The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 81, Issue 5

Articles | May 01, 1999

Long-Term Follow-up of Pyrolytic Carbon Metacarpophalangeal Implants*

STEPHEN D. COOK, PH.D.†; ROBERT D. BECKENBAUGH, M.D.‡; JACQUELINE REDONDO, M.D.†; LAURA S. POPICH, B.S.†; JEROME J. KLAWITTER, PH.D.†; RONALD L. LINSCHEID, M.D.‡, ROCHESTER, MINNESOTA

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Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester

J Bone Joint Surg Am, 1999 May 01;81(5):635-48

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Abstract

Background: The metacarpophalangeal joint is the most commonly involved joint when rheumatoid arthritis affects the hand. Many prosthetic implants have been designed for the replacement of this joint. Although studies of these implants have shown relief of pain, they have generally demonstrated a poor range of motion, progression of ulnar drift, and bone loss, as well as failure, fracture, and dislocation of the implant.Methods: From December 1979 to February 1987, 151 pyrolytic carbon metacarpophalangeal implants were inserted in fifty-three patients. The implants had an articulating, unconstrained design with a hemispherical head and grooved, offset stems. Forty-four patients had rheumatoid arthritis; five, posttraumatic arthritis; three, osteoarthritis; and one, systemic lupus erythematosus. Three patients (eleven implants) were lost to long-term follow-up, and twenty patients (fifty-one functioning implants) died after the implant had been in situ for an average of 7.2 years. Eighteen implants (12 percent) in eleven patients were revised. Fourteen of the eighteen implants were replaced with a silicone-elastomer or another type of implant, and the remaining four were removed and a pyrolytic carbon implant was reinserted with the addition of bone cement or bone graft, or both. Twenty-six patients (seventy-one implants) were available for long-term review at an average of 11.7 years (range, 10.1 to 16.0 years) after implantation.Results: The implants improved the arc of motion of the fingers by an average of 13 degrees and elevated the arc by an average of 16 degrees. As a result, fingers were in a more functional, extended position. A complete set of preoperative, postoperative, and follow-up radiographs was available for fifty-three of the seventy-one implants that were followed long term. There was a high prevalence of joint stability: fifty (94 percent) of the fifty-three implants were in a reduced position postoperatively, and forty-one (82 percent) of those fifty implants were still in the postoperative reduced position at the time of long-term follow-up. Ulnar deviation averaged 20 degrees preoperatively and 19 degrees at the time of follow-up, with only the long finger having an increase in deviation. No adverse remodeling or resorption of bone was seen. Fifty (94 percent) of the fifty-three implants had evidence of osseointegration, with sclerosis around the end and shaft of the prosthetic stems. Radiolucent changes were seen adjacent to twelve implants. There was minimum-to-moderate subsidence (four millimeters or less) of thirty-four implants; most of the subsidence occurred immediately postoperatively.Survivorship analysis demonstrated an average annual failure rate of 2.1 percent and a sixteen-year survival rate of 70.3 percent. The five and ten-year survival rates were 82.3 percent (95 percent confidence interval, 74.6 to 88.2 percent) and 81.4 percent (95 percent confidence interval, 73.0 to 87.8 percent), respectively.None of the revised implants had any visible changes of wear or deformity of the surfaces or stems. Four instances of chronic inflammatory tissue and three instances of proliferative synovitis were noted histologically. Focal pigment deposits were seen in three fingers, one of which had removal of the implant two months after a fracture. No evidence of intracellular particles or particulate synovitis was found.Conclusions: The results of this study demonstrate that pyrolytic carbon is a biologically and biomechanically compatible, wear-resistant, and durable material for arthroplasty of the metacarpophalangeal joint.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The metacarpophalangeal joint is the most commonly involved joint in hands affected by rheumatoid arthritis. Impairment of this joint can result in 100 percent impairment of the finger, and impairment of the hand can result in as much as 90 percent impairment of the extremity⁶. Since the early 1900s, when soft-tissue interposition arthroplasty was introduced, there have been many hinged^{10,17,18,21,28}, semiconstrained^1,11,38, and unconstrained^2,7,27,40,41 designs of prosthetic implants for the replacement of the metacarpophalangeal joint. Although the use of metacarpophalangeal implants has resulted in the relief of pain, such implants have generally been associated with a poor range of motion, progression of ulnar drift, and loss of bone^1,2,7,38,41. Multiple failures, fractures, and dislocations of the implants have been reported, and the implantation techniques have been found to be technically demanding^1,7,21,31,41.

Currently, the Swanson silicone-elastomer interpositional spacer is the most commonly used implant for metacarpophalangeal joint arthroplasty^5,15,26. However, the rates of mechanical failure for this implant have been high, with as many as 82 percent (twenty-eight of thirty-four) fracturing within five years after insertion^2,8,25,26. In addition, delayed infection, silicone lymphadenopathy, and malignant lymphoma have recently been reported to be associated with silicone arthroplasty^19,29.

Pyrolytic carbon is a synthetic material formed by the pyrolysis of a hydrocarbon gas. Pyrolytic carbon is formed as a coating that is deposited onto high-strength graphite substrates by heating a hydrocarbon gas, such as propane, to about 1300 degrees Celsius. The resulting pyrolytic carbon has a turbostratic, or disordered, two-dimensional crystal structure with a high concentration of three-dimensional diamond cross-linked bonding. The physical and mechanical properties of this isotropic material fall between those of graphite and diamond^9,24.

In 1969, pyrolytic carbon was first used to make a component of an artificial heart valve. Since then, about three million pyrolytic carbon heart-valve components have been implanted, resulting in more than fifteen million patient-years of experience²⁴. Its record of reliability in the very demanding service as an artificial heart valve has shown pyrolytic carbon to be high-strength, fatigue-resistant, and wear-resistant. The chemical stability of pyrolytic carbon makes it extremely compatible with living tissue and the engineering material most compatible with blood⁹. A variety of animal models of pyrolytic carbon implants have also shown direct bone apposition to its as-deposited surface^13,14,37.

Pyrolytic carbon also has very attractive mechanical properties as an orthopaedic implant material. It has an elastic modulus similar to that of cortical bone, which makes it ideal for implant-bone stress transfer¹². A preliminary evaluation of articulating pyrolytic carbon-on-pyrolytic carbon metacarpophalangeal joint implants in primates revealed no evidence of wear or wear debris, no evidence of an inflammatory reaction, and excellent bone-implant incorporation¹³. In 1979, clinical application of articulating, unconstrained pyrolytic carbon metacarpophalangeal joint implants began on a custom basis. Short-term results demonstrated an improvement in the range of motion, relief of pain, adequate biological fixation, and few complications³. The purpose of the present study was to review retrospectively the long-term outcomes of arthroplasties with these metacarpophalangeal joint implants.

*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the Joe W. and Dorothy Dorsett Brown Foundation, Metairie, Louisiana.

†Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112.

‡Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street S.W., Rochester, Minnesota 55905.

†Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112.

‡Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street S.W., Rochester, Minnesota 55905.

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Fig. 1-A Photograph of a pyrolytic carbon implant. The metacarpal (right) and proximal phalangeal (left) components have hemispherical bearing surfaces with offset stems that are inserted without cement.

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Fig. 1-B Schematic drawing of the implant, with the dimensions for the large, standard, and small implants.

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Figs. 2-A through 2-D: Photographs showing the cosmetic results for a patient with severe rheumatoid arthritis who was managed with four pyrolytic carbon metacarpophalangeal joint prostheses in the left hand. Fig. 2-A: Preoperative deformity.

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Fig. 2-B Postoperative appearance at three months, showing correction of the ulnar deviation.

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Fig. 2-C The patient had improved extension (Fig. 2-C) and satisfactory flexion (Fig. 2-D) at three months.

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Fig. 2-D The patient had improved extension (Fig. 2-C) and satisfactory flexion (Fig. 2-D) at three months.

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Fig. 3 Illustration of the average extensor lag, flexion, and arc of motion for all fingers combined at the preoperative, early postoperative, and long-term follow-up evaluations.

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Figs. 4-A and 4-B: Radiographs of the right hand of a seventy-five-year-old man with posttraumatic arthritis who was managed with a pyrolytic carbon metacarpophalangeal implant in the index finger. Fig. 4-A: Preoperative radiograph.

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Fig. 4-B Radiograph made eleven years after the operation. The implant is stable, and the index joint is in a reduced position. The radiolucent line about the implant represents the thickness of the pyrolytic carbon surface.

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Figs. 5-A, 5-B, and 5-C: Radiographs of the right hand of a sixty-year-old woman with rheumatoid arthritis who was managed with pyrolytic carbon metacarpophalangeal implants in the index, long, ring, and small fingers. Fig. 5-A: Before the operation, there was severe subluxation and dislocation with typical ulnar deviation of the metacarpophalangeal joints.

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Fig. 5-B At two months, the ulnar deviation was corrected.

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Fig. 5-C At 2.2 years, stability of the joints and articulation of the implants were maintained despite the recurrence of ulnar deviation over time.

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Figs. 6-A and 6-B: Radiographs of the right hand of a sixty-year-old man with osteoarthritis who was managed with a pyrolytic carbon metacarpophalangeal implant in the index finger. Fig. 6-A: Radiograph made immediately after the operation.

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Fig. 6-B: Radiograph made sixteen years after the operation. An excellent host-bone response to the implant and stable long-term fixation of the implant were observed.

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Figs. 7-A, 7-B, and 7-C: Radiographs of the right hand of a forty-eight-year-old woman who had rheumatoid arthritis. Fig. 7-A: Preoperative radiograph showing considerable destruction of the metacarpophalangeal joints of the index, long, and small fingers.

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Fig. 7-B: Early postoperative radiograph showing replacement of the metacarpophalangeal joints of the index and long fingers with pyrolytic carbon implants.

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Fig. 7-C: Radiograph, made twelve years postoperatively, showing a thin sclerotic rim of bone along the stem and end of the metacarpal and proximal phalangeal components, with moderate subsidence of the implants.

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Figs. 8-A and 8-B: Radiographs showing the results of replacement with the pyrolytic carbon metacarpophalangeal implants in two different patients. Fig. 8-A: Early follow-up radiograph of four implants in a sixty-six-year-old woman who had rheumatoid arthritis. Small radiolucent areas are visible along the proximal phalangeal components in the long and small fingers of the right hand. The bone-implant contact is good, with no signs of loosening of the implants.

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Fig. 8-B Radiograph made five years after the operation in a fifty-year-old man who had posttraumatic destruction of the long finger of the right hand. Radiolucency surrounds the stem of the proximal phalangeal component. Although the metacarpal component remained stable, it was revised because of loosening of the proximal phalangeal component (which was confirmed at operative removal).

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Fig. 9 Survival curve, with 95 percent confidence intervals, derived from the data in Table IV, for the pyrolytic carbon metacarpophalangeal prostheses. The survival rate at five, ten, and fifteen years after the operation was 82.3, 81.4, and 70.3 percent, respectively.

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TABLE I AVERAGE RANGE OF MOTION OF THE METACARPOPHALANGEAL JOINT OF EACH FINGER AND FOR ALL FINGERS COMBINED

*The values are given as the average and the standard deviation, with the range in parentheses.

	Range of Motion (degrees)*
Index Finger (N = 28)	Long Finger (N = 16)	Ring Finger (N = 13)	Small Finger (N = 14)	All Fingers (N = 71)
Preoperative
Extension deficit	-33 ± 20	-44 ± 20	-44 ± 26	-45 ± 37	-40 ± 25
	(0 to -80)	(-20 to -90)	(-10 to -110)	(0 to -130)	(0 to -130)
Active flexion	72 ± 16	78 ± 15	85 ± 14	87 ± 17	79 ± 17
	(40 to 105)	(40 to 95)	(60 to 110)	(60 to 130)	(40 to 130)
Arc of motion	39 ± 22	33 ± 19	41 ± 23	42 ± 30	39 ± 23
	(5 to 90)	(5 to 70)	(0 to 85)	(0 to 95)	(0 to 95)
Early postoperative
Extension deficit	-24 ± 17	-21 ± 14	-24 ± 19	-17 ± 16	-22 ± 16
	(0 to -70)	(0 to -45)	(0 to -55)	(15 to -45)	(15 to -70)
Active flexion	66 ± 17	67 ± 12	66 ± 22	61 ± 27	65 ± 19
	(30 to 105)	(35 to 90)	(15 to 90)	(10 to 95)	(10 to 105)
Arc of motion	43 ± 18	46 ± 14	42 ± 22	44 ± 20	43 ± 18
	(5 to 90)	(30 to 80)	(15 to 85)	(5 to 70)	(5 to 90)
Long-term follow-up
Extension deficit	-27 ± 22	-25 ± 20	-22 ± 18	-21 ± 20	-24 ± 20
	(0 to -65)	(0 to -65)	(0 to -60)	(15 to -45)	(15 to -65)
Active flexion	75 ± 22	77 ± 13	78 ± 17	73 ± 35	76 ± 22
	(0 to 120)	(55 to 95)	(50 to 95)	(15 to 110)	(0 to 120)
Arc of motion	49 ± 25	52 ± 23	57 ± 27	53 ± 27	52 ± 25
	(0 to 95)	(15 to 85)	(0 to 85)	(0 to 95)	(0 to 95)

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TABLE I AVERAGE RANGE OF MOTION OF THE METACARPOPHALANGEAL JOINT OF EACH FINGER AND FOR ALL FINGERS COMBINED

*The values are given as the average and the standard deviation, with the range in parentheses.

	Range of Motion (degrees)*
Index Finger (N = 28)	Long Finger (N = 16)	Ring Finger (N = 13)	Small Finger (N = 14)	All Fingers (N = 71)
Preoperative
Extension deficit	-33 ± 20	-44 ± 20	-44 ± 26	-45 ± 37	-40 ± 25
	(0 to -80)	(-20 to -90)	(-10 to -110)	(0 to -130)	(0 to -130)
Active flexion	72 ± 16	78 ± 15	85 ± 14	87 ± 17	79 ± 17
	(40 to 105)	(40 to 95)	(60 to 110)	(60 to 130)	(40 to 130)
Arc of motion	39 ± 22	33 ± 19	41 ± 23	42 ± 30	39 ± 23
	(5 to 90)	(5 to 70)	(0 to 85)	(0 to 95)	(0 to 95)
Early postoperative
Extension deficit	-24 ± 17	-21 ± 14	-24 ± 19	-17 ± 16	-22 ± 16
	(0 to -70)	(0 to -45)	(0 to -55)	(15 to -45)	(15 to -70)
Active flexion	66 ± 17	67 ± 12	66 ± 22	61 ± 27	65 ± 19
	(30 to 105)	(35 to 90)	(15 to 90)	(10 to 95)	(10 to 105)
Arc of motion	43 ± 18	46 ± 14	42 ± 22	44 ± 20	43 ± 18
	(5 to 90)	(30 to 80)	(15 to 85)	(5 to 70)	(5 to 90)
Long-term follow-up
Extension deficit	-27 ± 22	-25 ± 20	-22 ± 18	-21 ± 20	-24 ± 20
	(0 to -65)	(0 to -65)	(0 to -60)	(15 to -45)	(15 to -65)
Active flexion	75 ± 22	77 ± 13	78 ± 17	73 ± 35	76 ± 22
	(0 to 120)	(55 to 95)	(50 to 95)	(15 to 110)	(0 to 120)
Arc of motion	49 ± 25	52 ± 23	57 ± 27	53 ± 27	52 ± 25
	(0 to 95)	(15 to 85)	(0 to 85)	(0 to 95)	(0 to 95)

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TABLE II AVERAGE ULNAR DEVIATION OF THE METACARPOPHALANGEAL JOINT OF EACH FINGER AND FOR ALL FINGERS COMBINED

*The values are given as the average and the standard deviation, with the range in parentheses. Radial deviation was not included in the analyses. †Two index fingers were radially deviated 2 and 5 degrees preoperatively. ‡One ring finger was radially deviated 5 degrees preoperatively. §One small finger was radially deviated 10 degrees early postoperatively. #Three small fingers were radially deviated 5, 5, and 11 degrees at the long-term follow-up evaluation.

	Ulnar Deviation (degrees)*
Index Finger (N = 28)	Long Finger (N = 16)	Ring Finger (N = 13)	Small Finger (N = 14)	All Fingers (N = 71)
Preoperative	16 ± 10†	18 ± 14	26 ± 16‡	23 ± 16	20 ± 14
	(0 to 40)	(0 to 40)	(7 to 52)	(0 to 60)	(0 to 60)
Early postoperative	14 ± 13	10 ± 11	12 ± 13	11 ± 14§	12 ± 12
	(0 to 52)	(0 to 30)	(0 to 35)	(0 to 44)	(0 to 52)
Long-term follow-up	14 ± 12	23 ± 18	23 ± 14	22 ± 16#	19 ± 15
	(0 to 40)	(0 to 60)	(10 to 50)	(0 to 40)	(0 to 60)

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TABLE II AVERAGE ULNAR DEVIATION OF THE METACARPOPHALANGEAL JOINT OF EACH FINGER AND FOR ALL FINGERS COMBINED

	Ulnar Deviation (degrees)*
Index Finger (N = 28)	Long Finger (N = 16)	Ring Finger (N = 13)	Small Finger (N = 14)	All Fingers (N = 71)
Preoperative	16 ± 10†	18 ± 14	26 ± 16‡	23 ± 16	20 ± 14
	(0 to 40)	(0 to 40)	(7 to 52)	(0 to 60)	(0 to 60)
Early postoperative	14 ± 13	10 ± 11	12 ± 13	11 ± 14§	12 ± 12
	(0 to 52)	(0 to 30)	(0 to 35)	(0 to 44)	(0 to 52)
Long-term follow-up	14 ± 12	23 ± 18	23 ± 14	22 ± 16#	19 ± 15
	(0 to 40)	(0 to 60)	(10 to 50)	(0 to 40)	(0 to 60)

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TABLE III SUBSIDENCE OF THE METACARPAL AND PROXIMAL PHALANGEAL COMPONENTS AT THE TIME OF LONG-TERM FOLLOW-UP

*The prevalence is based on the total number of components with subsidence. †The prevalence is based on the total number of components.

Component	Subsidence (no.)
None	Minimum (<2 mm)	Moderate (2 to 4 mm)	Severe (>4 mm)	Total with Subsidence*
Proximal phalangeal (n = 53)	23	8	11	11	30 (60%)
Metacarpal (n = 53)	33	9	6	5	20 (40%)
Total†	56 (53%)	17 (16%)	17 (16%)	16 (15%)

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TABLE III SUBSIDENCE OF THE METACARPAL AND PROXIMAL PHALANGEAL COMPONENTS AT THE TIME OF LONG-TERM FOLLOW-UP

*The prevalence is based on the total number of components with subsidence. †The prevalence is based on the total number of components.

Component	Subsidence (no.)
None	Minimum (<2 mm)	Moderate (2 to 4 mm)	Severe (>4 mm)	Total with Subsidence*
Proximal phalangeal (n = 53)	23	8	11	11	30 (60%)
Metacarpal (n = 53)	33	9	6	5	20 (40%)
Total†	56 (53%)	17 (16%)	17 (16%)	16 (15%)

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TABLE IV LIFE TABLE FOR PYROLYTIC CARBON METACARPOPHALANGEAL IMPLANTS*

*Each prosthesis was categorized as a failure or as a withdrawal. Failures were defined as implants that had been revised or replaced, were lost to follow-up, or were dislocated at the time of long-term follow-up. Withdrawals were defined as implants that were successful at the time of long-term follow-up or that had been in situ and functioning at the time of death. The number of prostheses entering each follow-up interval was calculated as the number of survivors at the start of the previous interval minus the number of failures and withdrawals. For each interval, the number of implants at risk is the entering number minus one-half of the withdrawals. The failure rate is the number of failures in the interval divided by the number at risk, multiplied by 100. The success rate is 100 minus the probability of failure for that year. The annual survival rate is the cumulative multiplication of the probability of success. The survival curve is derived from the life table.

Follow-up Interval (yrs.)	No. of Implants Entering Each Interval	Number of Failures	No. of Withdrawals		No. of Implants at Risk	Annual Rates (percent)			Standard Error (percent)	95 Percent Confidence Interval (percent)
Successful at Time of Latest Follow-up	In Situ and Functioning at Time of Death	Failure	Success	Survival
0 to 1	151	10	0	0	151.0	6.6	93.4	93.4	2.0	88.2 to 96.5
1 to 2	141	9	0	3	139.5	6.5	93.6	87.4	2.6	80.9 to 92.0
2 to 3	129	0	0	6	126.0	0	100.0	87.4	2.8	80.7 to 92.1
3 to 4	123	6	0	4	121.0	5.0	95.0	83.0	3.1	75.6 to 88.7
4 to 5	113	1	0	4	111.0	0.9	99.1	82.3	3.3	74.6 to 88.2
5 to 6	108	0	0	9	103.5	0	100.0	82.3	3.4	74.4 to 88.3
6 to 7	99	0	0	0	99.0	0	100.0	82.3	3.5	74.3 to 88.4
7 to 8	99	0	0	0	99.0	0	100.0	82.3	3.5	74.2 to 88.4
8 to 9	99	0	0	1	98.5	0	100.0	82.3	3.5	74.1 to 88.5
9 to 10	98	1	0	4	96.0	1.0	99.0	81.4	3.6	73.0 to 87.8
10 to 11	93	7	29	8	74.5	9.4	90.6	73.8	4.4	64.5 to 81.5
11 to 12	49	2	6	6	43.0	4.7	95.4	70.3	5.8	60.2 to 79.0
12 to 13	35	0	11	4	27.5	0	100.0	70.3	7.3	59.2 to 79.8
13 to 14	20	0	11	1	14.0	0	100.0	70.3	10.2	57.3 to 81.3
14 to 15	8	0	6	1	4.5	0	100.0	70.3	18.2	52.2 to 85.5
15 to 16	1	0	1	0	0.5	0	100.0	70.3	54.2	27.9 to 119.5

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TABLE IV LIFE TABLE FOR PYROLYTIC CARBON METACARPOPHALANGEAL IMPLANTS*

Follow-up Interval (yrs.)	No. of Implants Entering Each Interval	Number of Failures	No. of Withdrawals		No. of Implants at Risk	Annual Rates (percent)			Standard Error (percent)	95 Percent Confidence Interval (percent)
Successful at Time of Latest Follow-up	In Situ and Functioning at Time of Death	Failure	Success	Survival
0 to 1	151	10	0	0	151.0	6.6	93.4	93.4	2.0	88.2 to 96.5
1 to 2	141	9	0	3	139.5	6.5	93.6	87.4	2.6	80.9 to 92.0
2 to 3	129	0	0	6	126.0	0	100.0	87.4	2.8	80.7 to 92.1
3 to 4	123	6	0	4	121.0	5.0	95.0	83.0	3.1	75.6 to 88.7
4 to 5	113	1	0	4	111.0	0.9	99.1	82.3	3.3	74.6 to 88.2
5 to 6	108	0	0	9	103.5	0	100.0	82.3	3.4	74.4 to 88.3
6 to 7	99	0	0	0	99.0	0	100.0	82.3	3.5	74.3 to 88.4
7 to 8	99	0	0	0	99.0	0	100.0	82.3	3.5	74.2 to 88.4
8 to 9	99	0	0	1	98.5	0	100.0	82.3	3.5	74.1 to 88.5
9 to 10	98	1	0	4	96.0	1.0	99.0	81.4	3.6	73.0 to 87.8
10 to 11	93	7	29	8	74.5	9.4	90.6	73.8	4.4	64.5 to 81.5
11 to 12	49	2	6	6	43.0	4.7	95.4	70.3	5.8	60.2 to 79.0
12 to 13	35	0	11	4	27.5	0	100.0	70.3	7.3	59.2 to 79.8
13 to 14	20	0	11	1	14.0	0	100.0	70.3	10.2	57.3 to 81.3
14 to 15	8	0	6	1	4.5	0	100.0	70.3	18.2	52.2 to 85.5
15 to 16	1	0	1	0	0.5	0	100.0	70.3	54.2	27.9 to 119.5

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TABLE V SUMMARY OF FINDINGS OF PREVIOUS LONG-TERM REVIEWS OF METACARPOPHALANGEAL JOINT IMPLANTS

*NR = not reported. †The values are given as the percentage with the number of implants in parentheses for all studies except that by Wilson et al.⁴¹. The value in parentheses represents the number of patients for the study by Wilson et al.

Authors	Type of Implant	Duration of Follow-up (yrs.)	Range of Motion (degrees)	Instability* (percent)	Ulnar Deviation* (degrees)	Radiolucency†	Rate of Revision* (percent)	Fracture of Implant* (percent)
Derkash et al.¹⁶	Silicone Dacron (n = 89)	11.5	55 to 83	58	36% > 20	87 (47/64)	11	NR
Blair et al.⁸	Metallic, prong (n = 41)	11.5	16 to 40	NR	NR	87 (33/38)	7	47
Wilson et al.⁴¹	Silicone (n = 375)	9.6	21 to 50	3.2	43% > 20	14 (5/35)	3	6
Adams et al.¹	Schultz (n = 36)	10.9	58 to 68	NR	28	80 (29/36)	NR	39
Present study	Pyrolytic carbon (n = 71)	11.7	24 to 76	18	19	23 (12/53)	12	<1

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TABLE V SUMMARY OF FINDINGS OF PREVIOUS LONG-TERM REVIEWS OF METACARPOPHALANGEAL JOINT IMPLANTS

Authors	Type of Implant	Duration of Follow-up (yrs.)	Range of Motion (degrees)	Instability* (percent)	Ulnar Deviation* (degrees)	Radiolucency†	Rate of Revision* (percent)	Fracture of Implant* (percent)
Derkash et al.¹⁶	Silicone Dacron (n = 89)	11.5	55 to 83	58	36% > 20	87 (47/64)	11	NR
Blair et al.⁸	Metallic, prong (n = 41)	11.5	16 to 40	NR	NR	87 (33/38)	7	47
Wilson et al.⁴¹	Silicone (n = 375)	9.6	21 to 50	3.2	43% > 20	14 (5/35)	3	6
Adams et al.¹	Schultz (n = 36)	10.9	58 to 68	NR	28	80 (29/36)	NR	39
Present study	Pyrolytic carbon (n = 71)	11.7	24 to 76	18	19	23 (12/53)	12	<1

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From December 1979 to February 1987, 151 pyrolytic carbon metacarpophalangeal implants were inserted in fifty-three patients at the Mayo Clinic and Mayo Foundation. The implant had an articulating, unconstrained design with a hemispherical head and grooved, offset stems (Figs. 1-A and 1-B). A nominal, 0.42-millimeter-thick pyrolytic carbon coating was applied to premachined graphite substrates. Later in the series, tungsten was added to the graphite substrate of some implants for better radiographic visualization. A total of eighteen small, seventy-one standard, and sixty-two large implants were used.

All patients who were candidates for replacement of the metacarpophalangeal joint were considered for treatment with an unconstrained pyrolytic carbon implant. In general, the implant was used in patients who had little deformity, subluxation, or dislocation of the metacarpophalangeal joint. Dislocated joints with shortening of more than one centimeter or with advanced cortical bone loss were not treated with the implant. Forty-four patients had rheumatoid arthritis, five had posttraumatic arthritis, three had osteoarthritis, and one had systemic lupus erythematosus. Fifty-four index fingers, forty-three long fingers, twenty-eight ring fingers, and twenty-six small fingers were treated with the implant. Forty-four patients were female, and nine were male. The average age at the time of the operation was fifty-eight years (range, twenty-one to eighty-five years). Fifty-one patients were right-hand dominant. One hundred and one implants were placed in dominant hands. Seven patients had bilateral involvement.

Three patients (eleven implants; 7 percent) were lost to follow-up within eleven to fourteen months after the initial operation. Twenty patients (fifty-one functioning implants; 34 percent) died before the time of review; the implants in these patients had been in situ for an average of 7.2 years (range, 1.7 to 14.9 years) at the time of death. Eighteen implants (12 percent) in eleven patients were revised, and fourteen of the eighteen were replaced with a silicone-elastomer or another type of implant. Thirteen of the fourteen implants were revised because of subluxation, dislocation, or soft-tissue imbalance. The fourteenth implant was revised secondary to a fracture of the implant that had occurred nine years postoperatively, while the patient was lifting a heavy suitcase. The four remaining implants were removed secondary to loosening, and a pyrolytic carbon implant was reinserted with the addition of bone cement or autogenous bone graft, or both.

Twenty-six patients (seventy-one implants) were available for long-term clinical follow-up at an average of 11.7 years (range, 10.1 to 16.0 years) after implantation. Nineteen of these patients (sixty-two implants) had rheumatoid arthritis; four (four implants), posttraumatic arthritis; two (four implants), osteoarthritis; and one (one implant), systemic lupus erythematosus.

Operative Technique

A transverse dorsal skin incision was used to expose multiple joints, and a longitudinal incision was used to expose a single joint. The operative technique, described previously⁴, included a longitudinal incision of the extensor hood along the radial border of the central tendon. The radial and ulnar portions of the extensor hood were retracted to expose the joint capsule. The capsule was then incised longitudinally to expose the articular surfaces of the joint. We removed only the minimum amount of bone necessary to allow insertion of the implant and articulation without tension. In general, two to four millimeters of bone was removed from the metacarpal head and one to two millimeters was removed from the base of the proximal phalanx. Additional bone was removed if necessary to achieve satisfactory space for and stability of the implant. In all instances, attempts were made to preserve the collateral ligament attachments at the metacarpal head and the base of the proximal phalanx. Occasionally, it was necessary, because of the amount of bone that had to be resected, to detach the bases of the proximal phalangeal attachments, which were then left in continuity with the proximal phalangeal periosteal sleeve.

With use of specially designed reamers that were slightly undersized relative to the implant, the canals were shaped by gently impacting and compressing the intramedullary cancellous bone. The largest implant possible was used for stability, with the limiting factor being the size of the medullary canal of the proximal phalanx. The components of the implant were then press-fit into the canals with special nonabrasive plastic impactors. The joint capsule was then repaired with running or interrupted sutures. The radial collateral ligament was repaired if necessary. The extensor hood was meticulously repaired to achieve proper centralization. Intrinsic release or transfer was performed occasionally, as necessary. All operations were performed by the senior two of us (R. D. B. and R. L. L.).

Postoperative Care

The initial postoperative care consisted of application of a sterile bulky dressing with the fingers immobilized in plaster splints in an extended position. Later in the study, a few patients had the fingers immobilized in extension splints for three weeks before beginning the mobilization protocol. In general, the mobilization protocol was begun between three and seven days after the procedure. Initially, active flexion and extension exercises were started in dynamic, extension-assist splints for daytime use. Resting extension splints were used at night. Between the eighth and fourteenth postoperative days, the splinting protocol was continued, with light activities allowed while the day splints were worn. Between two and three weeks, flexion exercises without the splints were initiated and scar and edema care was begun. At three to four weeks, flexion loops were occasionally added to the splints. During the sixth postoperative week, the patients were weaned from the dynamic splints, strengthening progressed, and resting splints were worn indefinitely as needed.

Methods of Evaluation

The long-term outcome of the arthroplasty was evaluated with several methods. Medical records were reviewed to obtain data regarding the satisfaction of the patient; residual symptoms; the range of motion of the metacarpophalangeal joint preoperatively, postoperatively, and at the time of the most recent follow-up; reasons for failure or revision of the implant; and long-term complications. In addition, the active range of motion was measured and was recorded in degrees²⁰. A neutral position of the metacarpophalangeal joint was recorded as 0 degrees, hyperextension and flexion were recorded as positive values, and extension deficits were recorded as negative values. Each patient was examined or interviewed by telephone to update data from the latest follow-up visit if the patient had not been seen within twelve months before the time of the review.

The preoperative, postoperative, and most recent follow-up radiographs were reviewed. A complete set of preoperative, postoperative, and follow-up radiographs was available for fifty-three of the seventy-one implants that were followed long term. The position of the joint (reduced, subluxated, or dislocated) was determined on each lateral radiograph. Measurements of radioulnar angulation of the metacarpophalangeal joint were made directly on the posteroanterior radiographs. Any changes in the appearance of the periprosthetic bone or in the position of the implant were noted by comparing the posteroanterior and lateral follow-up radiographs with the initial postoperative radiographs. Subsidence of either the proximal phalangeal or the metacarpal component of the implant was noted. Subsidence was measured in millimeters on the basis of a comparison of the postoperative and most recent follow-up posteroanterior radiographs and was categorized as none, minimum (less than two millimeters), moderate (two to four millimeters), or severe (more than four millimeters).

Pathological reports were examined to look for abnormal findings in any of the tissue specimens sent at the time of revision. Representative samples were sent from each hand but not from the site of each implant. Therefore, this material was evaluated for each patient and hand rather than for each individual implant site. Radiographs made before and after revision were also reviewed.

Finally, survivorship analysis was performed to determine the overall success rate of the metacarpophalangeal implants over the sixteen-year period^30,34. Failure was defined as an implant that was dislocated at the time of follow-up or that had been revised or replaced for any reason. Implants that were lost to follow-up were also considered as failures for the survivorship analysis. Implants withdrawn from the study included those that had been successfully followed throughout the trial as well as those that were functioning well, at the time of death, in patients who had died before the time of review. The average annual failure rate, determined from the life table, was calculated as the average of all failure rates for each year of follow-up. The survival curve was derived from the cumulative survival rate over time, as calculated from the actuarial life table. The standard error, given as a percentage, and the 95 percent confidence intervals were calculated from the data in the life table³⁰.

The difference between the preoperative and latest follow-up values for range of motion and ulnar deviation were analyzed for significance with one-way and two-way analysis of variance. Significance was defined as a p value of less than 0.05 (BMDP Statistical Software, Los Angeles, California). The log-rank test and chi-square distribution were used for the statistical comparison of the survivorship-analysis groups.

Results

Introduction | Materials and Methods | Results | Discussion | References

At the long-term follow-up evaluation, no patient reported pain specific to the implanted joint. One patient played golf several times per week, and another played guitar and climbed rocks. A third patient still performed strenuous farm work, and several occasionally played tennis. All of the patients were satisfied with the functional and cosmetic results of the procedure (Figs. 2-A, 2-B, 2-C and 2-D). The patients who noted a limitation of activities had restricted motion of the joint secondary to systemic complications of rheumatoid disease that were unrelated to the implants.

Range of Motion

The average arc of motion of the metacarpophalangeal joints was 39 degrees preoperatively, 43 degrees early postoperatively, and 52 degrees at the time of long-term follow-up (Table I and Fig. 3). The average arc of motion significantly increased by 13 degrees between the preoperative and most recent follow-up evaluations (analysis of variance, p = 0.01). The arc of motion of the long finger increased 19 degrees; that of the ring finger, 16 degrees; that of the index finger, 10 degrees; and that of the small finger, 11 degrees. The increase in range of motion was associated with a significant improvement in extension of the long finger (p = 0.003), ring finger (p = 0.03), small finger (p = 0.02), and all fingers combined (p < 0.001). An overall increase of 16 degrees in extension of the metacarpophalangeal joints was observed, ranging from 6 degrees for the index finger to 24 degrees for the small finger. With the numbers available for study, we could not detect significant differences between the preoperative and the long-term follow-up values for active flexion of all fingers combined (p = 0.38) or of any individual metacarpophalangeal joint (p > 0.05 for all comparisons).

Radiographic Evaluation

As seen on the preoperative radiographs, twenty-eight metacarpophalangeal joints were dislocated, fourteen were subluxated, and eleven were in a reduced position. As seen on the early postoperative radiographs, two metacarpophalangeal joints were dislocated, one was subluxated, and fifty were reduced. At the time of long-term follow-up, seven metacarpophalangeal joints were seen to be dislocated, five were subluxated, and forty-one were in a reduced or stable position (Figs. 4-A and 4-B). Thus, forty-one (82 percent) of fifty implants maintained their original postoperative reduced position at the time of long-term follow-up. Four of the seven dislocations and four of the five subluxations occurred ten to eleven years postoperatively in one patient who had severe rheumatoid arthritis.

Radiographic measurements revealed an average preoperative ulnar deviation of 20 degrees for all fingers combined, with the deviation ranging from an average of 16 degrees for the index finger to 26 degrees for the ring finger (Table II). At three months postoperatively, ulnar deviation had decreased in all fingers, and the decrease was found to be significant when the data for all fingers were combined (p = 0.01). At the time of long-term follow-up, ulnar deviation averaged 19 degrees, which was essentially equivalent to that noted preoperatively (p = 0.75) (Figs. 5-A, 5-B, and 5-C). Twenty-three (43 percent) of the fifty-three implants evaluated radiographically had an ulnar deviation of more than 20 degrees at the time of long-term follow-up. Compared with the preoperative value, ulnar deviation had increased in 43 percent (twenty-three) of the implants and had decreased or remained unchanged in the remaining 57 percent (thirty).

No adverse bone-remodeling or resorption was noted in the fifty-three fingers with long-term follow-up. Loosening of the implant and ulnar drift (as will be discussed later) occurred in some patients and necessitated revision. Host-bone acceptance of the pyrolytic carbon implants, which were inserted without cement, proved to be successful in most fingers (Figs. 6-A and 6-B). Fifty (94 percent) of the fifty-three fingers had evidence of sclerosis around the end and shaft of the prosthetic stems at the time of long-term follow-up (Figs. 7-A, 7-B, and 7-C). A rim of sclerotic bone was more frequently observed around the stem of the proximal phalangeal component (thirty-one implants; 58 percent) than around the stem of the metacarpal component (twenty-two implants; 42 percent). At the time of follow-up, radiolucency was observed adjacent to twelve implants (six patients), seven of which were metacarpal components (Fig. 8-A). None of these patients had clinical loosening of the implant. Six of the twelve implants were in one patient who had rheumatoid arthritis.

At the time of long-term follow-up, thirty-four (64 percent) of the fifty-three implants evaluated radiographically had some degree of subsidence of the metacarpal component or the proximal phalangeal component, or both (Table III). Of the fifty components that had subsided to some degree, twenty (40 percent) were metacarpal components and thirty (60 percent) were proximal phalangeal components (Fig. 7-C). There was subsidence of both the metacarpal and the proximal phalangeal component of sixteen implants, of only the proximal phalangeal component of fourteen implants, and of only the metacarpal component of four implants.

Revision

Complications led to the revision of eighteen implants (12 percent) in eleven patients. Four implants in three patients were removed, and a pyrolytic carbon implant was reinserted with the addition of bone cement or bone graft, or both. One of these three patients had revision because of flexion contracture of the metacarpophalangeal joints of the index and long fingers, which occurred ten months postoperatively. Stiffness was the reason for revision of one implant after 1.5 years in situ. Stiffness and loosening of the proximal phalangeal component necessitated revision of another implant after 4.9 years in situ.

Fourteen implants in eight patients were replaced with another implant. Subluxation, flexion contracture, stiffness, and dislocation led to replacement of ten metacarpophalangeal joints with a Swanson silicone implant after postoperative periods ranging from one month to 10.9 years. Two carbon implants were replaced with a second carbon implant, at nine months and 13.5 months after the operation, because of loosening and dislocation. One implant was fixed with cement, although this implant was replaced again after 3.9 years with a Sutter silicone-elastomer implant because of pain, loosening, and stiffness (Fig. 8-B). After nine years in situ, one implant fractured through the proximal phalangeal stem, while the patient was lifting a heavy suitcase. This implant was removed two months after the fracture and was replaced with a metal-and-plastic implant, which was fixed with cement.

There were no clinically observed instances of reactive synovitis. Black staining was seen in the pericapsular tissue in the patient who had a fracture of the implant. The joint capsule was slightly stained and showed minimum reactive material. There was marked black staining of the distal tissues near the site of the fracture. None of the revised implants had any visible wear or deformity of the surfaces or stems. Tissue from ten hands that had a revision was submitted for pathological evaluation. Four instances of chronic inflammatory tissue and three instances of proliferative synovitis were seen histologically. Focal pigment deposits were noted in three instances; the patient from whom the implant had been removed two months after it fractured had such deposits. No evidence of intracellular particles or particulate synovitis was found.

Survivorship Analysis

The eighteen implants that were revised, the eleven implants that were lost to follow-up, and the seven implants that were dislocated at the time of long-term follow-up were categorized as failures. Survivorship analysis for this worst-case scenario showed an average annual failure rate of 2.1 ± 3.2 percent (range, 0 to 9.4 percent) and a sixteen-year survival rate of 70.3 percent (Table IV and Fig. 9). The five and ten-year survival rates were 82.3 percent (95 percent confidence interval, 74.6 to 88.2 percent) and 81.4 percent (95 percent confidence interval, 73.0 to 87.8 percent), respectively. Survival of the implants was also determined on the basis of gender, diagnosis, and age at the time of the procedure. The sixteen-year survival rate for the women (69 percent) was notably lower than that for the men (82 percent). Similarly, a diagnosis of rheumatoid arthritis was associated with a sixteen-year survival rate of 68 percent, whereas other diagnoses (osteoarthritis, posttraumatic arthritis, or systemic lupus erythematosus) were associated with a survival rate of 84 percent. Patients who were less than fifty-five years old at the time of the initial operation and those who were at least fifty-five years old had equivalent sixteen-year survival rates (71 and 70 percent).

In the first ten years after the operation, the survival curves for the women and men were very similar, as were the curves based on diagnosis. After ten years, the survival rates for the women and for the patients who had rheumatoid arthritis progressively decreased compared with the rates for the men and for the patients who did not have rheumatoid arthritis. However, differences in the entire curves over time were not detectable on the basis of gender or diagnosis (chi square = 0.508, degrees of freedom = 1, p > 0.05). It should be noted that female patients and patients who had rheumatoid arthritis accounted for the overwhelming majority of this series' population and thus an increased number of failures would be expected to be found in those groups. Differences in survival curves were also not detectable on the basis of age (chi square = 0.003, degrees of freedom = 1, p > 0.05).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Despite the widespread use of metacarpophalangeal joint implants for approximately thirty years, there have been few reports with a follow-up period of ten years or longer (Table V). With regard to gender, age, and underlying diagnosis, our study population was comparable with those of previous reports^1,7,16,41.

At the time of long-term follow-up in the present study, the pyrolytic carbon implants had an average arc of motion of 52 degrees, with a range of motion of 24 to 76 degrees. Additionally, the metacarpophalangeal joints were in a more extended and therefore more functional position. Blair et al.⁷ reported a range of motion of 16 to 40 degrees with the Flatt metallic, pronged prosthesis. This range was similar to that reported with the silicone-elastomer prosthesis (21 to 50 degrees), by Wilson et al.⁴¹. The arc and range of motion of the pyrolytic carbon implants and those reported by Blair et al. and Wilson et al. were considerably better than those reported in association with a cemented Schultz ball-and-socket prosthesis¹ (range, 58 to 68 degrees) or the Niebauer silicone-elastomer Dacron prosthesis¹⁶ (range, 55 to 83 degrees).

The stability of the pyrolytic carbon implants was slightly higher than that reported for the Swanson silicone-elastomer implant in the study by Wilson et al.⁴¹, in which twelve (3.2 percent) of 375 implants had either subluxated or dislocated at the time of long-term follow-up. The stability of the pyrolytic carbon implants was better than that of the Niebauer prostheses in the series of Derkash et al.¹⁶, in which fifty-two (58 percent) of eighty-nine implants were reported as unstable. Although Adams et al.¹ did not report a rate of instability of the Schultz prosthesis, 39 percent (fourteen) of the thirty-six implants in their series fractured at the neck of the proximal phalangeal component distal to the level of the ball and socket; thus, measurement of the stability of this prosthesis would be of little value.

The natural resting position of the fingers is in slight ulnar deviation, with typical values of 15 degrees of ulnar deviation for the index finger, 13 degrees for the long finger, 3 degrees for the ring finger, and 7 degrees for the small finger²². A major portion of the deformity resulting from rheumatoid disease is caused by progression of this passive ulnar angulation. Although the ulnar deviation is initially corrected by most arthroplasties of the metacarpophalangeal joint, it has been noted to recur and then progress in short-term and long-term studies^1,8,16,38,41. Although initial postoperative improvements were not maintained, the pyrolytic carbon implants appeared to have halted the progression of ulnar deviation, with almost no difference between the preoperative average of 20 degrees and the long-term follow-up average of 19 degrees. Forty-three percent of the fifty-three implants that were assessed radiographically had ulnar deviation of more than 20 degrees at the time of long-term follow-up. These results are an improvement compared with those of other long-term studies, in which a large percentage of patients had more than 20 degrees of ulnar deviation and progression with time^1,7,16,25,41.

Perhaps the most consistent finding of previous long-term studies of metacarpophalangeal joint arthroplasties is the notable amount of cortical erosions, bone loss, and periprosthetic radiolucency^1,7,16,36,39. This finding is disturbing because it represents poor host-bone tolerance of the implant mechanically or biologically, or both. The rate of periprosthetic radiolucency was extremely low in our series; it was seen around only twelve (23 percent) of the pyrolytic carbon implants. The rate of radiolucency was as high as 80 percent in a series of thirty-six Schultz metacarpophalangeal joint implants¹ and as high as 87 percent in a series of thirty-eight radiographically assessed Flatt metallic, hinged prostheses⁷. Derkash et al.¹⁶ noted destructive bone loss around 87 percent of fifty-four silicone Dacron implants that had been radiographically evaluated in their series of eighty-nine prostheses. Wilson et al.⁴¹ reported that five (14 percent) of their thirty-five patients who had a Swanson silicone-elastomer prosthesis had evidence of cortical erosions due to impingement of the stem, although no functional loss was noted. Varma and Milward³⁸ reported cortical erosions around 14 percent of sixty-five Nicolle finger-joint prostheses, with the bone loss most notable along the proximal phalanges. Most of the pyrolytic carbon implants in our series had a rim of sclerotic bone, which is believed to be secondary to osseointegration combined with the well matched elastic modulus, resulting in uniform implant-bone stress transfer.

The pyrolytic carbon implants had an acceptable long-term rate of subsidence, with only sixteen of the fifty-three implants that were evaluated radiographically showing evidence of severe subsidence at the time of long-term follow-up. Although other authors have not quantified subsidence, they have described migration of the implant, joint-space collapse, so-called implant sink-in, and periarticular heterotopic ossification (which may represent subsidence of the implant)^7,17,26. Of the pyrolytic carbon implants with severe subsidence, none were noted to be painful, unstable, or in need of revision. In most cases, the subsidence resulted from osteopenic bone combined with initial settling of the implant and did not progress notably over time.

In long-term studies with an average follow-up period of more than five years^1,7,16,26,41, rates of fracture of the metacarpophalangeal joint implant have ranged from 6 percent⁴¹ to 47 percent⁷. Fractures of the implant and related complications do not always necessitate revision. In fact, in some studies of silicone-elastomer prostheses, fractures appeared to be unimportant clinically because the function of the metacarpophalangeal joint did not seem to be impaired^8,26,35,41. Regardless, only one of the pyrolytic carbon implants in our series fractured, at nine years postoperatively, and a relatively low rate of revision (eighteen of 151 implants; 12 percent) was observed after a maximum of sixteen years of follow-up. Pathology reports noted findings consistent with rheumatoid arthritis and no evidence of implant-related etiology; this observation attests to the long-term biological compatibility and wear resistance of pyrolytic carbon.

Long-term survivorship analyses of prosthetic implants, other than those in the finger joints, have been widely described^32-34. A survivorship analysis of metacarpophalangeal joint replacements was reported by Hansraj et al.²³ for a series of 170 Swanson silicone implants that had been followed for an average of 5.2 years (range, two to ten years). The patient population and clinical results in their series are comparable with the population and results in the present study. The cumulative survival rates of the Swanson silicone implant were 98.9, 94.0, and 90.3 percent at two, five, and ten years, respectively, with use of revision as the end point²³. Survivorship analysis of the pyrolytic carbon prosthesis with use of revision as the end point resulted in cumulative survival rates of 94.7, 89.6, 88.8, and 86.7 percent at two, five, ten, and sixteen years, respectively. The overall rate of success of joint replacements may be influenced by gender, diagnosis, and age. Women and patients who had rheumatoid arthritis had a slightly higher risk of failure of the pyrolytic carbon implant, but this may have been due to the distribution of the patients in the series. No difference in the survival rate was detected on the basis of age.

In summary, the pyrolytic carbon metacarpophalangeal implants in the present series were found to be biologically and biomechanically compatible and were associated with a low rate of fracture, a low rate of revision, and a high rate of patient satisfaction. The results of this and other implant procedures are far from normal and far from ideal. However, it can be logically presumed that, left untreated, the involved joints would have been considerably worse. These small gains over a long period of time seem worthwhile.

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Topics

rheumatoid arthritis ; carbon ; metacarpophalangeal joint ; range of motion ; fingers

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STEPHEN D. COOK, ROBERT D. BECKENBAUGH, JACQUELINE REDONDO, LAURA S. POPICH, JEROME J. KLAWITTER, RONALD L. LINSCHEID; Long-Term Follow-up of Pyrolytic Carbon Metacarpophalangeal Implants*. The Journal of Bone & Joint Surgery. 1999 May;81(5):635-48.

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