Osteoarthritis (OA) of the first carpometacarpal (CMC) joint is a common disabling condition that mostly affects women over 45 years of age.1 Surgical intervention is usually indicated in advanced stage OA of the first CMC joint that has failed conservative treatment. Several surgical techniques have been described, including partial or total trapeziectomy, interposition arthroplasty with or without ligament reconstruction,2,3 metacarpal osteotomy,4 hematoma and distraction arthroplasty,5 total joint arthroplasty, arthrodesis, and suspensionplasty.6 However, no single surgical procedure has proved to be superior.7
The Artelon implant (Artelon, Nashville, Tennessee) is a T-shaped spacer composed of a biocompatible and biodegradable polycaprolactone-based polyurethane urea polymer. The developers of the implant first presented its use in CMC OA in 2005.8 The device, an endoprosthetic replacement for the CMC joint, was designed to work through 2 modes of action: stabilization of the CMC joint by augmentation of the joint capsule and by formation of a new articular surface at the trapeziometacarpal interface. The interposed biomaterial has been described as preventing bony impingement and allowing time for replacement with a newly formed articular surface as it undergoes slow and controlled degradation.8
We present a patient with recurrent CMC pain and disability 4 years after arthroscopic hemitrapeziectomy and Artelon interposition and discuss the associated histologic findings. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 53-year-old man presented with painful disability of right thumb of several months’ duration. Clinical and radiographic evaluation supported the diagnosis of right thumb CMC joint Eaton stage III arthritis (Figures 1A, 1B). Surgical intervention was indicated after a failed course of conservative treatment, including splinting, nonsteroidal anti-inflammatory medications, activity modification, and corticosteroid injection. Preoperatively, the patient reported a visual analog scale (VAS) score of 8 with activity and 5 at rest, and a Disabilities of the Arm, Shoulder, and Hand (DASH) score of 72.5.
Arthroscopic débridement, hemitrapeziectomy, and interposition arthroplasty with the Artelon spacer were performed. Using standard thumb arthroscopy, 3 mm of the distal trapezium was excised and shaped parallel to scaphotrapezial joint. The wings of the standard-sized Artelon spacer were removed, and the central (articulating) portion was rolled into a tube and inserted through the 1R portal (directly radial to the abductor pollicis longus tendon) into the trapezial space. The Artelon spacer was unrolled within the joint to cover the remaining trapezium and was stabilized with the placement of a 0.045-inch Kirschner wire through the metacarpal, the spacer, and the remaining trapezium. The patient used a thumb spica splint for 4 weeks.
The postoperative radiographs showed a smooth and adequate hemitrapeziectomy with good alignment and implant position (Figures 2A, 2B). Four weeks after surgery, the Kirschner wire and cast were removed and physical therapy was initiated. The patient’s CMC pain gradually subsided. At the 3-month postoperative visit, the patient’s VAS score was 3 with activity and 1 at rest, with a DASH score of 28. His key pinch strength was 12 lb, compared with 20 lb on the contralateral side. At 6 months, the patient’s VAS score was 1 with activity and 0 at rest, with a DASH score of 12. His key pinch strength was 18 lb, compared with 22 lb on the contralateral side. At his 2-year postoperative visit, the patient was doing well with the exception of some mild residual pain when he opened tight jars. His VAS score was 1 with activity and 0 at rest, with a DASH score of 3. His key pinch strength was 20 lb, compared with 23 lb on the contralateral side. Radiographs showed good maintenance of the CMC space.
Four years postoperatively, the patient presented with worsening right CMC pain with decrease in pinch strength that interfered with his activities of daily living. His VAS score was 9 with activity and 6 at rest, with a DASH score of 70. On examination, pinch strength was 16 lb, compared with 22 lb on the contralateral side. Radiographs showed advancing arthritis with new osteophyte formation and irregular contour of distal trapezium (Figures 3A, 3B). The symptoms were refractory to conservative measures and continued to interfere with his activities of daily living. Revision surgical intervention was indicated and pursued in the form of an open CMC arthroplasty.
The intraoperative findings revealed degradation and disorganization of the Artelon implant within the central portion of the remaining distal trapezium. Rim osteophytes, especially along the ulnar aspect, were noted. Total trapeziectomy and débridement within the CMC space and suture-button suspensionplasty were performed.8 Slight degenerative changes of the distal scaphoid were also noted. The incision was irrigated, closed, and stabilized in a thumb spica splint (Figures 4A, 4B).
