Keywords osteoarthritis - trapeziometacarpal prosthesis - dual mobility - thumb - dislocation
Introduction
Trapeziometacarpal (TMC) osteoarthritis is the most common condition in hand surgery.
The prevalence of TMC osteoarthritis ranges from 8 to 12%, reaching up to 33% in postmenopausal
women.[1 ] TMC is the second most common location of osteoarthritis in the hand, after the
distal interphalangeal joint. In the general population, one in four women and one
in twelve men present degenerative changes at the TMC level, mostly asymptomatic.[2 ]
The static stability of the TMC joint depends on the joint capsule and the ligaments
surrounding it. It is controversial which is the primary stabilizer of the TMC joint.
Historically, the anterior oblique ligament had a greater significance. However, today,
we believe the stabilizing role of the dorsoradial ligament is higher in a joint affected
by wear resulting from the biomechanical effect of load translation.[2 ]
[3 ]
The treatment of symptomatic rhizarthrosis is broad and ranges from several conservative
treatment options to surgery. There are numerous specific surgical treatments for
TMC osteoarthritis: trapezectomy with or without tenosuspension, interposition arthroplasties,
joint arthrodesis, or prosthetic replacement, which has gained importance in recent
years. The technique used will depend on the patient's age and activities, the radiological
stage, and the experience of the surgeon.[3 ]
Historically, the surgical technique of choice in advanced TMC osteoarthritis has
been trapezectomy, whether total or partial. It is a simple technique with good short-
and medium-term outcomes for reducing pain and improving thumb mobility. In recent
years, its indication has increased thanks to the arthroscopic technique.
Although TMC arthroplasty has been used for decades, recent years have witnessed significant
growth in its performance. The first prosthesis described was the De La Caffiniére
in the 1970s, a ball-and-socket-type prosthesis, which presented frequent major complications,
such as osteolysis and loosening. Subsequently, similar non-cemented or constrained
prostheses were introduced and offered better long-term outcomes despite a considerable
dislocation rate (10%).[3 ]
[4 ] To reduce the probability of dislocation, dual-mobility TMC prostheses began to
be used in 2010, mimicking the concept of hip prostheses.
This study aimed to evaluate the outcomes of a series of patients diagnosed with advanced
TMC osteoarthritis with failed conservative treatment. These subjects underwent surgery
by the same professional, who placed a Moovis-type dual-mobility TMC prosthesis with
a ball-and-socket modular design and a conical cup ([Figure 1 ])
Fig. 1 Pre- and postoperative radiographs of a 68-year-old male patient with rhizarthrosis
in the left hand and undergoing dual-mobility thumb prosthesis placement.
Material and Methods
Study Design
This study was retrospective, based on a series of cases operated on in our center
using Moovis-type dual-mobility TMC prosthesis. In total, the analysis included 60
patients (66 prostheses) undergoing surgery from 2019 and 2022.
The demographic data collected included age, gender, dominant hand, and the degree
of osteoarthritis per the Eaton-Littler scale.
The Kapandji index assessed mobility in the first month after surgery. In addition,
we analyzed complications within the first year after surgery, pain according to the
visual analog scale (VAS), and the Quick Version of the Disabilities of the Arm, Shoulder,
and Hand (qDASH) functional questionnaire at the beginning and the end of follow-up.
The mean follow-up was 13.6 months (range, 11.3 to 16 months).
Surgical Technique and Postoperative Protocol
The same surgeon performed all procedures under regional anesthesia and ischemia.
The surgeon performed a longitudinal radial incision at the base of the first metacarpal,
centered on the TMC joint. After joint approach and protecting the sensory branch
of the radial nerve, the surgeon made an inverted L-shaped capsulotomy.
With a saw, the surgeon performed an oblique osteotomy at the base of the first metacarpal,
approximately 3 to 5 mm in thickness. Under scopic control, after exhaustive osteophyte
removal, the center of the trapezius was located and received a Kirschner wire to
serve as a guide for the cannulated drills. The neoacetabulum was reamed followed
by placing a press-fit impacted cup of appropriate size. Subsequently, the surgeon
performed an intramedullary reaming of the metacarpal bone and placed the corresponding
press-fit stem. The trial head and neck were added followed by implant reduction.
Definitive implant placement occurred after checking the stability and range of mobility.
Next, the surgeon proceeded to capsular closure, hemostasis, skin closure, and compressive
bandage placement.
From the first postoperative day, we allowed patients to use their hands for basic
activities for daily living. On the seventh postoperative day, after bandage removal,
rehabilitation began. We instructed the patients to avoid heavier tasks or carrying
weights for 6 weeks.
A radiological follow-up occurred after 4 weeks to identify potential complications
and assess thumb mobility.
Follow-up included periodic clinical and radiological examinations around 3 and 12
months. At the end of the follow-up period, we determined pain per VAS and functional
outcomes using the qDASH questionnaire.
Results
Patients undergoing surgery included 46 women (76.7%) and 14 men (23.3%). In six subjects,
surgery was bilateral. The average age of patients was 62.4 years, ranging from 47
to 77. The operated hand was the dominant one in 57% of the cases and the non-dominant
hand in 43% of patients ([Table 1 ])
Table 1
Characteristic
Value
Number of patients
60
Number of thumbs
66
Female:male ratio
46/14
Operated side (%)
Right
53%
Left
38%
Bilateral
9%
Mean age
62.4
Mean surgical time (minutes)
38.3
The Eaton-Littler classification evaluated the preoperative radiographs; 56 and six
joints had stage III and IV injuries, respectively. One patient received a thumb prosthesis
for a trapezium fracture. Another procedure occurred in 47% of the interventions;
the most frequent secondary procedures were the median nerve release in the carpal
tunnel and ganglion resection.
During follow-up, 93.9% of patients had no complications. Only four (6.1%) complications
occurred during the entire follow-up, three of them in the first postoperative month
and another one a year later.
Regarding complications during the first postoperative month, there were two cases
of cup mobilization treated by replacement and one trapezium fracture treated by a
surgical stapedectomy.
From the first month to the first postoperative year, there was one case of stem loosening
treated by replacement ([Table 2 ])
Table 2
Complications
Number of patients (%)
Cup loosening
2 (3%)
Trapezium fracture
1 (1.5%)
Stem loosening
1 (1.5%)
Total
4 (6%)
Reviewing the first postoperative month, we observed complete mobility in 92.6% of
the prostheses (Kapandji score, 9 to 10). The Kapanji score was 7 in two cases and
8 in two subjects.
The mean VAS before intervention was 8.1 compared to 1.5 at the end of the follow-up
([Table 3 ]). Regarding the qDASH questionnaire, the preoperative mean score was 46.2 (confidence
interval [CI], 41.4-50.1) and 9.8 (CI, 5.6-13.9) at the end of the follow-up period
([Table 4 ]). Comparing the beginning and the end of the follow-up period, the differences in
both questionnaires were statistically significant (p < 0.01).
Table 3
VAS
Mean
Confidence interval
Preoperative
8.1
7.7-8.5
Postoperative
1.5
0.5-2.6
Table 4
qDASH
Media
IC
Pre-quirúrgico
46.2
41.4-50.1
Post-quirúrgico
9.8
5.6-13.9
Discussion
In recent years, the use of dual-mobility TMC prostheses in patients with symptomatic
advanced rhizarthrosis has grown exponentially.
This increase results from improvements in surgical techniques and implants, evolving
from the first De La Caffiniére prostheses (with a high rate of osteolysis and loosening)
to the current dual-mobility prostheses that allow greater mobility and a lower rate
of dislocations.[4 ]
Our study revealed a significant improvement in thumb pain, mobility, and functionality.
Pain per VAS decreased by an average of 6.6 points, while mobility according to the
Kapandji scale was excellent at 92.6%, and the qDASH decreased from 46.2 to 9.8 points
on average.
These results are consistent with those published in the literature.
Dreant et al.[5 ] performed a retrospective study similar to ours, analyzing 28 Moovis-type dual-mobility
thumb prostheses. These authors reported improved strength, pain, and mobility, with
a postoperative Kapandji score of 10. They assessed the final functional outcomes
using the QuickDASH questionnaire, with an average score of 12, and the Michigan Hand
Outcomes questionnaire, with an average score of 87%.
In contrast, Lussiez et al.[6 ] analyzed 107 cases of dual-mobility thumb prostheses for more than 3 years and reported
an improvement in pain (postoperative VAS, 0.8), mobility (postoperative Kapandji
score, 9.4), and a good functional outcome (QuickDASH score, 20; increase in clamp
strength from 3.5 kg to 5.5 kg).
Although most patients have a good outcome, this surgery is not free of complications.
The most frequent complications in this type of intervention include cup mobilizations,
dislocations, trapezius fractures, and, to a lesser extent, infections.
In our series, we had two cases of cup loosening and one trapezius fracture during
the first postoperative month. From the first month to the first post-surgical year,
there was a stem loosening. We did not have any case of prosthetic dislocation. As
such, the complication rate in our sample was low, at 6.1%.
Regarding complications, Dreant et al.[5 ] reported one revision surgery for painful trapezium osteolysis.
Lussiez at al.[6 ] reported five complications requiring implant replacement, including one cup mobilization,
two painful osteolysis around the cup, and two cases of polyethylene wear.
As in our series, the two previous studies, both in patients undergoing surgery to
place a dual-mobility TMC prosthesis, had no case of prosthetic dislocation.
Cootjans et al.[7 ] followed up on 166 ARPE-type TMC prostheses (single-mobility prostheses) and found
eight cases of prosthetic dislocation. In four of them, the prosthesis was stable
after closed reduction, not requiring surgery. The remaining four patients underwent
a revision surgery.
A systematic review by Vermeulen et al.[8 ] found that the total TMC prosthesis is a good option to treat stages II and III
rhizarthrosis. These authors also mention that the outcome could be better, at least
in the short term, than trapezectomy with tendon interposition. However, they did
not find one surgical treatment superior to another to treat symptomatic advanced
TMC osteoarthritis.
Dual-mobility TMC prostheses were designed to reduce the dislocation rate. We had
no cases of prosthetic dislocation.
Our study has some limitations. Its retrospective nature has inherent limitations,
and the sample size was small. The follow-up time includes short and medium-term,
and longer patient evaluations are required to assess long-term survival and late
complications.
Conclusions
Outcomes from dual-mobility TMC prostheses were satisfactory concerning mobility,
functionality, and pain improvement. The rate of complications in the short and medium
term was low, with minimal risk of dislocation.
The placement of a dual-mobility prosthesis in patients with symptomatic TMC osteoarthritis
is a surgical option with good outcomes, recommended especially in patients with moderate
to high functional demand and requiring fast postoperative recovery.
