This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed. Cite this article: Bone Joint J 2022;104-B(12):1329–1333

Objective. Destruction and deformity in both PIP and MP joints are not uncommon and cause sever disabilities. Arthroolasty of the MP joint combined with arthrodesis of the PIP joint are the usual choice for this condition. Some motion in ulnar digits provides great benefits for rheumatoid patients. We report implant arthroplasty of the PIP joint and also simultaneous replacement of PIP and MP joint in same finger. Material & Methods. Twenty-five joints in 15 patients underwent PIP arthroplasty either with silicone or surface replacement implant. Twelve PIP joints in 6 patients used Silicone implant (6 Swanson and 6 Avanta) alone and mean follow up was 42(6–84) months. New cementless surface implant (Self Locking Finger Joint, SLFJ) were developed and clinically used for about 3 years. Because of the stem design, SLFJ are able to use both PIP and MP joint simultaneously or combined with silicone implant. Four PIP joints in 3 patients used SLFJ alone and 6 patients underwent both PIP and MP joint with implant simultaneously. Combination of SLFJ PIP and silicone MP was 4 finger in 2 hand, SLFJ PIP and SLFJ MP was 3 finger in 2 hand, silicone PIP and SLFJ MP was 3 finger in 2 patients and silicone PIP and silicone MP was 1 finger. Mean follow up for SLFJ in either PIP or MP was 18(4–37) months. Results. Average arc of the PIP with silicone implant alone was 38(10–50 ° and SLFJ alone was 55(45–60) °. One PIP SLFJ dislocates immediate after surgery and was converted silicone later on. Of 7 SLFJ with combined PIP and MP arthroplasties, 2 PIP lost motion completely, one PIP move only 15°, 4 PIP move 75 °in average. Four silicone PIP combined with MP arthroplasties move 45°in average. One PIP SLFJ had breakage in stem legs, which believed to occur during interaction of stem insertion from both side of the basal phalanx, and was seen at immediate post op X-ray. There was one instability in index replaced with SLFJ for sever Swan neck deformity and no infection. Patient satisfaction for simultaneous replacement in PIP and MP joint were excellent except one whose age was 72. Discussion. Stability of the PIP joint in index finger is important for pinch and PIP motion of ring and little fingers are required for grip motion. Although arthrodesis of the PIP joint were performed more often and functional improvement usually obtained compared to pre-operative condition, ulnar 2 digits better to preserve some motion in the PIP joint as long as there is a possibility, and especially for the young patients. The results of the simultaneous replacement in PIP and MP joint seems discourage, however, when considering the severity of the deformities of this series, there is a good chance in the future. We will improve implant design and surgical technique as well as post-operative therapy, and continue to challenge the simultaneous replacement of PIP and MP joint

During flexion of the joint from the fully extended position the collateral ligaments soon become tight as they pass over the apex of angulation of the side margin of the head and remain tight as they move over more vertical plane of the side of the head. From measurements on the dissected fingers, from measurements on radiographs and from tracings of photographs of the proximal phalanx it was not possible to draw any definite conclusions about the sagittal cam effect comparable to those relating to the metacarpo-phalangeal joint. A few specimens exhibited some degree of this cam but most did not. This may be related to functional variations of individual fingers and requires more detailed study. If the joint is immobilised for some time in flexion with the collateral ligaments well below the apex of angulation, the slack volar part of the collateral aspects of the capsule with fibres running to the lateral and palmar tubercies of the middle phalanx and the dorsal fibres of the flexor sheath may become contracted. Shortening of the fibres of the lower part of the collateral portions of the capsule (A) and of the most dorsal fibres of the flexor sheath (B) was a constant finding. Curtis (1964) advocated excision of a portion of flexor sheath over the joint in dealing with flexion contracture. Dissection of two fingers affected by extension contracture suggests that it takes a long time to produce shortening of the soft and pliable more dorsal part of the capsule. It appears therefore that if immobilisation of the proximal interphalangeal joint cannot be avoided, it should be for as short a period as possible, with the collateral ligaments just riding over the apex of the side margin on the head when fibres A and B are only slightly slack. The results of immobilising the injured finger with the proximal interphalangeal joint flexed not more than 15 degrees might be compared with those after immobilisation with the joint more flexed. Splintage of the joint in extension was advised by Stewart (1962) on functional and clinical grounds. He noted the importance of flexion of the metacarpo-phalangeal joint and used the position of extension in all cases except those of: 1) gross damage leading inevitably to stiffness; and 2) division of flexor tendons or infection in the tendon sheath. It is suggested that in correction of contracture of the proximal interphalangeal joint caused by Dupuytren's affection it may be advisable to excise fibres A and B

Fractures of the proximal interphalangeal joint include a wide spectrum of injuries, from stable avulsion fractures to complex fracture-dislocations. Stability of the joint is paramount in determining the appropriate treatment, which should aim to facilitate early mobilisation and restoration of function

We describe a case of rotational dislocation of the proximal interphalangeal joint of the ring finger. This injury was not initially appreciated and therefore closed reduction failed. The clinical findings included puckering of the skin on the dorsum of the joint and rotational incongruity on radiographs. At open reduction there was interposition of the lateral band. Identification of the pathology allows early successful treatment

Introduction: Traditionally flexion deformities in Proximal Interphalangeal joints of lesser toes like hammer toes and curly toes are treated with fusing the PIP joint with a single Large Kwire. We describe a new technique of fusing PIP joints using two 1.1mm K wires. The advantages of this technique over single K wire are:. Less post operative complications like pain and pin tract infection. Achieving normal biomechanics of the foot by fixing the PIP joint at 15–20 degrees of flexion. Using two K wires gives more rotational stability of the toes and reduces the complications of over riding, under riding and hyperextension of the toes. 15–20 degrees flexion at PIP joint will give good digital purchase and push off in stance phase. As the K wire engages the cortex of proximal phalanx, there is almost negligible chance of loosening of K wires which is a common problem in large single K wire which usually is driven in to the medullary cavity of proximal phalanx. Aim: To compare the clinical and radiological outcomes in two pin fusions with standard single pin fusions described by Coughlin. To prove that this is a technically and biomechanical better procedure. Materials and Methods: Two pin technique was used for 36 PIP joint fusions in 25 patients with a mean age of 58 years (range–42 to 87 years) and female preponderance. Results were analysed using foot function scale, AOFAS (American Orthopaedic Foot and Ankle Society) lesser metatarsophalageal-Interphalageal scale. Post operative complications were documented. Technique: Dorsal skin incision was used to approach the PIP joint. Articular surfaces were prepared and two 1.1mm K wires were inserted from the tip of the toe and joint fixed in 15 – 20 degrees of flexion which is optimal functional position of PIP joint. Patients were mobilised non weight bearing for 6 weeks when K wires were removed and weight bearing started. Results: The results were analysed at 3–6 months post operatively. The foot function scores and objective parameters of AOFAS scores are slightly better in two pin fusions compared with single pin fusions. Objective parameters of AOFAS scale like adduction/ abduction, flexion, rotational deformities are significantly less with two wire fusions compared with single wire procedures (Coughlin et al). Radiological analysis of the foot showed that 97% had bony union compared 81% with single pin, and only 3% had fibrous union compared to 19% with single wire. Both the procedures didn’t have any non-unions. Only one patient had superficial wound infection, and surprisingly none had pin tract infection. Conclusion: Two pin PIP Joint fusion is relatively easy procedure with many technical advantages over single pin technique. The clinical and radiological outcomes are good. Results of the biomechanical studies should be available soon

We present the outcome of the treatment of chronic post-traumatic contractures of the proximal interphalangeal joint by gradual distraction correction using an external fixator. A total of 30 consecutive patients with a mean age of 34 years (17 to 54) had distraction for a mean of 16 days (10 to 22). The fixator was removed after a mean of 29 days (16 to 40). Assessment at a mean of 34 months (18 to 54) after completion of treatment showed that the mean active range of movement had significantly increased by 63° (30° to 90°; p < 0.001). The mean active extension gained was 47° (30° to 75°). Patients aged less than 40 years fared slightly better with a mean gain in active range of movement of 65° (30° to 90°) compared with those aged more than 40 years, who had a mean gain in active range of movement of 55° (30° to 70°) but the difference was not statistically significant (p = 0.148). The use of joint distraction to correct chronic flexion contracture of the proximal interphalangeal joint is a minimally-invasive and effective method of treatment

Background: PIP joint surface replacement has been shown to be effective in the treatment of arthritis. We performed a retrospective review to evaluate the clinical results and functional outcome of pyrocarbon proximal interphalangeal joint replacement, motion preserving and function in selected patients. Method: The patients who underwent pyrocarbon PIP joint arthroplasty by the two senior authors were reviewed. Clinical assessment included range of motion, degree of pain and deformity pre and post operatively. Independent functional scores were collected. Radiographs were reviewed for evidence of loosening, fracture and dislocation. Patient overall satisfaction was assessed. Results: 25 patients had 27 pyrocarbon PIP joint replacements between 2004 and 2008. Of these patients, there were 21 female (84%) and 4 male (16%) with average age of 62.5 (43–78). Indications for surgery were pain and loss of function. The preoperative diagnosis was post traumatic osteoarthritis in 9 (33.3%) and primary osteoarthritis in 18 (66.7%). The average arc of motion preoperatively was 42.3 (5–60), and the average postoperative one was 74.3 (45–100). Pain was relieved in majority of patients. 23 patients (92%) were satisfied completely with the procedure. Pain was relieved in the majority of cases and we had 2 dislocations requiring revision to silicone joint replacement and 2 adhesions/stiffness requiring tenolysis. There were no infections. Conclusion: Our experience of pyrocarbon PIP joint replacement over the 4 years showed this implant is useful for relief of pain and function. A technically demanding procedure, it improves arc of motion, corrects deformity and achieves satisfactory function. We had 7 % revision rate and longer term follow-up is required

Introduction. Unstable dorsal fracture/dislocation of PIP joint is a complex injury and difficult to treat. Different treatment methods have been described with varying results. We describe a novel technique to combine fracture fixation with volar plate repair using micro anchor suture. Material and methods. Between July and December 2005, 11 consecutive patients with unstable dorsal PIP joint dislocations underwent open reduction and volar plate repair using our technique. Nine patients had dorsal fracture dislocations and two had open dislocations. All patients were males and their average age was 26 years. All patients were reviewed with the minimum follow up of 12 months. The pain score, range of movements and grip strength were recorded and compared to the normal side. Operative Technique. Volar approach was made using a semi Brunar incision. One or two micro bioabsorbable anchors (Mitek, Ethicon Ltd, UK) were used to stabilise the joint and repair the volar plate. Additional anchor was used to repair the collateral ligament when indicated. Post-operatively the hand was rested in Edinburgh functional splint for 10 days followed by active and assisted range of movements under hand physiotherapist supervision. Results. 10 out 11 patients had excellent pain relief. The average range of movement of the PIP joint was 100 degrees. One patient with neglected PIP joint fracture dislocation for 10 weeks had mild residual pain and stiffness. The mean grip strength was 87% of that of contralateral normal side. All patients returned to their same work as before. 8 out of 9 patients returned to play their regular sports at the same level. All patients were satisfied with the functional outcome. Conclusion. Combined fracture fixation and volar plate repair through anterior approach using micro bioabsorbable anchors appears to be very effective way of treating this otherwise complex unstable fracture/dislocation of PIP joint

We reviewed 13 patients with a complex fracture-dislocation of the proximal interphalangeal joint of a finger and one patient with a complex fracture-dislocation of the interphalangeal joint of thumb. We had treated these injuries using a pins and rubbers traction system which had been modified to avoid friction of the pins against the bone during mobilisation of the joint in order to minimise the risk of osteolysis. A Michigan hand outcome questionnaire was used for subjective assessment. The active range of movement (AROM) of the proximal and distal interphalangeal joints and the grip strength were used for objective assessment. The mean follow-up was 34 months (12 to 49). The mean normalised Michigan hand outcome score was 84. The mean AROM of the proximal interphalangeal joint was 85° and that of the distal interphalangeal joint 48°. The mean grip strength was 92% of the uninvolved hand. Twelve patients have returned to their original occupations. There has been no radiological osteolysis or clinical osteomyelitis. This modified traction system has given acceptable results with a low rate of complications. It is light, cheap, effective and easy to apply

We systematically reviewed all the evidence published in the English language on proximal interphalangeal joint (PIPJ) replacement, to determine its effectiveness on the function of the hand and the associated post-operative complications. Original studies were selected if they reported clinical outcome with a minimum of one year’s follow-up. Quality was assessed using the Cowley systematic review criteria modified for finger-joint replacements. Of 319 articles identified, only five were adequately reported according to our quality criteria; there were no randomised controlled trials. PIPJ replacements had a substantial effect size on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1) and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach was most successful. Post-operative loosening occurred in 10% (95% CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon replacements. Post-operative complications occurred in 27.8% (95% CI 20 to 37). We conclude that the effectiveness of PIPJ replacement has not been established. Small observational case studies and short-term follow-up, together with insufficient reporting of patient data, functional outcomes and complications, limit the value of current evidence. We recommend that a defined core set of patients, surgical and outcome data for this intervention be routinely and systematically collected within the framework of a joint registry

Proximal interphalangeal joint arthrodesis for lesser toe deformity is commonly stabilised using a Kirschner wire passed through the tip of the toe. Recently, a number of all-inside intramedullary fusion devices have been developed, with the aim of decreasing infection risk through avoiding exposed metalwork. We report our early experience with Stayfuse™ (Nexa Orthopaedics). Case records of patients undergoing Stayfuse™ proximal interphalangeal joint arthrodesis between July 2009 and November 2011 were examined. Twenty-eight Stayfuse™ proximal interphalangeal joint arthrodesis procedures in 14 patients were performed. Overall, 8 (29%) procedures required revision within 6 months. Of these, 3 (11%) intraoperative failures occurred, requiring immediate revision (Kirschner wire stabilisation or excision arthroplasty). All involved bending failure of the implant clip mechanism. A further 5 (18%) toes required revision procedures within 6 months of the index procedure, 3 (11%) for dissociation of the implant clip mechanism and 2 (7%) for periprosthetic fracture. For patients perceived to be at higher risk of infective complications, all-inside stabilisation systems are an attractive concept. However, with 29% of patients undergoing revision procedures within 6 months, we question the safety of choosing Stayfuse™ implants over Kirschner wire stabilisation

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone. Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply

Aims: We present a prospective study, with three-year follow-up, of the incidence, course and influence on surgical outcome of the abductor digiti minimi cord in Dupuytren’s contracture of the PIP joint of the little finger. Methods: All patients presenting for surgery with primary Dupuytren’s contracture of the little finger over a six-month period were included in the study. Patterns of disease cords and joint involvement were noted. All fingers underwent fasciectomy of the central and pre-tendinous cords. If significant contracture remained the abductor cord was excised next, and the PIP joint itself released only if correction could still not be obtained. Contracture and range of movement of affected joints measured with goniometer pre-operatively, at each stage intra-operatively and at 3 months and 3 years post-op. Results: The abductor cord was present in twleve of the nineteen fingers in the study, including all of those with ulnar-sided disease. The ulnar neurovascular bundle was found to be deep to the cord in nine fingers, encased by diseased tissue in two and displaced superficially in only one finger. Mean initial flexion deformity in these twelve fingers was 59, corrected to only 51 by resection of the central and pre-tendinous cords. Excision of the abductor cord further improved the contracture to 25 while PIP join release improved it to 6. Flexion deformity was 18 at three months and 21 at three years. For the seven fingers in which no abductor cord was found, mean initial flexion deformity was 42, improving to 24 following fasciectomy and 4 with joint release. It was 16 at three months and 18 at three years. No significant difference in outcome could be identified between the groups at three months or three years. Conclusions: The abductor cord is present in roughly two-thirds of little fingers with contracture pf the PIP joint. The ulnar digital nerve usually lies deep to the abductor cord but in roughly one quarter of cases is either encased in or superficial to it. In affected fingers, resection of the cord accounts for more than half of the total correction obtained and three quarters of that obtained by fasciectomy. Presence of the ADM cord does not prejudice long-term outcome provided it is adequately resected

Pain, stiffness, instability and degenerative arthritis are common sequelae of complex fracture-dislocations of the proximal interphalangeal (PIP) joint. Operations were carried out to obtain stability, followed by application of a dynamic external fixator in 20 patients with a mean age of 29 years. This provided stability and distraction, and allowed controlled passive movement. Most (70%) of the patients had a chronic lesion and the mean time from injury to surgery was 215 days (3 to 1953). The final mean range of movement was 12 to 86°. Complications included redislocation and septic arthritis, which affected the outcome. Four pin-track infections and two breakages of the hinge did not influence the result. The PIP Compass hinge is a useful adjunct to surgical reconstruction of the injured PIP joint

Introduction. PIPJ replacement has become increasingly popular however, there is very little clinical data available apart from small studies and those from the originators of the prostheses. We present a review of our initial experience with the Acension. (c). Pyro-carbon PIP joint. Results. Data was collected from 62 joints in 39 patients with one patient lost to follow-up. Mean age was 61.6 years. 29 patients were female and 10 male. Mean follow up was 22.3 months (range 11 to 54). 7 patients or 11% needed further surgery. The majority were for stiffness with 3 operations for dislocation or component malposition. The total complication rate was 32%, again the biggest problem was stiffness. 4 joints have subluxed or dislocated, 2 had superficial infections. There was no statistical difference in the rate of complications compared to the operated finger or the pre-operative diagnosis. Post-operatively patients had a mean fixed flexion deformity of 19° and flexed to 76° (58° arc). However patients undergoing surgery following trauma do not do as well as the other groups with a decrease in ROM of 33°. Conclusions. Subjectively patients are returning low pain scores and the majority are pleased with the outcome of their surgery. There is however a high rate of complications and re-operations. This is in part due to the complexity of the cases as patients with inflammatory arthritis, following trauma or infection or those who are undergoing revision procedures often have decreased bone stock, erosions and more complex soft tissue balancing resulting in an increase in the complication rate. We have found the early results to be encouraging and, when successful, better than the short term results for arthrodesis or silastic implants. We intend to continue with the technique but believe patients should be kept under review

Purpose: Since 1966 silicone implant arthroplasty has been used to treat arthritis of the PIP joint as an alternative to fusion. The volar approach to expose this joint spares the extensor mechanism at the cost of increased risk to neurovascular structures. In the dorsal approach, the extensor mechanism must be carefully handled, reattached and then protected during rehabilitation. Several surgical techniques have been used to handle the extensor mechanism. Swanson et al. recommended midline incision of the central tendon followed by release of the lateral insertion on the middle phalanx and then reattachment to the base of the middle phalanx. Our clinical experience led us to a new surgical technique; splitting then repairing the extensor mechanism without bone reattachment as recommended by Swanson. The purpose of this study was to biomechanically compare the strength and function of this proposed technique with that of Swanson. Method: Four pairs of fresh-frozen cadaveric hands were used. The index, long and ring finger were harvested for testing. Twelve digits (3 digits × 4 hands) were designated as control and were used to measure the fixation strength of Swanson’s procedure. The other 12 digits of the paired hands were designated as experimental and were used to measure the fixation strength of the proposed new technique. Results: The fixation strength mean ± SD were, respectively, 4.74 ± 0.46 N/mm for the control group and 4.62 ± 0.30 for the experimental group. The results were not statistically different, p=0.45. Conclusion: The simple repair of the central slip without the bone reattachment preserves the function of the extensor mechanism on the PIP joint. In our clinical cases we haven’t noticed any increase in the incidence of extensor lag or boutonnière deformity as a result of that. This technique can also be applied for fracture fixation in the area

Abstract: Although the unconstrained pyrocarbon prosthesis (Ascension®) has been presented as a new alternative in the treatment of idiopathic arthritis of the proximal interphalangeal joint of the hand a few years ago, there is still a lack of studies analyzing the results of this implant. In this study 10 patients (13 implants), that were tretated with this type of prosthesis between february 2002 and january 2005 were studied. All but one patient were satisfied with the postoperative situation and would agree to another operation. A significant pain reduction was observed. The average ROM was 58degrees. Five patients demonstrated a free extension, two patients had a swan neck defomity, which could be actively compensated for, and the remaining six patients had an extension deficit of 30–45degrees. The average flexion was 76° (+/−12°). X-ray examination was unremarkable in eight patients with a regular position of the endoprosthesis. However, in five patients significant radiolucent lines (> = 1mm) were observed. So far, a luxation of the prosthesis has not occurred and all implants are still in-situ. However, a dorsal tenoarthrolysis had to be performed in 3 patients. The results of this study show a high rate of patient satisfaction with a significant pain reduction. The radiological results have to be closely monitored in the future. Long-term results with a higher number of patients are necessary. A central registry for finger implants is recommended

Background. Evidence concerning the management of dorsal fracture dislocation (DFD) of the proximal interphalangeal joint (PIPJ) in the hand has been limited by small sample size and case heterogeneity within studies. This retrospective case control study examined clinical outcome of this specific subgroup managed by three different methods. Methods. Patients undergoing fixation of unstable DFD of the PIPJ between March 2005 and August 2011 were identified from theatre records. A retrospective review of case-notes and radiographs was undertaken to determine fracture characteristics, fixation methods and clinical outcomes. Results. 21 patients with DFD of the PIPJ were identified with a mean age of 40 years (range 22–65). The majority of patients were male (17/21, 81%) and the mean percentage articular surface involvement of fractures was 41% (Std. Dev. 11.3%). PIPJ DFD's were managed by reduction of the PIPJ and temporary transarticular K-wire fixation (12/21, 57%), hemi-hamate arthroplasty (7/21, 33%), or by open reduction and internal fixation (2/21,10%). PIPJ ROM following hemi-hamate arthroplasty was 65° (range 34–108°) and was greater than K-Wire fixation at 56. o. (range 9–85. o. ) (p = 0.82). Hemi-hamate arthroplasty and K-wire fixation resulted in fixed flexion deformity of 20° (range −12–52°) and 15° (range −6–50°) respectively (p = 0.61). Hand therapy data was available for one case undergoing ORIF with a post-operative ROM of 60° and 30° of fixed flexion. There was poor correlation between articular surface involvement and post-operative range of movement at the PIPJ (Co-efficient −0.16, p = 0.55). Conclusion. We present a relatively large series of outcomes following DFD of the PIPJ. We were unable to demonstrate any difference in post operative clinical outcomes between the fixation methods examined

Background

Traditional teaching recommends against arthroplasty in the index finger, due to concerns over failure with pinch stress, and prefers arthrodesis is for its stability. We aim to allay these fears and present the results of our series of index finger silastic PIPJ arthroplasties. Methods: Between 2007 & 2018 48 silastic index finger PIPJ arthroplasties were undertaken in 37 patients at our Hand Unit. All were performed under local anaesthetic ring block. Eleven patients underwent PIPJ arthroplasty in both Index fingers. Thirty-five women and two men made up the cohort with a mean age of 69 years. A retrospective analysis of all patients has been undertaken to determine the clinical results including patient satisfaction, grip and pinch strength and reoperation rates. Mean follow up was 5.1 years.