Arthroplasty in Hand Surgery E-Book
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- Herausgeber: Thieme
- Kategorie: Fachliteratur
- Sprache: Englisch
A state-of-the-art, reader-friendly reference on hand arthroplasty from renowned global experts
Recent research suggests the lifetime risk of hand arthritis may be greater than 40%. Concurrently, advances in small joint arthroplasty have greatly improved treatment and outcomes in patients with trauma, arthritis, stiffness, and instability of joints in the hand and wrist. Arthroplasty in Hand Surgery: FESSH Instructional Course Book 2020 provides in-depth coverage of the surgical reconstruction or replacement of these joints. Edited by renowned hand surgeons Stephan Schindele, Grey Giddins, and Philippe Bellemère, this unique resource features contributions from an international who's who of experts.
Organized in five sections and 35 chapters, the generously illustrated book encompasses a full spectrum of state-of-the-art arthroscopy techniques. Section one starts with discussions of the anatomy, biomechanics, and mode of action of the finger and thumb joints and concludes with an intriguing history of hand arthroplasty. Sections two through five cover the latest arthroplasty procedures to treat impaired joints of the fingers including proximal interphalangeal and distal interphalangeal, thumb, wrist, and distal radioulnar, respectively. These chapters include an introduction, indication and contraindication, author pearls and results, published outcomes, postsurgical care, and a wealth of photos.
Key Features
- Insightful data from the Norwegian Arthroplasty Register from 1994 to 2018, including procedural statistics (e.g., demographics and survival rates), revision risk factors, and more
- In-depth technical discussion of materials used in arthroplasty, including inherent characteristics, strengths, and weaknesses
- Consistent, reader-friendly section layout starts with a systematic review, followed by succinct and uniformly organized procedure-specific chapters
This highly practical resource is ideal for the classroom, symposiums, and review of procedural details prior to performing hand surgery. As such, it is essential reading for trainee and practicing orthopaedic surgeons and hand specialists.
This book includes complimentary access to a digital copy on https://medone.thieme.com.
Das E-Book können Sie in Legimi-Apps oder einer beliebigen App lesen, die das folgende Format unterstützen:
Veröffentlichungsjahr: 2021
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Arthroplasty in Hand Surgery
FESSH Instructional Course Book 2020
Stephan F. Schindele, MDOrthopaedic and Hand SurgeonDeputy Head, Department of Hand SurgerySchulthess KlinikZurich, Switzerland
Grey Giddins, FRCS (Orth)Consultant Orthopaedic and Hand SurgeonThe Royal United Hospitals;Visiting ProfessorUniversity of BathBath, UK
Philippe Bellemère, MDHand and Orthopaedic SurgeonInstitut de la Main Nantes-AtlantiqueNantes Saint-Herblain, France
520 illustrations
ThiemeStuttgart • New York • Delhi • Rio de Janeiro
Library of Congress Cataloging-in-Publication Data is available from the publisher.
© 2021 Thieme. All rights reserved.
Georg Thieme Verlag KGRüdigerstrasse 14, 70469 Stuttgart, Germany+49 [0]711 8931 421, [email protected]
Cover design: © ThiemeCover image source: Samuel Christen, MD;St. Gallen, SwitzerlandTypesetting by DiTech Process Solutions Pvt. Ltd., India
Printed in Germany by Beltz Grafische Betriebe 5 4 3 2 1
ISBN 978-3-13-243174-4
Also available as an e-book:eISBN 978-3-13-243175-1
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Contents
Preface
Contributors
Section 1 General
1. The Anatomy and Functional Importance of Finger Joints: A Short Atlas
Martin Franz Langer, David Warwick, Frank Unglaub, and Jörg Grünert
1.1 Introduction
2. Biomaterials in Arthroplasty of the Hand
Koo Siu Cheong Jeffrey Justin
2.1 Introduction
2.2 Behavior of Biomaterials
2.2.1 Biocompatibility
2.2.2 Nontoxicity
2.2.3 Corrosion Resistance
2.2.4 Strength
2.2.5 Modulus of Elasticity
2.2.6 Fatigue Resistance
2.2.7 Wear Resistance
2.2.8 Creep Resistance
2.2.9 Osteointegration
2.3 Classical Biomaterials
2.3.1 Polymers
2.3.2 “Nouvelle Vague” for Hand Arthroplasty Development
2.3.3 Surface Treatment to Improve Bone Bonding
2.3.4 Pyrolytic Carbon
2.4 The Limitations of Current Materials
2.5 Future of Biomaterials in Hand Arthroplasty
2.6 Conclusion
3. Proprioception and Neural Feedback in Thumb andWrist Arthroplasty
Elisabet Hagert and Susanne Rein
3.1 Basis of Proprioception for Joint Control
3.1.1 Conscious Proprioception Senses
3.1.2 Unconscious Proprioception Senses
3.1.3 Sensory Nerve Endings
3.2 Innervation Patterns (uFig.3)
3.2.1 Wrist
3.2.2 Trapeziometacarpal Joint
3.2.3 Distal Radioulnar Joint (DRUJ)
3.3 Innervation Patterns in Osteoarthritis
3.4 Neural Feedback of theWrist and Thumb
3.5 Clinical Implications
3.5.1 The Case for Nerve-Sparing Surgery
3.5.2 The Case for Denervation
3.6 In Conclusion—to Denervate or Reinnervate?
4. Outcome Measurement in Hand andWrist Arthroplasty
Miriam Marks
4.1 Introduction
4.2 Frequently Used PROMs Suitable for Patients Undergoing Hand Arthroplasty
4.2.1 Michigan Hand Outcomes Questionnaire (MHQ)/Brief MHQ
4.2.2 Patient-RatedWrist Evaluation (PRWE),
4.2.3 Disability of the Arm, Shoulder, and Hand Questionnaire (DASH)/QuickDASH?
4.2.4 Patient-Reported Outcomes Measurement Information System (PROMIS)
4.2.5 Patient-Specific Functional Scale (PSFS)
4.2.6 Single Assessment Numeric Evaluation (SANE) Score
4.2.7 Quality-of-Life Measures
4.2.8 Further Validated Hand-Specific PROMs
4.3 Core Sets
4.4 Measurement Properties
4.4.1 Reliability
4.4.2 Validity
4.4.3 Responsiveness
4.4.4 Interpretability
4.5 Choosing an Appropriate Outcome Measure
4.6 Collecting and Processing Outcome Measures
4.7 Interpretation of Outcomes
4.7.1 Minimal Important Difference (MID) and Minimal Important Change (MIC)
4.7.2 Patient Acceptable Symptom State (PASS)
4.8 Conclusion
5. The Norwegian Arthroplasty Register
Ynvar Krukhaug
5.1 Introduction
5.2 Wrist Replacements
5.2.1 Method
5.2.2 Results
5.3 CMC IA Replacements
5.3.1 Results
5.4 Finger Joint Replacement
5.4.1 MCP Joint Replacement
5.4.2 PIP Joint Replacement
6. The History of Arthroplasty in the Hand andWrist
Michael Brodbeck
6.1 The Very Early History
6.1.1 The Era of Zeus and His Fellow Gods
6.1.2 Amputation—Upper Paleolithic to the Middle Ages
6.2 Milestones in the Modern History of Wrist Arthroplasty
6.2.1 Resection Arthroplasty
6.2.2 Interposition Arthroplasty
6.2.3 The First Total Knee andWrist Replacement—Themistocles Gluck (1853–1942)
6.2.4 The Concept of Flexible Implant Arthroplasty—Alfred B. Swanson (1923–2016)
6.3 Early Design Developments inWrist Arthroplasty
6.3.1 First Generation: Elastomer Flexible Hinge Design
6.3.2 Second Generation: Multicomponent Implants
6.4 Contemporary Designs inWrist Arthroplasty
6.4.1 Third Generation: Minimal Bone Resection
6.5 Arthroplasty of the Distal Radioulnar Joint (DRUJ)
6.5.1 Resection/Interposition Arthroplasty
6.5.2 Ulna Head Replacement
6.5.3 Partial Ulna Head Replacement
6.5.4 Total DRUJ Replacement
6.6 Arthroplasty of Metacarpophalangeal and Proximal Interphalangeal Joints
6.6.1 Resection/Interposition Arthroplasty
6.6.2 Transplant Arthroplasty
6.6.3 Hinged Implant Arthroplasty
6.6.4 One-Piece Polymer Arthroplasty
6.6.5 Metalloplastic Arthroplasty
6.6.6 Surface Replacement Arthroplasty
6.6.7 Pyrocarbon Implant Arthroplasty
6.7 Arthroplasty of the Trapeziometacarpal (TMC) Joint
6.7.1 Interposition Arthroplasty
6.7.2 Hemiarthroplasty of the TMC Joint
6.7.3 Total TMC Arthroplasty
Section 2 Arthroplasty of Finger Joints
Section 2A MCP-Arthroplasty
7. Failure Analysis of Silicone Implants in Metacarpophalangeal and Proximal Interphalangeal Joints
Grey Giddins and Tom Joyce
7.1 Introduction
7.2 Failure Mechanisms
7.3 Material Properties
7.4 Improving Silicone Implants
7.5 Conclusion
8. Silicone Interposition Arthroplasty for MCP and PIP joints
Sarah E. Sasor and Kevin C. Chung
8.1 Introduction
8.2 Characteristics of Silicone Implants .
8.3 MCP Joint Arthroplasty
8.3.1 Indications
8.3.2 Contraindications
8.3.3 Preoperative Evaluation
8.3.4 Surgical Anatomy
8.3.5 Approach
8.3.6 Authors’ Preferred Technique
8.3.7 Postoperative Care
8.3.8 Expected Outcomes
8.4 PIP Joint Arthroplasty
8.4.1 Indications
8.4.2 Contraindications
8.4.3 Preoperative Evaluation
8.4.4 Surgical Anatomy
8.4.5 Approach
8.4.6 Authors’ Preferred Technique
8.4.7 Postoperative Care
8.4.8 Expected Outcomes
9. Surface Gliding Implants for the Metacarpophalangeal Joints
Marco Rizzo
9.1 Introduction
9.2 Characteristics of Surface Gliding Implants
9.2.1 Pyrocarbon
9.2.2 Surface Replacement Arthroplasty (SRA) MCP joint
9.3 Indications/Contraindications
9.4 Results in the Literature
9.4.1 Pyrocarbon
9.4.2 Surface Replacement Arthroplasty (SRA) 96
9.5 Personal Experience (Pearls/Pitfalls)
9.6 Conclusion
10. Vascularized Toe Joint Transfers for Proximal Interphalangeal and Metacarpophalangeal Joint Reconstruction
Gilles Dautel
10.1 Introduction
10.2 Anatomical Bases for Joint Transfer to the Hand
10.2.1 Arterial Network
10.2.2 Venous Drainage of Toe Joint Transfers .
10.3 Indications for Toe Joint Transfers .
10.4 Surgical Technique for PIP Transfer from the Second Toe
10.4.1 Preparation of the Recipient Site
10.4.2 Dissection of Transplant (Donor Site) .
10.4.3 In Situ Arrangement of Transplant
10.4.4 Reconstruction of Donor Site
10.5 Surgical Technique for MTP Transfer from the Second Toe
10.6 Outcomes of Vascularized Toe Joint Transfers
10.6.1 PIP Joint Reconstruction (uFig.1a-l)
10.6.2 MCP Reconstruction (uFig.2a-e)
10.7 Discussion
10.8 Conclusion
Section 2B PIP and DIP-Arthroplasty
11. The Treatment Strategy in PIP Arthroplasty
Daniel B. Herren
11.1 Introduction
11.1.1 Anatomical Considerations for PIP Arthroplasty
11.1.2 Evaluation of PIP Joint Problems
11.1.3 Nonoperative Treatment of PIP Destruction
11.2 PIP Joint Replacement
11.2.1 General Remarks
11.2.2 Choice of Implants
11.2.3 Combination of Different Interventions
11.3 Strategies and Indications in the Treatment of PIP Joint Destruction
11.3.1 Case Example (uFig.5)
11.3.2 Revision of Failed PIP Arthroplasty
11.3.3 Discussion of the Case Example
12. Second-Generation Surface Gliding Proximal Interphalangeal Joint Implants (Metal, Pyrocarbon, and Ceramic)
Athanasios Terzis, Florian Neubrech, Lukas Pindur, Nikolai Kuz, and Michael Sauerbier
12.1 Introduction
12.2 Characteristic of Implant or Technique
12.2.1 SR-PIP Prosthesis
12.2.2 Pyrocarbon Prosthesis
12.2.3 Ceramic Prosthesis
12.3 Indication and Contraindication
12.4 Results in the Literature
12.4.1 Results for SR-PIP
12.4.2 Results for Pyrocarbon PIP Arthroplasties
12.4.3 Results for the Ceramic PIP Arthroplasty
12.5 Authors’ Own Experience and Preferred Technique: Tips and Tricks
13. Third-Generation PIP Joint Arthroplasty: Tactys
Michaël Y. Papaloïzos
13.1 Introduction
13.2 Development
13.3 Characteristics of the Implant
13.3.1 Surgical Technique
13.3.2 Indications/Contraindications
13.4 Results in the Literature
13.5 Author’s Own Experience
13.6 Tips and Tricks
14. Third-Generation PIP Arthroplasty: CapFlex-PIP
Martin Richter
14.1 Introduction
14.2 Characteristic of Implant
14.3 Indication and Contraindication
14.4 Results in the Literature
14.5 Author’s Own Experience and Preferred Technique
14.5.1 Author’s Preferred Technique
14.5.2 After-Care
14.5.3 Author’s Own Results
15. Third-Generation PIP Arthroplasty: The PIP-R
Chris Williams and Timothy Hardwick
15.1 Design Rationale
15.2 Design Features
15.3 Indications
15.4 Contraindications
15.5 Published Results
15.6 Author’s Results
15.7 HowWe Do the Procedure and Tips .
15.8 Rehabilitation
16. Surgical Approaches for PIP Joint Arthroplasty
Massimo Ceruso, Sandra Pfanner, and Giovanni Munz
16.1 Introduction
16.2 Dorsal Approach
16.2.1 Dorsal Skin Incision
16.2.2 Dorsal Tenotomy to the PIP Joint
16.3 Lateral Approach
16.4 Volar Approach
16.5 Literature Review and Authors’ Preferred Technique
17. Joint Replacement of Osteoarthritic and Posttraumatic Distal Interphalangeal Joints
David Elliot, Maria Sirotakova, Adam Sierakowski, and Claire Jane Zweifel
17.1 Introduction
17.2 Characteristic of Silicone Implants for DIP Joint
17.3 Own Results in the Literature
17.4 Own Experience and Preferred Technique for DIP Joint Arthroplasty
17.5 Postoperative Care
17.6 Technique Modification
17.7 Thumb-IP-Joint Arthroplasty with Silicone Implant
17.8 Skin Closure
17.9 Discussion
Section 3 Arthroplasty of the Thumb
18. Silicone Implants and Total Joint Prostheses for Osteoarthritis of the Trapeziometacarpal Joint: A Systematic Review
Nadine Hollevoet and Grey Giddins
18.1 Introduction
18.2 Materials and Methods
18.3 Results
18.3.1 Silicone Implants
18.3.2 Total Trapeziometacarpal Joint Implants
18.4 Discussion
19. Pi2 and Nugrip Pyrocarbon Arthroplasties of the Thumb CMC Joint
Ludovic Ardouin
19.1 Introduction
19.2 Characteristic of Implants
19.2.1 Pi2
19.2.2 Nugrip
19.3 Results in the Literature
19.3.1 Pi2
19.3.2 Nugrip
19.4 Indications/Contraindications
19.4.1 Indications
19.4.2 Contraindications
19.5 Pi2 Implant: Author’s Own Experience and Preferred Technique
19.5.1 Anteroexternal Approach
19.5.2 Nontraumatic Trapeziectomy
19.5.3 Partial Trapezoidectomy
19.5.4 Placing a Trial Implant and the Final Implant
19.5.5 Capsuloplasty and Ligament Reconstruction
19.5.6 Closure and X-Rays
19.5.7 Postoperative Care and Rehabilitation
19.5.8 Possible Complementary Procedures
20. Pyrocardan and Pyrodisk Arthroplasties of the Thumb CMC Joint
Philippe Bellemère
20.1 Introduction
20.2 Pyrodisk
20.2.1 Characteristics of the Implant
20.2.2 Indications
20.2.3 Surgical Technique
20.2.4 Results in the Literature
20.2.5 Author’s Experience
20.3 Pyrocardan
20.3.1 Characteristics of the Implant
20.3.2 Indications
20.3.3 Surgical Technique (uFig.7)
20.3.4 Results in the Literature
20.3.5 Author’s Experience
20.4 Tips and Tricks for Pyrodisk and Pyrocardan Implants
20.5 Conclusion
21. Total Thumb CMC Arthroplasty
Bruno Lussiez
21.1 Introduction
21.2 Historical Aspects
21.3 Different Types of Total CMC Arthroplasty (TCA)
21.3.1 The Models (uTable 21.1)
21.4 Surgical Technique
21.4.1 Surgical Approaches for TCA
21.4.2 Steps for Insertion
21.4.3 Postoperative Care
21.5 Results
21.5.1 Results of the Prosthesis
21.5.2 Comparison with Trapeziectomies
21.5.3 Complications (uTable 21.2)
21.5.4 Revision
21.6 Indications
21.7 Conclusion
22. STT and Peritrapezium Joints Arthroplasties
Philippe Bellemère
22.1 Introduction
22.2 Pyrocarbon Implants for STT Arthroplasty
22.2.1 Indications
22.2.2 STPI
22.2.3 Pyrocardan Implant in STT Joint
22.3 Double Pyrocarbon Interposition for Peritrapezial OA: “Burger Arthroplasty”
22.3.1 Indications
22.3.2 Surgical Technique
22.3.3 Author’s Experience
22.4 Conclusion
23. Thumb IP Joint Arthroplasty: An Alternative to Arthrodesis
Stephan F. Schindele
23.1 Introduction
23.1.1 Treatment Strategies at the Thumb IP Joint
23.1.2 Arthroplasty
23.2 Characteristics of Possible Implants for Thumb IP Joint Replacement
23.3 Indications and Contraindications for Thumb IP Joint Replacement
23.4 Published Outcomes and Our Own Results
23.5 Author’s Own Experience and Preferred Technique (Tips and Tricks)
Section 4 Arthroplasty of theWrist
24. Systematic Review ofWrist Arthroplasty
Onur Berber, Lorenzo Garagnani, and Sam Gidwani
24.1 Introduction
24.1.1 Evolution of TotalWrist Arthroplasty
24.1.2 Current Implants
24.2 Objectives
24.3 Methods
24.3.1 Study Inclusion Criteria
24.3.2 Search Methods
24.3.3 Data Collection and Analysis
24.4 Results
24.4.1 Description of Studies
24.4.2 Effects of Interventions
24.5 Discussion
25. Surface ReplacementWrist Arthroplasty
Michel E. H. Boeckstyns and Guillaume Herzberg
25.1 Introduction
25.2 Implants
25.3 Indications and Contraindications
25.4 Results in the Literature (Short Version)
25.4.1 Complications
25.4.2 Functional Results
25.4.3 Implant Durability
25.5 Authors’ Own Experience and Preferred Technique (Tips and Tricks)
25.5.1 Personal Experience
25.5.2 Revision Surgery
25.5.3 Tips and Tricks
26. Ball-and-SocketWrist Arthroplasty
Ole Reigstad
26.1 History of Ball-and-SocketWrist Arthroplasty
26.1.1 MeuliWrist Arthroplasty
26.2 Development of a New Ball-and-Socket Arthroplasty
26.2.1 Fixation
26.2.2 Articulation
26.3 Introduction of a New Arthroplasty
26.3.1 The Implant
26.3.2 Patient Selection
26.3.3 Surgical Method and Follow-Up
26.3.4 Results
26.3.5 Revisions
26.4 Conclusion
27. Wrist Hemiarthroplasty for Acute Irreparable Distal Radius Fracture in the Independent Elderly
Guillaume Herzberg and Marion Burnier
27.1 Introduction
27.2 Current Therapeutic Options for Acute IDRF in the Independent Elderly
27.3 Current Evidence
27.4 Authors’ Experience
27.5 Conclusion
28. Pyrocarbon Implants in theWrist: Amandys and RCPI
Philippe Bellemère and Augusto Marcuzzi
28.1 Introduction
28.2 Amandys Implant
Philippe Bellemère
28.2.1 Characteristics of the Implant
28.2.2 Indications and Contraindications
28.2.3 Surgical Technique
28.2.4 Associated Procedures
28.2.5 Results
28.2.6 Pitfalls, Tips, and Tricks
28.2.7 Summary
28.3 RCPI Implant
Augusto Marcuzzi
28.3.1 Characteristics of Implant
28.3.2 Indications and Contraindications
28.3.3 Surgical Technique
28.3.4 Results in the Literature
28.3.5 Author’s Own (AM) Experience and Preferred Technique
28.4 Conclusion
29. PartialWrist Joint Arthroplasties: APSI, Capitolunate Joint, Pisotriquetral
Joint, and Little Finger Carpometacarpal Joint Marc Leroy
29.1 APSI: Adaptative Proximal Scaphoid Implant
29.1.1 Introduction
29.1.2 Implant and Surgical Technique
29.1.3 Indication and Contraindication
29.1.4 Results in Literature
29.1.5 Comparison with Other Techniques
29.2 Capitolunate Joint Arthroplasty
29.2.1 Introduction
29.2.2 Pi2 and RCPI Implants
29.2.3 Surgical Technique and Indication
29.2.4 Results in Literature and in Our Experience
29.3 Pisotriquetral Joint Arthroplasty
29.3.1 Introduction
29.3.2 Implant Pyrocardan
29.3.3 Surgical Technique and Management.
29.3.4 Results in Our Experience
29.4 Little Finger Carpometacarpal Joint Arthroplasty
29.4.1 Introduction
29.4.2 Current Surgical Techniques
29.4.3 Our Approach and Management
29.5 Conclusion
30. RevisionWrist Arthroplasty
Sumedh C. Talwalkar, Matthew Ricks, and Ian Trail
30.1 Introduction
30.2 Causes of Failure of aWrist Arthroplasty
30.2.1 Infection
30.2.2 Aseptic Loosening
30.2.3 Implant Fracture
30.2.4 Biomechanical Mismatch
30.3 Managing Bone Loss
30.3.1 Bone Grafting
30.3.2 Wrist Arthrodesis
30.3.3 Resection Arthroplasty
30.3.4 Summary of Options for Revision of aWrist Arthroplasty
30.4 Revision Arthroplasty Technique .
30.4.1 Technique
30.4.2 The Technique Steps
30.5 Unit Experience atWrightington Hospital
30.5.1 Unit Experience Background
30.5.2 Survivorship of the Revision TWA in Our Series
30.5.3 Comparison with Other Units
30.6 Summary
Section 5 Arthroplasty of the DRUJ
31. Systematic Review of Distal Radioulnar Joint (DRUJ) Arthroplasty
Lawrence Stephen Moulton and Grey Giddins
31.1 Introduction
31.2 Methods
31.2.1 Inclusion Criteria
31.2.2 Exclusion Criteria
31.2.3 Literature Search
31.2.4 Outcome Measures
31.2.5 Assessment of the Level of Evidence
31.2.6 Assessment of Methodological Quality 272
31.2.7 Assessment of Survivorship
31.3 Results
31.3.1 Studies Identified
31.3.2 Implant Types
31.3.3 Literature Quality and Risk of Bias
31.4 Discussion
31.5 Conclusions
32. First Choice Distal Radioulnar Joint Arthroplasty
Ladislav Nagy
32.1 Introduction
32.2 Implant Characteristics
32.3 Surgical Technique
32.4 Indications
32.5 Results in the Literature
32.6 Author’s Own Experience
33. UHP DRUJ Arthroplasty
Jörg van Schoonhoven
33.1 Introduction
33.2 Herbert Ulnar Head Prosthesis
33.3 Operative Technique
33.4 Indications
33.5 Contraindications
33.6 Results
33.6.1 Results in the Literature
33.6.2 Patient Example
33.7 Conclusion
34. Eclypse Distal Radioulnar Joint Arthroplasty
Dirck Ananos Flores and Marc Garcia-Elias
34.1 Introduction
34.2 Characteristics of the Implant and Technique
34.2.1 Technique
34.3 Indications and Contraindications
34.4 Results in the Literature
34.5 Author’s Experience and Preferred Technique (Tips and Tricks)
34.5.1 Results
34.5.2 Tips and Tricks
35. Salvage Distal Radioulnar Joint Arthroplasty with the Aptis Implant
Maurizio Calcagni, Thomas Giesen, Marco Guidi, Lisa Reissner, and Florian S. Frueh
35.1 Introduction
35.2 The Implant and Technique
35.3 Indications and Contraindications
35.4 Results in the Literature
35.5 Authors’ Own Experience and Preferred Technique (Tips and Tricks)
35.6 Conclusions
Index
Preface
Dear Colleagues and Friends,
As we write this in 2021, we reflect on what a year 2020 has been. Unfortunately, for the first time in its history, the annual FESSH congress was prevented from being held due to the pandemic. It was due to be held in June 2020 in Basel, Switzerland. It was, however, replaced by a brilliant FESSH (ON)-lineweek, at the beginning of September 2020, organized at short notice and in very testing circumstances.
We the Editors as well as all the authors and the publishing team worked on this book for nearly 2 years. We are very grateful to everyone involved. After considerable hardwork and logistic challenges, the instructional book will be available in printed and digital form. We hope that all the contributions will increase the knowledge among readers about artificial joint replacement in hand surgery and that everyone can benefit from this book in their daily work.
We would like to express special thanks to our families, who supported and motivated us at all times throughout this project.
Stephan Schindele thanks Ulrike, Flurin, and Jakob for their patience. Grey Giddins thanks Jane, Imogen, Miranda, and Hugo for their support and forebearance. Philippe Bellemère thanks his family, Catherine, Olivia, Chloé, and Matthieu.
All three of us would like to express our immense thanks to all the authors who haveworked so hard on their contributions, and to our colleagues for their support both during this project and for many years before.
Stephan F. Schindele, MDGrey Giddins, FRCS (Orth)Philippe Bellemère, MD
Contributors
Ludovic Ardouin, MD Elsan Santé Atlantique Institut de la Main Nantes Atlantique Nantes, France
Philippe Bellemère, MD Hand and Orthopaedic Surgeon Institut de la Main Nantes-Atlantique Nantes Saint-Herblain, France
Onur Berber, FRCS (Tr&Orth), MSc, BSc (Hons), SEM. UK&Ire, DipHandSurg Department of Trauma and Orthopaedics Whittington Health London, UK
Michel E. H. Boeckstyns, MD, PhD Consultant Hand Surgeon Capio Private Hospital Senior Researcher Clinic for Hand Surgery Herlev-Gentofte Hospital University of Copenhagen Hellerup, Denmark
Michael Brodbeck, MD Hand Surgeon Department of Hand Surgery Schulthess Klinik Zurich, Switzerland
Marion Burnier, MD Wrist Surgery Unit Department of Orthopaedics Claude-Bernard Lyon 1 University Herriot Hospital Lyon, France
Maurizio Calcagni, MD Division of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich, Switzerland
Massimo Ceruso, MD Full Professor of Orthopaedics Past President of SICM Past FESSH Secretary General Florence, Italy
Kevin C. Chung, MD Department of Surgery Section of Plastic Surgery University of Michigan Ann Arbor, Michigan, USA
Gilles Dautel, MD Centre Chirurgical Emile Gallé Nancy Medical School Nancy, France
David Elliot, MA (Oxon), FRCS Consultant Hand Surgeon (Retd.) Essex, UK
Dirck Ananos Flores, FRACS Consultant Sir Charles Gairdner Hospital Perth, Western Australia
Florian S. Frueh, MD Division of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich, Switzerland
Lorenzo Garagnani, MD, FRCS, EBHS DipHandSurg Department of Orthopaedics Guy's & St Thomas' Hospitals London, UK
Marc Garcia-Elias, MD, PhD Consultant and Co-Founder Kaplan Hand Institute Barcelona, Spain Honorary Consultant Pulvertaft Hand Center Derby, UK
Grey Giddins, FRCS (Orth) Consultant Orthopaedic and Hand Surgeon The Royal United Hospitals; Visiting Professor University of Bath Bath, UK
Sam Gidwani, MBBS, FRCS (Tr & Orth), DipHand Surg Department of Orthopaedics Guy's and St Thomas' Hospitals London, UK
Thomas Giesen, MD Chirurgia della Mano Ars Medica Gravesano, Switzerland
Jörg Grünert, MD Professor Clinic for Hand, Plastic and Reconstructive Surgery Kantonsspital St. Gallen St. Gallen, Switzerland
Marco Guidi, MD Division of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich, Switzerland
Elisabet Hagert, MD, PhD Department of Clinical Science and Education Karolinska Institutet; Arcademy H. M. Queen Sophia Hospital Stockholm, Sweden
Timothy Hardwick, MD Hand Unit, Department of Trauma and Orthopaedics Brighton and Sussex NHS Trust Royal Sussex County Hospital Brighton, UK
Daniel B. Herren, MD, MHA Schulthess Klinik Zurich, Switzerland
Guillaume Herzberg, MD, PhD Professor of Orthopaedic Surgery Lyon Claude Bernard University Herriot Hospital Lyon, France
Nadine Hollevoet, MD, PhD Associate Professor Department of Orthopaedic Surgery and Traumatology Ghent University Hospital Gent, Belgium
Tom Joyce, PhD Professor School of Engineering Newcastle University Newcastle upon Tyne, UK
Koo Siu Cheong Jeffrey Justin, MBBS (HK), FHKCOS, FHKAM (Orthopaedic Surgery), FRCSEd (Orth), MHSM (New South Wales), MScSMHS (CUHK)Associate Consultant (Orthopaedics Traumatology) Department of Orthopaedics & Traumatology Alice Ho Miu Ling Nethersole Hospital Tai Po, Hong Kong
Yngvar Krukhaug, MD, PhD Senior Consultant Orthopaedic Surgeon Associate Professor Orthopaedic Clinic Haukeland University Hospital University of Bergen Bergen, Norway
Nikolai Kuz, MD Physician Department of Hand, Plastic, and Reconstructive Surgery BG Trauma Center Frankfurt/Main, Germany
Martin Franz Langer, MD Professor Clinic for Trauma, Hand, and Reconstructive Surgery University Clinic Münster Münster, Germany
Marc Leroy, MD Institut de la main Nantes Atlantique Nantes, France
Bruno Lussiez, MD Orthopaedic Surgeon Clinique de Chirurgie orthopédique et traumatologique de Monaco Principality of Monaco
Augusto Marcuzzi, MD Department of Hand Surgery “Policlinico di Modena” University Hospital Modena, Italy
Miriam Marks, PhD Department of Teaching, Research and Development Schulthess Klinik Zurich, Switzerland
Lawrence Stephen Moulton, MD Consultant Orthopaedic Upper Limb Surgeon Department of Orthopaedic Surgery Royal Cornwall Hospitals NHS Trust Cornwall, UK
Giovanni Munz, MD Unit of Surgery and Reconstructive Microsurgery of the Hand Azienda Ospedaliero Universitaria Careggi Florence, Italy
Ladislav Nagy, MD Professor Hand Surgery Division University Clinic Balgrist Zurich, Switzerland
Florian Neubrech, MD Department for Plastic, Hand and Reconstructive Surgery BG Trauma Center Frankfurt am Main Frankfurt, Germany
Michaël Y. Papaloïzos, MD CH8-Center for Hand Surgery and Therapy Geneva, Switzerland
Sandra Pfanner, MD Unit of Surgery and Reconstructive Microsurgery of the Hand Azienda Ospedaliero Universitaria Careggi Florence, Italy
Lukas Pindur, MD Resident Plastic, Hand and Reconstructive Surgery BG Trauma Center Frankfurt AcademicHospital ofthe Goethe University Frankfurt Frankfurt, Germany
Ole Reigstad, MD, PhD Consultant EBHS Fellow Hand and Microsurgery Department Orthopedic Clinic Oslo University Hospital Oslo, Norway
Susanne Rein, MD, PhD, MBA Department of Plastic and Hand Surgery, Burn Unit Hospital Sankt Georg Leipzig, Germany
Lisa Reissner, MD Division of Hand Surgery The Balgrist Zurich, Switzerland
Martin Richter, MD Director Department of Hand Surgery Malteser Hospital Seliger Gerhard Bonn, Germany
Matthew Ricks, BSc Hons, MBBS, MRCS, MSc Trauma Surgery, MSc Adv HCP, FRCS (Tr & Orth) Consultant Upper Limb Trauma and Orthopaedic Surgeon Wrightington Hospital Wigan, UK
Marco Rizzo, MD Professor, Department of Orthopedic Surgery Chair, Division of Hand Surgery Mayo Clinic Rochester, Minnesota, USA
Sarah E. Sasor, MD Department of Plastic Surgery Medical College of Wisconsin Milwaukee, Wisconsin, USA
Michael Sauerbier, MD Professor Department for Plastic, Hand and Reconstructive Surgery BG Trauma Center Frankfurt am Main Frankfurt, Germany
Stephan F. Schindele, MD Orthopaedic and Hand Surgeon Deputy Head, Department of Hand Surgery Schulthess Klinik Zurich, Switzerland
Adam Sierakowski, FRCS(Plast) Consultant Plastic and Hand Surgeon St. Andrew's Centre for Plastic Surgery and Burns Chelmsford, UKMaria Sirotakova, MD Consultant Plastic and Hand Surgeon (Retd.) Chelmsford, UK
Sumedh C. Talwalkar, MBBS, MRCS, MS (Orth), MCh (Orth) Liverpool, FRCS (Tr & Orth)Consultant Hand and Upper Limb SurgeonDivisional Medical Director Specialist ServicesWWL NHS TrustWigan, UK
Athanasios Terzis, MD Orthopaedic and Trauma Surgeon, Hand SurgeonConsultant, Department for Plastic, Hand and Reconstructive Surgery BG Trauma Center Frankfurt Academic Hospital of the Goethe University FrankfurtFrankfurt, Germany
Ian Trail, MD, FRCS Consultant Orthopaedic Surgeon WWL NHS Trust Wigan, UK
Frank Unglaub, MD Professor Vulpiusklinik Bad Rappenau, Germany
Jörg van Schoonhoven, MD Professor and Senior Consultant Hand Center Bad Neustadt Bad Neustadt an der Saale, Germany
David Warwick, MD, FRCSOrth, Eur Dip Hand Surg Professor and Consultant Hand Surgeon University Hospital Southampton Southampton, UK
Chris Williams, FRCS(Orth) Consultant Hand Surgeon Trauma and Orthopaedic Department Royal Sussex County Hospital Brighton, UK
Claire Jane Zweifel, MD, FMH(Plast), EBOPRAS EDHSConsultant Plastic and Hand Surgeon St. Andrew's Centre for Plastic Surgery and BurnsBroomfield Hospital Chelmsford, UK
Section I
General
1 The Anatomy and Functional Importance of Finger Joints: A Short Atlas
2 Biomaterials in Arthroplasty of the Hand
3 Proprioception and Neural Feedback in Thumb and Wrist Arthroplasty
4 Outcome Measurement in Hand and Wrist Arthroplasty
5 The Norwegian Arthroplasty Register
6 The History of Arthroplasty in the Hand and Wrist
1 The Anatomy and Functional Importance of Finger Joints: A Short Atlas
Martin Franz Langer, David Warwick, Frank Unglaub, and Jörg Grünert
Abstract
The finger joints are incredible. They are effective and precise, mobile yet stable. This chapter presents an anatomical atlas to help the reader understand the detailed anatomy, kinematics, blood supply, and innervation of all the finger joints from the DIP to the CMC. Particular emphasis is placed on the precise structure and function of the collateral ligaments; the mechanics of the joints can be understood through the concept of two different centers of rotation of the joints: one osteocartilaginous and one ligamentous.
Keywords: finger joint, anatomy, biomechanics, innervation, kinematics, collateral ligaments, blood supply, center of rotation
1.1 Introduction
The wonderful diversity of hand function is achieved through the large freedom of movement of the fingers, which allows both stability and precise alignment of the finger joints. As Aristotle observes: “The hand is the ‘tool of tools'” (Aristotle, Parts of animals IV10, 687a: 8-10).
The anatomy, biomechanics, and mode of action of the finger and thumb joints are illustrated throughout this chapter.
Fig. 1.1 (a) When the extended interphalangeal joints are flexed at the metacarpophalangeal joints so the finger tips are brought together, they enclose a sagittal axis that runs through the head of Metacarpal III. (b) If the fingers are bent at the interphalangeal and metacarpophalangeal joints, they enclose an axis that runs transversely in front of the metacarpal heads on the palmar side. The axes of the middle phalanges are centered on a point above the scaphoid or distal radius. (c) If the thumb and fingers are spread as far as possible, the fingers align in a circular plane. The axes of the metacarpal bones run toward a point in the radius shaft. The metacarpophalangeal joints of the fingers have the greatest lateral freedom of movement (about 40°) in this position, more toward the ulnar than the radial direction. (© Martin F. Langer)
Fig. 1.2 (a) Range of movement of the finger joints (metacarpophalangeal [MP or MCP], proximal interphalangeal [PIP], and distal interphalangeal [DIP]): Red: maximum range of movement. Green: functional range of movement. Blue: recommended angle for arthrodesis. The arthrodesis angles vary from digit to digit and according to the patient's functional requirements. (b) Approximate distance of the flexor tendons and extensor tendons from the joint axes for simple rollover calculations. Tendon excursion with 10° joint flexion DIP 1 mm, PIP 1.5 mm, and MP 2 mm. (© Martin F. Langer)
Fig. 1.4 Synovial fluid of the finger joints. (a) The incongruity of the joints is necessary. The greatest possible synovial flow is required to feed the cartilage. The contact areas of the adjacent cartilage are significantly smaller than the total cartilage area. When the finger is extended, the flexor tendon and the accessory collateral ligaments press the palmar plate against the joint and the synovial fluid from the palmar recess is pressed dorsally into the dorsal recess. (b) When the finger is flexed, the flexor tendon pulls on the palmar plate through the pulley. A suction develops that pulls the synovial fluid from the dorsal into the palmar recess. (c–e) The contact surfaces (red arrows) on the proximal interphalangeal (PIP) joint are on the inner sides of the condyles. The synovial cavity on the PIP joint is shown in (d) and (e). (© Martin F. Langer)
Fig. 1.5 (a) Blood supply of the metacarpophalangeal (MCP) joint. The synovial sac is amply supplied with blood at the edges of the recess. The collateral ligaments are supplied from the proximal and distal margins. (b) Blood supply of the proximal interphalangeal (PIP) joint. (© Martin F. Langer)
Fig. 1.6 (a) Nerve supply of the metacarpophalangeal (MP) joint. (b) Nerve supply of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. (c) Innervation of the first carpometacarpal (CMC1) joint—dorsal view. (d) Innervation of the CMC 1 joint— palmar view. (© Martin F. Langer)
Fig. 1.7 CMC2 to CMC5 joints. (a) Dorsoulnar view of the hand skeleton. (b) Mobility of the CMC joints. Dorsopalmar mobility in metacarpal 3 (MC 3) is only 7°, in MC 4 20°, and in MC 5 28°. Together with MC 4, the MC 5 mobility is even 40°. (c) View of the distal articular surface of the distal carpal row. (d) There is very little mobility in the distal carpal row. (© Martin F. Langer)
Fig. 1.8(a) Area of mobility of the thumb. (b) CMC 1 surface of the trapezium. (c) CMC 1 surface of the base of MC 1. (© Martin F. Langer)
Fig. 1.9 (a) Palmar view of the bony structures of the CMC 1. (b) Palmar ligaments of the CMC1. (c) Thenar muscles acting on the CMC 1. ADD, adductor pollicis muscle; APB, abductor pollicis muscle; DAOL, deep anterior oblique ligament; DRL, dorsoradial ligament; FPB, flexor pollicis muscle; IML, intermetacarpal ligament; OPP, opponens pollicis muscle; SAOL, superficial anterior oblique ligament. (© Martin F. Langer)
Fig. 1.10 (a) Dorsal view of the bony structures of the CMC 1. (b) Dorsal ligaments of the CMC 1. (c) In abduction the radial ligaments are relaxed, the ulnar under tension. (d) In adduction the radial ligaments are tensioned the ulnar are relaxed. (e) The first carpometacarpal (CMC1) joint is a universal joint (Hooke or Cardan) with two axes. (f) Direction and position of the CMC 1 joint. (© Martin F. Langer)
Fig. 1.11 (a) Perimetry of the index MP joint. The axis of the metacarpal is the green line. (b) Perimetry—areas of MP 2 to MP 5. (Modified from Shiino and Fick 1925.) (© Martin F. Langer)
Fig. 1.12 Anatomy of the metacarpophalangeal (MP) joint. (a) Metacarpal head, view from distal lateral. Dorsal part of the joint is spheric and narrow, palmar part is bicondylar and wide.(b) Origins and insertions of the collateral ligaments (red, orange, and yellow) and the accessory collateral ligaments (green, turquoise, and blue) in 0°. (c) MP ligaments in 0°. (d) Origins and insertions of the MP ligaments in 90° flexion. (e) MP ligaments in 90°. (f) Trabeculae of the metacarpal head and proximal phalanx base in sagittal section. Observe the thickness of the cartilage and of the dorsal and palmar plates. (g) Oblique view of the sagittal section of the metacarpal head. (© Martin F. Langer)
Fig. 1.13 Alignment of the metacarpal heads and the radial and ulnar collateral ligaments. (a) Normal position of the metacarpal heads in slightly arched position in the view from distal. The midline sagittal plane of the metacarpals is represented by black dotted lines; the main dorsal-palmar movement line represented in red is always ulnar. (b) Metacarpal head of index finger in 90° flexion shows a more prominent and more dorsal position of the radial collateral ligament. (c) Projection of the positions of the radial (blue) and ulnar (red) ligaments of the metacarpal heads. The radial ligaments are always more dorsal and more prominent. (© Martin F. Langer)
Fig. 1.14 Anatomy of the proximal interphalangeal (PIP) joint. (a) Lateral view on the PIP joint in 0° and 90°. The “most accurate” center of rotation of the proximal phalanx head is the red point. The centers of rotation of the radius of the proximal phalanx base are the two blue points. They differ between 0° and 90°. Notice the central contact area of the base in 0° and the more dorsal contact area in 90°. Distalpalmar to the area of centers of rotation is a flat area of the head. This flat area is important for stretching out of the collateral ligaments in flexion by the hypomochlion (lever-arm) effect. (b) The condyles of the proximal phalanx heads have an angle of divergence of 10° to 37°.(c) Dimensions of the proximal phalanx head. The summits of the condyles and the lows of the central groove are in curved lines. (d) Dimensions of the middle phalanx base. The troughs of the ulnar and radial grooves and the summit of the central ridge form curved lines. (e) Dorsal aspect of the PIP joint. (f) Palmar aspect of the PIP joint. (© Martin F. Langer)
Fig. 1.15 Asymmetries of the proximal interphalangeal (PIP) joints. (a) Radial and ulnar condyles of the PIP joint in the view from dorsal. Blue points: small contact area. Red points: centers of rotation of radial and ulnar condyles. Green points: centers of rotation of the radial and ulnar groove of the middle phalanx base. (b) The “PIP paradox.” Top row: axial view on the proximal phalanx heads: in most cases the radial condyles are greater than the ulnar condyles in second and third finger, and the ulnar is greater in ring and little finger. Lower row: dorsopalmar view of the proximal phalanx heads. Index and middle finger show in most cases a more prominent ulnar condyle; ring and little finger a more prominent radial condyle. So the radial condyle in index finger has the greater radius but is more proximal and the ulnar condyle is smaller but more distal. This is important for the confluence of the fingers in flexion. (c) Confluence of the fingertips in PIP flexion. Most radial and most ulnar fingers show a greater centralization. (© Martin F. Langer)
Fig. 1.16 Capsular structures of the proximal interphalangeal (PIP) joint. (a) Ligaments and capsular structures inserting at the base of the middle phalanx. (b) View inside the PIP joint with partially resected head and base. (© Martin F. Langer)
Fig. 1.17 Ligament structures of the proximal interphalangeal (PIP) joint. (a) Ligaments of the PIP joint. (b) Origins and insertions of the collateral ligaments (red, orange, and yellow) and the accessory collateral ligaments (green, turquoise, and blue) in 0°. (c) PIP ligaments in 0°. (d) Origins and insertions of the ligaments in 90°. (e) PIP ligaments in 90°. (f) The palmar parts of the condyles are most prominent laterally and form the hypomochlion parts together with the flat area. (© Martin F. Langer)
Fig. 1.18 Distal interphalangeal (DIP) joint anatomy. (a) Lateral view of the head of the middle phalanx. (b) Lateral view of the distal phalanx. (c) Dimensions of the head of the middle phalanx. (d) Dimensions of the base of the distal phalanx. (e) Dorsal aspect of the DIP joint. (f) Palmar aspect of the DIP joint. (© Martin F. Langer)
Fig. 1.19 View in the distal interphalangeal (DIP) joint after resection of the second phalanx. (© Martin F. Langer)
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2 Biomaterials in Arthroplasty of the Hand
Koo Siu Cheong Jeffrey Justin
Abstract
Developments of hand-and-finger joint arthroplasty help to improve the quality of life for many patients suffering from rheumatoid arthritis, osteoarthritis, and posttraumatic conditions. Extensive research has been performed in the past few decades on biomaterials to replace damaged joints. Biomaterials are either used in their native form, altering their formulations, or combined with others materials such as for arthroplasties. We need to understand the mechanical properties of the biomaterials so that we can use the materials appropriately. The limitations of current materials and future research avenues will be discussed.
Keywords: Biomaterials, biocompatibility, hand, polymers, silicone elastomers, metal alloys, calcium hydroxyapatite, pyrolytic carbon
2.1 Introduction
Since 1890, when Themistocles Gluck performed the first wrist replacement using an ivory prosthesis, substantial effort has been directed onto the development of small joint prostheses for the hand. Success in arthroplasty relies upon a thorough understanding of joint mechanics, and implant design and materials employed for manufacturing the implant.
In 1969, Alfred Swanson defined the criteria for ideal joint arthroplasty (▶Table 2.1). He also pointed out that the materials used for manufacturing the implant component should be able to provide durable fixation to the host tissue and survive the stresses involved in joint movement. Moreover, the implant(s) should be biologically and mechanically acceptable to the host and should be easy to manufacture, sterile, and use.1
Any material that has been engineered to interact with biological systems for a medical purpose is collectively known as biomaterials. According to the definition proposed by the European Society for Biomaterials Consensus Conference II, a biomaterial is “a material intended to interface with biological system to evaluate, augment, or replace any tissue, organ, or function of the body.”2
Table 2.1 Criteria for ideal joint arthroplasty suggested by Swanson
●To maintain joint space
●To allow joint motion with stability
●To be of simple and efficient design
●To provide simple and durable fixation
●To be resistant to stress and deterioration
●To be biologically and mechanically acceptable to the host
●To be easy to manufacture, sterilize, and use
●To facilitate rehabilitation
I will provide an introduction to the basic concepts related to biomaterials science and review the main classes of biomaterials that are currently used in small joint and hand arthroplasty.
2.2 Behavior of Biomaterials
When an implant is inserted into the body, they are immersed into an environment that is more hostile than in air at room temperature. The higher temperature and sodium chloride content in the body as well as high stress concentrations lead to accelerated metal corrosion and degradation of polymers. At the same time, depending upon the types of material the human body will initiate a foreign body reaction. In order to allow the implant to perform the intended function for a sufficient period of time, the selection of biomaterials and their design must comply with the following basic requirements.
2.2.1 Biocompatibility
The definition of biocompatibility has been evolved over the years. In the 1960s and 1970s, the first-generation biomaterials tried to match the chemical and physical properties to those of the replaced tissue with a minimal host/foreign body response in order to minimize any biological rejection.3 “Bioinertness“ was the underlying principle for these biomaterials and still holds true today for many implants.
With better understanding on the foreign body response in the 1980s and 1990s, there was a paradigm shift to develop bioactive components that can elicit biological bonding response at the bone-implant interface to improve implant fixation.4 The ability to form an adherent interface with the living tissues has been defined as bioactivity.5 Currently biocompatibility is the “ability of a material to perform with an appropriate host response in a specific application”; the “appropriate host response” refers to acceptable levels of toxicity and immune response, a lack of foreign body reactions, and promotion of normal healing.6
2.2.2 Nontoxicity
Materials that are embedded into the body should not have any toxic effect due to release of ions or other harmful products that can develop unnecessary allergies, inflammatory, tissue necrosis, calcification, or even neoplastic hazards.7 Examples of the failure of this are silicone synovitis8,9,10,11 or metallosis in hip joint replacements.12,13
2.2.3 Corrosion Resistance
Corrosion is unwanted degradation of metal immersed inside solution, which may result from electrochemical dissolution phenomenon, wear, or both. This property determines the metallic implant durability and should be very high if the implant is intended to be permanent. Passivation helps to protect metal from corrosion by forming a thin layer of oxide layer.14
2.2.4 Strength
Strength describes the magnitude of stress at which the materials begin to fracture and correspond to implant durability. It depends on the type and vector of the force applied to the material. It can be described by multiple values, for example, compressive strength, tensile strength, and yield strength.15
2.2.5 Modulus of Elasticity
The modulus of elasticity describes the ability of a material to undergo elastic deformation under stress. ▶Table 2.2 provides the data of common biomaterials used in hand-and-finger joint arthroplasty.16,17,18 A favorable value for implant anchorage or the intramedullary stem of an implant should be as close to that of cortical bone as possible. Otherwise, it will lead to stress shielding with bone resorption around the implant and the potential for bone-implant interface failure.15,19
2.2.6 Fatigue Resistance
Fatigue is caused by a repetitive cyclic load below that of ultimate tensile strength of a material eventually causing deformations and fatigue fracture. For metallic biomaterials, this is strongly related to the type of processing and heat treatment used during manufacturing.20
Table 2.2 Modulus of elasticity of common biomaterials10,11,12
Material
Modulus of elasticity (GPa)
Cancellous bone
0.5-1.5
Cortical bone
7-30
Silicone elastomer
0.08
Ultrahigh-molecular-weight polyethylene
1.2
Polymethyl methacrylate bone cement
2.2
Titanium alloy (Ti6Al4V)
110
Stainless steel 316L
190
Cobalt chrome alloy
210
Pyrolytic carbon
13.7
2.2.7 Wear Resistance
Low wear resistance is undesirable as it will produce wear particles into the articular or bone-implant interface, leading to an inflammatory reaction, osteolysis, and eventually implant loosening. Furthermore, corrosion will be accelerated and increase release of cytotoxic metal ions from worn implants.21
2.2.8 Creep Resistance
Creep refers to plastic deformation of a material over a long period of time under constant pressure. High resistance to creep is important to decrease the deformation and wear of the articular component of arthroplasty.22 Creep is a material feature of bone cement and used by some implants such as the Exeter stem to optimize outcomes.
2.2.9 Osteointegration
Osteointegration refers to a direct structural and functional connection between living bone and the surface of a load-carrying part of the implant. It may depend on the surface topography of the implant.23 It can be critical for prosthesis longevity. Many methods of surface treatment have been developed to promote osteointegration, including trying to produce an optimal surface roughness or adding osteoconductive coating to promote bone ingrowth.24
2.3 Classical Biomaterials
Four main types of biomaterials are currently used in clinical practice: polymers; metal alloys; ceramics; and pyrolytic carbon. Most of them were developed for the first generation of biomaterials typically developed from industrial purposes.
2.3.1 Polymers
Numerous classes of polymers have been used, e. g., silicone, polyethylene (PE), and polymethyl methacrylate (PMMA; bone cement).
Silicone
Swanson marked the start of modern era of small joint arthroplasty with the development of the silicon spacer in 1966.1,25,26,27 Silicones also known as polysiloxanes are polymers composed of repeating siloxane units forming chains of alternating silicon and oxygen atoms (▶Fig. 2.1). Silicone elastomers are created by three-dimensional (3D) cross-linking of linear silicone polymer chains. Chemical inertness, heat stability, and durability have led to its widespread use in medicine. Good biotolerance, high hydrophobic capacity, and ability to withstand various sterilization process are further benefits allowing use of silicone elastomers in implant arthroplasty.26,28,29,30,31,32,33
Fig. 2.1(a) Chemical structure of silicone.(b)Silicone elastomer matrix.
Hardening of silicone elastomers is by curing, a chemical process which adds curatives to induce polymer cross-linking.29 Tensile strength is further enhanced by incorporation of “filler.” Silicone elastomers for medical applications normally utilize amorphous silica filler to reinforce the cross-linked matrix. While mixing the silica with the silicone polymers, a hydrogen bond is formed between hydroxyl groups on the filler's surface and silicone polymer, resulting in higher tensile strength and better capacity to resist elongation (▶Fig. 2.1).34
The original Swanson prosthesis was made from heatvulcanized, medical-grade silicone elastomer stock. The prostheses are single-piece and formed in a mold at 121.1 °C under 22.8 kg/cm2 of pressure.1 Most silicone finger prostheses consist of intramedullary stems bridged by a hinge26 (▶Fig. 2.2). The inherent flexibility of the silicone elastomer allows flexion and extension at the hinge and provides dampening effect on the bone. At the same time, it is stiff enough to maintain some joint alignment. The long-term functional stability ofsilicone prostheses occurs by development of well-encapsulated fibrous capsule which starts to develop within 3days of implantation.32
However, there are problems with the silicone elastomer implant. These include implant fracture, wear debris generation, and particulate synovitis.
Fig. 2.2 Swanson silicone finger joint implants.
Joyce et al analyzed the cause of silicone implant fracture by retrieving 12 Sutter metacarpophalangeal (MCP) prostheses from three patients.35 They found that fractures generally occurred at the junction of the distal stem and hinge as a result of subluxing forces concentrated on MCP joint and flexion occurring at the stem rather than the hinge. In addition, the cortical bone of the proximal phalanx impinges on the dorsal surface of the distal stem of prosthesis. It is presumed that sharp spurs from the proximal phalangeal bone will produce small cuts over dorsal surface of the prostheses. With time, the crack propagates resulting in a fatigue fracture (▶Fig. 2.3).35,36 Two-thirds of silicone MCP joint prostheses fracture by 14 to 17 years after implantation.37,38 Fortunately, by the time a fracture occurs, a fibrous pseudojoint is formed. The finger joint has some stability and often do not require revision surgery.26
During the process of abrasion and fatigue fracture, microscopic wear particles shed around the joint. This will stimulate proliferation and accumulation ofmononuclear cells which will secrete cytokines and proteolytic enzymes, causing swelling and inflammation of pseudosynovial and synovial membranes. Persistent chronic synovitis can lead to fibrosis, osteolysis, and bone necrosis surrounding the prosthesis. Despite these downsides, silicone arthroplasty remains popular options in finger joint arthroplasty.
Fig. 2.3 Illustration showing the fatigue fracture site over the retrieved Sutter metacarpophalangeal prosthesis. (a) Site of fatigue fracture; (b) end on view over fatigue fracture site showing abrasion over dorsal site and crack propagation with beach mark. (See also Joyce et al 2003.35)
2.3.2 “Nouvelle Vague” for Hand Arthroplasty Development
Successes in total hip-and-knee arthroplasty were eyecatching. This led to the introduction of surface replacement into hand arthroplasty pioneered by Linscheid and Dobyns in 1979.39
The concept was trying to reproduce a physiological articulation and retain the collateral ligaments to improve stability and in turn minimize osteolysis and subsidence.40 There is no single biomaterial that can replicate all the biomechanical properties of different structures inside the joint. By using two or more biomaterials with different characteristics in various parts of implant, it can more closely match the natural material properties. This resulted in a new surface replacement design with a cobalt-chrome proximal component and an ultrahighmolecular-weight polyethylene (UHMWPE) distal component for a proximal interphalangeal (PIP) joint surface replacement implant (▶Fig. 2.4).39
Ultrahigh Molecular Weight Polyethylene (UHMWPE)
Polyethylene (PE) has the advantage of easily being formed into many different shapes. It is mainly used coupled with a metallic component. It is formed from ethylene gas and is polymerized by Ziegler-Natta catalyst (titanium(III) chloride) into UHMWPE powder. The powder is consolidated under high temperatures and pressure. Because of its high melt viscosity, the final product is produced by compression molding and ram extrusion.41
UHMWPE is a high-density PE having a semicrystalline structure with a molecular mass more than 2,000,000 amu. The macromolecules consist of local ordered sheetlike crystalline lamellae embedded within amorphous regions and communicate with surrounding lamellae by tie molecules (▶Fig. 2.5).42 It has been extensively used in large joint arthroplasty because of its low friction, high resistance to wear, and high toughness.43
Fig. 2.4 Various designs for proximal interphalangeal (PIP) joint surface replacement implant:(a) SR MCP and PIP arthroplasty system (with courtesy of Stryker Corporation, USA).(b) CapFlex-PIP arthroplasty system (with courtesy of KLS Martin Group, Tuttlingen, Germany).
Medical-grade UHMWPE is free of calcium stearate and requirements are set according to the American Society for Testing and Materials (ASTM) 648-14.44 Since the polymerization of UHMWPE requires a specialized production plant to handle the dangerous chemicals, there are only two companies capable of making these resins (▶Table 2.3). Despite identical manufacturing methods, there are slight variations in molecular weight and resin morphology which affects their mechanical properties and wear abrasion resistance.45
The main factor responsible for UHMWPE failure in joint replacement is oxidative degradation. The presence of oxidation is related to the sterilization and storage methods. High-energy radiation such as gamma or electron beam radiation are the most commonly used sterilization methods for PE components.46 A nominal dose of 25 to 40 kGy gamma radiation is commonly used, which will emit energy higher than that of the polymeric chemical bonds. This would generate the scission of some chemical bonds of the UHMWPE, and decrease its molecular mass. In the presence of oxygen, this will lead to the formation of free radicals, causing worsening of some chemical and physical material characteristics.47,48,49 The oxidation process continues as long as there is an oxygen supply. This phenomenon is known as post-irradiation aging. It has been shown to occur in UHMWPE implants that were gamma sterilized in air and packaged in airpermeable packaging.50,51,52 Decreased abrasive wear resistance, due to oxidation, leads to a decrease in mechanical properties such as abrasive wear resistance which results in the formation of wear debris and consequently osteolysis, which has been recognized as being the main cause of failure in orthopaedic implants.53
Fig. 2.5 Chemical structure of ultrahigh-molecular-weight polyethylene (UHMWPE).
To decrease the effect of oxidation on wear and the mechanical properties of UHMWPE, orthopaedic implant manufacturers modified their sterilization protocols aiming to reduce the amount of oxygen exposure during storage. These include gamma radiation sterilization in vacuum-packaging or inert-gas packaging. However, free radicals that are already present cannot be eliminated and in vivo oxidation is still possible.54 Therefore, several methods have been attempted to improve the wear resistance of UHMWPE, including cross-linking, thermal treat-ment, and the addition of antioxidant vitamin E.
Cross-linking is achieved by formation of active sites at the chain ends, which can recombine to form trans-vinylene bonds.55 This can be achieved by gamma radiation and the peroxide method. The wear rate of highly crosslinked UHMWPE is six times less than conventional UHMWPE.56
