A 35-year-old woman sustained a fracture dislocation of the proximal interphalangeal (PIP) joint. She presents years later with persistent pain at the PIP joint and gross deformity of her ring finger of her left nondominant hand. The discomfort impairs her to deal with her work at the green grocery and the activities of daily living. The patient is an active manual worker who requires almost complete mobility with grip and pinch strength without pain.
The inspection of the patient’s left hand shows a rotational and ulnar deviation of the ring finger at the PIP joint. The passive PIP joint motion results in 40 degrees of flexion and −30 degrees of extension, with normal metacarpophalangeal and distal interphalangeal joints. Simple radiographs show the PIP joint with a dorsal dislocation with severe damage to the articular surfaces, not only the base of the middle phalanx but also the condyles of the proximal one (▶Fig. 53.1).
We should keep in mind that the best solution to this particular problem would have been to have dealt with it immediately. In spite of the easy diagnosis, these old injuries are very frequent, and the delayed diagnosis does not allow us to give them a better solution. The patient has severe arthritis at the PIP joint with deformity and joint discontinuity.
• With the two articular surfaces damaged, the PIP joint cannot be reconstructed so we need to think of an arthroplasty or an arthrodesis.
• Our first option is an arthroplasty with a second-toe vascularized articular transfer (SVAT).
Fig. 53.1 (a, b) The anteroposterior and lateral radiographs show ulnar deviation and dorsal dislocation of the PIP joint with a mirror articular damage.
• We do not recommend the use of PIP prosthesis in young patients with high strength demands.
• The PIP joint arthrodesis is an option, but our patients were dissatisfied with the lack of flexion and the aesthetic appearance.
At the recipient site, we make a curved dorsal incision centered at the PIP joint. The extensor apparatus is released and prepared for the tendon suture. The proximal and distal osteotomies are performed, and the damaged joint is elevated with the volar plate and kept on the operating table. Extreme care should be taken not to injure the flexor tendons, the digital nerves, and the digital vessels. The next step is the preparation of the recipient vessels. Depending on the length of the pedicle, we localize a proper digital artery close to the operative site or we make an extra incision at the distal palmar crease for a larger common digital artery. We identify a vein proximal to the dorsal incision.
The donor site is then addressed. With the patient in the supine position, the tourniquet is applied without exsanguination for an easy identification of the vascular tree. A dorsal approach is made on the ipsilateral foot over the first interosseous space and we proceed to identify the venous return of the flap. We continue the incision up to the first web space. If the dominant vessels are dorsal, we perform the dissection up to the digital artery, taking a long pedicle. But if the dominant pedicle is plantar, we go directly to the digital artery skipping the complex dissection of the plantar vessels. Venous interposition graft will likely be needed to acquire appropriate length to reach the recipient vessels. We always elevate the flap with a monitor skin paddle centered on the dorsomedial cutaneous vessels, which will not compromise the articular vessels. The tendon extensor is harvested and the transverse osteotomies are performed. We keep the flap vascularized for about 20 minutes to assure a correct perfusion before cutting the pedicle.
After adjusting the measurements of the transfer, the osteosynthesis is performed with one transarticular longitudinal nail and two extra-articular transversal ones to prevent rotation. Then the extensor tendon is reconstructed and the vessels are sutured either directly or with a bypass. Finally, the skin is closed keeping the monitor island to evaluate the correct flap perfusion. We use the excised articular block as a nonvascularized graft for the reconstruction of the donor site to minimize morbidity (▶Fig. 53.2).