13 Treatment of Complications after Surgery for Finger Joint Arthritis

Daniel B. Herren

Abstract

Joint arthroplasty and joint fusion are the most popular surgical treatment options for destroyed, painful, and nonfunctional finger joints. The complication rate of these procedures is significant and the challenges are diverse. A thorough analysis should identify the cause of the problem and an individual treatment plan needs to be established. General complications like infection and wound-healing problems need to be treated according to the usual treatment guidelines in hand surgery. More specific, procedure-related complications should be addressed at the source of the dysfunction. According to the author’s experience and the studies published, a good reason for revision of finger joint arthroplasty is residual pain, while stiffness and especially joint instability are more unpredictable in their postoperative results. Implant change, in given situations, to another type of implant, with or without soft tissue corrections, is demanding. An overview of the different treatment options will be given in this chapter.

Surgical treatment options for destroyed finger joints include joint replacement and joint arthrodesis. The ideal goal for reconstruction of end-stage joint arthritis is, if possible, a pain-free restoration of sufficient mobility and stability, providing adequate functionality. The metacarpal phalangeal (MCP) joint is one of the main targets in rheumatoid arthritis but rarely affected in degenerative osteoarthritis. The distal interphalangeal (DIP) joint and the proximal interphalangeal (PIP) joint are, together with the thumb saddle joint, the main affected joints in degenerative disease of the hand. The two joints have different functional tasks. While the DIP is responsible for grasping smaller objects and coordinates fine-tuning of finger function, the PIP joint is the main mobile motor for the finger. It has been shown that the PIP joint mobility has an important functional value within the scope of the entire hand depending on the position.1 On the ulnar rays, in particular, mobility has a great functional importance since it is only possible to grasp small objects while maintaining mobility of this joint. While on the radial side of the hand, especially in the index finger, stability is crucial for a stable pinch with the thumb and a forceful grip. However, a stiff index finger PIP joint is often a functional obstacle.² Therefore, arthroplasty of the PIP joint has become a predominant treatment of option for a painful PIP destruction even in the index finger. PIP joint arthrodesis in a functionally good position provides adequate function, although fine motor skills, in particular, may be affected.

On the other hand, arthrodesis is widely accepted as the standard treatment of DIP joint problems. Reliable pain relief is a well-documented outcome of DIP arthrodesis and the obtained stability achieved primarily in the radial rays for pinching with the thumb is of importance. However, DIP joint arthroplasty is able to provide reasonable functional results, especially in the ulnar finger rays.^3,4

For a systematic discussion, it is meaningful to categorize revision surgery of these two standard procedures by the cause of revision. It can be classified into general complications, soft tissue–driven complications, and implant-related complications. Table 13‑1 gives an overview of the different postsurgical complications after PIP arthroplasty and PIP/DIP fusion.

Table 13.1 Synopsis of the possible complications in the surgical treatment of finger arthritis including arthroplasty and joint fusion

In 2019 Yamamoto and Chung5 published a meta-analysis for complications following primary PIP arthroplasty with different implants. The revision rate for silicone implants was overall 6 to 11%. They also compared different approaches (volar, lateral, dorsal) and could find that the lowest number of revisions was found for the volar approach whereas the lateral and dorsal approaches showed a slight higher revision rate of 10 to 11%. In contrast, the revision rate for surface replacement with the first-generation implants was much higher with 18 to 37%. They concluded that the placement of the surface-replacing components from volar is more difficult, since the anatomical orientation is different and the implant alignment is difficult to control. Implant placement in silicone implants is more forgiving and through its material elastic properties a self-alignment is observed.

In 1995 Foliart6 published a literature review of 70 articles summarizing reasons for implant-related revision in a total of 15,556 Swanson original silicone arthroplasties for all different finger joints. Overall, the prevalence rate of complications after silicone implants was very low. Implant fractures were reported in only 2%. Systemic problems due to silicone particle wear, like synovitis or even lymphadenopathy, were rather anecdotal with a prevalence of around 0.6%.

Herren et al⁷ analyzed in a retrospective study the results after silicone revision arthroplasty. In 27 cases the outcome for revision procedures of silicone implants were evaluated. The main reason for revision was pain in 35% and stiffness in 26% of the patients. It could be showed that the revision procedure was best indicated in stiff joints with or without pain. The range of motion could be increased to a functional level, which satisfied most patients. Also, the pain could be improved to a substantial amount. However, joint instability and axis deviation in silicone implants could not be corrected sufficiently.

In a series from the Mayo Clinic, the results after PIP-revision arthroplasty with silicone interposition arthroplasty and surface replacement with pyrocarbon implants and metal on polyethylene (PE) implants were analyzed.⁸ From the revised silicone implants, 84% were converted into a surface replacement in order to achieve better joint stability. The 10-year survival rate after the revision procedure was overall 70%. However, 25% of all revised replacements needed an additional procedure. Also in their series, instability as a revision reason remained an unsolved problem with the worst results of all revision procedures.

Aversano and Calfee described in their publication a significant revision rate for PIP arthroplasty. Revision is associated with a significant complication rate and subsequent reinterventions.⁹ An analysis of the complications of the different implants in more detail helps to understand the individual problems and subsequent revision options. While the main problems of silicone devices are implant failure and cystic bone formation with time,¹⁰ two component implants show implant loosening and joint dislocation.

Overall, recurrence of pre-existing PIP joint deformity is high.^11,12

In summary, the different published studies on the results of PIP revision arthroplasty showed a similar picture: Revision of failed or problematic PIP arthroplasty is challenging and often gives unsatisfactory results. It seems that a good reason for revision is residual pain, while stiffness and especially instability are unpredictable in their postoperative results.

For the DIP joint, there are much less reports about arthroplasty replacement. In the series by Sierakowski et al³ the overall complication rate was 5%. Four out of 131 joints had a general complication and developed infection or soft tissue irritation requiring implant removal and subsequent fusion. Two joints were fused because of instability and marked ulnar deviation and one had a persistent mallet-type deformity corrected by tendon shortening. In the series by Neukom et al,⁴ 21% of the DIP arthroplasties underwent reoperation. Five out of 39 joints had to be fused due to instability. Three other arthroplasties were operated again, either due to an implant breakage (revised with a new silicone implant), a granuloma, which needed excision or for a painful osteophyte.

13.3 Indication for Revision Surgery of Finger Arthroplasty

As outlined, the reasons for a revision arthroplasty in failed primary implants are different and depend not only on the cause and symptoms but also on the type of implant. Silicone implants act as a spacer only and do not replicate the joint biomechanics. As a mono-block implant, it offers a certain primary stability in the different joint axes. The secondary stability relies on the scarring around the implant during the healing process.

13.3.1 Implant Fracture or Loosening

Silicone implant fracture does not automatically imply a revision intervention. Often implant fracture remain undetected since it is not always obvious to see implant fractures on regular X-rays. However, the fibrous capsule preserves the joint function even if the implant is not intact.

Silicone implant fracture and abrasion leads to a synovial reaction.^13,14,15 Erosive osteolysis can be seen on X-ray and remarkable bone defects may occur (Fig. 13‑1). The severity of this inflammatory reaction depends on the particle size and is much more often seen in silicone wrist implants than in finger arthroplasties.

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Complications: What They Do to the Patient Debunking Complex Regional Pain Syndrome/Sudeck/Reflex Sympathetic Dystrophy Management of Complications in the Treatment of Fingertip Injuries Management of Complications Following Open Reduction and Plate Fixation of Distal Radius Fractures Treatment of Complications after Scapholunate Ligament Repair Management of Complications of Extensor Tendon Surgery

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