Physical Examination

Physical examination of the hand begins with a careful inspection of the dorsal and palmar surfaces. Several distinguishing characteristics may be obvious in the osteoarthritic hand. At the metacarpophalangeal (MCP) joints, swelling and volar subluxation may be present, with an associated flexion contracture or extension lag. Likewise, the proximal interphalangeal (PIP) joints may display flexion contractures; a more common distinguishing characteristic is the Bouchard node. Similarly, inspection of the osteoarthritic distal interphalangeal (DIP) joint is heralded by the presence of Heberden nodes, which signifies swelling and periarticular osteophyte formation. Additionally, mucous cyst formation may occur in relation to an osteoarthritic DIP joint.

Palpation of the acutely inflamed osteoarthritic MCP, PIP, or DIP joint will elicit tenderness as well as a fullness about the joint and loss of the typical bony contour of the joint. While gently holding the joint between the dominant thumb and index finger, the examiner can carefully apply a small amount of pressure to detect tenderness and synovitis. The range of motion of each joint may be limited due to a superimposed flexion contracture. The digital range of motion is often expressed in terms of total active range of motion, approximately 250 degrees, but individual ranges are also often measured: The MCP joint has 0 to 90 degrees, the PIP joint 0 to 100 degrees, and the DIP joint 0 to 60 degrees.

Tendon integrity may be compromised in the osteoarthritic hand. Pathologic conditions of the flexor tendon may uncommonly occur, generally because chronic tenosynovitis of the flexor tendon sheath has caused a zone 2 flexor digitorum superficialis (FDS) or flexor digitorum profundus (FDP) tendon rupture. More commonly, the extensor tendons are involved, with ulnar subluxation of these tendons occurring at the level of the MCP joints owing to failure of the sagittal bands. The result is ulnar drift and flexion positioning of the digits at the level of the MCP joints. In the acute phase of this condition, extensor tendon subluxation and ulnar drift/MCP flexion may be passively correctable and amenable to individual digital splinting. In the more chronic situation, the only treatment option is surgical release of the sagittal bands, with or without intrinsic releases and extensor tendon realignment.

Erosive or inflammatory osteoarthritis is an uncommon variant of osteoarthritis first described in 1966 by Peter and coworkers. Like primary osteoarthritis, it is more common in women and the symptoms appear abruptly and interestingly involve the joints on the radial aspect of the hand while sparing the joints on the ulnar side ( Figure 11.1 ). The DIP joint is the most commonly affected joint, but the PIP joint is most commonly the symptomatic joint. In some patients, erosive osteoarthritis will seroconvert to rheumatoid arthritis at a later time.

51-year-old right hand–dominant female with a 1-year history of right index finger pain located at the MCP joint.

Diagnostic Imaging

Plain PA, lateral, and oblique radiographic views can adequately image the osteoarthritic hand. Further detail can be obtained by directly imaging the individual digit, with an attempt made to center the radiograph beam over the joint in question (i.e., the MCP, PIP, or DIP joint). Further definition of the MCP joints can be obtained with a Brewerton view radiograph. Originally described for the rheumatoid hand, this view is obtained by placing the supinated hand on the cassette and flexing the MCP joints 45 to 60 degrees. This view may also be helpful in imaging the hand with osteoarthritis or erosive osteoarthritis. Advanced imaging such as computed tomography (CT) scanning and magnetic resonance imaging (MRI) is seldom necessary for osteoarthritis of the small joints of the hand; however, it may be helpful in the early stages of the condition, showing synovial changes in the joint along with effusion.

Indications and Contraindications

The main indication for DIP joint arthrodesis is primary osteoarthritis or posttraumatic arthritis. The patient should have pain referable to the DIP joint and static deformity or instability that interferes with activities of everyday living. The symptomatic digit may become less painful and the deformity less of an impairment with time, rendering the need for surgery less imperative. Therefore, it is advisable to treat the patient nonoperatively with analgesics, hand therapy modalities, a removable finger-based splint, and a period of prolonged observation prior to deciding to proceed with surgery. DIP joint arthrodesis may be done following joint degeneration because of remote septic arthritis.

Contraindications for DIP arthrodesis include active infection of the finger, septic arthritis of the DIP joint, or an open wound in the proximity of the joint. Other potential contraindications include unhealthy atrophic skin over the joint, as may occur following long-term steroid usage. Patients with compromised blood flow or ischemic fingers should not undergo DIP joint arthrodesis.

Preoperative Planning

Critical to the preoperative assessment of the patient and planning for care are dedicated PA and lateral radiographs of the finger. It is important to identify the appropriate implant for arthrodesis based on the size of the distal phalanx. It is also important to identify any periarticular degenerative cyst formation or bone loss that may necessitate bone graft augmentation.

Technique

DIP joint arthrodesis can be performed under regional anesthesia or even digital block anesthesia using finger tourniquet control. The technique involves a dorsal exposure of the joint, followed by removal of all remaining articular cartilage. The natural contour of the head of the middle phalanx may be retained if it matches well with the resulting contour of the base of the distal phalanx following removal of articular cartilage. Typically, a reasonable fit is obtainable, but bone defect causing shortening may be encountered, which may require either allograft or autograft supplementation. Alternatively, the head of the middle phalanx and the base of the distal phalanx may be contoured into a cup and cone match. Full extension to slight flexion is desirable for positioning of the joint and is limited due to fixation considerations. Fixation techniques for DIP joint arthrodesis include percutaneous pin fixation or low-profile, variable-pitch compression screw fixation.

Percutaneous pin fixation configurations include crossed pinning of the arthrodesis site or percutaneous longitudinal pinning with two parallel Kirschner wires. Longitudinal pinning is best done by advancing two 0.045-inch wires antegrade through the distal phalanx articular surface and exiting the tuft of the distal phalanx. The arthrodesis site is reduced. The wires are recovered beyond the skin of the fingertip and sequentially advanced in a retrograde manner such that the arthrodesis site is stabilized ( Figure 11.3, A to F ).

A and B, Preoperative radiographs of a 55-year-old female with distal interphalangeal (DIP) joint destruction following septic arthritis caused by an infected mucous cyst. C and D, Postoperative radiographs following DIP joint arthrodesis with K-wire stabilization. E and F, Final follow-up radiographs of healed DIP joint arthrodesis.

If a headless variable-pitch screw is chosen for fixation, attention must be paid to the dimension of the distal phalanx because the diameter of the bone in smaller individuals, particularly of the small finger, may not accommodate the caliber of the screw. This technique is detailed below.

Author’s Preferred Method of Treatment

DIP joint arthrodesis is accomplished through the extensile “H” incision ( Figure 11.4 ). Full- thickness skin flaps are elevated and the terminal tendon is exposed. The terminal tendon is incised transversely, exposing the articular surfaces of the joint. Hyperflexion of the joint facilitates exposure of the articular surfaces. I avoid excessive shortening of the finger by using a 2-mm high speed bur to remove the remaining articular cartilage, preferably following the natural contours of the head of the middle phalanx and the articular base of the distal phalanx. Though desirable, a tight, flush contact of surfaces is often not achieved; the arthrodesis site can be supplemented with a small portion of autograft or allograft material of choice. The position of full extension is generally preferred.

“H” incision for arthrodesis of the distal interphalangeal joint of the finger.

For fixation, I prefer a variable-pitch, headless compression screw no larger than 2.4 mm in diameter. This affords immediate, stable fixation and is available from a variety of different manufacturers. Initially, a guidewire is driven retrograde to the level of the subchondral bone of the base of middle phalanx ( Figure 11.5 ). A cannulated drill is advanced over the guidewire, and a screw of appropriate length is advanced across the arthrodesis. Care is taken to avoid inside-out contact with the nail bed. It is also important that the distal aspect of the compression screw be completely buried in the tuft of the distal phalanx so there is no screw prominence.

Arthrodesis of the distal interphalangeal joint with the use of a cannulated, low-profile headless compression screw. A, Guidewire placement. B, Placement of cannulated drill. C, Headless, variable-pitch compression screw placement.

(© Mayo Clinic, Rochester, MN. Modified with permission.)

If inside-out contact with the nail bed occurs during placement of the compression screw, screw fixation is abandoned in favor of fixation with a 0.062-inch percutaneous pin placed longitudinally across the arthrodesis site in a retrograde fashion. To the extent possible, the drill track is packed with autograft or allograft bone substitute material. Placement of percutaneous pins or the cannulated drill bit and variable-pitch screw is done using biplanar fluoroscopy.

Postoperative Management and Expectations

At 5 days following operation, the dressings are removed and the wound is inspected. Following DIP arthrodesis with a variable pitch, headless compression screw, a removable finger-based splint is fabricated by a hand therapist. The splint may be removed and immediate motion initiated. This should include active and passive range-of-motion exercises of the PIP, MCP, and wrist joints. Radiographs are obtained at 6- to 8-week intervals, and the splint is maintained until radiographic healing is evident.

If DIP arthrodesis is performed with percutaneous pin fixation, the wires are cut at the surface of the pulp of the finger and left in place for 8 weeks. The patient is treated with a non-removable finger-based splint for 4 weeks, allowing active and passive MCP and wrist motion only. This is followed by fabrication of a removable finger-based splint allowing PIP motion at 4 weeks following operation. Radiographs are followed until solid fusion is achieved, at which time unrestricted activity is resumed.

Indications and Contraindications

The principle indication for PIP joint arthrodesis is painful primary osteoarthritis or posttraumatic osteoarthritis that is refractory to nonoperative measures. Patients will often complain of diminishing motion of the joint in conjunction with aching pain with use. Other indications are unreconstructable fractures, fracture-dislocations, or chronic instability of the joint.

Contraindications for the procedure are recent infection or a poor soft tissue envelope. A relative indication for PIP joint arthrodesis is a history of septic arthritis. Patients with residual articular destruction following chronic septic arthritis may under certain circumstances be considered for arthrodesis, assuming that the level of pain and functional loss warrant the intervention. Bone loss is a relative indication for arthrodesis in that bone can often be reconstructed in such a way as to achieve arthrodesis when the appropriate fixation is used.

Preoperative Planning

Critical to preoperative assessment and planning are dedicated, high-quality PA and lateral radiographs of the finger. It is important to identify the appropriate implant for arthrodesis; surgeon preference is the deciding factor in most circumstances. In cases of trauma where bone loss has occurred, fixation must be planned in order to best accommodate the bone deficiency. It is also important to identify any periarticular degenerative cyst formation, which may necessitate bone graft augmentation and fixation modification.

Technique

Arthrodesis of the PIP joint is performed under regional anesthesia and upper arm or forearm tourniquet control. A dorsal longitudinal incision can be used in most patients. In patients with atrophic or compromised skin, a longitudinal incision can create insufficient skin margins for closure. A carefully designed serpentine incision over the dorsal aspect of the affected digit creates a flap well positioned to cover the hardware and arthro­desis site. The articular surfaces are exposed, and an osteotomy of the head of the proximal phalanx and the base of the middle phalanx is performed so that two flush bony surfaces are achieved. This requires the removal of the entire articular surface of the head of the proximal phalanx and the entire articular base of the middle phalanx. Positioning of the PIP joint arthrodesis is critical. The index finger PIP arthrodesis is positioned in 30 degrees of flexion, and the arthrodesis position of each successive finger should be in approximately 10 degrees more of flexion ( Figure 11.6 ). Realistically, accuracy of arthro­desis positioning cannot often be scrutinized to the 10-degree level; an arthrodesis position of 30 to 40 degrees is preferred for the index and long fingers and 50 to 60 degrees for the ring and small fingers in most cases.

Drawing displaying the progressive degree of proximal interphalangeal joint arthrodesis flexion.

Several fixation techniques are available for stabilization of the arthrodesis. Options include K-wire fixation with or without tension band wiring; variable-pitch, headless compression screw fixation; or small joint plate fixation. Tension band wire fixation will be detailed in the following section. Variable-pitch, headless compression screw fixation requires adequate bone stock and accurate screw placement . A 2.4-mm cannulated screw is preferred. Plate fixation uses a 2-inch low-profile plate, bent to accommodate the bone contours and desired angle of the arthrodesed digit. In general, it is desirable to achieve six cortices of fixation on both sides of the arthrodesis. Immediate mobilization of the finger is possible following tension band wiring, screw fixation, and plate fixation. The compression screw has a low profile and usually does not cause irritation, as some hardware might. Plate fixation of an arthrodesis is generally reserved for situations in which trauma-related bone loss has occurred and a corticocancellous bone graft is needed to fill the defect.

Author’s Preferred Method of Treatment

The extensor mechanism is incised longitudinally and the articular surfaces exposed subperiosteally. The collateral ligaments are released, providing further PIP joint flexion and enabling correction of any joint contracture. Using a handheld oscillating saw, the articular surfaces of the PIP joint are removed just proximal to the condylar flares of the proximal phalanx and just distal to the articular surface of the middle phalanx. The angle of the arthrodesis is imparted on the bony cut of the proximal phalanx. Beginning with the index finger at 30 degrees, the long, ring, and small fingers are positioned at 40, 50, and 60 degrees, respectively. The oscillating saw is used to create the thin middle phalanx cut, just proximal to the articular base. It is important to make these cuts perpendicular to the longitudinal axis of the digit; otherwise, an angulated digit will result .

Once the bony surfaces are prepared, irrigated, and dried, the arthrodesis is stabilized. The author’s preferred method is a K-wire tension band technique ( Figure 11.7, A to D ). Using fluoroscopic guidance, two parallel 0.035-inch K-wires are drilled in a retrograde fashion perpendicular to the osteotomy cut at the distal aspect of the proximal phalanx. This is necessary in order that the K-wires, when driven antegrade, migrate down the center of the middle phalanx. It is important that the tips of the K-wires stop about 5 mm shy of the distal articular aspect of the middle phalanx because they will be advanced further later to capture the figure-of-eight tension band. Once the articular surfaces are stabilized, another 0.035-inch K-wire is drilled transverse to the axis of the middle phalanx through the dorsal cortex at the junction of the proximal and middle thirds of the shaft. Through this transverse hole, the 22-gauge wire is passed and then passed in a figure-of-eight fashion beneath the K-wires, which are still exposed beyond the dorsal cortex of the proximal phalanx. The 22-gauge wire is twisted several times on the radial or ulnar aspect of the digit prior to cutting and burying the twist. Although sometimes difficult, the twist of the wire can be turned down around the side of the digit to prevent prominence of the material beneath the skin. Next, the exposed K-wires are cut approximately 1 cm superficial to the dorsal cortex of the proximal phalanx and are bent 90 degrees in order to capture and secure the figure-of-eight wires. The figure-of-eight wire is gently driven down over the middle phalanx with a small bone tamp and mallet with the aid of fluoroscopic imaging. Bone grafting is usually not necessary (see Figure 11.7, A to D ). The extensor mechanism is closed over the hardware, and the skin reapproximated. The wounds are sterilely dressed and placed in a forearm-based resting hand splint.

A and B, An 80-year-old male with gradual onset of index finger pain and limited mobility. C and D, Index finger with fresh interphalangeal joint arthrodesis.

Postoperative Management and Expectations

The wounds are inspected at postoperative day 5, and a rigid finger-based splint supporting the affected digits is created by a hand therapist. The patient is allowed to remove the hand from the fabricated splint and begin gentle active range of motion. At 4 weeks following operation, most activities of daily living are resumed. Radiographs are assessed at 6 weeks and 12 weeks for healing of the arthrodesis. Once healing has been achieved radiographically, the patient is released to full activity. The rationale behind tension band wiring of the PIP joint arthro­desis is that active flexion of the digit enhances compression of the arthrodesis surface. Caution should be exercised in the patient with osteopenia or osteoporosis.

Indications and Contraindications

MCP joint arthrodesis is not typically recommended for osteoarthritis of the index, long, ring, and small fingers. It is, however, performed on the thumb MCP joint in cases of primary osteoarthritis or posttraumatic arthritis. Like the other arthrodeses, the procedure should not be performed in the setting of active or recent infection or in patients with a poor skin envelope. Reconstruction of chronic arthritis following a history of remote septic arthritis is considered a relative indication.

Preoperative Planning

Critical to the preoperative assessment and planning are dedicated PA and lateral radiographs of the thumb. An appropriate fixation technique is chosen based on surgeon preference. It is important to identify any periarticular degenerative cyst formation or bone loss that may necessitate bone graft augmentation of the arthrodesis or dictate the fixation technique.

Technique

Arthrodesis of the thumb MCP joint is accomplished through a dorsal longitudinal incision. The extensor mechanism is incised in line with the skin incision and the arthritic joint exposed. As in the PIP joint, the proximal phalanx and the metacarpal head are prepared with a handheld oscillating saw. The preferred position for arthrodesis is 20 degrees of flexion. As previously described for preparation of the PIP joint arthro­desis surfaces, a transverse osteotomy of the base of the middle phalanx is accomplished just proximal to the subchondral bone of the proximal articular surface of the thumb proximal phalanx. Next, the flexion angle of the arthrodesis is accomplished by orienting the oscillating saw 20 degrees volar, just proximal to the metacarpal head. The two bony surfaces are approximated and secured by any of several fixation techniques, including the tension band technique described for arthrodesis of the PIP joint. Alternatively, two crossing percutaneous K-wires placed from distal to proximal can be used. The K-wires can be removed in 8 weeks but are preferably maintained, if possible, until bony union is achieved. Fixation can also be achieved with a 2.0 dorsal plate, obtaining six cortices proximal and six cortices distal to the arthrodesis site. Variable-pitch, cannulated headless screw fixation with one or two screws is another option. Alternatively, use of a standard cortical screw and washer has been described. The extensor mechanism is closed and the skin approximated. A sterile dressing is applied, followed by a thumb spica splint.

Postoperative Management and Expectations

At 5 days following operation, the dressing and splint are removed, a removable forearm-based thumb spica splint is fabricated, and gentle active motion is initiated. For reasons stated previously, active motion, including pinch, is encouraged for patients with stabilization using the tension band wire or headless compression screw technique. Protective splinting is maintained, however, until radiographic healing is seen, at which time activity without restriction may resume.

Indications and Contraindications

Indications for use of the PIP surface replacement arthroplasty (SRA) include primary degenerative osteoarthritis or posttraumatic arthritis in elderly patients. Ideally, this would include less active patients who desire to maintain PIP joint motion in deference to arthrodesis. Relative indications include severe fractures or fracture-dislocations of the PIP joint in older, less active patients. Contraindications for use of PIP arthroplasty include current or chronic infection, loss of extensor mechanism integrity such that the patient has a boutonnière deformity, with either PIP joint extension lag or fixed flexion contracture, or complete absence of extensor function. Additional contraindications include poor or absent flexor tendon function, a poor soft tissue envelope including atrophic skin on the dorsum of the digit, absent PIP collateral ligament function, and incompetence of the PIP joint volar plate rendering the PIP joint unstable or creating a swan neck deformity.

Preoperative Planning

The preoperative evaluation should include a thorough assessment of patient expectations and a clear articulation of the activity restriction imposed by this procedure. Documentation should include PIP range of motion, angular deformity, joint stability, and soft tissue integrity. Dedicated PA and lateral radiographs of the digit centered over the PIP joint are necessary for templating purposes. Seldom do radiographs of the entire hand suffice. Irrespective of the device chosen for implantation, template devices are available from the device manufacturer.

Success has been reported with a variety of PIP joint implant arthroplasties, including the silicone, pyrocarbon, and surface replacement implants. Choice of the implant is largely left to surgeon preference and experience; evidence suggests that a semiconstrained implant is advantageous in the index PIP joint for resisting enhanced forces encountered during thumb-index pinch maneuvers.

Technique

PIP implant arthroplasty can be performed using one of three surgical approaches, each having advantages and disadvantages: dorsal, lateral and anterior. With the dorsal approach, care is taken to preserve the extensor tendon insertion at the base of the middle phalanx. Complications with this approach can include extensor tendon dysfunction and the development of a boutonnière deformity. The volar plate must be repaired following the volar or anterior approach. Failure to do so may result in PIP joint hyperextension instability and the development of a swan neck deformity (Video 11.1 ). With the lateral approach, the ulnar collateral ligament must be repaired in order to prevent PIP joint instability.

With the pyrocarbon and surface replacement arthroplasties, the proximal phalanx is prepared in such a way that the collateral ligaments of the PIP joint are preserved, although it has been shown that up to 50% of the radial or ulnar collateral ligament can be sacrificed without compromising stability of the joint. With the silicone implant, a more generous phalangeal osteotomy is required, which sacrifices the radial and lateral collateral ligament origins. Merle and coworkers have reported on a lateral approach technique for silicone implant placement that advances, embrocates, and repairs the ulnar and radial collateral ligaments following initial sectioning for exposure. Their study discusses 51 arthroplasties in 43 patients with a mean follow-up of 36 months, finding an average axial deviation of 17 degrees. The middle phalanx is prepared in order to accept the stem of either the middle phalanx component or the stem of the silicone implant. The canals are prepared with device-specific broaches and, not uncommonly, are further modified with a high-speed bur. Implantation of undersized components is a common mistake in implant arthroplasty of the digits and can result in limited motion because of subsi­dence and subsequent bony impedance to flexion.

Most authors currently recommend fixation of the pyrocarbon implant using a press-fit technique. Tagil and Geijer and colleagues reported subsidence of up to 8% of the prosthetic length of the proximal phalanx component and up to 7% of the prosthetic length of the middle phalanx component. Sweets and Stern reported a 48% radiographic loosening rate in their series of 31 patients, followed up at a minimum of 2 years. Silicone is implanted as a spacer and, therefore, is stabilized with neither a cement nor a press-fit technique.

Debate continues concerning the use of cement for implantation of the SRA of the PIP joint. Originally, the PIP surface replacement was designed for implantation using cement, but more recently there have been reports about a cementless version of the prosthesis and a press-fit technique. Jennings and Livingstone reported that the majority of loosening complications in their series of 43 arthroplasties in 25 patients with an average follow-up of 37 months were the result of inadequate cement technique. At an average follow-up of 4 years, Johnstone and associates compared the results of 18 patients with 27 cemented PIP SRAs, with 18 patients having 21 joint replacements using the uncemented PIP surface replacement version of the prosthesis with an average length of follow-up of 4 years. They reported a very strong association between cementless implantation and prosthetic subsidence. However, there was no correlation with the use of cement and postoperative pain, range of motion, or joint failure. In a study of 67 PIP SRAs in 47 patients with a follow-up averaging 8.8 years, Murray and colleagues showed no correlation with cement use and overall implant survival. Implant subsidence and radiolucencies about the prosthesis bore no clinical association with the patients’ final results in their series. A dorsal incision is generally preferred for silicone spacer implantation of the PIP joint. However, success has been reported with the use of the anterior approach as well as with the lateral approach as described by Segalman. Merle and associates reported on 51 NeuFlex silicone spacers in 43 patients with a mean follow-up of 36 months. They found improvement in pain and function scores. The primary technical distinction with silicone PIP arthroplasty is the more extensive proximal phalanx and middle phalanx bone resections required ( Figure 11.8 ). The proximal phalanx cut is made just proximal to the articular head of the phalanx after the radial and collateral ligaments are released from the proximal phalanx (with either the anterior or dorsal approach) or the ulnar collateral ligament alone when using the lateral approach.

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