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. 2024 Nov 30;17(1):100195. doi: 10.1016/j.jham.2024.100195

Dual-mobility thumb carpometacarpal joint arthroplasty. Keypoints of surgical procedure for a satisfying outcome

Efstratios D Athanaselis 1,⁎, Filippos Zigras 1, Theofilos Karachalios 1, Sokratis Varitimidis 1
PMCID: PMC11664162  PMID: 39720004

Abstract

Thumb carpometacarpal (CMC) arthritis is a prevalent pathology, particularly among elderly women, with a significant impact on patients' quality of daily life. Total joint replacement can provide a shorter rehabilitation period and satisfying function, at least in the short term with encouraging findings according to recent studies concerning its complications (e.g., dislocation, loosening) and longevity. TOUCH® is a second-generation, dual mobility prosthesis with promising results. Step-by-step surgical technique and keypoints for successful implantation and satisfying thumb function are presented in this article.

Keywords: Thumb carpometacarpal arthritis, CMC I arthroplasty, Dual mobility, Porous coated implants, Neck offset

Highlights

  • •

    Total joint replacement for CMC I arthritis is gaining popularity.

  • •

    TOUCH® is a second-generation, dual mobility pressfit prosthesis.

  • •

    Step-by-step surgical technique and keypoints for a satisfying outcome are presented.

1. Introduction

Thumb carpometacarpal (CMC) arthritis, also known as basal arthritis of the thumb, is a prevalent pathology, particularly among middle-aged and elderly women. The incidence ranges from 32 % of people over 50 years old to 91 % of those over 80.1 However, it seems that most people adapt to trapeziometacarpal arthrosis.

Treatment is indicated in cases of symptomatic CMC I arthritis. Decreased and painful mobility of the thumb affects pinch and grasp strength, impacting the patient's quality of life. Numerous surgical procedures have been documented as treatment options for this condition. However, the results vary, and yet none of the techniques has been proven significantly superior to others. Controversy regarding cost-effectiveness and a lack of comparable data makes the extraction of solid and definitive conclusions for the best treatment problematic.2,3 Total joint replacement has evolved since its introduction in the 1970s, and recently, an increasing number of studies have shown that it can provide a shorter rehabilitation period and improved function, at least in the short term, compared with other techniques. However, dislocation and aseptic loosening risk are the main considerations about these prostheses, with rates of 10 and 4.5–26 %, respectively, reported in the literature.4, 5, 6, 7, 8 Improvements in implant design aim to address these issues. TOUCH® by KeriMedical is a new generation, dual mobility prosthesis. This paper presents the operative procedure of prosthesis implantation in detail and provides useful surgical tips, aiming to maximize satisfactory clinical outcome and minimize complications.

2. Surgical technique

The patient is placed in a supine position, either axillary block or general anaesthesia is induced, and a padded tourniquet is placed on the upper arm. A dorsal approach by a 5 cm longitudinal incision over the carpometacarpal joint is used, utilizing the space between the EPL and 1st dorsal compartment tendons (EPB, APL). The terminal branches of the superficial radial nerve and the dorsal carpal branch of the radial artery must be identified and protected. The joint capsule is longitudinally or transversely cut and carefully detached from the distal half of the trapezium and the metacarpal base, preserving adequate sound flaps for capsule restoration. The carpometacarpal joint is exposed, osteophytes are resected using a bone rongeur, and the metacarpal base is mobilized. Using a special Hohmann retractor, the metacarpal bone is dorsally luxated, and its base is osteotomized, usually around 5 mm, with the aid of a metacarpal resection guide. Often, there is a large osteophyte on the palmar side of the metacarpal, which can cause impingement and instability during thumb flexion and opposition, and it must be removed either with the bone saw or a rongeur. The medullary canal is opened with a straight Ombredanne reamer aiming at the dorsal one-third of its height and in the center of its width. Using metacarpus rasps of increasing size, the metacarpal trunk is prepared, securing proper orientation of the cavity and avoiding over-reaming. Providing that there is rotational stability, the last rasp size indicates the size of the stem. Trial stem positioning is optional, and the surgeon may proceed with the permanent metacarpal stem, which has a spike indicating its dorsal side. The anatomic metacarpal stem, available in six sizes, is made of titanium coated with hydroxyapatite (HA) and porous titanium. The porous-coated surface must be fully inserted into the prepared metacarpal (Fig. 1).

Fig. 1.

Fig. 1

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Female patient 62 years old with thumb CMC arthritis and De Quervain tenosynovitis of the left hand. After the 1st dorsal compartment release, the CMC capsule is longitudinally opened, and the metacarpal is dorsally dislocated (a). The base of the metacarpal is resected by a saw using a guide tool (b). The medullary canal of the metacarpal is prepared using rasps of increasing size (c), and the permanent stem is press-fitted flush with the bone. Note that the palmar edge of the metacarpal at the level of osteotomy is additionally resected (d).

The next step in the procedure is trapezium preparation for cup placement. Using the special Hohmann retractor, the entire distal articular surface of the trapezium is exposed. Osteophytes on the ulnar (medial) side of the trapezium should be removed as they can cause mechanical impingement (cam effect) during thumb adduction. Lateral side osteophytes are resected mainly for aesthetic reasons. However, successful fixation of the cup requires an intact central, hard osteochondral area of the trapezium distal pole.9 The center of the trapezium joint surface is located, and a 1,6 mm guide K-wire is placed perpendicularly.

After confirming proper K-wire centering and direction by the image intensifier, the trapezium is reamed with cannulated reamers (the starter and the main reamer). The reamer should be fully inserted and flush with the trapezium joint surface. There are two types of cups (hemispherical and conical), with two available sizes (9 and 10 mm) for each one and congruous reamers. All cups are porous coated outside except for a distal flange of 0,7 mm. The porous surface must be fully inserted into the trapezium (Fig. 2). A trial cup handle is used for checking the size and scheme of the created cavity that will receive the press-fit permanent cup.

Fig. 2.

Fig. 2

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The distal articular surface of the trapezium is revealed using the special Hohmann retractor, and osteophytes of the circumference are excised with caution not to damage the central osteochondral area where a guide wire is put perpendicularly (a, b). The positioning and axis of the drill guide are checked by the image intensifier in anteroposterior and lateral views (c, d).

In the next stage, the appropriate size and type of neck are selected. The necks, both straight and offset (15°), are available in three lengths (6, 8, and 10 mm). The dual mobility mechanism relies on a 7 mm in diameter polyethylene liner and a 4 mm metallic head on neck which are pre-assembled. Trial necks are used, starting with the small size and evaluating metacarpal pistoning, passive thumb motion, and dislocation tendency. The head should not be tracked out of the cup for more than half of its height by pulling the thumb (piston effect). The absence of the cam effect is very important, especially during the opposition of the thumb at the base of the little finger and retropulsion. Straight and off-set necks are tested as well, and the proper one is selected. The permanent neck is fitted into the stem, and the arthroplasty is reduced. The stability and mobility tests are carried out again, and an X-ray is optional intraoperatively (Fig. 3, Fig. 4).

Fig. 3.

Fig. 3

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The reamer is inserted over the guide wire (a), and the cavity for cup fixation is prepared in trapezium (b). The cup is press-fitted with its outer polished flange left outside of the bone (c), and the proper neck (with an offset in this case) is fixed on the stem (d).

Fig. 4.

Fig. 4

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Mobility and stability check of the arthroplasty by putting the thumb in opposition (a), retropulsion (b), and tenodesis effect (c, d). Through these tests, the range of motion and the stability of the prosthesis are evaluated, and possible impingement can be detected.

The final step is the wound closure. The capsule should be closed tightly, adding stability to the arthroplasty. Final testing for unencumbered motion and stability of the thumb can be carried out at this stage. The skin is closed with absorbable sutures. There is no need for a cast, but during bandaging, care is taken to keep the thumb in abduction. After 7–10 days, the soft dressing is removed and the mobilization of the thumb begins, with the sole limitation of lifting no more than 2 kg for the next 3 months.

3. Discussion

There are two basic approaches to the thumb CMC joint that have been described: the dorsal and the lateral (or Wagner).10 In the lateral approach, almost always the detachment of the APL insertion is necessary to expose the base of the first metacarpal bone. In the dorsal approach, this can be avoided by preserving the thenar muscles' functionality, which is critical in the postoperative period. Though the dorsal scar is more visible, skin quality is better. We prefer the dorsal approach due to better visualization of the CMC joint. However, both approaches are widely used, and it is mainly a matter of the surgeon's preference.

There are also two types of arthrotomies that can be performed, the longitudinal one, just dorsal to the APL tendon, and the transverse one at the level of the CMC joint. In both, rigorous detachment of the capsule from the trapezium and metacarpal metaphysis is crucial in order to prepare flaps able to be sutured for joint closure as a tight capsuloligamentous closure is important for additional stability of the arthroplasty.

Preparing the metacarpal bone differs from femur preparation during hip arthroplasty in that rasping and stem size are not aiming for a rigid press-fit fixation, as tight cortical contact is not required to prevent stem subsidence.11 The funnel-shaped intramedullary canal of the first metacarpal does not provide longitudinal stability through three-point fixation. Thus, the cancellous bone is perturbed through broaching to generate a dense bone layer capable of withstanding the subsidence of the anatomical stem in combination with the cementless hydroxyapatite coat, yielding stable outcomes.12 Ledoux's analysis revealed that stress-shielding can be induced by cortical contact of the stem, as bone loss was observed in the proximal portion of the metacarpal.13 Moreover, extraction of the stem in case of revision surgery, is simplified when adequate space exists between the stem and the cortex to facilitate the insertion of osteotomes or pins to separate it.

As previously delineated in the technique, the permanent stem can be implanted after the preparation of the metacarpal and the determination of the appropriate stem size. If properly positioned, the stem is fitted into the bone at full length. Therefore, permanent implantation at this stage does not interfere with the rest of the procedure. However, maintaining the trial metacarpal stem until deciding on the neck size can be helpful in case the arthroplasty is finally under tension, even with the smallest available neck, making possible an additional osteotomy of the base of the metacarpal.

Resection of the osteophytes from the metacarpal base and trapezium is critical. An additional oblique osteotomy on the volar aspect of the metacarpal can be done by the saw after the base has been resected. It is also important to remove osteophytes from the rim of the articular surface of the trapezium while taking care to leave enough osteochondral surface for the placement of the cup, as Spartacus et al. pointed out.14 Depending on the shape of the distal pole of the trapezium, an attempt to flatten it can significantly decorticate the area needed for cup fixation, and this should be avoided. Moreover, the optimal position of the cup is reported to be in the center of the trapezium to prevent trapezium fracture during implantation.15 Duerinckx et al. found that the cup should be parallel to the proximal articular surface of the trapezium (PAST), according to a fluoroscopy study.16 Later, in a biomechanical cadaveric study, Brauns et al. also confirmed that when the cup is placed parallel to the PAST line, the dislocation risk is diminished.17 On the other hand, Druel et al. reported that neither the PAST nor the trapezoidal articular surface of the trapezium (TRAST) affect cup implantation when the height of the trapezium is maintained. However, when the trapezium height is low, these lines should be taken into consideration in order to avoid complications such as trapezium fracture, TRAST lesions, and cup instability. Additionally, they emphasize the option of the lateralization of the cup, especially when the trapezium height is low because there is a high risk of impingement with the TRAST.18 However, the distal surface of the trapezium may be inclined to the level of the scaphoid-trapezium (ST) joint, and sufficient osteochondral area may not be centralized due to congenital or excessively deformative arthritis. In such cases, taking into account that an adequate osteochondral area is a prerequisite for a rigid cup fixation and a stable arthroplasty, orienting the cup parallel to the PAST line and in the center of the trapezium may not be possible and modifications in cup placement may be needed by the surgeon. Furthermore, the cup has an uncoated flange at its distal outer surface, which should always be left out of the bone to prevent cup subsidence in the cancellous bone. This explains why, in post-operative x-rays, the cup frequently seems not to be well impacted into the trapezium.

Concerning cup characteristics, there is no correlation between the cup size and the size of the trapezium. The 10 mm cup is usually left for revision, and there is no need to use it primarily, regardless of the size of the trapezium, which, of course, must definitely be longer than 6–7 mm in height. Adequate bone stock is crucial for rigid fixation of the cup, avoiding fractures of the trapezium during preparation.19 There are two available cup shapes on the market, the hemispherical and the conical ones, which are composed of stainless steel covered by porous titanium and HA. According to a recent study, trapezium remodeling does not correlate with cup design, which causes similar bone reactions.20 Moreover, in a combined cadaveric and sawbones study, cup components had a slight migration under axial compression loads up to 40 kg, most likely below the threshold of clinical significance. There was no discernible difference between the two cup shapes, although osteoporosis may lead to greater cup migration.21 However, in another biomechanical study, Garnier et al. reported that the conical cup had more compression bending strength than the hemispherical one.22 They found that a conical shape would improve the cup's primary stability during osseointegration. Similar results were also provided in a pig bone model study, confirming that conical cups outperformed hemispherical cups in terms of fixation.23 The fact that the conical cup's surface area for osseointegration is 20 % larger than the hemispherical one can probably explain this finding. Conical cups can therefore offer superior bone support and rotational stability, and we strongly recommend them even though orientation modification intra-operatively is extremely restricted after the trapezium is prepared by the proper reamer.

Lussiez et al. highlighted the benefits of the dual mobility concept as well as the significance of head size. They reported that the larger diameter of the preassembled head increased the dislocation distance. Additionally, the dual mobility design results in a range of motion up to 117°, decreasing the likelihood of neck-cup contact.8 Another advantage is that shear forces at the bone-cup contact are decreased as they are absorbed in the inner interface, leading to a reduced risk of aseptic loosening. Furthermore, the neck size should be chosen so as not to create tension. Elongation of the construction stresses the anatomy of the area, resulting in pain, tendinopathies (especially of the 1st extensor compartment tendons), and poor functional result in general. In addition, tight capsule closure and soft tissue scarring will decrease further thumb mobility. Proper thumb ray length may be estimated relatively to the second ray, before and after implantation in order to avoid overtensioning.

The stability of the arthroplasty should be passively checked with multidirectional thumb movements and dislocation testing in extreme positions of the thumb. The thumb is checked in abduction and adduction, both in the radial and palmar planes; in flexion and extension (retropulsion), and in extreme opposition below the palmar crease, in which impingement phenomenon can occur at the TRAST or with a neglected osteophyte of the trapezium. Neck shape (straight or off-set) can be tested and selected during this stage, evaluating the thumb metacarpal ROM and possible impingement. Though proper placement of components regarding position, depth and rotation for the stem as well as position depth and orientation for the cup are prerequisites for a successful arthroplasty, neck selection regarding size and type (straight or offset) can overcome possible mistakes and anatomical restrictions to some extent.

It is important to verify that the APL tendon's insertion is intact before capsule closure. Usually, a partial tear is present, which can be reinforced with the joint capsule. In cases of complete detachment of the tendon from the metacarpal during the approach, APL can be reattached using trans-osseous sutures that are placed through drilled holes on metaphysis prior to stem implantation.

Concerning the contraindications of TOUCH® prosthesis, the patient's age, occupation, and the trapezium bone stock are the most important to our experience. Thumb CMC arthroplasty should be avoided for young, heavy workers due to the increased risk of implants' failure and aseptic loosening. In addition, inadequate trapezium bone stock, evaluated mainly by its longitudinal height may jeopardize cup placement and fixation. On the other hand, thumb CMC arthritis of stage IV according to the Eaton-Littler classification, which includes degenerative arthritis of the scapho-trapezium-trapezoid (STT) joint, is referred to as a relative contraindication. We believe that implant arthroplasty of the CMC relieves the pressure on the STT joint by increasing the mobility of the thumb. Moreover, there are available implants (INCA®, groupe lépine) for scaphoid resurfacing arthroplasty, which can be carried out even at the same time with CMC implantation.24

Finally, post-operative immobilization and rehabilitation are also dependent on the surgeon's opinion. Though it is still unclear how much time is required for stem osseointegration, temporary thumb unloading is suggested following surgery. Though many surgeons prefer to immobilize thumb in a thumb spica for up to 3 weeks, it is reported that simple soft dressing keeping thumb in slight abduction with padding in the first web space for up to 7–10 days that allows active motion in IP joint, is enough. Afterwards, active thumb exercises and normal activities are encouraged for achieving a satisfying range of motion (and opposition) while a hand therapist is usually not need.8,25,26

4. Conclusion

Implant arthroplasty is a treatment option for thumb CMC arthritis that has gained ground remarkably in the last years. TOUCH® prosthesis incorporates the specifications of second-generation implants, including hydroxyapatite-coated cementless metacarpal stem and trapezium cup, dual mobility ball-and-socket articulation, and neck off-set. These characteristics improve the stability and longevity of the arthroplasty, together with the functional outcome, as long as the surgical technique complies with the specific parameters of the trapezium and metacarpal preparation, implant placement, and arthroplasty's biomechanics.

CRediT authorship contribution statement

Efstratios D. Athanaselis: Conceptualization, Methodology, Project administration, Writing – review & editing. Filippos Zigras: Investigation, Writing – original draft, Visualization. Theofilos Karachalios: Supervision, Validation. Sokratis Varitimidis: Supervision, Validation.

Ethical Statement for Solid State Ionics

Hereby, I Efstratios D. Athanaselis consciously assure that for the manuscript “Dual-mobility thumb carpometacarpal joint arthroplasty. Keypoints of surgical procedure for a satisfying outcome” the following is fulfilled:

1) This material is the authors' own original work, which has not been previously published elsewhere.

2) The paper is not currently being considered for publication elsewhere.

3) The paper reflects the authors' own research and analysis in a truthful and complete manner.

4) The paper properly credits the meaningful contributions of co-authors and co-researchers.

5) The results are appropriately placed in the context of prior and existing research.

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7) All authors have been personally and actively involved in substantial work leading to the paper, and will take public responsibility for its content.

The violation of the Ethical Statement rules may result in severe consequences.

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I agree with the above statements and declare that this submission follows the policies of Solid State Ionics as outlined in the Guide for Authors and in the Ethical Statement.

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Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

None.

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