Anatomy

The MCP joints in the hand are multiaxial condyloid joints that permit flexion, extension, abduction, and adduction. The joint consists of a capsule, two collateral ligaments, two accessory ligaments, and a volar plate. The capsule around the joint is redundant and allows a significant amount of motion of the proximal phalanx on the metacarpal head. Because the metacarpal head is cam-shaped, the collateral ligaments are under greatest tension and thus greatest stability when the joint is flexed.

Replacement Arthroplasty

Currently, three types of implants are available in the United States to treat arthritic and posttraumatic painful MCP joints: silicone elastomer implants, which are used as hinged spacers after resection arthroplasty; classic metal on polyethylene cemented components; and pyrolytic carbon uncemented components.

Silicone elastomer arthroplasty is typically used in low-demand patients, often in the setting of rheumatoid or other inflammatory arthropathy, with significant joint destruction and deformity. The flexible silicone implant ( Fig. 16-1 ) was originally introduced by Swanson in the 1960s to improve the results of resection arthroplasty by functioning as an internal splint to maintain alignment and has provided good pain relief and improvement in deformity, motion, and function. The implant is less commonly used in younger, high-demand patients because of complications including implant fracture, limited MCP flexion, and silicone synovitis. However, it has been used in older patients with osteoarthritis with good results. Implant fracture rates are reported as high as 45% at 3 years, but with newer materials with improved fatigue-crack growth resistance, reported fracture rates are more on the order of 2% to 10%. However, even with significant rates of osteolysis and implant fracture, patient satisfaction is usually good even in the face of poor radiographic findings. Titanium grommets around the silicone stems have slightly improved rates of fracture and osteolysis. Reactive synovitis and osteolysis from silicone particulate wear debris occur around these implants, but usually with less frequency and severity than with silicone carpal implants.

Swanson Silastic implant

(Wright Medical Technology, Arlington, TN).

Total joint replacement prostheses in the fingers have undergone several iterations. First-generation components were simple metal-hinged prostheses that ultimately failed because of a nonanatomic center of rotation; a high coefficient of friction at the hinge mechanism; metallic implant debris; and, ultimately, breakage. Second-generation implants for the MCP joint were ball and socket designs to allow adduction and abduction in addition to flexion and extension, but these were complicated by proximal phalangeal component failure, hypertrophic bone formation, poor motion, and instability. Third-generation, minimally constrained unlinked designs attempt to recreate the normal anatomy with minimal bone resection and preservation of collateral ligaments. These implants, including the surface replacement arthroplasty (SRA) and pyrolytic carbon implants discussed later, are more appropriate for younger patients with higher grip-strength needs and longer life expectancy. Functional ligaments and muscles surrounding the joint are critical in providing joint stability and ultimate success, so these implants are more often used in patients with primary osteoarthritis, posttraumatic arthritis, or less advanced rheumatoid disease with intact collateral ligaments.

The SRA is a cobalt-chrome and polyethylene system ( Fig. 16-2 ) that parallels joint replacement systems that have enjoyed success in other joints such as the knee. The cobalt-chrome proximal (metacarpal) component and the polyethylene distal (proximal phalanx) component are usually cemented in place and have rectangular stems to maximize rotational stability. The components are designed to recreate the normal premorbid anatomy of the MCP joint to provide the potential for a nearly normal arc of motion.

SRA for the MCP joint

(Small Bone Innovations, Morrisville, PA).

The pyrolytic carbon implant ( Fig. 16-3 ) is similar in design to the SRA prosthesis. It is also an articulating, unconstrained prosthesis that is designed to recreate bony anatomy and provide good strength and durability. The material is made up of an isotropic carbon coating over a graphite substrate with wear properties similar to ceramic. The mechanical properties of pyrolytic carbon have demonstrated a modulus of elasticity similar to cortical bone, and wear models have revealed no evidence of wear or wear debris and no evidence of inflammatory reaction. Biomechanical studies show re-creation of the instantaneous center of rotation and normal kinematics of the native MCP joint, with the collateral ligaments being critical to stability. In terms of osseous integration of the implants, initial studies showed radiographic evidence of ingrowth, but a more recent animal-model study raised some concerns about pyrolytic carbon implant stability and suggested that the use of titanium implants would provide greater osseous integration. However, it has become more clear that pyrolytic carbon implant stability is derived not from osseous integration, but from appositional bone growth around the implants in response to stress according to Wolfe’s law. Initial implant stability is achieved by press-fit contact with cortical bone, whereas final implant stability from bone remodeling and appositional growth generally occurs 6 to 24 months after implantation. Long-term outcomes studies show excellent pain relief, improved arc of motion, retained joint stability, improved grip strength, and no implant wear in both rheumatoid arthritis and osteoarthritis. However, in one study patients with rheumatoid arthritis followed for more than 1 year showed significant subsidence (55%) and osteolysis around the implants (45%). This was not seen in patients with osteoarthritis. Another study showed radiographic evidence of osseous stability in 94% of the implants but subsidence in 64%, with most of the subsidence occurring immediately postoperatively. The authors also showed an overall 12% revision rate in their series and implant survivorship of 82.3% at 5 years, 81.4% at 10 years, and 70.3% at 16 years.

Pyrolytic carbon for the MCP joint

(Ascension Orthopedics, Austin, TX).

Prosthetic implants for the MCP joint are undergoing continuous modifications in design and materials. Anatomic third-generation components provide better strength and durability for younger patients, and pyrolytic carbon components have excellent biomechanical and wear properties. However, it is unclear at this point whether these newer implants will be better than the time-tested silicone elastomer implants in the long term for patients with rheumatoid arthritis. Newer implants will undoubtedly be developed in the near future, and it is hoped they will have a decreased incidence of subsidence and osteolysis and improved implant stability.

Anatomy

The PIP and DIP joints in the hand are ginglymus, or hinge, joints and, therefore, only permit flexion and extension. Both joints have two collateral ligaments, two accessory ligaments, and a volar plate. Unlike the MCP joints, the PIP and DIP joints do not have the cam effect at the phalangeal heads; therefore, the tension of the collateral ligaments is uniform throughout the arc of motion. The volar plate of the PIP joint has proximal extensions that insert onto the volar margins of the proximal phalanx called checkrein ligaments. The volar plate of the DIP joint does not have these checkrein ligaments; therefore, the DIP joint can hyperextend, whereas the PIP joint cannot.

PIP Replacement Arthroplasty

The average arc of motion after PIP joint arthroplasty is about 40 to 60 degrees. If a patient’s arc of motion is already in this range, restoration of additional motion is an unrealistic goal. A patient with a painless arc of motion of 60 degrees should probably be advised to avoid surgery. In patients with fixed deformities, poor bone stock, or joint destruction, arthrodesis may be a better alternative than arthroplasty. Consideration should also be given to the digit involved. The ulnar digits are primarily used for power grip and must be mostly stable in the volar–dorsal direction with the finger flexed. However, the radial digits, in particular the index finger, must also resist significant lateral bending loads with pinch activities. The implants available for replacement of the PIP joint are similar to the MCP joint prostheses and include silicone elastomer, surface replacement, and pyrolytic carbon implants.

Silicone elastomer implants have been used in PIP joints for many years. However, some authors do not recommend the implant for the index or long finger PIP joints, especially in young, active patients. The collateral ligaments often have to be resected when implanting the prosthesis, which compromises pinch stability. Results tend to correlate with the degree of deformity, with the best results obtained in patients with minimal deformity and worse results in those with rheumatoid swan neck and boutonnière deformities. Use of the implants for posttraumatic and degenerative arthritis generally has been met with unsatisfactory results, with reports of rotational deformity, alignment deviation, loss of pinch strength, decreasing range of motion, implant fracture rates of 7% to 15%, and revision rates of 40% at 2 years. However, others report no fractures or revisions in similar patient populations. A study of patients with rheumatoid arthritis at 5.8 years showed good pain relief in 67%, decreased average range of motion, 7% fractured implants, and bone resorption around 12% of the implants. Results seem to worsen as followup time increases, with longer-term studies actually showing poorer results in rheumatoid than posttraumatic or degenerative arthritis, no significant improvements in range of motion, cystic bone resorption in 45%, and implant fracture in 16%. As a result of modern systemic therapies, the lifespan of patients with rheumatoid arthritis is increasing; therefore, the concerns of silicone elastomer implant longevity will likely become more significant. Although patients with rheumatoid arthritis seem to function well with failed implants, we will likely see fewer surgeons offering the silicone implants to their patients in the future.

The SRA fot the PIP joint ( Fig. 16-4 ) is made of a cobalt-chrome proximal component, while the distal component features a titanium stem and polyethylene tray. Minimal bony resection is needed for these anatomic implants. Biomechanical studies have shown re-creation of the joint center of rotation and normal joint kinematics. As with the MCP implant, the integrity of the collateral ligaments is critical for stability. The central slip insertion should also be preserved when implanting this prosthesis. A small series with this implant showed excellent pain relief and good range of motion. A larger series at 4.5 years of patients with degenerative, posttraumatic, and rheumatoid arthritis found good results in 48%, fair in 29%, and poor in 23% when based on pain relief, motion, and deformity.

SRA for the PIP joint

(Small Bone Innovations, Morrisville, PA).

Pyrolytic carbon implants have also been developed for the PIP joints ( Fig. 16-5 ). For reasons that are not entirely clear, the results of this implant do not seem as favorable in the PIP joint as in the MCP joint. Perhaps the poorer results are related to more difficult ligamentous balancing at this joint. A recent 2-year minimum followup of PIP joint replacements with pyrolytic carbon for patients with osteoarthritis, posttraumatic arthritis, and rheumatoid arthritis at an average age of 53 years showed good pain relief and overall patient satisfaction. However, 8% required a revision arthroplasty and 40% showed settling of the implant to a stable position. Another study showed good pain relief with the implant, but 47% of the implants showed migration and another 18% showed radiolucent lines. Range of motion and grip strength were slightly worse in patients who had unstable implants, but these results were not significant. In a study of patients with posttraumatic arthritis, there was minimal improvement in pain and function, and range of motion actually decreased, although grip strength did improve. The authors of this study no longer use pyrolytic carbon implants for posttraumatic arthritis. Another study of posttraumatic and idiopathic arthritis showed good pain relief, variable range of motion, prosthesis loosening, and periprosthetic cysts. Three of the patients (15%) had to be converted to arthrodesis. Tuttle and Stern showed good pain relief, unchanged range of motion, 11% component loosening, 44% squeaky joints, 28% contractures, and 11% dislocations. In a recent retrospective study comparing silicone elastomer to pyrolytic carbon implants for the PIP joint, patients had similar range of motion and pain relief. Patients in the pyrolytic carbon group had less coronal plane deformity, but several patients noted that their implants squeaked. The authors concluded that the pyrolytic carbon implant did not clearly demonstrate superiority over the silicone implant.

Pyrolytic carbon for the PIP joint

(Ascension Orthopedics, Austin, TX).

In the PIP joint, the indications for the use of one implant over another in the different patient populations are still unclear. Most studies on pyrolytic carbon implants note that their results improved with experience. Perhaps surgical techniques, instrumentation, and prosthesis design still need refinement. Newer implants will undoubtedly be developed in the future, and different materials and designs may improve results.

DIP Replacement Arthroplasty

The DIP joint is the joint most commonly involved by degenerative arthritis, although deformities are usually not severe and hand function is usually minimally compromised by decreased motion at this level. Pain is the most common indication for surgery, and arthrodesis is the preferred method of treatment. However, if the patient desires motion at the joint, arthroplasty can be performed.

Although there are no reports of DIP arthroplasty with the newer third-generation implants, several small studies report on experience with the silicone elastomer implant for the joint. This procedure is usually pursued as an alternative to arthrodesis of the joint to preserve motion and provide pain relief. The most recent study in 1997 with an average followup of 10 years showed overall patient satisfaction with the procedure but a 10% revision rate for implant fractures and bony erosions. The most common complication was extension lag in 78% of the patients, measuring up to 45 degrees (mean 13 degrees). This occurs because the terminal extensor tendon is divided to expose the DIP joint and must be repaired after the arthroplasty is complete. Also, the extensor tendon often inserts directly onto large dorsal osteophytes at the base of the distal phalanx, and preservation of the tendon integrity with removal of the osteophytes is often difficult.

Arthrodesis

Arthrodesis of the finger joints for painful arthritis is indicated for pain, instability, deformity, or insufficient bone stock to support an arthroplasty. The most commonly arthrodesed finger joints are the PIP and DIP joints. With the improved results of newer implant arthroplasties of the MCP joint, arthrodesis is usually reserved for failed arthroplasty or insufficient bone stock to support an arthroplasty. If arthrodesis is chosen, the joints should be fused in a position of function, with increasing flexion from radial to ulnar digits. General recommendations for fusion position are shown in Table 16-1 . Obvious drawbacks to arthrodesis include complete loss of motion at the joint, which can result in loss of function such as grip strength, and difficulties with activities such as getting the hand in and out of pockets.

The two critical elements of a successful arthrodesis are surface preparation and fixation. Surface preparation should result in good cancellous-to-cancellous bone contact and should not shorten the digit excessively. The two techniques commonly used are the “cup and cone” and the flat surface osteotomy techniques. Spherical reamers can be used to prepare the bone surfaces for the cup and cone technique, and advocates feel that this technique allows for fine adjustment in all planes ( Fig. 16-6 ). Surface preparation with flat-angled resections, however, requires precision cuts, and slight deviation can result in undesirable positioning of the arthrodesed digit. Fixation of the joint can be carried out with crossed K-wires, interosseous wiring with two orthogonal loops of 26-gauge steel wiring, tension-band wiring, lag screws, headless and variable-pitch compression screws, and plate and screw constructs.

A. Cup and cone reamer system for finger joint arthrodesis. B. Preparing the “cup” portion in the distal phalanx. C. Preparing the “cone” portion on the proximal phalanx.

Volar Plate Arthroplasty

In the past few years, there have been reports of the use of volar plate arthroplasty to treat arthritic conditions in the fingers. The technique was originally developed to treat dorsal fracture-dislocations in the digits with significant articular surface comminution, most frequently in the PIP joint. The volar plate is mobilized by separating it from the collateral ligaments and then advanced into the defect in the middle phalanx. Outcomes studies of this technique for PIP fracture-dislocations show good pain relief, range of motion, and joint stability. Injuries treated acutely have better range of motion than chronic injuries treated with this procedure. The technique has also been successfully used in fracture-dislocations of the thumb interphalangeal joint and the DIP joint.

Volar plate arthroplasty has also been used to treat arthritic conditions. It has been used for rheumatoid arthritis in the MCP joint with good results for many years. More recently, however, it has been described as a technique to treat osteoarthritis and posttraumatic arthritis. When used for arthritic conditions, the volar plate must be detached from its distal insertion, preserving as much length as possible, and mobilized from the collateral ligaments. The volar two thirds of the base of the middle phalanx is resected, and the volar plate is then interposed into the created defect. When used for osteoarthritis of the PIP joint, Burton and colleagues showed good pain relief and no change in range of motion, pinch and grip strength, or stability. When used for posttraumatic arthritis in the PIP and MCP joints, Lin and colleagues showed good pain relief with greatly increased range of motion and stability. Volar plate arthroplasty, therefore, has become a viable alternative to arthrodesis or arthroplasty, in part owing to the less than ideal outcomes of implant arthroplasty of the PIP joint. Longer-term outcomes studies are needed to compare this technique to implant arthroplasty and arthrodesis.

Background

Painful arthritis at the base of the thumb is more common in women than in men and can cause significant impairment. This condition is known by several different but synonymous names, including basal joint arthritis, trapeziometacarpal (TM) arthritis, and carpometacarpal (CMC) arthritis of the thumb. Although the trapeziometacarpal joint is the second most commonly involved site of primary idiopathic osteoarthritis in the hand after the DIP joint, its involvement can cause far more significant functional disability secondary to painful, weakened pinch and grip.

Anatomy/Biomechanics

Five trapezial articulations can be involved in “basal joint arthritis”: the trapeziometacarpal, scaphotrapezial, scaphotrapezoidal, trapezium-index metacarpal, and trapezium-trapezoid joints. The trapeziometacarpal joint is the primary focus of the disease, and it is a complex biconcave saddle joint with minimal bony constraints that permits prehension, opposition, and circumduction. The evolution of the biconcave saddle joint in humans, along with the muscles to provide active opposition, has increased the importance of stabilizing ligaments during lateral pinch, which when incompetent or injured may lead to arthritic degeneration. Biomechanical studies have underscored the importance of strong supporting ligaments, particularly during pinch and grasp, when large axial and cantilever loads are transmitted to the TM joint. Compressive joint forces during pinch and grasp are four to five times the applied external forces. During pinch, most of these forces are transmitted to the dorsoradial articular surface. Cantilever bending of the thumb metacarpal further contributes to tangential dorsoradial subluxating forces and cartilage erosion.

One of the most important stabilizing ligaments during pinch and grasp is the anterior oblique “beak” ligament, so called for its attachment on the palmar beak of the thumb metacarpal. Eaton and Littler identified the beak ligament as the primary stabilizer of the TM joint and determined that the weakest portion of the capsule was between the beak ligament and the dorsal ligaments. The beak ligament is intracapsular and attaches to the beak on the ulnar side of the first metacarpal. It originates from the palmar aspect of the trapezium, and in this position it is an effective restraint against dorsal translation of the metacarpal on the trapezium, which is of particular importance during pinch and grip. However, many other ligaments are involved in the complex anatomy of the thumb TM joint. Bettinger and colleagues described a total of 16 ligaments that stabilize the trapezium and the TM joint. Seven of these ligaments, including the sAOL (superficial anterior oblique ligament), dAOL (deep anterior oblique ligament) “beak” ligament, dorsoradial (DRL), posterior oblique (POL), ulnar collateral (UCL), intermetacarpal (IML), and dorsal intermetacarpal ligament (DIML), are responsible for directly stabilizing the TM joint. The remaining nine ligaments stabilize the trapezium, providing a stable base for the TM joint.

The integrity of these ligaments that support the thumb CMC joint is critical. Women have a higher prevalence of basal joint arthritis than men (40% versus 25%, respectively, at 75 years old), and it is postulated that this may be related to differences in systemic joint laxity. Ligamentous hypermobility is more common in women and is thought to be attributed to the hormones prolactin, relaxin, and estrogen. Hypermobility in the thumb CMC joint has been correlated with the development of osteoarthritis. Similarly, patients with Ehler-Danlos syndrome, with collagen defects and resultant systemic hyperlaxity, have been shown to have a higher incidence of CMC joint subluxation and exhibit radiographic degenerative changes at a mean age of 15 years. Future treatments may include efforts to reverse laxity in these ligaments.

Pellegrini’s analysis of both surgical and postmortem specimens of the TM joint often revealed eburnated bone along the palmar aspect of the trapezium and metacarpal. Arthritic wear always began at the most palmar perimeter of the joint and spread dorsally with progressive disease, sparing only a small peripheral rim of pitted and softened cartilage in the dorsal compartment of end-stage joints. Palmar cartilage surface degeneration was closely associated with degeneration of the beak ligament from the articular margin of the metacarpal. In all cases of eburnation there was frank detachment of the ligament from its normal position confluent with the joint surface, effectively reducing its mechanical efficiency in checking dorsal migration of the metacarpal on the trapezium during dynamic flexion-adduction of the thumb. The primary loading areas during lateral pinch are in the same palmar regions of the joint as the eburnated surfaces in diseased joints. Division of the beak ligament in specimens with healthy cartilage surfaces alters the contact patterns and reproduces the topography of the eburnated lesions observed in arthritic joints.

Thus, in summary, degeneration of the beak ligament has been linked to the development of osteoarthritis. Functional incompetence of the beak ligament results in pathologic laxity; abnormal translation of the metacarpal on the trapezium; and generation of excessive shear forces between the joint surfaces, particularly within the palmar portion of the joint during grip and pinch activity. Because the beak ligament appears to be the primary stabilizer of the TM joint, and because its detachment results in dorsal translation of the metacarpal, its reconstruction has been recommended to restore thumb stability not only in cases of end-stage osteoarthritis but also for early-stage disease.

Presentation

Basal joint arthritis may present as mild pain localized to the thenar cone at the level of the TM joint, particularly during pinch and grip. Ultimately, the greatest functional impairment occurs with advanced disease, limiting breadth of grasp and forceful lateral pinch. Activities such as brushing teeth, turning a key, opening a jar, or picking up a book are commonly affected. Complaints are directed toward the base of the thumb, and pain is frequently associated with a sensation of “slipping” within the joint. An enlarging prominence, or “shoulder sign” (dorsal prominence of the base of the thumb metacarpal), inevitably develops as the clinical manifestation of dorsal metacarpal subluxation on the trapezium and thumb metacarpal shaft adduction. Pain can be reproduced by an examiner with the CMC grind test by axially loading and then rotating the thumb CMC joint. Over time, with continued subluxation of the CMC joint and avoidance of painful abduction of the thumb by the patient, a contracture may develop in the first web space. To compensate for the stiff and painful CMC joint and adducted posture of the thumb metacarpal, the thumb MCP joint may then develop a compensatory hyperextension deformity with permanent attenuation of the volar plate. The combined deformities of the CMC joint, the thumb metacarpal, and the MCP joint result in a characteristic zigzag collapse pattern of the patient’s thumb.

Eaton and Littler developed a staging system for basal joint arthritis. Stage I represents a painful joint that appears normal on radiographic examination with the exception of possible widening from synovitis. Stage II shows joint space narrowing with debris and osteophytes less than 2 mm. Stage III represents joint space narrowing with debris and osteophytes greater than 2 mm in size. Stage IV demonstrates scaphotrapezial joint space involvement in addition to narrowing of the TM joint. They underscored the importance of diagnosing scaphotrapezial arthritis (Stage IV) noting that hemitrapeziectomy alone, in such cases, will be complicated by residual pain.

Irwin and coworkers, in 1995, heightened our appreciation of unaddressed scaphotrapezoidal arthritis as a potential cause of residual pain after the ligament reconstruction tendon interposition (LRTI) arthroplasty. Arthritic involvement of the scaphotrapezoidal joint may not be evident on preoperative radiographs because of the low sensitivity and specificity for detecting disease at this joint. Therefore, routine intraoperative assessment of the scaphotrapezoidal joint is mandatory at the time of arthroplasty by pulling on the index and long fingers and inserting a Freer elevator to gently wedge the joint open. When arthritis is present, in what may be considered “Stage V disease,” a 2- to 3-mm excision of the proximal trapezoid can be an effective and safe strategy for eliminating this secondary pain generator.

In general, ligament reconstruction is recommended for Stage I disease; hemi-trapeziectomy, TM fusion, or implant arthroplasty for Stage II or III (TM arthritis only) disease; and complete trapezium excision with or without ligament reconstruction for Stage IV disease (pantrapezial arthritis).

Nonsurgical Treatment

Splinting, physical therapy, and injections are often first-line treatments for thumb CMC arthritis, especially in the early stages. Splinting the thumb in abduction can reduce pain and prevent first web space contracture and may minimize zigzag collapse of the thumb. By also splinting the MCP joint in flexion, the CMC joint may be partially unloaded. Physical therapy also can be useful by stretching the first web space and strengthening the thenar muscles to aid in joint stability.

Steroid injection is another widely used treatment modality for nonsurgical treatment of thumb CMC joint arthritis. However, recent outcomes studies have showed inconsistent effectiveness. A recent double-blind, randomized controlled trial showed no improvement in hand function or pain control in patients injected with triamcinolone compared to saline. However, another recent prospective study found good pain relief associated with steroid injections and splinting. Viscosupplementation is another option recently proposed as a result of its widespread use in knee osteoarthritis. Viscosupplementation of the thumb CMC joint with hyaluronate is not yet U.S. Food and Drug Administration approved and is used experimentally only, but a few recent studies have shown its potential effectiveness in comparison to steroid injection. Optimal volume and frequency of injections and long-term outcomes have yet to be defined, but viscosupplementation could be another tool for future treatment of basal joint arthritis.

Volar Ligament Reconstruction

Volar ligament reconstruction is indicated in the treatment of refractory prearthritic synovitis associated with thumb CMC joint laxity. It is most effective when preoperative stress radiographs show radial subluxation of the thumb metacarpal on the trapezium.

Surgical treatment of this laxity has centered around the reconstruction of the palmar beak ligament to stabilize the trapeziometacarpal joint. Until recently, this was most commonly accomplished with a slip of flexor carpi radialis (FCR) tendon as originally described by Eaton and Littler ( Fig. 16-7 ). However, for this stabilizing procedure alone to provide pain relief, the joint surfaces must be free of eburnation and demonstrate only the earliest changes of chondromalacia in the contact areas of the palmar compartment. More advanced arthritis that is not detected on preoperative imaging may be present at the time of surgery. Therefore, the plan to perform ligament reconstruction without an arthroplasty procedure must always be contingent on intraoperative confirmation of satisfactory articular surfaces, and both surgeon and patient must be prepared to exercise an alternative treatment option should this not be the case.

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