Long-term complications of trapeziometacarpal silicone arthroplasty

The trapeziometacarpal joint is often affected by arthritis and treated by surgical methods. The significant forces to which this joint is subjected challenge even the most sturdy prosthetic materials. Short-term complications of arthroplasty are caused by inadequate bony resection and instability. Serious long-term problems results from implant wear and the host tissues' response to the implant. Although silicone elastomer prostheses are generally well tolerated, wear-induced microparticles (15 micron or less) incite an intense inflammatory and destructive synovial response. This "silicone synovitis" typically presents more than two years after arthroplasty and is characterized by pain, swelling, and lytic lesions visible on roentgenogram. The silicone microparticles are generated by cyclic physiologic bearing, shear, and compression forces for which these implants have not been tested. The destructive synovitis is arrested by synovectomy, implant removal, and curettage of the lytic defects. Functional salvage requires conversion to resection arthroplasty or arthrodesis. Patients with silicone implant arthroplasty must be followed indefinitely, at frequent intervals, by clinical examination and roentgenograms. Overall, however, experience indicates that resection arthroplasty is the most predictable and functional procedure for the nonrheumatoid basal thumb joint.     

Long-term results of trapeziometacarpal silicone arthroplasty

Long-term results of trapeziometacarpal (TMC) joint silicone arthroplasty were evaluated. From 1975 to 1990, 90 TMC joint silicone implants were placed in 85 patients with TMC joint arthritis caused by osteoarthritis and inflammatory arthritis. Sixty-two implants in 58 patients were available for follow-up evaluation averaging 16.4 years (range, 10-25 years) with a 10-year minimum. Patient satisfaction; range of motion; grip, key pinch, and tip pinch strengths; and radiographs were recorded. Eighty-four percent of the thumbs had satisfactory results with good-to-excellent pain relief and function. Grip, key pinch, and tip pinch strengths increased. The number of thumb tips able to touch the palmar base of the small finger increased. Subluxation was apparent in 19% of implants but was not clinically important; however, implant fracture occurred in 6% and required revision. None of the 62 implants had frank silicone synovitis. Silicone arthroplasty seems to be a reliable option for disabling TMC joint arthritis and is associated with a high degree of patient satisfaction.     

Long-term results of tendon shortening trapeziometacarpal arthroplasty

Multiple soft tissue arthroplasties have been described for reconstruction of trapeziometacarpal arthritis. Trapeziectomy with abductor pollicis longus tendon shortening has been reported to have favorable short-term results, with 95% to 100% good or excellent pain relief at an average of 18 to 31 months. No long-term results of this reconstruction have been published. In the current study, 29 abductor pollicis longus shortening arthroplasties were reviewed at an average of 5.1 years. Although 83% of patients experienced good or excellent pain relief, pinch weakness, a small arthroplasty space, and first metacarpal instability were present in numerous patients. Because of these problems observed at long-term followup, the authors now use ligament reconstruction tendon interposition as the primary trapeziometacarpal arthroplasty.     

Constrained total shoulder arthroplasty. Long-term follow-up observations

Constrained total shoulder arthroplasty is a salvage procedure for patients with disabling pain and a nonfunctioning rotator cuff mechanism. Considering the advanced pathologic process and severe symptoms of these patients, the results of pain relief are gratifying. Many of the patients have weak or absent deltoid muscles, and active overhead motion is not possible. A method of attaching the metal glenoid to the scapula has been designed to reduce the risk of loosening. However, constrained total shoulder arthroplasty does produce considerable stress on bony attachments. Careful patient selection and an excellent, carefully supervised postoperative rehabilitation program are mandatory for success. Before considering a constrained total joint arthroplasty, the surgeon should carefully assess the patient's needs and consider other less extensive shoulder reconstructions.     

Long-term follow-up of Charnley arthroplasty of the hip.

A review of 11.5 year (average interval) follow-up examination of 409 low friction arthroplasties performed included only 3 late failures. The excellent results of the successes have been fully maintained for as long as 14 years. This was true with regard to pain, function of walking and mobility. Resorption of the calcar femorale was rare and no correlation was found with the wear of the socket. The average wear of 1.5 mm was less than predicted by Professor Sir John Charnley. Although 10 patients (7.8%) had excessive wear no patient is at present near the stage of requiring replacement of the socket for this reason. No adverse reaction was found to the implant or the cement.     

Revision of thumb trapeziometacarpal arthroplasty

PURPOSE: To determine the incidence of revision surgery after thumb trapeziometacarpal joint arthroplasty and to present the expected results of future surgical treatment. METHODS: We reviewed the patient database at our medical center and found 654 procedures performed between 1988 and 2000 for the treatment of thumb basal joint arthritis. From the database we found that revision arthroplasties were performed on 15 patients with 17 arthroplasties in the treatment of mechanical pain related to instability or bone impingement. Referred patients with primary surgery performed elsewhere and patients with neurogenic pain were reviewed but not included as a primary focus of this study. The revision surgical procedures included soft-tissue interposition alone or soft-tissue interposition with ligament reconstruction for mechanical symptoms and neurolysis of peripheral nerves for associated neurogenic pain. The assessment included preoperative and postoperative patient chart review, measurement of pinch and grip strengths, radiographic assessment, and patient contact to provide complete medical information including any further medical or surgical treatment. RESULTS: Based on a grading system previously used to evaluate thumb revision surgery, objective good (or satisfactory) results were found in 13 of 17 revision procedures. The method of soft-tissue revision (resection with soft-tissue interposition or resection with ligament reconstruction) did not influence the outcome of good versus fair or poor results. Persistent failures (2 fair, 2 poor) resulted from both soft-tissue interposition alone and revision with ligament support arthroplasties. Revision arthroplasty with soft-tissue procedures for mechanical pain provided predictably good results unless a nerve injury occurred at the time of the revision surgery. CONCLUSIONS: Failure of primary thumb trapeziometacarpal arthroplasty can be salvaged by a second surgery with ligament reconstruction procedures combined with soft-tissue interposition and provides satisfactory patient outcomes in more than 75% of cases studied. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Results following trapeziometacarpal arthroplasty of the thumb.

A retrospective follow-up study was performed on patients with degenerative joint disease (DJD) who underwent trapeziometacarpal arthroplasty of the thumb with 3-week immobilization and without the use of K-wire fixation. Pre- and post-operative pain, activities of daily living (ADLs), grip strength, and pinch strength were compared. Data were collected on 25 hands in 23 patients, 7 hands with full trapezium resections and 18 with hemi-trapezium resections. The median age was 60 years, with a range of 39 to 73 years, and the median follow-up period was 1 year 11 months, with a range of 3 months to 11 years. Grip and pinch strength were measured pre- and postoperatively. Pain was assessed on a visual analog scale (VAS), and ADLs were assessed by means of a 15-item survey. Both pain and ADLs were evaluated postoperatively with recall of preoperative status. Following surgery, all thumbs were immobilized in a static splint for 3 weeks and then allowed progressive use. Median improvements in hemi-trapezium resections included grip, 22.5 lb; pinch, 4.7 lb; and ADLs, 33%. Pain was reduced a median of 7.0 cm on the VAS. Median improvements in full trapezium resection included grip, 29.5 lb; pinch, 0 lb; ADLs, 60%; and pain reduction, 8 cm on the VAS. This follow-up study suggests that satisfactory results can be achieved in pain reduction, strength, and ADLs with an immobilization period of only 3 weeks and without the use of K-wires following carpometacarpal (CMC) arthroplasty.     

Zirconia陶瓷头-聚乙烯全髋关节的长期随访

目的: 通过对 28例 (30髋) zirconia-聚乙烯全髋关节的长期随访, 了解Zirconia陶瓷头的实际临床使用效果。方法: 用Harris评分分别评价术前和最后一次随访时髋关节功能。比较术后 1年及最后随访时的X线片, 记录假体松动、假体周围骨溶解、透亮线、及股骨矩吸收情况。根据Liv ermore的方法测量聚乙烯杯的磨损率。比较有骨溶解发生的髋关节与无骨溶解发生的髋关节的聚乙烯磨损率有无差别。结果: 共有 24例 (26髋) 获长期随访, 平均随访 9年 ( 6 ~13年 )。术前平均Harris评分 46分 ( 20 ~78分 ),最后随访时平均Harris评分 86分 (48~98分)。13髋 (50% ) 有假体周围的骨溶解发生。有 10髋 (38% ) 因髋臼假体的松动或髋臼周围骨溶解而接受翻修手术。平均聚乙烯髋臼磨损率为 0. 118mm/年。结论: 在本组研究病例中, 其髋臼磨损率并不比文献报道的传统的金属头低。而临床平均 9年翻修率更达 38%。其临床实际效果有待更深入的研究。     

Long-term follow-up of patients with biopsy-proven benign breast disease.

Three hundred sixty-five patients with biopsy-proven benign breast disease were followed annually in a prospective manner for 4-15 years to analyze breast cancer development, recurrence, and efficacy of management during follow-up. Eleven breast cancers developed in 11 patients during follow-up, giving a 2.6-fold increased cancer risk over the reference population. No association was found between patients who developed cancer and those who did not with respect to the initial histologic feature (p = 0.62), the age at entry by decades (p = 0.40), and relative to menopause (p = 0.54), the presence of cysts (p = 0.87), or calcification (p = 0.74) in the biopsy specimen, a family history of breast cancer (p = 0.80), or the number of observation years (p = 0.27). We conclude that an aggressive approach to benign breast disease is not justified for any type of lesion as defined in this report. Benign breast disease does not inevitably lead to recurrence. Moreover, 41% of our patients never had any recurrence and were free of symptoms during follow-up; 67% never had a mammogram and 82% never required a further operation. There was no association with initial histologic feature in patients who had clinical examination only and those who had mammogram, biopsy, or both during follow-up (p = 0.93). Mammograms were mainly used to clarify a clinical recurrence than as a screening tool, regardless of histologic feature (p = 0.76). Mammograms were mainly used in premenopausal patients (p less than 0.001) having lumps (p less than 0.001), namely, the most difficult patients for radiologic interpretation. This may be one important reason for the rather low sensitivity (75%) and specificity (40%) of mammography in this report. In conclusion, clinical examination is the outstanding investigational tool to follow patients with biopsy-proven benign breast disease, especially in young premenopausal patients.     

Tendon suspension sling arthroplasty for thumb trapeziometacarpal arthritis.

Forty consecutive tendon suspension sling arthroplasties for relief of pantrapezial osteoarthritis in 38 patients were reviewed. The procedure consists of excision of the trapezium and reconstitution of the tethering action of the first intermetacarpal and the palmar oblique carpometacarpal ligaments; 50% of the distally based flexor carpi radialis tendon is used. A double figure-eight sling suspends the first metacarpal securely, followed by distal advancement of the abductor pollicis longus to tighten the sling and palmarly abduct the thumb ray. The technique resulted in relief of pain, preservation of strength, maintenance of a normally contoured first web space, and functional carpometacarpal range of motion. Procedures were performed over a 4-year period (1986 to 1990), with an average follow-up of 21 months. At final follow-up, 85% of the patients had minimal symptoms; key pinch and grip strengths measured 76% and 81% of the contralateral uninvolved side, respectively. The logic of the mechanical design of the procedure and encouraging subjective and objective follow-up at 4 years make the technique of tendon suspension sling arthroplasty an attractive alternative to existing procedures for the surgical management of recalcitrant and disabling osteoarthritis of the basilar thumb joint.     

Distraction arthroplasty of the trapeziometacarpal joint

Trapeziometacarpal distraction arthroplasty is a surgical technique for the treatment of trapeziometacarpal arthrosis. It consists of distracting the first metacarpal and then anchoring it in suspension to the second metacarpal by means of a tendon graft. Both a reduction of the subluxation of the base of the first metacarpal and an opening or distraction of the trapeziometacarpal joint, with a clear decrease in the forces of attrition on its joint surfaces, are thereby obtained. Compared with the traditional techniques of arthroplasty, this technique avoids trapeziectomy; it is therefore less destructive and is quicker and easier to carry out. It appears to be equally effective regarding pain, correcting the deformity, and recovering grip strength.     

Weilby-Burton arthroplasty of the trapeziometacarpal joint of the thumb.

Twenty-three patients (25 thumbs) were treated by tendon interposition arthroplasty for trapeziometacarpal arthrosis as described by Weilby and modified slightly as described by Burton and Pellegrini. There was good (4/25, 16%) or complete (19/25, 76%) pain relief in 23 (92%) of the cases. Activities of daily living were generally easier. Mobility and strength of the thumb were satisfactory. One patient had signs of instability during a stress test. We conclude that our technique produces a stable and pain-free thumb joint. However, careful selection of the patients for this procedure is essential, and the patient must be given comprehensive information about all stages.     

Tendon suspension sling arthroplasty for degenerative arthritis of the thumb trapeziometacarpal joint: long-term follow-up

Twenty-two tendon suspension sling arthroplasties for thumb trapeziometacarpal osteoarthritis were reviewed. Age at operation ranged from 53 to 74 years (average, 65 years); 20 of the 22 patients were women. The average follow-up period was 101 months (range, 63–139 months). At the final follow-up, 18 of 22 thumbs were painless. Grip and side pinch measurements averaged 98% and 79% of unaffected opposite sides, respectively. Range of motion at the trapeziometacarpal joint improved, and the average shortening of the trapezial space was 6.4mm. Function was improved in all cases. The long-term results show that tendon suspension sling arthroplasty is a useful surgical procedure and an attractive alternative to existing tendon interposition arthroplasty with ligament reconstruction.     

Total arthroplasty of the thumb trapeziometacarpal joint

Considering the large number of procedures designed for the thumb trapeziometacarpal (TMC) joint, it is evident that none are completely satisfactory. Total arthroplasty attempts to improve the results of resection or space-occupying arthroplasties which, while providing good pain relief, have offered little thumb stability, strength, or normal motion. Conditions of surrounding joints indicate that this disease process is not always a straightforward clinical presentation and that a variety of surgical options are needed. When joint disease is limited to the TMC joint, bone stock is good and there is no excessive heterotopic bone. A total arthroplasty can be considered in selected patients. Careful analysis of comparative series between silicone spacers and tendon spacers for trapezium resection arthroplasty demonstrates that both pinch strength and motion are somewhat less than with total trapezial arthroplasty. Key-type pinch rarely was over 50% of the normal and averaged less than 5 kg for both interposition and silicone arthroplasty. Continued problems with implant subluxation, silicone reactive synovitis, and other complications suggest that these resections (replacement) of the trapezium are not error-free and sacrifice thumb stability. With all types of thumb reconstruction, high precision technique is required. With improved biomaterials, thumb biomechanics, and better fixation techniques, more physiologic implant arthroplasties can be anticipated to improve the current designs of total joint arthroplasties.