Silicone and Pyrocarbon Artificial Finger Joints

F. A. Alnaimat; H. A. Owida; A. Al Sharah; M. Alhaj; Mohammad Hassan

doi:10.1155/2021/5534796

Silicone and Pyrocarbon Artificial Finger Joints

Alnaimat, F. A.;Owida, H. A.;Al Sharah, A.;Alhaj, M.;Hassan, Mohammad 2021-06-04 00:00:00 Hindawi Applied Bionics and Biomechanics Volume 2021, Article ID 5534796, 12 pages https://doi.org/10.1155/2021/5534796 Review Article 1 1 2 2 3 F. A. Alnaimat , H. A. Owida, A. Al Sharah, M. Alhaj, and Mohammad Hassan Medical Engineering, Al-Ahliyya Amman University, Al-Saro, Al-Salt, Amman, Jordan Computer Engineering, Al-Ahliyya Amman University, Al-Saro, Al-Salt, Amman, Jordan Civil Engineering, Faculty of Engineering, Al-Ahliyya Amman University, Al-Saro, Al-Salt, Amman, Jordan Correspondence should be addressed to F. A. Alnaimat; f.alnaimat@ammanu.edu.jo Received 10 February 2021; Revised 23 May 2021; Accepted 27 May 2021; Published 4 June 2021 Academic Editor: Juan Carlos Prados-Frutos Copyright © 2021 F. A. Alnaimat et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Artiﬁcial ﬁnger joint design has been developed through diﬀerent stages through the past. PIP (proximal interphalangeal) and MCP (metacarpophalangeal) artiﬁcial ﬁnger joints have come to replace the amputation and arthrodesis options; although, these artiﬁcial joints are still facing challenges related to reactive tissues, reduced range of motion, and ﬂexion and extension deﬁcits. Swanson silicone artiﬁcial ﬁnger joints are still common due to the physician’s preferability of silicone with the dorsal approach during operation. Nevertheless, other artiﬁcial ﬁnger joints such as the pyrocarbon implant arthroplasty have also drawn the interests of practitioners. Artiﬁcial ﬁnger joint has been classiﬁed under three major categories which are constrained, unconstrained, and linked design. There are also challenges such as concerns of infections and articular cartilage necrosis associated with attempted retention of vascularity. In addition, one of the main challenges facing the silicone artiﬁcial ﬁnger joints is the fracture occurring at the distal stem with the hinge. The aim of this paper is to review the diﬀerent artiﬁcial ﬁnger joints in one paper as there are few old review papers about them. Further studies need to be done to develop the design and materials of the pyrocarbon and silicone implants to increase the range of motion associated with them and the fatigue life of the silicone implants. was attributed to a lack of understanding of the mechanics 1. Introduction of small joints and the use of ineﬀective interpositional mate- Orthopedic surgeons treat patients with rheumatoid and rials [7, 13]. Similarly, researchers note that earlier proce- osteoarthritic hand deformities from time to time. These dures were prone to various complications, including the deformities are distal to the wrist in the proximal interpha- lack of functional motion, loose implants, recurrent joint deformity, component wear, and component fractures, langeal (PIP) and metacarpophalangeal (MCP) joint [1–7]. The PIP joint links the ﬁrst and second phalanges of the ﬁn- which led to revision surgeries [14]. Most practitioners dur- ger [8]. The MCP, on the other hand, is a condylar, ball, and ing this time are also reported to have preferred arthrodesis socket joint that has a concave-shaped proximal phalanx sur- or amputation [15]. The major complications associated with face and convex-shaped metacarpal anterior [9]. Arthroplas- early PIP and MCP joint treatment in artiﬁcial ﬁnger joint tic surgery became the standard approach to the treatment of approaches have been overcome through more sophisticated these deformities in the 70s and 80s. Prior to this time, prac- techniques, improved understanding of the joint’s anatomy, titioners supported nonoperative interventions for arthritic and better prosthetic compounds, but modern treatments hand deformities, arguing that if surgical intervention trans- still report varying degrees of success among patients during formed into the standard intervention for proximal joints, postoperative follow-ups. The aim of this article is to review such as the elbow and the shoulder, it would prevent the the diﬀerent artiﬁcial ﬁnger joints in one paper as there are gravity-induced deformities of the hand [10–12]. However, few old review papers about them. Review papers about arti- it is important to note that early small joint arthroplasty ﬁcial ﬁnger joints are not very numerous and most of them was characterized by poor implant design, an aspect that are evaluating speciﬁc ﬁnger joint instead of reviewing all 2 Applied Bionics and Biomechanics Liebolt’s footsteps, Caroll and Taber sought to ﬁnd out if ﬁnger joints, their materials, and the failures associated with them. resection could be carried out, but the latter study did not combine soft tissue interposition with long-term postopera- tive digital traction in patients with ankylosed PIP joint 2. Resection/Interposition Arthroplasty [15]. Until this time, as the researchers report, studies had As noted earlier, severe arthritic conditions of the PIP joint not attempted to replace joint arthrodesis in the ﬂexed posi- have been a recurrent problem among patients. The most tion of function [15]. To be considered for treatment, a common treatment approach to this ailment before 1914 patient had to exhibit ankyloses in a position of great defor- mity, had to have perfectly functioning tendons that produce was arthrodesis [1]. Arthrodesis of the distal interphalangeal (DIP) joints has a wide history as with a diﬀerent range of motion in the middle joint, and be motivated to regain mobility [15]. Caroll and Taber reported that 83 percent of techniques including screw or plate ﬁxation, crossed Kirsch- ner wires (K-wires), and external ﬁxation, as shown in patients had notable improvement, but the process required Figure 1 [16–18]. Bunnell, who led the advocacy of this ther- closely supervised rehabilitation. As knowledge on digital joint replacement grew, apy, felt that patients with an ankylosed and malpositioned joint fared well after arthrodesis [12]. However, following researchers worked towards total replacement. In 1959, soldier’s devastating injuries, including deformed MCP and Brannon and Klein achieved this milestone by applying total PIP joints, the demand for improved therapy was high, replacement in 14 soldiers on active duty [23]. The approach prompting researchers to look for alternative approaches. taken by the researchers included a metal-hinged type of prosthesis, which the researchers used as a replacement for Usually, the therapy using arthrodesis will cause osteolysis failure of the surrounding bone as happened previously, lim- damaged joint [23]. The objective was to restore the function iting ﬁnger joint motion, infection, pain, and breakage [5, 13, of a destroyed part of a joint partially. However, the proce- 19]. Particularly, researchers sought to improve the func- dure required patients’ nerves, blood supply, and tendons tional range of ﬁnger motion among individuals with post- to be intact; moreover, the individuals had to be motivated. Some notable complications had to be overcome, including traumatic degenerative changes in the MCP and PIP joints [1]. According to Berger, some evidence exists of a number loose screws and sunken prostheses [23]. The researchers of researchers’ attempts to probe resection arthroplasty with reported that out of the 12 soldiers, 10 regained a painless various soft tissue interposition techniques [1]. motion within a functional range; moreover, the hand’s cos- In the 1940s, the calls for improved therapy heightened metic appearance was also improved [23]. However, later follow-ups on these patients reduced the eﬃcacy of the treat- due to the injuries suﬀered during the Second World War [1, 7]. Particularly, Adkinson and Chung report about the ment, with the results showing implant loosening and frac- introduction of biologically inert Vitallium caps as a replace- tures [7]. Brannon and Klein’s treatment was modiﬁed two years later in 1961 by Flat, who sought to improve the rota- ment of the PIP and MCP joints [7]. The approach taken by researchers in this new form of therapy was modelled on tional stability of the hand [24]. With PIP joints, the study outlined three prerequisites, namely, joint ankyloses at dys- arthroplasty techniques in the lower extremities [20]. Vital- lium cups were favored because they were not only inert functional positions, signiﬁcant joint damage, and persistent but also nonreactive [9]. Moreover, the approach was also swan-neck deformity. With MCP joints, on the other hand, a part from severe damage, as was the case with PIP joints, the attributed to increased motion in the connected joints, but the level of stability was low [9]. It is important to note that other prerequisites for the procedure were persistent ulnar drift and palmar joint dislocation [24]. In both PIP and researchers had previously experimented with Vitallium, cobalt-chromium alloy cups in hip arthroplasty between MCP joints, prosthetic replacement required suﬃcient mus- 1937 and 1939 [21]. Ineﬀective earlier approaches to MCP cle power for joint control [24]. However, as was the case with Brannon and Klein’s approach, patient follow-ups in and PIP joint therapy, including replacement with Vitallium cups and arthrodesis, paved the way for modern surface Flatt’s study also revealed some complications, including phalangeal fracture, boutonniere deformity, and poor or total replacement arthroplasty. At the beginning of the 50s, researchers began to look for lack of voluntary control [24]. Total digital joint replace- alternatives to Vitallium cups. Among these attempts were ments were initially faced with several complications that reduced the eﬃcacy of the studies. Liebolt’s recommendations following successful procedures on soldiers injured during the Second World War [22]. Lie- MCP joint resection arthroplasty was ﬁrst performed at the beginning of the 60s. Fowler is credited with pioneering bolt’s treatment was split into two phases. In the ﬁrst phase, the process involved a capsulectomy, a procedure that saw research into this area, but other researchers, including Tup- surgeons divide collateral ligaments as well. In the event, per and Vainio, soon followed with a similar approach [25, 26]. Berger reports that the techniques proposed by these articular cartilage had been destroyed, and the surgeon could resect either the distal or the proximal surface of the joint researchers were notable contributions to the medical ﬁeld’s [22]. In the second phase, the patients need to have postoper- attempt s to reduce pain among patients with severely degen- ative treatment by the physician in which it consists of daily erated MCP joints [1]. Nonetheless, the approaches were passive motion for three days and then active and passive associated with joint instability, and they are mostly motion four times daily done by the patient [22]. The objec- conducted in salvage situations. Modern practice of small tive was for the patient to develop between 30 degrees and 70 joint arthroplasty features several approaches, which will be degrees postoperative range of motion. In 1954, following in explored further below. Applied Bionics and Biomechanics 3 (a) (b) (c) Figure 1: Arthrodesis of ﬁnger joint such as (a) Kirschner wires (K-wires), (b) external ﬁxation, and (c) screw ﬁxation. 3. Silicone Implant Arthroplasty a one-piece heat-vulcanized implant could increasingly resist wear and tear more than either hand-molded or hand-carved When synthetic materials emerged as viable materials in implants [30]. More progress was made in the 80s through prosthetic surgery, researchers sought to experiment with continued experimentation. them in resection arthroplasty. The application of these Researchers in the 80s sought to enhance the ﬂexion materials to the restoration of unstable or stiﬀﬁngers was capabilities of the Swanson implants. Particularly, while particularly sought since ﬁnger joints presented one of the some researchers added metal grommets at the stem hub of most diﬃcult areas for reconstructive surgery. Swanson is the interface of the Swanson implants to halt bone erosion, inarguably the pioneer researcher who ushered in the mod- as shown in Figure 2 [35], others sought the same approach, ern era of small joint arthroplasty [7]. Particularly, Swanson’s but their intent was to prevent fracturing of implants [36]. In revolutionary idea involved the silicone spacer [27–31]. In the ﬁrst study [35], the researchers reported that patients this application, the researcher designed stems of the con- exhibited increased motion and a more functional arc; more- strained Swanson implant to operate as a piston within the over, the level of pain relief was also notable [35]. However, joint [32]. Deployment of silicone rubber for implants as a the researchers observed a high rate of complications among patients who underwent implant reconstruction to correct replacement for damaged joints had been suggested following Swanson’s previous experience regarding the rheumatoid swan-neck deformities [35]. In the second study, development of an intramedullary-stemmed silicone rubber on the other hand, no particulate synovitis and infection were implant, which had been designed to protect the long bone reported; moreover, the researchers observed favorable bone following amputation in the lower extremity [30]. Previous remodeling, with the experiment group showing better results concerning improved bone preservation at the meta- researchers had also aﬃrmed the eﬃcacy of silicone rubber as a unique implant material within the family of silicones physeal and midshaft levels [36]. However, the researchers [33, 34]. The material combined organic and inorganic ele- cautioned that the procedure required proper surgical staging ments, meaning that by fusing silicone and oxygen atoms and optimal preoperative and postoperative techniques [36]. to which organic groups were attached, one could merge In a recent study, researchers reported that the additional use of grommets in the MP joint arthroplasty was attributed to a the inertness of quartz with the fabrication character of plas- tics. Silicone implants were preferred because of their stabil- slight reduction in reactive osteolysis as the components ity, slow rate of deterioration, and nonadhesiveness [30]. acted by cushioning the spacers from breaking; moreover, Moreover, Swanson noted that these compounds had not the grommets were also noted to reduce pain [37]. Applica- only good ﬂexion but also damped force; however, their tion of grommets has also been tested in other joints, includ- ing the wrist [38–41]. application could only be termed optimal if the operation found a way to contain a reported fragility, which increased Overall, the application of silicone implants in research, the compound susceptibility to tear. To overcome these dis- with or without grommets, has been successful in not only advantages, Swanson focused on designing the implant cor- PIP and MCP joints but also other joints, such as the wrist; rectly, with the aim of improving the implant ﬂexural however, the problem of implant fracture persists in these studies. This fracture of the silicone artiﬁcial joint could start durability. Results from machine experiments revealed that 4 Applied Bionics and Biomechanics Figure 2: Swanson ﬁnger implant with metal grommets. Figure 3: Fatigue fracture of Swanson ﬁnger implant at the junction of hinge and stem. with small cut (initial cracks) caused by bone spurs from the bones in the ﬁnger or during the insertion the implant reaction to the implant and debris from the degenerating sil- icone. The NeuFlex, as shown in Figure 4, is another silicone could face some damages [42]. Another cause of damage is that the silicone artiﬁcial ﬁnger joint ﬂexes at the stem implant for MCP and PIP Finger Joints which is made from more than the hinge part of the implant [42–44]. Most of silicone. The NeuFlex metacarpophalangeal joint was tested the Swanson artiﬁcial ﬁnger joint fractures happened at in vitro using ﬁnger simulator, and there was imminent the junction of the distal stem and the hinge, as shown in fracture of the prosthesis across the pivot of the central hinge section [64]. Figure 3 [45–48]. Silicone synovitis is not that popular with the Swanson ﬁnger joint in comparison with the other PIP joint implant arthroplasty features various patient silicone implants [49]. and ﬁnger characteristics. One common approach is the sili- One problem with silicone implants regards inﬂamma- cone with volar approach, with which various researchers tory reactions. Some studies have reported increased inﬂam- have experimented [5, 65–69]. The objectives of existing studies vary from one study to another. In one study, matory reactions attributed to the debris from small joint implants that essentially incite the symptomatic reactions, researchers sought to assess the clinical and radiographic causing pain [50–52]. After successful silicone rubber outcomes on the short-term concerning PIP joint implants implants, some patients have been reported to revisit hospi- that had been conducted using a volar approach [65]. In a tals because of swellings and discomfort [51]. In one study, related study, researchers sought to ﬁnd out whether PIP joint arthroplasty through a volar approach preserved the Peimer et al. used a sample comprising such patients. The study group encompassed various types of silicone arthro- patient’s extensor apparatus that is necessary if early rehabil- plasty, including lunate, scaphoid, scapholunate, wrist, ﬁn- itation was to be achieved [67]. Proubasta et al. [65] com- ger, trapezium, and ulnar head [51]. The patients had an prised Avanta silicone implants, as shown in Figure 5, established erosive osteolysis, which was ascertained through which had been deployed as a replacement of the PIP joints of 26 patients. To be included in the study, patients had to X-ray ﬁlms; similarly, the study reported that progressive damage continued with time after initial surgery and implan- have not only failed to respond to conservative treatments tation. Another notable observation was that the extent of but also diagnosed with osteoarthritis of the PIP joint. The proliferative, inﬂammatory synovitis, and the foreign debris researchers employed various clinical assessments, such as in the multinucleated cells correlated with the time between pain scores, range of motion, and patient satisfaction. Regarding the results of the study, the researchers reported the ﬁrst surgery and the beginning of the research [51]. The silicon microparticles were evidence of continued degenera- that the level of pain was markedly lower during 18-month tion and erosion, and they were linked to the intense follow-up. Particularly, the decline was from a high of 7.2 particulate-tissue reaction that is referred to as metallosis prior to the operation to 0.4 after the operation [65]. Con- [53–57]. Other researchers report of symptomatic titanium cerning patient satisfaction, on the other hand, respondents returned a score of 4.8 on a ﬁve-point Likert scale, with the debris and metallosis from other joint arthroplasty surgeries, such as elbow procedures [58–62]. In evaluating pathology in majority of the individuals indicating that they would repeat bone formation and joint function, researchers focus on the the procedure [65]. However, despite these positive indica- presence of metal debris with an intense tissue reaction that tors, the researchers note that some fractures were reported also features ﬁbrosis and giant cells [63]. Silicone implants between one and two years after surgery; moreover, some deformity was notable in the coronal plane, and the ﬂexion are linked to various debilitating eﬀects attributed to tissue Applied Bionics and Biomechanics 5 30° 90° Figure 4: NeuFlex silicone ﬁnger joint with the diﬀerent motion angles. one implant fracture was observed at a 4-year follow-up. Over- all, the silicone dorsal approach is the most preferred tech- nique by surgeons owing to the relative ease with which the procedure can be conducted among other advantages. Figure 5: Avanta ﬁnger silicone implant. The last silicone implant technique is referred to as sili- cone with lateral approach. Various studies have tested the contracture also declined from 18 degrees in some patients to eﬃcacy of this approach [80–82]. Similar to the volar 0 degrees [65]. Overall, while the silicon and volar approach approach, the lateral approach also has its merits; however, has been reported to result in high rates of patient satisfac- the primary advantage of this technique is the ability to tion, reduced pain, and sustained range of motion, some preserve both the ﬂexor and extensor tendons [70]. The patients reported deformity and severely declined ﬂexion approach involves making a longitudinal skin incision on contracture. the lateral region of the proximal phalanx, which is then Apart from the silicone with volar approach, implants curved dorsally over the central phalanx [70]. After the sur- feature silicone with the dorsal approach. This technique is geon cuts the transverse ﬁbers of the underlying retinacular the most frequently deployed model by medical surgeons, ligament, they lift the extensor apparatus, and they dislocate and it involves either a v-shaped tenotomy or a longitudinal the tendon laterally to remain with the bony insertion of its extensor tendon-split that may be performed while preserv- central band [70]. The surgeon lifts the ligament complex ing the central band insertion [70, 71]. Various studies have in one triangular ﬂap before they proceed to reﬂect it proxi- tested the eﬃcacy of this approach with varying results [28, mally. The exercise involves making a V-shaped incision, 72–79]. With this model, a dorsal midline is made through ensuring that the cut’s longitudinal branch can ﬁt perfectly the extensor tendon all the way to the central slip insertion into the dorsal margin of the collateral ligament [70]. The that is separated from the endpoint of the middle phalanx anterior-oblique branch divides the phalango-glenoidal liga- [70]. The surgeon lifts the distally placed extensor tendon ment from the collateral and supplementary collateral [70]. ﬂap of the common extensor, which despite resulting in dis- To dislocate the joint laterally, the proximal insertion of location of the joint, it does not interfere with the central slip the dorsal capsule and the volar plate is released. The pivot insertion at the bottom of the middle phalanx [70]. Among point that enables this movement is the contralateral lateral the reasons why the dorsal approach is preferred by surgeons ligament complex [70]. In concluding the process, the sur- are the relative ease of the procedure, the possibility to pre- geon performs bone resectioning and reaming of the canals. serve collateral ligaments, access to the joint extensor muscles The actual implant of the pyro-carbon components follows, and tendons, and the ability of the surgeon to easily maneu- and the last step of the procedure involves reduction of the ver around articular surfaces while preparing implant canals joint and resuturing of the collateral ligament complex to [79]. In one study, involving this procedure, researchers merge it with the phalango-glenoidal component [70]. In sought to examine the outcomes of patients among whom one study, researchers examined the outcomes of lateral sur- the NeuFlex implant had been used for either a PIP or gical procedures for the PIP joint arthroplasty that had been MCP arthroplasty as a treatment of osteoarthritis [73]. The performed using silicone implants as a treatment approach researchers reported a signiﬁcant gain in ﬂexion and arc to degenerative osteoarthritis [80]. While the range of motion of between 61 and 65 degrees [73]. Similarly, the study motion in the preoperative period averaged at 38 , postoper- ° ° ° also reported a relatively low extension lag of 3 and 0 for the ative, the reported score was 68 [80]. The researchers con- MCP and PIP groups, respectively. While the overall rate of cluded that the procedure was not only minimally invasive satisfaction among patients in this study was 90 percent in but also eﬀective since surgeons had suﬃcient exposure to the aftermath of the procedures, the scores slightly dropped the area being operated on. However, to improve lateral postsurgery to 88 and 87 for the MCP and PIP groups, respec- stability, patients’ contralateral ligaments needed to be tively [73]. However, the researchers also acknowledge that reinforced. 6 Applied Bionics and Biomechanics 4. Metal Implant Arthroplasty Biomaterials are classiﬁed into ﬁve major groups, including ceramics, composites, metals, polymers, and materials of bio- logical origin. However, other classiﬁcation systems diﬀeren- tiate biomaterials on other bases, including inertness and smoothness of surface inertness and degree of porosity, chemical reactivity, and bioabsorbability [83]. These mate- rials have usage in joint replacement therapy with variable results. In clinical usage, metallic material can belong to either the ﬁrst or second classiﬁcation system. Diﬀerent metals, such as cobalt-chrome or stainless steel, react in vary- ing ways with body tissues. The eﬃcacy of a given type of metal in arthroplasty is a function of the ability to withstand or endure the surrounding biological conditions. With some metals, such as titanium, the oxide layer that covers their sur- face makes it possible for them to be in direct contact with the surrounding biological context without raising the risk of detrimental chemical reactions. This feature of titanium Figure 6: MatOrtho PIP ﬁnger joint replacement. and related metals is referred to as bioinertness. In bioengi- neering, surgeons are always weary of materials with chemi- cally reactive surfaces which have the potential to provoke goal of retaining the natural collateral ligaments, which tissue response that can lead to direct bonding to bone or would serve to provide the required stability and natural osteoid [83]. A case in point is calcium phosphate, contained functions. In a later study, researchers signiﬁcantly improved in glass ceramics, hydroxyapatite, and bioglass. The problem the degree of osseointegration through a thermal titanium with bioabsorbable materials, on the other hand, is that they spray on the surface of the proximal component stem. Cur- are prone to degradation, meaning, with time, they are rently, this implant is being oﬀered as PIP surface replace- replaced by regenerating tissue either in part or fully. ment arthroplasty (SRA) [7, 85]. Newer approaches have In medical practice, bioengineers have selected several since replaced hydroxyapatite-coated cobalt chrome bearing suitable metals. The most commonly deployed metals in on UHMWPE or pyrocarbon [9]. Some of the PIP implants medical practice, for this matter, comprise cobalt chrome, have been cemented and others not but coated with the titanium, and several of its alloys, gold, tantalum, surgical hydroxyapatite to allow bone integration [86]. These cemen- stainless steel, and mercury-based alloys [83]. Metals can be ted implants were facing problems such as pain, stiﬀness, and classiﬁed as either light or heavy, and this weight is a major loosening [86, 87]. A cementless cobalt-chromium metal issue in biological implants; hence, bioengineers have set against polyethylene prosthesis is coated with hydroxyapatite the limit of metal density for material that can be used in to accelerate bone integration called MatOrtho proximal implants at 5 g/cm . The lightest metals include aluminum interphalangeal (Mole Business Park, Leatherhead, UK), as and titanium, meaning the rest of the metals mentioned shown in Figure 6 [88]. The results if implanting cementless above comprise heavy metals. The least reactive type of metal against polymer ﬁnger joint could lead to problems such metals comprises those that occur as pure elements in nature. as pain, loosening, stiﬀness, instability, dislocated polyethylene Another notable feature regarding metals is that the majority insert, and dissociation of the whole implant [86, 88]. of these compounds have alloys, which reduce their purity. More important, such impurities signiﬁcantly determine 4.1. Pyrocarbon Implant Arthroplasty. Pyrocarbon, according to researchers, is increasingly strong due to a synthetically both the physical and chemical properties of metals. Various aspects of metals, including weight, purity, and chemical coated graphite core. The core is formed by heating a hydro- reactivity, are considered prior to the selection of the best carbon gas to extremely high temperatures [9]. These com- alternative for use as implants. pounds are a form of pyrolytic carbon, and they appear as Bioengineering research relating to the use of metals in ceramic material [89]. Regarding pyrocarbon implants, the Ontario Medical Advisory Secretariat notes that the compo- ﬁnger joint arthroplasty began at the end of the 70s. Linsc- heid and Dobyns are credited with pioneering a novel design nents comprise a pyrolytic carbon coating measuring 0.42 in which they experimented with a cobalt chrome proximal mm in thickness over an appropriately shaped graphite sub- component and high molecular weight polyethylene strate. For improved joint connection, the implant features (HMWPE) [84]. These researchers felt that available options ball and socket articulates, which have stems that come in the shape of the corresponding bones of the joint; hence, they for patients were limited; hence, they sought to resolve some of the issues associated with previous researcher’s proposals. can be inserted without bone cement [89]. Concerning the Among these issues was the lack of stability and poor physi- regulatory status of pyrocarbon ﬁnger joint implants, the ological articulation, an increased laterally directed stress. To United States Food and Drug Administration ﬁrst approved achieve their mission, the researchers continuously sought to the Ascension MCP in 2002, as shown in Figure 7, but the product was already in use in Europe following its earlier ﬁnd ways of minimizing bony resection of the joints with the Applied Bionics and Biomechanics 7 Figure 7: The ascension MCP. approval in 1999. The second pyrocarbon, Ascension PIP, 6. MCP Joint Surface Replacement which was developed by Ascension Orthopedics Inc., also The MCP is a ball and socket joint that appears as a convex received approval in 2002, but USFDA directed that the use shape on the metacarpal head. The joint is surrounded by of the components be limited to humanitarian. The Swanson collateral ligaments. Rheumatoid arthritis patients usually implant remains the most commonly used ﬁnger joint require MCP replacement, and the procedure includes silas- implant. tic interpositional replacement and rebalancing of the under- lying soft tissue. Before a patient can be considered for this procedure, the surgeon must conduct a preoperative assess- 5. PIP Joint Surface Replacement ment. More importantly, the approach is usually applied in cases of osteo- and posttraumatic arthritis, and individuals The proximal interphalangeal joint plays a major role in the must have adequate soft tissue and suﬃcient underlying liga- kinetic chain. This joint is attributed to approximately 40 ments. For individuals with rheumatoid arthritis, the inci- percent of the total range of active motions [9, 84, 90–92]. dence of soft-tissue imbalance might be severe; hence, the The joint helps individuals to grab smaller things and to hold surgeon needs to determine whether correcting ulnar devia- objects with an irregular shape. The ﬁxed center of the PIP tions and palmar subluxation deformities is possible. In other joint’s rotation falls at the proximal insertion of the collateral words, the physician needs to assess whether the joint will ligaments, whereby, according to Singh and Dias, at diﬀerent remain intact after the procedure has been performed. The joint positions, the tension in the collateral ligaments does success rate of these procedures is reported to be increasingly not change. Destruction of this joint is usually attributed to high, with some studies reporting one revision out of 13 inﬂammation or degeneration [5]. With a ﬁnger tourniquet, joints ﬁve years postoperation [99]. In this study, the the surgical technique for a PIP joint surface replacement researchers developed an unconstrained surface MCP joint can be performed while a patient is under local anesthesia replacement with a polyethylene and metacarpal phalangeal [9]. With this procedure, the joint is essentially approached material, which were attached to uncemented ﬁnned dorsally, longitudinally, or laterally. Singh and Dias note that polyethylene plugs to generate some level of motion in the a longitudinal split of the extensor tendon is preferable [9]. components [99]. Apart from the aforementioned complica- Under this approach, the incision is made to the attachment tions, the researchers also observed that out of the 13 joints, of the central slip, with the aim of detaching it from the liga- two exhibited lucency in the area of the phalangeal compo- ments in the middle phalanx to access the underlying soft tis- nent, while one exhibited some degradation in the metacar- sue. A number of complications are reported with this pal component [99]. Subluxation of the unconstrained approach associated with anatomical alignment, tendon component was also reported by other researchers [100– repair, and careful balance of soft tissue [93–98]. More- 103]. Like is the case with PIP joint surface replacement over, Singh and Dias report that pyrocarbon implants have arthroplasty, MCP joint surface replacement arthroplasty been noted to result in squeaks, and surgeons need to has varying success rates since some patients are reported inform patients prior to conducting the procedure. Among to experience dislocations of unconstrained implants. the reasons why patients who undergo PIP pyrocarbion arthroplasty require revision surgery are poorly selected cases or inclusion of patients who do not ﬁt the criteria, 7. Autologous Small Joint Arthroplasty poor surgical procedures, the use of inappropriate pros- thetic material, and poorly designed prosthetic components Compatibility has been a major concern when it comes to [9]. Overall, since patients who undergo PIP joint replace- PIP and MCP joint arthroplasty. In a response to the result- ment with pyracarbons are prone to various complications, ing challenge of noncompatible components that react with they should be monitored closely both in pre- and postop- the surrounding tissue, resulting in degradation, pain, and erative periods. reduced postoperation motion, researchers sought to ﬁnd Singh and Dias note that, with PIP surface implants, an alternative approach to treatment [104–107]. Autologous physicians are increasingly concerned about the range of small joint arthroplasty speciﬁcally focused on developing a progressive loss that patients are likely to experience as the technique that was not only biocompatible but also provided implants settle. patients with potential immediate vascularity and possible 8 Applied Bionics and Biomechanics future growth. Goebell is credited for experimenting with the [3] L. W. Catalano Iii, A. C. Skarparis, S. Z. Glickel, O. A. Barron, D. Malley, and L. B. 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Lin, “Second toe extensor digitorum brevis provides a simultaneous abductorplasty to free vascularized metatarsophalangeal joint transfer for post- traumatic thumb composite metacarpophalangeal joint defect,” Journal of Trauma and Acute Care Surgery, vol. 66, no. 5, pp. 1374–1378, 2009. [125] M. Liu, J. Jia, and Z. Hou, “Clinical observation of traumatically-damaged joint after its repair with transplanta- tion of allogenic joint,” Zhongguo xiu fu chong jian wai ke za zhi= Zhongguo xiufu chongjian waike zazhi= Chinese journal of reparative and reconstructive surgery, vol. 21, no. 8, pp. 797–800, 2007. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Applied Bionics and Biomechanics Hindawi Publishing Corporation http://www.deepdyve.com/lp/hindawi-publishing-corporation/silicone-and-pyrocarbon-artificial-finger-joints-0TIrCMUtC0

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Publisher: Hindawi Publishing Corporation
Copyright: Copyright © 2021 F. A. Alnaimat et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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DOI: 10.1155/2021/5534796
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Abstract

Hindawi Applied Bionics and Biomechanics Volume 2021, Article ID 5534796, 12 pages https://doi.org/10.1155/2021/5534796 Review Article 1 1 2 2 3 F. A. Alnaimat , H. A. Owida, A. Al Sharah, M. Alhaj, and Mohammad Hassan Medical Engineering, Al-Ahliyya Amman University, Al-Saro, Al-Salt, Amman, Jordan Computer Engineering, Al-Ahliyya Amman University, Al-Saro, Al-Salt, Amman, Jordan Civil Engineering, Faculty of Engineering, Al-Ahliyya Amman University, Al-Saro, Al-Salt, Amman, Jordan Correspondence should be addressed to F. A. Alnaimat; f.alnaimat@ammanu.edu.jo Received 10 February 2021; Revised 23 May 2021; Accepted 27 May 2021; Published 4 June 2021 Academic Editor: Juan Carlos Prados-Frutos Copyright © 2021 F. A. Alnaimat et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Artiﬁcial ﬁnger joint design has been developed through diﬀerent stages through the past. PIP (proximal interphalangeal) and MCP (metacarpophalangeal) artiﬁcial ﬁnger joints have come to replace the amputation and arthrodesis options; although, these artiﬁcial joints are still facing challenges related to reactive tissues, reduced range of motion, and ﬂexion and extension deﬁcits. Swanson silicone artiﬁcial ﬁnger joints are still common due to the physician’s preferability of silicone with the dorsal approach during operation. Nevertheless, other artiﬁcial ﬁnger joints such as the pyrocarbon implant arthroplasty have also drawn the interests of practitioners. Artiﬁcial ﬁnger joint has been classiﬁed under three major categories which are constrained, unconstrained, and linked design. There are also challenges such as concerns of infections and articular cartilage necrosis associated with attempted retention of vascularity. In addition, one of the main challenges facing the silicone artiﬁcial ﬁnger joints is the fracture occurring at the distal stem with the hinge. The aim of this paper is to review the diﬀerent artiﬁcial ﬁnger joints in one paper as there are few old review papers about them. Further studies need to be done to develop the design and materials of the pyrocarbon and silicone implants to increase the range of motion associated with them and the fatigue life of the silicone implants. was attributed to a lack of understanding of the mechanics 1. Introduction of small joints and the use of ineﬀective interpositional mate- Orthopedic surgeons treat patients with rheumatoid and rials [7, 13]. Similarly, researchers note that earlier proce- osteoarthritic hand deformities from time to time. These dures were prone to various complications, including the deformities are distal to the wrist in the proximal interpha- lack of functional motion, loose implants, recurrent joint deformity, component wear, and component fractures, langeal (PIP) and metacarpophalangeal (MCP) joint [1–7]. The PIP joint links the ﬁrst and second phalanges of the ﬁn- which led to revision surgeries [14]. Most practitioners dur- ger [8]. The MCP, on the other hand, is a condylar, ball, and ing this time are also reported to have preferred arthrodesis socket joint that has a concave-shaped proximal phalanx sur- or amputation [15]. The major complications associated with face and convex-shaped metacarpal anterior [9]. Arthroplas- early PIP and MCP joint treatment in artiﬁcial ﬁnger joint tic surgery became the standard approach to the treatment of approaches have been overcome through more sophisticated these deformities in the 70s and 80s. Prior to this time, prac- techniques, improved understanding of the joint’s anatomy, titioners supported nonoperative interventions for arthritic and better prosthetic compounds, but modern treatments hand deformities, arguing that if surgical intervention trans- still report varying degrees of success among patients during formed into the standard intervention for proximal joints, postoperative follow-ups. The aim of this article is to review such as the elbow and the shoulder, it would prevent the the diﬀerent artiﬁcial ﬁnger joints in one paper as there are gravity-induced deformities of the hand [10–12]. However, few old review papers about them. Review papers about arti- it is important to note that early small joint arthroplasty ﬁcial ﬁnger joints are not very numerous and most of them was characterized by poor implant design, an aspect that are evaluating speciﬁc ﬁnger joint instead of reviewing all 2 Applied Bionics and Biomechanics Liebolt’s footsteps, Caroll and Taber sought to ﬁnd out if ﬁnger joints, their materials, and the failures associated with them. resection could be carried out, but the latter study did not combine soft tissue interposition with long-term postopera- tive digital traction in patients with ankylosed PIP joint 2. Resection/Interposition Arthroplasty [15]. Until this time, as the researchers report, studies had As noted earlier, severe arthritic conditions of the PIP joint not attempted to replace joint arthrodesis in the ﬂexed posi- have been a recurrent problem among patients. The most tion of function [15]. To be considered for treatment, a common treatment approach to this ailment before 1914 patient had to exhibit ankyloses in a position of great defor- mity, had to have perfectly functioning tendons that produce was arthrodesis [1]. Arthrodesis of the distal interphalangeal (DIP) joints has a wide history as with a diﬀerent range of motion in the middle joint, and be motivated to regain mobility [15]. Caroll and Taber reported that 83 percent of techniques including screw or plate ﬁxation, crossed Kirsch- ner wires (K-wires), and external ﬁxation, as shown in patients had notable improvement, but the process required Figure 1 [16–18]. Bunnell, who led the advocacy of this ther- closely supervised rehabilitation. As knowledge on digital joint replacement grew, apy, felt that patients with an ankylosed and malpositioned joint fared well after arthrodesis [12]. However, following researchers worked towards total replacement. In 1959, soldier’s devastating injuries, including deformed MCP and Brannon and Klein achieved this milestone by applying total PIP joints, the demand for improved therapy was high, replacement in 14 soldiers on active duty [23]. The approach prompting researchers to look for alternative approaches. taken by the researchers included a metal-hinged type of prosthesis, which the researchers used as a replacement for Usually, the therapy using arthrodesis will cause osteolysis failure of the surrounding bone as happened previously, lim- damaged joint [23]. The objective was to restore the function iting ﬁnger joint motion, infection, pain, and breakage [5, 13, of a destroyed part of a joint partially. However, the proce- 19]. Particularly, researchers sought to improve the func- dure required patients’ nerves, blood supply, and tendons tional range of ﬁnger motion among individuals with post- to be intact; moreover, the individuals had to be motivated. Some notable complications had to be overcome, including traumatic degenerative changes in the MCP and PIP joints [1]. According to Berger, some evidence exists of a number loose screws and sunken prostheses [23]. The researchers of researchers’ attempts to probe resection arthroplasty with reported that out of the 12 soldiers, 10 regained a painless various soft tissue interposition techniques [1]. motion within a functional range; moreover, the hand’s cos- In the 1940s, the calls for improved therapy heightened metic appearance was also improved [23]. However, later follow-ups on these patients reduced the eﬃcacy of the treat- due to the injuries suﬀered during the Second World War [1, 7]. Particularly, Adkinson and Chung report about the ment, with the results showing implant loosening and frac- introduction of biologically inert Vitallium caps as a replace- tures [7]. Brannon and Klein’s treatment was modiﬁed two years later in 1961 by Flat, who sought to improve the rota- ment of the PIP and MCP joints [7]. The approach taken by researchers in this new form of therapy was modelled on tional stability of the hand [24]. With PIP joints, the study outlined three prerequisites, namely, joint ankyloses at dys- arthroplasty techniques in the lower extremities [20]. Vital- lium cups were favored because they were not only inert functional positions, signiﬁcant joint damage, and persistent but also nonreactive [9]. Moreover, the approach was also swan-neck deformity. With MCP joints, on the other hand, a part from severe damage, as was the case with PIP joints, the attributed to increased motion in the connected joints, but the level of stability was low [9]. It is important to note that other prerequisites for the procedure were persistent ulnar drift and palmar joint dislocation [24]. In both PIP and researchers had previously experimented with Vitallium, cobalt-chromium alloy cups in hip arthroplasty between MCP joints, prosthetic replacement required suﬃcient mus- 1937 and 1939 [21]. Ineﬀective earlier approaches to MCP cle power for joint control [24]. However, as was the case with Brannon and Klein’s approach, patient follow-ups in and PIP joint therapy, including replacement with Vitallium cups and arthrodesis, paved the way for modern surface Flatt’s study also revealed some complications, including phalangeal fracture, boutonniere deformity, and poor or total replacement arthroplasty. At the beginning of the 50s, researchers began to look for lack of voluntary control [24]. Total digital joint replace- alternatives to Vitallium cups. Among these attempts were ments were initially faced with several complications that reduced the eﬃcacy of the studies. Liebolt’s recommendations following successful procedures on soldiers injured during the Second World War [22]. Lie- MCP joint resection arthroplasty was ﬁrst performed at the beginning of the 60s. Fowler is credited with pioneering bolt’s treatment was split into two phases. In the ﬁrst phase, the process involved a capsulectomy, a procedure that saw research into this area, but other researchers, including Tup- surgeons divide collateral ligaments as well. In the event, per and Vainio, soon followed with a similar approach [25, 26]. Berger reports that the techniques proposed by these articular cartilage had been destroyed, and the surgeon could resect either the distal or the proximal surface of the joint researchers were notable contributions to the medical ﬁeld’s [22]. In the second phase, the patients need to have postoper- attempt s to reduce pain among patients with severely degen- ative treatment by the physician in which it consists of daily erated MCP joints [1]. Nonetheless, the approaches were passive motion for three days and then active and passive associated with joint instability, and they are mostly motion four times daily done by the patient [22]. The objec- conducted in salvage situations. Modern practice of small tive was for the patient to develop between 30 degrees and 70 joint arthroplasty features several approaches, which will be degrees postoperative range of motion. In 1954, following in explored further below. Applied Bionics and Biomechanics 3 (a) (b) (c) Figure 1: Arthrodesis of ﬁnger joint such as (a) Kirschner wires (K-wires), (b) external ﬁxation, and (c) screw ﬁxation. 3. Silicone Implant Arthroplasty a one-piece heat-vulcanized implant could increasingly resist wear and tear more than either hand-molded or hand-carved When synthetic materials emerged as viable materials in implants [30]. More progress was made in the 80s through prosthetic surgery, researchers sought to experiment with continued experimentation. them in resection arthroplasty. The application of these Researchers in the 80s sought to enhance the ﬂexion materials to the restoration of unstable or stiﬀﬁngers was capabilities of the Swanson implants. Particularly, while particularly sought since ﬁnger joints presented one of the some researchers added metal grommets at the stem hub of most diﬃcult areas for reconstructive surgery. Swanson is the interface of the Swanson implants to halt bone erosion, inarguably the pioneer researcher who ushered in the mod- as shown in Figure 2 [35], others sought the same approach, ern era of small joint arthroplasty [7]. Particularly, Swanson’s but their intent was to prevent fracturing of implants [36]. In revolutionary idea involved the silicone spacer [27–31]. In the ﬁrst study [35], the researchers reported that patients this application, the researcher designed stems of the con- exhibited increased motion and a more functional arc; more- strained Swanson implant to operate as a piston within the over, the level of pain relief was also notable [35]. However, joint [32]. Deployment of silicone rubber for implants as a the researchers observed a high rate of complications among patients who underwent implant reconstruction to correct replacement for damaged joints had been suggested following Swanson’s previous experience regarding the rheumatoid swan-neck deformities [35]. In the second study, development of an intramedullary-stemmed silicone rubber on the other hand, no particulate synovitis and infection were implant, which had been designed to protect the long bone reported; moreover, the researchers observed favorable bone following amputation in the lower extremity [30]. Previous remodeling, with the experiment group showing better results concerning improved bone preservation at the meta- researchers had also aﬃrmed the eﬃcacy of silicone rubber as a unique implant material within the family of silicones physeal and midshaft levels [36]. However, the researchers [33, 34]. The material combined organic and inorganic ele- cautioned that the procedure required proper surgical staging ments, meaning that by fusing silicone and oxygen atoms and optimal preoperative and postoperative techniques [36]. to which organic groups were attached, one could merge In a recent study, researchers reported that the additional use of grommets in the MP joint arthroplasty was attributed to a the inertness of quartz with the fabrication character of plas- tics. Silicone implants were preferred because of their stabil- slight reduction in reactive osteolysis as the components ity, slow rate of deterioration, and nonadhesiveness [30]. acted by cushioning the spacers from breaking; moreover, Moreover, Swanson noted that these compounds had not the grommets were also noted to reduce pain [37]. Applica- only good ﬂexion but also damped force; however, their tion of grommets has also been tested in other joints, includ- ing the wrist [38–41]. application could only be termed optimal if the operation found a way to contain a reported fragility, which increased Overall, the application of silicone implants in research, the compound susceptibility to tear. To overcome these dis- with or without grommets, has been successful in not only advantages, Swanson focused on designing the implant cor- PIP and MCP joints but also other joints, such as the wrist; rectly, with the aim of improving the implant ﬂexural however, the problem of implant fracture persists in these studies. This fracture of the silicone artiﬁcial joint could start durability. Results from machine experiments revealed that 4 Applied Bionics and Biomechanics Figure 2: Swanson ﬁnger implant with metal grommets. Figure 3: Fatigue fracture of Swanson ﬁnger implant at the junction of hinge and stem. with small cut (initial cracks) caused by bone spurs from the bones in the ﬁnger or during the insertion the implant reaction to the implant and debris from the degenerating sil- icone. The NeuFlex, as shown in Figure 4, is another silicone could face some damages [42]. Another cause of damage is that the silicone artiﬁcial ﬁnger joint ﬂexes at the stem implant for MCP and PIP Finger Joints which is made from more than the hinge part of the implant [42–44]. Most of silicone. The NeuFlex metacarpophalangeal joint was tested the Swanson artiﬁcial ﬁnger joint fractures happened at in vitro using ﬁnger simulator, and there was imminent the junction of the distal stem and the hinge, as shown in fracture of the prosthesis across the pivot of the central hinge section [64]. Figure 3 [45–48]. Silicone synovitis is not that popular with the Swanson ﬁnger joint in comparison with the other PIP joint implant arthroplasty features various patient silicone implants [49]. and ﬁnger characteristics. One common approach is the sili- One problem with silicone implants regards inﬂamma- cone with volar approach, with which various researchers tory reactions. Some studies have reported increased inﬂam- have experimented [5, 65–69]. The objectives of existing studies vary from one study to another. In one study, matory reactions attributed to the debris from small joint implants that essentially incite the symptomatic reactions, researchers sought to assess the clinical and radiographic causing pain [50–52]. After successful silicone rubber outcomes on the short-term concerning PIP joint implants implants, some patients have been reported to revisit hospi- that had been conducted using a volar approach [65]. In a tals because of swellings and discomfort [51]. In one study, related study, researchers sought to ﬁnd out whether PIP joint arthroplasty through a volar approach preserved the Peimer et al. used a sample comprising such patients. The study group encompassed various types of silicone arthro- patient’s extensor apparatus that is necessary if early rehabil- plasty, including lunate, scaphoid, scapholunate, wrist, ﬁn- itation was to be achieved [67]. Proubasta et al. [65] com- ger, trapezium, and ulnar head [51]. The patients had an prised Avanta silicone implants, as shown in Figure 5, established erosive osteolysis, which was ascertained through which had been deployed as a replacement of the PIP joints of 26 patients. To be included in the study, patients had to X-ray ﬁlms; similarly, the study reported that progressive damage continued with time after initial surgery and implan- have not only failed to respond to conservative treatments tation. Another notable observation was that the extent of but also diagnosed with osteoarthritis of the PIP joint. The proliferative, inﬂammatory synovitis, and the foreign debris researchers employed various clinical assessments, such as in the multinucleated cells correlated with the time between pain scores, range of motion, and patient satisfaction. Regarding the results of the study, the researchers reported the ﬁrst surgery and the beginning of the research [51]. The silicon microparticles were evidence of continued degenera- that the level of pain was markedly lower during 18-month tion and erosion, and they were linked to the intense follow-up. Particularly, the decline was from a high of 7.2 particulate-tissue reaction that is referred to as metallosis prior to the operation to 0.4 after the operation [65]. Con- [53–57]. Other researchers report of symptomatic titanium cerning patient satisfaction, on the other hand, respondents returned a score of 4.8 on a ﬁve-point Likert scale, with the debris and metallosis from other joint arthroplasty surgeries, such as elbow procedures [58–62]. In evaluating pathology in majority of the individuals indicating that they would repeat bone formation and joint function, researchers focus on the the procedure [65]. However, despite these positive indica- presence of metal debris with an intense tissue reaction that tors, the researchers note that some fractures were reported also features ﬁbrosis and giant cells [63]. Silicone implants between one and two years after surgery; moreover, some deformity was notable in the coronal plane, and the ﬂexion are linked to various debilitating eﬀects attributed to tissue Applied Bionics and Biomechanics 5 30° 90° Figure 4: NeuFlex silicone ﬁnger joint with the diﬀerent motion angles. one implant fracture was observed at a 4-year follow-up. Over- all, the silicone dorsal approach is the most preferred tech- nique by surgeons owing to the relative ease with which the procedure can be conducted among other advantages. Figure 5: Avanta ﬁnger silicone implant. The last silicone implant technique is referred to as sili- cone with lateral approach. Various studies have tested the contracture also declined from 18 degrees in some patients to eﬃcacy of this approach [80–82]. Similar to the volar 0 degrees [65]. Overall, while the silicon and volar approach approach, the lateral approach also has its merits; however, has been reported to result in high rates of patient satisfac- the primary advantage of this technique is the ability to tion, reduced pain, and sustained range of motion, some preserve both the ﬂexor and extensor tendons [70]. The patients reported deformity and severely declined ﬂexion approach involves making a longitudinal skin incision on contracture. the lateral region of the proximal phalanx, which is then Apart from the silicone with volar approach, implants curved dorsally over the central phalanx [70]. After the sur- feature silicone with the dorsal approach. This technique is geon cuts the transverse ﬁbers of the underlying retinacular the most frequently deployed model by medical surgeons, ligament, they lift the extensor apparatus, and they dislocate and it involves either a v-shaped tenotomy or a longitudinal the tendon laterally to remain with the bony insertion of its extensor tendon-split that may be performed while preserv- central band [70]. The surgeon lifts the ligament complex ing the central band insertion [70, 71]. Various studies have in one triangular ﬂap before they proceed to reﬂect it proxi- tested the eﬃcacy of this approach with varying results [28, mally. The exercise involves making a V-shaped incision, 72–79]. With this model, a dorsal midline is made through ensuring that the cut’s longitudinal branch can ﬁt perfectly the extensor tendon all the way to the central slip insertion into the dorsal margin of the collateral ligament [70]. The that is separated from the endpoint of the middle phalanx anterior-oblique branch divides the phalango-glenoidal liga- [70]. The surgeon lifts the distally placed extensor tendon ment from the collateral and supplementary collateral [70]. ﬂap of the common extensor, which despite resulting in dis- To dislocate the joint laterally, the proximal insertion of location of the joint, it does not interfere with the central slip the dorsal capsule and the volar plate is released. The pivot insertion at the bottom of the middle phalanx [70]. Among point that enables this movement is the contralateral lateral the reasons why the dorsal approach is preferred by surgeons ligament complex [70]. In concluding the process, the sur- are the relative ease of the procedure, the possibility to pre- geon performs bone resectioning and reaming of the canals. serve collateral ligaments, access to the joint extensor muscles The actual implant of the pyro-carbon components follows, and tendons, and the ability of the surgeon to easily maneu- and the last step of the procedure involves reduction of the ver around articular surfaces while preparing implant canals joint and resuturing of the collateral ligament complex to [79]. In one study, involving this procedure, researchers merge it with the phalango-glenoidal component [70]. In sought to examine the outcomes of patients among whom one study, researchers examined the outcomes of lateral sur- the NeuFlex implant had been used for either a PIP or gical procedures for the PIP joint arthroplasty that had been MCP arthroplasty as a treatment of osteoarthritis [73]. The performed using silicone implants as a treatment approach researchers reported a signiﬁcant gain in ﬂexion and arc to degenerative osteoarthritis [80]. While the range of motion of between 61 and 65 degrees [73]. Similarly, the study motion in the preoperative period averaged at 38 , postoper- ° ° ° also reported a relatively low extension lag of 3 and 0 for the ative, the reported score was 68 [80]. The researchers con- MCP and PIP groups, respectively. While the overall rate of cluded that the procedure was not only minimally invasive satisfaction among patients in this study was 90 percent in but also eﬀective since surgeons had suﬃcient exposure to the aftermath of the procedures, the scores slightly dropped the area being operated on. However, to improve lateral postsurgery to 88 and 87 for the MCP and PIP groups, respec- stability, patients’ contralateral ligaments needed to be tively [73]. However, the researchers also acknowledge that reinforced. 6 Applied Bionics and Biomechanics 4. Metal Implant Arthroplasty Biomaterials are classiﬁed into ﬁve major groups, including ceramics, composites, metals, polymers, and materials of bio- logical origin. However, other classiﬁcation systems diﬀeren- tiate biomaterials on other bases, including inertness and smoothness of surface inertness and degree of porosity, chemical reactivity, and bioabsorbability [83]. These mate- rials have usage in joint replacement therapy with variable results. In clinical usage, metallic material can belong to either the ﬁrst or second classiﬁcation system. Diﬀerent metals, such as cobalt-chrome or stainless steel, react in vary- ing ways with body tissues. The eﬃcacy of a given type of metal in arthroplasty is a function of the ability to withstand or endure the surrounding biological conditions. With some metals, such as titanium, the oxide layer that covers their sur- face makes it possible for them to be in direct contact with the surrounding biological context without raising the risk of detrimental chemical reactions. This feature of titanium Figure 6: MatOrtho PIP ﬁnger joint replacement. and related metals is referred to as bioinertness. In bioengi- neering, surgeons are always weary of materials with chemi- cally reactive surfaces which have the potential to provoke goal of retaining the natural collateral ligaments, which tissue response that can lead to direct bonding to bone or would serve to provide the required stability and natural osteoid [83]. A case in point is calcium phosphate, contained functions. In a later study, researchers signiﬁcantly improved in glass ceramics, hydroxyapatite, and bioglass. The problem the degree of osseointegration through a thermal titanium with bioabsorbable materials, on the other hand, is that they spray on the surface of the proximal component stem. Cur- are prone to degradation, meaning, with time, they are rently, this implant is being oﬀered as PIP surface replace- replaced by regenerating tissue either in part or fully. ment arthroplasty (SRA) [7, 85]. Newer approaches have In medical practice, bioengineers have selected several since replaced hydroxyapatite-coated cobalt chrome bearing suitable metals. The most commonly deployed metals in on UHMWPE or pyrocarbon [9]. Some of the PIP implants medical practice, for this matter, comprise cobalt chrome, have been cemented and others not but coated with the titanium, and several of its alloys, gold, tantalum, surgical hydroxyapatite to allow bone integration [86]. These cemen- stainless steel, and mercury-based alloys [83]. Metals can be ted implants were facing problems such as pain, stiﬀness, and classiﬁed as either light or heavy, and this weight is a major loosening [86, 87]. A cementless cobalt-chromium metal issue in biological implants; hence, bioengineers have set against polyethylene prosthesis is coated with hydroxyapatite the limit of metal density for material that can be used in to accelerate bone integration called MatOrtho proximal implants at 5 g/cm . The lightest metals include aluminum interphalangeal (Mole Business Park, Leatherhead, UK), as and titanium, meaning the rest of the metals mentioned shown in Figure 6 [88]. The results if implanting cementless above comprise heavy metals. The least reactive type of metal against polymer ﬁnger joint could lead to problems such metals comprises those that occur as pure elements in nature. as pain, loosening, stiﬀness, instability, dislocated polyethylene Another notable feature regarding metals is that the majority insert, and dissociation of the whole implant [86, 88]. of these compounds have alloys, which reduce their purity. More important, such impurities signiﬁcantly determine 4.1. Pyrocarbon Implant Arthroplasty. Pyrocarbon, according to researchers, is increasingly strong due to a synthetically both the physical and chemical properties of metals. Various aspects of metals, including weight, purity, and chemical coated graphite core. The core is formed by heating a hydro- reactivity, are considered prior to the selection of the best carbon gas to extremely high temperatures [9]. These com- alternative for use as implants. pounds are a form of pyrolytic carbon, and they appear as Bioengineering research relating to the use of metals in ceramic material [89]. Regarding pyrocarbon implants, the Ontario Medical Advisory Secretariat notes that the compo- ﬁnger joint arthroplasty began at the end of the 70s. Linsc- heid and Dobyns are credited with pioneering a novel design nents comprise a pyrolytic carbon coating measuring 0.42 in which they experimented with a cobalt chrome proximal mm in thickness over an appropriately shaped graphite sub- component and high molecular weight polyethylene strate. For improved joint connection, the implant features (HMWPE) [84]. These researchers felt that available options ball and socket articulates, which have stems that come in the shape of the corresponding bones of the joint; hence, they for patients were limited; hence, they sought to resolve some of the issues associated with previous researcher’s proposals. can be inserted without bone cement [89]. Concerning the Among these issues was the lack of stability and poor physi- regulatory status of pyrocarbon ﬁnger joint implants, the ological articulation, an increased laterally directed stress. To United States Food and Drug Administration ﬁrst approved achieve their mission, the researchers continuously sought to the Ascension MCP in 2002, as shown in Figure 7, but the product was already in use in Europe following its earlier ﬁnd ways of minimizing bony resection of the joints with the Applied Bionics and Biomechanics 7 Figure 7: The ascension MCP. approval in 1999. The second pyrocarbon, Ascension PIP, 6. MCP Joint Surface Replacement which was developed by Ascension Orthopedics Inc., also The MCP is a ball and socket joint that appears as a convex received approval in 2002, but USFDA directed that the use shape on the metacarpal head. The joint is surrounded by of the components be limited to humanitarian. The Swanson collateral ligaments. Rheumatoid arthritis patients usually implant remains the most commonly used ﬁnger joint require MCP replacement, and the procedure includes silas- implant. tic interpositional replacement and rebalancing of the under- lying soft tissue. Before a patient can be considered for this procedure, the surgeon must conduct a preoperative assess- 5. PIP Joint Surface Replacement ment. More importantly, the approach is usually applied in cases of osteo- and posttraumatic arthritis, and individuals The proximal interphalangeal joint plays a major role in the must have adequate soft tissue and suﬃcient underlying liga- kinetic chain. This joint is attributed to approximately 40 ments. For individuals with rheumatoid arthritis, the inci- percent of the total range of active motions [9, 84, 90–92]. dence of soft-tissue imbalance might be severe; hence, the The joint helps individuals to grab smaller things and to hold surgeon needs to determine whether correcting ulnar devia- objects with an irregular shape. The ﬁxed center of the PIP tions and palmar subluxation deformities is possible. In other joint’s rotation falls at the proximal insertion of the collateral words, the physician needs to assess whether the joint will ligaments, whereby, according to Singh and Dias, at diﬀerent remain intact after the procedure has been performed. The joint positions, the tension in the collateral ligaments does success rate of these procedures is reported to be increasingly not change. Destruction of this joint is usually attributed to high, with some studies reporting one revision out of 13 inﬂammation or degeneration [5]. With a ﬁnger tourniquet, joints ﬁve years postoperation [99]. In this study, the the surgical technique for a PIP joint surface replacement researchers developed an unconstrained surface MCP joint can be performed while a patient is under local anesthesia replacement with a polyethylene and metacarpal phalangeal [9]. With this procedure, the joint is essentially approached material, which were attached to uncemented ﬁnned dorsally, longitudinally, or laterally. Singh and Dias note that polyethylene plugs to generate some level of motion in the a longitudinal split of the extensor tendon is preferable [9]. components [99]. Apart from the aforementioned complica- Under this approach, the incision is made to the attachment tions, the researchers also observed that out of the 13 joints, of the central slip, with the aim of detaching it from the liga- two exhibited lucency in the area of the phalangeal compo- ments in the middle phalanx to access the underlying soft tis- nent, while one exhibited some degradation in the metacar- sue. A number of complications are reported with this pal component [99]. Subluxation of the unconstrained approach associated with anatomical alignment, tendon component was also reported by other researchers [100– repair, and careful balance of soft tissue [93–98]. More- 103]. Like is the case with PIP joint surface replacement over, Singh and Dias report that pyrocarbon implants have arthroplasty, MCP joint surface replacement arthroplasty been noted to result in squeaks, and surgeons need to has varying success rates since some patients are reported inform patients prior to conducting the procedure. Among to experience dislocations of unconstrained implants. the reasons why patients who undergo PIP pyrocarbion arthroplasty require revision surgery are poorly selected cases or inclusion of patients who do not ﬁt the criteria, 7. Autologous Small Joint Arthroplasty poor surgical procedures, the use of inappropriate pros- thetic material, and poorly designed prosthetic components Compatibility has been a major concern when it comes to [9]. Overall, since patients who undergo PIP joint replace- PIP and MCP joint arthroplasty. In a response to the result- ment with pyracarbons are prone to various complications, ing challenge of noncompatible components that react with they should be monitored closely both in pre- and postop- the surrounding tissue, resulting in degradation, pain, and erative periods. reduced postoperation motion, researchers sought to ﬁnd Singh and Dias note that, with PIP surface implants, an alternative approach to treatment [104–107]. Autologous physicians are increasingly concerned about the range of small joint arthroplasty speciﬁcally focused on developing a progressive loss that patients are likely to experience as the technique that was not only biocompatible but also provided implants settle. patients with potential immediate vascularity and possible 8 Applied Bionics and Biomechanics future growth. Goebell is credited for experimenting with the [3] L. W. Catalano Iii, A. C. Skarparis, S. Z. Glickel, O. A. Barron, D. Malley, and L. B. Lane, “Treatment of chronic, ﬁrst free-nonvascularized autologous joint transfer in 1913 traumatic hyperextension deformities of the proximal inter- [108]. However, the procedure has limited application in phalangeal joint with ﬂexor digitorum superﬁcialis tenod- modern practice, which is attributed to articular cartilage esis,” The Journal of hand surgery, vol. 28, no. 3, pp. 448– necrosis [109]. In 1967, researchers attempted to perform a 452, 2003. vascularized joint transfer [110]. In the mid-seventies, a [4] N. M. Vranis, B. Marascalchi, and E. Melamed, “Trends in study reported the ﬁrst successful free toe joint transfer proximal interphalangeal and metacarpophalangeal joint [111]. Studies that followed the initial research have reported arthroplasty utilization using statewide databases,” The Jour- joint space preservation and maintenance of the hyaline car- nal of Hand Surgery (Asian-Paciﬁc Volume), vol. 25, no. 1, tilage [112–125]. 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Journal

Applied Bionics and Biomechanics – Hindawi Publishing Corporation

Published: Jun 4, 2021

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Transplantation of entire bones with their joint surface: A. Bruce Gill MD (1876-1965). The 6th president of the AAOS 1937,

A. B. Gill
Transplantation of joints to replace diseased or damaged articulations in the hands,

W. C. Graham
The fate of autogenous whole joints transplanted by microvascular anastomoses,

H. Buncke Jr., A. Daniller, W. Schulz, R. Chase, and H. J. Buncke Jr.
The transfer from toe in reconstructive surgery of the hand : about seventy cases toe-to-hand transfers in reconstructive surgery of the hand : experience with seventy-one cases (In French),

G. Foucher, F. Van Genechten, M. Merle et al.
Experimental vascularized total joint autografts--a primate study,

T.-M. Tsai, L. Ogden, S. H. Jaeger, and K. Okubo
Free vascularized small joint transfer to the hand,

B. M. O'Brien, J. S. Gould, W. A. Morrison, R. C. Russell, A. M. MacLeod, and J. J. Pribaz
Elective free vascularized double transfer of toe joint from second toe to proximal interphalangeal joint of index finger: a case report,

T.-M. Tsai and R. Singer
Immediate free vascularized joint transfer from second toe to index finger proximal interphalangeal joint: a case report,

T. Tsai, R. Singer, E. Elliott, and H. Klein
Customizing extensor reconstruction in vascularized toe joint transfers to finger proximal interphalangeal joints: a strategic approach for correcting extensor lag,

C. Y. Y. Loh, C.-C. Hsu, C.-H. Lin et al.
Long-term results of free vascularized second toe joint transfers to finger proximal interphalangeal joints,

N. Tsubokawa, T. Yoshizu, and Y. Maki
Vascularized autogenous whole joint transfer in the hand--a clinical study,

T.-M. Tsai, J. B. Jupiter, J. E. Kutz, and H. E. Kleinert
Long-term results after vascularized joint transfer for finger joint reconstruction,

A. Berger and R. Hierner
Vascularized toe joint transfer to the hand,

S. H.-T. Chen, F.-C. Wei, H.-C. Chen, V. R. Hentz, D. C. Chuang, and M.-C. Yeh
A systematic review of outcomes and complications of vascularized toe joint transfer, silicone arthroplasty, and PyroCarbon arthroplasty for posttraumatic joint reconstruction of the finger,

L. Squitieri and K. C. Chung
Free vascularized toe joint transfer to the hand. A technique for simultaneous reconstruction of the soft tissue,

K. Kimori, Y. Ikuta, O. Ishida, M. Ichikawa, and O. Suzuki
The impact of transferred vascularized toe joint length on motion arc of reconstructed finger proximal interphalangeal joints: a cadaveric study,

C.-C. Hsu, C. Y. Y. Loh, D. Kao, S. L. Moran, and Y.-T. Lin
Second toe extensor digitorum brevis provides a simultaneous abductorplasty to free vascularized metatarsophalangeal joint transfer for posttraumatic thumb composite metacarpophalangeal joint defect,

C.-H. Lin, P.-L. Tang, and C.-H. Lin
Clinical observation of traumatically-damaged joint after its repair with transplantation of allogenic joint,

M. Liu, J. Jia, and Z. Hou

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Silicone and Pyrocarbon Artificial Finger Joints

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Silicone and Pyrocarbon Artificial Finger Joints

Silicone and Pyrocarbon Artificial Finger Joints

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