Total Joint Arthroplasty in the Treatment of Advanced ......Feb 12, 2019 · Alejandro Badia, MD,...

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Total Joint Arthroplasty in the Treatmentof Advanced Stages of Thumb

Carpometacarpal Joint OsteoarthritisAlejandro Badia, MD, Senthil Nathan Sambandam, MS

From the Miami Hand Center, Miami, FL.

Purpose: Osteoarthritis of the thumb basal joint is a very common and disabling conditionthat frequently affects middle-aged women. Many different surgical techniques have beenproposed for extensive degenerative arthritis of the first carpometacarpal (CMC) joint. Jointreplacement has been an effective treatment of this condition. The purpose of this article isto present the outcome of a total cemented trapeziometacarpal implant in the treatment ofmore advanced stages of this disease.Methods: Total joint arthroplasty of the trapeziometacarpal joint was performed on 26thumbs in 25 patients to treat advanced osteoarthritis (Eaton and Littler stages III and IV)between 1998 and 2003. Indications for surgery after failure of conservative treatment weresevere pain, loss of pinch strength, and diminished thumb motion that limited activities ofdaily living. A trapeziometacarpal joint prosthesis was the implant used in this series. Theaverage follow-up time was 59 months.Results: At the final follow-up evaluation, thumb abduction averaged 60° and thumb oppo-sition to the base of the small finger was present. The average pinch strength was 5.5 kg (85%of nonaffected side). One patient had posttraumatic loosening, which was revised withsatisfactory results. Radiographic studies at the final follow-up evaluations did not show signsof atraumatic implant loosening. One patient complained of minimal pain, and the remaining24 patients were pain free.Conclusions: In our series, total joint arthroplasty of the thumb CMC joint has proven to beefficacious with improved motion, strength, and pain relief. We currently recommend thistechnique for the treatment of stage III and early stage IV osteoarthritis of the CMC joint inolder patients with low activity demands. (J Hand Surg 2006;31A:1605.e1–1605.e13. Copy-right © 2006 by the American Society for Surgery of the Hand.)Type of study/level of evidence: Therapeutic IV.Key words: Carpometacarpal, cemented arthroplasty, osteoarthritis, thumb.

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he trapeziometacarpal joint has an exclusive an-atomic design that allows arcs of motion in 3different planes (abduction–adduction, flexion–

xtension, axial rotation) to place the thumb in a pre-xial position to resist axial loads.1 These variable po-itions of load may explain why it is common for thisoint to develop osteoarthritis (OA) even when othermall joints in the vicinity remain uninvolved.2 It haseen shown that there is a strong correlation betweenasal joint laxity (specifically volar ligament instability)nd the evolution of early degenerative changes. Theselterations lead to pain, weakness, and adduction defor-

ity.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

obility and a transfer of reaction forces to the

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1605.e2 The Journal of Hand Surgery / Vol. 31A No. 10 December 2006

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 (France) is another im-lant that has been reported in the French67,85,86

nd German84 literature (Appendix 2 can beiewed at the Journal’s Web site, http://www.handsurg.org). Even though surgeons in differentarts of the world continue to use other implantsAppendix 3 can be viewed at the Journal’s Webite, http://www.jhandsurg.org), the indicationsnd long-term outcomes of those implants are noteported frequently and hence are not adequatelystablished.

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

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 Eaton andlickel stage III trapeziometacarpal arthritis87 and

elected stage IV patients with clinically painlessild scaphotrapezial joint involvement were in-

luded in this study. Patients with clinically painfulcaphotrapezial joints and those who had advancedadiologic osteoarthritic changes in the scaphotrape-ial joint were excluded from having total joint ar-hroplasty of the thumb CMC joint. We also ex-luded patients who were younger than 60 years oldr whose jobs involved strenuous manual work, be-ause we believed that more active patients are notood candidates 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)

At rest 20During strain 25

ad previous thumb surgery. Most patients com-

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lained of diffuse pain about the thumb basal jointvisual analog scale score, 8 to 9 out of a total of 10)nd decreased lateral pinch strength and griptrength. One patient had severe loss of the first webpace. Patients experienced symptoms an average ofyears (range, 1–4 y) before surgery. Positive phys-

cal findings included a grind test in all patients.onsistent preoperative radiographic findings wereorsal metacarpal subluxation, the presence of prom-nent marginal osteophytes on the ulnar border of theistal trapezium, joint space narrowing, cystichanges, and sclerotic bone (Fig. 1). No patients hadevere flattening or loss of trapezial height of therapezium, which would preclude the use of a CMCmplant.

Based on radiographic staging, 21 thumbs showed

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.

vidence of Eaton stage III OA and 5 of stage IV OA. i

dditional procedures performed at the time of CMCrthroplasty 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 evaluated individually. No patientas lost to follow-up study.

urgical Techniquehe Braun-Cutter trapeziometacarpal joint pros-

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 not

mpinge on the edge of the trapezium. Once the

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omponents are implanted and the cement hasardened, the stem is pressed into place in the cupn 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 splintJohnson & Johnson, New Brunswick, NJ) is ap-lied for further protection when thumb exercisesre not performed. Patients rapidly regain thumb–o– base of small finger opposition with an activend gentle active assisted range-of-motion (ROM)

igure 2. First, the polyethylene cup is cemented in therapezium. White arrow, metacarpal side; black arrow, tra-ezial side.

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linical Assessmentollow-up assessments of the patients were per-ormed by an independent examiner who had noteen 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-

igure 3. Cementing and placement of the metacarpal stem

n the medullary canal are performed.

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te cup migration, stem subsidence, zones of oste-lysis, and joint subluxation as defined by Wachtlt al.83,90

esultslinical 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 than

igure 4. Reduction of both components is followed by test-ng for stability and impingement of the prosthesis.

0° in all patients, and all patients were able to c

omfortably hold large objects between the thumbnd index finger. Flexion and extension were notuantified but were satisfactory at the final follow-upxamination. The final ROM of the metacarpopha-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 any

igure 5. Fluoroscopic views are obtained to assess proper

ementing and correct implant positioning.

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ain 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 theutcome. The mean total in our series was 53 pointsrange, 47–54), constituting an excellent outcomeAppendices 4 and 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

igure 6. Radiographic study at the final follow-up exami-ation with no signs of implant loosening.

n our series had an excellent outcome, and 1 had F

good outcome based on the Buck-Gramckocore. Complete pain relief was achieved in 24atients (96%), and the average strength was 85%f that on the unaffected side. Implant survival was6% in our study. The only complication seen inur 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 byachtl83 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-

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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 anverage of 26 months of follow-up evaluation.here was no revision surgery in that series, but

ucent 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 in

ur series. r

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 componentrticulated 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 and

equired rapid recovery to continue living indepen-

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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 whoad revision surgery, were happy with the outcomend indicated they would have the same procedureerformed on 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.No benefits in any form have been received or will be received fromcommercial party related directly or indirectly to the subject of this

rticle.Corresponding author: Alejandro Badia, MD, FACS, Hand, Upper

xtremity and Microsurgery, Miami Hand Center, 8905 SW 87th Ave,te 100, Miami, FL 33176;e-mail: [email protected] © 2006 by the American Society for Surgery of the Hand0363-5023/06/31A10-0023$32.00/0doi:10.1016/j.jhsa.2006.08.008

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Appendix 1. Total Cemented Joint Arthroplasty of the Thumb: Outcome Studies in the English Literature

Study YearNo. of

Pts/JointsAge,

ySTJ

InvolvedSide,

D/NDGender,

M/F ImplantFollow-Up

Period

Outcome Revision, n(Implant

Survival, %)

Complications, n

RelevantConclusionsE G F P ASL SL Other

de la Caffiniere andAucouturier 65

1979 29/34 59 Yes NM NM DLC 24 mo — 20 — 4 4 5 NM — —

Braun71 1982 22/29 NM NM NM NM Braun 1–7 y — 22 — — 3 3 NM 1 septiclooseningHO,6 CE, 1

Revision possiblebecause of intactbone stock

August et al69 1984 20/21 57 NM 2.5:1 1:3 DLC 15 mo NM 5 (76) 9 5 — —Braun36 1985 50/50 NM NM NM NM Braun 6 mo–10 y — 26 — — 4 1 4 (2

PT)— —

Alnot and SaintLaurent68

1985 15/17 56 Yes NM NM DLC 1–10 y;avg, 3 y

— 13 — — 3 NM NM — Repeat surgeryalways possible.Pantrapezialdisease not acontraindication

Ferrari and Steffee77 1986 38/45 61 NM 21/29 7/31 Steffee 2–6 y NM 3 11 5 1 septicloosening

Loosening does notincrease withtime. Salvageprocedurepossible in theevent of failure

Cooney et al66 1987 57/63 62 NM 39/23 6/56 Mayo 4–6 y 21 28 6 7 12(81) 20 12 1 septicloosening HO,36%

Careful prostheticalignment,cementingtechniquesrequired

Boeckstyns et al70 1989 28/31 62 NM 8/12 3/25 DLC 13–77 mo NM 4 3 4 — —Sondergaard et al81 1991 20/22 60 NM 18/7 3/20 DLC 9 y NM 3(82) 3 3 — Accelerated

tendency of latefailure not seen

Nicholas andCalderwood80

1992 20/20 57.2 NM NM 4/13 DLC 10 y — — — 3 NM 1 NM 1 Dis 1 TC Radiologic lucencydoes not affectfunction

Chakrabarti et al73 1997 71/93 57 NM NM 9/62 DLC 6–16 y NM 11(89) 13 9 1 Dis 1 CE Implant failed inmen younger than65 y

Wachtl et al83 1998 84/88 61 Yes NM NM DLC 63 mo NM 10 (66.4) 52% NM — Pantrapezial diseasenot acontraindication.Revision givessatisfactory result.Most revisionsoccur within 2 y

van Cappelle et al82 1999 63/77 62 NM 38/39 11/60 DLC 2–16 y;avg, 8.5y

NM 16(72) 13 14 — Cemented prosthesishas better survival

De Smet et al76 2004 40/43 54 NM 22/21 3/37 DLC NM 1 14 10 — Loosening related toyoung age

ASL, asymptomatic loosening; avg, average; CE, cement extrusion; D, dominant; Dis, dislocation; DLC, de la Caffiniere; E, excellent; F, fair; G, good; HO, heterotopic ossification; ND,nondominant; NM, no mention; P, poor; PT, posttraumatic; pts, patients; SL, symptomatic loosening; STJ, scaphotrapezial joint; TC, trapezial collapse.

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Appendix 2. Total Cemented Joint Arthroplasty of

Study Year

No. ofPatients/

JointsST JointInvolved

de la Caffiniere75 1991 NM/13 Yes

Alnot et al67 1993 32/36 Yes

Alnot andMuller86

1998 NM/90 NM

de la Caffiniere74 2001 NM/13 Yes

Guggenheim-Gloor et al78

2000 NM/43 NM

Masmejan et al84 2003 NM/51 NM

Masmejan et al85 2003 60/64 Yes

avg, average; DLC, de la Caffiniere; NM, no mention; ST, scaphot

Appendix 3. Various Implant Designs Available on the Market

Design ManufacturerMetacarpalComponent

TrapezialComponent

Collar inthe Stem

Horizontal Groovesin the Stem

FixationTechnique

Lewis79 Howmedica (Rutherford, NJ) Polyethylene cup Metallic ball NA NA CementMayo66 Depuy (Warsaw, IN) Polyethylene cup Metallic ball NA NA Cementde la Caffiniere65,74–76,91 Francobal (Francobal, France) Cobalt chromium

stemPolyethylene cup Yes No Cement

Braun-Cutter prosthesis Avanta Orthopedics (now SBI)(San Diego, CA)

Titanium Polyethylene cup No Yes Cement

Braun36,71 Zimmer (Warsaw, IN) Metallic stem Polyethylene cup No Yes CementGUEPAR67,84,85 GUEPAR Group (Herouville

Saint Clair, France)Metallic stem Polyethylene cup Yes No Cement

Steffee77 Laure Prosthetics (Portage, MI) Metallic stem Polyethylene cup Yes No Cement

the Thumb: Outcome Studies in Non-English Literature

ImplantUsed

Follow-UpPeriod Conclusions

DLC 12 y Long-term result seems to be gooddespite high level of loosening

GUEPAR 1–9 y (avg,3.5 y)

Trapezial height is an important factor

GUEPAR 5.75 y Trapezial height �7 mm, young age,and dominant hand are adversefactors affecting outcome

DLC 12–17 y Dominant hand in heavy workers is acontraindication. Involvement of STjoint is not a contraindication.Trapezial height is an importantfactor.

DLC 63 mo This procedure is reserved for elderlypatients not involved in strenuousexercise

GUEPAR 27 mo Radiologic loosening does not affectclinical outcome

GUEPAR 29 mo Revision and salvage procedurepossible in the event of failure.Trapezial height is an importantfactor affecting outcome

NA, not available.


Appendix 4. Objective Outcome Based on Buck-Gramcko Score at Final Follow-Up Evaluation

Measurement No. of Points Thumbs

Palmar abduction, °�40 6 2630–39 420–29 2�20 0

Radial abduction, °�40 6 2630–39 420–29 2�20 0

Tip pinch compared withcontralateral side, %�100 6�80 4 2660–79 2

�60 0

Appendix 5. Subjective Outcome Based onBuck-Gramcko Score at Final Follow-UpEvaluation

Characteristic No. of Points Patients

Pain frequencyNever 6 24Occasional 4 1Frequent 2Constant 0

StrengthImproved 6 25Same 3Worse 0

Daily functionNo difficulty 6 25Mild difficulty 4Moderate difficulty 2Severe difficulty 0

DexterityImproved 6 25Same 3Worse 0

AppearanceExcellent 6 24Good 3 1Acceptable 2Poor 0

Would you have surgery again?Yes 4 25No 0 0

Overall assessmentExcellent 6 24Good 4 1Fair 2Poor 0

Grade of total scoreExcellent 49–56 24Good 40–48 1Fair 28–39Poor 28

Mean total score, points 53

Total Joint Arthroplasty in the Treatment of Advanced Stages of Thumb Carpometacarpal Joint OsteoarthritisMaterials and MethodsDemographicsSurgical TechniqueClinical AssessmentRadiologic Evaluation

ResultsClinical AssessmentPain reliefStrengthMobilityLoosening analysisSurvival analysisObjective assessment

DiscussionReferencesAppendix 1. Total Cemented Joint Arthroplasty of the Thumb: Outcome Studies in the English LiteratureAppendix 2. Total Cemented Joint Arthroplasty of the Thumb: Outcome Studies in Non-English LiteratureAppendix 3. Various Implant Designs Available on the MarketAppendix 4. Objective Outcome Based on Buck- Gramcko Score at Final Follow-Up EvaluationAppendix 5. Subjective Outcome Based on Buck-Gramcko Score at Final Follow-Up Evaluation

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