JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Charles A. Goldfarb and Peter J. Stern
Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis: A Long-Term Assessment
J Bone Joint Surg Am 2003; 85: 1869-1878 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Drs. Goldfarb and Stern respond:
Charles A Goldfarb, Peter J. Stern   (8 January 2004)
[Read Letter to the Editor] Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis
Klemens Trieb, M.D., Catharina Chiari, M.D.   (5 January 2004)

Drs. Goldfarb and Stern respond: 8 January 2004
Previous Letter to the Editor Top
Charles A Goldfarb,
Orthopaedic Surgeon
Department of Orthopaedic Surgery Washington University in St Louis,
Peter J. Stern

Send letter to journal:
Re: Drs. Goldfarb and Stern respond:

goldfarbc{at}wustl.edu Charles A Goldfarb, et al.

We thank Dr. Trieb for his comments on our article, “Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. A Long- Term Assessment.”

Dr Trieb's report on 76 MCP arthroplasties at an average of 8.4 years follow- up demonstrates similar ranges of motion and implant fracture rates to those reported in multiple publications(1-10). These previous investigations demonstrated active MCP range of motion varying from 27 to 43 degrees at follow- up ranging from 2.5 to 10.1 years. Implant fracture rates varied from 0% to 28%.

Our findings, at more than 14 years postoperative, are significantly different in two primary ways. We found a significantly higher implant fracture rate compared to studies with intermediate term follow up. The reasons for this are unclear, but there are three possible explanations. Most simply (and most likely), the additional follow- up interval for our patients may account for the increased fracture rate. Alternatively, we use multiple radiographic views to confirm implant integrity and may, therefore, identify additional fractures. And finally, although we adhere to standard operative and rehabilitation techniques, there may be subtle differences in our protocols which explain the disappointing outcome.

The second major difference is patient satisfaction. At intermediate follow- up, several investigations have found satisfactory outcomes through simple patient questionnaires. Indeed, the majority of our patients state that they are happy with the outcome of their surgery. However, the use of a hand- specific, validated subjective outcome instrument noted a less satisfactory outcome. We believe that the use of this instrument provides a more realistic assessment of outcome- results which are difficult to compare to other, non- validated tools. However, we feel strongly that until a validated outcome instrument is applied preoperatively and at regular intervals postoperatively (with a consideration of systemic disease), the true utility of this surgery will remain somewhat unclear.

We appreciate Dr Trieb's comments and look forward to reading the longer term results of his investigation. We agree that silicone arthroplasty remains the gold standard for the treatment of MCP disease and we continue to utilize these implants in our clinical practices.

1. Mannerfelt L, Andersson K. Silastic arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis. J Bone Joint Surg 1975; 57A:484-9.

2. Beckenbaugh R, Dobyns J, Linscheid R, Bryan R. Review and analysis of silicone-rubber metacarpophalangeal implants. J Bone Joint Surg 1976; 58 A:483-7.

3. Blair W, Shurr D, Buckwalter J. Metacarpophalangeal joint implant arthroplasty with a silastic spacer. J Bone Joint Surg 1984; 66 A:365-70.

4. Bieber E, Weiland A, Volenec-Dowling S. Silicone-rubber implant arthroplasty of the metacarpophalangeal joints for rheumatoid arthritis. J Bone Joint Surg 1986; 68 A:206-9.

5. Maurer R, Ranawat C, McCormack J, RR, Inglis A, Straub L. Long- term follow-up of the Swanson MP arthroplasty for rheumatoid arthritis. Proceedings of ASSH Abstract. J Hand Surg Am 1990; 15 A:810-11.

6. Kirschenbaum D, Schneider L, Adams D, Cody R. Arthroplasty of the metacarpophalangeal joints with use of silicone-rubber implants in patients who have rheumatoid arthritis. J Bone Joint Surg 1993; 75 A:3-12.

7. Wilson Y, Sykes P, Niranjan N. Long-term follow-up of Swanson's silastic arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis. J Hand Surg Br 1993; 18 B:81-91.

8. Olsen I, Gebuhr P, Sonne-Holm S. Silastic arthroplasty in rheumatoid MCP-joints: 60 joints followed for 7 years. Acta Orthop Scand 1994; 64:430-1.

9. Hansraj K, Ashworth C, Ebramzadeh E, et al. Swanson metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis. Clin Orth Related Research 1997; 342:11-15.

10. Schmidt K, Willburger R, Miehlke R, Witt K. Ten-year follow-up of silicone arthroplasty of the metacarpophalangeal joints in rheumatoid hands. Scand J Plast Reconstr Hand Surg 1999; 33:433-8.
Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis 5 January 2004
Next Letter to the Editor Top
Klemens Trieb, M.D.,
Orthopaedic Surgeon
Department of Orthopedics, University of Vienna, Wahringergurtel 18-20, A-1090 Vienna, Austria,
Catharina Chiari, M.D.

Send letter to journal:
Re: Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis

Klemens.Trieb{at}akh-wien.ac.at Klemens Trieb, M.D., et al.

To the Editor:

"Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. A Long-Term Assessment" (2003: 85:1869-78) by Goldfarb et al. represents long-term results with an average of 14 years of follow-up. In this study a high percentage of implant fractures (63%), a loss of joint motion and recurrence of u1nar drift and, to the authors, disappointing subjective outcomes with a mean of 55 of possible 100 points in the MHQ led to their conclusion, that the indications for metacarpophalangeal arthroplasty have to be examined carefully.

At our clinic a similar study is being conducted. To date, we have evaluated 22 patients with rheumatoid arthritis who have Swanson implants (76 metacarpophalangeal and 18 proximal interphalangeal joints). After an average follow-up of 8.4 years, we have found a slightly better mean range of motion(41.5°) in the metacarpophalangeal joints when compared to the proximal interphalangeal joints (43°) The mean extension deficit was 17° and 23.3° respectively. Patient satisfaction was generally high (93.3% were found in the highest or second highest level of satisfaction on a five point scale). Additionally, disease specific quality of life was high with a mean HAQ Score of 1.16 (0 no impairment, 3 maximum impairment).

In contrast to the recently published data, we detected only 6.4% spacer fractures. Although our preliminary results are not comparable concerning the duration follow-up and number of implants, we have an overall positive impression of the implants' performance. As Goldfarb and al. discussed, the morbidity of rheumatoid arthritis has been and will be further reduced by advances in medical management-- thus, the indications for finger joint arthroplasties will decrease.

Our experience leads us to believe, that the silicone spacer fmgerjoint arthroplasty is still the gold standard in patients with Rheumatoid Arthritis.