Mano y muñeca

The Nottingham Palmar Plate Arthroplasty for Metacarpophalangeal Joint Noninflammatory Arthritis

Trickett, Ryan W. MBBCh, MRCS, MSc, FRCS, MD*; Oni, John A. MA, MBBCh, FRCS, FRCS

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Techniques in Hand & Upper Extremity Surgery 26(2):p 122-126, June 2022. | DOI: 10.1097/BTH.000000000000037


Palmar (volar) plate interposition arthroplasty for osteoarthritis (OA) of the metacarpophalangeal (MCP) joints of the fingers is a well-established technique. Its use has diminished since its initial description and introduction because of poor results in patients with inflammatory arthropathy and a difficult surgical technique. We report the surgical technique and mid-term results of the novel Nottingham interposition arthroplasty for noninflammatory MCP joint OA. A dual dorsal and palmar incision is utilized to maximize the harvest of interposition substance. The surgical technique is described and illustrated in full. Prospective data concerning pain, range of movement and function are reported. The results of 12 arthroplasties in 9 patients are reported. At a median follow-up of 76.1 months the median arc of movement was 44 degrees, favoring an improvement in flexion. The median visual analog score for pain was 0, with all but 1 patient reporting no pain at all. Range of movement has been further improved with a progressively less restrictive rehabilitation regimen giving a median arc of 70 degrees in the more recent patients. Compared with modern implant arthroplasty techniques, the Nottingham Palmar Plate Arthroplasty has demonstrated favorable results in terms of range of movement and most importantly resolution of pain. We consider it to be a viable option in the first line management of MCP joint OA.

The palmar (volar) plate interposition arthroplasty, originally described by Tupper at the Japanese Society for Surgery of the Hand1 and later published in print,2,3 was an alternative to Vainio’s extensor tendon interposition arthroplasty.4,5 It was used in the treatment of rheumatoid arthritis; the purpose being to prevent the ulna drift and palmar subluxation of the metacarpophalangeal (MCP) joint.2 The technique utilized a single, dorsal approach to perform a full synovectomy, divide the radial collateral ligament which allowed harvest and interposition of a distally based flap of the fibrocartilagenous portion of the palmar plate. This flap was sutured to the dorsal aspect of the metacarpal stump and the radial collateral sutured to the palmar plate.2 Because of the generous osteotomy of the metacarpal head, extensor rebalancing was necessary. Although the results have been favorable in some series,6 the technique has largely been superseded by silastic implant arthroplasty in the treatment of painful rheumatoid MCP joints and pyrocarbon replacement in osteoarthritis (OA).7

The surgical goals of an interposition arthroplasty of the MCP joint are to replace the articulating surfaces with a robust interposition substance, ensure stability of the joint, minimize bone loss and permit early range of movement postoperatively in order to achieve pain relief and good function. The original Tupper technique presented practical difficulties: surgical access to the palmar plate was difficult without a large metacarpal head osteotomy; the available volume of interposition material from the fibrocartilaginous portion of the palmar plate was limited; and the radial collateral ligament was divided, potentially compromising joint stability.

The Tupper interposition has been proposed as an acceptable treatment for postseptic or traumatic arthritis of the MCP joint.8,9 However, the range of movement published in these series is disappointing compared with that achieved using current unconstrained arthroplasty implants.7

This paper reports the novel Nottingham Palmar Plate Arthroplasty (NPPA) surgical technique. In order to overcome the apparent limitations of the Tupper interposition, the NPPA utilizes a separate palmar approach to expose the palmar plate. This allows harvest of the entire palmar plate along with the A1 pulley whilst preserving collateral ligament stability

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