Metacarpal-phalangeal joint arthroplasty of the rheumatoid thumb Fifty patients with rheumatoid arthritis had 59 Swanson implants of the metacarpal-phalangeal joint of the thumb. Eleven patients (15 implants) have since died and only 1 patient (1 implant) has been lost to follow-up leaving 43 implants available for study. The most common preoperative deformity was a boutonniere deformity with a flexible interphalangeal pain after operation.
joint. All thumbs had less
The average range of active motion is 25 degrees, with a flexion arc from
15 to 40 degrees. There is an average key pinch strength of 4 pounds (range, 0.5 to 10). Improvement in activities of daily living were noted in 40 hands. One thumb required reoperation for instability; Radiographic
the implant was removed and a metacarpal-phalangeal
and in two other thumbs at the carpometacarpal operations.
arthrodesis
was done.
progression of disease was noted in only one thumb at the interphafangeal The maintenance
joint
joint. None of these have required further
of motion appears to help in activities of daily living as stability
and pinch strength are often adequate.
(J HAND SURG 1990;15A:210-16.)
M. P. Figgie, MD, A. E. Inglis, MD, M. Sobel, MD, New York, N.Y., W. W. Bohn, MD, Kansas City, MO., and D. A. Fisher, BS, Nogolk, Vu.
A
mobile, pain-free thumb that can provide pinch strength is vital to the rheumatoid patients’ ability to perform the activities of daily living including eating and buttoning clothes. Numerous previous studies have discussed the types of deformities in the rheumatoid thumb. l-3 The boutonniere deformity (type I), occurring in more than 50% of rheumatoid thumbs, is seen initially with a flexed metacarpal-phalangeal joint and an extended interphalangeal (IP) joint. In the early stages, the MP and IP joints maintain passive motion but become more fixed as the disease progresses. The other thumb deformities include a swan-neck deformity (type III), ulnar collateral ligament instability (type IV) and carpal-metacarpal dislocation with IP joint hyperextension (type II). There have been numerous studies
From the Hospital for Special Surgery, New York, N.Y.; the Research Medical Center, Kansas City, MO., and Norfolk, Va. Presented at the Eighteenth Annual Meeting of The American Association for Hand Surgery, Toronto, Canada, October 1988. Received for publication May 5, 1989.
Dec. 12, 1988; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mark P. Figgie, MD, The Hospital Surgery, 535 E. 70th St., New York, NY 10021. 311114327
210
for Special
on surgical reconstruction of the thumb,2-‘3 with various operations described depending on the amount of joint involvement, the status of the ligaments and tendons, and the status of the other joints of the thumb. Surgical options for the MP joint of the thumb range from synovectomy with dorsal hood reconstruction, to arthroplasty, and arthrodesis. Synovectomy with extensor reconstruction is recommended in those patients with reconstructable ligaments and a satisfactory joint.‘. ‘. ‘I. ” Arthrodesis is recommended for the painful, unstable joint and has enjoyed good results.2-4, ‘. ‘o-” Arthroplasty of the MP joint has been recommended for the MP joint that has ligamentous support but a destroyed articular surface combined with either carpometacarpal (CMC) or IP joint disease. However, there have been only two previous reports of implant arthroplasty for the thumb MP joint. Swanson and Hemdon’” reported on use of the Swanson silicone implant in 1977, and Beckenbaugh and Steffee6 reported their use of the cemented Steffee implant in 198 1. This study represenets a review of the Swanson silicone arthroplasty for the reconstruction of the rheumatoid thumb MP joint and specifically addresses whether the IP and the CMC joints deteriorated after MP joint surgery. Materials
and methods
Between April 1975 and June 1985,51 patients with seropositive rheumatoid arthritis had 59 Swanson
Vol. 15A, No. 2 March 1990
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211
Fig. 1. A, This 60-year-old right-handed woman had significant erosion of the MP joints. B-C, She had implant arthroplasty of her MP joints on the right hand. Six years after operation, she has maintained excellent function and alignment. In addition, there has been no progression of disease at the IP or CMC joints of the thumb.
metacarpal-phalangeal implant arthroplasties of the thumb. Nine patients had bilateral procedures. Eleven patients (15 implants) died before the time of this study, and 1 patient (1 implant) was lost to follow-up. Thus 43 implants in 38 patients were available for review. The procedures were performed or supervised by the senior author (A. E. I.). The average length of follow-up was 6% years (range, 3 to 13 years). Thirtyfour of the surviving 38 patients were women and four were men. The average age at the time of operation was 58 years (range, 26 to 82 years).
common deformity was a boutonniere (type I) deformity that occurred in 36 thumbs (Fig. 1). Thirty-one of these were flexible (stage I), three were fixed (stage II), and two had fixed MP and IP deformities (stage III). In addition, there were three thumbs with a swan-neck deformity (type III). There were four type II deformities with MP joint flexion, IP joint hyperextension, and CMC joint subluxation. No thumbs with ulnar collateral ligament instability (type IV) were included in this series.
Preoperative deformity
The prostheses used were the high performance tomer Swanson silicone metacarpal-phalanageal plants. No grommets were used.
The preoperative deformities were classified according to the system described by Nalebuff.2 The most
Prosthesis and surgical technique elasim-
212
The Journal of HAND SURGERY
Figgie et al.
The operation is done with the patient under regional anesthesia and tourniquet control. An oblique longitudinal incision is made dorsally over the MP joint. The tendons of the extensor pollicis longus and brevis are identified. The extensor hood is split between these tendons, and the extensor pollicis brevis, which is usually attenuated, is detached from the base of the proximal phalanx. The metacarpal head is then resected at the flair, perpendicular to the shaft. The collateral ligaments are protected and preserved. If the ligaments are inadequate, or are inadvertently transected at the time of surgery, then the MP joint should be arthrodesed. The proximal phalanx requires minimal resection, especially since the collateral ligaments attach proximally on the phalanx and should be protected. The canals of the metacarpal and the proximal phalanx are then reamed to accept the Swanson implant. Occasionally, the palmar plate must be released to correct a flexion contracture. The Swanson implant trials are then used to size for an adequate prosthesis. The prosthesis should be large enough to give a snug fit and good stability but should not cause a marked flexion contracture. If a flexion contracture occurs, more bone may need to be resected. After the correct prosthesis is implanted, the tendon of the extensor pollicis brevis is reattached to the proximal phalanx using drill holes for the sutures. The joint is held in extension when the tendon is sewn in and the extensor hood is then repaired. The joint is held in extension by the use of a Kirschner wire that is passed manually from the tip of the thumb proximally along the flexor sheath of the flexor pollicis longus to the base of the thumb. This acts as an internal splint. The wound is then closed and the thumb is held in a bulky splint. The Kirschner wire is left in place for 3 weeks and once it is removed the thumb is splinted for an additional 3 weeks. The patient is then allowed to begin range of motion exercises.
Clinical evaluation All patients were clinically and radiographically evaluated. They were examined by one of us (M. P. F.). Clinical examination included an evaluation of the CMC, MP, and IP joints of the thumb for pain, stability, range of motion, and function. Pain was rated on a scale of 1 to 5, with 1 equaling no pain and 5 being severe, disabling pain. Range of motion was measured by use of a goniometer in a manner consistent with that described by the American Academy of Orthopaedic Surgeons. Both active and passive motions were recorded. Function was assessed by the ability to perform the activities of daily living including feeding, buttoning clothes, and writing. Key pinch and grip strength
were measured and recorded by taking the maximum of three efforts. Key pinch was measured using a mechanical pinch meter and grip strength was recorded with a dynamometer.
Radiographic evaluation Radiographic evaluation included preoperative, postoperative, and current evaluations of the thumb. These were reviewed for implant position, breakage, and bony changes around the implant, including sclerosis around the implant and bony resorption. The CMC and IP joints of the thumb were evaluated for radiographic signs of disease and were compared for progression of the disease. All radiographs were evaluated by two of us (M. P. F. and M. S.).
Concomitant surgery Concomitant surgery was done on the ipsilateral hand in 40 of the 43 cases. The most common procedure in addition to the thumb implant was MP arthroplasty of the fingers. This was done in 17 cases. The second most common procedure was a dorsal stabilization of the wrist, which was done in 9 cases. A variety of other procedures were done including proximal interphalangeal (PIP) fusions, IP fusion of the thumb, extensor realignment of the hand, carpal tunnel release and flexor synovectomy. A combination of procedures was usually used, but always within a 2-hour tourniquet time limit.
Results Forty-two of the 43 implants available for study are still intact and only 1 has required revision for instability. Of these 42 implants, all patients have had improvement in pain relief and 34 have no pain at all at current follow-up. The remaining eight scored a four out of five on the pain scale. The active range of motion of the MP joint in these thumbs is 25 degrees (range, 10 to 40 degrees) in a flexion arc from 15 to 40 degrees. Passive range of motion averaged nearly 35 degrees. Function improved in 39 hands, as 38 patients were now able to perform activities of daily living including opening a door, buttoning their clothes, and picking up a coin. The average key pinch strength was 4 pounds (range, 0.5 to 10) and the average grip strength was 12.2 pounds (range, 0 to 25). Stability at the MP joint was obtained in 42 cases; however, all patients had at least a lodegree arc of radial and ulnar deviation when tested passively. Eleven patients had fusions of the IP joint at the time of surgery for malalignment or instability. All of these healed satisfactorily. Of the remaining 21 thumbs, the
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Metacarpal-phalangeal
joint arthroplasty of rheumatoid thumb
213
average range of motion at the IP joint was 50 degrees (range, 20 to 80). Forty-one thumbs had no pain at the 1P joint. However, six thumbs had recurrence of their hyperextension deformity, but none were fixed in hyperextension. TWO thumbs had pain at the CMC joint before operation and four thumbs had pain at current follow-up. NO thumbs have required further surgery at the CMC joint. NO thumbs had recurrence of synovitis, and there was no evidence of silicone synovitis. Complications
and revisions
There was only one superficial wound infection, which healed satisfactorily with local care. There have been no implant fractures. Only one revision surgery was necessary and this was in a patient who had the implant removed at another institution and had an arthrodesis done. Retrospectively, the patient preferred the implant as she finds the loss of motion with the arthrodesis hampers her functionally. Six patients had MP arthrodesis of the thumb on their opposite side (Fig. 2). In each instance, the patient preferred the side with the implant arthroplasty because of the preservation of motion. In addition, three of the patients with MP arthrodesis have gone on to have further CMC pain and one has gone on to have further difficulty with the IP joint of the thumb. Radiographic
evaluation
Radiographic evaluation of the MP joint of the thumbs show that no fractures of the implants had occurred. Bone resorption was present in only five of the thumbs for a rate of 12%. Bony sclerosis around the implant stems was present in 27 thrumbs for a rate of 64%. Seventeen of the thumbs had radiographic evidence of disease at the IP joint before operation. Eleven of these were arthrodesed at the time of surgery and 6 thumbs have radiographic evidence of disease at current follow-up. Two of these has shown progression of disease. Twelve thumbs had radiographic evidence of disease of the CMC joint before surgery and 13 thumbs at current follow-up have radiographic evidence of disease. Two of these thumbs had evidence of radiographic progression of disease (Fig. 3). Discussion The treatment of the thumb in rheumatoid arthritis is complex, especially when there is concomitant disease at the IP, MP, and CMC joints. A stable, pain free, and mobile thumb can be achieved through a variety of operations depending on the status of the thumb and the type of deformity. In the early stages of the disease,
Fig. 2. A, This 20-year-old right-handed woman had marked hand deformities. B, She had MP arthroplasties on both hands
with implant arthroplasty of the left thumb MP joint with arthrodesis of the IP joint. On the right side, she had arthrodesis of the MP and IP joints of the thumb. Currently at 8 years after operation she prefers the left side due to maintenance of motion in spite of the fact that she is right-handed.
synovectomy of the MP joint with extensor tendon reconstruction may give satisfactory results with good pain relief. Inglis et al.” noted complete pain relief in 11 of 21 patients, with an average arc of motion of 35 degrees. Salgeback and colleagues” noted significant pain relief in 76% of their patients who had synovectomy. However, synovectomy with dorsal hood reconstruction may not produce durable long-term results. Also, when there is significant joint destruction, synovectomy alone may not result in adequate pain relief. In these cases the options include either implant arthroplasty or MP athrodesis. Arthrodesis of the MP joint offers a durable result with adequate pain relief as noted in several studies.3. 4. ‘-l’ Union rates of MP arthrodesis have ranged from 80% as noted by Brumfield and Conaty’ to 100% as noted by Beckenbaugh.4 Stability of the thumb is often improved, which aids in activities
214
Figgie et al
The Journal of HAND SURGERY
Fig. 3. A, This 56-year-old woman had significant boutonniere deformities before operation. B, She had MP arthroplasty of both hands in 1983. On the left side, there has been maintenance of the IP and CMC joints, although a recurrence of the hyperextension deformity at the IP joint has occurred. C, On the right side, there has been radiographic progression of disease at the CMC joint. but she has maintained excellent function.
requiring opposition. However, activities requiring precision handling are often impaired because of the loss of mobility of the thumb. In addition, greater stresses are often placed on the IP and CMC joints of the thumb. This was noted in the study by Inglis et al.” where 10 of 16 patients with MP arthrodesis developed CMC and IP joint complaints at later follow-up. Thus there is a need for implant arthroplasty in those patients who would be hampered by loss of motion at the MP joint and whose joint does not allow a simple synovectomy. There are few published studies of implant arthroplasty for MP joint of the thumb. Swanson and Herndon13 reported on 44 flexible implant arthroplasties of the metacarpal-phalangeal joint of the thumb in 1977.
Beckenbaugh and Steffee6 reported on 40 implant arthroplasties using the cemented Steffee device in 198 1. In the study by Swanson and Hemdon, the 44 thumbs were done predominantly for rheumatoid arthritis. The average follow-up was 30 months, with a range of 2 to 6% years. They found the results to be good-toexcellent in 42 of the 44 thumbs, with excellent pain relief, an increased arc of motion and an increase in the ability to perform activities of daily living. Overall, the average arc of range of motion at follow-up was 29 degrees (range, 10 to 60 degrees). They also found that the flexion deformity was corrected by an average of 26 degrees. Stability was much improved after operation. Key pinch strength was measured in only 29 of
Vol. 15A, No. 2 March 1990
Metacarpal-phalangeal joint arthroplasty of rheumatoid thumb
their 44 patients and only 6 showed increases in strength; while 23 showed slight decreases in key pinch strength. They also noted that after implant arthroplasty, no patients required further surgery on their CMC or IP joints. However, they did note a recurrence of hyperextension deformity of the IP joint in several patients. Five implants fractured within the first 8 months after operation. In the series by Beckenbaugh and Steffee6 42 cemented prostheses were evaluated at a follow-up from 12 to 40 months. The average motion of the MP joint was only 16 degrees with good pain relief, however, 12 of 35 implants with radiographic evaluation had lucent lines at the bone cement interface. We report the results of 43 implant arthroplasties of the thumb with an average 6% year follow-up. The average active range of motion was 25 degrees, which is consistant with that reported by Swanson and Hemdon. I3 Pain relief was excellent and functional improvements were noted in 39 hands. Patients noted an improvement in the ability to open a door, button clothes, and pick up a coin. Key pinch strength in these patients averaged 4 pounds (range, 0.5 to 10). Although this is a great deal less than the 15 to 17 pounds of key pinch strength seen in average females,14 we believe that this is more due to the extent of the disease and the instability of other joints. In all cases in this series, there was disease of the MP joint of the index finger, 24 of which required arthroplasty. Thus stability of the index finger was hampered in the majority of the cases. Key pinch strength was more reflective of the inability of the index finger to sustain pinch as the thumb almost universally overpowered the index finger. No implant fractures were noted in this series. Other series of silicone implant arthroplasty of the MP joints of the fingers have noted fracture rates from 9% as noted by Ferlic and associatesI to 21% as noted by Blair and colleaguesi and 26% as noted by Beckenbaugh et al. ” None of these included any thumb implants. Swanson and Hemdon13 noted a 11% fracture rate in their series of Swanson implant arthroplasties for the metacarpalphalangeal joint of the thumb. All of these occurred in patients who did not have the high performance Elastomer implant. The absence of implant fractures in our series is most likely due to a combination of factors including the deforming force occurring in a flexion and extension plane rather than a radial and ulnar plane and also the low demands in the severely involved patients. In addition, the thumbs were immobilized for a 6-week period allowing development of a soft tissue sleeve around the implant, which may provide greater stability. There was only one superficial infection in this series
215
that resolved with conservative treatment. This is comparable to other infection rates seen with Swanson implant arthroplasties of the MP joints of the hand. Beckenbaugh et al.17 noted a deep infection rate of 0.6% and Blair and associates16 had 3 in 115 implants and Bieber and colleagues” had 2 in 210 implants. Mannerfelt and AndersonI had 1 in 144 implants. Thus the silicone implants appear to be well tolerated even in patients with severe rheumatoid arthritis who are receiving high-dose steroid therapy. No evidence of silicone synovitis was observed. Bony sclerosis was noted in 64% of the cases, which is higher than that seen by Swanson and Hemdon, who stated they saw no reactive bone formation in 42 thumbs. This rate is almost double that seen by Blair and colleagues’6 who reported bone production around 35% of their implants in the MP joints of the hand. The bone erosion rate in this series was extremely low with a 12% rate, which is in between the rate seen by Swanson and HemdonL3 with erosion in 2 of 44 thumbs and BlairI who noted a bone erosion rate of 41% in the MP implants of the fingers. The effect of arthrodesis of the MP joint of the thumb on the other joints of the thumb has been previously discussed by Inglis et al.” In that article, they noted that 10 of 16 patients developed further CMC or IP joint symptoms. Beckenbaugh and Linscheid5 has stated that fusion of the MP and IP joints places a greater stress on the CMC joint. This may lead to an unsatisfactory result as the patient must use the CMC joint to position the thumb in space and cannot use the thumb for activities requiring fine dexterity. In addition, they noted that the length of the thumb is often not maintained with MP arthrodesis, but they believed that this is usually not a significant problem. In this series, maintenance of motion of the MP joint of the thumb with the use of an MP arthroplasty allowed preservation of the IP and CMC joints. No further operations were required on any IP or CMC joints in any of the thumbs. Only one thumb had radiographic and clinical progression of disease of the IP joint and two thumbs had clinical and radiographic progression of disease of the CMC joint. We believe that the maintenance of motion of the MP joint allows for decreased stress at the IP and CMC joints. Thus we approach the patient with rheumatoid arthritis in the following manner. The patient’s functional needs and level of pain must be determined in addition to the patient’s ability to perform activities of daily living. The entire upper extremity and rest of the hand must be considered in conjunction with the thumb. With regard to the thumb itself, the type of deformity and status of the MP joint must be determined. A patient
216
Fig@
et al.
with early disease of the MP joint can be treated with
a synovectomy and dorsal hood reconstruction. Patients with severe disease with significant bone loss, inadequate collateral ligaments, and joint dislocation are candidates for arthrodesis. Patients with erosions of the MP joint but with satisfactory collateral ligaments are candidates for implant arthroplasty depending on the patient’s functional requirements. In patients with IP and MP joint involvement, if the IP joint requires fusion then we recommend implant arthroplasty of the MP joint. Patients who require motion at the MP joint to perform activities requiring fine dexterity are candidates for MP arthroplasty. Patients with high demands, such as laborers, may be better treated by MP arthrodesis unless they also have CMC or IP joint involvement. REFERENCES 1. Millender LN, Nalebuff EA. Reconstructive surgery in the rheumatoid hand. Orthop Clin North Am 1975:6:70932. 2. Nalebuff EA. Diagnosis, classification and management of rheumatoid thumb deformities. Bull Hosp Jt Dis 1968;29:119-37. 3. Swanson AB, Swanson GD. Thumb disabilities in rheumatoid arthritis: classification and treatment. A.A.O.S. Symposium on Tendon Surgery in the Hand. St. Louis: The CV Mosby Company, 1974:233-54. 4. Beckenbaugh RD. Arthrodesis of the metacarpalphalangeal joint of the thumb. Ortho Trans 1980;4:291. 5. Beckenbaugh RD, Linscheid RL. Metacarpal-phalangeal joint of the thumb. In: Green’s operative hand surgery. New York: Churchill-Livingstone, 1988:185-189. 6 Beckenbaugh RD, Steffee AD. Total joint arthroplasty for the metacarpal-phalangeal joint of the thumb-a preliminary report. Orthopaedics 1981;4:295-8. 7. Brumfield RH. Conaty JP. Reconstructive surgery of the
The Journal of HAND SURGERY
thumb in rheumatoid arthritis. Orthopaedics 1980;3:52933. 8. Ferlic DC, Turner BD, Clayton ML. Compression arthrodesis of the thumb. J HAND SURG 1983;2:207- 10. 9. Harrison SH, Ansel BM. Surgery of the rheumatoid thumb. Br J Plast Surg 1974;27:242-7. IO. Harrison SH, Smith P, Maxwell D. Stabilization of the first metacarpal-phalangeaI and terminal joints of the thumb. The Hand 1977;9;242-9. 11. Inglis AE, Hamlin C, Senglemann RP, Straub LR. Reconstruction of the metacarpal-phalangeal joint of the thumb in rheumatoid arthritis. J Bone Joint Surg 1972;54A:704- 12. 12. Salgeback S, Eiken 0, Haga T. Surgical treatment of the rheumatoid thumb. Stand J Pfast Reconstr Surg 1976; 10;153-6. 13. Swanson AS, Hemdon JH. Flexible (silicone) implant arthroplasty of the metacarpal-phalangeal joint of the thumb. J Bone Joint Surg 1977:59A:362-8. 14. Mathlowetz V, Kashman N. Volland G, Weber K, Dowe M. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 1985;66:69-74. 1.5. Ferlic DC, Clayton ML, Holloway M. Complications of silicone implant surgery in the metacarpal-phalangeaf joint. J Bone Joint Surg 1975;57A:991-4. 16 Blair WF, Shurr DG, Buckwalter JA. Metacarpalphalangeal joint implant arthroplasty with a silastic spacer. J Bone Joint Surg 1986;66A:365-70. 17. Beckenbaugh RD, Dobyns JH, Linscheid RL, Bryan RS. Review and analysis of silicone rubber metacarpalphalangeal implants. J Bone Joint Surg 1986;58A: 483-7. 18. Bieber EJ, Weiland JA, Volenec-Dowling S. Silicone rubber implant arthroplasty of the metacarpal-phalangeal joints for rheumatoid arthritis. J Bone Joint Surg 1986;68A:206-9. 19. Mannerfelt M, Anderson K. Sifastic arthroplasty of the metacarpal-phalangeal joints in rheumatoid arthritis. J Bone Joint Surg I975;57A:484-9.
joint. All thumbs had less
The average range of active motion is 25 degrees, with a flexion arc from
15 to 40 degrees. There is an average key pinch strength of 4 pounds (range, 0.5 to 10). Improvement in activities of daily living were noted in 40 hands. One thumb required reoperation for instability; Radiographic
the implant was removed and a metacarpal-phalangeal
and in two other thumbs at the carpometacarpal operations.
arthrodesis
was done.
progression of disease was noted in only one thumb at the interphafangeal The maintenance
joint
joint. None of these have required further
of motion appears to help in activities of daily living as stability
and pinch strength are often adequate.
(J HAND SURG 1990;15A:210-16.)
M. P. Figgie, MD, A. E. Inglis, MD, M. Sobel, MD, New York, N.Y., W. W. Bohn, MD, Kansas City, MO., and D. A. Fisher, BS, Nogolk, Vu.
A
mobile, pain-free thumb that can provide pinch strength is vital to the rheumatoid patients’ ability to perform the activities of daily living including eating and buttoning clothes. Numerous previous studies have discussed the types of deformities in the rheumatoid thumb. l-3 The boutonniere deformity (type I), occurring in more than 50% of rheumatoid thumbs, is seen initially with a flexed metacarpal-phalangeal joint and an extended interphalangeal (IP) joint. In the early stages, the MP and IP joints maintain passive motion but become more fixed as the disease progresses. The other thumb deformities include a swan-neck deformity (type III), ulnar collateral ligament instability (type IV) and carpal-metacarpal dislocation with IP joint hyperextension (type II). There have been numerous studies
From the Hospital for Special Surgery, New York, N.Y.; the Research Medical Center, Kansas City, MO., and Norfolk, Va. Presented at the Eighteenth Annual Meeting of The American Association for Hand Surgery, Toronto, Canada, October 1988. Received for publication May 5, 1989.
Dec. 12, 1988; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mark P. Figgie, MD, The Hospital Surgery, 535 E. 70th St., New York, NY 10021. 311114327
210
for Special
on surgical reconstruction of the thumb,2-‘3 with various operations described depending on the amount of joint involvement, the status of the ligaments and tendons, and the status of the other joints of the thumb. Surgical options for the MP joint of the thumb range from synovectomy with dorsal hood reconstruction, to arthroplasty, and arthrodesis. Synovectomy with extensor reconstruction is recommended in those patients with reconstructable ligaments and a satisfactory joint.‘. ‘. ‘I. ” Arthrodesis is recommended for the painful, unstable joint and has enjoyed good results.2-4, ‘. ‘o-” Arthroplasty of the MP joint has been recommended for the MP joint that has ligamentous support but a destroyed articular surface combined with either carpometacarpal (CMC) or IP joint disease. However, there have been only two previous reports of implant arthroplasty for the thumb MP joint. Swanson and Hemdon’” reported on use of the Swanson silicone implant in 1977, and Beckenbaugh and Steffee6 reported their use of the cemented Steffee implant in 198 1. This study represenets a review of the Swanson silicone arthroplasty for the reconstruction of the rheumatoid thumb MP joint and specifically addresses whether the IP and the CMC joints deteriorated after MP joint surgery. Materials
and methods
Between April 1975 and June 1985,51 patients with seropositive rheumatoid arthritis had 59 Swanson
Vol. 15A, No. 2 March 1990
Metacarpal-phalangeal joint arthroplasty of rheumatoid thumb
211
Fig. 1. A, This 60-year-old right-handed woman had significant erosion of the MP joints. B-C, She had implant arthroplasty of her MP joints on the right hand. Six years after operation, she has maintained excellent function and alignment. In addition, there has been no progression of disease at the IP or CMC joints of the thumb.
metacarpal-phalangeal implant arthroplasties of the thumb. Nine patients had bilateral procedures. Eleven patients (15 implants) died before the time of this study, and 1 patient (1 implant) was lost to follow-up. Thus 43 implants in 38 patients were available for review. The procedures were performed or supervised by the senior author (A. E. I.). The average length of follow-up was 6% years (range, 3 to 13 years). Thirtyfour of the surviving 38 patients were women and four were men. The average age at the time of operation was 58 years (range, 26 to 82 years).
common deformity was a boutonniere (type I) deformity that occurred in 36 thumbs (Fig. 1). Thirty-one of these were flexible (stage I), three were fixed (stage II), and two had fixed MP and IP deformities (stage III). In addition, there were three thumbs with a swan-neck deformity (type III). There were four type II deformities with MP joint flexion, IP joint hyperextension, and CMC joint subluxation. No thumbs with ulnar collateral ligament instability (type IV) were included in this series.
Preoperative deformity
The prostheses used were the high performance tomer Swanson silicone metacarpal-phalanageal plants. No grommets were used.
The preoperative deformities were classified according to the system described by Nalebuff.2 The most
Prosthesis and surgical technique elasim-
212
The Journal of HAND SURGERY
Figgie et al.
The operation is done with the patient under regional anesthesia and tourniquet control. An oblique longitudinal incision is made dorsally over the MP joint. The tendons of the extensor pollicis longus and brevis are identified. The extensor hood is split between these tendons, and the extensor pollicis brevis, which is usually attenuated, is detached from the base of the proximal phalanx. The metacarpal head is then resected at the flair, perpendicular to the shaft. The collateral ligaments are protected and preserved. If the ligaments are inadequate, or are inadvertently transected at the time of surgery, then the MP joint should be arthrodesed. The proximal phalanx requires minimal resection, especially since the collateral ligaments attach proximally on the phalanx and should be protected. The canals of the metacarpal and the proximal phalanx are then reamed to accept the Swanson implant. Occasionally, the palmar plate must be released to correct a flexion contracture. The Swanson implant trials are then used to size for an adequate prosthesis. The prosthesis should be large enough to give a snug fit and good stability but should not cause a marked flexion contracture. If a flexion contracture occurs, more bone may need to be resected. After the correct prosthesis is implanted, the tendon of the extensor pollicis brevis is reattached to the proximal phalanx using drill holes for the sutures. The joint is held in extension when the tendon is sewn in and the extensor hood is then repaired. The joint is held in extension by the use of a Kirschner wire that is passed manually from the tip of the thumb proximally along the flexor sheath of the flexor pollicis longus to the base of the thumb. This acts as an internal splint. The wound is then closed and the thumb is held in a bulky splint. The Kirschner wire is left in place for 3 weeks and once it is removed the thumb is splinted for an additional 3 weeks. The patient is then allowed to begin range of motion exercises.
Clinical evaluation All patients were clinically and radiographically evaluated. They were examined by one of us (M. P. F.). Clinical examination included an evaluation of the CMC, MP, and IP joints of the thumb for pain, stability, range of motion, and function. Pain was rated on a scale of 1 to 5, with 1 equaling no pain and 5 being severe, disabling pain. Range of motion was measured by use of a goniometer in a manner consistent with that described by the American Academy of Orthopaedic Surgeons. Both active and passive motions were recorded. Function was assessed by the ability to perform the activities of daily living including feeding, buttoning clothes, and writing. Key pinch and grip strength
were measured and recorded by taking the maximum of three efforts. Key pinch was measured using a mechanical pinch meter and grip strength was recorded with a dynamometer.
Radiographic evaluation Radiographic evaluation included preoperative, postoperative, and current evaluations of the thumb. These were reviewed for implant position, breakage, and bony changes around the implant, including sclerosis around the implant and bony resorption. The CMC and IP joints of the thumb were evaluated for radiographic signs of disease and were compared for progression of the disease. All radiographs were evaluated by two of us (M. P. F. and M. S.).
Concomitant surgery Concomitant surgery was done on the ipsilateral hand in 40 of the 43 cases. The most common procedure in addition to the thumb implant was MP arthroplasty of the fingers. This was done in 17 cases. The second most common procedure was a dorsal stabilization of the wrist, which was done in 9 cases. A variety of other procedures were done including proximal interphalangeal (PIP) fusions, IP fusion of the thumb, extensor realignment of the hand, carpal tunnel release and flexor synovectomy. A combination of procedures was usually used, but always within a 2-hour tourniquet time limit.
Results Forty-two of the 43 implants available for study are still intact and only 1 has required revision for instability. Of these 42 implants, all patients have had improvement in pain relief and 34 have no pain at all at current follow-up. The remaining eight scored a four out of five on the pain scale. The active range of motion of the MP joint in these thumbs is 25 degrees (range, 10 to 40 degrees) in a flexion arc from 15 to 40 degrees. Passive range of motion averaged nearly 35 degrees. Function improved in 39 hands, as 38 patients were now able to perform activities of daily living including opening a door, buttoning their clothes, and picking up a coin. The average key pinch strength was 4 pounds (range, 0.5 to 10) and the average grip strength was 12.2 pounds (range, 0 to 25). Stability at the MP joint was obtained in 42 cases; however, all patients had at least a lodegree arc of radial and ulnar deviation when tested passively. Eleven patients had fusions of the IP joint at the time of surgery for malalignment or instability. All of these healed satisfactorily. Of the remaining 21 thumbs, the
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average range of motion at the IP joint was 50 degrees (range, 20 to 80). Forty-one thumbs had no pain at the 1P joint. However, six thumbs had recurrence of their hyperextension deformity, but none were fixed in hyperextension. TWO thumbs had pain at the CMC joint before operation and four thumbs had pain at current follow-up. NO thumbs have required further surgery at the CMC joint. NO thumbs had recurrence of synovitis, and there was no evidence of silicone synovitis. Complications
and revisions
There was only one superficial wound infection, which healed satisfactorily with local care. There have been no implant fractures. Only one revision surgery was necessary and this was in a patient who had the implant removed at another institution and had an arthrodesis done. Retrospectively, the patient preferred the implant as she finds the loss of motion with the arthrodesis hampers her functionally. Six patients had MP arthrodesis of the thumb on their opposite side (Fig. 2). In each instance, the patient preferred the side with the implant arthroplasty because of the preservation of motion. In addition, three of the patients with MP arthrodesis have gone on to have further CMC pain and one has gone on to have further difficulty with the IP joint of the thumb. Radiographic
evaluation
Radiographic evaluation of the MP joint of the thumbs show that no fractures of the implants had occurred. Bone resorption was present in only five of the thumbs for a rate of 12%. Bony sclerosis around the implant stems was present in 27 thrumbs for a rate of 64%. Seventeen of the thumbs had radiographic evidence of disease at the IP joint before operation. Eleven of these were arthrodesed at the time of surgery and 6 thumbs have radiographic evidence of disease at current follow-up. Two of these has shown progression of disease. Twelve thumbs had radiographic evidence of disease of the CMC joint before surgery and 13 thumbs at current follow-up have radiographic evidence of disease. Two of these thumbs had evidence of radiographic progression of disease (Fig. 3). Discussion The treatment of the thumb in rheumatoid arthritis is complex, especially when there is concomitant disease at the IP, MP, and CMC joints. A stable, pain free, and mobile thumb can be achieved through a variety of operations depending on the status of the thumb and the type of deformity. In the early stages of the disease,
Fig. 2. A, This 20-year-old right-handed woman had marked hand deformities. B, She had MP arthroplasties on both hands
with implant arthroplasty of the left thumb MP joint with arthrodesis of the IP joint. On the right side, she had arthrodesis of the MP and IP joints of the thumb. Currently at 8 years after operation she prefers the left side due to maintenance of motion in spite of the fact that she is right-handed.
synovectomy of the MP joint with extensor tendon reconstruction may give satisfactory results with good pain relief. Inglis et al.” noted complete pain relief in 11 of 21 patients, with an average arc of motion of 35 degrees. Salgeback and colleagues” noted significant pain relief in 76% of their patients who had synovectomy. However, synovectomy with dorsal hood reconstruction may not produce durable long-term results. Also, when there is significant joint destruction, synovectomy alone may not result in adequate pain relief. In these cases the options include either implant arthroplasty or MP athrodesis. Arthrodesis of the MP joint offers a durable result with adequate pain relief as noted in several studies.3. 4. ‘-l’ Union rates of MP arthrodesis have ranged from 80% as noted by Brumfield and Conaty’ to 100% as noted by Beckenbaugh.4 Stability of the thumb is often improved, which aids in activities
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Fig. 3. A, This 56-year-old woman had significant boutonniere deformities before operation. B, She had MP arthroplasty of both hands in 1983. On the left side, there has been maintenance of the IP and CMC joints, although a recurrence of the hyperextension deformity at the IP joint has occurred. C, On the right side, there has been radiographic progression of disease at the CMC joint. but she has maintained excellent function.
requiring opposition. However, activities requiring precision handling are often impaired because of the loss of mobility of the thumb. In addition, greater stresses are often placed on the IP and CMC joints of the thumb. This was noted in the study by Inglis et al.” where 10 of 16 patients with MP arthrodesis developed CMC and IP joint complaints at later follow-up. Thus there is a need for implant arthroplasty in those patients who would be hampered by loss of motion at the MP joint and whose joint does not allow a simple synovectomy. There are few published studies of implant arthroplasty for MP joint of the thumb. Swanson and Herndon13 reported on 44 flexible implant arthroplasties of the metacarpal-phalangeal joint of the thumb in 1977.
Beckenbaugh and Steffee6 reported on 40 implant arthroplasties using the cemented Steffee device in 198 1. In the study by Swanson and Hemdon, the 44 thumbs were done predominantly for rheumatoid arthritis. The average follow-up was 30 months, with a range of 2 to 6% years. They found the results to be good-toexcellent in 42 of the 44 thumbs, with excellent pain relief, an increased arc of motion and an increase in the ability to perform activities of daily living. Overall, the average arc of range of motion at follow-up was 29 degrees (range, 10 to 60 degrees). They also found that the flexion deformity was corrected by an average of 26 degrees. Stability was much improved after operation. Key pinch strength was measured in only 29 of
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their 44 patients and only 6 showed increases in strength; while 23 showed slight decreases in key pinch strength. They also noted that after implant arthroplasty, no patients required further surgery on their CMC or IP joints. However, they did note a recurrence of hyperextension deformity of the IP joint in several patients. Five implants fractured within the first 8 months after operation. In the series by Beckenbaugh and Steffee6 42 cemented prostheses were evaluated at a follow-up from 12 to 40 months. The average motion of the MP joint was only 16 degrees with good pain relief, however, 12 of 35 implants with radiographic evaluation had lucent lines at the bone cement interface. We report the results of 43 implant arthroplasties of the thumb with an average 6% year follow-up. The average active range of motion was 25 degrees, which is consistant with that reported by Swanson and Hemdon. I3 Pain relief was excellent and functional improvements were noted in 39 hands. Patients noted an improvement in the ability to open a door, button clothes, and pick up a coin. Key pinch strength in these patients averaged 4 pounds (range, 0.5 to 10). Although this is a great deal less than the 15 to 17 pounds of key pinch strength seen in average females,14 we believe that this is more due to the extent of the disease and the instability of other joints. In all cases in this series, there was disease of the MP joint of the index finger, 24 of which required arthroplasty. Thus stability of the index finger was hampered in the majority of the cases. Key pinch strength was more reflective of the inability of the index finger to sustain pinch as the thumb almost universally overpowered the index finger. No implant fractures were noted in this series. Other series of silicone implant arthroplasty of the MP joints of the fingers have noted fracture rates from 9% as noted by Ferlic and associatesI to 21% as noted by Blair and colleaguesi and 26% as noted by Beckenbaugh et al. ” None of these included any thumb implants. Swanson and Hemdon13 noted a 11% fracture rate in their series of Swanson implant arthroplasties for the metacarpalphalangeal joint of the thumb. All of these occurred in patients who did not have the high performance Elastomer implant. The absence of implant fractures in our series is most likely due to a combination of factors including the deforming force occurring in a flexion and extension plane rather than a radial and ulnar plane and also the low demands in the severely involved patients. In addition, the thumbs were immobilized for a 6-week period allowing development of a soft tissue sleeve around the implant, which may provide greater stability. There was only one superficial infection in this series
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that resolved with conservative treatment. This is comparable to other infection rates seen with Swanson implant arthroplasties of the MP joints of the hand. Beckenbaugh et al.17 noted a deep infection rate of 0.6% and Blair and associates16 had 3 in 115 implants and Bieber and colleagues” had 2 in 210 implants. Mannerfelt and AndersonI had 1 in 144 implants. Thus the silicone implants appear to be well tolerated even in patients with severe rheumatoid arthritis who are receiving high-dose steroid therapy. No evidence of silicone synovitis was observed. Bony sclerosis was noted in 64% of the cases, which is higher than that seen by Swanson and Hemdon, who stated they saw no reactive bone formation in 42 thumbs. This rate is almost double that seen by Blair and colleagues’6 who reported bone production around 35% of their implants in the MP joints of the hand. The bone erosion rate in this series was extremely low with a 12% rate, which is in between the rate seen by Swanson and HemdonL3 with erosion in 2 of 44 thumbs and BlairI who noted a bone erosion rate of 41% in the MP implants of the fingers. The effect of arthrodesis of the MP joint of the thumb on the other joints of the thumb has been previously discussed by Inglis et al.” In that article, they noted that 10 of 16 patients developed further CMC or IP joint symptoms. Beckenbaugh and Linscheid5 has stated that fusion of the MP and IP joints places a greater stress on the CMC joint. This may lead to an unsatisfactory result as the patient must use the CMC joint to position the thumb in space and cannot use the thumb for activities requiring fine dexterity. In addition, they noted that the length of the thumb is often not maintained with MP arthrodesis, but they believed that this is usually not a significant problem. In this series, maintenance of motion of the MP joint of the thumb with the use of an MP arthroplasty allowed preservation of the IP and CMC joints. No further operations were required on any IP or CMC joints in any of the thumbs. Only one thumb had radiographic and clinical progression of disease of the IP joint and two thumbs had clinical and radiographic progression of disease of the CMC joint. We believe that the maintenance of motion of the MP joint allows for decreased stress at the IP and CMC joints. Thus we approach the patient with rheumatoid arthritis in the following manner. The patient’s functional needs and level of pain must be determined in addition to the patient’s ability to perform activities of daily living. The entire upper extremity and rest of the hand must be considered in conjunction with the thumb. With regard to the thumb itself, the type of deformity and status of the MP joint must be determined. A patient
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with early disease of the MP joint can be treated with
a synovectomy and dorsal hood reconstruction. Patients with severe disease with significant bone loss, inadequate collateral ligaments, and joint dislocation are candidates for arthrodesis. Patients with erosions of the MP joint but with satisfactory collateral ligaments are candidates for implant arthroplasty depending on the patient’s functional requirements. In patients with IP and MP joint involvement, if the IP joint requires fusion then we recommend implant arthroplasty of the MP joint. Patients who require motion at the MP joint to perform activities requiring fine dexterity are candidates for MP arthroplasty. Patients with high demands, such as laborers, may be better treated by MP arthrodesis unless they also have CMC or IP joint involvement. REFERENCES 1. Millender LN, Nalebuff EA. Reconstructive surgery in the rheumatoid hand. Orthop Clin North Am 1975:6:70932. 2. Nalebuff EA. Diagnosis, classification and management of rheumatoid thumb deformities. Bull Hosp Jt Dis 1968;29:119-37. 3. Swanson AB, Swanson GD. Thumb disabilities in rheumatoid arthritis: classification and treatment. A.A.O.S. Symposium on Tendon Surgery in the Hand. St. Louis: The CV Mosby Company, 1974:233-54. 4. Beckenbaugh RD. Arthrodesis of the metacarpalphalangeal joint of the thumb. Ortho Trans 1980;4:291. 5. Beckenbaugh RD, Linscheid RL. Metacarpal-phalangeal joint of the thumb. In: Green’s operative hand surgery. New York: Churchill-Livingstone, 1988:185-189. 6 Beckenbaugh RD, Steffee AD. Total joint arthroplasty for the metacarpal-phalangeal joint of the thumb-a preliminary report. Orthopaedics 1981;4:295-8. 7. Brumfield RH. Conaty JP. Reconstructive surgery of the
The Journal of HAND SURGERY
thumb in rheumatoid arthritis. Orthopaedics 1980;3:52933. 8. Ferlic DC, Turner BD, Clayton ML. Compression arthrodesis of the thumb. J HAND SURG 1983;2:207- 10. 9. Harrison SH, Ansel BM. Surgery of the rheumatoid thumb. Br J Plast Surg 1974;27:242-7. IO. Harrison SH, Smith P, Maxwell D. Stabilization of the first metacarpal-phalangeaI and terminal joints of the thumb. The Hand 1977;9;242-9. 11. Inglis AE, Hamlin C, Senglemann RP, Straub LR. Reconstruction of the metacarpal-phalangeal joint of the thumb in rheumatoid arthritis. J Bone Joint Surg 1972;54A:704- 12. 12. Salgeback S, Eiken 0, Haga T. Surgical treatment of the rheumatoid thumb. Stand J Pfast Reconstr Surg 1976; 10;153-6. 13. Swanson AS, Hemdon JH. Flexible (silicone) implant arthroplasty of the metacarpal-phalangeal joint of the thumb. J Bone Joint Surg 1977:59A:362-8. 14. Mathlowetz V, Kashman N. Volland G, Weber K, Dowe M. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 1985;66:69-74. 1.5. Ferlic DC, Clayton ML, Holloway M. Complications of silicone implant surgery in the metacarpal-phalangeaf joint. J Bone Joint Surg 1975;57A:991-4. 16 Blair WF, Shurr DG, Buckwalter JA. Metacarpalphalangeal joint implant arthroplasty with a silastic spacer. J Bone Joint Surg 1986;66A:365-70. 17. Beckenbaugh RD, Dobyns JH, Linscheid RL, Bryan RS. Review and analysis of silicone rubber metacarpalphalangeal implants. J Bone Joint Surg 1986;58A: 483-7. 18. Bieber EJ, Weiland JA, Volenec-Dowling S. Silicone rubber implant arthroplasty of the metacarpal-phalangeal joints for rheumatoid arthritis. J Bone Joint Surg 1986;68A:206-9. 19. Mannerfelt M, Anderson K. Sifastic arthroplasty of the metacarpal-phalangeal joints in rheumatoid arthritis. J Bone Joint Surg I975;57A:484-9.
