The article "Metacarpophalangeal Joint Arthroplasty in Rheumatoid
Arthritis. A Long-Term Assessment"
(2003;85:1869-78), by Goldfarb
and Stern, represents the long-term results with an average follow-up of
fourteen years. In the study, the high rate (63%) of implant fractures, loss
of joint motion, and recurrence of ulnar drift and, to the authors, the
disappointing subjective outcomes (mean, 55 of a possible 100 points on the
Michigan Hand Outcomes Questionnaire) led them to conclude that the
indications for metacarpophalangeal arthroplasty need to be examined
carefully.
At our clinic, a similar study is being conducted. To date, we have
evaluated twenty-two patients with rheumatoid arthritis who have Swanson
implants (seventy-six metacarpophalangeal and eighteen proximal
interphalangeal joints). After an average follow-up of 8.4 years, we found a
slightly better mean range of motion in the proximal interphalangeal joints
(43°) than in the metacarpophalangeal joints (41.5°). The mean
extension deficit was 17° and 23.3°, respectively. Patient
satisfaction was generally high (93.3% had the highest or second highest level
of satisfaction on a 5-point scale). Additionally, the disease-specific
quality of life was high, with a mean score of 1.16 points on the Health
Assessment
Questionnaire1 (with
0 indicating no impairment and 3, maximum impairment).
In contrast to the recently published data, the rate of fracture of the
spacers in our study is only 6.4%. Although our preliminary results concerning
the duration of follow-up and the number of implants are not comparable, we
have an overall positive impression of the performance of the implants. As
Goldfarb and Stern discussed, the morbidity of rheumatoid arthritis has been
and will be further reduced by advances in medical management—thus, the
indications for finger joint arthroplasty will decrease.
Our experience has led us to believe that the finger joint arthroplasty
with a silicone spacer is still the "gold" standard for the
treatment of patients with rheumatoid arthritis.
We thank Dr. Chiari and Dr. Trieb for their comments on our article. Their
report on seventy-six metacarpophalangeal arthroplasties with an average
follow-up of 8.4 years demonstrates ranges of motion and implant fracture
rates that are similar to those reported in multiple
studies2-11.
These previous investigations have demonstrated an active range of motion of
the metacarpophalangeal joint that varied from 27° to 43° after 2.5 to
10.1 years of follow-up. Implant fracture rates ranged from 0% to 28%.
Our findings, at more than fourteen years postoperatively, are
substantially different in two primary ways. We found a substantially higher
rate of implant fracture compared with that in 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, subtle differences in our
protocols may explain the disappointing outcome.
The second major difference is patient satisfaction. At intermediate-term
follow-up, several investigations have found satisfactory outcomes through
simple patient questionnaires. Indeed, the majority of our patients stated
that they were happy with the outcome of their surgery. However, with the use
of a hand-specific, validated subjective outcome instrument, less satisfactory
outcomes were noted. We believe that the use of this instrument provides a
more realistic assessment of the outcome or results, which are difficult to
compare with those provided by other, nonvalidated tools. However, we believe
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. Chiari and Dr. Trieb's comments and look forward to
reading the longer-term results of their investigation. We agree that silicone
arthroplasty remains the "gold" standard for the treatment of
metacarpophalangeal joint disease, and we continue to use these implants in
our clinical practices.
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