1

©2011 British Editorial Society of Bone and Joint Surgery

Focus OnAnatomical Small Joint Replacement in the Hand

IntroductionThis review will focus on arthroplasty in the hand using implantsintended to recreate normal anatomy and biomechanics. The sur-gical considerations for anatomical small joint replacement arequite different to those for a silastic arthroplasty, in which theimplant acts as an internal splint allowing the soft tissues to rebal-ance. Silastic joint replacement certainly has an important role inthe management of inflammatory arthropathy in the hand. Withanatomical implants attention must be paid to critical soft-tissueattachments, bone resection and implant alignment to avoidissues of instability, maximise movement and provide longevity.

Consideration will be given to the surgical anatomy, biome-chanics, implant design, surgical tips, reported outcomes andcomplications for arthroplasty of the metacarpophalangeal joint(MCPJ), proximal interphalangeal joint (PIPJ) and first carpomet-acarpal joint (CMCJ). Readers are directed to the implant manu-facturers' literature for information on implantation technique.

Metacarpophalangeal Joint (MCPJ)The most common indication for arthroplasty of the MCPJs isrheumatoid arthritis; in these cases silastic arthroplasty withsoft-tissue rebalancing is most usually indicated and doeswell.1,2 In patients with primary and post-traumatic osteoarthritis(OA), the silastic implant fares less well. Early failure may occuras a result of the high demands placed through the implant in anotherwise normal hand.3 In these cases anatomical replace-ment is probably a better alternative.Surgical Anatomy. The MCPJ is a condylar joint with a convex,cam-shaped surface on the metacarpal head and an incongruent(larger radius of curvature) concave surface on the proximal pha-lanx. This allows 150° of flexion/extension and up to 57° of radio-ulnar deviation in extension, although most activities of daily livingare achieved in an arc of 10° to 70° of flexion.4,5 The primary sta-bilisers of the joint form a sling, whose sides are formed by the col-lateral ligaments which originate from the tubercle on themetacarpal head and insert onto the base of the proximal pha-lanx, the accessory collateral ligaments which insert into the floorof the sling, and the volar plate, which is mobile at the MCPJ.

Work from the Mayo clinic in 1984 showed that the collateralligaments have differing actions at various positions of the joint.The ligaments are, however, at full stretch in MCPJ flexion,thereby preventing abduction and rotation but are relativelyslack in full extension in order to allow these movements.6 Thesecondary stabilisers are the musculotendinous units that cross

the joint; the long extensors (primary extensors of the MCPJ), thelong flexors (primarily act on the PIPJ and distal interphalangealjoint (DIPJ)) and the intrinsic interosseous and lumbrical muscleswhich are the primary flexors of the MCPJs.Biomechanics. The MCPJ is subjected to significant forces, up to190 Newtons during a pinch manoeuvre and probably more withpower grip.7 The centre of rotation is unlikely to be through afixed point on the metacarpal head because of the latter's camshape. Despite this, most prostheses are designed to incorpo-rate a fixed point of rotation.Surgical tips. The MCPJ is best approached through a dorsalincision, orientated either longitudinally over the MCPJ or trans-versely if multiple joints are to undergo surgery. It is important topreserve the vascular bundles that run in the gutters betweenthe metacarpals in order to retain venous drainage and preventswelling. We would advocate a radial paratendinous approach,as the radial sagittal band often requires imbrication to central-ise the tendon. The tendon can be elevated from the underlyingcapsule and a median capsulotomy performed. With anatomicaljoint replacement, any soft-tissue release should be limited and,in particular, care must be taken to retain the attachments of thecollateral ligaments.Implant design. Early implants were of the constrained-hingedesign, but these often failed by fracture or loosening, leading torecurrent deformity. The first unconstrained “anatomical”implant was made from alumina ceramic with favourable out-comes, but the authors felt that the design could be improved bymoving the centre of rotation more volarward.8-11 Other designsnow use pyrocarbons and other composite materials. Pyrocar-bon is a synthetic material with a high strength graphite corecoated with a pyrolytic carbon layer formed by heating a hydro-carbon gas to approximately 1300°C. Pyrocarbon was first usedin mechanical heart valves, is inert and compatible with normalbone. It was initially thought that osseointegration would occurbut this has been shown not to be the case.12

Reported outcomes. In 1999, Cook et al reported their experi-ence in 53 predominantly rheumatoid patients with 151 ana-tomical unconstrained MCPJ implants made from pyrocarbon(Fig. 1).13 Despite the use of this material, the authors reporteda revision rate of 12% with a ten-year survival rate of 81.4%. Theshort-term outcome of a pyrolytic carbon implant in patients withOA has also been shown to be good.14 In both rheumatoid arthri-tis (RA) and OA, pyrocarbon MCPJ arthroplasty has been shownto reduce pain scores and increase range of movement in the

2 A. C. WATTS, I. A. TRAIL

THE JOURNAL OF BONE AND JOINT SURGERY

short term. In rheumatoid patients implant subsidence has beendocumented.15

Harris and Dias have reported their results using ananatomical implant with cobalt chrome on an ultra-high-molecular-weight polyethylene (UHMWPE) bearing.16 The proxi-mal cobalt-chrome component is inserted into an UHMWPEpress-fit sleeve that is itself inserted into the metacarpal with aninterference fit. The authors followed up 13 joints for a mean offive years; there was one revision for infection, and evidence ofloosening of two phalangeal and one metacarpal component.Complications. The complications seen after anatomical MCPJarthroplasty are different to those for silastic arthroplasty. Sub-luxation or dislocations of the unconstrained components, loos-ening of the implants, implant fracture and joint stiffness haveall been described.13,17

These complications can be a challenge to address. A looseimplant may be revised to a larger prosthesis with bone grafting.If an implant is to be removed, then the surgeon may considerrevision to a silastic implant or volar plate arthroplasty.

Proximal Interphalangeal Joint (PIPJ)Enthusiasm for PIPJ arthroplasty has recently increased as aresult of the success of MCPJ replacement, although PIPJ fusioncan result in acceptable hand function and excellent pain relief.However, where there is concomitant disease of the MCPJ orDIPJ, fusion of the PIPJ will result in a stiff finger and impairedfunction, and a motion-retaining arthroplasty may be preferred.Equally, an adequately counselled patient may choose to acceptthe risk of arthroplasty in order to maintain some movement inthe joint rather than opt for a fusion. The only contraindicationsto arthroplasty in our practice are young active patients, manualworkers, and patients with significant bone loss, gross instabilityor previous infection.Surgical anatomy. The PIPJ is a bicondylar joint with an inter-condylar concavity on the proximal phalanx.18,19 On either side ofthe head of the proximal phalanx are pits from which the collat-

eral ligaments originate. On the middle phalanx are two con-cavities, incongruent with the middle phalanx possessing alarger radius of curvature, separated by a saddle-shaped ridgethat dorsally extends into a tubercle for the attachment of thecentral slip. On the volar margin of the articular surface is arough, flat area for insertion of the volar plate; this takes originproximally from the checkrein ligaments attached to the neck ofthe proximal phalanx. The accessory collateral ligament takesorigin close to the true collateral near the pit on the proximalphalanx and inserts into the volar plate. This completes the wallsof a box made up of the articular surface, volar plate and collat-eral and accessory collateral ligaments. Biomechanics. Movement of the PIPJ varies from 0° to 30° ofhyperextension to 100° of flexion. The PIPJ is not a true hingejoint as there is a small amount of rotation and angulation of thecoronal plane during flexion; the axis of rotation is centred on afixed point on the head of the proximal phalanx. Minamikawaetal demonstrated that with a lateral stress, 5° of adduction and9° of supination is seen at the PIPJ.20 In full extension and flex-ion the joint is more stable.Surgical tips. Arthroplasty of the PIPJ can be performed underlocal anaesthetic (if only one joint), regional block or generalanaesthesia. The joint may be approached through dorsal or volarapproaches, or through the ulnar lateral border. The dorsalapproach allows for excellent exposure and is of particular benefitwhere large osteophytes are present. Our preferred technique is tosplit the extensor hood in the midline, elevating the central slipinsertion off the middle phalanx as a continuous sleeve for re-attachment with a transosseous suture. Alternatively, a dorsal, dis-tally based chevron Chamay approach may be used.21 The centralslip is divided in a chevron shape with the base on the middle pha-lanx. The lateral bands are preserved and allowed to sublux volar-ward to allow the joint to be hinged open. Here too, retention of softtissue attachments is critical to the stability of the prosthesis.

In the operation note the surgeon should document the sta-bility of the PIPJ, and whether the joint is suitable for early activemobilisation. The finger should be splinted immediately with avolar slab, with the wrist in neutral, the MCPJ and PIPJ in slightflexion and the hand elevated to reduce swelling. Rehabilitationshould begin on day two, preferably under the supervision of anexperienced hand therapist. If suitable, early active mobilisation

Fig. 1

Radiographs of the Ascension pyrocarbon MCPJ arthro-plasty (Ascension Orthopedics, Austin, TX).

Fig. 2

A resting splint to block extension of the PIPJ at 20°.

ANATOMICAL SMALL JOINT REPLACEMENT IN THE HAND 3

can be commenced with a resting splint to block extension at20° (Fig. 2). If a lateral approach has been used the collateralrepair should be protected with a radial outrigger or by buddystrapping. At six weeks protective splints can be discontinuedbut a resting night splint should be worn for a minimum of threemonths.Implant designs. The first anatomical resurfacing PIPJ wasdeveloped by Linscheid using stemmed unconstrained implantswith a bearing of UHMWPE on cobalt chrome.22 The stems werefixed with polymethylmethacrylate cement. An uncementedimplant with an UHMWPE on cobalt chrome bearing, the PIPr(Depuy, Warsaw, IN) (Fig. 3), is now available as well as a pyrocar-bon implant (Ascension Orthopedics, Austin, Texas) (Figs. 4 & 5). Reported outcomes. In 1979, Linscheid et al reported theresults of 66 of their implants in 47 patients with a minimumfollow-up of one year.22 Using their own criteria they reported32 good, 19 fair and 15 poor outcomes. The outcomes wereworst in digits with pre-existing deformity or extreme bone and/or soft-tissue loss. A more recent cohort from Australia reportedexcellent long-term results in 18 of 20 patients.23

The outcomes of uncemented anatomical pyrocarbon PIPJarthroplasty have been reported in a number of studies.24-30 AtWrightington, we have undertaken the largest study to date of97 joints in 72 patients with a minimum follow-up of two years.The results of our study, and of previously published series, aregiven in Table I. The main concern with the pyrocarbon implantsis at the bone-implant interface. Osseo-integration does notoccur and, in many cases, a radiolucent line may be seen aroundthe implant.24 To date this worrisome lucency has not translatedinto large numbers of implant failures but it does give cause forconcern. A comparative study of pyrocarbon arthroplasty against

silastic arthroplasty showed equivalent outcome in all parame-ters except stability in the coronal plane, which was better in thepyrocarbon group.27

The Finsbury PIPr (DePuy) has a mobile UHMWPE-bearingdistal component articulating with a cobalt-chrome proximal com-ponent; both components have a hydroxyapatite-coated cobalt-chrome uncemented stem (Fig. 3). The one-year results with thisprosthesis in 43 digits have been reported from our unit at theBritish Hand Society31 with favourable results; pain scores andrange of movement improved although two revisions occurred atsix months and two years and three patients developed a swan-neck deformity. More long-term data are clearly required.Complications. As with all implants, infection is a major concernafter PIPJ arthroplasty. From our own data we estimate the risk atapproximately 1%. This is best treated by excision and secondaryreconstruction with a silastic implant, or volar plate arthroplasty.With unconstrained implants instability is a problem that is bestavoided with careful soft-tissue balance and accurate implantalignment at the primary procedure. Early dislocations may beaddressed with closed reduction and splintage. If this manage-ment fails then revision to a hinged, silastic implant is likely toprovide a stable, pain-free joint. Implant loosening, a commonproblem with highly constrained arthroplasty, is also seen withunconstrained components. Revision with larger componentsand bone grafting may be successful, otherwise a silastic hingedimplant can be used.

First Carpometacarpal Joint (CMCJ)First carpometacarpal osteoarthritis is a very common condition,particularly among elderly females. A number of prostheseshave been developed to address this problem but comparative

Table I. Reported outcomes of the Ascension pyrocarbon PIPJ arthroplasty (Ascension Orthopedics, Austin, TX)24-30

Year Author No. m/f Follow-up (mths) Age Increase arc Re-operation Revision Satisfaction Pain

2006 Herren 17 19 (12-27) 64 (55-81) 8 6% 6% 71% 8 to 12006 Nunley 7 02:03 7 (12-23) 40 (28 -56) 2 28% 28% 14% 6 to 42006 Tuttle 18 00:08 13 (6-30) 62 (52-69) 0 11% 0 84% 8 to 02007 Branam 19 00:10 19 (6-36) 62 (52-69) 1 0 81% 22007 Ng 15 02:12 27.4 (7-44) 62 (38-82) 15.3 20% 0 8 to 22007 Bravo 50 15:20 37 (27-46) 53 (21-73) 7 28% 8% 80% 6 to 12010 Wijk 53 07:36 24 (12-60) 59 (40-85) -8 13% 2% 3 to 0.42010 Watts (unpublished) 97 21:51 60 (24-109) 56 (24-79) 13 23% 13% 76% 0

Fig. 3

Finsbury PIPr Implant (Depuy, Warsaw, IN)

Fig. 4

Ascension PIP Implant (Ascension Orthopedics, Austin,TX)

4 A. C. WATTS, I. A. TRAIL

THE JOURNAL OF BONE AND JOINT SURGERY

studies have not demonstrated an advantage of prostheticreplacement over simple trapeziectomy with or without tendoninterposition. As a result many surgeons have been reluctant toexpose patients to the risks of first CMCJ arthroplasty.Surgical anatomy. Imaeda et al studied the surgical anatomyof the first CMCJ and described five major ligaments; the ante-rior oblique, ulnar collateral, first intermetacarpal, the poste-rior oblique and dorsal radial ligament.32 Of these, the anterioroblique, also known as the beak ligament, is the most impor-tant for stability of the joint and should be retained for success-ful joint reconstruction. The double, saddle-shaped articularsurface is asymmetrical, the convex surface is an ovoid arc(similar in cross-section to an aircraft wing where the radius ofcurvature decreases from back to front). The opposing concavesurface has a small radius of curvature centrally that is main-tained on one side of the central ridge but has a gentler slopeon the other. Xu et al demonstrated that the joint is incon-gruent, allowing flexion, extension, adduction and abduction.The contact area is small, particularly in females, which mayaccount for the increased female susceptibility to OA of the firstCMCJ.33

Biomechanics. The forces that the first CMCJ must withstandare considerable. Cooney and Chao calculated that a tip pinch of1kg will generate 12kg of joint compression. For power grip theload may be as high as 120kg.34

Surgical tips. The surgical approach to the first CMCJ may bedorsal-radial or volar. The dorsal-radial approach is centred overthe first CMCJ in line with the first extensor compartment. Care

must be taken to identify and protect the branches of the super-ficial radial nerve as injury may result in painful neuromata. Theradial artery should be mobilised and protected, any finebranches being cauterised with diathermy. A distally based T-shaped capsulotomy is performed to expose the joint.

The volar approach is through a curvilinear incision on theradial border of the thenar eminence centred over the firstCMCJ. Cutaneous branches of the median nerve should be pro-tected. The thenar muscles are elevated from the underlyingcapsule by sharp volar-ward dissection andthe abductor pollicisbrevis tendon is mobilised dorsally before a longitudinal cap-sulotomy to expose the joint is performed. For successful arthro-plasty, capsular stability is essential. If there is instability as aresult of the previous pathology then ligament reconstructionmay also be performed using tendon grafts such as a split flexorcarpi radialis tendon graft. At Wrightington the joint is immobi-lised in a static splint for six weeks with the thumb abducted andthe nail plate aligned at 90°to the palm.Implant design. As with other joints in the hand, the initial expe-rience of first CMCJ arthroplasty was with silastic implants. Initialreports indicated increased movement, grip strength anddecreased pain with these implants; however, instability wasalso reported.35-38 With longer follow-up there were increasingreports of implant fragmentation, silicon synovitis and continu-ing instability.39-41

Alternatives to silicon arthroplasty include total joint replace-ment with ball and socket designs, and anatomical resurfacingarthroplasty.

Fig. 5

Lateral Radiograph ofAscension PyrocarbonPIP Implant (Ascen-sion Orthopedics, Aus-tin, TX)

Fig. 6

Lateral radiograph of the Ascension pyrocarbon first metacar-pal hemiarthroplasty(Ascension Orthopedics, Austin, TX).

ANATOMICAL SMALL JOINT REPLACEMENT IN THE HAND 5

Reported outcomes. The SR trapezometacarpal prosthesis(Avanta Orthopaedics, CA) was the first anatomical design, withbiconcave cobalt-chrome on UHMWPE-bearing stemmedimplants. Initial results reported by the originators were encour-aging and were supported by impressive kinematic studies.42,43

However, an independent study by Perez-Ubeda et al reported70% failure in 20 implants followed for between 24 and 45months, with loosening in 55% and ankylosis in 15%.44

In 1982 Braun reported the initially favourable results of atitanium metacarpal component and a polyethylene trapezialcomponent, both cemented with PMMA cement.45 Good out-comes were also reported at a mean of 59 months with only onepatient complaining of minimal pain, and one revision for post-traumatic loosening.46

A new anatomical pyrocarbon resurfacing hemiarthroplastyprosthesis for the base of the first metacarpal has now beendeveloped (Ascension Orthopedics, Austin, Texas) (Fig. 6). AtWrightington a review of the first 19 patients to undergo pyrocar-bon hemiarthroplasty with a minimum follow-up of one year pre-sented at the British Hand Society47 indicated an improvementin pain scores but no change in function or grip strength. How-ever, four of 19 joints were subluxed. The authors conclude thatthe implant may have a role in the young patient who wishes toretain strength.Complications. Painful neuromata can be difficult to treat andare best avoided by appropriate care being taken at the initialsurgery. For refractory cases some success has been seen withexcision of the tender skin and a full-thickness skin graft. Withmore recent resurfacing implants new complications haveemerged. Painful loosening of the implant can be addressedwith revision to a larger prosthesis and bone grafting, or simpleimplant excision. Resurfacing hemiarthroplasty may be associ-ated with trapezial erosion which, if painful, may require removalof the implant.

Further Reading: Trail IA. Arthroplasty of the Hand and Wrist.Published by Lawrencekirk, UK.

A. C. Watts, Consultant Hand and Upper Limb Surgeon

I. A. Trail, Consultant Hand and Upper Limb Surgeon

Correspondence: Mr Adam C Watts, Upper Limb Unit, WrightingtonHospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP

E-mail: adam.c.Watts@wwl.nhs.uk

Telephone: +44(0)1257256259

References1. Kimani BM, Trail IA, Hearnden A, Delaney R, Nuttall D. Survivorship of the Neu-

flex silicone implant in MCP joint replacement. J Hand Surg Eur Vol 2009;34:25-8.

2. Goldfarb CA, Stern PJ. Metacarpophalangeal joint arthroplasty in rheumatoidarthritis. A long-term assessment. J Bone Joint Surg [Am] 2003;85-A:1869-78.

3. Trail IA. Metacarpophalangeal Joint Silicone Implant Arthroplasty. J Am Soc SurgHand 2005;5:201-8.

4. Youm Y, Gillespie TE, Flatt AE, Sprague BL. Kinematic investigation of normalMCP joint. J Biomech 1978;11:109-18.

5. Rand DT, Nicol AC. An instrumented glove for monitoring MCP joint motion. ProcInst Mech Eng H 1993;207:207-10.

6. Minami A, An KN, Cooney WP, 3rd, Linscheid RL, Chao EY. Ligamentous struc-tures of the metacarpophalangeal joint: a quantitative anatomic study. J Orthop Res1984;1:361-8.

7. Berme N, Paul JP, Purves WK. A biomechanical analysis of the metacarpophalan-geal joint. J Biomech 1977;10:409-12.

8. Minami M, Yamazaki J, Kato S, Ishii S. Alumina ceramic prosthesis arthroplastyof the metacarpophalangeal joint in the rheumatoid hand. A 2-4-year follow-up study.J Arthroplasty 1988;3:157-66.

9. Adams BD, Blair WF, Shurr DG. Schultz metacarpophalangeal arthroplasty: a long-term follow-up study. J Hand Surg Am 1990;15:641-5.

10. Blair WF, Shurr DG, Buckwalter JA. Metacarpophalangeal joint arthroplasty witha metallic hinged prosthesis. Clin Orthop 1984;184:156-63.

11. Griffiths RW, Nicolle FV. Three years' experience of metacarpophalangeal jointreplacement in the rheumatoid hand. Hand 1975;7:275-83.

12. Daecke W, Veyel K, Wieloch P, Jung M, Lorenz H, Martini AK. Osseointegrationand mechanical stability of pyrocarbon and titanium hand implants in a load-bearingin vivo model for small joint arthroplasty. J Hand Surg Am 2006;31:90-7.

13. Cook SD, Beckenbaugh RD, Redondo J, Popich LS, Klawitter JJ, LinscheidRL. Long-term follow-up of pyrolytic carbon metacarpophalangeal implants. J BoneJoint Surg [Am] 1999;81-A:635-48.

14. Nunez VA, Citron ND. Short-term results of the Ascension pyrolytic carbon metacar-pophalangeal joint replacement arthroplasty for osteoarthritis. Chir Main2005;24:161-4.

15. Parker WL, Rizzo M, Moran SL, Hormel KB, Beckenbaugh RD. Preliminaryresults of nonconstrained pyrolytic carbon arthroplasty for metacarpophalangeal jointarthritis. J Hand Surg [Am] 2007;32:1496-505.

16. Harris D, Dias JJ. Five-year results of a new total replacement prosthesis for thefinger metacarpo-phalangeal joints. J Hand Surg Br 2003;28:432-8.

17. Syed MA, Smith A, Benjamin-Laing H. Pyrocarbon implant fracture after metacar-pophalangeal joint arthroplasty: an unusual cause for early revision. J Hand Surg EurVol 2010;35:505-6.

18. Ash HE, Unsworth A. Proximal interphalangeal joint dimensions for the design of asurface replacement prosthesis. Proc Inst Mech Eng H 1996;210:95-108.

19. Ash HE, Unsworth A. Further studies into proximal interphalangeal joint dimensionsfor the design of a surface replacement prosthesis: medullary cavities and transverseplane shapes. Proc Inst Mech Eng H 1997;211:377-90.

20. Minamikawa Y, Horii E, Amadio PC, Cooney WP, Linscheid RL, An KN. Stabil-ity and constraint of the proximal interphalangeal joint. J Hand Surg Am 1993;18:198-204.

21. Chamay A. A distally based dorsal and triangular tendinous flap for direct access tothe proximal interphalangeal joint. Ann Chir Main 1988;7:179-83.

22. Linscheid RL, Dobyns JH, Beckenbaugh RD, Cooney WP, 3rd. Proximal inter-phalangeal joint arthroplasty with a total joint design. Mayo Clin Proc 1979;54:227-40.

23. Johnstone BR. Proximal interphalangeal joint surface replacement arthroplasty.Hand Surg 2001;6:1-11.

24. Herren DB, Schindele S, Goldhahn J, Simmen BR. Problematic bone fixationwith pyrocarbon implants in proximal interphalangeal joint replacement: short-termresults. J Hand Surg Br 2006;31:643-51.

25. Nunley RM, Boyer MI, Goldfarb CA. Pyrolytic carbon arthroplasty for posttrau-matic arthritis of the proximal interphalangeal joint. J Hand Surg Am 2006;31:1468-74.

26. Tuttle HG, Stern PJ. Pyrolytic carbon proximal interphalangeal joint resurfacingarthroplasty. J Hand Surg Am 2006;31:930-9.

27. Branam BR, Tuttle HG, Stern PJ, Levin L. Resurfacing arthroplasty versus siliconearthroplasty for proximal interphalangeal joint osteoarthritis. J Hand Surg Am2007;32:775-88.

28. Ng MFY, Clarkson JHW, Wilmshurst AD. Pyrocarbon Proximal InterphalangealJoint Arthroplasty: Outcome Audit in the Patient's Environment. The Internet Journalof Hand Surgery 2007;1-1.

29. Bravo CJ, Rizzo M, Hormel KB, Beckenbaugh RD. Pyrolytic carbon proximalinterphalangeal joint arthroplasty: results with minimum two-year follow-up evalua-tion. J Hand Surg Am 2007;32:1-11.

30. Wijk U, Wollmark M, Kopylov P, Tagil M. Outcomes of proximal interphalangealjoint pyrocarbon implants. J Hand Surg Am 2010;35:38-43.

31. Broadbent M, Trail IA. The one year outcome of Finsbury PIPr Joint Arthroplasty.British Society for Surgery of the Hand Autumn Scientific Meeting. Nottingham, 2009.

32. Imaeda T, An KN, Cooney WP, 3rd, Linscheid R. Anatomy of trapeziometacarpalligaments. J Hand Surg Am 1993;18:226-31.

33. Xu L, Strauch RJ, Ateshian GA, Pawluk RJ, Mow VC, Rosenwasser MP.Topography of the osteoarthritic thumb carpometacarpal joint and its variations withregard to gender, age, site, and osteoarthritic stage. J Hand Surg Am 1998;23:454-64.

6 A. C. WATTS, I. A. TRAIL

THE JOURNAL OF BONE AND JOINT SURGERY

34. Cooney WP, 3rd, Chao EY. Biomechanical analysis of static forces in the thumb dur-ing hand function. J Bone Joint Surg [Am] 1977;59-A:27-36.

35. Swanson AB. Disabling arthritis at the base of the thumb: treatment by resection ofthe trapezium and flexible (silicone) implant arthroplasty. J Bone Joint Surg Am1972;54-3:456-71.

36. Poppen NK, Niebauer JJ. "Tie-in" trapezium prosthesis: Long-term results. J HandSurg Am 1978;3:445-50.

37. Eaton RG. Replacement of the trapezium for arthritis of the basal articulations: a newtechnique with stabilization by tenodesis. J Bone Joint Surg [Am] 1979;61:76-82.

38. Swanson AB, deGoot Swanson G, Watermeier JJ. Trapezium implant arthro-plasty. Long-term evaluation of 150 cases. J Hand Surg Am 1981;6:125-41.

39. Pellegrini VD, Jr., Burton RI. Surgical management of basal joint arthritis of thethumb. Part I. Long-term results of silicone implant arthroplasty. J Hand Surg Am1986;11:309-24.

40. Creighton JJ, Jr., Steichen JB, Strickland JW. Long-term evaluation of Silastictrapezial arthroplasty in patients with osteoarthritis. J Hand Surg Am 1991;16:510-19.

41. Lanzetta M, Foucher G. A comparison of different surgical techniques in treatingdegenerative arthrosis of the carpometacarpal joint of the thumb. A retrospectivestudy of 98 cases. J Hand Surg Br 1995;20:105-10.

42. Linscheid RL, Murray PM, Vidal MA, Beckenbaugh RD. Development of a sur-face replacement arthroplasty for proximal interphalangeal joints. J Hand Surg Am1997;22:286-98.

43. Uchiyama S, Cooney WP, Niebur G, An KN, Linscheid RL. Biomechanical analy-sis of the trapeziometacarpal joint after surface replacement arthroplasty. J HandSurg Am 1999;24:483-90.

44. Perez-Ubeda MJ, Garcia-Lopez A, Marco Martinez F, Junyent Vilanova E,Molina Martos M, Lopez-Duran Stern L. Results of the cemented SR trapeziomet-acarpal prosthesis in the treatment of thumb carpometacarpal osteoarthritis. J HandSurg Am 2003;28:917-25.

45. Braun RM. Total joint replacement at the base of the thumb--preliminary report. JHand Surg Am 1982;7:245-51.

46. Badia A, Sambandam SN. Total joint arthroplasty in the treatment of advancedstages of thumb carpometacarpal joint osteoarthritis. J Hand Surg Am 2006;31:1605-14.

47. Odak S, Trail IA, Swamy K, Birch A. A Prospective Study to Evaluate the Outcomeof the Saddle-Shaped Pyrolytic Carbon Hemiarthroplasty Treating Arthritis at the Tra-peziometacarpal Joint. British Society for Surgery of the Hand Autumn ScientificMeeting. London, 2010.