Abstract
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Thumb carpometacarpal joint (CMCJ) arthritis is a common and painful condition. Thumb CMCJ prosthetic replacement aims to restore thumb biomechanics and improve pain and function. Early reviews demonstrated a lack of high-quality studies, but more recently a significant number of higher-quality studies have been published. This review provides a concise and systematic overview of the evidence to date.
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A systematic review of several databases was conducted according to PRISMA guidelines. Studies evaluating the outcomes of thumb CMCJ prosthetic total joint replacement were included. Data extracted included patient-reported outcome measures (PROMs), pain scores, range of motion, strength, survival rates and complications.
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A total of 56 studies met all inclusion criteria and were analysed. There was one randomized controlled trial, three prospective comparative cohort studies, five retrospective comparative cohort studies, and 47 descriptive cohort studies. The reported studies included 2731 patients with 3048 thumb total CMCJ prosthetic joint replacements. Follow up ranged from 12 months to 13.1 years.
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In general, good results were demonstrated, with improvements in PROMs, pain scores and strength. Failure rates ranged from 2.6% to 19.9% depending upon implant studied. Comparative studies demonstrated promising results for replacement when compared to resection arthroplasty, with modest improvements in PROMs but at a cost of increased rates of complications.
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Studies reporting outcomes in thumb CMCJ prosthetic total joint replacement are increasing in both number and quality. Failure, in terms of loosening and dislocation, remains a concern, although in the medium-term follow up for modern implants this issue appears to be lower when compared to their predecessors.
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Functional outcomes also look promising compared to resection arthroplasty, but further high-quality studies utilizing a standardized resection arthroplasty technique and modern implants, together with standardized core outcome sets, will be of value.
Cite this article: EFORT Open Rev 2021;6:316-330. DOI: 10.1302/2058-5241.6.200152
Introduction
Thumb carpometacarpal joint (CMCJ) arthritis is a painful and debilitating condition with a preponderance for women and clinically affecting around 1.4% of the population. 1 Surgical treatment options include trapeziectomy, interposition arthroplasty, arthrodesis, or total joint replacement. Despite the use of total joint arthroplasty being widespread in Europe, early systematic reviews have highlighted a lack of high-quality evidence to support its use. 2 More recently, however, a large number of articles have been published on this topic, and therefore a contemporary review of the literature is necessary. This review aims to provide a systematic and concise update of the available evidence for the use of thumb CMCJ prosthetic total joint replacement.
Materials and methods
Search strategy
We conducted an online systematic literature search in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO).
PubMed, MEDLINE, EMBASE and The Cochrane Library were searched in April 2020 using the terms (thumb CMC or thumb CMCJ or thumb carpometacarpal or trapeziometacarpal or TMCJ) and (arthroplasty or replacement or prosthesis). Our search was not limited by year of publication, journal type, language, or level of evidence. All bibliographies of included articles were checked for further relevant studies.
Eligibility criteria
The inclusion criteria were: articles with patients undergoing thumb CMCJ prosthetic total joint replacement for arthritis, results published as a full paper in any language; outcome measures including patient or clinician-reported, subjective scales (e.g. pain), radiographic analysis, failure rates; randomized controlled trials, cohort studies, case series (with greater than 10 patients); mean follow up of at least 12 months.
The exclusion criteria were: case reports; case series with fewer than 10 patients; meeting abstracts without full articles; revision procedures; cadaveric studies; biomechanical studies; interposition arthroplasties (including hemiarthroplasty, spacer implants); studies where it is not possible to separate the patients with different underlying aetiologies (i.e. inflammatory arthritis from osteoarthritis); follow up less than 12 months.
Two authors reviewed all abstracts for inclusion according to the above criteria, and where a study met all the criteria, or where there was uncertainty, the full texts were obtained and reviewed by both authors to assess eligibility. In cases of disagreement over study inclusion, a senior author was consulted and disagreement resolved by consensus.
Data extraction and analysis
The following data were extracted: study type, exclusion/inclusion criteria, recruitment procedure used, number of cases, patient demographics, underlying pathology, surgical treatment details including implants (and approaches where available), post-operative rehabilitation protocols, follow up period/timings, clinical and radiological outcomes, adverse events, failure rates.
Risk of bias of the studies was assessed according to the Coleman Methodology score. 3 This method was designed to evaluate the study design of the included articles.
Statistical analysis
All continuous data were pooled, and a descriptive data analysis performed.
Results
The initial literature search resulted in a total of 1047 articles. Fig. 1 shows the PRISMA flowchart for study selection. A total of 56 studies met all inclusion criteria and were analysed. There was one randomized controlled trial, three prospective comparative cohort studies, five retrospective comparative cohort studies, and 47 descriptive cohort studies. The methodological bias assessment for all 56 studies is included in Table 1.
Study characteristics
| Implant | Author (year) | Evidence level | Final follow up patients (implants) | Original cohort lost to follow up | Age (years) | Follow up (months) | Coleman score | Survivorship (*cumulative survival analysis) |
|---|---|---|---|---|---|---|---|---|
| ARPE | Dumartinet-Gibaud (2020) 5 | DC | 43 (53) | 34% | 59 | 138 (120–280) | 41 | 10 years 92%. 15 years 85% (without learning curve cases)* |
| ARPE | Gómez-Garrido (2019) 6 | DC | 137 (137) | – | 61.6 | 60.5 (55–66) | 41 | 60.5 months 92.7% |
| ARPE | Martin-Ferrero (2020) 7 | DC | 188 (216) | 5% | 59 | 126 (120–?) | 52 | 10 years 93% (offered revision surgery whether agreed or not)* |
| ARPE | Craik (2017) 8 | RCC | 62 (83) | 24% | 65 | 2 yrs | 67 | 2 years 95% |
| ARPE | Robles-Molina (2017) 9 | RCC | 31 (31) | 0% | 56.37 | 55.81 (SD 41.66) | 46 | – |
| ARPE | Martínez-Martínez (2016) 10 | PCC | 15 (15) | 0% | 61 | 12 | 49 | – |
| ARPE | Eecken (2012) 11 | DC | 29 (35) | 29% | 55 | 6 yrs (3–11) | 45 | 5 years 97% |
| ARPE | Apard (2007) 12 | DC | 26 (32) | 26% | 59.4 | 86 (5 yrs–?) | 41 | 5 years 85%. 11 years 79% |
| ARPE | Jacoulet (2005) 42 | DC | 25 (–) | – | 67 | 36 (?–7 yrs) | 24 | – |
| ARPE | Brutus (2004) 40 | DC | 63 (63) | – | 55.3 | 14.8 (5–40) | 27 | – |
| ARPE | Isselin (2001) 43 | DC | 45 (45) | 25% | 61.8 | 22.4 (4–51) | 12 | – |
| Beznoska | Jurča (2016) 13 | RCC | 11 (11) | 0% | 59 | 12 | 32 | – |
| Braun- Cutter |
Badia (2006) 44 | DC | 25 (26) | 0% | 71 | 59 (26–68) | 55 | – |
| DLC | Skyttä (2005) 4 | DC | 24 (27) | 53% | 50 | 13 yrs (7–22) | 52 | 10 years 87% (95% CI 73–94)* |
| DLC | De Smet (2004) 14 | DC | 40 (43) | 0% | 54 | 26 (15–69) | 59 | – |
| DLC | Van Cappelle (1999) 45 | DC | 49 (61) | 21% | 62 | 8.5 yrs (2–16) | 36 | 16 years 72%* |
| DLC | Nonnenmacher (1994) 46 | DC | 16 (20) | 0% | 55 | 5 yrs (1–11) | 27 | – |
| DLC | Nicholas (1992) 47 | DC | 17 (20) | 0% | 57.25 | 64.2 (8–120) | 24 | – |
| Elektra | Froschauer (2020) 15 | RCC | 29 (32) | 14% | 54 | 13.1 yrs (12.2–14.3) | 33 | – |
| Elektra | Thorkildsen (2019) 48 | RCT | 19 (19) | 5% | Md 64 | 2 yrs | 86 | 2 years 75% (95% CI 55–94)* |
| Elektra | Chug (2014) 16 | DC | 14 (16) | 0% | 70 | 26 (12–38) | 37 | – |
| Elektra | Hernández-Cortéz (2012) 17 | DC | 19 (19) | 0% | 57 | 29 (24–36) | 39 | – |
| Elektra | Hansen (2008) 18 | DC | 16 (17) | 0% | 54 | 35 (22–52) | 39 | – |
| Elektra | Ulrich-Vinther (2008) 41 | PCC | 36 (36) | 14% | 58 | 12 | 57 | – |
| Elektra | Regnard (2006) 54 | DC | 100 (100) | 0% | 59 | 54 (36–78) | 35 | – |
| Elektra | Krukhaug (2014) 57 | DC | – (29) | 0% | 62 | Md 2 yrs | 14 | 5 years 90% (95% CI 75–100)* |
| Elektra | Hansen (2013) 58 | DC | 13 (13) | 19% | 60 | 24 months | 35 | – |
| Guepar I | Alnot (1993) 49 | DC | 32 (36) | 0% | 62 | 3.5 yrs (1–9) | 24 | – |
| Guepar II | Lemoine (2009) 50 | DC | 68 (84) | 0% | 61 | 50 (12–115) | 38 | – |
| Guepar II | Masmejean (2003) 55 | DC | 60 (64) | 0% | 58.1 | 29 (12–84) | 37 | – |
| ISIS | Seng (2013) 19 | DC | 26 (30) | 0% | 59.8 | 30 (18–47) | 37 | 42 months 93% (loosening or non-osteointegration)* |
| IVORY | Tchurukdichian (2020) 20 | DC | 90 (105) | 5% | 61 | – (120–?) | 61 | 10 years 95.5%* |
| IVORY | Cebrian-Gomez (2019) 21 | PCC | 84 (84) | 0% | 60 | 4.1 yrs (2–5) | 80 | 5 years 96.4% (95% CI 92.5–100.0)* |
| IVORY | Erne (2018) 22 | RCC | 39 (39) | 0% | 56.2 | 42 (12–72) | 34 | – |
| IVORY | Vissers (2019) 23 | DC | 24 (26) | 22% | 71 | 130 (120–142) | 49 | 10 years 85% |
| IVORY | Spaans (2016) 24 | DC | 20 (20) | 17% | 60 | 37 (26–52) | 44 | – |
| Maia | Andrzejewski (2019) 25 | DC | 93 (113) | 41% | 59.5 | 63 (32–143) | 34 | 5 years 92% (retained implants) |
| Maia | Caekebeke (2018) 26 | DC | 35 (50) | 0% | 57 | 65 (56–71) | 39 | 65 months 96% (95% CI 85–99) |
| Maia | Toffoli (2017) 27 | DC | 80 (96) | – | 68 | Md 76 (60–102) | 56 | 5 years 93% (95% CI 87–98) (any significant complication)* |
| Maia | Bricout (2016) 28 | DC | 139 (156) | 0% | 62.7 | 37.8 (13.4–71.0) | 36 | 62 months 90.8% |
| Maia | Kubát (2012) 29 | DC | 34 (36) | 0% | 60 | 42 (37–?) | 30 | – |
| Moje | Kaszap (2012) 30 | DC | 12 (12) | 0% | 64 | 50 | 26 | – |
| Moje | Kollig (2017) 31 | DC | 26 (27) | 7% | 62 | 33 (9–62) | 39 | – |
| Moovis | Martins (2020) 32 | DC | 41 (41) | 11% | 68 | 60 (24–72) | 53 | – |
| Moovis | Tchurukdichian (2019) 33 | DC | 175 (196) | 2% | 66 | 48.2 (36–60) | 62 | – |
| Moovis | Dreant (2019) 34 | DC | 25 (28) | 10% | 63.4 | 27.5 (12–45) | 48 | – |
| Motec | Thillemann (2016) 35 | DC | 40 (42) | 0% | 59 | 26 (14–46) | 38 | 1 year 79% (95% CI 63–88). 2 years 58% (95% CI 40–72)* |
| Motec | Krukhaug (2014) 57 | DC | – (53) | 0% | 63 | Md 1.9 yrs | 14 | 3 years 91% (95% CI 81–100) |
| Nahigan | Hannula (1999) 56 | DC | 30 (34) | 19% | 58 | 47 (15–86) | 24 | – |
| Roseland | Semere (2015) 36 | DC | 51 (64) | 37% | 58.2 | 12.5 yrs (SD 1.8) | 39 | – |
| Roseland | Guardia (2010) 51 | DC | 68 (79) | 0% | 61.1 | 43.8 | 49 | – |
| Roseland | Zollinger (2010) 39 | DC | 34 (40) | 0% | 60.8 | 44 | 45 | – |
| Roseland | Moutet (2001) 52 | DC | 24 (27) | 0% | 62 | 38 (24–61) | 39 | – |
| Roseland | Schuhl (2001) 59 | DC | 43 (45) | 0% | 59.7 | 14 (1–50) | 27 | – |
| Rubis II | Dehl (2017) 37 | DC | 95 (115) | 55% | 71 | 10 yrs (6–17) | 39 | 10 years 89% |
| SR TMC | Pendse (2009) 38 | DC | 50 (62) | 0% | Md 64.5 | Md 36 (24–84) | 55 | 3 years 91% (revision surgery or loosening)* |
| SR TMC | Pérez-Ubeda (2003) 53 | DC | 19 (20) | 0% | 65 | 33 (24–45) | 43 | – |
Notes. All values mean (range) unless otherwise stated. DC, descriptive cohort; RCC, retrospective comparative cohort; PCC, prospective comparative cohort; RCT, randomized controlled trial; Md, median; CI, confidence interval.
Study characteristics
The 56 studies (Table 1) included a total of 2731 patients with 3048 thumb total CMCJ prosthetic joint replacements; 84% of patients were female (2210/2632 reported), with a mean age of 62.5 years (range, 50 to 71). Methodological analysis was poor to moderate across most of the studies, with higher Coleman scores for those with a more rigorous study design i.e. comparative cohorts or randomized controlled trials. Surgical experience level, surgical approaches, and post-operative rehabilitation were sporadically reported.
Follow up
All studies reported their follow up period, with mean follow up ranging from 12 months to 13.1 years.
Underlying aetiology
In all but one study the underlying aetiology was exclusively osteoarthritis (OA), and in the remaining study the underlying aetiology was inflammatory joint disease. 4 Of the 16 studies excluded due to mixed aetiologies, few of these included a significant proportion of inflammatory arthritis cases.
Assessment of clinical outcomes
Quantifiable patient-reported outcome measures were reported in 34 studies. 5–38 Comparable pre and post-operative values were reported in 12 studies. 7,9,10,13,16,17,19,23,27,29,32,33 The most commonly used patient-reported outcome measures (PROMs) were the Disabilities of the Arm Shoulder and Hand measure (DASH) or quick DASH which are general upper extremity scoring systems. Other measures included the Michigan Hand Questionnaire (MHQ) which is more specific to hand complaints, the Nelson score, which is specific to thumb outcomes, the Patient Related Wrist Evaluation (PRWE) score which is a wrist-specific measure, and the Sollerman score which is a measure of hand function. Most studies reporting pre and post-operative PROMs demonstrated a significant improvement from pre-operative values. The measures of spread of data (i.e. standard deviation or equivalent) were inconsistently reported.
Quantifiable satisfaction scores were reported in seven studies, 8,11,16,22,24,39,40 and pain scores in 30 studies. 4–7,9–11,13,15–17,19–24,26,27,29–35,38–41 Comparable pre and post-operative values were reported in two studies for satisfaction, 16,39 and 16 studies for pain. 7,9,10,13,16,17,19,20,23,27,29,32–34,39,41 Subjective satisfaction and pain scores using the visual analogue scale (VAS) system were collected to provide a comparative outcome measure. A number of studies reported pain and satisfaction as a percentage of patients ‘satisfied’ or ‘pain free’, but these measures were not felt to be reliable and useful for comparative analysis. The use of the VAS score for pain, documented pre and post-operatively was well utilized in 29% of studies. Most studies reporting pre and post-operative VAS scores for pain and/or satisfaction showed significant improvements from pre-operative values.
Quantifiable range of motion measurements/scores were reported in 38 studies. 4,5,9,10,12–17,19,21,23–27,30,32–34,36–40,42–53 Comparable pre and post-operative values were reported in 13 studies. 10,13,19,23,24,27,33,34,36,39,48,50,53 Objective range of motion assessment included the Kapandji Opposition score, degrees of thumb abduction (either radial or palmar), and the Buck-Gramcko score, which is a measure of various movements. Small improvements in range of motion were seen in most studies reporting pre and post-operative scores/ranges.
Strength measurement was reported in 36 studies. 4,6,7,9,10,12,14,16,19–27,29,32–34,36–38,40–42,44,46,48–50,53–56 Comparable pre and post-operative values were reported in 16 studies. 7,9,10,14,20,23,27,29,33,40,41,44,48,49,53,56 Strength measurements of grip, key pinch and tip pinch were included. Modest improvements in strength were seen, particularly for grip and key pinch strength in most studies reporting pre and post-operative scores.
The most significant complications were those of failure, loosening or dislocation of implants. A number of other complications including fracture, infection, chronic regional pain syndrome, superficial radial nerve symptoms, tendon irritation, and heterotopic ossification were noted, but only reported in this review for the comparative studies.
Survival estimates were provided in 21 studies. 4–8,11,12,19–21,23,25–28,35,37,38,45,48,57 The definition of survival varied considerably between studies, with the most common definition being that of an implant that has not either been removed or had a component exchanged. The most common cumulative survival analysis method was that of Kaplan-Meier; however, a number of studies either did not perform a formal analysis or did not provide details.
Outcomes of different prostheses
The ARPE prosthesis was reported in 11 studies comprising three comparative cohorts 8–10 and eight descriptive cohorts, 5–7,11,12,40,42,43 with a total of 735 replacements (Tables 2 and 3, Figures 2 and 3). Two studies reported > 10 year survival rates with cumulative survivorship analysis. One study reported significantly better survivorship after correcting for the learning curve procedures (15 year survival 80% to 85% after correction), demonstrating the importance of technical performance in obtaining good long-term results and minimizing complications. 5 The other study reported 93% survival at 10 years as defined by being offered revision surgery, although 50% of these declined. 7 One study demonstrated much poorer survival rates of 79% at 11 years with most of the failures being due to loosening. 12 A small trapezium was found to be a risk factor for trapezial loosening/failure, 7 emphasizing the importance of appropriate patient selection. At a mean of 78 months follow up, failure rates were 10.3%, loosening rates 4.8%, and dislocation rates 6.8%.
Study outcomes
| Implant | Author (year) | Patient-reported outcomes | Range of motion | Grip strength (Kgf) | Key pinch strength (Kgf) | Tip pinch strength (Kgf) | Failures | Loosening | Dislocation |
|---|---|---|---|---|---|---|---|---|---|
| ARPE | Dumartinet-Gibaud (2020) 5 | qDASH: Md 23. VAS Pain: 3 | KS: 9 | – | – | – | 40% | 13% | 13% |
| ARPE | Gómez-Garrido (2019) 6 | DASH: 19.55. VAS Pain: 1 | – | – | 5.8 | – | 7% | 4% | 4% |
| ARPE | Martin-Ferrero (2020) 7 | DASH: Pre 59 Post 13. VAS Pain: Pre 8.2 Post 1.1 | – | – | Pre 3.1 Post 4.5 |
– | 7% | 5% (cup) | 6% |
| ARPE | Craik (2017) 8 |
qDASH: 16.8. VAS Satisfaction: 8.7 |
– | – | – | – | 5% | 0% | 10% |
| ARPE | Robles-Molina (2017) 9 | qDASH: Pre 74.67 Post 21.79 VAS Pain: Pre 9.3 Post 1.33 | KS: 9.52 | – | Pre 11.14 lbs Post 11.8 lbs |
– | 10% | 0% | 10% |
| ARPE | Martínez-Martínez (2016) 10 | DASH: Pre 58.72 Post 11.44 VAS Pain: Pre 7.67 Post 1.27 |
KS: Pre 7.2 Post 9.4 Abd: Pre 40.73° Post 52.67° |
Pre 19.13 Post 23.47 |
Pre 4.78 Post 7.03 |
Pre 3.67 Post 5.83 |
0% | 0% | 0% |
| ARPE | Eecken (2012) 11 |
DASH: 8 VAS Satisfaction: 9.6 VAS Pain: 1 |
– | – | – | – | 11% | 3% (cup) | 6% |
| ARPE | Apard (2007) 12 | DASH: 27.4 | KS: 9.8 | Op 20 NonOp 19.6 |
Op 5.7 NonOp 5.3 |
– | 22% | 16% | 3% |
| ARPE | Jacoulet (2005) 42 | – |
KS: 10 Abd: 56° |
23 | 4 | – | 12% | 4% | 12% |
| ARPE | Brutus (2004) 40 | VAS Function: 9.9 Satisfaction: 4.7 (0–5 scale) Residual pain: 0.1 (0–4 scale) | KS: 10 | – | – | Pre 2.4 Post 6.6 |
6% | 6% | 10% |
| ARPE | Isselin (2001) 43 | – | Abd: 45.4° | – | – | – | – | – | – |
| Beznoska | Jurča (2016) 13 |
DASH: Pre 56 Post 7 VAS Pain: Pre 5 Post 1 |
KS: Pre 7.4 Post 9.8 | – | – | – | 9% | 9% | 0% |
| Braun-Cutter | Badia (2006) 44 | – |
Buck-Gramcko score: 53 RAbd: 60° |
– | Pre 3.5 Post 5.5 |
– | 4% | 0% | 4% |
| DLC | Skyttä (2005) 4 | VAS Pain: Md 90 |
KS: 5 PAbd: 42° RAbd: 37° |
12.4 | 4.2 | 3.3 | 26% | 30% (26% cup) | 11% |
| DLC | De Smet (2004) 14 | DASH: 24.2 |
KS: 9 Abd: Op 89° NonOp 95° |
Pre 17.63 Post 23.81 |
Pre 5.32 Post 5.97 |
– | 2% | 44% (42% cup) | 0% |
| DLC | Van Cappelle (1999) 45 | – | RAbd: 33° | – | – | – | 25% | 44% | 2% |
| DLC | Nonnenmacher (1994) 46 | – | Abd: 30° | 17 | – | – | – | 40% (15% cup) | 0% |
| DLC | Nicholas (1992) 47 | – | Abd: 39° | – | – | – | 10% | 5% (cup) | 5% |
| Elektra | Froschauer (2020) 15 |
DASH: 23 VAS Pain: 0 |
RAbd: 56° PAbd: 50° |
– | – | – | 53% | 65% (cup) | 3% |
| Elektra | Thorkildsen (2019) 48 |
– |
KS: Pre Md 9 Post Md 9 Abd: 49° |
Pre Md 17 Post Md 23 | Pre Md 6 Post Md 7 | Pre Md 4 Post Md 5 | 26% | 11% (cup) | 16% |
| Elektra | Chug (2014) 16 |
PRWE: Pre 68.6 Post 11.6 MHQ Satisfaction: Pre 39.2 Post 84.5 PRWE Pain: Pre 34.2 Post 5.3 |
KS: 8.2 RAbd: Op 47° NonOp 50° PAbd: Op 40° NonOp 41° |
Op 27 NonOp 28 | Op 3.6 NonOp 3.9 | Op 4 NonOp 4.3 | 6% | 0% | 0% |
| Elektra | Hernández-Cortéz (2012) 17 | qDASH: Pre 69.4 Post 37.9 VAS Pain: Pre 8.4 Post 4.6 | KS: 9 | – | – | – | 21% | 47% (cup) | 0% |
| Elektra | Hansen (2008) 18 | DASH: 38 | – | – | – | – | 35% | 29% (cup) | 6% |
| Elektra | Ulrich-Vinther (2008) 41 |
VAS Pain: Rest Pre 3.8 Post 0.5 Activity: Pre 8.2 Post 1.1 |
– | – | – | Pre 4 Post 5.2 | 3% | 3% | 0% |
| Elektra | Regnard (2006) 54 | – | – | 28 | 6 | – | 18% | 15% | 7% |
| Elektra | Krukhaug (2014) 57 | – | – | – | – | – | 7% | 3% | 3% |
| Elektra | Hansen (2013) 58 | – | – | – | – | – | 15% | 8% | 8% |
| Guepar I | Alnot (1993) 49 | – | Abd: 40° | Pre 16 Post 30 | – | Pre 2 Post 8 | 6% | 36% (14% cup) | 0% |
| Guepar II | Lemoine (2009) 50 | – |
KS: Pre 8.8 Post 9.5 Abd: Pre 35° Post 36° |
Op 20.8 NonOp 20.4 | Op 6 NonOp 5.8 | Op 4 NonOp 4.2 | 1% | 6% (3% cup) | 0% |
| Guepar II | Masmejean (2003) 55 | – | – | 19 | 6.1 | – | 2% | 2% (0% cup) | 0% |
| ISIS | Seng (2013) 19 |
qDASH: Pre 68.5 Post 37.8 VAS Pain: Pre 8.1 Post 3.4 |
KS: Pre 7.8 Post 9.1 Abd: 31.7° |
Op 17.2 NonOp 22 |
Op 5.1 NonOp 6.8 |
‘Pulp’ pinch: Op 3.1 NonOp 4.3 |
3% | 10% (7% cup) | 0% |
| IVORY | Tchurukdichian (2020) 20 |
qDASH: all ⩽ 14 VAS Pain: Pre 7.5 Post 0.24 |
– | Pre 19 Post 26 |
Pre 3.8 Post 6.4 |
Pre 1.9 Post 3.5 |
6% | 0% | 8% |
| IVORY | Cebrian-Gomez (2019) 21 |
qDASH: 11.4 VAS Pain: 0.6 |
KS: 9.7 RAbd: 38.8° |
20.3 | 2.3 | – | 4% | 1% | 2% |
| IVORY | Erne (2018) 22 |
DASH: 10.1 VAS Satisfaction: 9.5 VAS Pain: 0.5 |
– | – | 1 bar | – | 8% | 3% | 0% |
| IVORY | Vissers (2019) 23 | qDASH: Pre 58.9 Post 29.2 VAS Pain: Pre 7.3 Post 1.4 |
KS: Pre 8.4 Post 9.1 Abd: 54.6° |
Pre 16.7 Post 19.2 |
Pre 4.1 Post 4.4 |
‘Pulp’ pinch: Post 3.1 |
12% | 8% (cup) | 0% |
| IVORY | Spaans (2016) 24 |
DASH: 32.1 MHQ: 68.2 VAS Satisfaction: 2.9 VAS Pain: 1.9 |
KS: Pre 8.8 Post 8.8 RAbd: Op 50.4° NonOp 57.4° PAbd: Op 41.8° NonOp 48.7° |
Op 23.7 NonOp 26.1 |
Op 4.5 NonOp 4.5 |
Op 2.4 NonOp 2.6 |
10% | 0% | 10% |
| Maia | Andrzejewski (2019) 25 | DASH: 26.7 |
KS: 8.9 Abd: 44° |
– | Op 4.8 NonOp 5.4 |
– | 12% | 2% | 10% |
| Maia | Caekebeke (2018) 26 |
DASH: 7 MHQ: 91 VAS Pain: Rest 0 Loading activities 1 |
KS: 9 Abd: 76° |
Op 29 NonOp 27 |
Op 7 NonOp 7 |
– | 4% | 0% | 0% |
| Maia | Toffoli (2017) 27 | qDASH: Pre 61.3 Post 17.5 VAS Pain: Pre 7.9 Post 1.2 |
KS: Pre 9 Post 9.2 RAbd: Pre 32.9° Post 33° PAbd: Pre 32.1° Post 34.2° |
Pre 13.3 Post 23.4 |
Pre 4.3 Post 5.6 |
– | 8% | 4% (cup) | 1% |
| Maia | Bricout (2016) 28 | qDASH: 14.3 | – | – | – | – | 12% | 3% (cup) | 4% |
| Maia | Kubát (2012) 29 | qDASH: Pre 71.7 Post 22.5 VAS Pain: Pre 8.4 Post 0.4 | – | Pre 15.8 Post 26.8 |
Pre 2.7 Post 5.7 |
Pre 2.3 Post 4.9 |
6% | 3% (cup) | 3% |
| Moje | Kaszap (2012) 30 |
DASH: 27 VAS Pain: Rest 1.4 Maximal loading 3.9 |
RAbd: 37° PAbd: 38° |
– | – | – | 42% | 100% | 0% |
| Moje | Kollig (2017) 31 |
DASH: 23 VAS Pain: 1.9 |
– | – | – | – | 56% | 48% | 0% |
| Moovis | Martins (2020) 32 |
qDASH/Md: Pre 68 Post 24 MHQ/Md: 90 VAS Pain/Md: Pre 6 Post 0 |
KS: Op 9 NonOp 8 RAbd: Op 45 NonOp 50 PAbd: Op 50° NonOp 50° |
Md: Op 21 NonOp 19 |
Md: Op 7 NonOp 6 | – | 0% | 0% | 0% |
| Moovis | Tchurukdichian (2019) 33 |
qDASH: Pre 79.3 Post 35 VAS Pain: Pre 6.2 Post 0.76 |
KS: Pre 5.46 Post 9.1 | Pre 18.3 Post 26.8 |
Pre 4.2 Post 7.5 |
– | 3% | 0% | 0.5% |
| Moovis | Dreant (2019) 34 |
qDASH: 12 MHQ: 87.5 VAS Pain: Pre 8 Post 1 |
KS: Pre 7 Post 10 | 28 | 7.5 | ‘Pulp’ pinch: 4.5 | 4% | 4% | 0% |
| Motec | Thillemann (2016) 35 |
DASH: 28.4 VAS Pain: Rest 1 Activity 4 |
– | – | – | – | 40% | 21% (cup) | 7% |
| Motec | Krukhaug (2014) 57 | – | – | – | – | – | 6% | 6% | 0% |
| Nahigan | Hannula (1999) 56 | – | – | Pre 36.2 Post 43.4 |
Pre 3.6 Post 6.2 |
– | 15% | 32% | 0% |
| Roseland | Semere (2015) 36 | qDASH: 27.6 |
KS: Pre 8.1 Post 9.3 Abd: Pre 36.7° Post 39.2° |
21.7 | 6.1 | 4.5 | 9% | 3% (cup) | 2% |
| Roseland | Guardia (2010) 51 | – | KS: 97% 9–10 | – | – | – | 4% | 0% | 3% |
| Roseland | Zollinger (2010) 39 |
VAS Satisfaction: Pre 2.2 Post 8.7 VAS Pain: Pre 7.6 Post 1.3 |
Abd: Pre 59.3° Post 74.7° | – | – | – | 10% | 3% (cup) | 5% |
| Roseland | Moutet (2001) 52 | – | Abd: 50° | – | – | – | – | 4% (stem) | 0% |
| Roseland | Schuhl (2001) 59 | – | – | – | – | – | 18% | 27% (cup 22%) | 0% |
| Rubis II | Dehl (2017) 37 | qDASH: 30 |
KS: 9 Abd: 51° |
11 | 8.3 | 6.3 | 10% | 1% | 13% |
| SR TMC | Pendse (2009) 38 |
qDASH: 30.4 Sollerman score: 77.3 VAS Pain: 1.29 |
KS/Md: 8 Abd/Md: 59.1° |
19.2 | – | 4.1 | 11% | 8% | 3% |
| SR TMC | Pérez-Ubeda (2003) 53 | – | KS: Pre 8 Post 9 Abd: Pre 27° Post 35° | Pre 13.8 Post 16.25 |
Pre 3.75 Post 4.38 |
Pre 3.49 Post 4.2 |
20% | 55% | 0% |
Notes. All values mean (range) unless otherwise stated. (q)DASH, (quick) Disabilities of the Arm, Shoulder and Hand score; VAS, visual analogue scale; KS, Kapandji score; Abd, abduction; RAbd, radial abduction; PAbd, palmar abduction; Md, median; PRWE, Patient-Rated Wrist Evaluation; MHQ, Michigan Hand Outcomes Questionnaire.
Implant outcomes
| Implant | N | Follow up (months) | Failure | Loosening | Dislocation |
|---|---|---|---|---|---|
| ARPE | 735 | 78 | 10.3% | 4.8% | 6.8% |
| DLC | 144 | 68 | 14.5% | 38.2% | 1.4% |
| Elektra | 281 | 48 | 19.9% | 19.6% | 5.0% |
| IVORY | 274 | 82 | 6.2% | 1.5% | 4.4% |
| Maia | 451 | 59 | 9.8% | 2.4% | 4.4% |
| Moovis | 265 | 48 | 2.6% | 0.4% | 0.4% |
| Roseland | 255 | 60 | 9.2% | 6.3% | 2.0% |
Notes. All values mean unless otherwise stated. Follow up for each implant group calculated using the following formula: (N individual study implants × mean individual study follow up)/N total implants. Only incorporates studies with OA as underlying aetiology.
Implant outcomes.
Note. DLC, de la Caffinière
Citation: EFORT Open Reviews 6, 5; 10.1302/2058-5241.6.200152
Examples of implants
Implants: (a) ARPE, (b) IVORY 73 , (c) Touch.
Citation: EFORT Open Reviews 6, 5; 10.1302/2058-5241.6.200152
The de la Caffinière (DLC) prosthesis was reported in five studies, 4,14,45–47 all of which were descriptive cohorts, with a total of 171 replacements (144 for osteoarthritis). Two studies reported survival rates with cumulative survival analysis. One of these reported 72% survival at 16 years. 45 The other study reported 87% survival at 10 years. 4 At a mean of 68 months follow up, cases undertaken for osteoarthritis demonstrated failure rates of 14.5%, loosening rates of 38.2%, and dislocation rates of 13.8%. The single series evaluating cases undertaken for inflammatory arthritis evaluating outcomes at a mean of 13 years demonstrated, out of 27 cases, failure rates of 26%, loosening rates of 29.6%, and dislocation rates of 11.1%. 4
The Elektra prosthesis was reported in nine studies, comprising one randomized controlled trial, 48 two comparative cohorts, 15,41 and six descriptive cohorts, 16–18,54,57,58 with a total of 281 replacements. Two studies reported survival rates with cumulative survival analysis, demonstrating 72% survival at two years 48 and 90% survival at five years 57 respectively. At a mean of 48 months follow up, failure rates were 19.9%, loosening rates 19.6%, and dislocation rates 5%.
The IVORY prosthesis was reported in five studies, comprising two comparative cohorts, 21,22 and three descriptive cohorts, 20,23,24 with a total of 274 replacements. Two studies reported survival rates with cumulative survival analysis, demonstrating 95.5% survival at 10 years 20 and 96.4% survival at five years 21 respectively. At a mean of 82 months follow up, failure rates were 6.2%, loosening rates 1.5%, and dislocation rates 4.4%.
The Maia prosthesis was reported in five studies, 25–29 all of which were descriptive cohorts, with a total of 451 replacements. One study reported survival rates with cumulative survival analysis, demonstrating 93% survival at five years. 27 At a mean of 59 months follow up, failure rates were 9.8%, loosening rates 2.4%, and dislocation rates 4.4%.
The Moovis prosthesis was reported in three studies, 32–34 all of which were descriptive cohorts, with a total of 265 replacements. At a mean of 48 months follow up, failure rates were 2.6%, loosening rates 0.4%, and dislocation rates 0.4%.
The Roseland prosthesis was reported in five studies, 36,39,51,52,59 all of which were descriptive cohorts, with a total of 255 replacements. At a mean of 60 months follow up, failure rates were 9.2%, loosening rates 6.3%, and dislocation rates 2%.
The other prostheses were reported in much lower numbers and fewer studies, thus limiting the interpretation of the results. The Beznoska, 13 Braun-Cutter, 44 ISIS, 19 first generation Guepar, 49 second generation Guepar, 50,55 Moje, 30,31 Motec, 35,57 Nahigan, 56 Rubis II, 37 and SR TMC 38,53 prostheses have been described in mostly retrospective series (Table 2). Of these the Moje prosthesis demonstrated a particularly high failure rate of 42–56%.
Radiolucencies were common in some series, 19,25,27,48,50,55,56 but most cases were minor with no significant progression or clinical symptoms. 37 Heterotopic ossification was identified post-operatively in some series, but only rarely causing significant enough symptoms to warrant intervention. 6,7,12,25,27,37,38 Trapezial fracture, either intra-operatively, or after surgery due to trauma was identified in several studies, but in most cases the fracture was not severe enough to cause cup loosening or displacement and responded well to a period of immobilization. 5,33,36,46,52
Outcomes of comparative studies
The resection arthroplasty groups underwent trapeziectomy with ligament reconstruction and tendon interposition (LRTI) using flexor carpi radialis (FCR) in five studies, 9,10,13,21,48 abductor pollicis longus (APL) in two studies, 22,41 extensor carpi radialis longus (ECRL) in one study, 15 and a synthetic interposition in one study 8 (Table 4). Due to both the heterogeneity of surgical techniques and outcome measures, it was not possible to perform a meta-analysis of these data.
Comparative studies
| Implant – Author (year) | Study details | Patient-reported outcomes | Kapandji score/ Abduction (°) |
Grip strength (Kgf) | Key pinch strength (Kgf) | Tip pinch strength (Kgf) | Complications |
|---|---|---|---|---|---|---|---|
| Beznoska – Jurča (2016) 13 |
RCC
Repl: 11 (age 59) RA: 17 (age 58) Both 12 months follow up |
DASH:
Repl
Pre 56 Post 19
RA
Pre 58 Post 7 VAS Pain: Repl Pre 5 Post 1 RA Pre 5 Post 1 |
KS: Repl Pre 7.4 Post 9.8 RA: Pre 6.4 Post 8.9 | – | – | – |
Repl
: failure 1, loosening 1 (traumatic) RA : infection 1, parasthesias 4 |
| Elektra – Froschauer (2020) 15 |
RCC
Repl: 37 (5 lost to f/u, age 54, 13.1 yrs f/u) RA: 18 (5 lost to f/u, age 58, 13.6 yrs f/u) |
DASH:
Repl
23
RA
37 VAS Pain/Md: Repl 0 RA 0 |
RAbd: Repl 56 RA 51 PAbd: Repl 50 RA 57 | – | – | – |
Repl
: failures 17, aseptic cup loosening 17, cup tilting 4, dislocation 1, allergic reaction 1 RA : proximal migration of thumb 1, instability 1 |
| Elektra – Thorkildsen (2019) 48 |
RCT
Repl: 20 (1 lost to f/u, age Md 64, 2 yrs f/u) RA: 20 (age 61, 2 yrs f/u) |
*qDASH better in
Repl
at 3/6 months but not 1–2 yrs (MCID set at 15) *Nelson score better at 3 months but not beyond |
KS:
Repl
Pre 9 Post 9
RA
Pre 9 post 9 Abd: Repl 49 RA 42 |
Repl
Pre 17 Post 23 RA Pre 19 Post 20 |
Repl
Pre 6 Post 7 RA Pre 6 Post 6 |
Repl
Pre 4 Post 5 RA Pre 5 Post 6 |
Repl
: failures 5, cup loosening 2, dislocation 3, infection 1 RA : haematoma 1, FCR pain 1, thumb base pain 1 |
| Elektra – Ulrich-Vinther (2008) 41 |
PCC
Repl: 42 (6 lost to f/u, age 58, 12 months f/u) RA: 70 (8 lost to f/u, age 62, 12 months f/u) |
* VAS Pain: better in Repl from 3 months | *Repl better in flex/ext, abd/add, pulp palm distance from 3 months onwards | *Better in Repl from 3 months | *Better in Repl from 3 months | *Better in Repl from 3 months |
Repl
: failure 1, tendon issues 2, implant failure 1 RA : tendon issues 6, scar tenderness 1, sensory changes 1 |
| IVORY – Cebrian-Gomez (2019) 21 |
PCC
Repl: 84 (age 60, 4.1 yrs f/u) RA: 62 (age 60 3.6 yrs f/u) |
*qDASH:
Repl
11
RA
16 *VAS Pain: Repl 0.6 RA 1.7 |
*KS:
Repl
9.7
RA
9 *RAbd: Repl 38.8 RA 30.5 |
*Repl
20.3 RA 19.9 |
*Repl
2.3 RA 1.7 |
– |
Repl
: failures 3, infection 1, SRN dysthesia 1, CRPS 1, dislocation 2, cup loosening 1 RA : CRPS 1, painful TMCJ collapse 2, STT OA progression with pain 2 |
| IVORY – Erne (2018) 22 |
RCC
Repl: 39 (age 56.2, 42 months f/u) RA: 32 (age 54.3, 36 months f/u) |
*DASH:
Repl
10.1
RA
21.5 VAS Pain: Repl 0.5 RA 1 VAS Satisfaction: Repl 9.5 RA 8.5 |
– | – |
Repl
: 1 bar RA : 0.8 bar |
– |
Repl
: failures 3, broken proximal component 2, loosening 1, SRN injury 1 RA : SRN injury 1 |
| ARPE – Craik (2017) 8 |
RCC
Repl: 110 (24% loss to f/u, age 65, 2 yrs f/u) RA: 75 (39% loss to f/u, age 69, 3.4 yrs f/u) |
*qDASH:
Repl
16.8
RA
25.1 *VAS Satisfaction Repl 8.7 RA 7.8 |
– | – | – | – |
Repl
: failures 4, atraumatic dislocation 5, traumatic dislocation 3, fracture 1, HO 1, infection 1 RA : 0 |
| ARPE – Robles-Molina (2017) 9 |
RCC
Repl: 31 (age 56.3, 56 months f/u) RA: 34 (age 60.5, 59 months f/u) |
qDASH:
Repl
Pre 75 Post 22
RA
Pre 78 Post 26 VAS Pain: Repl Pre 9.3 Post 1.3 RA Pre 9.2 Post 1.4 |
*KS: Repl 9.5 RA 9 | – |
*Repl
: Pre 11.1 lbs Post 11.8 lbs *RA : Pre 9.9 lbs Post 8.4 lbs |
– |
Repl
: SRN dysthesias 2, dislocation 3 RA : SRN dysthesias 2, repeat surgery for MCPJ hyperextension 2 |
| ARPE – Martínez-Martínez (2016) 10 |
PCC
Repl: 15 (age 61, 56 months f/u) RA: 15 (age 58, 59 months f/u) |
DASH:
Repl
Pre 59 Post 11
RA
Pre 64 Post 17 VAS Pain: Repl Pre 8 Post 1 RA Pre 6 Post 1 |
KS:
Repl
Pre 7.2 Post 9.4
RA
Pre 7.5 Post 9.3 *Abd: Repl Pre 41 Post 53 RA Pre 44 Post 49 |
Repl
: Pre 19.1 Post 23.5 RA : Pre 17.2 Post 23.5 |
*Repl
: Pre 4.8 Post 7 RA : Pre 4.3 Post 5.3 |
*Repl
: Pre 3.7 Post 5.8 RA : Pre 3.1 Post 5.3 |
Repl
: SRN dysthesia 1, suture irritation 1, trapezial fracture 1 RA : SRN dysthesia 1, infection 1, CRPS 1 |
Notes. All values mean unless otherwise stated. RCC, retrospective comparative cohort; PCC, prospective comparative cohort; RCT, randomized controlled trial; Repl, replacement; RA, resection arthroplasty; (q)DASH, (quick) Disabilities of the Arm, Shoulder and Hand score; VAS, visual analogue scale; KS, Kapandji score; Abd, abduction; RAbd, radial abduction; PAbd, palmar abduction; Md, median; FCR, flexor carpi radialis; SRN, superficial radial nerve; CRPS, chronic regional pain syndrome; MCPJ, metacarpophalangeal joint; TMCJ, trapeziometacarpal joint; STT OA, scaphotrapeziotrapezoidal osteoarthritis; HO, heterotopic ossification.
*Statistically significant p < 0.05.
Thorkildsen et al 48 undertook a randomized controlled trial (RCT) comparing the Elektra prosthesis to trapeziectomy with LRTI using FCR with 20 patients in each group, with a follow up of two years. qDASH scores were better in the replacement group at three and six months but not at one to two years (based upon a minimally clinical important difference (MCID) of 15). The Nelson score demonstrated better results in the replacement group at three months but not beyond this. Range of movement and grip strength were not significantly different between the two groups. The prosthetic group demonstrated five failures (two for cup loosening, three for dislocation) and one infection. The trapeziectomy group demonstrated three complications, with one haematoma, one FCR-related pain, and one base of thumb pain.
The other studies were comparative cohorts comparing ARPE, 8–10 IVORY, 21,22 Elektra, 15,41 and Beznoska 13 prostheses against resection arthroplasty. Follow up ranged from 12 months to 13.6 years. PROMs were shown to be statistically significantly better in the replacement group in 4/7 studies, 8,13,21,22 pain relief better in 3/7 studies, 9,21,41 range of motion better in 4/6 studies, 9,10,21,41 and strength better in 4/5 studies. 9,10,21,41 In the remainder of studies any difference seen was statistically insignificant. There were no studies demonstrating a statistically significant superiority of resection arthroplasty over replacement. Pain relief was achieved faster in the replacement group in three studies, 21,22,41 and return to work was faster in one study. 22 Complications were more common in the replacement groups in terms of failures, with the majority of issues in the replacement group being loosening and dislocation. Out of a total of 389 replacements, there were 62 reported complications (16%). This comprised 26 cases of loosening, 17 dislocations, five superficial radial nerve symptoms, three implant failures, three infections, two tendon issues, two fractures, one suture irritation, one heterotopic ossification, one chronic regional pain syndrome (CRPS), and one allergic reaction. Out of a total of 343 resection arthroplasties, there were 31 reported complications (9%). This comprised nine superficial radial nerve symptoms, six tendon issues, three proximal migrations, two infections, two CRPS, two STTJ OA progression, two metacarpo-phalangeal joint hyperextension deformities, one case of scar tenderness, one base of thumb pain, one FCR pain, one haematoma, and one instability.
Discussion
Thumb CMCJ prosthetic total joint replacement outcomes have now been published with fair to good long-term functional outcomes, and demonstrate encouraging clinical outcomes in comparative studies with resection arthroplasty at short–medium-term follow up. This comes with a cost of increased rates of complications, largely in terms of loosening and dislocation of the implants.
Thumb CMCJ replacement is a technically demanding procedure, and appropriate patient selection and surgical experience are thought to be fundamental to obtaining optimal outcomes and reducing complications. There is a significant learning curve to replacement operations, with higher failure rates and complications demonstrated in one series in the first 30 cases as compared to subsequent 50 cases. 5 Accurate and comparative reporting of experience level is important to aid the interpretation of published results, with systems in existence to enable this. 60 Computer-assisted surgery has been piloted in a cadaveric study to attempt to obtain reliable and accurate position of the cup component, but has not yet been translated into clinical practice. 61
OA is the most common indication for replacement procedures. Several manufacturers advise specifically not to undertake CMCJ replacement in patients with inflammatory arthritis due to the theoretically higher risks of failure due to poor bone and soft tissue quality. Only one study evaluated CMCJ replacement in purely inflammatory arthritis cases, 4 with a failure rate of 26%, loosening rate of 30% and dislocation rate of 11%, somewhat supporting this theory.
Surgical approach is thought by some surgeons to determine either optimal exposure or preservation of important ligamentous/capsular complexes. Surgical approaches were not reported in a significant number of studies; however, dorsal approaches were described in 29 studies, and volar approaches in eight studies. Advocates of the volar (Wagner) approach suggest that because the two important structures in stability of the thumb CMCJ are the anterior oblique ligament (which is already attenuated in CMCJ OA) and the dorsal capsule, a volar approach preserves the remaining dorsal capsule to maximize post-operative stability and reduce dislocation rates. 62 Advocates of the dorsal approach suggest that the trapezial exposure is significantly better with this approach, and therefore a more accurate implantation of the trapezial component can be established. 5,7 The only study to assess this found that implant positioning was significantly better in their cohort with the dorsal approach compared to the volar approach. 7 This has yet to be validated by other studies and with other prostheses and no conclusions regarding optimal approach can be made on the basis of this.
Patient-reported outcomes are critical to evaluating the subtle differences in improvement between CMCJ replacement and resection arthroplasty. The most commonly used outcome measures, i.e. DASH/qDASH, may not be sensitive enough to assess this. Thorkildsen et al 48 reported an MCID of 15 in their randomized controlled trial using qDASH as the comparative outcome measure, but this was based upon a study evaluating a heterogenous group of hand conditions and therefore was not specific to thumb outcomes. 63 The Nelson score is a thumb-specific measure with positive ratings according to the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN), 64 but is not commonly used. Pain is the major presenting feature with which patients pursue surgical intervention, and therefore the accurate and comparable recording of pain-related outcomes is essential. The use of the VAS score for pain, documented pre and post-operatively is probably the most easily comparable score available. Standardization of whether this represents pain at rest or on activity will help define outcomes even further. Survival rates are a key index reporting measure in large joint arthroplasty, and will play a useful role in the comparative outcomes of thumb CMCJ replacement. It is important, however, to standardize the definition of survival e.g. as removal or exchange of prostheses, and to perform cumulative survival analysis to enable accurate comparison of implants at different time points. A core outcome set for thumb CMCJ outcomes has not yet been defined, but will be important in future comparative studies. 65,66
Early implants, e.g. de la Caffinière, used cemented fixation techniques of the trapezial and metacarpal components with a semi-constrained prosthesis, which may explain the relatively high loosening rates for these protheses, as the thumb CMCJ will undergo significant shear as well as compressive forces. 67 Subsequent protheses (Table 5) developed either hydroxyapatite coated or porous coated titanium implants (e.g. ARPE, Elektra, IVORY, Maia, Roseland) to encourage more robust bone integration. Other implants, e.g. Moovis, have evolved to incorporate dual mobility bearing characteristics with the theoretical advantages of reducing both loosening and dislocation rates. This is borne out in the early–medium-term data presented in this review, as Moovis has the lowest rates of both loosening and dislocation, although with a mean follow up of two years (maximum five years). Longer-term results are awaited to determine the longevity of these implants.
Characteristics of commonly used implants
| Implant | Cup | Stem | Bearing | Still marketed? | Manufacturer | Origin of publications |
|---|---|---|---|---|---|---|
| ARPE | HAC | HAC | Metal on PE | Yes | Zimmer Biomet | France, Italy, Spain, UK, Belgium |
| DLC | Cemented, polyethylene | Cemented, cobalt chrome | Metal on PE | No | Fixano/Sbi | Belgium, Netherlands, France, UK, Finland |
| Elektra | HAC | HAC | Metal on PE | No | Fixano/Sbi | Austria, Norway, Australia, Spain, Denmark, France |
| IVORY | HAC | HAC | Metal on PE | No | Stryker | France, Spain, Germany, Belgium, Netherlands |
| Maia | HAC | HAC | Metal on PE | Yes | Lepine | Belgium, France, Czech Republic |
| Moovis | HAC | HAC | Metal on PE (dual mobility) | Yes | Sbi/Stryker | France |
| Roseland | HAC | HAC | Metal on PE | No | De Puy | France, Netherlands |
Note. HAC, hydroxyapatite coated metal (uncemented); PE, polyethylene.
Of the commonly reported implants, DLC, Elektra, Roseland and IVORY are no longer on the market. This has occurred either due to high levels of failure (e.g. Elektra) or for commercial reasons (e.g. Roseland, IVORY). ARPE, Moovis, and Maia are CE marked for use in Europe. Another promising modern implant with CE marking is the Touch prosthesis (Keri Medical, dual mobility). It has not yet been reported upon but is commonly used in Europe and as a result Keri Medical are in the process of seeking Food and Drug Administration (FDA) approval for its use in the USA.
Resection arthroplasty, i.e. trapeziectomy with or without LRTI, is held as the standard of surgical care for CMCJ OA for which to compare other interventions. The comparative studies in this review use a wide range of LRTI interventions, which alongside different reporting outcomes negates the usefulness of meta-analysis of the data. In addition to clinical measures, failure is often reported as a measure of comparison between the interventions. 68 One option for a failed replacement is to perform a secondary trapeziectomy, which has been shown to have equivalent outcomes when compared to patients who undergo a primary trapeziectomy from the beginning (i.e. no replacement at all). 50,56,69–71 The main comparative study utilized trapeziectomy without LRTI. 70
There are concerns regarding the increased cost of using implants in replacement compared to trapeziectomy, and cost-effectiveness studies are lacking in the literature. Only one study has evaluated relative costs of trapeziectomy vs. trapeziectomy with LRTI vs. CMCJ replacement/fusion (as a combined group due to low overall numbers). 72 They looked at 3501 patients from 2001–2010, and calculated the Medicare and secondary insurance payouts for each procedure. They calculated the hospital outpatient total spending at a mean of 3199 USD for trapeziectomy, 3412 USD for CMCJ replacement/fusion, and 4186 USD for trapeziectomy with LRTI. It is difficult to extrapolate this fully to our day-to-day practice due to the combined replacement/fusion group, and now relatively old data. Further studies should incorporate cost-effectiveness evaluations into the study design.
A precise definition of how loosening was identified was lacking in most studies. Only two studies specifically defined how they assessed loosening – one with radiolucent lines in three or more zones of 0.5 mm or more, 38 and one with radiolucent lines greater than 1 mm. 14 The other studies simply described radiographic loosening or migration of the implant. A universal definition of loosening would help make reliable comparisons across studies and implants.
This systematic review has some weaknesses. The quality of evidence has improved since the last systematic review on this topic, 2 with a further seven comparative trials (including one RCT), however the majority of studies are still of a moderate methodological quality, even amongst the comparative studies. The quality of reporting did not allow for a meta-analysis due to the heterogeneous datasets. Therefore it is not possible to draw a definitive conclusion regarding the superiority of replacement versus resection arthroplasty. The definitions of loosening were variable and therefore difficult to accurately report between studies. The inclusion of core outcome sets, standardizing reporting of outcomes, will help in future meta-analyses of datasets to enable more definite conclusions to be reached.
Conclusion
The number of studies reporting outcomes in thumb CMCJ prosthetic total joint replacement are increasing both in number and quality. Failure, in terms of loosening and dislocation, remains a concern, although in the medium-term follow up for modern implants this issue appears to be of less concern when compared to their predecessors. Functional outcomes also look promising compared to resection arthroplasty, but further high-quality studies utilizing a standardized resection arthroplasty technique and modern implants, together with standardized core outcome sets, will be of value.
Open access
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The authors declare no conflict of interest relevant to this work.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.
References
- 1.↑
Moriatis Wolf J , Turkiewicz A , Atroshi I , Englund M . Prevalence of doctor-diagnosed thumb carpometacarpal joint osteoarthritis: an analysis of Swedish health care. Arthritis Care Res (Hoboken) 2014; 66:961–965 .
- 2.↑
Huang K , Hollevoet N , Giddins G . Thumb carpometacarpal joint total arthroplasty: a systematic review. J Hand Surg Eur Vol 2015; 40:338–350 .
- 3.↑
Coleman BD , Khan KM , Maffulli N , Cook JL , Wark JD ; Victorian Institute of Sport Tendon Study Group. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Scand J Med Sci Sports 2000; 10:2–11 .
- 4.↑
Skyttä ET , Belt EA , Kautiainen HJ , Lehtinen JT , Ikävalko M , Mäenpää HM . Use of the de la Caffinière prosthesis in rheumatoid trapeziometacarpal destruction. J Hand Surg [Br] 2005; 30:395–400 .
- 5.↑
Dumartinet-Gibaud R , Bigorre N , Raimbeau G , Jeudy J , Saint Cast Y . Arpe total joint arthroplasty for trapeziometacarpal osteoarthritis: 80 thumbs in 63 patients with a minimum of 10 years follow-up. J Hand Surg Eur Vol 2020; 45:465–469 .
- 6.↑
Gómez-Garrido D , Triviño-Mayoral V & Delgado-Alcala V et al. Five year long term results of total joint arthroplasties in the treatment of trapeziometacarpal osteoarthritis. Acta Biomed 2019; 90:451–456 .
- 7.↑
Martin-Ferrero M , Simon-Perez C , Coco-Martin MB , Vega-Castrillo A , Aguado-Hernandez H , Mayo-Iscar A . Trapeziometacarpal total joint arthroplasty for osteoarthritis: 119 patients with a minimum of 10 years follow-up. J Hand Surg Eur Vol 2020; 45:443–451 .
- 8.↑
Craik JD , Glasgow S & Andren J et al. Early results of the ARPE arthroplasty versus trapeziectomy for the treatment of thumb carpometacarpal joint osteoarthritis. J Hand Surg Asian Pac Vol 2017; 22:472–478 .
- 9.↑
Robles-Molina MJ , López-Caba F , Gómez-Sánchez RC , Cárdenas-Grande E , Pajares-López M , Hernández-Cortés P . Trapeziectomy with ligament reconstruction and tendon interposition versus a trapeziometacarpal prosthesis for the treatment of thumb basal joint osteoarthritis. Orthopedics 2017; 40:e681–e686 .
- 10.↑
Martínez-Martínez F , García-Hortelano S , García-Paños JP , Moreno-Fernández JM , Martín-Ferrero MA . [Comparative clinical study of 2 surgical techniques for trapeziometacarpal osteoarthritis]. Rev Esp Cir Ortop Traumatol 2016; 60:59–66 .
- 11.↑
Eecken SV , Vanhove W , Hollevoet N . Trapeziometacarpal joint replacement with the Arpe prosthesis. Acta Orthop Belg 2012; 78:724–729 .
- 12.↑
Apard T , Saint-Cast Y . [Results of a 5 years follow-up of Arpe prosthesis for the basal thumb osteoarthritis]. Chir Main 2007; 26:88–94 .
- 13.↑
Jurča J , Němejc M , Havlas V . Surgical treatment for advanced rhizarthrosis: comparison of results of the burton-pellegrini technique and trapeziometacarpal joint arthroplasty. Acta Chir Orthop Traumatol Cech 2016; 83:27–31 .
- 14.↑
De Smet L , Sioen W , Spaepen D , Van Ransbeeck H . Total joint arthroplasty for osteoarthritis of the thumb basal joint. Acta Orthop Belg 2004; 70:19–24 .
- 15.↑
Froschauer SM , Holzbauer M , Hager D , Schnelzer R , Kwasny O , Duscher D . Elektra prosthesis versus resection-suspension arthroplasty for thumb carpometacarpal osteoarthritis: a long-term cohort study. J Hand Surg Eur Vol 2020; 45:452–457 .
- 16.↑
Chug M , Williams N , Benn D , Brindley S . Outcome of uncemented trapeziometacarpal prosthesis for treatment of thumb carpometacarpal joint arthritis. Indian J Orthop 2014; 48:394–398 .
- 17.↑
Hernández-Cortés P , Pajares-López M , Robles-Molina MJ , Gómez-Sánchez R , Toledo-Romero MA , De Torres-Urrea J . Two-year outcomes of Elektra prosthesis for trapeziometacarpal osteoarthritis: a longitudinal cohort study. J Hand Surg Eur Vol 2012; 37:130–137 .
- 18.↑
Hansen TB , Snerum L . Elektra trapeziometacarpal prosthesis for treatment of osteoarthrosis of the basal joint of the thumb. Scand J Plast Reconstr Surg Hand Surg 2008; 42:316–319 .
- 19.↑
Seng VS , Chantelot C . [Isis(®) trapeziometacarpal prosthesis in basal thumb osteoarthritis: 30 months follow-up in 30 cases]. Chir Main 2013; 32:8–16 .
- 20.↑
Tchurukdichian A , Guillier D , Moris V , See L-A , Macheboeuf Y . Results of 110 IVORY® prostheses for trapeziometacarpal osteoarthritis with a minimum follow-up of 10 years. J Hand Surg Eur Vol 2020; 45:458–464 .
- 21.↑
Cebrian-Gomez R , Lizaur-Utrilla A , Sebastia-Forcada E , Lopez-Prats FA . Outcomes of cementless joint prosthesis versus tendon interposition for trapeziometacarpal osteoarthritis: a prospective study. J Hand Surg Eur Vol 2019; 44:151–158 .
- 22.↑
Erne H , Scheiber C & Schmauss D et al. Total endoprosthesis versus lundborg’s resection arthroplasty for the treatment of trapeziometacarpal joint osteoarthritis. Plast Reconstr Surg Glob Open 2018; 6:e1737 .
- 23.↑
Vissers G , Goorens CK & Vanmierlo B et al. Ivory arthroplasty for trapeziometacarpal osteoarthritis: 10-year follow-up. J Hand Surg Eur Vol 2019; 44:138–145 .
- 24.↑
Spaans AJ , van Minnen LP , Weijns ME , Braakenburg A , van der Molen ABM . Retrospective study of a series of 20 ivory prostheses in the treatment of trapeziometacarpal osteoarthritis. J Wrist Surg 2016; 5:131–136 .
- 25.↑
Andrzejewski A , Ledoux P . Maïa® trapeziometacarpal joint arthroplasty: survival and clinical outcomes at 5 years’ follow-up. Hand Surg Rehabil 2019; 38:169–173 .
- 26.↑
Caekebeke P , Duerinckx J . Can surgical guidelines minimize complications after Maïa® trapeziometacarpal joint arthroplasty with unconstrained cups? J Hand Surg Eur Vol 2018; 43:420–425 .
- 27.↑
Toffoli A , Teissier J . MAÏA trapeziometacarpal joint arthroplasty: clinical and radiological outcomes of 80 patients with more than 6 years of follow-up. J Hand Surg Am 2017; 42:838.e1–838.e8 .
- 28.↑
Bricout M , Rezzouk J . Complications and failures of the trapeziometacarpal Maia® prosthesis: a series of 156 cases. Hand Surg Rehabil 2016; 35:190–198 .
- 29.↑
Kubát P , Trtík L . [Maïa trapeziometacarpal implant for treatment of advanced osteoarthritis of the basal joint of the thumb]. Acta Chir Orthop Traumatol Cech 2012; 79:520–523 .
- 30.↑
Kaszap B , Daecke W , Jung M . High frequency failure of the Moje thumb carpometacarpal joint arthroplasty. J Hand Surg Eur Vol 2012; 37:610–616 .
- 31.↑
Kollig E , Weber W , Bieler D , Franke A . Failure of an uncemented thumb carpometacarpal joint ceramic prosthesis. J Hand Surg Eur Vol 2017; 42:599–604 .
- 32.↑
Martins A , Charbonnel S , Lecomte F , Athlani L . The Moovis® implant for trapeziometacarpal osteoarthritis: results after 2 to 6 years. J Hand Surg Eur Vol 2020; 45:477–482 .
- 33.↑
Tchurukdichian A , Gerenton B , Moris V , See L-A , Stivala A , Guillier D . Outcomes of double-mobility prosthesis in trapeziometacarpal joint arthritis with a minimal 3 years of follow-up: an advantage for implant stability. Hand (N Y) 2019;1558944719855690 .
- 34.↑
Dreant N , Poumellec M-A . Total thumb carpometacarpal joint arthroplasty: a retrospective functional study of 28 MOOVIS prostheses. Hand (N Y) 2019; 14:59–65 .
- 35.↑
Thillemann JK , Thillemann TM , Munk B , Krøner K . High revision rates with the metal-on-metal Motec carpometacarpal joint prosthesis. J Hand Surg Eur Vol 2016; 41:322–327 .
- 36.↑
Semere A , Vuillerme N , Corcella D , Forli A , Moutet F . Results with the Roseland(®) HAC trapeziometacarpal prosthesis after more than 10 years. Chir Main 2015; 34:59–66 .
- 37.↑
Dehl M , Chelli M , Lippmann S , Benaissa S , Rotari V , Moughabghab M . Results of 115 Rubis II reverse thumb carpometacarpal joint prostheses with a mean follow-up of 10 years. J Hand Surg Eur Vol 2017; 42:592–598 .
- 38.↑
Pendse A , Nisar A , Shah SZ , Bhosale A , Freeman JV , Chakrabarti I . Surface replacement trapeziometacarpal joint arthroplasty: early results. J Hand Surg Eur Vol 2009; 34:748–757 .
- 39.↑
Zollinger PE , Unal H , Ellis ML , Tuinebreijer WE . Clinical results of 40 consecutive basal thumb prostheses and no CRPS Type I after vitamin C prophylaxis. Open Orthop J 2010; 4:62–66 .
- 40.↑
Brutus JP , Kinnen L . [Short term results of total carpometacarpal joint replacement surgery using the ARPE implant for primary ostearthritis of the thumb]. Chir Main 2004; 23:224–228 .
- 41.↑
Ulrich-Vinther M , Puggaard H , Lange B . Prospective 1-year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis. J Hand Surg Am 2008; 33:1369–1377 .
- 42.↑
Jacoulet P . [Results of the ARPE trapezometacarpal prosthesis: a retrospective study of 37 cases]. Chir Main 2005; 24:24–28 .
- 44.↑
Badia A , Sambandam SN . Total joint arthroplasty in the treatment of advanced stages of thumb carpometacarpal joint osteoarthritis. J Hand Surg Am 2006; 31:1605–1614 .
- 45.↑
van Cappelle HG , Elzenga P , van Horn JR . Long-term results and loosening analysis of de la Caffinière replacements of the trapeziometacarpal joint. J Hand Surg Am 1999; 24:476–482 .
- 46.↑
Nonnenmacher J , Graftiaux AG . ‘De la Caffiniere’ trapezometacarpal prostheses in trapezometacarpal osteoarthritis: report of a series of twenty cases operated between 1978 and 1990. Ann Chir Main Memb Super 1994; 13:26–35 .
- 47.↑
Nicholas RM , Calderwood JW . De la Caffinière arthroplasty for basal thumb joint osteoarthritis. J Bone Joint Surg Br 1992; 74:309–312 .
- 48.↑
Thorkildsen RD , Røkkum M . Trapeziectomy with LRTI or joint replacement for CMC1 arthritis, a randomised controlled trial. J Plast Surg Hand Surg 2019; 53:361–369 .
- 49.↑
Alnot JY , Beal D , Oberlin C , Salon A , Guepar . GUEPAR total trapeziometacarpal prosthesis in the treatment of arthritis of the thumb: 36 case reports. Ann Chir Main Memb Super 1993; 12:93–104 .
- 50.↑
Lemoine S , Wavreille G , Alnot JY , Fontaine C , Chantelot C ; groupe GUEPAR. Second generation GUEPAR total arthroplasty of the thumb basal joint: 50 months follow-up in 84 cases. Orthop Traumatol Surg Res 2009; 95:63–69 .
- 51.↑
Guardia C , Moutet F , Corcella D , Forli A , Pradel P . [Roseland® prosthesis: quality of life studies about 68 patients with a mean followed-up of 43.8 months]. Chir Main 2010; 29:301–306 .
- 52.↑
Moutet F , Lebrun C , Massart P , Sartorius C . [The Roseland prosthesis]. Chir Main 2001; 20:79–84 .
- 53.↑
Pérez-Ubeda MJ , García-López A , Marco Martinez F , Junyent Vilanova E , Molina Martos M , López-Duran Stern L . Results of the cemented SR trapeziometacarpal prosthesis in the treatment of thumb carpometacarpal osteoarthritis. J Hand Surg Am 2003; 28:917–925 .
- 54.↑
Regnard P-J . Electra trapezio metacarpal prosthesis: results of the first 100 cases. J Hand Surg [Br] 2006; 31:621–628 .
- 55.↑
Masmejean E , Alnot JY , Chantelot C , Beccari R . [Guepar anatomical trapeziometacarpal prosthesis]. Chir Main 2003; 22:30–36 .
- 56.↑
Hannula TT , Nahigian SH . A preliminary report: cementless trapeziometacarpal arthroplasty. J Hand Surg Am 1999; 24:92–101 .
- 57.↑
Krukhaug Y , Lie SA , Havelin LI , Furnes O , Hove LM , Hallan G . The results of 479 thumb carpometacarpal joint replacements reported in the Norwegian Arthroplasty Register. J Hand Surg Eur Vol 2014; 39:819–825 .
- 58.↑
Hansen TB , Stilling M . Equally good fixation of cemented and uncemented cups in total trapeziometacarpal joint prostheses: a randomized clinical RSA study with 2-year follow-up. Acta Orthop 2013; 84:98–105 .
- 59.↑
Schuhl JF . The Roseland prosthesis in the trapeziometacarpal arthritis: a five years experience with the same operator. Chir Main 2001; 20:75–78 .
- 60.↑
Tang JB , Giddins G . Why and how to report surgeons’ levels of expertise. J Hand Surg Eur Vol 2016; 41:365–366 .
- 61.↑
Facca S , Liverneaux PA . Feasibility of computer-assisted surgery for trapeziometacarpal prosthesis: a preliminary experimental study. Surg Radiol Anat 2012; 34:857–864 .
- 62.↑
Braunohler WM , Waddell RW . Thumb metacarpal trapezium implant scaphoid instability. Orthop Rev 1982; 11:59–69 .
- 63.↑
Wong JYP , Fung BKK , Chu MML , Chan RKY . The use of Disabilities of the Arm, Shoulder, and Hand Questionnaire in rehabilitation after acute traumatic hand injuries. J Hand Ther 2007; 20:49–55 .
- 64.↑
Marks M , Schoones JW , Kolling C , Herren DB , Goldhahn J , Vliet Vlieland TPM . Outcome measures and their measurement properties for trapeziometacarpal osteoarthritis: a systematic literature review. J Hand Surg Eur Vol 2013; 38:822–838 .
- 65.↑
Giddins G . Functional outcomes after surgery for thumb carpometacarpal joint arthritis. J Hand Surg Eur Vol 2020; 45:64–70 .
- 66.↑
Copeland A , Gallo L & Weber C et al. Reporting outcomes and outcome measures in thumb carpometacarpal joint osteoarthritis: a systematic review. J Hand Surg Am 2021; 46:65.e1–65.e11 .
- 67.↑
Cooney WP III , Chao EY . Biomechanical analysis of static forces in the thumb during hand function. J Bone Joint Surg Am 1977; 59:27–36 .
- 68.↑
Ganhewa AD , Wu R & Chae MP et al. Failure rates of base of thumb arthritis surgery: a systematic review. J Hand Surg Am 2019; 44:728–741.e10 .
- 69.↑
Boeckstyns ME , Sinding A , Elholm KT , Rechnagel K . Replacement of the trapeziometacarpal joint with a cemented (Caffinière) prosthesis. J Hand Surg Am 1989; 14:83–89 .
- 70.↑
Kaszap B , Daecke W , Jung M . Outcome comparison of primary trapeziectomy versus secondary trapeziectomy following failed total trapeziometacarpal joint replacement. J Hand Surg Am 2013; 38:863–871.e3 .
- 71.↑
Apard T , Saint-Cast Y . [Revision of the ARPE prosthesis by the Jones procedure: a study of 6 cases and review of literature]. Chir Main 2007; 26:95–102 .
- 72.↑
Mahmoudi E , Yuan F , Lark ME , Aliu O , Chung KC . Medicare spending and evidence-based approach in surgical treatment of thumb carpometacarpal joint arthritis: 2001 to 2010. Plast Reconstr Surg 2016; 137:980e–989e .
- 73.↑
Froschauer S.M. , Holzbauer M. & Schnelzer R.F et al. Total arthroplasty with Ivory® prosthesis versus resection–suspension arthroplasty: a retrospective cohort study on 82 carpometacarpal-I osteoarthritis patients over 4 years. Eur J Med Res 25, 13 (2020).
