The proximal interphalangeal (PIP) joint is the third most common site of the osteoarthritis in the hand (1). Although historically the gold standard for pain relief and stability for arthritic PIP joints has been arthrodesis, PIP arthroplasty is also indicated in specific patients. The initial long-term outcomes of PIP arthroplasty were marred by complications including loosening, fracture, instability, and frequent revision surgery (2,3,4). Advancements in implant design and patient selection have led to more durable outcomes in PIP arthroplasty.

The overriding goal is to create a stable implant that recreates a painless flexible joint while maintaining the function of the digit. PIP joint arthroplasty is primarily considered for patients with arthritis in the long, ring, and small fingers. In the index finger, arthrodesis of this joint is typically considered, but bicondylar resurfacing arthroplasty will maintain pinch strength and lateral stability, and we use this frequently.

Appropriate management of PIP arthritis begins with thorough assessment of the patient. It is essential to confirm with the patient that the primary goal of surgical intervention is pain relief and secondarily to maintain and occasionally increase the range of motion at the joint. Patients should
be informed that recent long-term investigations with pyrolytic carbon resurfacing implants have shown that initial increases in range of motion are not always maintained after 5 years (2).

On exam, it is important to assess the competency of the collateral ligaments, the extensor mechanism, and to establish any fixed contractures at the joint. Visual inspection of the alignment of the digit, as well as standard hand radiographs, can help evaluate the degree of asymmetric degeneration at the joint.

Any evidence of an arthritic mallet deformity of greater than 15 degrees should be addressed surgically at the time of surgery with an arthrodesis. It is our experience that these mallet deformities progress and lead to swan-neck deformities of the finger.

Two category types of PIP joint implants are presently available for arthroplasty: one-piece silicone and two-piece SRA constructed from either PyroCarbon or metal and plastic. All implants offer consistent pain relief postoperatively. The debate over implant selection revolves around long-term durability and postoperative range of motion. Silicone has the longest history of implantation with its original description by Swanson in 1966 (5). The long-term implant stability and wear for more demanding patients is often questioned, but even today, silicone implants are used more frequently (6). PyroCarbon implants have been available since 2000 and are constructed of a graphite core coated with pure carbon. This surface is advocated because of the potential for sclerotic bone ongrowth and good wear characteristics. Recent longer-term follow-up has questioned the rates of stability of the implant and range of motion after 5 years (2). Metal and polyethylene 2-piece bicondylar surface implants are frequently used implants for PIP arthroplasty. Advocates for these implants praise the implant stability and postoperative range of motion; however, one longer-term follow-up utilizing a more difficult volar approach showed similar results as PyroCarbon implants (7). Overall, all implants can provide excellent pain relief, but reproducible increases in postoperative range of motion remain elusive in published series. However, our personal experience has been very favorable for two-piece metal-on-plastic implants, and they remain our implant of choice except in “wet” inflammatory arthritis (3,4).

Higher rates of revision surgery from PIP arthroplasty have been blamed on the initial approach, and even among experts, controversy exists regarding the ideal surgical approach (8). Four techniques have been widely investigated and described, each with its own reported benefits: Chamay, dorsal tendon splitting, volar, and lateral approaches. The benefit of the Chamay technique is that it respects the extensor mechanism, but it has been criticized for not providing access to 50% of the proximal phalanx head, as well consistently developing an extensor lag postoperatively (9). The dorsal tendon-splitting approach was originally described by Swanson, and the benefit of this approach is that it spares the volar plate, collateral ligaments, and dissection of the neurovascular bundles. This approach will be described in detail in the next section, with a specific surgical and particularly therapy modification to avoid significant extensor lag. The volar approach has recently been repopularized and minimizes risk to the extensor complex and allows early postoperative motion (7

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