Thay khớp bàn-ngón tay (khớp đốt gốc, MCPJ) Thông tin In-depth Đồng ý

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• MCP joint arthroplasty was performed safely in the setting of acute complex open MCP joint trauma [1].
• Revision MCP arthroplasty is a challenging procedure with one in five patients requiring a revision procedure at 5 years [2].
• Revision MCP arthroplasty has a relatively high rate of postoperative dislocations [2].
• Dorsal capsule interposition arthroplasty provides a viable surgical option for isolated degenerative or traumatic arthritis of the MCPJ at an average follow-up of 2 years [3].
• Treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation [4].
• MCP joint arthroplasty is an effective treatment option from a patient-centered perspective, improving appearance, pain, and function [5].
• Silastic interposition arthroplasty of the MCPJ is reliable in terms of pain relief and correction of deformity [6].
• Patient satisfaction with Silastic interposition arthroplasty of the MCPJ is high despite only modest improvements in the objective assessment of hand function [6].
• The nonconstrained implant design for the MCP joint can have good outcomes and excellent arc of motion in OA patients [8].
• Periprosthetic joint infection is uncommon after MCP or PIP arthroplasties [9].
• Patient expectations of MCP joint arthroplasty were uniformly high, with functional improvement being the greatest motivation for surgery [11].
• Joint goal-setting is essential for understanding patients' unique reasons for undergoing MCP arthroplasty and facilitating realistic expectations [14].
• Implant arthroplasty of the PIP, MCP, and TMC joints predictably produces pain relief and high satisfaction [24].
• Implant arthroplasty of the PIP, MCP, and TMC joints has historically suffered from high rates of complications [24].
• The evidence regarding MCP arthroplasty for OA consists of retrospective cohorts with small sample sizes and relatively short evaluations [26].

Anatomy & Pathophysiology

Joint Mechanics and Kinematics

• The metacarpophalangeal joint allows hyperextension up to approximately 20° [17].
• Radial and ulnar deviation at the metacarpophalangeal joint decreases with flexion due to the associated tightening of the collateral ligaments [17].
• Volar and proximal translation of the proximal phalanx is observed on 4-dimensional computed tomography following silicone implant arthroplasty [48].

Bony and Ligamentous Anatomy

• The metacarpophalangeal articulations serve as the keystones of the longitudinal arches of the hand [39].
• The thick anterior glenoid capsules, known as volar plates, prevent hyperextension at the metacarpophalangeal joints [39].
• The volar plates are interconnected by the transverse interglenoid ligament [39].
• The stability of the metacarpophalangeal joints is essential to the support of both the longitudinal arch and the transverse metacarpal arch [39].
• The deep transverse intermetacarpal ligament, also named the interglenoid ligament, ties together the anterior glenoid ligaments of the metacarpophalangeal articulations [39].
• The lateral accessory ligaments, sagittal bands of the extensor apparatus, and the first annular segment of the flexor tendon pulley insert on the volar plate [39].

Muscular Anatomy

• The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint [36].
• The deep head of the dorsal interosseous muscles flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [36].
• Transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [36].
• Oblique fibers from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx [36].
• The oblique fibers extend the middle phalanx at the proximal interphalangeal joint [36].
• The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [36].
• The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon [36].
• The terminal tendon inserts at the base of the distal phalanx to extend it [36].
• The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [36].
• The flexor digiti quinti brevis forms the ulnar lateral band of the little finger [36].

Pathophysiology

• Rheumatoid arthritis is a chronic, progressive, systemic inflammatory disease that affects multiple organ systems, including the musculoskeletal system [17].
• The inflammatory process in rheumatoid arthritis is triggered and perpetuated by a cascade of mediators that result in synovial proliferation, collagenous destruction of the cartilage and soft tissues, and bone resorption [17].
• The metacarpophalangeal joint is the most common site of involvement in the rheumatoid hand [17].
• The metacarpophalangeal and proximal interphalangeal joints of the hand are typically involved early in rheumatoid arthritis [17].

Classification

• Silicone rubber implants are the most frequently used device for treatment of revised metacarpophalangeal arthroplasty [17].
• The nonconstrained implant design for the MCP joint can have good outcomes and excellent arc of motion in osteoarthritis patients [8].
• Pyrocarbon implants were designed as a resurfacing implant for the MCP joint [28].
• A radiographic classification system was modified to differentiate stable implant migration patterns (grade 2) from unstable patterns (grade 3) based on cortical breach status [28].
• In a radiographic analysis of 37 pyrocarbon arthroplasties, 34 (92%) were determined to be stable at last follow-up [28].
• Three (7%) pyrocarbon implants became unstable from migration, all involving grade 3 implant loosening [28].
• Evidence of implant subsidence greater than 1 mm occurred in 6 (16%) of 37 pyrocarbon implants [28].
• Postoperative ulnar deviation greater than 10° occurred in 8 (22%) fingers following pyrocarbon arthroplasty [28].
• Implant fractures in silicone MCP arthroplasty are determined based on criteria including lucent lines, fragmentation, translation greater than one-half the diameter of the bone, and dislocation defined as proximodistal overlap more than one-half the width of the midportion of the implant [20].
• Coronal plane deviation greater than 45° is an additional criterion for determining implant fracture or instability in silicone MCP arthroplasty [20].

Clinical Presentation

Indications and Etiology

• Metacarpophalangeal joint arthroplasty is most often performed in patients with rheumatoid arthritis, although it is occasionally performed for joints affected by osteoarthritis [17].
• Dorsal capsule interpositional arthroplasty provides a viable surgical option for isolated degenerative or traumatic arthritis of the MCPJ [3].
• Metacarpophalangeal joint arthroplasty continues to play a central role in the management of the rheumatoid hand [15].

Patient Expectations and Motivation

Functional Outcomes and Range of Motion

• Silastic interposition arthroplasty of the MCPJ is reliable in terms of pain relief and correction of deformity, and patient satisfaction is high despite only modest improvements in the objective assessment of hand function [6].
• Pain ratings and MCP arc of motion significantly improved following arthroplasty for noninflammatory arthritis [10].
• Implant arthroplasty of the PIP, MCP, and TMC joints predictably produces pain relief and high satisfaction but has historically suffered from high rates of complications [24].
• This study showed improved range of motion and DASH score, excellent pain relief, and excellent patient satisfaction in patients undergoing MCP arthroplasty for nonrheumatic arthritis [30].
• 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 [19].

Complications and Complications Management

• Revision MCP arthroplasty is a challenging procedure with one in five patients requiring a revision procedure at 5 years and a relatively high rate of postoperative dislocations [2].
• The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation [4].
• Increasing MCP joint flexion range was associated with increased fractures of the implants in silicone metacarpophalangeal joint arthroplasty for patients with rheumatoid arthritis [7].
• If squeaking is associated with pain and swelling, revision MCP joint arthroplasty is recommended to identify and correct the underlying cause, such as implant subsidence or an incongruous joint [53].
• An articulating spacer allows movement of the joint and reduces the chance of immobilisation associated complications such as bone loss, joint stiffness, and soft tissue contracture in the management of infected MCPJ arthroplasties [13].

Investigations

• A careful physical examination is essential to direct care and future testing if indicated [27].
• Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [27].

Treatment

Indications and Patient Expectations

• MCP joint arthroplasty is most often performed in patients with rheumatoid arthritis, though it is occasionally performed for osteoarthritis [17].
• The MCP joint is the most common site of involvement in the rheumatoid hand [17].
• MCP joint arthroplasty continues to play a central role in the management of the rheumatoid hand [15].
• Given improvements in the medical management of rheumatoid disease, the indications for and long-term expectations of silicone metacarpophalangeal arthroplasty must be carefully examined [50].

Implant Types and Outcomes

• Both NeuFlex and Swanson implant groups obtained satisfactory clinical improvement after MCP reconstruction of the hand [12].
• Pain ratings and MCP arc of motion significantly improved following surface replacement arthroplasty in metacarpophalangeal joints affected by noninflammatory arthritis [10].
• Good pain relief, a functional range of motion, and high satisfaction were seen in the majority of patients undergoing pyrocarbon metacarpophalangeal joint arthroplasty for noninflammatory arthritis [31].
• Silicone arthroplasty for nonrheumatic metacarpophalangeal joint arthritis showed improved range of motion and DASH score, excellent pain relief, and excellent patient satisfaction [30].
• Follow-up studies show that MCP arthroplasty improves function and deformity and achieves nearly uniform patient satisfaction [17].

Alternative Techniques

• Limited clinical follow-up in a perichondrium transplant group showed reasonably good, and in some cases excellent, results several decades after the surgery, especially at the MCP level [16].
• Arthrodesis has been the gold standard in treating isolated end-stage MP arthritis, whether inflammatory or post-traumatic arthropathies [32].
• Arthrodesis is able to provide effective pain relief as well as restore stability to the joint, even in the setting of severe arthritis [32].
• The key to why MP fusion in the thumb is so successful lies in the relatively negligible loss of motion that results from MP fusion [32].
• By fusing the MP joint between 20 and 40° of flexion, stress can be relieved from the CMC joint by minimizing the activity required at the CMC for thumb opposition [32].

Complications and Revision

• Metallosis is a potential long-term complication of grommets in silicone MCP joint arthroplasty, and given the lack of documented benefit from grommets, the authors recommend against their use [52].
• Static spacers with consequent immobilisation can lead to bone loss, joint stiffness and soft tissue contracture, often causing significant complications at reimplantation [13].
• An articulating spacer allows movement of the joint and reduces the chance of immobilisation associated complications [13].
• An articulated spacer technique can be considered as an option to maintain motion while treating infected MCPJ arthroplasties and the co-morbidity resulting from immobilisation of the whole hand [13].

Specific Clinical Scenarios

Complications

Dislocation and Instability

• Revision MCP arthroplasty is associated with a relatively high rate of postoperative dislocations [2].
• Treatment of acute MCP joint arthroplasty dislocation with revision to a silicone implant appears to hold the most promise in achieving a stable MCP joint [4].
• In a cohort of 37 cases, acute prosthetic dislocation was managed with revision surgery [4].

Implant Fracture and Failure

• One in five patients undergoing revision MCP arthroplasty required a revision procedure at 5 years [2].
• Increasing MCP joint flexion range was associated with increased fractures of silicone implants in patients with rheumatoid arthritis [7].
• In a longitudinal analysis of 325 cases, implant fractures were determined based on criteria including lucent lines, fragmentation, translation greater than one-half the diameter of the bone, and dislocation defined as proximodistal overlap more than one-half the width of the midportion of the implant [20].
• In a study of 40 silicone implants for MCP osteoarthritis, radiographs demonstrated fractured implants in 5 of 40 (12.5%) implants, although none of these patients had clinical instability, pain, or deterioration in range of motion [33].
• For the Neuflex silicone implant, survivorship at 7 years was 88% when revision was the end point, but dropped to 68% when implant fracture was the end point [56].
• In a study of pyrocarbon arthroplasty for rheumatoid arthritis, complication and overall reoperation rates were high, with 1 in 10 patients undergoing revision within 5 years postoperatively [57].
• Patients with greater hand function preoperatively may be at higher risk of revision surgery after silicone MCP arthroplasty for inflammatory arthritis [18].

Infection

• Periprosthetic joint infection (PJI) is uncommon after MCP or PIP arthroplasties [9].
• Management of infected MCP joint replacements can involve removing the prosthesis and inserting gentamycin-loaded bone cement balls for 3 weeks before a final exchange operation [13].
• Static spacers used in MCPJ infection management can lead to bone loss, joint stiffness, and soft tissue contracture, often causing significant complications at reimplantation [13].
• An articulating spacer allows movement of the joint and reduces the chance of immobilization-associated complications compared to static spacers [13].

Other Complications

• Intraoperative periprosthetic fractures are associated with metacarpophalangeal joint arthroplasty [21].
• Swanson arthroplasty frequently results in a range of flexion of the MCP joint of the little finger that may be insufficient for its principal functions [19].
• In a study of pyrocarbon arthroplasty for osteoarthritis, postoperative ulnar deviation greater than 10° occurred in 8 (22%) fingers [28].
• In a study of pyrocarbon arthroplasty for osteoarthritis, 3 (7%) implants became unstable from migration, all with grade 3 implant loosening [28].
• Evidence of implant subsidence greater than 1 mm occurred in 6 (16%) of 37 pyrocarbon implants, but no implants studied at more than 1 year after surgery demonstrated progressive subsidence resulting in implant instability [28].
• Implant arthroplasty of the MCP joint has historically suffered from high rates of complications [24].

Recovery

Functional Outcomes and Patient Satisfaction

• MCP joint arthroplasty improves appearance, pain, and function from a patient-centered perspective [5].
• Silastic interposition arthroplasty of the MCPJ is reliable for pain relief and correction of deformity [6].
• Patient satisfaction is high following Silastic interposition arthroplasty despite only modest improvements in the objective assessment of hand function [6].
• The HAPY spherical pyrocarbon interposition arthroplasty for the metacarpophalangeal joint demonstrates satisfactory short- to mid-term outcomes with considerable improvements in pain relief and joint mobility [59].

Complications and Revision

Patient Expectations and Indications

Specialized Scenarios

Key Evidence

• [L4] MCP joint arthroplasty was performed safely in the setting of acute complex open MCP joint trauma. [1] (10.1016/j.jhsa.2015.09.012)
• [L4] Revision MCP arthroplasty is a challenging procedure with one in five patients requiring a revision procedure at 5 years and a relatively high rate of postoperative dislocations. [2] (10.5435/jaaos-d-17-00042)
• [L4] This technique of dorsal capsule interposition arthroplasty provides a viable surgical option for isolated degenerative or traumatic arthritis of the MCPJ at an average follow-up of 2 years. [3] (10.1177/1558944720911215)
• [L4] The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation. [4] (10.1016/j.jhsa.2017.10.001)
• [L4] MCP joint arthroplasty is an effective treatment option from a patient-centered perspective, improving appearance, pain, and function. [5] (10.1016/j.hcl.2006.02.001)
• [L4] Silastic interposition arthroplasty of the MCPJ is reliable in terms of pain relief and correction of deformity, and patient satisfaction is high despite only modest improvements in the objective assessment of hand function. [6] (10.1054/jhsb.2000.0402)
• [L4] Increasing MCP joint flexion range was associated with increased fractures of the implants. [7] (10.1016/j.jhsa.2020.09.002)
• [L5] The nonconstrained implant design for the MCP joint can have good outcomes and excellent arc of motion in OA patients. [8] (10.1016/j.jhsa.2012.11.025)
• [L4] PJI is uncommon after MCP or PIP arthroplasties. [9] (10.1016/j.jhsa.2024.12.008)
• [L4] Pain ratings and MCP arc of motion significantly improved following arthroplasty. [10] (10.1177/15589447211028917)
• [L1] Patient expectations of MCP joint arthroplasty were uniformly high, with functional improvement being the greatest motivation for surgery. [11] (10.1016/j.jhsa.2011.02.002)
• [L1] Both implant groups obtained satisfactory clinical improvement after MCP reconstruction of the hand. [12] (10.1016/j.jhsa.2009.09.020)
• [L5] [13] (10.1177/17531934251323067)
• [L4] Joint goal-setting is essential for understanding patients' unique reasons for undergoing MCP arthroplasty and facilitating realistic expectations. [14] (10.1002/msc.1061)
• [L5] Metacarpophalangeal joint arthroplasty continues to play a central role in the management of the rheumatoid hand. [15] (10.1177/17531934261430139)
• [L3] [16] (10.1186/s12891-020-03687-3)
• [L5] [17] (10.5435/00124635-200305000-00005)
• [L3] Patients with greater hand function preoperatively may be at higher risk of revision surgery. [18] (10.1177/1558944719831236)
• [L4] 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. [19] (10.1007/s11552-007-9051-5)
• [L4] [20] (10.1177/1753193418778461)
• [L3] [21] (10.1016/j.jhsa.2014.12.038)
• [L4] Implant arthroplasty of the PIP, MCP, and TMC joints predictably produces pain relief and high satisfaction but has historically suffered from high rates of complications. [24] (10.1016/j.jhsa.2017.07.030)
• [L4] The evidence regarding MCP arthroplasty for OA consists of retrospective cohorts with small sample sizes and relatively short evaluations. [26] (10.1016/j.jhsa.2015.05.019)
• [L4] [28] (10.1016/j.jhsa.2022.08.013)
• [L3] This study showed improved range of motion and DASH score, excellent pain relief, and excellent patient satisfaction in patients undergoing MCP arthroplasty for nonrheumatic arthritis. [30] (10.1016/j.jhsa.2013.09.016)
• [L4] Good pain relief, a functional range of motion, and high satisfaction were seen in the majority of patients. [31] (10.1016/j.jhsa.2015.06.104)
• [L5] [32] (10.1016/j.hcl.2006.02.010)
• [L4] [33] (10.1016/j.jhsa.2017.10.010)
• [L4] Volar and proximal translation of the proximal phalange was observed on 4-dimensional computed tomography. [48] (10.1016/j.jhsa.2021.10.001)
• [L4] 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. [50] (10.2106/00004623-200310000-00001)
• [Case_report] Metallosis is a potential long-term complication of grommets in silicone MCP joint arthroplasty, and given the lack of documented benefit from grommets, the authors recommend against their use. [52] (10.1007/s11552-012-9401-9)
• [L5] If squeaking is associated with pain and swelling, revision MCP joint arthroplasty is recommended to identify and correct the underlying cause, such as implant subsidence or an incongruous joint. [53] (10.1016/j.jhsg.2022.10.002)
• [L4] [56] (10.1177/1753193408094437)
• [L4] Complication and overall reoperation rates were high, while 1 in 10 undergo revision within 5 years postoperatively. [57] (10.1177/15589447211063577)
• [L4] The HAPY spherical pyrocarbon interposition arthroplasty for the metacarpophalangeal joint demonstrates satisfactory short- to mid-term outcomes, with considerable improvements in pain relief and joint mobility. [59] (10.1016/j.jhsg.2025.100804)

References

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