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Primary endoprosthetic replacement of the arthritic CMC-1 joint

Primärer Endoprothesenersatz bei Arthrose des Daumensattelgelenks

  • Surgical Techniques
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Abstract

Objective

Osteoarthritis of the carpometacarpal (CMC)-1 joint is a common condition that can cause significant pain and functional problems. When nonoperative management fails, surgery may be indicated. Resection of the trapezium, often combined with soft tissue stabilization, is still considered the gold standard. But recovery time is often prolonged and a significant number of patients remain unsatisfied in the long term. Knowing that total endoprosthetic joint replacement is one of the most successful achievements of orthopedic surgery, many attempts have been made to produce a replacement for the CMC‑1 joint that provides a better outcome than trapeziectomy.

Indications

Eaton–Glickel stage 2–3 CMC‑1 osteoarthritis.

Contraindications

Symptomatic pan-trapezial osteoarthritis (Eaton–Glickel stage 4), infection, young manual worker, poor bone quality or insufficient trapezium size.

Surgical technique

A dorsoradial approach to the CMC‑1 joint is used. Minimal resection of the trapezial and metacarpal articular surfaces, including osteophytes and loose bodies. Reaming of the trapezium and broaching of the metacarpal stem with dedicated instruments. Implantation of the endoprosthetic components. Selection of the correct neck length to ensure a stable joint. Closure of the capsule and skin.

Postoperative management

Immobilization of thumb for 2 weeks in a splint. Followed by a removable thumb CMC brace for 4 weeks, starting with gentle mobilization exercises. No forceful gripping or pinching the first 6 weeks.

Results

A specific design—the uncemented, ball in socket, metal on polyethylene total joint replacement—has stood the test of time and successful long-term clinical and radiographic outcome results have been published. Recent comparative trials have shown better pinch strength, better pain relief and faster functional recovery, when compared to trapeziectomy with ligament reconstruction and tendon interposition. The incidence of complications such as dislocation, polyethylene wear and cup loosening is acceptable.

Zusammenfassung

Operationsziel

Eine Arthrose des CMC(Karpometakarpal)-1-Gelenks ist eine häufige Erkrankung und kann erhebliche Schmerzen und Funktionsstörungen verursachen. Wenn konservative Behandlungsmaßnahmen keinen Erfolg zeigen, kann eine Operation indiziert sein. Als Goldstandard gilt nach wie vor die Trapeziumresektion, oft kombiniert mit einer Weichteilstabilisierung. Allerdings ist die Genesungszeit oft verlängert, und eine nicht unerhebliche Gruppe von Patienten bleibt auf Dauer unzufrieden. Angesichts der Tatsache, dass der vollständige endoprothetische Gelenkersatz eine der erfolgreichsten Entwicklungen in der orthopädischen Chirurgie darstellt, wurden viele Versuche unternommen, einen Ersatz für das CMC-1-Gelenk herzustellen, der ein günstigeres Ergebnis als die Trapezektomie bietet.

Indikationen

Stadium 2‑3 nach Eaton und Glickel, CMC-1-Arthrose.

Kontraindikationen

Symptomatische pantrapeziale Arthrose (Stadium 4 nach Eaton und Glickel), Infektion, junge, körperlich arbeitende Personen, unzureichende Knochenqualität oder eine zu geringe Größe des Trapeziums.

Operationstechnik

Der Zugang zum CMC-1-Gelenk erfolgt von dorsoradial. Minimale Resektion der Gelenkflächen des Trapeziums und des Mittelhandknochens, einschließlich Osteophyten und freier Gelenkkörper. Fräsen des Trapeziums und Aufrauen des Metakarpalschafts mit speziellen Instrumenten. Implantation der endoprothetischen Komponenten. Auswahl der richtigen Halslänge, um die Gelenkstabilität zu gewährleisten. Verschließen von Gelenkkapsel und Haut.

Weiterbehandlung

Immobilisierung des Daumens für 2 Wochen mit einer Orthese. Anschließend abnehmbare Daumen-CMC-Schiene für 4 Wochen, Beginn der Mobilisierung mit sanften Übungen. Kein kraftvolles Greifen oder Zusammendrücken in den ersten 6 Wochen.

Ergebnisse

Ein spezielles Design – eine zementfreie, Kugel-in-Pfanne‑, Metall-auf-Polyethylen-Totalendoprothese – hat sich über Jahre bewährt, Langzeitergebnisse zum erfolgreichen klinischen und radiologischen Verlauf wurden publiziert. Neuere vergleichende Studien haben gegenüber der Trapezektomie mit Bandrekonstruktion und Sehneninterponat eine höhere Pinch-Kraft, eine wesentlichere Schmerzlinderung und eine schnellere funktionelle Rekonvaleszenz gezeigt. Die Inzidenz von Komplikationen, wie Dislokationen, Polyethylenabrieb und Pfannenlockerung, liegt im akzeptablen Bereich.

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Further Reading

  1. Borgers A, Vanhees M, Verstreken F (2021) Primary CMC arthroplasty. In: King G, Rizzo M (eds) Arthroplasty of the upper extremity: a clinical guide from elbow to fingers. Springer, Berlin Heidelberg https://doi.org/10.1007/978-3-030-68880-6

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Authors and Affiliations

  1. Orthopedic Department, AZ Turnhout Hospital, Turnhout, Belgium

    Anton Borgers MD

  2. Orthopedic Department, Antwerp University Hospital, Edegem, Belgium

    Andreas Verstreken, Matthias Vanhees MD, PhD & Frederik Verstreken MD

  3. Orthopedic Department, AZ Monica Hospital, Antwerp, Belgium

    Matthias Vanhees MD, PhD & Frederik Verstreken MD

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  1. Anton Borgers MD
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  2. Andreas Verstreken
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  3. Matthias Vanhees MD, PhD
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  4. Frederik Verstreken MD
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Correspondence to Frederik Verstreken MD.

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Conflict of interest

A. Borgers, A. Verstreken, M. Vanhees and F. Verstreken declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Editor

J. van Schoonhoven, Bad Neustadt/Saale

Illustrator

R. Himmelhan, Mannheim

Supplementary Information

Surgical technique video: placement of carpometacarpal (CMC)-1 endoprosthesis (Courtesy of F. Verstreken, Antwerp, Belgium. All rights reserved)

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Borgers, A., Verstreken, A., Vanhees, M. et al. Primary endoprosthetic replacement of the arthritic CMC-1 joint. Oper Orthop Traumatol 33, 228–244 (2021). https://doi.org/10.1007/s00064-021-00713-y

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