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Pyrolytic Carbon Resurfacing Arthroplasty for Osteoarthritis of the Proximal Interphalangeal Joint of the Finger
Thomas M. Sweets, MBA, MD1; Peter J. Stern, MD2
1 Department of Orthopedic Surgery, University of Tennessee College of Medicine Chattanooga, 975 East Third Street, Box 260, Chattanooga, TN 37403
2 Department of Orthopedic Surgery, University of Cincinnati College of Medicine, P.O. Box 670-212, Cincinnati, OH 45267-0212. E-mail address: pstern@handsurg.com
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Department of Orthopedic Surgery, University of Cincinnati College of Medicine, Cincinnati, and Hand Surgery Specialists, Cincinnati, Ohio
A commentary by Jennifer Moriatis Wolf, MD, is linked to the online version of this article at jbjs.org.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Aug 03;93(15):1417-1425. doi: 10.2106/JBJS.J.00832
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Abstract

Background: 

Pyrolytic carbon resurfacing arthroplasty of the proximal interphalangeal joint has been reported to provide favorable results. The purpose of this study was to evaluate the effectiveness of pyrolytic carbon joint replacement at an average follow-up of fifty-five months.

Methods: 

A retrospective review of thirty-one arthroplasties of the proximal interphalangeal joint performed by a single surgeon in seventeen patients with interphalangeal joint osteoarthritis was conducted. Assessment included range of motion, patient satisfaction, and pain scores. Radiographs were evaluated for alignment, implant subsidence, and implant failure. The Michigan Hand Outcomes Questionnaire was administered at the time of the final follow-up.

Results: 

The average follow-up period was fifty-five months (minimum, two years). No patient was lost to follow-up. The arc of motion of the interphalangeal joint decreased from 57° preoperatively to 31° (p < 0.05) at the time of the final follow-up. The average score for pain was 3 of 10 on a visual analog scale. Satisfaction averaged 3.4 points on a 5-point Likert scale, and twelve of seventeen patients stated that they would repeat the surgery. Data from the Michigan Hand Outcomes Questionnaire were compared for the involved and noninvolved hands of the fifteen patients who received implants unilaterally. Significant deficits were observed in the total outcome score, activities of daily living, function, and satisfaction for the operatively treated hand. Pain was also greater in the operatively treated hand. Complications included implant fracture (one joint), dislocation (five joints), squeaking (eleven), loosening (fifteen), and interphalangeal joint contracture (twenty). Six joints required a reoperation (an arthrodesis in four joints, a silicone arthroplasty in one, and excision of exostosis in one). Implant migration was severe for seven proximal phalanx implants and three distal phalanx implants, and one implant breached the phalangeal cortex.

Conclusions: 

Interphalangeal joint motion decreased significantly at the final follow-up evaluation, following short-term gains in the initial postoperative period. Complications were numerous, and implant loosening with migration was a major problem. Arthroplasty of the proximal interphalangeal joint with a pyrolytic carbon implant has a high complication rate, poor outcomes, and variable patient satisfaction. On the basis of these findings, we no longer use this implant in our practice.

Level of Evidence: 

Therapeutic Level IV. 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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    John Stanley, MD, Robert D. Beckenbaugh, MD
    Posted on October 03, 2011
    Comments on Failed PIP Arthroplasty
    Mayo Clinic

    Thomas Sweets, MBA, and Peter Stern, M.D., reported in the Journal of Bone and Joint Surgery from August 2011, volume 93(15), pages 1417-142 on the experience with longer-term follow-up (55 months) of 31 PyroCarbon PIP implants in 17 patients. These results were very disappointing, reporting on decreased range of motion and follow-up with 60 complications with 5 significant surgical revisions. Implant loosening occurred as well as one fracture and serious deformity was present in many patients which lead the authors to discontinue use of the device. With the results and interpretation of complications and the authors’ experience, it is appropriate that they should no longer do this surgery. However, many different surgeons in England, Germany, Australia, and the United States have reported markedly different longer-term results at the International Federation of Societies for Surgery of the Hand Annual Meeting in Seoul, Korea, in 2010. In addition, this commentator, in addition to the primary prosthetic developing surgeon John Stanley, M.D., has encountered very successful results with this implant in osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis. In the authors’ study, only osteoarthritis was evaluated, and in these patients, our very best results have been achieved. The authors report one patient with five implants and one patient with four implants separately which represents more than 20% of their case study. We have found that the group of patients with generalized osteoarthritis involving multiple digits and soft tissue periarthrosis did not experience significant gains in range of motion following implant arthroplasty while those with one or two joints involved with oligoarticular osteoarthritis demonstrated a rather remarkable improvement in range of motion and pain relief. The authors report a decreased range of motion and persistence of pain in many patients. In reviewing their paper their work indicates several possible reasons for their poor results. (1) X-rays of the implant which migrated severely were reported to be satisfactory postoperatively in a final recheck but interval x-rays or evaluation with fluroscan or with standard x-rays in splints, etc., was not reported. (2) Their described postoperative therapy program was listed as beginning at seven days with active motion on page 1418 and beginning at three weeks with active motion on 1419, with additional splints holding the finger at rest in full extension and dynamic extension assist, regardless of the situation after three weeks. Report of radiographic evaluation of the position of the finger in splints was not mentioned and was presumably not done. If the finger is straight appearing clinically but is hyperextended on x-ray, the therapy protocol is changed. That case scenario would lead to progressive hyperextension leading to stiffness and squeaking and eventually occasionally dorsal subluxation of the implant with marked dorsal repositioning of the stem proximally. This phenomenon is described in many of their cases. (3) While the authors recognize that lucency occurs about the implant, they fail to recognize that “looseness” and slightly variable thickness on x-ray (9 mm in this study) related partially to radiographic technique as well as fibromembranous formation as the implant becomes encased by a boney shell.. In addition, the biological stress remodeling with some shift in implant position (remodeling according to Wolff’s Law) is a normal finding not an abnormal finding. In the authors’ paper and a recent article in the Journal of Hand Surgery, July 2011, volume 36(7), page 1385, an example of a PIP implant in marked hyperextension is shown. This has gone on to what they describe as loosening. Surgical intervention can be done to correct this malpositioning. In addition, this implant has a uniform lucent seam, and the x-ray is normal and there is no loosening in this implant. (4) Squeaking of the implant occurs primarily with hyperextension of the implant. . Allowing this to happen is generally associated with absence of closely followed regular x-ray assessment. Squeaking may also occur with irregular orientation of the prosthetic component and increased pressure on one side versus another. This type of squeaking always eventually goes away. However, squeaking associated with hyperextension will continually get worse util the joint get fixed in hyperextension. When corrected it no longer squeaks as it begins to flex. The authors have had one implant fracture unrelated to this in a patient with gross displacement of the components. We have not seen fracture but have seen gross displacement associated with poor bone formation adjacent to PyroCarbon. We are suspicious of this being physiological (plus or minus pharmacologic, for example vitamin D deficiency). These patients do not form bone appropriately in reaction to stress from a PyroCarbon implant. Clearly, the authors have shown a case behaving like this, and we believe other technical problems are present (implant orientation and position control with intraoperative postoperative x-rays). . PyroCarbon PIP implant surgery is technically demanding. We and many authors believe that it offers a remarkable reconstruction procedure for PIP joint arthroplasty as opposed to silicone salvage arthroplasty or arthrodesis. With careful patient selection and meticulous surgical technique follow-up results have been satisfactory in over 80% of patients in many surgeons’ experience with intermediate length follow-up equal to those of the authors.

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