith a resorbable suture and apply a well-paddedhort-arm thumb spica splint with the thumb inpposition for 1 week, after which rehabilitation istarted. An orthoplast thumb-based spica splint ispplied for further protection when thumb exer-ises are not performed. Patients rapidly regainhumb–to– base of small finger opposition with anctive and gentle active assisted range-of-motionROM) protocol.
linical Assessmentollow-up assessments of the patients were per-
igure 2. First, the polyethylene cup is cemented in therapezium.
ormed by an independent examiner who had not i
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een involved in either the surgical procedure oratient care. A VAS was used to assess the pain level0, absence of pain to 10, severe pain). The frequencyf pain was also registered (never, occasional, fre-uent, constant). The grip strength was determinedith a dynamometer (Jamar Digital Hand Dynamom-
ter) and lateral pinch strength was determined withpinchmeter (Preston pinchmeter). Complete inter-
halangeal and metacarpophalangeal joint ROMsnd radial abduction were recorded with a goniom-ter. The ability to oppose the thumb to the base ofhe small finger was recorded as the distance from thehumb distal pulp to the fifth metacarpal head. Anbjective assessment was performed with the Buck-ramcko score.88,89
adiologic Evaluationosteroanterior and lateral radiographs were ob-
ained at the final follow-up evaluations to evalu-te cup migration, stem subsidence, zones of oste-lysis, and joint subluxation as defined by Wachtlt al.83,90
igure 3. Cementing and placement of the metacarpal stem
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linical Assessmentain relief. Complete pain relief was achieved in4 patients (96%). Mild pain was present in 1 patientfter traumatic injury to the hand. A revision of therosthesis was required for secondary loosening be-ieved to be caused by the injury.
trength. The preoperative pinch strength was 6.0g in the noninvolved side and 3.5 kg in the affectedhumb (61% of the contralateral side). The postoper-tive pinch strength was 6.5 kg in the noninvolvedide and 5.5 kg in the affected one (85% of theontralateral side).
obility. The final thumb radial abduction was 60°range, 50°–65°). Palmar abduction was more than0° in all patients, and all patients were able toomfortably hold large objects between the thumbnd index finger. Flexion and extension were notuantified but were satisfactory at the final follow-up
igure 4. Reduction of both components is followed by test-ng for stability and impingement of the prosthesis.
xamination. The final ROM of the metacarpopha- c
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angeal joint was 5°–40°, and thumb oppositioneached the base of the small finger in all cases.
oosening analysis. Radiographic studies at thenal follow-up evaluation showed no evidence of
mplant loosening, cup migration, stem subsidence,r subluxation in either the anteroposterior or lateraliews of the thumb (Fig. 6). This was also the caseor the 1 patient in the series who had revisionurgery performed.
urvival analysis. There was only 1 revision (96%urvival) in our series, performed in a woman whoell after the primary replacement and dislocated theomponents. Closed reduction was obtained, and ahumb spica splint was used. Even though the pa-ient’s ROM continued improving she had mild dis-omfort, and 3 years after the original procedure shead revision surgery using the same type of prosthe-is for posttraumatic loosening. At the final fol-ow-up examination (5 years), she did not have anyain and radiographic findings were the same as foratients who did not have revision surgery.
bjective assessment. We used the Buck-Gram-ko score in this study to objectively assess the
igure 5. Fluoroscopic views are obtained to assess proper
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range, 47–54), constituting an excellent outcomeAppendices 4, 5) can be viewed at the Journal’s
eb site, http://www.jhandsurg.org). There were 24xcellent results, and the patient who required revi-ion of her joint had good result (47 points ) after theevision surgery.
iscussionestoration of thumb function ideally should pro-ide pain-free, stable motion at the basal joint withdequate strength and proper balance of the entireay. In this study, we reported good to excellentesults after total joint cemented arthroplasty withhe Braun-Cutter implant) for the treatment ofMC OA in select patients. Twenty-four patients
n our series had an excellent outcome, and 1 hadgood outcome based on the Buck-Gramcko
core. Complete pain relief was achieved in 24atients (96%), and the average strength was 85%f that on the unaffected side. Implant survival was
igure 6. Radiographic study at the final follow-up exami-ation with no signs of implant loosening.
6% in our study. The only complication seen in a
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ur series was an implant dislocation due to trauman 1 patient that later required revision surgeryecause of pain and posttraumatic loosening. Nopontaneous loosening was found. Fracture or dis-ocations of the prosthesis and posttraumatic loos-ning have been reported by few other researchersn the past. In 1985 Braun36 reported 2 cases ofosttraumatic loosening that required revision sur-ery. Complications such as asymptomatic orymptomatic loosening,36,65,66,69,70,71,82,83 hetero-ropic ossification,36,66,71 cement extrusion withendon and nerve injury,36 or reflex sympatheticystrophy36 were not seen in our series.Various surgical procedures have been described
or stage III and early stage IV OA of the thumbMC joint. The literature specifically regarding tra-eziometacarpal total joint arthroplasty is rather lim-ted, and the indications are not clearly delineated.
The de la Caffiniere implant is the most widelysed and most extensively studied im-lant65,69,70,73–76,78,80 – 83,91 (Appendix 3). TheUEPAR is another implant that has been reported
n the French67,85,86 and German84 literature. Evenhough surgeons in different parts of the worldontinue to use other implants, the indications andong-term outcomes of those implants are not re-orted frequently and hence are not adequatelystablished. In 1979, de la Caffiniere and Aucou-urier65 reported their experience with a total CMCrosthesis with 34 thumbs in 29 patients with anverage follow-up period of 2 years. That seriesncluded patients with both OA and rheumatoidrthritis of the thumb. There were 5 cases of ra-iographic loosening, but the functional resultsemained adequate and these were not revised.ther researchers have reported similarly good
esults with the de la Caffiniere prosthesis (Appen-ix 1). The only exception was the report byachtl33 in 1998. He reported his extensive expe-
ience in 84 patients with 88 thumbs involved.mplants required revision surgery in 10 cases withn overall survival rate of 66%, and asymptomaticoosening was detected in 52%. The reasons for hisoor results were not clearly evident, but the av-rage age of patients in his series was 61 years. Heid not report the activity levels of his patients.urther, he mentioned revision surgery for loosen-
ng but failed to mention whether his patients wereymptomatic or not. Recently, De Smet et al76
eported their experience with the de la Caffiniererosthesis with 43 thumbs in 40 patients with an
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here was no revision surgery in that series, butucent zones appeared in 44% (most of them oc-urring in patients younger than 60 years old);rogression to clinical loosening was not reported.he Braun prosthesis has been less extensivelytudied. Braun reported his initial experience in 22atients in 198271 and later in 50 patients in985.36 In the initial report he had to revise 3ases, and later in the larger series 4 implantsequired revision surgery. Braun believed that re-ision is possible in the context of implant failureecause of the well-preserved bone stock. Thereave been no reports by unbiased surgeons on theutcomes with use of this particular implant.We believe that the appropriate selection of pa-
ients for this procedure is an important factor deter-ining the outcome. Trapeziometacarpal total joint
rthroplasty is most commonly indicated for lateaton-Littler stage II and stage III OA. It is important
o determine if scaphotrapezial-trapezoidal joint in-olvement will influence the decision of whether tose an implant, which obviously requires trapezialreservation. North and Eaton92 found that 47% ofadavers had scaphotrapezial joint arthritic changeslong with trapeziometacarpal joint arthritis and sug-ested that routine complete trapezial excision wasot necessary. Several researchers68,81 included pa-ients with moderate scaphotrapezial joint involve-ent in their arthroplasty series and concluded that
nvolvement of the scaphotrapezial joint is not aontraindication for total joint implant arthroplasty ofhe thumb trapeziometacarpal joint. Our clinical ex-erience has also suggested that certain early stageV cases are amenable to this method of treatment.
e clinically assessed the scaphotrapezial-trapezoi-al joint by direct palpation of the joint dorsally. Aainful scaphotrapezial-trapezoidal joint was consid-red a contraindication to this procedure, as weredvanced radiographic changes in this joint.
Few reports78,84 have highlighted the importancef trapezial height for good surgical outcome in totaloint arthroplasty. With this in mind, we excludedhose patients with advanced radiographic OAhanges of the scaphotrapezial joint with a wedge-haped trapezium. We believe this factor might havelso contributed to the favorable outcome achieved inur series.Accurate implant design plays a vital part in de-
eloping a dependable and successful system. Dif-erent implant designs have been developed in theast. The Braun-Cutter design (SBI/Avanta Ortho-
aedics) consists of a metallic metacarpal component h
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rticulated with a polyethylene cup trapezial compo-ent. The form and length of the metacarpal compo-ent of the Braun-Cutter prosthesis allows for centrallacement at an appropriate depth in the medullaryanal. Subsidence of this titanium metacarpal com-onent is prevented by 3 transverse troughs strategi-ally located on the stem of the implant. The conicalmplant shape and porous coated surface provides aood cement–prosthesis interface. The ultra-high–olecular-weight polyethylene of the trapezium
omponent has a cylindric outer shape that resembleschampagne cork and permits pressurization of the
ement and proper positioning. Once implanted, therticulated components lie at the normal anatomicevel of the trapeziometacarpal joint, which promotesppropriate muscle balance in the thumb. Further-ore, the relation between the neck diameter of theetacarpal component and the open surface and cupalls allows for unrestrained rotation and nearly 90°f motion in any direction without impingement.part from implant design, other possible factors
esponsible for good outcome are appropriate com-onent alignment, proper cementing techniques, andddressing the hyperextension of the thumb metacar-ophalangeal joint and metacarpal adduction.66
In our series, we revised the implant in only 1atient. The reason for revision in this caseas posttraumatic loosening with a painful
oint. This is in contrast to previous stud-es36,65,66,68,69,70,71,73,76,77,81– 83 in which the mostommon indication for revision was symptomaticontraumatic loosening. The sole patient who hadevision surgery in our series had a satisfactoryesult.
Total joint arthroplasty has been shown to giveetter or comparable functional results comparedith other surgical procedures performed for ad-anced trapeziometacarpal joint OA. Apart from theomparable functional results, another importantenefit it offers to patients is rapid recovery and theeed for minimal rehabilitation. The constrained de-ign principle obviates the need for prolonged immo-ilization, because soft-tissue and capsular healingre not critical for implant function. This key elementannot be overemphasized, because most of our pa-ients were elderly patients who lived alone andequired rapid recovery to continue living indepen-ently. Many had physical difficulty getting to theherapy sites. We believe this particular aspect con-ributed to the high level of satisfaction seen in ouratient group. All patients, including the one who
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nd indicated they would have the same procedureerformed the other thumb if the need arose.We recognize that there are some shortcomings to
his study: The study is a prospective, noncompara-ive study without any control group. Furthermore,his study was performed on a selected subset ofatients who were over 60 years of age and wereow-demand patients and who had stage III or earlytage IV OA of the thumb basal joint. We believe thiss the group of patients who would most benefit fromhis procedure while maximizing success with anmplant.
eceived for publication August 30, 2004; accepted in revised formugust 9, 2006.The Journal of Hand Surgery / Vol. 31A No. 9 November 2006No benefits in any form have been received or will be received fromcommercial party related directly or indirectly to the subject of this
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