Key words: Rheumatoid arthritis; Metacarpophalangeal joint; Constrained arthroplasty; Resurfacing arthroplasty
MCPJ(s): metacarpophalangeal joint(s)
PIPJ(s): proximal interphalangeal joint(s)
DIPJ(s): distal interphalangeal joint(s)
IPJ: interphalangeal joint
UHMW: ultra-high molecular weight
ROM: range of motion
A stable and functioning MCP joint is the key for satisfactory function of the overall finger in particular in RA patients with concomitant mutilating proximal interphalangeal joint (PIPJ) destruction Grade V according to the classification by Larsen et al.  when PIPJ and/or distal interphalangeal joint (DIPJ) fusions become necessary as the merely surgical treatment of choice (Figure 1A-B) . The constrained MCPJ arthroplasty was designed to decrease the risk of recurrence of palmar (sub) luxation and ulnar deviation postoperatively due to the inherent lack of ligamentous support that was found in up to 31% of patients with RA who underwent a silicone rubber implant arthroplasty . However, the rates of loosening and mechanical failure of almost all types of constrained prostheses are so high that their use cannot be recommended at present ; and the role of the piston effect, primarily known from the silicone rubber implant that increases the range of motion of the proximal phalanx , for breakage of prosthesis in cases of loosened nonsilicone uncemented MCPJ implants such as in unconstrained resurfacing pyrocarbon arthroplasty [8, 9] or in constrained arthroplasty such as in our following case presentation, is not clearly understood currently. The second generation of the constrained and uncemented MCPJ RM prosthesis (Mathys, Bettlach, Switzerland) is one type that is in use .
(B) Same patient after surgical correction of the PIPJs II-IV in their anatomic axes (lines) with fusions, note there was a spontaneous realignment of the silicone rubber implants (circles) in the MCPJs II/III in their anatomic axes postoperatively (lines).
Eight years postoperatively, the patient reported increasing pain with loss of function isolated in his MCPJ IV since 6 months; all other finger joints did not reveal any clinically relevant symptoms. Radiographically, distinctive osteolyses with cortical thinning around all components of the 4 RM prostheses accompanied with its subsidences were seen, and the hinge joint of implant in MCPJ IV was broken (Figure 2C). A total exchange arthroplasty of the MCPJ IV using the unconstrained MCP joint resurfacing SRTM MCP (formerly Avanta SR, Small Bone Innovations, Morrisville, PA, USA) implant with cementation of both components was performed, and intraoperatively, the breakage of the RM prosthesis was confirmed and both components were loosened (Figure 3A). The further course was uncomplicated again.
At the 10-year follow-up, that includes a 2-year followup after MCPJ IV exchange arthroplasty, there was unchanged correct positioning of all MCPJ implants (Figure 3B); and despite d distinctive radiographic loosening and subsidence . of the 3 other RM prostheses, the patient reported a good outcome regarding his finger functions and he is able to perform his high-demand activities of daily living again (Figure 4). Pain in visual analogue score (0 - 10 points) improved from 7 before MCPJ IV exchange arthroplasty to 2, and the patient reported that he would have the same procedures again if it would be necessary.
(B) Surgical treatment with fusions of the thumb’s MCPJ and IPJ, and MCPJ II - V arthroplasties using the RM prosthesis (with its design), note the periprosthetic fracture of the metacarpal IV (arrow) that was treated conservatively;
(C) 8 years postoperatively there was a marked bone resorption with cortical thinning around all prostheses, and the MCPJ IV prosthesis was broken (arrow).
(B) 10 years after primary MCPJ II-V arthroplasties and 2 years after MCPJ IV exchange arthroplasty, all RM prostheses of the MCPJs II/III/V well functioning despite marked signs of radiographic loosening and subsidence, SRTM MCP resurfacing implant in the MCPJ IV without any signs of radiographic loosening, and the wires for fusion of the MCPJ of the thumb were removed.
For high-demand patients with RA such as in our case, stable and functioning MCPJ II-V arthroplasties have been recommended, and various (semi) constrained prostheses were designed (started in 1953 with the Brannon and Klein type; followed by other typs since 1961: Flatt, Griffith-Nicolle, Schetrumpf, Schultz, Steffe, George-Buchholtz, Minami, Strickland, Walker, Weightman, Link, Weko, Daphne) to increase the grip strength and to decrease the risk of recurrence of ulnar deviation with or without (sub)luxation postoperatively due to the inherent lack of ligamentous support which is usually observed after silicone rubber MCPJ arthroplasties. The first type of the constrained and uncemented Mathys prosthesis, introduced in the 70th, was an all-plastic implant that consisted of a polyacetal-resin and a polyester component, a metal core, and a screw. The two components are implanted separately and are fixed intramedullary by an expanding mechanism (rawl plug principle). A cone shaped metal piece is pressed into the stem by a screw to secure the stems into the medullary spaces. The two components are snapped together afterwards (hinge joint). The main problem was the migration of the prosthesis so, within a few months postoperatively, the Range Of Motion (ROM) was very poor [21-23], which led to its withdrawn from the marketplace. The second design of the constrained Mathys prosthesis (RM prosthesis) with its hinge joint which was used in our case consists of two polyetheretherketone (PEEK) components (Figure 2B). There is an internal titanium screw for initial fixation and the stems are coated with titanium for bone ingrowth . PEEK has been proven to be a biocompatible biomaterial and with sufficient strength for a joint replacement . One retrospective study that compared the outcome of 86 silicone implants versus 22 RM prostheses for the MCPJs and PIPJs in a short to medium follow-up has been demonstrated a significant higher functionality and stability of the RM prostheses versus the silicone implants . However, long-term results with a larger number of patients could not be found in the literature.
For high-demand patients with RA such as in our case, stable and functioning MCPJ II-V arthroplasties have been recommended, and various (semi) constrained prostheses were designed (started in 1953 with the Brannon and Klein type; followed by other typs since 1961: Flatt, Griffith-Nicolle, Schetrumpf, Schultz, Steffe, George-Buchholtz, Minami, Strickland, Walker, Weightman, Link, Weko, Daphne) to increase the grip strength and to decrease the risk of recurrence of ulnar deviation with or without (sub)luxation postoperatively due to the inherent lack of ligamentous support which is usually observed after silicone rubber MCPJ arthroplasties. The first type of the constrained and uncemented Mathys prosthesis, introduced in the 70th, was an all-plastic implant that consisted of a polyacetal-resin and a polyester component, a metal core, and a screw. The two components are implanted separately and are fixed intramedullary by an expanding mechanism (rawl plug principle). A cone shaped metal piece is pressed into the stem by a screw to secure the stems into the medullary spaces. The two components are snapped together afterwards (hinge joint). The main problem was the migration of the prosthesis so, within a few months postoperatively, the Range Of Motion (ROM) was very poor [21-23], which led to its withdrawn from the marketplace. The second design of the constrained Mathys prosthesis (RM prosthesis) with its hinge joint which was used in our case consists of two polyetheretherketone (PEEK) components (Figure 2B). There is an internal titanium screw for initial fixation and the stems are coated with titanium for bone ingrowth . PEEK has been proven to be a biocompatible biomaterial and with sufficient strength for a joint replacement . One retrospective study that compared the outcome of 86 silicone implants versus 22 RM prostheses for the MCPJs and PIPJs in a short to medium follow-up has been demonstrated a significant higher functionality and stability of the RM prostheses versus the silicone implants . However, long-term results with a larger number of patients could not be found in the literature. Hence, further studies are needed to validate the RM prosthesis. Intraoperative periprosthetic fracture in MCPJ arthroplasty such as in our case is a concern, its occurrence is reported to be 3% associated with an increased risk with the use of pyrocarbon implants, cementless fixation of components such as in our case, and in the presence of diabetes mellitus . Ceramic prostheses for replacement of the small joints in the hand are discussed in general in the literature critically [27-30].
The new generation of MCPJ arthroplasty is unconstrained surface replacement either with pyrocarbon prostheses [8, 31, 32] or prostheses with a metal-on-polyethylene (PE) articulation [33, 34]. The goal of these prostheses is that they are low profile, anatomically designed implants limit the amount of bone removed . The unconstrained partial cemented MCPJ resurfacing SRTM MCP implant is one of the new generation types that are current in use . It has a cobalt-chrome (CoCR) alloy metacarpal hemispherical head that articulates against an Ultra-High Molecular Weight (UHMW) PE phalangeal component (Figure 3A). The phalangeal component is to be inserted generally with cementation, whereas the metacarpal component with its titanium coated stem was primarily manufactured for uncemented insertion based on the osseointegration concept for endoprosthetic reconstruction of small joints in the hand [37, 38]. However, if the metacarpal intramedullary space is widened due to bone resorption with cortical thinning such as in our case, cementation of the titanium coated stems, that is useful in PIPJ arthroplasty as well , is inevitable. The MCPJ is a condylar ball-and-socket joint with a convex surface on the metacarpal head and an incongruent (larger radius of curvature) concave surface on the proximal phalanx. The major problem of unconstrained resurfacing MCPJ implants is dislocation tendency in the ulnopalmar direction if the palmar plate and/or the collateral ligaments are insufficient. The SRTM MCP implant was designed to decrease this risk by having a greater arc of curvature on the dorsal aspect of the metacarpal component. In a biomechanical study, a higher intrinsic stability of this implant compared to un-affected human cadaver joints could be evaluated . One disadvantage of this implant is that cement removal is difficult in the necessity of revision and also there is a concern about the effect of heat polymerization . Ibsen Sørensen  reported in a prospective study including 105 SRTM MCP joint arthroplasties (88 patients with RA, including severe conditions such as palmar (sub) luxation preoperatively) with a follow-up from 1 month to 5 years (74 patients with a minimum of 1 year), that clinical parameters (ROM, pain, pinch grip) had improved, there was only 1 loosening of a metacarpal component after 3 years (0,95%), and early implant dislocation due to collateral ligament insufficiency was observed in 8 cases (7,6%) postoperatively. All 8 dislocated prostheses have survived after surgical repair of collateral ligaments without any negative influence on clinical parameters. However, in comparison to the use of constrained MCPJ arthroplasty with the RM prosthesis, long-term results with the use of the SRTM MCPJ resurfacing arthroplasty could not be found in the literature as well. The longterm survival rate for resurfacing pyrocarbon MCPJ arthroplasty is reported to be 81, 4% .
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