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Scientific Article   |    
Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis A Long-Term Assessment
Charles A. Goldfarb, MD; Peter J. Stern, MD
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Investigation performed at University of Cincinnati College of Medicine and Hand Surgery Specialists, Cincinnati, Ohio

Charles A. Goldfarb, MD
Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110-1010. E-mail address: goldfarbc@msnotes.wustl.edu

Peter J. Stern, MD
Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, 5508 Medical Sciences Building, P.O. Box 670212, Cincinnati, OH 45267-0212

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

J Bone Joint Surg Am, 2003 Oct 01;85(10):1869-1878
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Abstract

Background: The long-term results of silicone metacarpophalangeal arthroplasty in patients with rheumatoid arthritis are uncertain. The purpose of this investigation was to evaluate the subjective, objective, and radiographic outcomes at the time of long-term follow-up.

Methods: Patients with rheumatoid arthritis who underwent simultaneous silicone metacarpophalangeal joint arthroplasties of all four fingers by one surgeon were eligible for inclusion in the study. The results of a total of 208 arthroplasties in fifty-two hands of thirty-six patients were evaluated at an average of fourteen years postoperatively. Active metacarpophalangeal joint motion, ulnar drift, and radiographs were assessed. The radiographs were reviewed for changes in bone length, erosions, and implant fractures. The Michigan Hand Outcomes Questionnaire (MHQ) was administered to the patients.

Results: The mean arc of motion of the metacarpophalangeal joints improved from 30° preoperatively to 46° immediately after the surgery but decreased to 36° at the time of final follow-up. The mean extension deficit of the metacarpophalangeal joints improved from 57° preoperatively to 11° immediately after the surgery but worsened to 23° at the time of final follow-up. The mean ulnar drift improved from 26° preoperatively to <5° in the immediate postoperative period and then recurred to an average of 16° at the time of final follow-up. Implant fractures were associated with increased ulnar drift (p < 0.001). Bone reaction adjacent to the implant was demonstrated by bone-shortening in most patients and by erosions in 29% of the patients. One hundred and thirty implants (63%) were broken and forty-five (22%) more were deformed at the time of final follow-up. The MHQ score averaged 48 of 100 points. The patients expressed satisfaction with the function of only 38% of the hands, and only 27% of the hands were pain-free at the time of final follow-up. A greater degree of ulnar drift was associated with decreased patient satisfaction and a decreased score for the cosmetic appearance (p = 0.01).

Conclusions: The outcome after silicone metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis worsens with long-term follow-up. Given these findings, the indications for and long-term expectations of silicone metacarpophalangeal arthroplasty must be carefully examined in light of the improvements in the medical management of rheumatoid disease.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Charles A Goldfarb
    Posted on January 08, 2004
    Drs. Goldfarb and Stern respond:
    Department of Orthopaedic Surgery Washington University in St Louis

    We thank Dr. Trieb for his comments on our article, “Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. A Long- Term Assessment.”

    Dr Trieb's report on 76 MCP arthroplasties at an average of 8.4 years follow- up demonstrates similar ranges of motion and implant fracture rates to those reported in multiple publications(1-10). These previous investigations demonstrated active MCP range of motion varying from 27 to 43 degrees at follow- up ranging from 2.5 to 10.1 years. Implant fracture rates varied from 0% to 28%.

    Our findings, at more than 14 years postoperative, are significantly different in two primary ways. We found a significantly higher implant fracture rate compared to studies with intermediate term follow up. The reasons for this are unclear, but there are three possible explanations. Most simply (and most likely), the additional follow- up interval for our patients may account for the increased fracture rate. Alternatively, we use multiple radiographic views to confirm implant integrity and may, therefore, identify additional fractures. And finally, although we adhere to standard operative and rehabilitation techniques, there may be subtle differences in our protocols which explain the disappointing outcome.

    The second major difference is patient satisfaction. At intermediate follow- up, several investigations have found satisfactory outcomes through simple patient questionnaires. Indeed, the majority of our patients state that they are happy with the outcome of their surgery. However, the use of a hand- specific, validated subjective outcome instrument noted a less satisfactory outcome. We believe that the use of this instrument provides a more realistic assessment of outcome- results which are difficult to compare to other, non- validated tools. However, we feel strongly that until a validated outcome instrument is applied preoperatively and at regular intervals postoperatively (with a consideration of systemic disease), the true utility of this surgery will remain somewhat unclear.

    We appreciate Dr Trieb's comments and look forward to reading the longer term results of his investigation. We agree that silicone arthroplasty remains the gold standard for the treatment of MCP disease and we continue to utilize these implants in our clinical practices.

    1. Mannerfelt L, Andersson K. Silastic arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis. J Bone Joint Surg 1975; 57A:484-9.

    2. Beckenbaugh R, Dobyns J, Linscheid R, Bryan R. Review and analysis of silicone-rubber metacarpophalangeal implants. J Bone Joint Surg 1976; 58 A:483-7.

    3. Blair W, Shurr D, Buckwalter J. Metacarpophalangeal joint implant arthroplasty with a silastic spacer. J Bone Joint Surg 1984; 66 A:365-70.

    4. Bieber E, Weiland A, Volenec-Dowling S. Silicone-rubber implant arthroplasty of the metacarpophalangeal joints for rheumatoid arthritis. J Bone Joint Surg 1986; 68 A:206-9.

    5. Maurer R, Ranawat C, McCormack J, RR, Inglis A, Straub L. Long- term follow-up of the Swanson MP arthroplasty for rheumatoid arthritis. Proceedings of ASSH Abstract. J Hand Surg Am 1990; 15 A:810-11.

    6. Kirschenbaum D, Schneider L, Adams D, Cody R. Arthroplasty of the metacarpophalangeal joints with use of silicone-rubber implants in patients who have rheumatoid arthritis. J Bone Joint Surg 1993; 75 A:3-12.

    7. Wilson Y, Sykes P, Niranjan N. Long-term follow-up of Swanson's silastic arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis. J Hand Surg Br 1993; 18 B:81-91.

    8. Olsen I, Gebuhr P, Sonne-Holm S. Silastic arthroplasty in rheumatoid MCP-joints: 60 joints followed for 7 years. Acta Orthop Scand 1994; 64:430-1.

    9. Hansraj K, Ashworth C, Ebramzadeh E, et al. Swanson metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis. Clin Orth Related Research 1997; 342:11-15.

    10. Schmidt K, Willburger R, Miehlke R, Witt K. Ten-year follow-up of silicone arthroplasty of the metacarpophalangeal joints in rheumatoid hands. Scand J Plast Reconstr Hand Surg 1999; 33:433-8.

    Klemens Trieb, M.D.
    Posted on December 29, 2003
    Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis
    Department of Orthopedics, University of Vienna, Wahringergurtel 18-20, A-1090 Vienna, Austria

    To the Editor:

    "Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. A Long-Term Assessment" (2003: 85:1869-78) by Goldfarb et al. represents long-term results with an average of 14 years of follow-up. In this study a high percentage of implant fractures (63%), a loss of joint motion and recurrence of u1nar drift and, to the authors, disappointing subjective outcomes with a mean of 55 of possible 100 points in the MHQ led to their conclusion, that the indications for metacarpophalangeal arthroplasty have to be examined carefully.

    At our clinic a similar study is being conducted. To date, we have evaluated 22 patients with rheumatoid arthritis who have Swanson implants (76 metacarpophalangeal and 18 proximal interphalangeal joints). After an average follow-up of 8.4 years, we have found a slightly better mean range of motion(41.5°) in the metacarpophalangeal joints when compared to the proximal interphalangeal joints (43°) The mean extension deficit was 17° and 23.3° respectively. Patient satisfaction was generally high (93.3% were found in the highest or second highest level of satisfaction on a five point scale). Additionally, disease specific quality of life was high with a mean HAQ Score of 1.16 (0 no impairment, 3 maximum impairment).

    In contrast to the recently published data, we detected only 6.4% spacer fractures. Although our preliminary results are not comparable concerning the duration follow-up and number of implants, we have an overall positive impression of the implants' performance. As Goldfarb and al. discussed, the morbidity of rheumatoid arthritis has been and will be further reduced by advances in medical management-- thus, the indications for finger joint arthroplasties will decrease.

    Our experience leads us to believe, that the silicone spacer fmgerjoint arthroplasty is still the gold standard in patients with Rheumatoid Arthritis.

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