Coordination: Christian FONTAINE (Lille, France) with Daniel HERREN (Zürich, Switzerland), Philippe KOPYLOV (Lund, Sweden)

Transcription

1 Flexible silicone vs. rigid 2-component arthroplasties in the fingers Coordination: Christian FONTAINE (Lille, France) with Daniel HERREN (Zürich, Switzerland), Frank HAGENA (Munich, Germany) and Philippe KOPYLOV (Lund, Sweden)

2 Introduction Silastic spacers have been widely used in RA, both in MCP and PIP joints New prostheses have been designed According current concepts about joint arthroplasties using polyethylene, titanium, hydroxyapatite, etc. Better fitting to not so severe situations, as we meet today with the use of new biologic treatments Time to assess their results and indication

3 Objectives of the round table To give the state of art of each major operation To help the audience to choose the right implant for a given case To build an algorithm to choose it With the hope of finding a consensus

4 Plan of the round table MCP joint PIP joint Silastic: D HERREN Silastic: D HERREN Elogenics : F HAGENA Avanta : F HAGENA Ascension : P KOPYLOV Ascension : P KOPYLOV Discussion with the audience Presentation and discussion of clinical cases Tables of consensus?

5 MCP arthroplasties: the consensus Christian FONTAINE

6 What have the surgeon to face with? The problem Joint destruction Incongruity Instability and soft tissue problem The solution Replace the joint Reduce the malposition Balance the soft tissue The implant cannot solved all problems by itself

7 MCP surgical procedures Associated always to a synovectomy Cartilage and bone involvement are irreversible, usually more severe in radial fingers than in ulnar ones

8 Previous wrist stabilisation First Secondly Finally according to functional needs

9 Approaches Unique transverse approach in case of simultaneous surgery of the 4 MCP joints Single longitudinal approach hto approach a single joint

10 Basics of soft tissue management Weaken the ulnar side Retighten the radial side Relocalise the extensor apparatus at the dorsum of the MCP joint

11 Weakening of the ulnar side Division of the ulnar collateral ligament if retracted Division or transfer of the ulnar intrinsic muscles (8, 9) Division of the dorsal band of abductor digiti minimi (7)

12 Retightening g of the radial side Rtiht Retightening/reinsertion i i of the radial collateral ligament (1, 2) Transfer of the ulnar interosseous muscle on the radial side of the neighbouring finger (9) Transfer of the extensor indicis proprius onto the 1 st dorsal interosseous

13 Relocalisation of the extensor apparatus at the dorsum of the MCP joint Division of the ulnar sagittal band Shortening/retightening of the radial sagittal band Ulnar Radial

14 Importance of postoperative p rehabilitation Transitory immobilisation in extension of MCP joints, with free PIP mobilisation Dynamic splints for 3-6 weeks

15 MCP Silicone arthroplasty Daniel HERREN Schulthess Klinik Zurich (Switzerland)

16 MCP Silicone arthroplasty: the implant 30

17 MCP Silicone arthroplasty: advantages Documented long term results Relatively l good biocompatibility Some primary stability good secondary stability Easy insertion Easy revision

18 MCP Silicone arthroplasty: limits Almost none in terms of implantation Durability limited in patients with high demands Spacer concept

19 MCP Silicone arthroplasty: surgical approach Classic dorsal approach Emphasis on soft tissue handling: Capsular release Intrinsic release / transfer from digits III-V Collateral ligaments: suture/reinsertion Extensor tendon relocation

20 MCP Silicone arthroplasty: management of difficult situations Ulnar drift: Soft tissue handling and strict rehabilitation Wrist reduction and stabilisation Volar subluxation: Soft fttissue release Bone resection Instability: y Soft tissue handling and strict rehabilitation

21 MCP Silicone arthroplasty: rehabilitation Dynamic splinting in extension for 6 weeks Individualized Resting splint for the night for up to 3 months

22 MCP Silicone arthroplasty: results ROM in ROM präop ROM 3 Mon. ROM 6 Mon. ROM 12 Mon. ROM Preop: 37 Postop:57 Follow -up t in Drift 25 Ulnar drift Preop: 20 Postop: 3 0 Ulnardrift präop. Ulnardrift postop. No revision in 5 years No osteolysis No implant fracture

23 Elogenics - MCP prosthesis F.-W. Hagena, Chr. H. Meuli

24 Elogenics MCP prosthesis: Design Design: unconstrained, uncemented to avoid wear and metallosis > polyethylene head to avoid subluxation / dislocation > enlargement metacarpal head phalangeal base relation to secure osteointegration > X-shaped titanium stems to increase ROM > anatomical shaped head HgNa@aol.com, Munich

25 Elogenics MCP prosthesis: Limits Contract hand (clinch fist s.) Contract imbalance of the wrist: correct malposition of the wrist, first! Mutilating arthritis Munich

26 Elogenics MCP prosthesis: Approach Horizontal for 2 and more joints Longitudinal for a single joint replacement HgNa@aol.com, Munich

27 Elogenics MCP prosthesis: Soft tissue problems Ulnar deviation Intrinsic release Volar plate release Realignment of the extensor tendons Intrinsic transfer (5 th MCP) Munich

28 Elogenics MCP prosthesis: Soft tissue problems Volar subluxation Bilateral intrinsic release Volar plate release Balancing of the soft tissues Munich

29 Elogenics MCP prosthesis: Soft tissue problems Postop splinting: After soft tissue balancing postoperative p splinting is mandatory for up to 6 weeks (dynamic and stabilizing) HgNa@aol.com, Munich

30 ROM MCP [ ] preop last follow up ( 12 months) 16 Häufigkeiten n Veränderung in Ve eränderung in 46 Preop FUP ROM aktiv präop [ ]: N = 68, Mw. = 46.2, Stdabw. = 16.8, Max. = 85, Min. = 10 ROM aktiv FUP [ ]: N = 68, Mw. = 54.8, Stdabw. = 19.7, Max. = 80, Min. = 5

31 Elogenics MCP prosthesis: Complications - Results Intraoperative: Phalanx perforation (same pt.) 2 Metacarpal perforation 1 Perioperative: Dislocation 2 1x open reduction 1x closed reduction Survival-Funktion Surviv al-zeit [Monate] Postoperative /at FUP ulnar deviation 20 Arthrofibrosis (same pt.) 2 Algodystrophia (same pt.) 4 N = 113 Aseptic loosening 3 HgNa@aol.com, Munich

32 Ascension MCP Pyrocarbon Prosthesis Philippe KOPYLOV MD, PhD Hand and Upper Extremity Unit Dept. of Orthopaedics Lund University Hospital (Sweden)

33 Arthroplasties of finger joints The problem Joint destruction Incongruity Instability and soft tissue problem The solution Replace the joint Reduce the malposition Balance the soft tissue The implant cannot solved all problems by itself

34 The implant. What do we need? Anatomic design Minimal resection Non constrained Good stem fixation No deterioration of bone and soft tissue over time Reoperation possibilities Experience in other joints: hip, knee, shoulder, elbow

35 Ascension MCP Pyrocarbon Prosthesis Two components Non hinged Non constrained Stemmed metacarpal hemispherical head Stemmed concave phalangeal component Avoid volar dislocation Can be used as hemi

36 Recentralization and stabilization always part of MCP surgery, including arthroplasty Associated always to a synovectomy Cartilage and bone involvement are irreversible Ligaments Reconstruction Shortening Reinsertion Tendons Reorientation Transfer

37 Ascension MCP Pyrocarbon Prosthesis Advantages Biological compatible No wear Low friction Early ysurgery Anatomical design No cement Pyrocarbon heads. possibility to hemi Drawbacks Stem fixation has to be improved Cannot tbe used In very advanced destruction ti When soft tissues cannot be reconstructed t When constrained is a necessity

38 Surgical technique Dorsal approach pp Through the tendon or radial/ulnar hooden depending of reconstruction/balancing necessity Surgical precision and good instrumentation, including saw guides Soft tissue reconstruction Tendon recentralization Collateral ligt reconstruction Tendon transfer The implant allows all techniques of recentralization /stabilization Post operative care

39 Postoperative care Postoperative ti dressing with cast in 30 degrees flexion Extension device with radial and dorsal tension for 6 weeks. Active flexion after 5 to 10 days Volar rest splint during the nights 3 months Customized treatment depending of The patient The need The stabilization used during surgery

40 MCP Carbon: Material in Lund 39 patients 23 RA 9 osteoarthrosis 7 post-traumatrauma 81 implants 1, 2, 3 or 4 implants / patient Follow up Maximum 7 years

41 Material in RA 65 MCP joints Results 40 MCP joints Minimum follow-up 36 months 19 MCP joints 60 months 11 MCP joints 48 months 14 patients (16 hands) 13 women All Rheumatoid Arthritis 55 years (36-67)

42 Results No infection 1 joint dislocated Revised with Swanson spacer which ruptured after 5 months 4 joints were revised after 48 months for progressive recurrence of stiffness 3 joints were revised after 48 months for progressive recurrence of ulna deviation 2 joints were revised after 40 months in reason of implant tloosening

43 Results 12/14 patients were painfree 11/14 patients increased their functional score 39/40 joints were stable 33/40 joints increased their range of motion

44 IPP arthroplasties: the consensus Christian FONTAINE

45 Soft tissues! Resurfacing the articular surfaces is not the most difficult part Balancing soft tissues to correct sagittal deformities: boutonniere, swan neck Balancing soft tissues to correct frontal imbalance : ulnar or radial drift Postoperative splinting letting the DIP free

46 IPP Silicone arthroplasty Daniel HERREN Schulthess Klinik Zurich (Switzerland)

47 PIP Silicone arthroplasty: the implant

48 PIP Silicone arthroplasty: advantages Predictable results Relatively easy insertion (approach) Easy revision Almost never Silicone synovitis Rarely implant fractures Good dlong-term results

49 PIP Silicone arthroplasty: limits Almost no limits it

50 PIP Silicone arthroplasty: limits

51 PIP Silicone arthroplasty: surgical approach

52 PIP Silicone arthroplasty: management of difficult situations Lateral instability: Difficult to correct in the long term Soft tissue balancing Collateral ligament reinforcement Re-centering of the flexor tendons Contracture: Soft tissue release Almost never unstable a/p

53 PIP Silicone arthroplasty: rehabilitation Early mobilisation Protection splint 3-6 weeks Protection of the collateral ligaments Buddy taping

54 PIP Silicone arthroplasty: result % PIP Arthroplasty Survivor 1991 bis 2000 N = Years 94% Survival 94% after 9 years ROM Average 55

55 Prosthesis register of the German Society of Hand Surgery «DGH» W. Daecke 1, P. Wieloch 3, A.K. Martini 2, M. Jung 2 1 Klinik für Unfall-, Hand- und Wiederherstellungschirurgie Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main 2 Orthopädische Universitätsklinik Heidelberg 3 Uniklinik für Orthopädie + Unfallchirurgie Freiburg

56 Prosthesis register of the DGH Director: PD. Dr. W. Daecke Start Summer 2005 Ein nationales Endoprothesenregister der Hand P. Wieloch, A.K. Martini, W. Daecke, Handchir Mikrochir Plast Chir ; 37(4): Active centres 26 Passive P i centres 64 Prostheses 272 Examinations 909

57 Prosthesis register of the DGH Avanta PIP Prosthesis 131 patients 483 examinations 16 centres (1 51 patients) 47% 26% Distribution 24% Advantages: Unconstrained Uncemented Anatomical resurfacing 12%

58 Prosthesis register of the DGH Avanta PIP Prosthesis Preliminary results Limits: Instability Loss L of fbone 12% Approach: Dorsal Curved skin incision Central C t l splitting the extensor Distribution 47% 24% 26%

59 Prosthesis register of the DGH Avanta PIP Prosthesis Preliminary results Soft tissue problems: Re-balancing Transosseous refixation of the ligaments Distribution 47% 26% 24% 12% Postoperative splinting: 4 weeks

60 Prosthesis register of the DGH PIP Prostheses ttest:*p>0,05 test: ROM all patients Pre- OP 2 w. 3 mo. 6 mo. 1 y. 2 yrs. 3yrs. 4yrs. PIP 43,7 45,6 52,3 * 48,6 50,9 51, Legende ROM prä-op ROM post-op Preop 2 w. 3 mo. 6 mo. 1 y. 2 yrs. 3 yrs. 4 yrs. Significant individual increase of ROM ( 10 )

61 Prosthesis register of the DGH PIP Prostheses Complications 2 superficial infections 3 3swan neck deformity 2 boutonniere deformity 12 loosening 7 fibrosis 2 ossifications Revision surgery 3 tenolysis/tenodesis 6 implant exchange 1 1arthrodesis

62 SBI Prosthesis Johnstone (2001) n= 20 14,6 months Painfree: 18 Flex / Ext: 73,1 Linscheid (1997) n= months Painfree: 70% Flex / Ext: 47 (zunehmend besser)

63 Ascension IPP Pyrocarbon Prosthesis Philippe KOPYLOV MD, PhD Hand and Upper Extremity Unit Dept. of Orthopaedics Lund University Hospital (Sweden)

64 Ascension PIP Pyrocarbon Prosthesis Two components Non hinged Non constrained Stemmed phalangeal bicondylar head Stemmed biglenoidal id l phalangeal component Avoid volar dislocation Can be used as hemi

65 Ascension PIP Pyrocarbon Prosthesis Advantages Biological compatible No wear Low friction Early surgery Anatomical design No cement Pyrocarbon heads. Possibility to hemi Drawbacks Stem fixation has to be improved Cannot be used in very advanced destruction, when soft tissues cannot be reconstructed When constrained is a necessity

66 Surgical technique D l h Dorsal approach Central slip vs. Chamay Surgical precision and good instrumentation, including saw guides. No heat Soft tissue reconstruction Tendon recentralization Collateral ligament reconstruction

67 Postoperative care Postoperative immobilization in extension PIP Tk Take care of fdip Extension device after 5-7 days Extension block -10 degrees to avoid hyperextension Immobilisation in extension by night Customized and hand based Only the operated finger

68 Material 40 PIP 35 patients (1, 2 or 3 joints) Indications 8 RA 22 primary osteoarthrosis 5 post-traumatic osteoarthrosis

69 Results 20 PIP joints 15 patients Mean age 56 years (48-64) Osteoarthrosis and RA pain decreased ROM Aetiology 14 primary osteoarthrosis 2 post-traumatic costeoarthrosis s 4 RA

70 Results Follow up >36 months 14/15 patients were painfree 14/15 patients increased their functional score 20/20 joints were stable 16/20 joints increased their range of motion ROM 53 degrees (30-90) Extension lack 10 degrees (0-45)

71 Results In degrees Preop Postop > 3 years ROM finger * 185 * ROM PIP * 59 * Extension ns 11 ns Def Flexion * 70 *

72 Complications No dislocation No infection 1 case developed a swan neck deformity. The hyperextension was corrected with Littler tendon transfer 1 case became stiff and was re-operated after 8 months. The preoperative ROM was obtained

73 Take home message No solution fit all Analyze the patient, discuss the need Treatment for function not for anatomy Stability vs. mobility Implant evaluated vs. resection arthroplasty vs. fusion Immobilization time and necessity

74 Proposition of MCP algorithm No volar subluxation, ulnar tilt <20 Non constrained prosthesis Reducible volar subluxation, ulnar tilt Non constrained prosthesis + soft tissue reconstruction Irreducible volar subluxation ulnar tilt >40 Silicone arthroplasty

75 Proposition of IPP algorithm No bone loss, no bending Non constrained prosthesis No bone loss, bending <20 Non constrained prosthesis or Silicone arthroplasty + soft tissue reconstruction Bone loss, bending >20, irreducible boutonniere or swan neck deformity Ath Arthrodesis