Rheumatic hand's clinical, functional and imagiological correlations following metacarpophalangeal joint silicone arthroplasty

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

Article

Rheumatic

hand’s

clinical,

functional

and

imagiological

correlations

following

metacarpophalangeal

joint

silicone

arthroplasty

夽

Sergio

Figueiredo

a,∗

_,

_Ana

_Daniela

_Pereira

a

_,

_Marta

_Santos

_Silva

b

_,

_Luciana

_Leite

b

_,

Grac¸a

Costa

b

_,

_Cesar

_Silva

b

a_Department_of_Orthopaedics_II,_Centro_Hospitalar_de_Leiria,_Leiria,_Portugal b_Department_of_{Orthopaedics,}_Centro_Hospitalar_do_Porto,_Oporto,_Portugal

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Articlehistory:

Received21December2016 Accepted17February2017 Availableonline30March2017

Keywords: Arthritis,Rheumatoid Arthroplasty Metacarpophalangealjoint Handstrength Silicones

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Objective:Evaluation ofrheumatoidhand-associatedmetacarpophalangealjointsilicone arthroplastymostoftenreliesonfunctionalscoresalone.Thisstudyaimedtounderstand thecorrelationbetweenperceivedandobservedfunction,strength,andalignment. Methods:Cross-sectionalstudyincludingall11women(15hands)submittedtosecondto fifthmetacarpophalangealjointarthroplastyduetorheumatoidarthritisinvolvementfora timeperiodofsevenyears.MeasurementsreliedontheMichiganHandOutcomes Ques-tionnaire,LafayettePurduePegboard,pinchandgripstrength, andanalysisofa lateral “OK-sign”X-rayview.CorrelationanalysisusedSpearman’scoefficient,assumingstatistical significanceforp-values<0.05.

Results:Objectivefunctionwasstronglycorrelatedwithallothervariables(p<0.05),while perceivedfunction failed to correlate with articular alignment in both measurements (p=0.240andp=0.354).Strengthandalignmentwerealsostronglycorrelated(p<0.05). Conclusions:Most measurements stronglycorrelate with eachother, with emphasis on objectivedexteritymeasurement.

夽_Work_performed_at_the_Department_of_{Orthopaedics,}_Centro_Hospitalar_do_Porto,_Oporto,_Portugal. ∗ _{Corresponding}_author.

E-mail:sergio.ﬁgueiredo@gmail.com(S.Figueiredo). https://doi.org/10.1016/j.rboe.2017.03.012

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Correlac¸ões

clínicas,

funcionais

e

imagiológicas

após

artroplastia

da

articulac¸a˜o

metacarpofalangiana

com

implante

de

silicone

na

mão

reumatóide

Palavras-chave: Artritereumatoide Artroplastia Articulac¸ão metacarpofalangiana Forc¸adamão Silicones

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Objetivo: Na maioria dasvezes, a avaliação da artroplastiada articulaçaõ metacarpo-falangeanacomimplantedesiliconeéfeitaapenaspormeiodeescoresfuncionais.Este estudotevecomoobjetivocompreenderacorrelaçãoentrefunção,forçaealinhamento percebidoseobservados.

Métodos: Esteestudotransversalincluiutodasas11mulheres(15mãos)queforam sub-metidasaartroplastiametacarpofalangeananosegundoaoquintodedodevidoaartrite reumatoideemumperíododeseteanos.Asmediçõesbasearam-senoMichiganHand Out-comesQuestionnaire,noLafayettePurduePegboardenasforçasdepinçaepreensão,além daanálisederadiografiadamãoemleque.OcoeficientedeSpearmanfoiusadoparaavaliar acorrelação;valoresdep<0,05foramconsideradosestatisticamentesignificantes. Resultados: A funçãoobjetivafoifortementecorrelacionadaa todasasoutrasvariáveis (p<0,05).Poroutrolado,afunçãopercebidanãofoicorrelacionadaaoalinhamentoarticular emambasasmedições(p=0,240ep=0,354).Aforçaeoalinhamentotambémestiveram fortementecorrelacionados(p<0,05).

Conclusões: Amaioriadasmedic¸õessecorrelacionoufortementeentresi,comênfasena medic¸ãoobjetivadadestreza.

Introduction

Rheumatoidarthritis(RA),achronic,systemic,Tcell-driven autoimmunedisease,iswidelyknownforitsrepercussions inthehand,particularlyinthe middle-agedwoman.1 _Early and severeinvolvementofthe metacarpophalangeal (MCP) andinterphalangealjointsleadstothenearlypathognomonic handdeformitycomposedbysubluxationoftheformerand ulnar deviation ofthe ﬁngers.2 _After_initial _efforts _in con-trolling the disease through a conservative approach, late stagesofthediseasefrequentlyrequiresurgicalintervention inordertorestorehandalignment.SiliconeMCParthroplasty (SMPA),popularizedbySwansonnearly50 yearsago,relies onthereactiveencapsulation oftheprosthesis.3 _By _raising the MCP joint arc of motion, it aims to improve function andaesthetics,whileattainingpainrelief.4,5 _Arc_of_motion measurementshavealreadyproventhemselvesasareliable method toapproach patient satisfaction. However, despite thisandotherobjectivetechniques,postoperativeevaluation mostoftenreliesonperceivedfunctionscoring,notablyusing MichiganHandOutcomes’Questionnaire(MHQ), aswell as pinchandgripstrengths.5_Radiological_ﬁnger_alignment,_as_an example,hasbeenscarcelyused.5_To_our_knowledge,_however, objectivehanddexterityhasnotsofarbeenevaluatedforthe post-operativerheumatoidhand.Thegoalofourstudywasto determinetherelevanceofhanddexteritymeasurementasan objectiveapproachtoevaluatepostoperativeresultsofSMPA.

Materials

and

methods

Weperformedacross-sectionalstudyincludingall11patients submittedto2ndto5thMCPjointsiliconearthroplastyusing

theNeuflexMCPprosthesis(DepuySynthes,Warsaw,IN,USA) due to local involvementof rheumatoid arthritis, between July 1st, 2008 and June 30th, 2015. This gave us a conve-niencesampleof15hands,fourofwhichwerenon-dominant. All patientswerewomen,withamedianageof67.0 years-old (interquartilerange:12.63)andafollow-uptimeof30.0 months(interquartilerange:32.43).Perceivedhandfunction was evaluatedbyMHQ, withoutmedicalsurveillance, with strict helponlyin situations ofdoubt, aimingforlowering answering bias. MHQ comprises 37 outcome questions for eachhand,onitsfunction,itsinfluenceondailyroutineand work,relatedpain,aestheticsandpatientsatisfaction, scor-ingfrom0to100.Objectivefunctionmeasurementreliedon Purdue Pegboard’s test(Lafayette InstrumentCo, Lafayette, IN,USA),inanadaptationoftwoofitsfour designed exer-cises.Afteranadaptationtryout,patientsperformedthefirst exercise,modifiedfromtheoriginal,inwhichthemeasured hand was the one already submitted to surgery, consist-ing ofsequential pin placement in a predefined board for a time periodof 30s (in the original form, bothdominant andnondominanthandsaremeasuredforthefirstand sec-ondexercises).Eachpincorrectlyplacedcountedasapoint. The second exerciseconsisted on a60-s runin which the patienthadtoassembleapin-washer-collar-washerstructure inasequentialmanner,usingbothhands.Eachpieceapplied countedasapoint.Tip-pinchandgripstrengths,measured inkilograms-force,weregatheredcalculatingthemeanof 5-tryoutmeasurements,usingaJamar hydraulicpinchgauge andaJamarhydraulichanddynamometer(Lafayette Instru-mentCo, Lafayette,IN,USA).Lastly,dexterity-relatedfinger alignmentwasmeasured onalateral “OK-sign”X-rayview, consistingontheangleformedbythedistalphalanxofboth thethumbandtheindexfinger(D1–2␣),aswellastheindex

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Fig.1–Determinationoftheangleformedbythedistal phalanxofboththethumbandtheindexﬁnger(D1–2␣),in alateral“OKsign”sideX-ray.

formed by the minor over major diameters of the ellipse formedbythefirstandsecondfingers(Figs.1and2).Duetoour smallsamplesize,correlationanalysishadtorelyona non-parametrictest,thusthechoiceforSpearman’scoefficients. Statisticalsignificancewasconsideredwheneverwefounda p-valueunder0.05.AnalysiswasperformedusingIBMSPSS Statisticsv20.0.0(IBMCorporation,Armonk,NY,USA).

Results

Table 1 summarizes the descriptive data. It is noteworthy to mention high interquartile ranges for most measured variables,incompliance withhighlydifferent surgical out-comes.Subjective function,asmeasured byMHQ,revealed statisticallysigniﬁcant correlationswithobjective function, asmeasuredbyPP’saffectedhand(rho=0.702;p=0.004)and assembly scores (rho=0.521; p=0.047), and also with tip-pinch strength (rho=0.746; p<0.001). Neither grip strength (rho=0.298; p=0.280) nor X-rayalignment as measured by D1–2␣(rho=−0.323;p=0.240)andminorovermajorelliptical diameterindex(rho=−0.257;p=0.354)foundthesame.Apart fromsubjectivefunction,asmentionedabove,objective func-tionmeasurementinitsassemblyscorealsocorrelatedwith

Fig.2–Determinationoftheindexformedbytheminor(a) overmajor(b)diametersoftheellipseformedbytheﬁrst andsecondﬁngers,inalateral“OKsign”sideX-ray.

all othervariables inastatisticallysignificantfashion (key-pinchstrength:rho=0.850,p<0.001;gripstrength:rho=0.677, p=0.006;D1–2␣:rho=−0.543,p=0.037;minorovermajor ellip-ticaldiameterindex:rho=−0.619,p=0.014).Theaffectedhand scoresolely correlatedwithkey-pinch strength (rho=0.659; p=0.008),apartwiththeassemblyscore(rho=0.675;p=0.006) andMHQ.Alignment(boththefirst-secondfingerdistal pha-lanxangle andminorover majorellipticaldiameterindex) wasalsostatisticallysignificantlycorrelatedwithbothpinch (rho=−0.798;p<0.001andrho=−0.720;p=0.002,respectively) and grip strengths (rho=−0.798; p<0.001 and rho=−0.720; p=0.002).ThisissummarizedinTable2.

Discussion

SynovitisoftheMCPjointendsupinitsulnardeviationand volarjointsubluxationcausedbychangesinthevolarplate andligamentoussupport.Thisalsoleadstoshorteningofthe intrinsicmusclesand consequentproximalinterphalangeal joint hyperextension, aggravated by long extensor tendon attachmentchangesattheproximalphalanx.4 _All_this_may posedifﬁcultiesinhandfunction,mainlyonstrengthand dex-terity,lastlyleadingtoadecreaseinpatient’ssatisfaction.In

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Table1–Collectedmeasurementdataregarding perceived(MHQ)andobjective(PP)functions,strength (key-pinchandgrip)andalignment(throughX-ray measurements).

Median P25–P75

A.MichiganHandOutcomes Questionnaire(%) 21.00 48.00 1.Generalscore 41.18 43.64 2.Workscore 25.00 55.00 3.Painscore 25.00 65.00 4.Appearancescore 12.50 32.25

5.Finalquestionsscore 5.17 70.83

B.PurduePegboarddexteritytest(points)

1.Affectedhandscore (30s) 10 6 2.Assemblyscore(60s) 15 10 C.Strength(KgF) 1.Tip-pinch 3.00 1.50 2.Grip 5.00 4.00 D.X-raymeasurements 1.DistalphalanxD1–D2 angle(◦) 91.0 70.8 2.D1–D2ellipse:minor overmajordiameter index

0.55 0.20

awaytosolve it,SMPA hasalready provenitselfeffective, consideringproperlyselected patients.6 _A_high _focus _relies onmeetingpatients’expectations,thusrenderingit impor-tanttounderstandwhat,onobjective terms,isunderstood assuch.7 _In _our_trial, _the _existence_of_strong_{relationships} betweenmostof the measuredvariables stronglysuggests theirvalidityinmeasuringsuccessfollowingSMPA.Thisisnot surprisingconsideringhandfunctiondependsonitsstrength andproperjointalignment.Whatendsupassurpriseisthe majorutilityofhanddexteritymeasurementswhencompared withMHQ.Itismorerelatableand,therefore,more univer-salandmostlikelylesspronetobias.Whencomparingpre withpostoperativepatientsatisfaction,regardingSMPA,ithas alreadybeenfoundthatitisnotdirectlyrelatedwithpinch andgripstrengthbut rathertoimprovementsinalignment andarc ofmotion.3,5,7 _{Postoperative}_satisfaction _per_se,_on anygivenmoment,wasnotyetanalyzed,toourknowledge.

As a surrogatemeasurement, arc ofmotiondoes notalso directlyreflectfunction,asitdoesnotmeasurethemajor ben-efitscomingoutofit.Handdexteritymeasurements,onthe other hand,arewidelyusedinindustrialand medical pur-poseswithinterestingresults.8_An_apparent_benefit_coming outfromregularhandpractice,despiteinfluencesoriginating onhandsizeandage,hasalreadybeenreported.8_As_a_cross sectionalstudy,itislimitedbyreadingsperformedat differ-entfollow-up timesatdifferentages.Althoughnotdirectly affectingtheobservedcorrelationbetweenmeasurements,it hasalready beenobservedthat handfunction, asawhole, declinesovertime,lastlyresultinginimplantfailure.9–11This isofmajorconcernwhendesigningnewimplants,asRAis punishingnotonlyjointsurfacesbutalsocapsularand tendi-nousstructures.Themaingoalistoallowforencapsulation, inordertoreachstability,atthesametimeproperalignment andfunctionareachieved.Siliconeimplantsrelytheir move-mentonacentralhinge,whichcannotbeeithertoothin,for resistancepurposes,nortoothick,forflexibilitypurposes.12,13 Theimplantitselfisnotdesignedtoaspecificpatientleading tovariableresults,withcomplicationratesvaryingfromstudy tostudy,withoursinbetween.11,13,14_As_strength_seems_not tobeofmajorconcerninregardsofperceivedand objecti-fiedfunction,andalthoughnoneofourpatientshadfailed implants or was submitted to revision surgery, it may be of interest to design prosthesis better related to durabil-ity,althoughfailedimplantsseemnottobecorrelatedwith patientsatisfaction.5,9,14 Assemblyscoresondexterity mea-surementrequiresbothhands,whichmayposebiasedresults assomepatientsweresubmittedtobilateralsurgerieswhile themajoritywasnot.Anyhow,thisdidnotdisturb correla-tionanalysis,possiblybecausetheirdiseasewasalreadymore severeinregardsofjointinvolvement.Thesmallsamplesize isrelatedtothereasonablysmallpopulationundergoing com-pletesecondtofifthSMPAinourinstitution,possiblydueto theincreasingsuccessofnon-surgicalapproacheswhen deal-ingwithRA.Wealsofailedinnotdirectlysurveyingforpain, eitheritbeingconstantorrecurrent,relyingontheMHQalone, althoughitcouldcomeasamajorindependentfactor relat-ing topatients’satisfaction.15 _All _added,_and _comparing_to what’sbeendiscoveredsofarinregardsofsurgicalsuccess, ourstudyisimportantinsuggestingdexteritytestsasmajor playersinmeasuringobjectivefunction.5_This_may_be_futurely

Table2–CorrelationanalysisofthedifferentvariablesusingSpearman’stest.

Spearman’s correlation“rho” (p-value)

A.MHQ B.1.PPAHS B.2.PPAS C.1.PinchS. C.2.GripS. D.1.X-rayD1–2␣ D.2.X-rayellipse

A.MHQ 1.000 0.702(0.004) 0.521(0.047) 0.746(<0.001) 0.298(0.280) −0.323(0.240) −0.257(0.354) B.1.PPAHS 1.000 0.675(0.006) 0.659(0.008) 0.191(0.496) −0.148(0.598) −0.076(0.789) B.2.PPAS 1.000 0.850(<0.001) 0.677(0.006) −0.543(0.037) −0.619(0.014) C.1.PinchS. 1.000 0.643(0.010) −0.627(<0.001) −0.581(0.002) C.2.GripS. 1.000 −0.798(<0.001) −0.720(0.002) D.1.X-rayD1–2␣ 1.000 0.533(0.041) D.2.X-rayellipse 1.000

MHQ,MichiganHandOutcomesQuestionnaire,totalscore;PPAHS,PurduePegboard’stestaffectedhandscore;PPAS,PurduePegboard’stest assemblyscore;PinchS.,keypinchstrength;GripS.,gripstrength;X-rayD1–2␣,Thumb-indexﬁngerdistalphalanx“OK-sign”sideangle;X-ray ellipse,indexofminorovermajorellipticaldiameterformedbythe“OK-sign”.

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testedinapretopostoperativeanalysis,inordertoimprove bothimplantsandtechniquesrelatedtotherheumatoidhand. Obviouslysuchshouldbealwayscorrelatedwithqualityoflife assessmentsurveys,astheremaybealimitinwhichfunction doesnotnecessarilyresultingeneralpatientsatisfaction.16,17

Conclusions

Summarizing,hand dexterity as measured by Purdue Peg-board’s test offers a relatable and reliable approach to objectivelymeasurethe outcomeofpatientswith rheuma-toidhandsubmittedtoSMPA.Alignmentandstrength also correlatedstrongly,thuspointingouttherelevanceofproper arthroplastypositioningduringtheprocedure.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

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