6.1.1 The Era of Zeus and His Fellow Gods

The human dream of replacing a destroyed joint is as old as Greek mythology and depicted through the legend of “The Ivory Shoulder”: Tantalus, king at Mount Sipylus in Anatolia, cut his son Pelops into pieces, made his flesh into a stew, and served it to the gods on Olympus to test their omniscience. The gods perceived the deception and left the meal untouched. Only Demeter, deep in grief after the abduction of her daughter Persephone, absentmindedly accepted the offering and ate the left shoulder. Zeus, the father of the gods, commanded Hermes, who could freely move between the worlds of mortal and divine and was the conductor of souls into the afterlife, to put the remaining pieces of Pelops in a cauldron. As one of the Three Fates who spin the thread of life, Clotho assisted Hermes in bringing Pelops back to life. Demeter replaced the missing shoulder with a chunk of ivory, ¹ a material used in the modern age by Themistocles Gluck for the first total wrist implant in 1890.

6.1.2 Amputation—Upper Paleolithic to the Middle Ages

Before the 19th century, amputation of an infected limb was the surgical treatment of choice to save the human body from septicemia and death. It is one of the oldest surgical procedures. In the caves of Gargas in south-western France, several negative imprints from the Upper Paleolithic period—about 22,000 to 25,000 years BP—show mutilated hands with a loss of some or all fingers. Almost all possible combinations occur, including part or total loss of a thumb. From the knowledge of more modern practices among various tribes, one can assume that these French paintings represent a form of mutilation carried out for ritual or religious purposes. Yet other more natural events including trauma, frostbite, leprosy, and Raynaud’s phenomenon can contribute to such imprints of hands and amputated fingers that have also been found on other continents of the world. ²

During the Islamic Golden Age, the most common reason for amputation was punishment for crimes. Consequently, some patients refused amputation for medical reasons because it would identify them as criminals. The first artificial hand replacement dates from the Egyptian and Roman times; an Egyptian cosmetic hand was found on a mummy dating from 200 BC, and the Roman general Marcus Sergius (167 BC) lost his right hand and used an artificial metal one with which he continued to fight in battle. ²

6.2.1 Resection Arthroplasty

In 1536, the first attempt to excise a joint while maintaining the distal part of the limb so as to restore motion at the level of the former joint was recorded. This intervention is accredited to a barber who served in the French military, Ambroise Paré. Known as the founder of French surgery, he resected an elbow joint of a patient with a destructive infection. ³

Two centuries later, a German surgeon, Johann Ulrich Beyer, serving in the Prussian army documented the first wrist resection for the musketeer, Adam Kilian, who sustained a severe crush trauma caused by a howitzer. Despite fulminant infection and severe blood loss, “complete recovery” was achieved four months later; the final outcome was a natural-looking, nonfunctional hand. ⁴

At the end of the 18th century, Victor Moreau and his son, two surgeons from Bar-le-Duc in France, reported their experiences with joint resections to the “Académie Royale de Chirurgie” and published a book describing their technique. However, they did not receive credit for their contribution to wrist arthroplasty. ⁵

A common dream of surgeons from the earlier days was to make a stiff joint movable and painless by means of an arthroplasty technique. John Rhea Barton is often credited with having performed the first resection arthroplasty in Lancaster, Pennsylvania in 1826. His observations that pseudarthrosis of long bones were often painless inspired him to create an artificial pseudarthrosis in the proximal femur, which may provide a limited degree of controlled hip movement. In seven minutes and without the benefit of modern anesthesia, he performed a subtrochanteric osteotomy just above the level of the lesser trochanter. The wound was left open to develop the expected postoperative infection and early mobilization was enforced. ⁶

After introducing the foundations of modern surgery in the 19th century—namely, anesthesia and Lister’s concept of aseptic surgery in 1888—an explosive development in surgery took place in Europe and the United States. ⁶ Surgeons including Kocher, Lister, von Langenbeck, and Ollier all followed Barton’s concept of early mobilization after joint resection. Von Langenbeck recommended the technique of subperiosteal dissection to ensure that some degree of bone restoration might occur. ⁷

6.2.2 Interposition Arthroplasty

Interposing material between the resected joint was a logical progression from the simple resection procedures. It is accredited to John Murray Carnochan of New York, who described the interposition of a small block of wood after resecting the mandibular neck to mobilize an ankylosed jaw in 1840. Twenty years later, Aristide Verneuil, a French surgeon, used soft parts for interposition, initially using muscle followed by adipose tissue and fascia. ⁶ Adipose tissue interposition was soon discarded because of its rapid absorption. By the end of the 19th century, a plethora of materials was tested and used: skin, glass, pig’s bladder, celluloid, rubber, magnesium, and gold foil. In 1894, Péan, recognizing the reactivity of human tissues, used platinum plates as interpositional material in human joints including the wrist. Murphy widely advocated the use of fascia lata for interposition arthroplasties of the hip and knee from 1902; he performed his first wrist interposition arthroplasty after 1910. This method found widespread use in Europe at the beginning of the 20th century. ³

6.2.3 The First Total Knee and Wrist Replacement—Themistocles Gluck (1853–1942)

Themistocles Gluck was born in Jassy, Romania in 1853, the son of a famous German doctor who was the attending physician to the royal family. In 1873, Gluck began his preclinical medical studies in Leipzig and continued in Berlin, where Virchow and von Langenbeck were among his teachers. He was von Langenbeck’s last assistant; he received the title of university professor in 1883. Upon von Langenbeck’s retirement, Gluck did not receive a position to continue his university career and so worked as an industrial physician in Berlin until 1890, when he was appointed as head of surgery at the Kaiser- und Kaiserin-Friedrich-Kinderkrankenhaus in Berlin.

His early work concentrated on using guide rails for tissue regeneration following nerve and tendon replacement. He was interested in the field of tissue transplantation. After experimenting with autologous transplantation and heterologous transplants in animals, he began to work with foreign materials. He successfully bridged tendon, muscle, and bone defects by interposing silk and catgut suture bundles, and named the resulting fibrous tissue formation “autoplastic.” During his services as a doctor in the two Balkan Wars of 1877 and 1885, Gluck used nickel-coated steel plates and screws for internal fracture fixation. After performing animal experiments with inserts of aluminum, wood, glass, celluloid, and steel, he decided that ivory was the most suitable material for implantation because it would be incorporated into bone with minimal inflammatory response. He began using ivory intramedullary pegs and intramedullary nails for fracture fixation. Gluck rapidly developed models for the total replacement of shoulder, elbow, hand, and knee joints. More than 65 years before Sir John Charnley, he already used bone cement and experimented with a variety of substances including copper amalgam, plaster of Paris, and putty materials (i.e., resin with pumice stone or gypsum), which hardened rapidly after mixing.

On 20 May 1890, Gluck performed his first ivory total knee replacement, which was followed by a total wrist replacement three weeks later on 9 June 1890 (Fig. 6.1). Overall, he completed four total arthroplasties (three knees and one wrist) in septic joints affected by tuberculosis. Although the short-term results were strikingly successful, all ultimately failed due to chronic infection.

Gluck intended to present his implant arthroplasties to the International Medical Congress in 1890. For this purpose, he prepared a skeleton with several implants at the hip, shoulder, elbow, wrist, and knee, which became well-known as the “skeleton of Paris.” A former superior, von Bergmann, refused Gluck’s participation at the congress and in preventing his lecture wrote: “As the leader of German surgery I cannot allow that you discredit German science in front of a platform of international surgical specialists. My pupils and I will fight you with all means.” ³ Finally, only the “skeleton of Paris” was exhibited and Gluck stopped his work on joint replacement.

In his later years, Gluck was honored for his work. In 1921, he reported on the good long-term outcome of his implants at the 45th German Society for Surgery annual meeting. If his first implants had not been used to treat tuberculous joints, the humiliation of 1891 might not have occurred. However, his rationale was that these joints were completely destroyed by tuberculosis and there was nothing to lose by his experimental surgery. In 1922, he was made an “extraordinary professor” and in 1930, at the age of 77, was invited to join the honor roll of the German Surgical Society. Themistocles Gluck died in Berlin aged nearly 90 on 25 April 1942. ⁸

6.2.4 The Concept of Flexible Implant Arthroplasty—Alfred B. Swanson (1923–2016)

Alfred Bertil Swanson, the son of Swedish parents, was born in 1923 in Wisconsin, USA. He graduated from the University of Illinois medical school in 1947 and subsequently underwent orthopaedic training at Illinois, Northwestern, and Indiana universities. Starting his career at the time of the thalidomide disaster and the great polio epidemic, Swanson was interested in treating children with polio, cerebral palsy, congenital limb differences, and arthritic deformities of the hand. He became Professor of Surgery at Michigan State University and served three terms between 1963 and 1978 as Chief of Staff at the Mary Free Rehabilitation Hospital. As a member of numerous national and international societies, he presented lectures and surgical demonstrations worldwide. He authored more than 300 publications, many of them together with his wife, Geneviève de Groot Swanson. He was President of the American Society for Surgery of the Hand (1979–1980), and Secretary General (1976–1983), President (1983–1989), and Historian (1990–2003) of the International Federation of Societies for Surgery of the Hand (IFSSH). Swanson died at the age of 93 in 2016.

By applying silicone as an internal pad for below-knee amputations, Swanson discovered that this material would be suitable for joint arthroplasty. ⁹ In 1962, he introduced the concept of flexible implants for the reconstruction of small joints of the extremities and performed the first ever biocompatibility studies of silicone in bone. The Swanson one-piece implant comprises an intramedullary stem on either side bridged by a hinge. The inherent flexibility of the silicone elastomer allows flexion and extension at the hinge of the implant and provides a dampening effect on the bone. The implant is stiff enough to maintain joint alignment after bony resection and soft tissue balancing. Silicone implants have been machine tested for more than 130 million cycles without evidence of breakdown. ⁹ Swanson described two processes that occur with implantation and theoretically enhance implant performance. The first process is “encapsulation” or development of a fibrous joint capsule surrounding the implant, which enhances joint stability. The second process is the “piston effect” or the gliding motion of the stems within the medullary canals during joint flexion and extension. Theoretically, the piston effect increases the lifespan of the implant because forces are dispersed over a broad area of the implant. Gliding also allows a greater range of motion (ROM). ¹⁰ The original Swanson implant was made from a heat-vulcanized, medical-grade silicone elastomer stock. Swanson’s silicone elastomer implant fulfilled most of his criteria for an ideal joint replacement: maintenance of joint space, preservation of stable joint motion, simple and efficient design, simple and durable fixation, resistance to stress and deterioration, biologically and mechanically acceptable to host, ease of manufacturing and sterilization, and facilitating rehabilitation. ⁹

Swanson’s concepts of a nonrigid prosthesis and the development of silicone elastomer, titanium, and other implants for small joint reconstruction revolutionized the surgical treatment of the arthritic hand, upper extremity, and forefoot. His work has benefited millions of arthritis sufferers worldwide and the finger joint silicone implant remains the golden standard of care more than 50 years later.

6.3.1 First Generation: Elastomer Flexible Hinge Design

The Swanson implant was the first commonly used wrist prosthesis developed in 1967. It is a double-stemmed, flexible hinge silicone prosthesis, which acts as a spacer between the hand and forearm and allows some motion (Fig. 6.2). Following the concepts of “encapsulation” and the “piston effect,” the implant was not intended for bone fixation, but to allow motion between the implant and bone, and over time, fibrous tissue would form around the wrist joint. A proximal row carpectomy including the distal edge of the capitate and removal of the distal radius and ulnar head was performed to create space for the barrel-shaped midsection of the implant. The core of the implant was reinforced with Dacron (polyethylene terephthalate [PET]) to provide axial stability and resistance to rotational force. In 1974, the original silicone rubber was changed to a high-performance silicone elastomer that is more biocompatible and resistant to wear and fatigue. There have been several updates of the initial design to address breakage and wear, which include the application of titanium grommets in 1982 to protect the elastomer from rubbing against sharp bone. Swanson reported good pain relief, an acceptable ROM (34-degree flexion, 26-degree extension, 10-degree radial, and 18-degree ulnar deviation), a significant improvement in grip strength, and a relatively low complication rate in 181 wrists with a mean follow-up of 4 (range 0.5–10) years; 25 wrists were revised and 3 wrists were converted to arthrodesis. ¹² These results have been difficult to reproduce by other working groups, and high complication rates for fracture, destructive silicone synovitis, persistent pain, and extensor tendon imbalance have been reported. ¹³ Prosthetic fracture occurs in up to 50% of patients, usually at the junction of the distal stem and barrel, although the incidence has decreased with the addition of metal grommets. ¹⁴ The reported incidence of silicone synovitis is 30%. ¹⁵

6.3.2 Second Generation: Multicomponent Implants

In the 1970s, a second generation of hard-bearing multicomponent implants was introduced. There is no consensus on the definition of this implant type, although they generally consist of a radial component and a carpal component that is fixed to one or more metacarpal bones. Most of these implants are no longer available on the market because of unsatisfactory long-term results and the associated adverse events of loosening, soft tissue imbalance and dislocation.

Ball-and-Socket Designs

Meuli/MWP III

H. C. Meuli from Berne, Switzerland introduced his original prosthesis in 1972, an unconstrained reversed ball-and-socket implant. The proximal and distal metal components had two pliable prongs for cement fixation in the radius and metacarpal bones, respectively. The initial head on the proximal component was made of polyester, which resulted in marked tissue reactions in some of the first patients. It was abandoned in favor of high-molecular-weight polyethylene (HMWPE). Additionally, the center of rotation was too far radial, which resulted in significant ulnar deviation. The prosthetic design was modified in 1978 with a slightly volar and ulnar offset to the axis. ¹⁶ To adjust for problems with stability and imbalance, the Meuli 3rd generation implant (MWP III) was released in 1986 Fig. 6.3. The prosthesis was made from a titanium alloy with a corundum, rough-blasted surface for implantation using either cement or a press-fit technique. The nitride-coated ball was fixed to the proximal component and articulated with a relatively deep ultra-HMWPE (UHMWPE) socket distally. The anchoring prongs of the carpal component were angled 15 degree dorsal to the median axis. Meuli published satisfactory clinical results of 38 MWP III implants with a mean follow-up of 5.5 (range 3–9.5) years, but a revision rate of 30%. ¹⁷ The working group of Cooney revised 53 of 140 Meuli wrist implants as a result of dislocation, implant loosening, soft tissue deformity, median nerve compression, tendon rupture, and hematomas. ¹⁸

Elos/Gibbon/Motec

A. Reigstad and colleagues developed the Elos prosthesis, a modular ball-and-socket wrist implant in the late 1990s. ¹⁹ Despite the ball-and-socket design and long metacarpal stem, the Motec implant should, in fact, be considered as an implant of the third generation, and will be discussed in further detail later in Chapter 26.

Constrained Designs

Figgie/Trispherical

H. E. Figgie III and colleagues developed the only fully constrained wrist prosthesis in 1977. The trispherical implant has metacarpal and radial components articulating with a HMWPE bearing and an axle restraint. The axle prevents dislocation, but does not absorb the load produced under normal activities of daily living. ²⁰ Long-term results have been documented in 34 patients with rheumatoid arthritis (RA) at a mean follow-up of 9 (range 5–11) years. ²¹ Twenty-eight wrists were rated as good to excellent. The mean arc of flexion and extension improved from 35 to 50 degree. There were no deep infections or dislocations. Two wrists both required the removal of the implant and conversion to an arthrodesis, one for loosening and the other due to persistent pain. Postoperative tendon attrition occurred in six wrists, all of which had preoperative tendon ruptures necessitating tendon transfer. Radiographs showed radiolucency in seven wrists including seven around the metacarpal stem and one around the radial stem. ²¹ Lorei et al reported a 9% (8 implants) revision rate at a mean of 8.7 (range 3–18) years for 87 trispherical total wrist implants ²² ; the primary complications were loosening, attritional rupture of extensor tendons and late sepsis. Five patients underwent implant removal and arthrodesis, two revision arthroplasty, and the last a resection arthroplasty.

Volz/Arizona Medical Center

R. G. Volz was inspired by the success of Charnley’s low friction concept in hip arthroplasty using metal articulating with polyethylene and bone fixation with methyl methacrylate cement. In 1973, he designed a semiconstrained cemented wrist implant at the Arizona Medical Center based on these concepts (Fig. 6.4). The implant had a hemispherical design with radii of two different dimensions to achieve motion in two planes without rotation, whilst providing 90-degree flexion/extension and 50-degree radial/ulnar deviation. The depth of the metal on polyethylene interface was designed to provide sufficient stability, especially to distraction forces. Proximal and distal component cementation further enhanced prosthesis stability. ²³ Wrist imbalance was the main cause of poorer results with the double-prong metacarpal component, which was later modified to a single-prong counterpart. Long-term review at a mean of 8.6 (range 3.5–12.5) years in patients mostly with RA demonstrated pain relief in 83 to 86% with a flexion/extension arc of 49 degree and a radial/ulnar deviation arc of 25 degree. Metacarpal loosening was noted in 22%, a loss in carpal height in 24% and radial loosening in 6%. ²⁴ Bone resorption under the collar of the radial component occurred in 79%. ²⁵

Convex–Concave Ellipsoidal Component Designs

Biaxial

The Biaxial implant was developed by and used at the Mayo Clinic since the early 1980s. It has a cobalt-chrome (CoCr) alloy metacarpal component with an ellipsoidal-shaped head articulating against a UHMWPE bearing surface attached to the metal radial component. The long stem of the metacarpal component is inserted into the middle finger metacarpal, and a small stud that fits into the trapezoid bone provides additional stability and fixation. Cement is used to fix the metacarpal and radial stems into position, but press-fit fixation is possible. The proximal surfaces of the implant also have a porous coating for enhanced stress distribution at the cement fixation interface. ²⁶

Cobb and Beckenbaugh performed a retrospective review of 46 patients with RA treated with the Biaxial implant with a mean follow-up of 6.5 (range 5–9.9) years. The authors reported significant improvements in pain, ROM (extension and radial deviation), and grip strength. While the Biaxial total wrist prosthesis had an overall 5-year survival of 83% (67% without cement), there was radiographic loosening in 22% with subsequent revision in eight cases. ²⁶ A systematic literature review showed that 22 (8%) of 278 Biaxial implants in seven patient series were reported to have dislocated. ²⁷ A retrospective review of 32 Biaxial total wrist implants found a survival rate of 81% after 7 years. ²⁸ Thirty-one complications were noted and 22 wrists showed signs of radiographic loosening. Overall, ROM improved with the exception of pronation, and both the mean pain and DASH scores improved.

Guépar/Horus

The Guépar was developed by Y. Alnot in Paris, France in 1979. The radial component is made entirely of UHMWPE and is cemented into the radius. The carpal component has a metal plate that is fixed by two screws into the index and middle finger metacarpals. An egg-shaped CoCr alloy–bearing surface is then fitted over the plate and secured with a small screw. The distal radius and ulna are resected and a straight cutting plane is prepared at the level of the proximal capitate. ²⁹

In a retrospective follow-up of 72 wrists with a mean follow-up of 4 (range 1–10) years, 11 wrists underwent revision due to loosening of the small screw and proximal components. Osteolysis and bone resorption was noted under the carpal plate, which increased with time. ²⁹ A redesigned version of the implant is marketed as the Horus total wrist prosthesis since 2009.

Universal

The Universal wrist implant, developed by J. Menon, is an unconstrained arthroplasty with titanium radial and carpal components. The concave articular surface of the radial component has a 20-degree inclination with a Y-shaped stem surrounded by a titanium mesh for bone ingrowth. The component can be inserted with or without bone cement. With this particular implant, almost 95% of the capitate is preserved along with part of the scaphoid and triquetrum. Primary fixation of the carpal plate is in the capitate and not in the medullary canal of the middle finger metacarpal. The carpal component is ovoid with three holes in the carpal plate for screw fixation into the carpal/metacarpal bones. A convex toroid-shaped HMWPE inlay slides over the carpal plate and is locked in place by a locking pin. The surgical technique involves an intercarpal arthrodesis at the level of the distal carpal resection through the proximal pole of the capitate, including the distal scaphoid, resection of the ulnar head, and an inclined resection of the distal radius. ³⁰ The initial results for 37 wrists after a mean follow-up of 6.7 years (range 48–120 mo) were good pain relief in 88% and an increase in the flexion/extension arc from 73 to 96 degrees. But there was a complication rate of 28% which included dislocations, radial component loosening, and deep infection. ³⁰ In a second, revised design, the distal component was altered to have a centrally placed peg with indentations and screws on each side (Fig. 6.5). The radial-sided distal screw was made longer in order to allow for improved purchase in the index finger metacarpal. Cement was used on the proximal side and for the distal peg. Prospective results of 19 revised Universal implants in 15 patients with RA showed a high rate of failure with 50% revision rate at the latest follow-up at average 7.3 (range 5.0–10.8) years. Nine prostheses (45%) had undergone revision surgery because of carpal component loosening. ³¹

Destot

The Destot prosthesis was designed in 1991 in France and Belgium to specifically treat posttraumatic osteoarthritis (OA). With a sandblasted and porous-coated steel proximal and distal component, UHMWPE radial cup, proximal steel carpal ball, condylar UHMWPE cylinder, and distal steel component, the distal component is designed to stay next to the triquetrum after resection of the scaphoid and lunate, while preserving the distal radioulnar joint (DRUJ).

Levadoux and Legré published their experiences treating stage 2 or 3 scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists in 25 patients with a mean follow-up of 47 (range 12–72) months. ³² A high rate of revisions and distal component loosening were observed. The revisions included three wrists revised due to pain or infection. The 4-year survival rate was 85%. The mean ROM increased for flexion/extension from 26/20 to 48/41 degree, for radial/ulnar deviation from 7/25 to 15/22 degree, and for pronation/supination from 60/45 to 90/77 degree. The mean grip strength increased from 20 to 32 kgf. ³²

Anatomic Physiologic (APH)

The APH wrist prosthesis was designed and introduced by S. Radmer and colleagues in Berlin, Germany. ³³ The implant, developed for patients with RA, is a two-component hydroxyapatite-coated CoCr alloy prosthesis with titanium-coated stems for cement-free implantation. The articular surface of the radial component and the mobile-bearing surface of the carpal component have a radioulnar inclination of 10 degree. The distal component is anchored in the middle finger metacarpal and distal carpal bones. ³³ Although short-term outcome was good, the results gradually deteriorated. At a mean follow-up of 52 (range 24–73) months, 39 of 40 patients required revision surgery mainly because of loosening with subsequent dislocation. ³⁴ Severe titanium wear staining the soft tissues was noted at every revision.

6.4.1 Third Generation: Minimal Bone Resection

The third generation of wrist arthroplasties was designed with the goal of minimizing bone resection, sparing the DRUJ, avoiding fixation in the metacarpal bones, restoring the “anatomical” centers of wrist rotation and improving soft tissue balance and stability. An exception is the Motec design, which differs because its fixation with a large screw in the radius and middle finger metacarpal uses a ball-and-socket joint; this implant has been referred to as a second-generation implant. ³⁵ A recently published systematic review of total wrist arthroplasty and wrist arthrodesis shows significantly lower overall complication rates for the newer generation implants compared to their older counterparts that are defined as second-generation implants in this overview. Survival rates of 78% at 15 years (Universal 2), 95% at 8 years (Maestro), 90% at 9 years (ReMotion), and 86% at 10 years (Motec) have been reported. ³⁵ Those current available implants will be discussed in further detail in a subsequent chapter of this book.

6.5.1 Resection/Interposition Arthroplasty

For the arthritic DRUJ, several nonprosthetic procedures have been described in the past, which are still common solutions in the armamentarium of many hand surgeons. The Darrach’s procedure involves the resection of the ulnar head. ³⁶ The first description of ulnar head resection was documented in the French literature in 1855 by J. F. Malgaine; this method was used for irreducible open dislocations to prevent infection with subsequent loss of the whole hand. For acute injuries, E. M. Moore was the first to mention this procedure in the American literature in 1880, and C. Lauenstein made his contribution to the German literature in 1887. ³⁷ Segmental resection of the ulna shaft without arthrodesis of the DRUJ was first performed by the French surgeons R. Le Fort and P. Cololian in 1918, but is often cited as the Lauenstein procedure. ³⁷ Segmental resection of the distal ulna shaft with radioulnar arthrodesis known as the Sauve–Kapandji procedure was described by L. Sauvé and M. Kapandji in 1936 ³⁸ and modified by I. A. Kapandji in 1986. ³⁹ Longitudinal hemi-resection of the distal ulna was described in the 1980s by W. H. Bowers with interposition of either the dorsal capsule or an “anchovy” made of tendon/muscle, ⁴⁰ and by H. K. Watson who performed a “matched” distal ulna resection leaving the ulnar shaft-styloid axis along with the triangular fibrocartilage (TFC) complex and the distal ulnar ligamentous attachments intact. ⁴¹

Although modifications of these “salvage procedures” have evolved, complications related to instability of the distal forearm remain the most common problem leading to pain often related to ulnoradial impingement, and weakness of grip and torsional forearm strength. ⁴² Optimal load transfer from the wrist to the elbow requires a functioning DRUJ. About 20% of the total load passes into the ulnar through the normal DRUJ. ⁴³ The greatest forces of up to 34% occur through the ulna in supination. If the ulnar head is excised, only 1.8 to 2.7% of the total load is transmitted to the ulna at the wrist. ⁴⁴

6.5.2 Ulna Head Replacement

Partial DRUJ arthroplasty was developed in the 1970s by replacing the ulnar head with a silastic implant. ⁴⁵ Due to the extremely high bone resorption rates of up to 100%, and high (40–63%) rates of prosthesis migration or breakage, these implants are no longer used. ^{46 , 47} In recognizing the shortcomings of silicone rubber implants, a group of European and US hand surgeons, under the leadership of T. J. Herbert, designed a modular ulnar head replacement that was released onto the market in 1995. This system comprises a ceramic ulnar head fitting onto a metallic stem for insertion into the ulna. ⁴⁸ The head is capable of rotating on the stem as the radius dynamically rotates around the ulna. Soon after the release of the Herbert ulnar head prosthesis, similar implants became available from several other manufacturers. The predominantly used implants are the Avanta U-Head or Integra First Choice ulna head replacement. The outcomes of these implants are described in more detail in Chapters 31 to 33.

6.5.3 Partial Ulna Head Replacement

The Eclypse implant, developed by M. Garcia-Elias, is a pyrocarbon spacer used for DRUJ hemiarthroplasty. It replaces the articular portion of the ulnar head while preserving the insertion of the TFC at the level of the fovea, the ulnocarpal ligaments, and the extensor carpi ulnaris sheath. ⁴⁹ This implant is described in more detail in Chapter 34.

6.5.4 Total DRUJ Replacement

As an alternative to the “salvage procedures” of the destroyed DRUJ described earlier, L. R. Scheker designed a total DRUJ replacement. The Aptis total DRUJ replacement prosthesis consists of a semiconstrained and modular implant designed to replace the function of the ulnar head, the sigmoid notch of the radius, and the TFC ligaments. The ulnar components include a press-fit endomedullary CoCr alloy stem with a titanium plasma-sprayed surface for osteointegration, and a UHMWPE ball. The ulnar head is attached to the radial plate intraoperatively to ensure that the adequate level of implant constraint is maintained. ⁵⁰ This implant is described in more detail in Chapter 35.

6.6.1 Resection/Interposition Arthroplasty

Stiffness of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints after trauma was the stimulus for developing partial or complete resection arthroplasties in an effort to regain some motion.

In 1946, S. B. Fowler described a technique for the MCP joint in which the metacarpal head was shaped in a transverse pointed end by resecting dorsal and volar half wedges. ⁵¹ A thin line of bone was left to articulate with the center of the proximal phalanx base. The former sliding joint was changed to a hinge joint, which allowed only limited flexion. In severe volar-dislocated rheumatoid MCP joint deformities, Fowler recommended an additional tenodesis of the extensor tendon to the proximal phalanx base so as to prevent recurrence of volar dislocation. ⁵¹ In 1956, D. C. Riordan modified the technique by excising only the volar wedge from the metacarpal head and immobilizing the joint with a Kirschner wire to allow the collateral ligaments to heal to their new insertion on the dorsal cortex of the metacarpal. ⁵¹

Inspired by the positive outcome of the Vitallium (CoCrMo alloy) cup arthroplasty of the hip, ⁵² M. S. Burman and R. H. Abrahamson attempted an interposition arthroplasty of the MCP and PIP joints in 1943 with Vitallium and Lucite (methyl methacrylate) caps which lead to lateral joint instability. ⁵³ In the 1964 fourth edition of Bunnell’s Surgery of the Hand, an interposition arthroplasty technique is described using fascia lata. ⁵⁴

K. Vainio and colleagues introduced an interposition arthroplasty of the MCP joint in RA patients in 1968. They resected the metacarpal head and interposed the distal stump of the transected extensor tendon into the joint, sewing it down to the volar plate and additionally transposed the radial interosseous muscles. ⁵⁵

In the late 1960s, A. Tupper described a resection arthroplasty of the MCP joint, interposing the proximally detached volar plate and suturing it to the dorsal edge of the resected metacarpal. ⁵⁶

There is general agreement that the long-term follow-up of RA patients who receive any type of resection arthroplasty eventually reveals absorption and shortening of the metacarpal bone accompanied by progressive instability, recurrence of volar subluxation, ulnar drift, and finger shortening. ⁵¹

The earliest report on resection arthroplasty of the PIP joint without interposing any material was published in 1954 by Carroll and Taber who presented 30 cases of deformed and ankylosed PIP joints with a follow-up ranging from 6 months to 7 years. ⁵⁷ They resected the distal part of the proximal phalanx through a mid-lateral approach. A Kirschner wire was passed through the middle phalanx to maintain joint distraction for 6 weeks.

For the PIP joint, volar plate arthroplasty was not immediately applicable during this early time because the volar plate was responsible for joint stability to prevent dorsal subluxation during hyperextension. In 1967, R. G. Eaton adapted the volar plate interposition arthroplasty for posttraumatic PIP joint destruction. The volar plate was detached from the middle phalanx and sutured into a trough in the base of the middle phalanx to reconstruct the volar articular surface. The aim of this reconstruction was to restore a smooth gliding surface to the base of the middle phalanx. ⁵⁸ Satisfactory function and pain-free motion were reported after a mean follow-up of 11.5 years. ⁵⁹

6.6.2 Transplant Arthroplasty

As early as 1910, the German surgeon H. Wolff reported the successful autologous transplantation of an entire proximal phalanx of the second toe, with its periosteum and both joints, in a case of tuberculosis affecting the proximal phalanx of a female ring finger. ⁶⁰ Three years later, W. Goebel used the same procedure for a case of enchondroma. ⁶⁰ Oeleker performed a cadaver joint transplantation in the case of an ankylosed PIP joint sustained after a gunshot wound. ¹⁰ In 1948, W. C. Graham and D. C. Riordan replaced several metacarpal heads with fourth metatarsal heads and published satisfactory 1-year postoperative ROM without any radiological signs of degenerative changes. ⁶¹ In 1954, Graham replaced an entire thumb MCP joint in a 3-year-old boy with a fourth metatarsophalangeal joint. ¹⁰ Transplant arthroplasty using the vascularized toe transfer technique will be discussed in further detail later in Chapter 10.

6.6.3 Hinged Implant Arthroplasty

E. B. Brannon and G. Klein developed a metal, hinged prosthesis for posttraumatic damaged joints of the finger in selected cases, which would serve as an alternative to amputation or arthrodesis. In 1959, they published their results in 14 patients with a follow-up of approximately 3 years. The original device made of steel, is now a titanium implant consisting of both uncemented proximal and distal stems articulating with a hinge that is locked by a screw (Fig. 6.6). Significant bone resorption around the stems, longitudinal rotation, and subsidence led to revision with fixation of the stems to the adjacent bone by staples. ⁶² As a result, A. E. Flatt developed another hinged, metal prosthesis with two-pronged stems for rheumatoid MCP and PIP joints. ⁶³

Although several types of hinged MCP and PIP implants have been developed, they all share common problems. Lateral as well as subluxation forces are transmitted through the implant shaft and place stress on the bone–stem interface. Bone resorption with subsequent loosening or fracture around the intramedullary shaft, fibrosis around the hinge mechanism, fracturing of prongs, screw failure, wear within the conventional hinge mechanism with subsequent deposit of metallic debris, and breakdown of the overlying skin have been documented. ^{63 , 64 , 65 , 66}

6.6.4 One-Piece Polymer Arthroplasty

After the unsatisfactory results of metal-hinged implants, the use of plastics was favored. Several polymer one-piece prostheses were then developed in the late 1960s. Polypropylene and silicone are relatively cheap, inert, durable, and simple to mold. ⁶⁴ The former allowed the design of a thin hinge to complement flexion while good lateral stability was retained. Under axial compression, however, buckling of the hinge and subsequent subluxation occurred. F. V. Nicolle and J. S. Calnan developed a thin-hinged polyethylene implant with an encapsulating silicone polymer balloon to prevent direct contact between soft tissues and the hinge ⁶⁴ (Fig. 6.7). J. J. Niebauer and colleagues designed a laminated silicone-Dacron, thin-hinge device with stems covered by a Dacron mesh to provide fibrous fixation. ^{67 , 68}

Swanson began the development of various novel MCP and PIP implants in 1962. The basic design of these devices comprised a single silicone unit with tapered proximal and distal stems and a dorsal offset hinge region. ⁹ The broad stem-hub junction resisted buckling, but the tensile stress in the convex aspect of the hinge under a bending moment increased disproportionately as the square of thickness and inversely with length. Over time this led to fracture in or near the hinge element and the development of cold flow deformities or structural changes. ⁶⁵ Later improvements involved alterations of the silicone polymer composition to provide greater strength and the inclusion of protective metal grommets at the stem-hub junction to prevent erosion at the bone ends. ⁶⁹ The Swanson-designed silicone implant has, nonetheless, remained the joint replacement of choice for several decades.