Introduction
This chapter covers common problems encountered long after digital and metacarpal fractures or dislocation. We focus on indications and surgical techniques for correction of malunion and nonunion and for arthrodesis and arthroplasty after fractures and dislocations.
Fracture malunion and bony defects (Carlos Henrique Fernandes)
Malunion
With proper treatment, fractures of the hand most often heal and result in good function. Unfortunately, complications such as nonunion, malunion, and/or bone defects can occur. The identification of factors that may lead to complications is important for prevention and prognosis. The risk factors include tobacco consumption, obesity, diabetes mellitus, mental disorders, drug use, the complexity of the injury, infection, localization of fracture (blood flow), bone loss, and avascular necrosis.
Deformity after a malunited fracture of a tubular bone can result in substantial disability, including distortion of the normal arc of digital motion, interference with adjacent digital mobility, tendon imbalance or adhesions, articular stiffness, loss of strength or dexterity, aesthetic concerns, and/or pain. The malunion can be classified regarding the bone involved, the location of the deformity, the type of deformity (angulation, rotation, shortening, or a combination) ( Figs. 4.1 and 4.2 ), and age of the patient (pediatric or adult). Radiographic evaluation is necessary and includes anteroposterior, lateral, and oblique views with comparative views of the opposite hand if necessary. CT is especially helpful in assessing an intraarticular malunion.
Phalanx.
A phalangeal deformity can comprise rotation, angulation, and shortening, singularly or in combination. Crush injuries frequently involve the distal phalanx, and most distal phalangeal fractures fully heal. Complications are unusual. The diagnosis of nonunion can be made by the presence of deformity and instability. An asymptomatic nonunion of the distal phalanx tuft does not require intervention. Symptomatic patients, such as those with pain on motion or instability in pinching and grasping objects, need surgical treatment. The nonunion of the tuft can be managed by removing the small fragments. The nonunion of the distal phalangeal shaft usually causes functional limitations. It can be treated with a single compression screw inserted by a minimally invasive approach. In cases of bone resorption, a bone graft is a treatment alternative. In the distal phalanx, however, it is difficult to perform grafting because there is little bone contact surface. Olecranon bone grafting combined with Kirschner (K) wire fixation has been reported to result in relief of pain, deformity, and instability along with radiological union.
Distal phalangeal fractures are common pediatric injuries. The displaced distal phalangeal physeal fractures with an associated nail bed laceration (Seymour fractures) have a high incidence of complications, including nail deformity, persistent extensor lag, and infection, which occurred in 25% of patients in one study.
Fractures at the base of the distal phalanx are often unstable because this is the insertion site for both the flexor and extensor tendons. A dorsal hump deformity, the consequence of an avulsion fracture with a dorsal displacement, does not have clinical importance because only 15% of digital total active motion occurs at the distal interphalangeal (DIP) joint ( Fig. 4.3 ). The intraarticular malunion associated with bone loss or degenerative changes can be treated with arthrodesis. It causes a 20% to 25% reduction in grip strength but is well tolerated and imparts the least detriment to hand function ( Fig. 4.4 ).
The deforming forces that act on the middle phalanx fractures are the flexor digitorum superficialis (FDS) and the intrinsic tendons. Middle phalangeal fractures proximal to the FDS insertion have an apex dorsal angulation, whereas fractures distal to the FDS insertion have an apex volar angulation. When a clear functional deficit from a malunited fracture is noted, surgical intervention should be considered within the first 3 to 4 months. Remarkable angular deformities in the dorsal or palmar direction require an opening wedge osteotomy. The exact degree of angulation for which corrective osteotomy is indicated varies in individuals and also depends on the location of the angulation. An angulation at the shaft more often requires osteotomy, and an angulation in the index finger presenting with ulnar deviation may need corrective osteotomy, but the same angulation in the little finger does not need surgery, as the latter does not interfere with hand function. For angular deformities in the radial/ulnar plane, a closing wedge osteotomy can be performed with the use of sequentially larger burrs, leaving the opposite cortex and periosteum intact. The osteotomy can be fixed with K-wires either alone or combined with cerclage wire applied on the tension side.
A proximal interphalangeal (PIP) joint fracture-dislocation is a complex injury. Restoring articular congruence is a challenge. An inadequate treatment in the acute phase causes a PIP joint fracture-dislocation and consequent chronic degenerative arthritis in the case of a partial joint defect ( Fig. 4.5 and Box 4.1 ). The treatment for malunited fractures of the base of the middle phalanx needs to be identified and treated promptly. Del Pinal et al. propose the hyperextension volar (shotgun) approach, which permits fixation with screws and a cerclage wire and allows immediate motion. In cases of joint instability, an extension block K-wire is needed to maintain the reduction and unload the comminuted volar fragments. If during the procedure the cartilage on the base of the middle phalanx is noted to be damaged severely, articular reconstruction should be considered. Reduction of the dislocation and resurfacing of the depressed volar segment of the middle phalanx has been accomplished by an arthroplasty using the volar plate (VP) to resurface the joint.
- 1.
Corrective osteotomy is considered if the angulation in the phalangeal shaft/base or metacarpal shaft affects hand function. The exact degree of angulation for such surgery should be decided individually.
- 2.
Bone grafting is indicated for a bony defect or sometimes after osteotomy. Autogenous or allograft cancellous bone is used for a small defect (without long cortical defects). Corticocancellous bone graft is used for a larger bony defect (>1–2 cm) in the phalangeal or metacarpal shaft.
- 3.
The corrective osteotomy may be needed for malunited unicondylar fractures of the proximal interphalangeal joint, often with collateral ligament release or/and volar plate plasty. An osteochondral or implant arthroplasty may be necessary for a damaged joint (with >50% articular surface destruction).
- 4.
Deformity in the malunited metacarpal neck or shaft fracture does not need treatment if hand function is not affected or if the cosmetics is acceptable.
- 5.
A neglected Bennett fracture may need corrective osteotomy. A painful trapeziometacarpal (TMC) joint with traumatic arthritis or chronic TMC subluxation often need arthrodesis.
The initial indication for VP arthroplasty was the acute fracture-dislocation in which reduction was not possible. Over time, the indications have been expanded to include chronic dorsal fracture-dislocation of the PIP joint without degenerative changes and for fractures involving less than 50% of the middle phalanx joint surface. The PIP joint is approached through a volar Bruner incision, the flexor tendons are retracted, and the VP is incised along its lateral margins, which detaches it from the accessory collateral ligaments, and the accessory collateral ligaments are excised. The VP is separated from the comminuted fragments at its distal border and divided transversely as far distally as possible, leaving some volar periosteum. The VP is adequately advanced distally into the articular defect, reducing and resurfacing the joint. The reattachment can be performed with two bone anchors. The joint need not be flexed more than 35° to maintain reduction. A K-wire is inserted across the joint to maintain joint stability and is removed at 2 weeks when active, protected flexion with dorsal block splinting is started.
The indication for osteochondral autografting from the hamate is when 50% or more of the articular surface of the middle phalanx is involved and an intact dorsal cortex with more than 20% of the normal cartilage surface preserved. The surgical technique for PIP exposure here is the same described for VP arthroplasty. The phalangeal base is prepared for placement of the hamate autograft. A rongeur or saw is used to create a smooth surface with caution to avoid excessive removal of bone that could lead to fracture of the intact dorsal cortex. If a saw is used, saline irrigation is used to decrease thermal osteonecrosis. The dimensions of the bony defect then are measured to plan the harvest of an appropriately sized hamate graft. After a fluoroscopic anatomical identification, a 3-cm transverse incision is made in the dorsal region at the anatomical topographic site of the carpometacarpal joint at the bases of the ring and small metacarpals. A dorsal capsulotomy is made, and the hamate is visualized. The graft, centered between its articulations with the ring and small metacarpals as a reference point, should be slightly larger than the measured defect to allow further contouring to the exact size and shape. The autograft then is placed into the defect at the base of the middle phalanx. If necessary, any additional contouring is performed. Direct visualization of the articular surfaces will confirm that no step-off is present. In the center of the graft, a K-wire is used for a provisional fixation, followed by two microfragment screws inserted into the graft in a volar to dorsal direction. A third screw can replace the previously inserted provisional fixation pin. The VP is reattached to the stumps of the collateral ligaments along the lateral margins of the middle phalanx. The reflected flexor sheath then is interposed between the palmar plate and flexor tendons. A dorsal splint is applied to maintain the PIP joint in approximately 20 degrees of flexion.
The corrective osteotomy for malunited unicondylar fractures through the site of the original fracture is demanding technically and has risks. These include loss of fixation, avascular necrosis, and joint stiffness. The osteotomy can be fixed with screw fixation or a tension band with wires. Harness et al. reported that an extraarticular osteotomy creating a closing wedge osteotomy and fixation with a tension band accomplished realignment of the joint, with improvement of the PIP joint motion.
Neck or shaft fractures of the proximal phalanx are characterized by volar angulation at the fracture site and dorsal displacement of the distal fragment. In mature bone, the corrective osteotomy can be fixed with K-wire or with a plate and locking screws. A comparative study by Chen et al. showed that the K-wire group had a shorter duration of operation and shorter time to the union than the plating group. The functional outcomes were not significantly different between the groups. The incidence of complications was also similar between the groups, whereas the locking plate group had a higher incidence of secondary surgery. If the malunion occurs in the thumb, pinch is weaker than on the contralateral side. Al-Qattan used iliac crest bone grafting after performing an osteotomy in the thumb. The thumb length was increased; however, the motion of the interphalangeal joint was not fully restored.
Neck or shaft fractures (of the middle and proximal phalanges) in children are uncommon. Minimally displaced fractures with less than 30 degrees of angulation, 25% translation, and no rotational deformity can be treated with immobilization. In cases of displacement, most can be managed by closed reduction and immobilization. Percutaneous fixation or open reduction with K-wire fixation results in good digital motion. Unfortunately, many of these fractures present in a subacute or delayed manner as a consequence of being considered minor injuries during the first clinical visit. In the past, percutaneous manipulation and the use of one or two small K-wires to break down the callus and to lever the dorsally displaced and rotated condylar fragment back into the correct anatomical position was advised. Once the fracture was reduced, other percutaneous K-wires were used to stabilize the fracture. Puckett et al. presented a series of eight phalangeal neck fracture malunions in children with a 5.3-year mean follow-up. They demonstrated the remodeling capability of these fractures without surgical intervention. This report highlights that these fractures may not need surgery.
The posttraumatic degenerative changes of the PIP joint can lead to pain, deformity, stiffness, and functional disability. When nonsurgical management fails, surgical treatment options include arthroplasty and joint arthrodesis. Arthroplasty is often discouraged in the index and little fingers because of the mediolateral stresses that the PIP joints of these digits encounter during pinch. Joint arthrodesis is considered a salvage procedure. A wide variety of joint positions ranging from 20 to 60 degrees have been recommended to maintain function.
Posttraumatic malunion of the proximal phalanx can cause cosmetic deformity and impaired hand function. The angular and rotational deformities can be observed as isolated or associated. Apex volar angulation of 10 degrees or more involving the proximal phalangeal diaphysis will affect the balance of the extensor mechanism, potentially producing a pseudoclaw deformity. Lateral deformities, in general, are associated with bone loss as a consequence of more complex injuries. Malunited fractures of the phalanges can be corrected at the site of the malunion or at the base of the metacarpal ( Fig. 4.6 ). Corrective osteotomy of the rotated proximal phalanx is technically challenging and fraught with complications. Exposure of the proximal phalanx necessitates opening of the extensor mechanism, with the possibility of subsequent scarring and stiffness. It is frequentily necessary to undergo additional surgery to remove implants and tenolisys of the extensor mechanism. The corrective osteotomy at the site of the original fracture better corrects a combined deformity and enables the surgeon to simultaneously perform tenolysis and capsulolysis. A corrective osteotomy at the site of the malunion can be performed 6 weeks after fracture. The screws can be used only when osteoclasia (i.e., deliberate breaking of a malformed or malunited bone) is performed and the refracture line is oblique or spiral. Mini plates or screws are used for fixation. Both techniques obtain a stable fixation and allow for active digital motion exercises immediately after surgery.
The minimally invasive method of using cannulated headless screws and no bone graft can also be used. The surgical technique consists of inserting the screw guidewire into the base of the proximal phalanx and making fluoroscopic checks to confirm the correct position in the medullary canal. In malunions, the medullary canal may be partially obliterated, and the cortex may be weak. As a consequence, it is commonly difficult to find the correct path for the guidewire, which can penetrate the cortex in an incorrect location. The guidewire is withdrawn distal to the osteotomy site, and a 2-cm transverse skin incision is followed by an opening wedge transverse osteotomy using a narrow oscillating sawblade. The bone is aligned placing the fingers into a composite fist. Finally, the guidewire is reinserted, and any correction can be made by tightening or loosening the screw.
Rotational metacarpal osteotomy is especially advantageous for the correction of developmental deformities of the fingers such as those observed with prolonged finger sucking where rotation occurs at the level of the proximal and middle phalanges. It is technically easy and avoids adhesions of the tendons that surround the proximal phalanx, which can increase stiffness.
A cadaver study demonstrated that 1 degree of metacarpal rotation provides about 0.7 degrees of phalangeal correction and that corrections of up to 19 degrees can be achieved in the index, middle, and ring fingers. Correction in the small finger is limited to 20 degrees of pronation and 30 degrees of supination. Osteotomies at the metaphyseal bone at the base of the metacarpal heal readily, and the osteotomy can be secured with plate fixation with a lesser risk of extensor adhesions. Secondary tenolysis is rarely required.
Metacarpal.
Malunion of a metacarpal may have a less functional impact than one involving a phalanx. Flexion deformities of the neck of the fourth or fifth metacarpals rarely present functional deficit or mobility limitation of metacarpophalangeal (MCP) joints ( Box 4.1 ), although they may result in prominence of the metacarpal head in the palm. However, most people with malunited apex-dorsal angulations do not have functional impairment, unless there is a rotational deformity, and thus do not need surgical correction. If there is notable functional impairment, especially a rotation deformity causing scissoring of the finger during grasp, corrective surgery is indicated. The exact degree of deformity that requires surgery depends on individual function and appearance. The surgeon and patient should make a joint decision regarding the need for surgery after careful clinical evaluation of hand function and the needs of the patient. The correction of the angular malunion is usually performed using a dorsal closing wedge osteotomy and internal fixation with a plate, transverse or longitudinal K-wires, or intramedullary screws. A palmar opening wedge osteotomy and bone graft permit the metacarpal length to be increased. The patient often tolerates mild shortening of the dorsal angulation of the fifth metacarpal shaft well, but the patient does not often tolerate the shortening of the fourth metacarpal if the fourth metacarpal head is shorter than that of the fifth, so surgical lengthening is often requested by the patient. The surgeon can use the third and fifth metacarpal bones as the frame to support the transverse K-wires to avoid plating after osteotomy and bone grafting ( Fig. 4.7 ).
The advantages of transverse K-wires that fix the metacarpal to the adjacent metacarpal bones after osteotomy and bone grafting or an intramedullary screw for fixation after osteotomy are its technical simplicity and the benefit of permitting immediate hand motion exercises. Plate and screw fixation provides rigid fixation and allows early hand motion, but a second operation is often needed for hardware removal or tenolysis.
Intraarticular fractures of the second through fifth metacarpal bases are uncommon injuries but can result in serious morbidity. If they are improperly managed, arthrosis and pain may develop. A neglected Bennett fracture can be treated with an intraarticular osteotomy, extraarticular metacarpal osteotomy, trapezial resection with or without tendon interposition arthroplasty, fascial or implant arthroplasty, or arthrodesis of the carpometacarpal (CMC) joint. A Wagner incision with subperiosteal elevation of the thenar muscles permits access to explore the metacarpal base step-off. Callus is stripped off the bone until the malunion site is reached, and then an osteotome is introduced to the site working from distal to proximal. After anatomical reconstitution, internal fixation is performed. If posttraumatic CMC arthritis occurs, it is often treated with arthrodesis ( Fig. 4.8 and Box 4.1 ). It is often indicated for a young, active male or for a manual worker who needs a strong pinch. Fixation implants include K-wires, plates and screws, and cannulated screws. The most common complication of arthrodesis is nonunion.
Angulation or deformity of the base of the second to fifth metacarpals usually does not need treatment as hand function is not affected. The fifth CMC joint may be subluxed or may have an incompletely reduced intraarticular fracture, but functional impairment is uncommon, and arthritis rarely develops, which is different from the thumb CMC joint. If there is no functional loss or pain, a stable, although subluxed, fifth CMC joint does not require treatment. CMC arthrodesis may be needed on rare occasions.
Bone defect
High-energy injuries, posttraumatic infection, or tumor resection may cause large segmental bone loss of the phalanges and metacarpals. In severe cases involving a stiff or chronically infected finger, digital amputation is favored because protracted treatment and rehabilitation with poor digital function and low patient satisfaction are anticipated. In treating a digit with infection and bony defect, it is necessary to ensure an appropriate exposure to permit efficient debridement to reach healthy bone stock, stable skeletal fixation, and adequate soft tissue coverage.
Nonvascularized bone grafting is used for bone defects in the phalanges and metacarpals ( Box 4.1 ). Autologous bone is considered the reference standard owing to its histocompatibility and osteogenicity. Cancellous autografts allow for rapid remodeling and incorporation into existing bone, but they are not appropriate in cases that necessitate immediate mechanical strength. Corticocancellous bone provides structural support and immediate mechanical strength, which is helpful when the cortical bone defect is over 1 cm. The most common donor sites are the iliac crest (larger bony loss), distal radius, or olecranon (small bony loss) ( Fig. 4.9 ). A long-term complication is bone graft resorption.
For a small bony defect in the phalanges or metacarpals, allograft cancellous bone, if available, can be used instead of an autograft. Allograft bone can be used at the site of corrective osteotomy for a malunited fracture or for a small bone defect after lengthening a shortened phalanx or metacarpal bone. Osteochondral graft from the base of the little finger metacarpal can be used for the patient with a defect in a part of the finger joint ( Fig. 4.10 ).
A vascularized bone graft is indicated for reconstruction of large (>6 cm) osseous defects or those with established avascular necrosis, which is rarely needed in a digit or metacarpal except when a metacarpal is nearly or completely lost. Its advantages are the maintenance of viable osteocytes, primary healing without creeping substitution, faster union, and improved biomechanics. The common donors are the radius, fibula, and iliac crest. ,
Phalanges and metacarpals with posttraumatic segmental bone loss can be reconstructed either primarily or in a second stage. Primary bone grafting offers some advantages, including decreased number of surgeries/anesthesias and days hospitalized, less cost, and immediate osseous fixation, which allows for early active motion. The immediate reconstruction with the use of corticocancellous bone graft for an open fracture with a bony defect can be safely performed with a high incidence of union and no increased risk of infection. A delayed primary bone grafting requires a clean wound, good blood supply, adequate fixation, and secure soft tissue cover. In cases of articular loss, arthrodesis can be performed via intraosseous cerclage wires, K-wires, tension-band wiring, cannulated headless screws, or plates.
A progressive distraction of metacarpals and phalanges using an external fixator permits recovery of length achieved by bony regeneration with or without a bone graft.
The advantage of using bone grafts is to hasten healing, and the disadvantage is the possibility of donor site morbidity.
In the hand, nonvascularized bone grafts from a metatarsal, iliac crest, or fibula are also used after resection of malignant bone tumors or benign aggressive expansile osteolytic lesions such as giant cell tumors and aneurysmal bone cysts. ,
Arthroplasty (Michel Ernest H. Boeckstyns)
Prosthetic replacement of a painful finger joint after malunion of an intraarticular fracture can be an alternative to arthrodesis. Early attempts to replace destroyed finger joints included resurfacing hemiarthroplasty and hinged total arthroplasty of the MCP and PIP joints. Results were generally disappointing due to the high incidence of complications, and these implants are no longer used.
In the 1960s, Swanson introduced the concept of a single component flexible silicone spacer (FSS) for joint replacement. Subsequently, surface replacement arthroplasty (SRA) with unconstrained multicomponent implants have been designed. They are used mainly in the PIP joints and more rarely in the MCP joints due to the relative rarity of intraarticular MCP joint fractures. CMC joint arthroplasty after an intraarticular fracture of the base of the first metacarpal is discussed in another chapter of this book. DIP joint arthroplasty has been reported but is not widely used, and arthrodesis in these joints is a reliable and rewarding intervention. Likewise, arthrodesis is preferred for the MCP joint of the thumb. The focus of this section is primarily PIP joint arthroplasty.
Types of implants
Flexible silicone spacers.
To this day, silicone spacers are the most used and are often considered the reference standard for finger joint arthroplasty. The implant is not designed for bony ingrowth. Rather, it relies on the formation of a capsule around the prosthesis and proper tendon and ligament balance to maintain stability. The most used are the Swanson spacer (Wright Medical Technology, Inc.) and the Neuflex (Depuy). An important difference between these two implants is that the Neuflex has a hinge that is preset in flexion, which is meant to improve postoperative flexion and lower the risk of implant fracture.
Unconstrained surface replacement arthroplasty.
SRA prostheses may consist of a metallic alloy stem that has an external surface to promote bone growth and a metal-on-polyethylene articular part. Examples are the Tactys (DJO), CapFlex-PIP1 resurfacing implant (KLS Martin), and the PIP-R1 implant (MatOrtho). The pyrocarbon implant Ascension PIP joint (Ascension Orthopedics) consists of two nonconstrained components implanted by press-fit rather than aiming for osseointegration. Stability relies on the ligaments and joint capsule. The advantages comprise biocompatibility with bone and cartilage and its elastic modulus, which is close to that of bone. However, a meta-analysis of 718 arthroplasties found higher incidence of complications associated with the use of pyrocarbon (30%) versus silicone implants (8%). The implant has recently been withdrawn from the market. The MOJE implant (Moje Keramik Implantate) is a ceramic unconstrained two-component implant with a hydroxyapatite coating. ,
Indications
Arthritis after intraarticular fractures.
In the context of trauma, painful arthritis after malunion of an intraarticular fracture of the PIP joint is the main indication for arthroplasty. Replacement for posttraumatic arthritis in the MCP joints is relatively rare, and replacement of the distal interphalangeal joints is rarely performed.
Primary arthroplasty for an irreparable intraarticular fracture.
Emergency or or an SRA has been used to salvage digits with complex injuries and intraarticular bone loss in the PIP joint.
Which fingers?
In the radial fingers and especially the index, arthroplasty is controversial due to the large lateral and axial rotational joint forces during pinch. A retrospective study compared arthrodesis versus SRA arthroplasty for osteoarthritis or posttraumatic arthritis in the index PIP joint. There were no differences in pain relief, satisfaction, or Michigan Hand Questionnaire scores between treatment groups. Patients undergoing arthroplasty had a fourfold greater mean number of complications. At final follow-up after a mean of 50 months (range, 17–64) after operation, eight of 65 arthroplasties required revision with upsizing to a larger implant, six underwent repositioning of components, and four were converted to arthrodesis for instability, contracture, or wound complications. More than 50% of the SRA components exhibited periprosthetic osteolysis, a high incidence of component migration including complete breach of prosthetic stems through phalangeal cortices in five patients, and approximately 2 mm of combined subsidence of proximal and distal components.
In a systematic review, Milone et al. reported an instability incidence of 33% in the index and 29% in the middle finger, compared to 6% in the ring finger and 6% in the little finger, after arthroplasty for the treatment of osteoarthritis or posttraumatic arthritis of the PIP joint. They concluded that the instability-related deformity and the incidence of complications for long finger PIP joint arthroplasty may not be different from that of the index finger and that PIP joint arthroplasty for the long finger may be contraindicated.
Which patients?
In general, young age and high demands are considered relative contraindications for prosthetic joint replacement in the hand. The findings of Wagner et al. also point in that direction. The 10-year implant survival rate was 72% for the patients younger than 60 years versus 86% for those older than 60 and was particularly lower in younger patients with posttraumatic problems. Older patients had improved PIP joint motion compared with younger patients. In the study of Notermans et al., the reoperation rate after pyrocarbon PIP SRA was 30%. Younger age, male sex, and noninflammatory arthritis were significantly associated with a higher reoperation rate.
Surgical techniques
Approaches.
The PIP joint may be approached dorsally, palmarly, or laterally. The choice of approach will often be determined by the surgeons’ personal preference and experience.
The dorsal approach has advantages of wide exposure and easy access to the joint ( Fig. 4.11 ), but whether a midline or a Chamay exposure through the extensor tendon is used, the approach can result in considerable extensor tendon scarring and carries a risk for extensor tendon adhesion and reduced mobility. , Another advantage is the easy access for repair, correction, or reconstruction of the extensor apparatus.
The palmar approach has the advantage of preserving the extensor mechanism, and it may allow a simpler and earlier postoperative mobilization and may yield a better range of motion (ROM). In a systematic review, Yamamoto et al. calculated that the mean postoperative ROM, and the mean gain in ROM with silicone spacers with the volar approach was greater than silicone with the dorsal approach and also larger than SRA with the dorsal approach. Conversely, a retrospective study compared 38 rheumatoid or osteoarthritic PIP joints that had implantation of a Swanson silicone spacer from a palmar approach with 21 PIP joints that had implantation of the spacer from a dorsal approach with an extensor tendon split according to Chamay. The investigators found an average ROM of approximately 50 degrees in both groups and no difference regarding stability. In the study of Trumble and Heaton, four of 21 SRAs through a palmar approach needed subsequent extensor tenolysis. Shirakawa and Shirota showed that the palmar approach could carry a risk of perioperative extensor tendon rupture due to the frail attachment of the tendon on the base of the middle phalanx.
A lateral approach for PIP arthroplasties has been reported, but it has not gained widespread popularity. This approach needs to release the capsule and collateral ligaments of the PIP joint at their proximal insertion.
Outcomes
Range of motion.
An average ROM of 50 to 60 degrees and an average extension deficit of 5 to 20 degrees can be expected after PIP joint replacement (all diagnoses combined). According to the systematic review of Yamamoto et al., the largest ROM was found in replacement with a silicone spacer and a volar approach (58 degrees), followed by silicone spacers with a lateral approach (54 degrees), and by silicone spacers with a dorsal approach (51 degrees). SRA gave a ROM of 51 degrees with a dorsal approach and 47 degrees with a palmar approach. Although many authors report comparable pre- and postoperative values, , , Yamamoto et al. found an average gain in ROM up to 17 degrees. Many report postoperative stiffness sometimes requiring tenolysis. , , , , Some have found that there was a tendency for restriction of motion over the years. , , Only a few publications report specifically on posttraumatic cases ( Table 4.1 ). The results of PIP joint replacement for posttraumatic arthritis tend to be inferior compared with replacement for other indications. Posttraumatic PIP joint problems may be the result of complex lesions involving bone and soft tissues and are not always merely intraarticular fractures without soft tissue involvement.
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