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Journal of Hand Surgery (European Volume)
http://jhs.sagepub.com/content/38/8/866
The online version of this article can be found at:
DOI: 10.1177/1753193413488494
2013 38: 866 originally published online 14 May 2013J Hand Surg Eur Vol
J. F. Goubau, C. K. Goorens, P. Van Hoonacker, B. Berghs, D. Kerckhove and T. Scheerlinck
with a minimum of 5 years of follow-up: a prospective single-centre cohort study
Clinical and radiological outcomes of the Ivory arthroplasty for trapeziometacarpal joint osteoarthritis
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The Journal of Hand Surgery
(European Volume)
38E(8) 866 –874
© The Author(s) 2013
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DOI: 10.1177/1753193413488494
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JHS(E)
Introduction
When conservative treatment of trapeziometacarpal
(TM) osteoarthritis fails, surgical options such as tra-
peziectomy, arthroplasty, and arthrodesis can be
offered to the patient. Recently, TM narrow pseudar-
throsis has been proposed as a reliable technique
Clinical and radiological outcomes
of the Ivory arthroplasty for
trapeziometacarpal joint osteoarthritis
with a minimum of 5 years of follow-up:
a prospective single-centre cohort study
J. F. Goubau, C. K. Goorens
Department of Orthopaedics and Traumatology – Upper Limb Unit, AZ Sint-Jan AV Brugge–Oostende, Campus Brugge,
Brugge, Belgium
Department of Orthopaedics and Traumatology, University Hospital of Brussels, Brussels, Belgium
P. Van Hoonacker, B. Berghs, D. Kerckhove
Department of Orthopaedics and Traumatology – Upper Limb Unit, AZ Sint-Jan AV Brugge–Oostende, Campus Brugge,
Brugge, Belgium
T. Scheerlinck
Department of Orthopaedics and Traumatology, University Hospital of Brussels, Brussels, Belgium
Abstract
We present the results of a 5 year prospective follow-up study on the functional outcome after total
replacement of the trapeziometacarpal joint with the Ivory prosthesis (Memometal, Stryker Corporate,
Kalamazoo, Michigan, USA) in 22 patients. The female to male ratio was 21:1 and the mean age was 66
(range 54–78) years. The mean follow-up period was 67 (range 60–77) months after operation. Patient
satisfaction was high. The mobility of the operated thumb was restored to a range of motion comparable
to the contralateral thumb. Key pinch and grip strength improved by 13% and 31%, respectively. Overall
function, according to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, improved by
59%. Pain decreased by 85% according to the numerical rating scale. Radiological evaluation revealed no
loosening of the implant after 5 years except in one patient who required revision due to polythene wear
with secondary joint instability. Another patient had asymptomatic polythene wear that required no revision
but remains in follow-up. The 5 year overall survival of the prosthesis was 95%. These medium-term results
suggest that the Ivory arthroplasty is a reliable option for treating advanced trapeziometacarpal arthritis,
because it appears to give a very good functional outcome and has the potential for long-term survival
rates.
Keywords
Trapeziometacarpal arthroplasty, trapeziometacarpal arthritis, Ivory prosthesis
Date received: 16th April 2012; revised: 27th March 2013; accepted: 1st April 2013
Corresponding author:
Jean F. Goubau MD, Department of Orthopaedics and
Traumatology – Upper Limb Unit, AZ Sint-Jan AV Brugge–
Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge,
Belgium.
Email: jean.goubau@azsintjan.be; jean@goubau.eu
488494JHS38810.1177/1753193413488494The Journal of Hand SurgeryGoubau
2013
Full length article
by Jean GOUBAU on March 16, 2014jhs.sagepub.comDownloaded from
Goubau 867
(Rubino et al., 2012). TM prostheses are designed to
regain an acceptable level of mobility, stability, and
grip strength, and restore normal length of the thumb
column. Dislocation may be a complication, and in the
longer term, wear of components and implant loos-
ening can occur.
At our centre, we regularly use a prosthesis
known as the Ivory (Memometal, Stryker Corporate,
Kalamazoo, Michigan, USA), which was introduced
in 1992 as a replacement for the TM joint and con-
sists of a fully modular ball and socket prosthesis.
To our knowledge, there are no prospective follow-
up studies that assess the outcome of this prosthe-
sis. Our aim therefore was to study the clinical and
radiological outcomes of this prosthesis with a view
to potentially providing an alternative surgical solu-
tion for TM arthritis when conservative treatment
has failed.
Methods
Patients
Between 2005 and 2006, the Ivory prosthesis was
inserted in 22 patients with isolated primary TM
degenerative osteoarthritis that had failed to respond
to conservative management. None had a history of
previous TM trauma, and none had undergone previ-
ous thumb surgery or other related treatment. A
choice of trapeziectomy as an alternative to the ivory
prosthesis was discussed with each patient pre-
operatively, and patients were free to select their pre-
ferred treatment approach. However, the advice was
given to consider the Ivory arthroplasty over tra-
peziectomy in those cases with a high demand for
thumb grip and strength. The criteria for inclusion
were based on pain present at rest and during activity,
despite conservative treatment of more than 3
months. This included night splinting, non-steroidal
anti-inflammatory medication, or intra-articular infil-
tration of corticosteroids.
The Ivory arthroplasty was inserted in all patients
by the same consultant hand surgeon. Two patients
also underwent sesamoid-metacarpal arthrodesis of
the radial sesamoid to correct persistent hyperexten-
sion of the metacarpophalangeal (MP) joint of the
thumb at the same time.
Pre- and post-operative radiographical evalua-
tion included frontal and profile views of the TM joint
as described by Kapandji et al. (1980) (Figure 1), a
frontal view (Bett’s view) (Taleisnik, 1985) of the sca-
photrapezial joint, and Eaton views with and without
stressing (Kapandji and Kapandji., 1993; Kapandji
et al., 1980) (Figure 2). The Ivory arthroplasty was
considered to be suitable for treating symptomatic
TM osteoarthritis of stages II and III according to
Dell’s radiological classification (Dell et al., 1978).
The presence of a non-symptomatic scaphotrape-
zial and/or scaphotrapezoidal arthritis was not a
contraindication.
Ivory prosthesis
The arthroplasty is composed of an anatomical
hydroxyapatite-covered metal stem, a double-coned
hydroxyapatite-covered cup, and an ultra-high
molecular weight (UHMW) polyethylene liner.
Modularity is possible with different neck heights
(short-medium-long). In addition, the neck can be
fixed on the stem in different rotations (–30°, 0°,
+30°). This provides an optimal assessment of sta-
bility and avoidance of impingement throughout the
procedure. In our patient group, the amount of rota-
tion was determined during surgery to ensure sound
stability with no dislocation in opposition or retro-
pulsion. In the majority of cases, a neutral (0°) rota-
tion was selected.
Figure 1. (A) Kapandji frontal view: the two sesamoids pro-
jected under the head of the thumb metacarpal and visual-
ization of the (narrowed) TM joint. (B) Kapandji profile view:
perfect superposition of the sesamoids under the thumb
metacarpal head and visualization of the TM joint.
by Jean GOUBAU on March 16, 2014jhs.sagepub.comDownloaded from
868 The Journal of Hand Surgery (Eur) 38(8)
Operative technique
The procedure was performed under loco-regional
anaesthesia using a plexus block. Before starting the
surgical procedure, a mark was drawn on the skin of
the index finger to indicate the length of the thumb
column before the arthroplasty; the comparison with
this after implantation of the prosthesis provided an
indication of the obtained lengthening.
The procedure begins by exposing the TM joint
through an anterolateral approach according to the
incision described by Gedda and Moberg (1953). Some
anterior branches of the superficial branch of the
radial nerve are sacrificed. The abductor pollicis lon-
gus (APL) slip to the opponens is disinserted. The
opponens and APL origin are then dissected from the
anterior side of the TM joint. The capsule is opened
longitudinally and the base of the thumb metacarpal
is freed anterolaterally from all of its ligamentous and
capsular attachments; the anterior oblique and ulno
collateral ligament are sacrificed. Care must be taken
to free the structures attached to the dorsal side of
the trapezium and base of the thumb. On the ulnar
side, the dorsal TM and intermetacarpal ligaments
are preserved (Ladd et al., 2012). All osteophytes are
then carefully resected, especially at the anterior side
of the thumb metacarpal and trapezium.
A thin slice of articular surface is resected from the
trapezium and thumb metacarpal. The thumb meta-
carpal is reamed with the single reamer. The size of
this is measured and the test stem then firmly
inserted. A small 3 mm high-speed burr is used to
prepare and weaken the subchondral bone at the
location site for acceptance of the cup. The smallest
diameter of 9 mm is preferred in all primary cases.
Reaming of the trapezium by hand with the cup
reamer should be continued until an adequate depth
is reached. The cup is then inserted and press-fitted
into the trapezium. Primary stability is ensured. The
polyethylene liner is then positioned in the metal cup.
The definitive metacarpal component is put in place.
The appropriate length and rotation of the neck is
tested after reduction to verify that opposition and
retropulsion can be achieved without dislocation. The
incision is closed in two layers on a suction drain. The
hand is placed in a fluffy bandage and a forearm plas-
ter cast taking in the thumb.
Post-operative care
The suction drain was removed 24 hours after surgery
and a forearm cast was then applied, including the
MP joint of the thumb but not the interphalangeal
joint. This was retained for 3 weeks. A K-wire was
placed across the MP joint and kept in place for 6
weeks for those patients who were also treated for
MP joint hyperextension. These patients also had a
more prolonged immobilization of 6 weeks in a fore-
arm cast protecting the thumb. Self-mobilization was
started after 3 weeks in all cases (except those with
hyperextension), and patients were told to avoid force-
ful gripping between thumb and fingers for 3 months.
A removable thumb splint in thermoplastic material
(Orfit; Orfit Industries, Wijnegem, Belgium) was pro-
vided to wear between periods of mobilization for an
additional month. No hand therapy programme was
necessary because self-rehabilitation provided ade-
quate progression of recovery. After 3 months, nor-
mal occupational activities could be resumed.
Assessment
All patients were assessed pre-operatively and then
post-operatively annually up to and after a minimum
Figure 2. Eaton view (A) without and (B) with stress. These views allow assessment of the dynamic loss in joint height in the
arthritic TM joint and of the intrinsic laxity at the base of the thumb metacarpal.
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Goubau 869
of 5 years. The pre-operative and 5 years post-
operative assessment was carried out independently
by a second experienced surgeon who was not pre-
sent during the pre-surgical assessment or at the
operation. Assessment criteria were radiology, mobil-
ity, strength, function, and pain. Radiological assess-
ment of the components was done immediately after
operation and continued up to the minimum of 5 years
follow-up. Satisfaction and external appearance were
also assessed up to 5 years post-operatively.
Patients were followed-up on the first day post-
operatively, then at 10 days, 3 weeks, 6 weeks, 3
months, 6 months, and annually thereafter with radi-
ological review. Kapandji views (Kapandji and
Kapandji, 1993) were required for all visits until the
third month.
After 3 months it is safe to assess the dynamic sta-
bility of the prosthesis. Eaton views were obtained
with and without stressing by pushing the radial bor-
ders of the thumb tips against each other (Eaton and
Littler, 1973; Eaton et al., 1984).
The mobility of the thumb in opposition (0-10) and
retropulsion (0-3) was graded as described by
Kapandji (1990) (Figure 3). The opening of the first
web (thumb abduction) and MP mobility in flexion and
extension were also graded. Grading of the first web
opening was measured using the axis of the index fin-
ger and index metacarpal compared with the axis of
the thumb measured from the base of the thumb
metacarpal to the tip of the thumb. MP mobility was
measured dorsally in maximal extension and maxi-
mal flexion. Strength was measured using a cali-
brated hydraulic pinch gauge and calibrated hydraulic
hand dynamometer (Baseline Fabrication Enterprises
Inc., New York, USA). Function was assessed using
the Quick Disabilities of the Arm, Shoulder and Hand
(QuickDASH) score. Pain was scored with a numerical
rating scale (0 = no pain, 10 = severe pain). The radio-
graphical outcome was assessed using the profile
view described by Kapandji and Kapandji (1993)
(superposition of the two sesamoids under the head
of the thumb metacarpal). This approach was selected
in order to compare the immediate post-operative
position of the prosthesis versus the 5-year post-
operative position with a view to noting precisely any
displacement of the stem and cup in the presence of
radiolucent lines and osteolysis (Figure 4).
Statistical analysis
Differences in pre- and post-operative data were ana-
lyzed using paired Student’s t-tests or Wilcoxon non-
parametric equivalent in the case of pain, Kapandji,
and QuickDASH scores. Statistical significance was
accepted at the level of p 0.05.
Results
Originally, 24 patients were treated with the Ivory
arthroplasty; however, one patient died and one patient
Figure 3. (A,B) grading of retropulsion (0–3) and (C,D) grading of opposition (1–10) (Kapandji, 1990).
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870 The Journal of Hand Surgery (Eur) 38(8)
was lost to follow-up. Twenty-two patients remained in
the study, of which 21 were women and one a man with
a mean age of 66 (range 54–78) years. The group con-
sisted of 11 retired persons, five housewives, four
manual workers, and two office employees. Surgery
was carried out on 11 dominant and 11 non-dominant
hands. Patients had a mean follow-up of 67 (range 60–
77) months post-operatively.
Professional or leisure activities were resumed
after 3 months of recovery after surgery without
exception, suggesting that strength and mobility were
restored to a useful functional level.
The results are shown in Table 1. These results after 5
years of follow-up are compared with the pre-operative
status and also with the contralateral non-symptomatic
thumb. Although the contralateral TM joint may also
have been affected by asymptomatic osteoarthritis, clini-
cally the impact of this was negligible.
Several of the measured parameters revealed sig-
nificant improvements 5 years post-operation.
Opposition was no worse and retropulsion was ini-
tially improved, but this effect was only marginally
improved from the initial state after 5 years (Figure 5).
Key pinch and grip strength improved by 13% and 31%
(Figure 6). The difference in grip strength was statisti-
cally significant. The QuickDASH score improved by
59% and pain decreased according to the visual ana-
logue scale by 85%. Both of these differences were
statistically significant.
There was no statistical difference between open-
ing of the first web in either the contra-lateral or
operated thumb. MP flexion, extension, opposition,
retropulsion, precision pinch, key pinch, and grip
strength were also not significantly different (Table 1).
All patients were satisfied with the appearance of
the incision scar. Discrete dysaesthesia due to tran-
section of small terminal braches of the superficial
radial nerve in the approach disappeared within 3
months. All patients were either satisfied or highly
satisfied with the surgical outcome and had no spon-
taneous complaints at the time of questioning.
Figure 4. Radiographic follow-up: Kapandji profile view
with the two sesamoids superimposed under the head of
the thumb metacarpal. (Left) immediate post-operative
radiograph. (Right) 5 years post-operative. Displacement of
the cup is the distance in mm of a1 – a2. Displacement of the
stem is the distance in mm of b1 – b2.
Table 1. Changes in range of motion, opposition, retropulsion, key pinch, grip strength, function (QuickDASH), and pain
score pre- and post-operatively. Range of motion of the MP joint of the operated thumb compared with the non-operated
thumb.
Mean pre-
op (SD)
Mean
post-op
(SD)
%
change
p value,
pre- vs
post-op
95% CI, pre-
vs post-op
Non-
operated
side (SD)
p-value, 5 year
post-op vs non-
operated side
Opening first web
space (°)
– 60 (7) – – – 58 (9) 0.11
Opposition** 9 (1) 9 (1) 0 0.43 −0.5 to 0.3 9 (1) 0.57
Retropulsion** 2 (1) 2 (1) 0 0.27 −0.5 to 0.1 1 (1) 0.07
MP flexion (°) – 48 (12) – – – 44 (10) 0.09
MP extension (°) – 7 (12) – – – 9 (11) 0.49
Key pinch (kg) 4.5 (1.4) 5.1 (1.8) 13 0.18 –1.5 to 0.3 4.6 (1.8) 0.06
Precision pinch (kg) – 3.4 (1.3) – – – 3.2 (1.2) 0.23
Grip strength (kg) 17.2 (7.2) 22.5 (7.2) 31 0.0004* −8.0 to −2.7 21.2 (8.4) –
QuickDASH 56.3 (16.4) 23.2 (15.3) 59 0.0001* 23.7 to 42.5 – –
Pain score 8.1 (1.2) 1.2 (1.1) 85 0.0001* 6.2 to 7.8 – –
*p 0.05.
**As defined by Kapandji (1990).
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Goubau 871
Ninety-five percent said that they would have the
operation again. Only one patient hesitated owing to a
prolonged post-operative inflammatory reaction
which settled such that after 1 year of follow-up she
reported no further problems. A second patient in the
study suffered from post-operative complex regional
pain syndrome, but this also soon spontaneously
resolved. Two patients (10%) continued to experience
intermittent dysaesthesia. One patient remained
apprehensive about forceful gripping, although radio-
graphically no abnormality could be detected.
Radiological assessment demonstrated small (and
clinically insignificant) mean differences in cup and
stem displacement respectively after 5 years com-
pared with the immediate post-operative phase and
no osteolysis was observed (Table 2). However, the
retired male patient had clear radiological evidences
of polyethylene wear, but this was asymptomatic
(Figure 7). There was a 95% 5 year overall survival of
the prosthesis. Only one patient had a cup revision
due to instability diagnosed using Eaton view radio-
graphs (Figure 8).
Discussion
These results after a minimum follow-up of 5 years
appear to be encouraging. The implant was, however,
only used in patients who were in continuous pain and
who had failed to respond to any form of conservative
treatment. In agreement with other studies of TM
arthroplasty, a high patient satisfaction rate was
obtained (Apard et al., 2007; Burke et al., 2012; Skytta
et al., 2005). This is in contrast with other implants
(Moje and Pi2) that have a high complication rate even
in the short term (Kaszap et al., 2012; Maru et al.,
2012). Klahn et al. (2012) reported a revision rate of
44% at medium term for the Elektra prosthesis. Our
study confirmed restoration of a substantial func-
tional range of motion and grip strength, reduction in
pain, and restoration of daily functioning, and these
improvements were well appreciated by the patients.
We found a 95%, 5 year overall survival of the Ivory
prosthesis. Other authors have reported a 5 year sur-
vival for the Arpe prosthesis of 85% (Apard et al.,
2007) and a 94% survival at 5 years for the de la
Caffinière prosthesis implanted in rheumatoid
patients (Skytta et al., 2005). Van Capelle et al. (1999)
and Chakrabarti et al. (1997) reported a survival of
greater than 16 years (72% and 89%, respectively) for
the de la Caffinière prosthesis. Johnston et al. (2012)
Table 2. Results of measurements of radiological displacement of the implant (see Figure 4).
Cup (a) Stem (b)
Distance a1Distance a2Collapse (a2 – a1) Distance b1Distance b2Collapse (b2 – b1)
Mean (SD), mm 3.1 (0.9) 2.7 (0.8) 0.4 (0.7) 15.3 (3.3) 15.0 (3.4) 0.3 (0.4)
95% CI, mm 2.7–3.4 2.4–3.0 0.1–0.7 13.8–16.7 13.5–16.5 0.1–0.4
p value 0.02 0.006
a1 = distance from cup to trapezial articular surface immediately after operation.
a2 = distance from cup to trapezial articular surface 5 years after operation.
b1 = distance from stem to metacarpal articular surface immediate after operation.
b2 = distance from stem to metacarpal articular surface 5 years after operation.
Figure 5. Change in opposition and retropulsion according
to Kapandji (1990).
Figure 6. Change in power grip strength and key pinch
strength over 5 years.
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872 The Journal of Hand Surgery (Eur) 38(8)
reported a survivorship of 73.9% for the de la
Caffinière prosthesis at 26 years. Functional long-
term outcome was less predictable in highly active
male individuals and patients younger than 65 years
because of high peak forces during activities with
higher demand, resulting in wear on the prosthesis.
Indeed, Chakrabarti et al. (1997) and Van Capelle
et al. (1999) concluded that the prosthesis should not
be used in male patients younger than 65 years. In our
series, the only male patient showed clear asympto-
matic wear of the polyethylene.
Peri-operative trapezial fractures and immediate
post-operative dislocations are possible complica-
tions in the short-term with a non-constrained ball
and socket prosthesis, occurring in 2–5% (Comtet,
2000). Comtet (2000) concluded that prosthetic stabil-
ity and possible episodes of dislocation in the first
post-operative year are decisive predictors for the
long-term durability of the implant. In our series no
dislocations occurred. This might be explained by the
arc of mobility of the Ivory prosthesis, which is only
91° compared to 120° for the Arpe prosthesis. To min-
imize risk of dislocation, careful attention should be
paid to primary stability and tension, and to the rein-
sertion of the APL to the muscles of the thenar emi-
nence during the intra-operative testing phase. A
well-balanced tension allows some longitudinal joint
laxity with axial traction. This tension will also correct
the MP hyperextension (swan-neck) deformity in most
cases. Too much tension will cause pain and will
accentuate the polyethylene wear and reduce the
range of motion (Teissier et al., 2001). In the medium
to longer term, it is important to examine for loosen-
ing and instability that usually affect the cup, or peri-
articular calcifications, post-traumatic fractures, and
development of scaphotrapezial and MP arthritis.
These longer term complications, however, rarely
occur (Apard et al., 2007; de la Caffinière, 2001).
Our radiological assessment revealed no implant
displacement or osteolysis, but only one case of poly-
ethylene wear and one case of dynamic instability.
This corresponds with the report of Apard et al. (2007).
Figure 7. Radiographic view of the prosthesis (A) 1 month and (B) 70 months after surgery in the only male patient. Note
the radial translation of the head of the metacarpal component due to the wear of the polyethylene cup in (B).
Figure 8. Radiographical follow-up 3.5 years after joint
replacement in 72-year-old female patient. (A) Eaton view
without stress and (B) with stress. Dislocation of the left
thumb metacarpal component occurs with stress.
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Goubau 873
Loosening can be a complication, but the absence of
cement does not automatically lead to loosening of
the stem; whilst this can occur, it is more usual that
this happens at the cup side (Apard et al., 2007).
Regnard (2006) experienced a low rate of osteointe-
gration (only 15%) on the trapezial part when using
the Elektra prosthesis which, like the Ivory, is also
coated with hydroxyapatite. Similarly, Hernandez-
Cortes et al. (2012) also reported a disappointing fail-
ure rate of 10 out of 19 cases with the Elektra after
only a 2 year follow-up and concluded that this was
mostly due to the same osteointegration problem at
the trapezoidal side. We experienced no problems
with osteointegration of the cup in our series.
The modular construction of the Ivory arthroplasty
facilitates the replacement of the polyethylene when
wear or instability is present, even after several years.
Eaton views (with and without stress) are particularly
important during follow up because these facilitate
early diagnosis of instability in a ball and socket pros-
thetic implant of the TM joint. Cup loosening can be
revised using a larger cup, spacer interpositioning, or
trapeziectomy. The stem can be left in place if it
causes no impingement.
There are some limitations to this study. Obviously
a multicentre trial would enable greater generaliza-
tion of the results. Although we report only 22 cases,
this was felt sufficient to be of interest given the lim-
ited number of medium to longer term follow-up
studies on similar devices. We did not set out to do a
randomized controlled trial to compare two or more
devices or procedures, because this would require a
much larger study effort and cost than was available.
Rather, we offer our results and experiences to com-
pare with the reports of others who have used other
prostheses.
Our medium-term follow-up results ( 5 years)
with a 95% survival rate indicate that the Ivory arthro-
plasty appears to be an effective surgical option for
advanced TM osteoarthritis for patients in whom all
conservative measures have failed. We strongly
believe that future long-term studies in excess of 10
years post-operatively are essential before full vali-
dation of the efficacy of this implant can be realized.
Acknowledgements
The authors would like to thank Kim Jones, PhD, and
Malcolm Forward, PhD, for the statistics and reviewing the
manuscript. Thanks to Sofia Pensaert for the corrections
and verifications of the text.
Conflict of interests
Dr Jean Goubau performs surgical demonstrations of this
prosthesis and his payment from the company consists only
of expenses for these demonstrations and attending the
French Hand Society and European Hand Surgery con-
gresses. All other named authors hereby declare that they
have no conflict of interests to disclose.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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