A 78-year-old woman presents with difficulty moving her right hand. She has a several year history of right hand digital pain of the index and long fingers. She has noticed a progressive loss of digital range of motion of the right hand, particularly involving the index and long fingers. She is now 6 months postoperative following proximal interphalangeal (PIP) joint surface replacement arthroplasty for advanced, symptomatic degenerative osteoarthritis of the index and long PIP joints. Prior to surgery, she was treated with a variety of nonoperative measures including nonsteroidal anti-inflammatory drugs, outpatient hand therapy, a resting orthosis, and activity modifications. Her preoperative ranges of motion for the index and long finger PIP joints were 20 to 47 degrees of flexion and 20 to 60 degrees of flexion, respectively.
The modified Chamay dorsal approach was used for both the index and long finger PIP joint surface replacement arthroplasties whereby a 3-cm longitudinal incision was first made over the proximal phalanx. A distally based flap of the extensor mechanism was then made to expose the PIP joint and the collateral ligaments were maintained (▶Fig. 52.1). The proximal phalanx and middle phalanx components were inserted in a press fit fashion and cement was deemed not necessary.
Rehabilitation was started at 5 days postoperative and consisted of a volar-based digital short arc motion orthosis, which allowed for progressive, controlled PIP flexion as follows: 0 to 30 degrees of flexion from week 0 to 2, 0 to 60 degrees of flexion from week 2 to 4, and unrestricted PIP joint flexion thereafter (▶Fig. 52.2).
At 3 months postoperative, the long finger PIP joint motion was 20 to 80 degrees of flexion and was considered functional. The index finger PIP joint, however, was contracted in 0 degrees of extension with no demonstrative digital flexion (▶Fig. 52.3). Due to failure of progression of index finger digital motion, aggressive hand therapy was instituted including active-assisted and passive range of motion of the isolated index finger PIP joint as well as a dynamic flexion orthosis for the PIP joint (▶Fig. 52.4). Despite continued hand therapy, no progress was made in the index finger PIP joint contracture by 6 months postoperative. It was determined at that time that surgical intervention was necessary.
The recommended solution to the problem is extensor tenolysis, supraclavicular regional anesthesia with indwelling catheter placement for 3 days, and immediate, postoperative aggressive, supervised hand therapy to include active-assisted and passive range of motion as well as a dynamic flexion orthosis.