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Jump C, Hayton MJ. Outcomes of Small Joint Arthroplasty for the Rheumatoid Hand. Hand Clin 2025; 41:65-73. [PMID: 39521591 DOI: 10.1016/j.hcl.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
The number of patients presenting to the hand surgeon with severe rheumatoid disease has decreased with the introduction of more effective medical management. However some rheumatoid patients will undergo disease progression despite this. MCPJ and PIPJ replacement can be effective surgical treatments in these patients but patient selection is crucial. Patients undergo surgery hoping to achieve improvements in pain, hand function and appearance. Multiple types of implant have been introduced over the years; however, silicone remains the most reliable option in terms of survivorship, complications and achieving the aims of rheumatoid patients.
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Affiliation(s)
- Christopher Jump
- Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire, WN6 9EP, UK.
| | - Michael J Hayton
- Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire, WN6 9EP, UK
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Nakayama M, Kiyota Y, Nakamura S, Yagi M. Trends in Rheumatoid Hand Surgery: Indications, Techniques, and Outcomes. J Clin Med 2025; 14:319. [PMID: 39860324 PMCID: PMC11766085 DOI: 10.3390/jcm14020319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 12/26/2024] [Accepted: 01/06/2025] [Indexed: 01/27/2025] Open
Abstract
Rheumatoid arthritis (RA) causes persistent synovitis and arthritis, resulting in joint deformity and destruction throughout the body. As RA medications have evolved over the past 30 years, the surgical indications and techniques for RA joint deformities have changed. The aim of this review article is to summarize the recent trend of surgery for rheumatoid hand/finger deformities in previous reports and to present our recent surgical methods and outcomes for these deformities. A typical hand and finger deformity caused by RA is ulnar deviation, which is mainly caused by joint laxity and dislocation of the metacarpophalangeal joints, in addition to extensor tendon dislocation and/or wrist joint deformity. Although the incidence of hand/finger deformity and ulnar deviation caused by RA is decreasing due to advances in RA medications, patients with long-term RA or those with difficult-to-treat RA may still develop hand/finger deformity and ulnar deviation. If the hand/finger deformity is mild, it can be reduced manually, and conservative treatment with orthoses or splints may be required. If joint pain is severe despite good medical control of RA, or if the patient hopes to improve the appearance of the hand or fingers, surgical intervention is required. If there is only subluxation of the joints, which preserves their structure, reconstruction with only soft tissue surgery may be required. For example, for swan-neck deformity and boutonniére deformity, two of the most typical finger deformities due to RA, when the joint structures are almost intact and can be corrected manually, we opt for a surgical procedure that involves only soft tissue manipulation without the use of prosthetic implants. For ulnar deviation without joint destruction, we usually use a soft tissue-only surgical procedure. Our results have shown that the soft tissue-only surgery for ulnar deviation is as effective as joint replacement with implants. If the destruction of the joint has occurred and its dislocation/subluxation cannot be reduced manually, implant arthroplasty becomes necessary. If the joint destruction is severe, only intra-articular arthrodesis is required. In the era when RA can be controlled by medication, the hand surgeon should not overlook the change in the stage of the rheumatoid hand and should perform surgical intervention via the appropriate surgical method.
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Affiliation(s)
- Masanori Nakayama
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Narita Hospital, 852 Hatakeda, Narita 286-8520, Japan
| | - Yasuhiro Kiyota
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Soichiro Nakamura
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Narita Hospital, 852 Hatakeda, Narita 286-8520, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Narita Hospital, 852 Hatakeda, Narita 286-8520, Japan
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Risk Factors Contributing to Early Implant Fracture in Silicone Metacarpophalangeal Joint Arthroplasty for Patients With Rheumatoid Arthritis. J Hand Surg Am 2021; 46:243.e1-243.e7. [PMID: 33162271 DOI: 10.1016/j.jhsa.2020.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 07/06/2020] [Accepted: 09/10/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify the risk factors associated with early implant fracture of silicone metacarpophalangeal (MCP) joint arthroplasty using the volar hinge silicone implant for patients with rheumatoid arthritis. METHODS We retrospectively reviewed 113 fingers of 31 hands that underwent MCP joint arthroplasty between 2008 and 2014, with a minimum follow-up of 3 years,. An implant fracture within 3 years after surgery was regarded as an early implant fracture. Patient records were reviewed for potential risk factors of age, affected fingers, ulnar drift angle, and range of motion of the MCP joint before surgery and 1 year after surgery. Candidate risk factors were compared at the level of the digit and at the patient level. RESULTS With fracture of the implants as the end point, Kaplan-Meier estimated survival rate was 74.3% at 3 years and 67.9% at 5 years. Early implant fracture was detected in 29 fingers. Bivariate analyses showed significant associations between early implant fracture and MCP joint arc of motion before surgery, MCP joint flexion range 1 year after surgery, and MCP joint arc of motion 1 year after surgery. Multiple logistic regression analysis showed that increased MCP joint flexion range 1 year after surgery was an independent risk factor for early implant fracture. CONCLUSIONS Increasing MCP joint flexion range was associated with increased fractures of the implants. We propose that the MCP joint flexion range should be restricted to less than 60° in postoperative rehabilitation; it is necessary to educate the patient to permanently avoid excessive flexion of the MCP joint. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Chung KC, Kotsis SV, Burns PB, Burke FD, Wilgis EFS, Fox DA, Kim HM. Seven-Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study. Arthritis Care Res (Hoboken) 2017; 69:973-981. [PMID: 27696739 DOI: 10.1002/acr.23105] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 09/20/2016] [Accepted: 09/27/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) causes destruction of the metacarpophalangeal (MCP) joints, leading to hand deformities, pain, and loss of function. This study prospectively assessed long-term functional and health-related quality-of-life outcomes in RA patients with severe deformity at the MCP joints. METHODS RA patients between ages 18 to 80 years with severe deformity at the MCP joints were referred to 1 of the 3 study sites. Subjects who elected to undergo silicone metacarpophalangeal joint arthroplasty (SMPA) while continuing with medical management were followed in the SMPA cohort. Subjects who elected to continue with medical management alone without surgery were followed in the non-SMPA cohort. Objective measurements included grip and pinch strength as well as arc of motion, ulnar drift, and extensor lag of the MCP joints. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Radiographs of SMPA implants were assessed and graded as intact, deformed, or fractured. RESULTS MHQ scores showed large improvements post-SMPA, and baseline-adjusted expected outcomes in the SMPA group were significantly better at year 7 in function, aesthetics, satisfaction, and overall score compared to non-SMPA. SMPA subjects did not improve in grip or pinch strength, but achieved significant improvement and maintained the improvement long term in ulnar drift and extensor lag. CONCLUSION Benefits of the SMPA procedure are maintained over 7 years with low rates of implant fracture or deformity. Non-SMPA patients remained stable in their hand function over the 7-year study duration.
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Affiliation(s)
- Kevin C Chung
- The University of Michigan Medical School, Ann Arbor
| | | | | | - Frank D Burke
- Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK
| | - E F Shaw Wilgis
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - David A Fox
- The University of Michigan Medical School, Ann Arbor
| | - H Myra Kim
- The University of Michigan School of Public Health, Ann Arbor
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Zhang H, Xue D, Yu J. Is Swanson prosthesis better than Sutter prosthesis for metacarpophalangeal joint arthroplasty? A meta-analysis. J Plast Surg Hand Surg 2014; 49:45-51. [PMID: 25166510 DOI: 10.3109/2000656x.2014.942313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this meta-analysis is to compare the outcomes of the Swanson and Sutter prostheses (previously the Avanta prosthesis) used for metacarpophalangeal joint arthroplasty, and provide a powerful and rational conclusion regarding the use of prosthesis in MCP joint surgery. The literature search was based on PubMed, Cochrane Library, MEDLINE, EMBASE, and the Chinese National Knowledge Infrastructure. Data were evaluated using a generic evaluation tool designed by the Cochrane Bone, Joint, and Muscle Trauma Group and analysed using RevMan, version 5.0. Six randomised controlled trials were contained in this review, and five of them involving 143 patients were included in the meta-analysis. The results suggested that using the Sutter prosthesis could significantly decrease the rates of recurrence of drift when compared with the Swanson prosthesis for metacarpophalangeal joint arthroplasty (OR = 2.05, 95% Confidence interval (CI) = 1.31-3.20, p = 0.002). No significant difference in the outcomes of prosthesis fracture was found in two groups (OR = 1.07, 95% CI = 0.41-2.79, p = 0.88). Due to the limited data, the outcomes of range of motion, correction of ulnar deviation, pain, grip strength, and radiographic osteolytic changes could not be included in the meta-analyses. Theoretically, recurrence of drift was more common with Swanson prosthesis when compared with the Sutter prosthesis. No significant difference in the outcomes of prosthesis fracture was observed in two groups. More high-quality studies are required in long-term follow-up.
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Affiliation(s)
- Huahui Zhang
- Department of Plastic Surgery, The Second Affiliated Hospital of Medical College, Zhejiang University , Hangzhou , PR China
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The effect of swan neck and boutonniere deformities on the outcome of silicone metacarpophalangeal joint arthroplasty in rheumatoid arthritis. Plast Reconstr Surg 2013; 132:597-603. [PMID: 23985634 DOI: 10.1097/prs.0b013e31829ad1c1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rheumatoid arthritis patients with swan neck deformities are postulated to have greater metacarpophalangeal joint arc of motion because of their need to flex the joint to make a fist, whereas the boutonniere deformity places the fingers into the flexed position, creating less demand on the joint for grip. This study analyzes the effect of these deformities on the joint's arc of motion and hand function. METHODS The authors measured the metacarpophalangeal joint arc of motion in 73 surgical patients. Data were allocated into groups by finger and hand deformity. Linear regression models were used to analyze the effect of the deformity on the joint's arc of motion. Functional outcomes were measured by the Michigan Hand Outcomes Questionnaire and the Jebson-Taylor Test. RESULTS Nineteen fingers had boutonniere deformity, 95 had swan neck deformities, and 178 had no deformity. The no-deformity group had the least arc of motion at baseline (16 degrees) compared with the boutonniere (26 degrees) and swan neck (26 degrees) groups. Mean arc of motion in the no-deformity group compared with the boutonniere group at baseline was statistically significant, but all groups had similar arc of motion at long-term follow-up. Only mean Jebson-Taylor Test scores at baseline between the boutonniere and no-deformity groups were significantly different. CONCLUSIONS The results did not support the hypothesis that swan neck deformities have better arc of motion compared with boutonniere deformity. Boutonniere deformity has worse function at baseline, but there was no difference in function among groups at long-term follow-up.
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Tiihonen R, Honkanen PB, Belt EA, Ikävalko M, Skyttä ET. The Mean Seven Years' Results of the Use of Poly-L/D-Lactic Acid (PLDLA) Interposition Implant and Bone Packing in Revision Metacarpophalangeal Arthroplasty: A Prospective Cohort Study. Scand J Surg 2012; 101:265-70. [DOI: 10.1177/145749691210100408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Aims: Revision arthroplasty of metacarpophalangeal (MCP) joints in chronic inflammatory arthritis patients after silicone implants is challenging due of severe bone loss and soft tissue deficiencies. The aim of this study was to evaluate the outcome of revision MC Parthroplasty using poly-L/D-lactic acid 96:4 (PLDLA) interposition implant and morcelised allograft or autograft bone packing in patients with failed MCP arthroplasties and severe osteolysis. Material and Methods: The study group consisted of 15 patients (15 hands and 36 joints) at a mean follow-up of seven years (range 5–10 years). The radiographs were reviewed for osteolysis and incorporation of the grafted bone. The clinical assessments included active range of motion, evaluation of pain, subjective outcome and assessment of grip power. Results: PLDLA interposition arthroplasty combined with bone packing provided satisfactory pain relief, but function was limited. Radiographic analysis showed complete incorporation of the grafted bone to the diaphyseal portion of the host metacarpal and phalangeal bones in 30 of the 36 joints. All the patients had very limited grip strength, both on the operated and non-operated side. Conclusions: Due to soft tissue deficiencies long-term function and alignment problems can not be resolved with PLDLA interposition implant.
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Affiliation(s)
- R. Tiihonen
- Department of Orthopaedics, Päijät-Häme Central Hospital, Lahti, Finland
| | - P. B. Honkanen
- COXA Hospital for Joint Replacement, Tampere, Finland
- Centre for Rheumatic Diseases, Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - E. A. Belt
- Rheumatism Foundation Hospital, Heinola, Finland
| | - M. Ikävalko
- Rheumatism Foundation Hospital, Heinola, Finland
| | - E. T. Skyttä
- COXA Hospital for Joint Replacement, Tampere, Finland
- Centre for Rheumatic Diseases, Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
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Abstract
Rheumatoid metacarpophalangeal joint deformities remain an important cause of disability. Surgical intervention in carefully selected patients improves function and prolongs independence. This article discusses the commonly used reconstructive techniques and their benefits. Case selection through a combined clinic with rheumatologists and hand therapists is recommended.
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Acquired Diseases of the Hand (Rheumatoid Arthritis and Dupuytren's Contracture). Plast Reconstr Surg 2010. [DOI: 10.1007/978-1-84882-513-0_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tägil M, Geijer M, Malcus P, Kopylov P. Correlation between range of motion and implant fracture: a 5 year follow-up of 72 joints in 18 patients in a randomized study comparing Swanson and Avanta/Sutter MCP silicone prosthesis. J Hand Surg Eur Vol 2009; 34:743-7. [PMID: 19786405 DOI: 10.1177/1753193409346793] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Eighteen out of 18 rheumatoid patients (at one centre of a two-centre 30 patient study previously reported) with a mean age of 56 years, and 72/72 operated joints were randomized to Avanta/Sutter or Swanson MCP prostheses and followed for 5 years. Both ulnar deviation and extension lag were improved already at 6 weeks and remained improved at 5 years. The Avanta prosthesis had a better range of motion (ROM) than the Swanson. Six of nine patients with Avanta/Sutter implants had at least one implant fracture compared to 1/9 patients with the Swanson implant (P = 0.05) but fracture did not change the outcome subjectively. The ROM at 3 months correlated with the occurrence of an implant fracture at 5 years and a greater early ROM may be related to implant fracture. At 5 years patients remained satisfied and the deformities remained corrected.
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Affiliation(s)
- M Tägil
- Department of Orthopedics, Lund University Hospital, Lund, Sweden.
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Chung KC, Kotsis SV, Shaw Wilgis EF, Fox DA, Regan M, Kim HM, Burke FD. Outcomes of silicone arthroplasty for rheumatoid metacarpophalangeal joints stratified by fingers. J Hand Surg Am 2009; 34:1647-52. [PMID: 19896008 PMCID: PMC4413434 DOI: 10.1016/j.jhsa.2009.06.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 06/26/2009] [Accepted: 06/29/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE Previous studies have demonstrated that outcomes for the ulnar digits appear to be worse than those of the radial digits after silicone metacarpophalangeal joint arthroplasty (SMPA) for the rheumatoid hand. This study examines various components of hand deformities in an effort to understand SMPA outcomes in terms of metacarpophalangeal (MCP) joint range of motion and alignment. We hypothesize that the ulnar fingers will have less improvement, marked by greater ulnar drift, extension lag, and less MCP joint arc of motion than the radial fingers. METHODS Sixty-eight surgical patients were recruited from 3 sites in this multicenter, international prospective cohort study. All patients had a diagnosis of rheumatoid arthritis, were between the ages of 18 and 80, and were eligible to have SMPA based on measured hand deformities (extensor lag and ulnar drift). Ulnar drift, extension lag, and arc of motion for the MCP joint of each finger were measured at baseline (before surgery) and 1 year after SMPA. RESULTS All fingers showed an improvement in ulnar drift from baseline to 1 year after surgery. The smallest improvement was in the index finger, and the largest improvement was in the little finger. Similarly, the largest improvement in extension lag was seen in the little finger, and the smallest improvement was seen in the index finger. In terms of MCP joint arc of motion, all fingers moved to a more extended posture and gained an improved arc of motion, but the biggest improvement was observed in the 2 ulnar fingers and less in the 2 radial fingers. CONCLUSIONS Our hypothesis that the ulnar fingers would have worse outcomes than the radial fingers was not proven by this study. Although experiences have indicated that it is more difficult to maintain posture for the ring and little fingers after SMPA owing to the deforming forces, sufficient correction of the deformities in the ulnar fingers is possible, if adequate bone resection and realigning of the extensor mechanism are carefully performed during the procedure. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic I.
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Affiliation(s)
- Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System
| | - Sandra V. Kotsis
- Research Associate, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System
| | | | - David A. Fox
- Professor of Internal Medicine, Department of Internal Medicine, Division of Rheumatology, University of Michigan Health System
| | - Marian Regan
- Consultant in Rheumatology, Derbyshire Royal Infirmary
| | - H. Myra Kim
- Associate Research Scientist, Center for Statistical Consultation and Research, University of Michigan
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Abstract
Eleven fractured Sutter metacarpophalangeal prostheses were obtained from the hands of three patients. All of the implants had fractured at the junction of the distal stem and the hinge. After visual examination, the fracture faces were prepared and viewed using a scanning electron microscope. These images indicated that fracture was initiated by abrasion on the dorsal aspect of the distal stem of the prostheses, close to the hinge. Crack propagation was shown to be due to a fatigue process. Once a crack started, its direction of travel could be followed, using topographical features common to engineering fracture analyses. Propagation was from radial to ulnar and from dorsal to palmar.
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Affiliation(s)
- T J Joyce
- Centre for Rehabilitation and Engineering Studies, School of Mechanical and Systems Engineering, Newcastle University, Newcastle upon Tyne, UK.
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Bogoch ER, Escott BG, Judd MGP. Insufficient flexion of the metacarpophalangeal joint of the little finger following Swanson silicone arthroplasty for rheumatoid arthritis. Hand (N Y) 2008; 3:24-9. [PMID: 18780116 PMCID: PMC2528972 DOI: 10.1007/s11552-007-9051-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 05/10/2007] [Indexed: 11/28/2022]
Abstract
Twenty-one patients with rheumatoid arthritis who underwent Swanson metacarpophalangeal (MP) arthroplasty from 1994 to 1999 were assessed for active flexion of individual MP joints an average of 59 months (range 27-114 months) postoperative. Published articles of Swanson MP arthroplasty were reviewed. Experienced hand surgeons were surveyed regarding outcomes of metacarpophalangeal arthroplasty. The MP joint of the little finger displayed significantly less flexion than that of the middle and index finger. Seven of eight published studies which present active MP flexion by individual digit demonstrated less flexion in the little finger compared to the index, middle, and ring finger. Half of surgeons surveyed reported that MP range of motion is shifted toward a more extended position, that MP flexion is limited in the ulnar digits, and that an implant that encourages MP flexion would be helpful. Our experience with this cohort, a review of published literature, and a survey of international experts suggest that Swanson arthroplasty frequently results in a range of flexion of the MP joint of the little finger that may be insufficient for its principal functions.
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Affiliation(s)
- Earl R Bogoch
- Department of Surgery, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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