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Speaker: New hand, wrist arthroplasty implants provide movement, but need further perfection
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Most patients prefer the return of the normal, although somewhat limited movement that hand and wrist arthroplasty provides. But, according to the presenter of the Watson Jones Lecture at the British Orthopaedic Association Annual Congress, despite improvements in hand and wrist prosthesis designs and surgical techniques, surgeons have continued to observe some complications.
In his update on hand and wrist arthroplasty, Ian A. Trail, MBChB, MD, FRCS(Ed), FRCS(Eng), of Wrightington Hospital, in Wigan, England, said, “Arthroplasty does check off all of the boxes. If you do a joint replacement, the hand patient will potentially need medical care for the rest of their life.”
The benefits of hand and wrist arthroplasty include pain relief, stability, strength and movement, according to Trail. Many surgeons rely on the well-tolerated arthrodesis, although patients prefer the arthroplasty procedures because they return motion to the hand, even though they are rife with complications and have not been perfected, he said.
“Hand and wrist arthroplasties are difficult to replicate,” he said. “There are seven individual bones.”
Image: Rapp SM, Orthopaedics Today Europe
Biaxial-brand implants studied
About 20 years ago, surgeons first used Biaxial wrist replacement (DePuy Orthopaedics Inc.; Warsaw, Ind., USA) with metal and polyethylene stems and cement fixation, Trail said. Then researchers learned that the radiocarpal joint moves in three dimensions, not two, as did the biaxial implants.
“The Biaxial replacement is congruous and does not allow any rotation, so that transmitted to the distal component,” he said.
Researchers at Wrightington Hospital tested survivorship of the Biaxial wrist prosthesis in a 2002 study led by Takwale and colleagues and found an 83% survival rate.
Images: Trail IA
New modular wrist replacement implants with metal and polyethylene components fixed through bone ingrowth are now available. Trail and colleagues assessed their survivorship in patients with inflammatory arthritis. He said the results are not yet published, but when the team examined 32 implants with 2-year follow-up they noticed patients had “considerable improvements in function and wrist pain.”
There were some complications, however. They included one case of carpal tunnel syndrome and cases of swelling from the metal parts, dislocation, stiffness and subsidence of the disc component of the prosthesis seen on radiographs.
Ulnar head replacement
Trail said fusion has been unsuccessful for distal radial ulnar joint (DRUJ) repair. Therefore, he and his colleagues use the Herbert Ulnar Head Prosthesis (Martin Medizintechnik; Tuttlingen, Germany) with either a metal or ceramic head. Trail noted its use is effective in post-trauma patients with malunited distal radius disease of the DRUJ and patients with primary osteoarthritis (OA).
After studying the implant in 32 post-traumatic cases, 19 inflammatory arthritis cases and 12 OA cases, Kaplan-Meier survivorship was 90% at 11 postoperative years, Trail said. The complications included dorsal subluxation, sigmoid notch rupture due to too large a prosthetic head and malpositioned stems.
Silastic implants
Thumb arthroplasty may pose difficulties because of its engineering challenges. In a study by Lovell and colleagues at Wrightington Hospital, Trail and others compared silastic thumb implants with trapeziectomies they performed and found women reported less pain with the silastic implants after 1 year, but these results were not significantly different from the results in the men.
On the contrary, survivorship of silastic MCP joint replacement was 63% in 1,336 patients at 17 years follow-up in a 2004 study by Trail and colleagues. They revised about 6% of patients for reasons of fracture or deformity; 94% of implants were in situ. Two-thirds of the implants were broken at the latest follow-up.
Furthermore, any other operations performed on hands with silastic MCP joint replacements increased the revision risk, according to Trail.
“If you had the wrist fused or replaced, the number of revisions was zero,” he said at the meeting. “If you had the proximal interphalangeal joints fused, the revisions were much higher.”
Crossed intrinsic transfer, soft tissue balancing and realignment of the wrist increased the odds for implant survival.
Additionally, metal grommets designed to protect the implant from fracture did not work, according to Trail, and he warned hand surgeons to be meticulous with the soft tissues.
Flexion after MCP replacement
When researchers compared the Swanson silastic MCP joint replacement prosthesis (Wright Medical Technology Inc., Arlington, Tenn., USA) with the NeuFlex prosthesis (DePuy Orthopaedics; Warsaw, Ind., USA), Trail said they found greater flexion with the NeuFlex product.
Product engineers and surgeons now seek to perfect proximal interphalangeal (PIP) joint replacement implants and the corresponding surgical techniques. PIP joint replacement must be learned, Trail said.
The good news is there has been significant improvement and progress in this area, he said. The “learning curve has gone up” in terms of length of time needed to complete the surgery and selecting the best patients for PIP joint arthroplasty. – by Renee Blisard Buddle
- References:
- Delaney R. J Hand Surg Br. 2005;30(1):3-7.
- Lovell ME. J Hand Surg Br. 1999;24(4):453-455.
- Takwale VJ. J Bone Joint Surg Br. 2002;84(5):692-699.
- Trail IA. J Bone Joint Surg Br. 2004;86(7):1002-1006.
- Trail IA. Watson Jones Lecture: Rediscovering the wheel: Is there a role for joint replacement in the hand and wrist? Presented at: British Orthopaedic Association Congress; Sept. 11-14, 2012; Manchester.
- For more information:
- Ian A. Trail, MBChB, MD, FRCS(Ed), FRCS(Eng), can be reached at Wrightington Hospital, Royal Albert Edward Infirmary Trust Headquarters, Wigan Lane, Wigan, WN1 2NN, United Kingdom; email: upperlimb@wrightington.org.uk.
Disclosure: Trail is a paid consultant to MatOrtho for PIP joint replacement.
Perspective
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Jean Goubau, MD
Wrist prostheses remain challenging, and the mentioned arguments are of importance. It is, however, important to stress the origin of the destruction of the joint in order to forecast results. Post-traumatic cases are harder to treat than rheumatoid and idiopathic degenerative cases. It is important to stress the importance of preserving some motion to the wrist when considering a treatment option when all conservative treatment has been tried. We should not forget that 5° of motion is still infinitely more than no motion. In activities of daily living, this is a tremendous difference.
Thumb replacement is successful. Some authors report a 5-year survival in the Apard study of 85% and in the Skyttä study of 94% when used in patients who were diagnosed with rheumatoid arthritis and fitted with the de la Caffiniere prosthesis for thumb trapeziometacarpal joint arthroplasty. Henk and colleagues and Chakrabarti and colleagues reported a survival of more than 16 years (72% and 89%, respectively) with both authors using the de la Caffiniere prosthesis. Functional long-term outcome is less predictable in patients aged younger than 65 years, highly active individuals and men because of higher induced peak forces and consecutive wear on the prosthesis during higher demand activities.
Proximal interphalangeal joint replacement remains challenging. The type of implant has its importance, but the environment the extensor apparatus and its tendency to adhere around this joint is the problematic area which will guide success regarding motion. Indications should be kept to painful mobile arthritis. Some prostheses give satisfactory results regarding pain relief, although range of motion is not very successful.
References:
Apard T. Chir Main. 2007;26(2):88-94
Chakrabarti AJ. J Hand Surg Br. 1997;22(6):695-698.
Henk GJ. J Hand Surg. 1999;doi:10.1053/jhsu.1999.0476.
Skyttä ET. J Hand Surg Br. 2005;30(4):395-400.
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