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Figure 72—3. Exposure of the PIP joint; release of collateral ligaments.

Pip Joint Arthroplasty
Figure 72—4. Drawing showing a small bur being used to shape the proximal bone into a rounded cone and the distal articular surface into a cup.

Upon delivery of the articular surfaces into the operative field, all articular cartilage is removed. The proximal bone is then shaped into a rounded cone while the distal articular surface is configured into a cup using a small bur (Fig. 72-4). Cancellous bone removed during this step may be saved for later bone graft. One 0.045-inch K wire is drilled down the medullary canals of the middle and proximal phalanx. A second and third K wire is passed obliquely to add further rotational stability (Fig. 72-5). The

Pip Joint Fracture Fixation With Wires

Figure 72—5. Pin placement after cup and core position has been contoured.

image intensifier is used to confirm appropriate placement and prevent inadvertent violation of the distal interphalangeal joint and/or the MP joint. The position of 40 degrees of flexion with 5 degrees of supination, and neutral radial and ulnar deviation is recommended for the index finger. Each subsequent digit may be progressively positioned 5 degrees greater than its adjacent PIP neighbor. Bone graft may be added to the fusion site, followed by suture reapproximation of the extensor tendon. The skin is closed with a 5—0 nylon interrupted suture.

Postoperative Management

A bivalved splint is applied at the angle of fusion postoperatively for 4 to 6 weeks. Care should be taken to allow MP joint motion. The K wire may be removed at the end of this time period as suggested by clinical and radiographic examination. Further splinting for an additional 3 to 4 weeks may be required for healing. This patient went on to union, and at his last follow-up was noted to have good relief of his pain and return of his pinch strength for activities of daily living and recreational pursuits.

Alternative Methods of Management

Alternative management methods are listed in Table 72—2.

Complications

Complications after PIP joint fusion include hardware irritation, nonunion, deformity, infection, cold intolerance, and acute vascular compromise. Nonunion is typically not determined by the method of fixation, in a patient with rheumatoid arthritis; rather, bone stock appears to be the primary determinant. Complications related to deformity are usually related to surgical technique. Meticulous attention to detail to include appropriate bony preparation, positioning, and reapproximation of the extensor tendon helps avoid nonunion, malunion, or postoperative boutonniere deformity. Vascular compromise may occur in cases where chronic fixed flexion contractures are corrected without first resecting adequate bone to relieve soft tissue tension. Intraoperative evaluation of vascular status by deflating the tourniquet can prevent this disastrous complication. Superficial infections should be treated with antibiotics, soaks, and if indicated pin or hardware removal.

Table 72-2 Alternative Methods of Management

Type of Management

Advantages

Disadvantages

Arthrodesis

Resection Joint arthroplasty

Avoid surgical complications

Good pain relief and acceptable function Good pain relief Good pain relief

Continued pain and disability

Loss of motion and some function Significant loss of function Extension lag/stiffness and difficult

Useful in patients with mild symptoms or too ill for surgery

Treatment of choice except in face of MP pathology Useful in septic joint Not complement MP arthro-plasty

Deeper infections require debridement, acquisition of cultures and sensitivities, and systemic antibiotics.

In summary, complications after PIP joint arthrodesis represent an infrequent though serious occurrence. Prevention through attention to surgical detail and appropriate patient education remain the mainstay of addressing these unwelcome events.

Suggested Readings

Allende BT, Engelem JC. Tension-band arthrodesis in the finger joints. J Hand Surg [Am] 1980;5:269-271.

Burton RI, Margles SW, Lunseth PA. Small joint arthrodesis in the hand. J Hand Surg [Am] 1986;11A:678-682.

Carroll RE, Hill NA. Small joint arthrodesis in hand reconstruction. J Bone Joint Surg [Am] 1969;51A:1219-1221.

Faithfull DK, Herbert TJ. Small joint fusions of the hand using the Herbert none screw. J Hand Surg [Br] 1984;9B:167-168.

Leibovic SJ, Strickland JW. Arthrodesis of the proximal interphalangeal joint of the finger: comparison of the use of the Herbert screw with other fixation method. J Hand Surg [Am] 1993;19A:181-188.

McGlynn JT, Smith RA, Bogumill GP. Arthrodesis of small joint of the hand. J Hand Surg [Am] 1988;13A:595-599.

Swanson AB, Maupin BK, Gajjar NV, deGroot Swanson G. Flexible implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg [Am] 1985; 10A:796-805.

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