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Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis

A Long-Term Assessment

Investigation performed at University of Cincinnati College of Medicine and Hand Surgery Specialists, Cincinnati, Ohio

Charles A. Goldfarb, MD
Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110-1010. E-mail address: goldfarbc{at}msnotes.wustl.edu

Peter J. Stern, MD
Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, 5508 Medical Sciences Building, P.O. Box 670212, Cincinnati, OH 45267-0212

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

Background: The long-term results of silicone metacarpophalangeal arthroplasty in patients with rheumatoid arthritis are uncertain. The purpose of this investigation was to evaluate the subjective, objective, and radiographic outcomes at the time of long-term follow-up.

Methods: Patients with rheumatoid arthritis who underwent simultaneous silicone metacarpophalangeal joint arthroplasties of all four fingers by one surgeon were eligible for inclusion in the study. The results of a total of 208 arthroplasties in fifty-two hands of thirty-six patients were evaluated at an average of fourteen years postoperatively. Active metacarpophalangeal joint motion, ulnar drift, and radiographs were assessed. The radiographs were reviewed for changes in bone length, erosions, and implant fractures. The Michigan Hand Outcomes Questionnaire (MHQ) was administered to the patients.

Results: The mean arc of motion of the metacarpophalangeal joints improved from 30° preoperatively to 46° immediately after the surgery but decreased to 36° at the time of final follow-up. The mean extension deficit of the metacarpophalangeal joints improved from 57° preoperatively to 11° immediately after the surgery but worsened to 23° at the time of final follow-up. The mean ulnar drift improved from 26° preoperatively to <5° in the immediate postoperative period and then recurred to an average of 16° at the time of final follow-up. Implant fractures were associated with increased ulnar drift (p < 0.001). Bone reaction adjacent to the implant was demonstrated by bone-shortening in most patients and by erosions in 29% of the patients. One hundred and thirty implants (63%) were broken and forty-five (22%) more were deformed at the time of final follow-up. The MHQ score averaged 48 of 100 points. The patients expressed satisfaction with the function of only 38% of the hands, and only 27% of the hands were pain-free at the time of final follow-up. A greater degree of ulnar drift was associated with decreased patient satisfaction and a decreased score for the cosmetic appearance (p 0.01).

Conclusions: The outcome after silicone metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis worsens with long-term follow-up. Given these findings, the indications for and long-term expectations of silicone metacarpophalangeal arthroplasty must be carefully examined in light of the improvements in the medical management of rheumatoid disease.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis • C.A. Goldfarb and P.J. Stern reply

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