We report a case of a 67-year-old woman who had suffered from known severe osteoarthritis in the finger joints, long-standing complaints, and pain of several proximal interphalangeal (PIP) joints with resultant loss of mobility. Prior to our consultation, an implantation of a PIP silicone arthroplasty to the PIP joint of the middle finger using volar approach was performed at another hospital due to severe pain.
After the surgery, the patient was satisfied initially and showed a significant pain relief. However, fixated ulnar longitudinal axis deviation, active range of motion (ROM), and pain aggravated over the following years. At the time of our first consultation of the patient, which took place 3 years after primarily performed surgery, the treated finger showed an ulnar axis deviation of 20 degrees and a ROM of 55 degrees; full extension was possible. Increased functional restriction in combination with pain due to disturbing ulnar axis deviation with instability of the radial collateral ligament and loss of mobility provided the indication for further treatments (▶Fig. 50.1).
Arthroplasty is a well-established proven treatment option for destructed PIP joints caused by degenerative or posttraumatic osteoarthritis. Compared to arthrodesis, arthroplasty shows increased patient acceptance and significant improvement of function as a result of preserved mobility especially of the ulnar rays. Our own experience in accordance to literature show promising outcome and low complication rate in the long term; an average of 50- to 60-degree ROM can be expected.
Disadvantages of silicone arthroplasty are low implant stiffness and necessary partial resection of collateral ligaments, which often causes a postoperative axis deviation, especially to the ulnar side. In particular, preoperative axis deviation with insufficiency of the collateral ligaments plays a key role for a renewed axis deviation in the long term. This phenomenon is accentuated by implant breakages, which are usually not clinically symptomatic and do not require treatment or revision arthroplasty, as this occurrence is not necessarily painful. The rate of implant breakage occurrence varies from 10 to 30% according to the literature.
Finger joints treated with silicone arthroplasty do not show a physiological rolling motion such as anatomically healthy joints or joints with surface replacement. In such interposition arthroplasties as represented by silicone arthroplasty, volar bony impingement occurs frequently due to deformation of material. Therefore, it is particularly important that the bone be resected sufficiently volar on the proximal and distal side.
In our presented case, pain could not be significantly alleviated by the priorly performed silicone arthroplasty in the long term. Active flexion postoperatively was similar to the possible flexion preoperatively. However, there was a temporary flexion contracture of 30 degrees. Three years after the primary surgery, the patient suffered from pain again, showed an increased ulnar deviation of 20 degrees, a restriction of ROM with a flexion of 55 degrees, and full extension. Fingertip to palmar distance was 2 cm at the affected finger (▶Fig. 50.2a). Implant breakage was suspected radiologically (▶Fig. 50.2b).
Fig. 50.1 (a, b) Photographs show the patient 3 years after primary silicone replacement of the middle finger. Patient with limited ROM, persistent pain, and increasingly ulnar angulation.
Fig. 50.2 (a) Restricted active flexion with fingertip to palm distance of 2 cm at the middle finger. (b) X-ray shows a broken silicone implant between the proximal stem and the hinge.
Persistent pain after primary silicone arthroplasty is rare. Not every breakage of a silicone implant necessitates revision, because the silicone implant still serves as a spacer with the result that no increased pain is expected and good function can be preserved. Additionally, Swanson described in the early 60s a soft-tissue reaction due to the silicone material, which he called “encapsulation.” This soft-tissue capsule should provide in the long term stability and pain-free mobility even in broken silicone implants. However, revision is recommended and promising, if pain and active restricting mobility are dominant. The correction of an axis deviation after silicone arthroplasty is not always satisfying due to flexibility of the material. Nevertheless, soft-tissue reconstruction with the reconstruction of the radial collateral ligament should be carried out during the revision surgery together with replacement of the silicone implant. Arthrodesis as revision surgery is recommended for strong deformity with unstable collateral ligaments.
• Not every implant failure needs revision.
• Pain and restriction of ROM can often be well addressed by revision surgery.
• Massive ulnar deviation is difficult to correct in the long term. In these cases, arthrodesis is recommended.
• Collateral ligament reconstruction should be performed together with the revision surgery involving a change of the silicone implant.
• Silicone arthroplasty of the PIP joint can be done using a dorsal or a volar approach depending on the previous operation and clinical findings.
Revision procedure takes place in the operation theater under local, regional, or general anesthesia with tourniquet to the upper arm or forearm level. As the primary procedure was carried out from the volar side, a Bruner incision in the area of the scar with the base of the flap on the radial side was performed. Visualization of both vascular and nerve bundles and preparation leading to the flexor tendons are shown in ▶Fig. 50.3a–c. A flexor tendon sleeve between A2 and C1 pulleys under entrainment of the volar plate and checkrein ligaments are formed (▶Fig. 50.3d,e). After release of the ulnar-sided collateral ligament, the complete visualization succeeds with hyperextension of the joint dorsally like a shotgun approach (▶Fig. 50.3f–h). Then the broken silicone implant is completely removed. The volar cortical bone lip at the base of the middle phalangeal is smoothened. Both marrow spaces are prepared for any possible placement of the implant using the corresponding rasps. The next step is positioning of the definitive silicone implant and clinical and radiological control. Overstuffing must be avoided, because this often leads to strong impairment of ROM. Thereafter, the radial collateral ligament is reconstructed with nonabsorbable suture (▶Fig. 50.3i) in an anatomical position. The flexor tendon sheath is refixed with a 4–0 or 5–0 absorbable sutures (▶Fig. 50.3j). The next steps are skin closure (▶Fig. 50.3k), sterile hand bandage, and volar splint in slightly flexed position of the fingers. The first change of dressing is done after 3 to 5 days with application of a thermoplastic splint in intrinsic plus position immobilizing the PIP joints for 3 to 4 weeks.
1. Volar approach as described by Simmen and Schneider.
2. Resection of the volar cortical bone lip at the base of the middle phalanx.
3. Reconstruction of the collateral ligaments with nonabsorbable 3–0 suture.
4. Postoperative immobilization for 3 to 4 weeks after collateral ligament reconstruction.
In our case report, pain could be positively influenced by the performed revision arthroplasty. The active ROM improved significantly to a flexion of 75 degrees and an extension lag of 15 degrees active and 0 degrees passive. The ulnar axis deviation was corrected from 20 to 10 degrees (▶Fig. 50.4a,b). In contrast to the primary PIP arthroplasty with early immobilization, we recommend an additional postoperative immobilization of 3 to 4 weeks after PIP revision surgery in case of preoperative axis deviation (▶Fig. 50.5). This immobilization relieves the reconstructed collateral ligament and additionally corrects the most contract and fixed soft tissues of the entire finger. The approach in the case of revision is dependent on the primary approach. However, there is a prevailing problem on the volar side after a dorsal approach (osseous impingement); we recommend relocating the approach to volar. The postoperative radiograph shows the resection of the volar cortical bone lip at the base of the middle phalanx as recommended (▶Fig. 50.6).