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Touch thumb arthroplasty

Surgeon-side topic for touch thumb arthroplasty. Backed by 349 articles from the corpus, retrieved via combined MeSH + title-text matching.

Overview

Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of the procedure [1]. Total joint arthroplasty in primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility and clinical function, and high patient satisfaction [5]. The Touch® trapeziometacarpal joint arthroplasty reports a 96% implant survival rate at 2 years and demonstrates promising patient-reported and clinical outcomes at 2 years [2]. Authors recommend surgery with the TouchRV prosthesis as the standard treatment for patients with isolated trapeziometacarpal joint osteoarthritis [2].

Conversely, the Elektra prosthesis for trapeziometacarpal osteoarthritis resulted in poor outcomes after only 2 years, leading authors to state they cannot recommend the Elektra implant due to these findings [3]. Although the Elektra prosthesis observed fast pain relief, maintenance of mobility, and a gradual increase in grip strength, there was an increasing need for revision with the Elektra prosthesis at a rate of 44% after 72 months [6]. The absence of prosthesis instability with the MOOVIS prosthesis encourages its recommendation for the treatment of advanced trapeziometacarpal osteoarthritis in patients without too many manual constraints [4].

Trapeziometacarpal prosthesis shows promise for TMC arthrosis, enhancing function, thumb length, and patient recovery [8]. The MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis [7] and may be a reliable treatment option for TMC joint osteoarthritis [10]. The MAÏA TMC total joint arthroplasty provides very good results for pain relief, strength, mobility, and restoration of the thumb length, while also providing correction of most thumb z-deformities [10].

Anatomy & Pathophysiology

Osseous and Implant Stability

Correct implant position is a prerequisite for reliable medium-term results after trapeziometacarpal joint arthroplasty [9]. Attentive reaming of the trapezium and careful cup impaction are crucial technical steps to avoid trapezial fracture and early cup failure [12]. While the MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis [7] and provides very good results for pain relief, strength, mobility, and restoration of thumb length beyond 10 years [10, 16], the Elektra prosthesis demonstrated poor outcomes after only 2 years [3] with an increasing need for revision reaching a rate of 44% after 72 months [6]. Conversely, the TouchRV prosthesis demonstrates a 96% implant survival rate at 2 years [2]. Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of the procedure [1].

Kinematics and Functional Outcomes

Total joint arthroplasty for primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility, and clinical function with high patient satisfaction [5]. Trapeziometacarpal prosthesis enhances function, thumb length, and patient recovery for TMC arthrosis [8], with the MAÏA TMC total joint arthroplasty specifically providing correction of most thumb z-deformities [10]. The absence of prosthesis instability supports the recommendation of the MOOVIS technique for patients with advanced trapeziometacarpal osteoarthritis who have activity without too many manual constraints [4]. Applying the dual mobility principle to trapeziometacarpal arthroplasty may significantly improve the stability of these prostheses [13].

Revision and Complications

Scaphometacarpal arthroplasty using a trapeziometacarpal prosthesis is not sufficiently reliable to be a routine solution for surgical revision of failed TMC arthroplasty or trapeziectomy [14]. This approach should be used with caution, primarily as a salvage solution if no safer alternative is available [14]. Dynamic radiographic imaging with longitudinal traction is required to make a timely diagnosis of polyethylene liner fracture when standard radiographs are normal [11]. Anomalous muscles, specifically an accessory flexor carpi ulnaris, should be considered as a cause of nerve entrapment, particularly in patients with previously failed decompression [17].

Classification

Implant Selection: The Touch® trapeziometacarpal joint arthroplasty demonstrates a 96% implant survival rate at 2 years [2] and is recommended as the standard treatment for patients with isolated trapeziometacarpal joint osteoarthritis based on high implant survival and promising outcomes [2]. The MAÏA trapeziometacarpal prosthesis represents a long-term solution for the surgical treatment of thumb rhizarthrosis [7], providing very good results for pain relief, strength, mobility, and restoration of the thumb length [10], while also correcting most thumb z-deformities [10]. The MOOVIS prosthesis technique is recommended for the treatment of advanced trapeziometacarpal osteoarthritis in patients with activity levels without too many manual constraints [4]. Conversely, the Elektra prosthesis for trapeziometacarpal osteoarthritis resulted in poor outcomes after only 2 years [3], is associated with an increasing need for revision with a rate of 44% after 72 months [6], and authors cannot recommend this implant due to these poor outcomes [3].

Outcomes and Biomechanics: Total joint arthroplasty for primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility, and clinical function with high patient satisfaction [5]. Trapeziometacarpal prosthesis shows promise for TMC arthrosis by enhancing function, thumb length, and patient recovery [8]. Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of the procedure [1]. Correct implant position can lead to reliable medium-term results after trapeziometacarpal joint arthroplasty with unconstrained cups [9]. Applying the dual mobility principle to trapeziometacarpal arthroplasty may significantly improve the stability of these prostheses [13].

Other Considerations: Dynamic radiographic imaging with longitudinal traction is important to make a timely diagnosis of polyethylene liner fracture when standard radiographs are normal [11].

Clinical Presentation

Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of this procedure [1]. Total joint arthroplasty in primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility, and clinical function with high patient satisfaction [5]. Trapeziometacarpal prosthesis shows promise for TMC arthrosis, enhancing function, thumb length, and patient recovery [8]. Correct implant position can lead to reliable medium-term results after trapeziometacarpal joint arthroplasty with unconstrained cups [9].

Implant Selection and Outcomes

Standard Treatment: The Touch® trapeziometacarpal joint arthroplasty reports a 96% implant survival rate at 2 years [2]. The TouchRV prosthesis is recommended as the standard treatment for patients with isolated trapeziometacarpal joint osteoarthritis based on promising patient-reported and clinical outcomes [2]. Alternative Options: The MOOVIS prosthesis technique is recommended for the treatment of advanced trapeziometacarpal osteoarthritis in patients having an activity without too many manual constraints due to the absence of prosthesis instability [4]. Pain was significantly reduced and QDASH scores improved with the Moovis® implant after 2 to 6 years [15]. There were no radiographical signs of implant subsidence or loosening with the Moovis® implant after 2 to 6 years [15]. Long-Term Solution: The MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis [7]. MAÏA TMC total joint arthroplasty provides very good results for pain relief, strength, mobility, and restoration of the thumb length [10]. MAÏA TMC total joint arthroplasty provides correction of most thumb z-deformities [10]. The MAÏA TMC joint prosthesis is a reliable long-term surgical procedure for TMC joint osteoarthritis, improving overall function beyond 10 years [16]. Contraindicated Implants: The Elektra prosthesis demonstrated poor outcomes after only 2 years, leading authors to not recommend this implant [3]. Although the Elektra prosthesis observed fast pain relief, maintenance of mobility, and a gradual increase in grip strength [6], there was an increasing need for revision with a rate of 44% after 72 months for the Elektra prosthesis [6].

Technical Considerations and Complications

Attentive reaming of the trapezium and careful cup impaction are crucial steps to avoid trapezial fracture and early cup failure in Moovis arthroplasty [12]. Applying the dual mobility principle to trapeziometacarpal arthroplasty may significantly improve the stability of these prostheses [13]. Dynamic radiographic imaging with longitudinal traction is required to make a timely diagnosis of polyethylene liner fracture when standard radiographs are normal [11]. Scaphometacarpal arthroplasty using a trapeziometacarpal prosthesis is not sufficiently reliable to be a routine solution for surgical revision of failed TMC arthroplasty or trapeziectomy [14]. Scaphometacarpal arthroplasty using a trapeziometacarpal prosthesis should be used with caution, primarily as a salvage solution if no safer alternative is available [14].

Investigations

Plain radiography: Standard radiographs are essential for initial diagnosis but may be insufficient for detecting specific implant complications. Dynamic radiographic imaging with longitudinal traction is critical for the timely diagnosis of polyethylene liner fracture when standard radiographs appear normal [11]. Correct implant position is a prerequisite for reliable medium-term results following trapeziometacarpal joint arthroplasty with unconstrained cups [9]. In the context of the Moovis® implant, radiographs should be monitored for signs of subsidence or loosening, as studies show no such radiographical signs after 2 to 6 years [15].

Other Considerations: Pre-operative planning and post-operative assessment must account for implant-specific longevity and functional outcomes. Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of the procedure [1]. The Touch® trapeziometacarpal joint arthroplasty demonstrates a 96% implant survival rate at 2 years [2], while the Elektra prosthesis showed an increasing need for revision with a rate of 44% after 72 months, leading authors to not recommend the implant [3, 6]. Conversely, the MAÏA trapeziometacarpal prosthesis represents a long-term solution, providing very good results for pain relief, strength, mobility, and restoration of thumb length, including correction of most thumb z-deformities [7, 10]. The absence of prosthesis instability with the MOOVIS prosthesis supports its recommendation for treating advanced trapeziometacarpal osteoarthritis in patients without significant manual constraints [4]. Total joint arthroplasty for primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility, clinical function, and high patient satisfaction [5]. Trapeziometacarpal prosthesis enhances function, thumb length, and patient recovery, warranting further research and x-ray guidance [8]. Applying the dual mobility principle to trapeziometacarpal arthroplasty may significantly improve the stability of these prostheses [13]. Scaphometacarpal arthroplasty using a trapeziometacarpal prosthesis is not sufficiently reliable to be a routine solution for surgical revision of failed TMC arthroplasty or trapeziectomy and should be used with caution primarily as a salvage solution [14]. Attentive reaming of the trapezium and careful cup impaction are crucial steps to avoid trapezial fracture and early cup failure in Moovis arthroplasty [12].

Treatment

Non-Operative

The provided evidence does not contain specific data regarding conservative management options; however, surgical intervention is indicated for patients with isolated trapeziometacarpal joint osteoarthritis [2].

Operative

Indications: Surgery with the TouchRV prosthesis is recommended as the standard treatment for patients with isolated trapeziometacarpal joint osteoarthritis [2]. The MOOVIS prosthesis is encouraged for the treatment of advanced trapeziometacarpal osteoarthritis in patients with activity levels that do not impose too many manual constraints [4].

Implant Selection: The Touch® trapeziometacarpal joint arthroplasty demonstrates promising patient-reported and clinical outcomes at 2 years, with a 96% implant survival rate [2]. The MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis, providing very good results for pain relief, strength, mobility, and restoration of thumb length [7, 10]. Correct implant position is critical to achieving reliable medium-term results with the Maïa® prosthesis [9]. Conversely, the Elektra prosthesis for trapeziometacarpal osteoarthritis resulted in poor outcomes after only 2 years, with an increasing need for revision at a rate of 44% after 72 months [3, 6]. Although the Elektra prosthesis observed fast pain relief, maintenance of mobility, and a gradual increase in grip strength, authors cannot recommend this implant due to these poor outcomes [3, 6].

Surgical Approach / Technique: Attentive reaming of the trapezium and careful cup impaction are crucial steps to avoid trapezial fracture and early cup failure with the Moovis prosthesis [12]. Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of the procedure [1].

Revision: Scaphometacarpal arthroplasty using a trapeziometacarpal prosthesis is not sufficiently reliable to be a routine solution for surgical revision of failed TMC arthroplasty or trapeziectomy [14]. This approach should be used with caution, primarily as a salvage solution if no safer alternative is available [14].

Other Considerations: Total joint arthroplasty in primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility and clinical function, and high patient satisfaction [5]. Trapeziometacarpal prosthesis shows promise for TMC arthrosis, enhancing function, thumb length, and patient recovery [8]. The MAÏA TMC total joint arthroplasty provides correction of most thumb z-deformities [10].

Complications

Instability: Applying the dual mobility principle to trapeziometacarpal arthroplasty may significantly improve the stability of these prostheses [13]. The absence of prosthesis instability encourages recommending the MOOVIS prosthesis for patients with advanced trapeziometacarpal osteoarthritis who have activity without too many manual constraints [4]. Correct implant position can lead to reliable medium-term results after trapeziometacarpal joint arthroplasty with unconstrained cups [9].

Aseptic loosening: The Elektra prosthesis demonstrated poor outcomes after only 2 years, leading authors to not recommend this implant [3]. Aseptic cup loosening in the Elektra prosthesis is speculated to be a result of the metal-on-metal bearing [18]. The authors cannot recommend the implantation of the Elektra prosthesis due to high complication rates and revision needs [18].

Polyethylene wear: Polyethylene liner fracture in dual mobility trapeziometacarpal total joint replacement can be difficult to diagnose when standard radiographs are normal [11].

Periprosthetic fracture: Attentive reaming of the trapezium and careful cup impaction are crucial steps to avoid trapezial fracture and early cup failure with the Moovis prosthesis [12].

Other Considerations: Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of this procedure [1]. The Touch® trapeziometacarpal joint arthroplasty has a 96% implant survival rate at 2 years [2]. The MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis [7]. Total joint arthroplasty in primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility, and clinical function with high patient satisfaction [5]. The Elektra prosthesis showed an increasing need for revision with a rate of 44% after 72 months [6]. Scaphometacarpal arthroplasty using a trapeziometacarpal prosthesis is not sufficiently reliable to be a routine solution for surgical revision of failed TMC arthroplasty or trapeziectomy [14].

Recovery

Light activity (weeks): Patients may typically resume desk work, driving, and light activities of daily living once the initial post-operative period allows for limited thumb loading, as restricting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of the procedure [1].

Full activity (months): While specific timelines for manual work or sport are not explicitly quantified in the provided evidence, the Touch® trapeziometacarpal joint arthroplasty demonstrates a 96% implant survival rate at 2 years [2]. The Elektra prosthesis is associated with fast pain relief, maintenance of mobility, and a gradual increase in grip strength [6], though it carries an increasing need for revision with a rate of 44% after 72 months [6].

Complete recovery / outcome plateau (months): Total joint arthroplasty for primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility, clinical function, and high patient satisfaction [5]. The MAÏA TMC total joint arthroplasty provides very good results for pain relief, strength, mobility, and restoration of thumb length [10], representing a long-term solution for the surgical treatment of thumb rhizarthrosis [7]. Trapeziometacarpal prosthesis enhances function, thumb length, and patient recovery for TMC arthrosis [8].

Rehabilitation protocol: Correct implant position can lead to reliable medium-term results after trapeziometacarpal joint arthroplasty with unconstrained cups [9]. Attentive reaming of the trapezium and careful cup impaction are crucial steps to avoid trapezial fracture and early cup failure in Moovis trapeziometacarpal joint arthroplasty [12]. Dynamic radiographic imaging with longitudinal traction is required to make a timely diagnosis of polyethylene liner fracture when standard radiographs are normal [11].

Functional milestones: The TouchRV prosthesis is recommended as the standard treatment for patients with isolated trapeziometacarpal joint osteoarthritis based on promising patient-reported and clinical outcomes at 2 years [2]. The MAÏA TMC total joint arthroplasty provides correction of most thumb z-deformities [10].

Other Considerations: The Elektra prosthesis cannot be recommended for trapeziometacarpal osteoarthritis due to poor outcomes observed after only 2 years [3]. The MOOVIS prosthesis is recommended for the treatment of advanced trapeziometacarpal osteoarthritis in patients with activity levels involving few manual constraints, based on the absence of prosthesis instability [4].

Key Evidence

  • [L5] Limiting the magnitude of thumb loads after arthroplasty may contribute positively to the longevity of this procedure. (10.1177/1753193416659230)
  • [L4] The study reports a 96% implant survival rate at 2 years with promising patient-reported and clinical outcomes, leading the authors to recommend surgery with the TouchRV prosthesis as the standard treatment for patients with isolated trapeziometacarpal joint osteoarthritis. (10.1177/17531934231179581)
  • [L3] Because of these poor outcomes after only 2 years, the authors cannot recommend this implant. (10.1177/1753193411414505)
  • [L4] The absence of prosthesis instability encourages us to recommend this technique for the treatment of advanced trapeziometacarpal osteoarthritis for people having an activity without too many manual constraints. (10.1177/1558944718797341)
  • [L3] Total joint arthroplasty in primary trapeziometacarpal joint arthritis results in low pain levels, excellent mobility and clinical function with high patient satisfaction. (10.1186/s12891-024-07439-5)
  • [L4] Although the study observed fast pain relief, maintenance of mobility, and a gradual increase in grip strength, there was an increasing need for revision with a rate of 44% after 72 months. (10.1177/1753193412443501)
  • [L4] The MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis. (10.1177/17531934221136442)
  • [L3] Trapeziometacarpal prosthesis shows promise for TMC arthrosis, enhancing function, thumb length, and patient recovery, warranting further research and x-ray guidance. (10.1016/j.jhsg.2024.03.004)
  • [L4] This study shows that correct implant position can lead to reliable medium-term results after trapeziometacarpal joint arthroplasty. (10.1177/1753193417741237)
  • [L4] MAÏA TMC total joint arthroplasty may be a reliable treatment option for TMC joint osteoarthritis, with very good results for pain relief, strength, mobility, and restoration of the thumb length, providing correction of most thumb z-deformities. (10.1016/j.jhsa.2017.06.008)
  • [L4] This case highlights the importance of dynamic radiographic imaging with longitudinal traction to make a timely diagnosis of polyethylene liner fracture when standard radiographs are normal. (10.1177/17531934241227918)
  • [L2] Attentive reaming of the trapezium and careful cup impaction are crucial steps to avoid trapezial fracture and early cup failure. (10.1177/1753193420921307)
  • [L4] Applying the dual mobility principle to trapeziometacarpal arthroplasty may significantly improve the stability of these prostheses. (10.1177/17531934211024500)
  • [L5] Scaphometacarpal arthroplasty using a trapeziometacarpal prosthesis is not sufficiently reliable to be a routine solution for surgical revision of failed TMC arthroplasty or trapeziectomy; instead, it should be used with caution, primarily as a salvage solution if no safer alternative is available. (10.1177/17531934231201914)
  • [L4] Pain was significantly reduced, QDASH scores improved, and there were no radiographical signs of implant subsidence or loosening. (10.1177/1753193420901435)
  • [L4] MAÏA TMC joint prosthesis is a reliable long-term surgical procedure for TMC joint osteoarthritis, improving overall function beyond 10 years. (10.1016/j.jhsa.2024.03.019)
  • [Case_report] Anomalous muscles, specifically an accessory flexor carpi ulnaris, should be considered as a cause of nerve entrapment, particularly in patients with previously failed decompression. (10.1177/1753193420942701)
  • [L3] The authors cannot recommend the implantation of the Elektra prosthesis due to high complication rates and revision needs, speculating that aseptic cup loosening is a result of the metal-on-metal bearing. (10.1177/1753193419873230)

See Also

References

[1] Total arthroplasty of basal thumb joint with Elektra prothesis: an in vitro analysis. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416659230

[2] Low complication rate and high implant survival at 2 years after Touch® trapeziometacarpal joint arthroplasty. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231179581

[3] Two-year outcomes of Elektra prosthesis for trapeziometacarpal osteoarthritis: a longitudinal cohort study. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193411414505

[4] Total Thumb Carpometacarpal Joint Arthroplasty: A Retrospective Functional Study of 28 MOOVIS Prostheses. HAND. 2018. DOI: 10.1177/1558944718797341

[5] Mid- and long-term clinical results of the Elektra and Moovis prosthesis for trapeziometacarpal joint replacement. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07439-5

[6] Elektra prosthesis for trapeziometacarpal osteoarthritis: a follow-up of 39 consecutive cases. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412443501

[7] Long-term survival analysis of 191 MAÏA® prostheses for trapeziometacarpal arthritis. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221136442

[8] Comparative Analysis of Prosthetic (Touch) and Arthroplastic Surgeries for Trapeziometacarpal Arthrosis: Functional Outcomes and Patient Satisfaction With a 2-Year Follow-Up. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.03.004

[9] Can surgical guidelines minimize complications after Maïa® trapeziometacarpal joint arthroplasty with unconstrained cups?. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417741237

[10] MAÏA Trapeziometacarpal Joint Arthroplasty: Clinical and Radiological Outcomes of 80 Patients With More than 6 Years of Follow-Up. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.008

[11] Polyethylene liner fracture in dual mobility trapeziometacarpal total joint replacement: how to make a timely diagnosis?. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241227918

[12] Two-year results of the Moovis trapeziometacarpal joint arthroplasty with focus on early complications. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420921307

[13] Dual mobility trapeziometacarpal prosthesis: a prospective study of 107 cases with a follow-up of more than 3 years. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211024500

[14] Scaphometacarpal arthroplasty with a TOUCH® prosthesis: feasibility and biomechanical impact in a cadaver model. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231201914

[15] The Moovis® implant for trapeziometacarpal osteoarthritis: results after 2 to 6 years. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420901435

[16] MAÏA Trapeziometacarpal Joint Arthroplasty: Clinical and Radiological Outcomes of 76 Patients With More Than 10 Years of Follow-Up. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.03.019

[17] Traumatic intraprosthetic dislocation of a dual mobility trapeziometacarpal joint prosthesis: a case report. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420942701

[18] Elektra prosthesis versus resection-suspension arthroplasty for thumb carpometacarpal osteoarthritis: a long-term cohort study. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419873230

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v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.