18.11.2014
Long term outcome of trapeziectomy with ligament reconstruction/tendon
interposition versus thumb basal joint prosthesis
Controversies in hand surgery
Vandenberghe L et al; J Hand Surg Eur 2013
Implants
n = 519
No significant differences were found when comparing impairment, pain,
patient satisfaction and disability
- in CMC-1 osteoarthritis -
we recommend the trapeziectomy with ligament reconstruction and
tendon interposition as opposed to arthroplasty
Cochrane database 2005 Surgery for thumb osteoarthritis:
S. Schindele
Wajon A, Ada L, Edmunds I. Surgery for thumb (trapeziometacarpal joint). Osteoarthritis. Cochrane Database. Syst Rev. 2005,
No procedure was superior
Zürich
trapeziectomy only: 16% fewer adverse events
48. SGH Kongress 14.11.2014, Thun
CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
Handchirurgie
2 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
1. Do we need an implant or is resection arthroplasty always successful?
1. Do we need an implant or is resection arthroplasty always successful?
2. Do you trust completly in resection arthroplasty, if it would be your thumb?
2. Do you trust completly in resection arthroplasty, if it would be your thumb?
Problems in resection-arthroplasty:
Problems in resection-arthroplasty:
• Up to 10-15 % bad results in elderly
• Dissatisfaction >20% in young/ active patients
• Up to 10-15 % bad results in elderly
• Dissatisfaction >20% in young/ active patients
• Proximalisation of metacarpal-1
in combination with hyperextension MP-1
• Sometimes instability
• Power-loss during pinch (10-20% of normal)
• Limitation of presicion in grasping
• Long rehabilitation (6-12 mo)
• Proximalisation of metacarpal-1
in combination with hyperextension MP-1
• Sometimes instability
• Power-loss during pinch (10-20% of normal)
• Limitation of presicion in grasping
• Long rehabilitation (6-12 mo)
3 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
Theoretical advantage in total joint replacement
•
•
•
•
Preservation of normal anatomy
Preservation of normal biomechanics
Immediate stability
short rehabilitation
„Forgotten joint“ as in hip-arthroplasty
Different implants/ typs in the thumb
• Interposition-arthroplasty (total / partial)
• Hemi-arthroplasty
• Total joint replacement
5 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
4 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
Interposition arthroplasty:
Partial trapeziectomy
Different materials:
• Pyrocarbon (Pyrocardan, PyroDisc,
PyroSphere)
• Polyurethaneurea (Artelon)
• Polyethylenterephthalat (Dacron)
PyroDisc
Pyrocarbon-Results:
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•
•
•
•
Small number of patients
Bellmere: Beginning OA (Stage 1-2)
Barrera-Ochoa: Stage 2-3 (Eaton-Littler)
Short term good results (B-O 5y)
Complication rate in short term ≅10%
Bellemère P et al: Pyrocardan implant: free pyrocarbon interposition for resurfacing trapeziometacarpal joint Chir main 09/ 2011
Barrera-Ochoa S et al.: Pyrocarbon Interposition (PyroDisk) Implant for Trapeziometacarpal Osteoarthritis: Minimum 5-Year Follow-Up
6 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
1
18.11.2014
Interposition arthroplasty:
Partial trapeziectomy
Different materials:
Interposition arthroplasty:
Total trapeziectomy
Different materials:
• Pyrocarbon (Pyrocardan, PyroDisc,
PyroSphere)
• Polyurethaneurea (Artelon)
• Polyethylenterephthalat (Dacron)
8y
• Silicone
• Regenerative tissue matrix
(Graftjacket)
• Metal (TrapEZX)
• Pyrocarbon (Pi2)
Artelon - Results:
• n = 32
• No significant improvement to LRTI
• Complication rate 8 - 37%
TrapEZX
Pi2
Dacron – Results:
• Lot of foreign body reactions
Blount AL et al: Porous polyurethaneurea (Artelon) joint spacer compared to trapezium resection and ligament reconstruction. J Hand Surg Am 2013
Nilsson A. et al. The Artelon CMC spacer compared with tendon interposition arthroplasty. Acta Orthop 2010
Martinet X. et al: Reaction à corps étranger .... Interposition d‘un << anchois >> en Dacron. 5 cas . Chir de la main 2004
7 │ CMC-1 osteoarthritis – IMPLANTS
8 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
Interposition arthroplasty:
Total trapeziectomy
Stephan Schindele
Interposition arthroplasty:
Total trapeziectomy
• Silicone
• Silicone
• Regenerative tissue matrix
(Graftjacket)
• Metal (TrapEZX)
Norwegian Arthroplasty Register 2014 (n= 515 (1994 -2011))
• Pyrocarbon (Pi2)
• Regenerative tissue matrix (Graftjacket)
Revision rate: 8.2%
• Other autors: high complication rate (osteolysis, dislocation, wear, ...)
• Metal (TrapEZX)
• Pyrocarbon (Pi2)
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•
•
•
Interposition as tendon substitue
started in shoulder surgery (severe rotator cuff defect)
Up to now no literature in handsurgery available
own experience: results about the same as tendon interposition
Krukhaug Y et al. The results of 479 thumb carpometacarpal joint replacements reported in the Norwegian Arthroplasty Register. J Hand Sur Eur 2014
van Cappelle HG et al.: Swanson silicone trapezium implant for treatment of primary osteoarthritis: long-term results. J Bone Joint Surg Am. 2001
Creighton JJ Jr et al.: Long-term evaluation of Silastic trapezial arthroplasty in patients with osteoarthritis. J Hand Surg Am. 1991
9 │ CMC-1 osteoarthritis – IMPLANTS
10 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
Interposition arthroplasty:
Total trapeziectomy
Stephan Schindele
Interposition arthroplasty:
• Silicone
• Regenerative tissue matrix
(Graftjacket)
• Metal (TrapEZX)
• Silicone
• Regenerative tissue matrix
(Graftjacket)
• Metal (TrapEZX)
• Pyrocarbon (Pi2)
• Pyrocarbon (Pi2)
•
•
•
Total trapeziectomy
Bellémere, Ardouin: n=260
• Excellent clinical results
• Fast recovery
• Low complication ( need of capsuloplasty)
Total trapezium replacement (metal)
Fixation on metacarpal -2
Up to now no literature in handsurgery available
Maru M et al & Szalay et al: n=18 / 30
• same clinical result as LRTI
• High comlication rate 13-33% (dislocation)
Bellemére P, Ardouin L.: Pi2 Spacer Pyrocarbon Arthroplasty Technique for Thumb Basal Joint Osteoarthritis. Tech Hand Surg 2011
Maru M et al.: Thumb carpometacarpal osteoarthritis: trapeziectomy versus pyrocarbon interposition implant (Pi2). J Hand Surg Eur Vol 2012
Szalay et al.: Die operative Versorgung der Rhizarthrose mittels Pyrocarbonspacer als Trapeziumersatz. Handchir Mikrochir Plast Chir 2009
courtesy Mark Ross
11 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
12 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
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18.11.2014
Hemi-arthroplasty:
Total joint replacement:
De la Caffiniere 1979
Pyrocarbon Saddle/ Nugrip/ CMI
Martinez (Mayo): n=54
• Good clinical results
• Excellent grip strength
• High complication ( 28% reoperations)
Colegate-Stone TJ: n=38
• Prospective comparative study ( Trapezectomy
vs. Pyrocarbon)
• No significant differences clinicaly at 1 year
• Higher complication rate in pyrocarbon (n=7)
Martinez de Aragon J.S. et al.: Early Outcomes of Pyrolytic Carbon Hemiarthroplasty for the Treatment of Trapezial-Metacarpal Arthritis. J Hand Surg 2009
Colegate-Stone TJ. Et al.: Outcome analysis of trapezectomy with and without pyrocarbon interpo. to treat primary arthrosis of TMT joint. Hand Surg 2011
13 │ CMC-1 osteoarthritis – IMPLANTS
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•
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Van Cappelle et al.: survival rate 70% after 16 years
De Smet et al.: loosening rate of 44%
.... unacceptable high rates of loosening (cup), particular in
young patients
de la Caffiniere JY, Aucouturier P. Hand. 1979
Wachtl SW, Guggenheim PR, Sennwald GR.:Cemented and non-cemented replacements of the trapeziometacarpal joint. J Bone Joint Surg Br. 1998
van Cappelle HG et al.: Long-term results and loosening analysis of de la Caffinière replacements of the trapeziometacarpal joint. J Hand Surg Am 1999
De Smet L et al.: Total joint arthroplasty for osteoarthritis of the thumb basal joint. Acta Orthop Belg. 2004
14 │ CMC-1 osteoarthritis – IMPLANTS
Total joint replacement:
Steffee
• Cup: polyethylen
• Head & stem: metal
(Co/Cr), Cemented
• ball and socket joint
Wachtl et al.: n = 88
De la Caffiniere n=43 ; Ledoux n= 45
• Survival rate: 66.4% (5.7y FU) AND 58.9% (1.3y FU)
• Loosening of stem and cup
• ...... a constrained ball-and-socket prosthesis is not suitable for
the trapeziometacarpal joint.
Ferrari B, Steffee AD: Trapeziometacarpal total joint replacement using the Steffee prosthesis. J Bone Joint Surg Am. 1986
Hannula TT, Nahigian SH: A preliminary report: cementless trapeziometacarpal arthroplasty. J Hand Surg Am. 1999
Wachtl, Guggenheim, Sennwald.:Cemented and non-cemented replacements of the trapeziometacarpal joint. J bone joint Surg Br. 1998
15 │ CMC-1 osteoarthritis – IMPLANTS
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•
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•
Stephan Schindele
Stephan Schindele
Total joint replacement: second generation
Ledoux
• Cup: PE metalbacked
• Head & stem: metal
(Co/Cr), Uncemented
• ball and socket joint
Cup: polyethylen
Head & stem: metal (Co/Cr)
Cementet
Surface: ball and socket joint
GUEPAR II / Braun-Cutter
•
•
•
•
GUEPAR
Braun-Cutter
Cup: polyethylen
Head & stem: metal (Co/Cr)
Cementet
Surface: ball and socket joint
Lemoine, Alnot (Guepar group):n=84 (4.2y FU)
• Good clinical midterm results
• Revision rate only 1.3%
Badia, Sambandam: n= 27 (3.8 y FU)
• 96% pain free
• Only 1 revision, no signs of implant loosening
Masmejean E, Alnot JY, Beccari R.: Surgical replacement of the thumb saddle joint with the GUEPAR prosthesis . Orthopade. 2003
Lemoine S et al.: Second generation GUEPAR total arthroplasty of the thumb basal joint: 50 months follow -up in 84 cases. Orthop Traum Surg Res. 2009
Badia A, Sambandam SN. Total joint arthroplasty in the treatment of advanced stages of thumb carpometacarpal joint osteoarthritis. J Hand Surg Am 2006
16 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
Total joint replacement: second generation
Total joint replacement: second generation
Elektra
ARPE
Cup: metalbacked
Head & stem: metal (Co/Cr)
osteointegration
Surface: ball and socket joint
Regnard: n=100 (4.4 years FU)
• Good clinical midterm results
• Revision rate 15%
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•
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Cup: Polyethylen (pressfit)
Head & stem: metal (Co/Cr)
Osteointegration (hydroxiapatid)
Surface: ball and socket joint
Martin-Ferreo: n=69 (10y FU)
• Survival rate 10 y: 93.9%
• Complication rate 7.7%
Ulrich-Vinther et al: prospective comparing Elektra vs. LRTI (n=98)
• Elektra faster and better pain relief, stronger grip, functions, improved range of
motion, and faster reconvalescence
Regnard PJ. Electra trapezio metacarpal prosthesis: results of the first 100 cases. J Hand Surg Br. 2006
Ulrich-Vinther M, Puggaard H, Lange B.: Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment
of trapeziometacarpal osteoarthritis. J Hand Surg Am. 2008
17 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
M. Martin-Ferrero: Ten-year long-term results of total joint arthroplasties with ARPEimplant in the treatment of trapeziometacarpal osteoarthritis.
J Hand Surg Eur 2013
Vander Eecken S et al.: Trapeziometacarpal joint replacement with the Arpe prosthesis. Acta Ortop Belg 2012
18 │ CMC-1 osteoarthritis – IMPLANTS
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18.11.2014
Total joint replacement: second generation
Summary: Implants in CMC-1 osteoarthritis
Rubis 2 (reversed implant)
 Several designs:
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•
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Metal-cup in stem: (pressfit)
Trapezial head: metal (Co/Cr)
Osteointegration- Thread
Surface: reversed ball and socket joint
Dunaud: n=49 (3y FU)
• Conclusion: too short follow up, so results
will be presented at 5 years
Maes/ Dunaud: n=118 (7.3y FU)
• Survival rate: 93%
• Complication: 7.6%
Interposition implants/ Hemiarthroplasty /Total joint replacement
 Literature: no superior treatment
 Good clinical results with a lot of implants
 High complication rate in the beginning
 There are signs that total joint replacement may have a fast recovery
 Currently: total joint replacement only as ball and socket joint
 possible solution: restore the anatomy (saddle joint)
Dunaud JL et al.: Rubis 2 trapezometacarpal prosthesis: concept, operative technique. Chir main 2001
Maes C, Dunaud JL et al.: Results of the treatment of basal thumb OA by Rubis II prosthesis after more than 5 years. Chir main 2010
19 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
20 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
So, what should we recommend our patients?
Goldstandart at our institution in elderly:
Resection-arthroplasty with/without interposition
Young
1.
2.
3.
and active (posttraumatic cases):
Arthrodesis
Pyrocardan
Total joint replacement (not yet)
Thank you very much
21 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
22 │ CMC-1 osteoarthritis – IMPLANTS
Stephan Schindele
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