Abstract
Background
The purpose of this study was to investigate the outcomes of surface replacement arthroplasty (SRA) for noninflammatory arthritis of the metacarpophalangeal (MCP) joint.
Methods
Records from 20 SRAs performed between 1995 and 2017 in 17 patients with noninflammatory arthritis affecting the MCP joint were retrospectively reviewed. The mean follow up was 6.6 years.
Results
Three arthroplasties (15%) underwent 4 revision operations. The 2-, 5-, 10-, and 15-year rates of survival from surface replacement implant revision were 90%, 90%, 79%, and 79%, respectively. Major complications occurring in revised joints included arthrodesis (n = 1) and amputation (n = 1). The overall reoperation rate was 35%. The 2-, 5-, 10-, and 15-year rates of overall reoperation-free survival were 75%, 69%, 60%, and 60%, respectively.
Conclusions
Pain ratings and MCP arc of motion significantly improved following arthroplasty. Metacarpophalangeal SRA for noninflammatory arthritis can improve arc of motion and pain. Revision is uncommon; however, 1 in 3 joints requires reoperation.
Keywords: MCP joint, metacarpophalangeal joint arthritis, metacarpophalangeal joint arthroplasty, noninflammatory arthritis, surface replacement arthroplasty
Introduction
Metacarpophalangeal (MCP) joint arthritis is a painful and functionally limiting condition.1,2 Arthroplasty is a common surgical treatment for arthritis of the MCP joint.3-5 Silicone implants are the criterion standard for MCP joint arthroplasty and have shown to reduce pain and improve function.6-13 Despite this, limited motion, implant fracture, and joint instability are common complications, particularly with long-term follow-up.6,7,12-19 Along with silicone implants, pyrolytic carbon implants are used in the surgical management of MCP arthritis.20-23 Arthritic hand joints can additionally be surgically managed using surface replacement arthroplasty (SRA) (Figure 1).3,24,25 In arthritic proximal interphalangeal (PIP) joints, SRA has been reported to improve pain and function.26-28 Most studies focus on the use of surface replacement (SR) implants in the PIP joint in combined groups of patients with osteoarthritis, posttraumatic arthritis, and rheumatoid arthritis.25-28 Metacarpophalangeal SRA has shown to be beneficial in the treatment of rheumatoid arthritis. 29 However, there is a paucity of data on SRA of the MCP joint for noninflammatory arthritis. The goal of our study was to analyze outcomes of SRA of the MCP joint in cases of noninflammatory arthritis. Implant revision rates, reoperations, complications, and clinical outcomes are investigated.
Figure 1.
Implant used for metacarpophalangeal surface replacement arthroplasty.
Materials and Methods
Data Collection
After institutional review board approval, a retrospective review of electronic medical records and an institutional joint registry was used to analyze patients having undergone MCP SRA for noninflammatory arthritis between January 1, 1995, and December 31, 2017. A 2-year minimum follow-up inclusion criterion was used, excluding 5 arthroplasties. Data collected included patient demographics, reoperations, and complications. Revision operations were defined as any reoperation involving replacement or alteration of the SR implant complements. Secondary operations were defined as those reoperations not involving the alteration of implant components. Patient clinical outcome data included pain ratings, MCP range of motion (ROM), and patient subjective satisfaction with arthroplasty outcome.
Study Population
The study consisted of 20 MCP SRAs in 17 patients with degenerative joint disease (DJD). The mean follow-up for the group was 6.6 years (range, 2.3-15.9 years). Primary operative indication was posttraumatic DJD in 6 cases (30%). Cement was used in 14 arthroplasties (70%), and bone graft was used in 1 arthroplasty (5%). Patient demographics are summarized in Table 1.
Table 1.
Study Group Demographics.
| Variable | N |
|---|---|
| Joints replaced | 20 |
| Patients | 17 |
| Mean follow-up, y | 6.6 (range 2.3-15.9) |
| Mean age, y | 60 (range 47-76) |
| Female (male) | 9 (11) |
| Mean BMI | 29.2 (range 18.3-40.7) |
| Posttraumatic DJD | 6 (30%) |
| Digit, No. (%) | |
| 2nd finger | 11 (55) |
| 3rd finger | 8 (40) |
| 4th finger | 1 (5) |
| Hand, No. (%) | |
| Dominant hand | 14 (70) |
| Nondominant hand | 4 (20) |
| Unknown dominant hand | 2 (10) |
| Implant size, No. (%) | |
| Small | 3 (15) |
| Medium | 10 (50) |
| Large | 5 (25) |
| Extra-large | 2 (10) |
Note. BMI = body mass index; DJD = degenerative joint disease.
SRA Technique
The MCP SRA implant is currently manufactured by Stryker, having previously been manufactured by Avanta (n = 15), Orthomet (n = 3), and RMS (n = 2) during the study period. In SRA, the metacarpal head is resected, followed by resection of the articular surface of the proximal phalanx. The intramedullary canals are then prepared and implant components inserted. Following collateral ligament reattachment, the capsule is closed. For 2 to 6 weeks postoperatively, the MCP joints are immobilized in extension. This is followed by removable splinting and hand therapy. Figure 2 shows a postoperative radiographic image of a patient having undergone SRA of the index finger to treat DJD.
Figure 2.
Postoperative radiograph following surface replacement arthroplasty of a metacarpophalangeal joint.
Statistical Analysis
The Kaplan-Meier model was used in survival analysis. Odds ratios were calculated to analyze risk factors for revision operation. JMP software was used for statistical analysis. Statistical significance was determined for P < .05.
Results
Arthroplasty Revision and Survival of Implant
The 2-, 5-, 10-, and 15-year rates of survival from arthroplasty revision were 90%, 90%, 79%, and 79%, respectively (Figure 3). Four revision operations occurred in 3 (15%) arthroplasties. One (5%) arthroplasty required revision operation 6 years postoperatively. This case required a new distal implant component, with no further complications or reoperations at final follow-up. Two arthroplasties (10%) in 1 patient required 1 revision operation at the middle finger and 2 revisions at the index finger. These 2 cases were considered to be failed revisions after arthrodesis at the middle finger and amputation at the index finger. Seventeen arthroplasties (85%) were free of revision at final follow-up.
Figure 3.
Survival from arthroplasty revision.
Reoperations
Including implant revision operations, reoperation occurred in 7 arthroplasties (35%). Overall 2-, 5-, 10-, and 15-year rates of survival from reoperation were 75%, 69%, 60%, and 60%, respectively (Figure 4). Secondary operations to treat complications occurred in 6 arthroplasties (30%) (Table 2). Two joints (10%) in 1 patient underwent reduction to treat limited motion 2 days postoperatively. Secondary operation to treat a soft tissue contracture occurred in 1 joint (5%). One joint (5%) underwent resection of the heterotopic bone to treat pain and limited function 6 years postoperatively. One joint (5%) that was previously revised to a silicone implant underwent silicone implant removal and arthrodesis. Amputation occurred in 1 finger (5%) to treat infection after 2 arthroplasty revision operations.
Figure 4.
Overall survival from reoperation.
Table 2.
Reoperation and Complication Data.
| Variable | N |
|---|---|
| Arthroplasties requiring revision | 3 (15%) |
| Total arthroplasty revision operations | 4 |
| Replacement of multiple components | 2 |
| Replacement of distal component | 1 |
| Removal of revised SRA implant | 1 |
| Indication for revision | |
| Deformity and pain | 3 |
| Infection | 1 |
| Joints requiring secondary operation | 6 (30%) |
| Total secondary operations | 7 |
| Reduction/Manipulation | 2 |
| Soft tissue repair | 2 |
| Other a | 3 |
| Joints with at least 1 complication | 13 (65%) |
| Total complications | 23 |
| Soft tissue contracture | 6 (30%) |
| Limited motion | 4 (20%) |
| Ligament loosening | 3 (15%) |
| Subluxation/Instability | 3 (15%) |
| Other | 7 (35%) |
| Mean time to first complication, mo | 20 (range 0-75) |
Note. SRA = surface replacement arthroplasty.
Other secondary operations included amputation (n = 1), revised implant removal (n = 1), and heterotopic bone resection (n = 1).
Clinical Outcomes
Patient-reported pain rating significantly improved postoperatively (P < .0001) (Table 3). In all, 80% (n = 16) of arthroplasties resulted in no or mild pain postoperatively, compared with 0% (n = 0) of arthroplasties preoperatively. Thirteen arthroplasties (65%) yielded a pain-free outcome. Of the 18 joints in which the SR implant was retained at final follow-up, all 18 joints (100%) experienced improvement in pain ratings. Arc of motion at the MCP joint significantly improved from 37° preoperatively to 56° postoperatively (P = .04). Mean postoperative ROM was 62° for the 18 joints with a retained SRA and 0° for the 2 failed revision cases. In all, 14 patients (82%) reported an improvement in their condition after undergoing MCP arthroplasty.
Table 3.
Clinical Outcomes.
| Outcome measure | Preoperative | Postoperative | P value |
|---|---|---|---|
| No or mild pain at joint | 0 (0%) | 15 (79%) | <.0001 |
| MCP arc of motion | 37° | 56° | .04 |
| Patient-reported improvement | — | 14 patients (82%) | — |
Note. MCP = metacarpophalangeal.
Complications
Complications occurred in 13 joints (65%) and 10 patients (59%) (Table 2). Mean time to first complication was 20 months (range, 0-75 months). Multiple complications occurred in 4 arthroplasties (20%). Major complications associated with reoperations included limited motion (n = 3), subluxation/functional instability (n = 3), soft tissue contracture (n = 2), heterotopic bone (n = 2), protrusion of distal implant component (n = 1), and infection (n = 1). Less significant complications not directly associated with reoperations included soft tissue contracture (n = 4), ligament loosening (n = 3), delayed healing and drainage (n = 2), limited motion (n = 1), and ankylosis (n = 1).
Discussion
Although silicone arthroplasty is the criterion standard for the surgical management of MCP arthritis, SR and pyrolytic carbon implants are also used.3-5,20,21,24,25 Most studies on SRA in the hand investigate outcomes at the PIP joint.25-28 To the authors’ knowledge, no study to date has demonstrated the use of MCP SRA for noninflammatory arthritis.
Implant revision occurred more frequently in our series of MCP SRAs than similar studies investigating the treatment of this condition with pyrocarbon arthroplasty or silicone arthroplasty.11,20,22,23 Implant revision rates with pyrocarbon arthroplasty have been reported to range from 6% to 12% in this condition, compared with 15% in our study.20,22,23 Dickson et al 20 reported an 88% 10-year rate of survival from implant revision in a series of patients with noninflammatory arthritis treated with pyrocarbon MCP arthroplasty. This can be compared with a 79% 10-year survival from revision in our study. Similarly, Rettig et al 11 reported a 7% revision rate at a mean follow-up of 40 months in silicone implants for idiopathic osteoarthritis of the MCP joint.
Three arthroplasties underwent revision in 2 patients. One patient underwent revision of an index SRA 6 years postoperatively. This revision involved replacement of a protruding distal polyethylene component, effectively managing recurrent pain and deformity with no further reoperations or complications during follow-up. One patient underwent revision of implants at the index and long finger. The index finger underwent replacement of the distal component to manage subluxation of the MCP joint 7 months postoperatively. Revision was complicated by infection, resulting in removal of the implant, followed by index finger amputation for progressive infection 3 weeks later. In the same patient, the long finger was revised 16 months postoperatively to a silicone implant to treat a progressive flexion contracture and associated pain. Three years after revision, silicone implant removal and arthrodesis were performed to treat pain and limited function due to a flexion contracture. Co-occurring conditions including intrinsic handle muscle paralysis, carpal tunnel syndrome and release, and a history of long finger PIP synovectomy may have contributed to the difficulties experienced by this patient.
Revision of an SRA can be challenging, particularly due to cementing of the proximal component at initial operation. All 3 revised arthroplasties in our study required removal of cement from the metacarpal canal during revision. To contrast this, pyrocarbon arthroplasty is less reliant on cement fixation, potentially offering fewer difficulties at revision. The challenges of revising a previously cemented SR implant remain a concern.
Similar to studies on pyrocarbon and silicone implants, SRA was shown to reliably improve pain.4,12,17,22,28 Studies investigating pyrocarbon implants for this condition have shown improvements in mean arc of motion ranging from 10° to 14°, compared with a mean increase in arc of motion of 19° in our study.21-23 Similar to our study, postoperative arc of motion has been reported to range from 40° to 76° in pyrocarbon implants.20-23 Our study showed more reliable improvement in arc of motion than that reported for silicone implants by Rettig et al. 11 These results suggest SRA can provide similar or greater ROM at the MCP joint similar to other arthroplasty methods, with similar improvements in pain.
The SRA of the MCP joint can be more challenging than that of the PIP joint, for which much of the data on this procedure are published. 6 Joints in our study frequently encountered complications. While most frequently occurring, it is unclear whether all soft tissue contractures should be considered true SRA complications as only 2 of 6 contractures required surgical intervention. Of the 4 arthroplasties experiencing limited motion, 1 ultimately underwent amputation, 1 yielded a postoperative arc of motion of 90° without surgical intervention, and 2 resulted in arcs of motion of 20° and 10° despite surgical attempts to correct limited motion. Some patients may have a greater predisposition for complications following SRA, as the 1 patient who eventually underwent arthrodesis and amputation accounted for 35% (n = 8) of complications in the study. Further research with larger volumes of arthroplasties is needed for statically significant assessment of risk factors for complications, reoperations, and implant revision.
This study has limitations. Retrospective collection of data from electronic medical records and a joint registry limit the data available for analysis. The limited number of arthroplasties performed prevented us from conducting a powered statistical analysis of risk factors for revision operation. We did not assess grip strength or pinch strength due to lack of preoperative values for several patients. Clinical outcome analysis is additionally limited due to the lack of functional outcome scores in this study.
Surface replacement arthroplasty serves as an additional surgical treatment for arthritic hand joints. Our study demonstrated that MCP SRA for noninflammatory arthritis can effectively improve pain ratings and arc of motion with good patient satisfaction in many cases. Clinical outcomes were comparable with other arthroplasty methods for this condition, while revision occurred more frequently in SRA. This study describes the benefits SRA can offer to patients with noninflammatory arthritis and examines the range of shortcomings that may occur in the setting of revision operations and complications.
Footnotes
Authors’ Note: All authors were actively involved in the planning, enactment, and writing of this study
Ethical Approval: Institutional review board approval was obtained: 17-003699.
Statement of Human and Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.
Statement of Informed Consent: Informed consent for research purposes was obtained per institutional protocol.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Matthew R. Claxton 
https://orcid.org/0000-0001-9309-1228
Marco Rizzo https://orcid.org/0000-0001-9363-2768
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