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swollen. ROM of the long finger PIP joint was 20 to 30 degrees active and 20 to 60 degrees passive. Sutures were removed and Steri-strips applied. She was started on a Coban wrapping protocol for edema control and was fitted with additional "blocking splints," which allow for DIP motion while preventing PIP motion and vice versa.

Physical therapy was discontinued at 9 weeks postoperation and she was instructed in a home exercise program. She was seen again in the office at 2.5 months and had a painless active arc of motion at the long finger PIP from 20 to 60 degrees with passive arc from 0 to 90 degrees. She demonstrated composite active flexion to within 3 cm of the distal palmar crease.

Alternative Methods of Management

Alternative methods of managing OA of the PIP joint apply to three areas: alternative surgical approaches to the PIP joint for Silastic arthroplasty, alternative implants, and alternative reconstructive procedures (Table 67—2). The approach to the PIP joint may

Table 67-2 Alternative Methods of Management

Surgical Approach Advantages

Disadvantages

Comments

Palmar

Dorsal

Lateral

Surgical procedure Silicone arthroplasty

Arthrodesis

Vascularized whole joint transplant

Perichondral resurfacing

Osteochondral composite transplant

Biologic interposition and/or dynamic ex-fix

Easy approach; no risk to central slip; allows flexor tenolysis; collateral ligaments often spared Allows adjustment of central slip tension

Allows visualization and manipulation of central slip without requiring its release

Predictable results; adequate, pain-free motion in most cases

Stable construct with predictable results; may be used in heavy labor Provides an intact, stable joint with the potential for further growth in children Replaces joint surface with biologic material with theoretic long-term advantages Allows reconstruction of large bony defects with biologic tissue

Interposition procedures are relatively simple compared with other biologic arthroplasties

Can't be used if central slip is lax, avulsed, or covered in osteophyte

Requires central slip release and repair; delays postoperative mobilization Requires release of at least one or both collateral ligaments; more complex approach

Relative radial/ulnar instability; risk of particulate wear debris

Significant decrease in finger's ROM, preventing firm grasp

Difficult procedure, less predictable results; significant donor site morbidity Less predictable results; can't resurface both sides of joint with good results; slight donor site morbidity Technically demanding; addresses only one side of the joint; unpredictable results External fixator application can be technically demanding; ROM and pain relief not as predictable as in sili-cone arthroplasty

Our approach of choice

Used in boutonniere deformity

Used when the condition of the central slip is uncertain

Not indicated after infection

May be used after or during infection; less ideal in the long, ring, and small fingers Occasionally indicated in children with posttraumatic arthritis Not indicated after infection; works best in patients <30 years old

Best reserved for young patients with large bony defects

Consideration in young patients with both sides of joint involved and with minimal bone loss be palmar (as described above), dorsal (central slip splitting), or lateral (central slip sparing). The advantage of the true dorsal approach is that it allows easy exposure of the central slip and (since the central slip is detached) allows for removal of substantial osteophytes from the proximal aspect of P2. It is also a favored approach when dealing with a chronic boutonniere deformity. The disadvantage is that after detaching the central slip, it must be repaired and postoperative motion is delayed. This approach results in an average of 10 degrees less ultimate flexion than the other two approaches. The lateral approach has the advantage of offering adequate exposure of the central slip while not necessitating its resection; however, large osteophytes still can't be removed dorsally without releasing the central slip, and the collateral ligament must be fully released to dislocate the joint laterally for sufficient exposure. The palmar approach offers excellent exposure of the joint and flexor tendons without requiring complete collateral ligament (in most cases) or central slip release. Another advantage is that the strength of the flexor tendons allows immediate postoperative motion. It is not a suitable approach when the central slip is known to be incompetent (boutonniere deformity) or when a very large dorsal P2 osteophyte must be resected (placing the central slip at risk).

Although the vast majority of clinical experience is with the Swanson silicone implant, other implants such as the Niebauer (which can be sutured in place and uses a Dacron augmented hinge), and the NeuFlex (which incorporates a 30-degree neutral angle) may be considered. Other, more experimental devices have been proposed, including cemented prostheses and metallic implants with high-density polyethylene bearing surfaces, but these more rigid implants entail problems with implant fracture and with breakout through the bone. Clinical outcomes data are not yet complete for the most recent additions to the implant market.

There are several alternatives to Silastic implant arthroplasty when managing PIP joint OA. The surgeon must consider the patient's age, activity level, bone quality, soft tissue coverage, and functional needs. Arthrodesis provides a very stable digit that may be used for heavy labor; it is also one of the few procedures that could be recommended in a patient with an ongoing infection. The obvious disadvantage is that the finger will lose much ROM, and in the ulnar digits PIP fusion will interfere with the ability to form a firm grasp. In young patients with severe posttraumatic OA, some surgeons have used free vascularized whole joint or double joint transplants from the toes. This type of procedure offers the possibility of a stable digit with good ROM. In children, this procedure has been performed with epiphyseal growth plates intact. However, one must carefully consider donor site morbidity and patient suitability before embarking on this treatment path. Autograft techniques with less donor site morbidity include perichondral resurfacing arthroplasty and osteochondral composite transplants. Perichondral resurfacing is performed by covering the denuded articular surfaces with perichondrium harvested from the ribs. Osteochondral composite transplants have been used when the OA is accompanied by more severe bone loss requiring the harvest of subchondral bone with overlying cartilage from the costochondral junction and using it to reconstruct the PIP joint. Finally, resection arthroplasty with or without tissue interposition, FDS tenodesis, and dynamic external fixator application (such as the compass hinge) may be used in some situations.

Complications

The early complications of PIP joint Silastic arthroplasty include wound breakdown, nerve injury, prosthesis dislocation, and infection. Preoperative antibiotic prophylaxis, careful soft tissue handling, and attention to detail during the broaching process help diminish the incidence of early complications. In the event of a dislocation, revision surgery is indicated. The cause of dislocation must be discovered and corrected by further soft tissue balancing and/or use of alternate prostheses. Superficial infections may be managed with postoperative oral antibiotics, but deeper infections (which are rare) often require implant removal and a course of pathogen specific IV antibiotics. Postinfection revision arthroplasty following a disease-free interval has been attempted, but conversion to an arthrodesis is the more common practice.

Late complications include implant fracture, stiffness, recurrent deformity, reactive bony changes, and chronic pain. Although the incidence of confirmed particulate synovitis is reported to be only 0.06%, some form of postoperative bony changes with erosions are reported in 4% to 20% of cases. The incidence of implant fracture is ~2% and is amenable to revision arthroplasty. Stiffness and recurrent pain are relatively frequent outcomes. Only 67% of cases demonstrate greater than a 50-degree pain-free flexion arc; 16% are seen to have a poor result due to pain and/or stiffness. Although these outcomes are not particularly encouraging, they are as good as or better than the alternative surgical techniques listed previously.

Suggested Readings

Bain GI, Mehta JA, Heptinstall RJ, Bria M. Dynamic external fixation for injuries of the proximal interphalangeal joint. J Bone Joint Surg [Br] 1998;80B:1014-1019.

Chaisson CE, Zhang Y, McAlindon TE, et al. Radiographic hand osteoarthritis: incidence, patterns, and influence of pre-existing disease in a population based sample. J Rheumatol 1997;24:1337-1343.

Hasegawa T, Yamano Y. Arthroplasty of the proximal interphalangeal joint using costal cartilage grafts. J Hand Surg [Br] 1992;17B:583-585.

Iselin F, Conti E. Long-term results of proximal interphalangeal joint resection arthroplasties with a silicone implant. J Hand Surg 1995;20A:S95.

Ishida O, Tsai T-M. Free vascularized whole joint transfer in children. Microsurgery 1991;12:196-206.

Krakauer JD, Stern PJ. Hinged device for fractures involving the proximal interphalangeal joint. Clin Orthop 1996;327:29-37.

Ostgaard SE, Weilby A. Resection arthroplasty of the proximal interphalangeal joint. J Hand Surg [Br] 1993;18B:613-615.

Seradge H, Kutz JA, Kleinert HE, Lister GD, Wolff TW, Atasoy E. Perichondrial resurfacing arthroplasty in the hand. J Hand Surg [Am] 1984;9A:880-886.

Swanson AB, Swanson GG. Flexible implant resection arthroplasty of the proximal interphalangeal joint. Hand Clin 1994;10:261-266.

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