Arthrodesis of the distal interphalangeal joint using a bioabsorbable rod as an intramedullary nail.

There are several fixation techniques for arthrodesis of the distal interphalangeal joint. Since February 1999 we have used a bioabsorbable (poly-L-lactide, PLLA) rod as an intramedullary nail for arthrodesis of 15 distal interphalangeal joints and one interphalangeal joint of the thumb. The advantages include the absence of protruding hardware that would require removal, and technical simplicity. Preoperative diagnoses included degenerative arthritis in five patients, post-traumatic arthritis in 10 patients, and non-union after arthrodesis with crossed Kirschner wires in one patient. All patients were observed until there was clinical and radiographic evidence of fusion with the mean interval to fusion of 8 weeks (range 6-12). There were two cases of minor intermittent local swelling, which resolved. Fixation with a PLLA rod for arthrodesis of the distal interphalangeal joint is a simple and effective technique.     

Distal interphalangeal joint arthrodesis: treatment with Herbert screw

From 1996 to 2000, 20 patients with a mean age of 53 underwent 20 arthrodeses with Herbert screws. There were 16 (80%) distal interphalangeal joint (DIP) and 4 (20%) thumb interphalangeal (IP) joint arthrodeses. Average follow-up was 25 months (range, 6-39 months). The diagnoses included rheumatoid arthritis in 10 patients, degenerative arthritis in 4, and post-traumatic arthritis in 6. Arthrodesis relieved pain and restored stability in all patients. Solid osseous union occurred in 19 patients (95%). The average interval to fusion was 8 weeks for DIP and 12 weeks for IP joint arthrodesis. Solid osseous union occurred in 19 patients (95%). The average interval to fusion was 8 weeks for distal interphalangeal joint arthrodesis and 12 weeks for interphalangeal joint of the thumb. There were three complications: one delayed union, one nonunion because of a short screw, and one dorsal skin necrosis with amputation. It was shown that distal interphalangeal joint arthrodesis with a Herbert screw is a technique with several advantages: good clinical results, high rates of fusion, early mobilization, and the screw does not need to be removed after the fusion heals. Potential complications may be avoided by using the Herbert mini-screw.     

Long-term results of digital arthrodesis with the Harrison-Nicolle peg

This study determined the long-term success of digital arthrodesis with the Harrison-Nicolle peg. We reviewed 90 digital joints in 60 patients fused with the peg between 1986 and 1998 at a mean follow-up of 6 (range 2-11) years. The prime indication for surgery was rheumatoid arthritis. The early complication rate was 8%. At 1 month 89% of joints were pain-free and stable. In the long-term follow up, 96% of the joints were pain-free and stable, with the original angle of fusion. 85% achieved bony fusion, with no clinical difference between bony and fibrous fusion. Overall there was a significantly higher complication rate in the distal interphalangeal joint. We conclude that, with the exception of the distal interphalangeal joint, the Harrison-Nicolle peg is extremely effective for digital arthrodesis in the rheumatoid patient.     

Silicone interpositional arthroplasty of the distal interphalangeal joint

Twenty-three female patients had silicone interpositional arthroplasty of the distal interphalangeal joint in 38 digits. The operative indications were pain and deformity of the distal interphalangeal joint. The underlying diagnosis was osteoarthritis in all but one patient who had rheumatoid arthritis. The average age at the time of operation was 58.3 years. The implants have been in place for a mean period of 72.2 months (range, 12.6 to 123.1 months). At follow-up, extension lag averaged 12.7 degrees and the range of motion of the distal interphalangeal joint had a mean value of 33.2 degrees. Compared with arthrodesis, silicone interpositional arthroplasty offers the advantage of retained motion while preserving stability.     

Osteosynthesis in digital replantation using bioabsorbable rods

There are several fixation techniques for osteosynthesis in digital replantation. Kirschner wire fixation is used commonly but the wires protrude and disturb mobilization. Moreover, it requires removal. Since February 1995, the authors have been using a bioabsorbable rod made of poly-L-lactide as an intramedullary nail for osteosynthesis in digital replantation. The advantages of this technique include the absence of protruding hardware that would require removal and technical simplicity. This method has been applied for 15 arthrodeses (12 distal interphalangeal joints, 1 proximal interphalangeal joint, and 2 interphalangeal joints of the thumb) and for 11 diaphysis fractures (5 proximal, 5 middle, and 1 distal phalanx). All patients were observed until there was clinical and radiographic evidence of fusion (average interval to fusion, 8.4 wk). Bone resorption occurred in one patient. There were no cases of nonunion or infection. Poly-L-lactide rod fixation is a simple and effective technique.     

Treatment of Symptomatic Distal Interphalangeal Joint Arthritis with Percutaneous Arthrodesis: a Novel Technique in Select Patients

Arthrodesis of the distal interphalangeal (DIP) joint is a reliable means of achieving pain relief in a symptomatic DIP joint afflicted by a variety of degenerative, inflammatory, or posttraumatic conditions. Successful arthrodesis is more reproducible when rigid compression of the joint is achieved. The emergence of an increasing number of commercially available headless or variable pitch compression screws reflects the growing trend among hand surgeons to utilize rigid stabilization of the DIP joint so that motion at more proximal levels can be initiated immediately without affecting arthrodesis rates. Successful closed percutaneous DIP arthrodesis can be achieved in a patient with hypertrophic osteoarthropathy, passively correctable deformity, and patients at increased risk for perioperative soft tissue complications associated with open arthrodesis. We present a novel percutaneous DIP fusion technique utilizing a cannulated headless compression screw in a select group of patients. The sagittal plane diameters of the distal and middle phalanges are templated. Cannulated headless compression screws, 2.4 and 3.0 mm, with short or long terminal threads at the leading end of the screw are selected based upon patient-specific anatomic considerations. Pain-free status and radiographic fusion were achieved in both patients (gout arthropathy, n = 1; posttraumatic arthritis, n = 1) at an average of 6 weeks postoperatively. Our current indications, along with pearls and pitfalls with this technique, are reviewed. In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques.     

Distal interphalangeal joint flexible implant arthroplasty

Twenty-one osteoarthritic distal interphalangeal joints in 13 patients were treated by flexible implant arthroplasty. Follow-up to 5 years showed results that were good to excellent, with only one complication, and a high degree of patient satisfaction. The procedure should be considered a good alternative to the more traditional distal interphalangeal joint arthrodesis.     

Distal interphalangeal joint silicone interpositional arthroplasty: surgical technique and functional outcome

Distal interphalangeal joint arthroplasty is effective in alleviating the pain of degenerative arthritis while preserving motion and stability. This procedure was undertaken as an alternative to arthrodesis for 17 women with osteoarthritis and 1 woman with rheumatoid arthritis. Silicone interpositional arthroplasty was performed in 31 digits of patients whose mean age was 58.3 years. The patients were evaluated at an average of 72.2 months (range, 12.6 to 123.1 months) after surgery. All patients reported that their primary preoperative symptom of pain was effectively eliminated by the procedure. At reevaluation, the active range of motion of the distal interphalangeal joint averaged 32.2 degrees and extension lag averaged 12.7 degrees . Lateral stability of the distal joint was present in all but one middle finger implant. Two implants were removed at 3 months postoperatively for wound problems and one at 31 months because of prothesis fracture.     

Failure of Small Joint Arthrodesis from Resorption Around a Compression Screw in a Patient with Lupus-Associated Arthritis Mutilans: Case Report

We report the unusual case of a patient with systemic lupus erythematosus (SLE)-associated arthritis mutilans. Arthritis mutilans is a variant of erosive arthritis that is more commonly reported with psoriatic and rheumatoid arthritis and not with SLE. Joint fusion has been shown to be the most effective measure to preserve bone length and prevent further erosive joint changes in arthritis mutilans. We attempted to enhance success of a thumb interphalangeal joint fusion in our patient by adding compression across the fusion with implant screws, given the difficulty of achieving solid bone fusion ordinarily. Osteolysis around the compression screw resulted in arthrodesis failure. We were finally able to achieve successful fusion with iliac crest corticocancellous bone grafts and Kirschner wire fixation. Implant athroplasty in patients with bone loss is risky as it often furthers joint instability because of bone resorption around the prosthesis. This is a point of caution regarding use of any implant (including large screws) in patients with arthritis mutilans, as osteolysis around the implant may occur.     

Alternative to the distal interphalangeal joint arthrodesis: lateral approach and plate fixation

PURPOSE: Several fixation techniques for distal interphalangeal (DIP) joint arthrodesis have been described, with good clinical results and complication rates between 10% and 20%. We propose an alternative technique and fixation method using a lateral approach and 1.3-mm plate and screws fixation. METHODS: Between March and September 2005, 11 patients, totaling 15 fingers, had DIP joint arthrodesis by the described technique. The indications were posttraumatic arthritis in 8 fingers, degenerative or rheumatoid arthritis in 5 fingers, and isolated flexor digitorum profundus tendon lesions in 2 fingers. Patients were analyzed for osseus union, pain relief, and functional mobility of the finger. RESULTS: Arthrodesis relieved pain and restored stability at the 12th week, on average, with osseous union in all patients. All patients maintained full proximal interphalangeal joint motion with pulp-to-palm distance of zero at 6 months of follow-up evaluation. There were no rotational or angular deformities, nail bed lesions, or skin complications. CONCLUSIONS: The lateral approach with plate and screws fixation is an option for DIP joint arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Opera-glass hand in rheumatoid arthritis.

Characteristic deformities occur in the fingers, thumb, and wrist in the opera-glass hand in rheumatoid arthritis. Shortening and instability are the result of bone resorption and dislocation and can be severely disabling. Early spontaneous fusion of the proximal interphalangeal joint preserves digital length. Functional improvement can be obtained in the fingers by interphalangeal joint arthrodesis and metacarpophalangeal prosthetic arthroplasty and in the thumb with metacarpophalangeal and/or interphalangeal arthrodesis. With interphalangeal arthrodesis, interposition grafts often are required in order to restore length and secure fusion. "Prophylactic" arthrodesis of interphalangeal joints should be considered when resorption seems imminent.     

Silicone rubber arthroplasty of the wrist

The wrist is often referred to as the keystone of the hand. It is often affected in rheumatoid arthritis. Salvage procedures for patients with rheumatoid arthritis involving the wrist include silicone wrist arthroplasty, total joint arthroplasty, and wrist arthrodesis. In 1967, Swanson developed a double-stem, flexible-hinge implant for the radial carpal joint. In 1982, metal titanium bone liners (grommets) were added to help decrease the incidence of fractures. The authors feel that the gold standard is still wrist arthrodesis. However, they would use a flexible wrist arthroplasty in a patient who has bilateral wrist involvement with marked digital deformity and/or proximal interphalangeal stiffness. This is especially true in low-demand patients who have good alignment, good bone stock, and the associated proximal and distal disease. If these criteria are met and meticulous technique used, successful reconstruction of the wrist with a flexible wrist silicone implant can be performed in the patient with rheumatoid arthritis.     

Der Fingermittelgelenkersatz mit Pyrocarbonprothesen

OBJECTIVE: Prosthetic joint replacement to reduce pain and maintain function of the proximal interphalangeal joint. INDICATIONS: Symptomatic arthritis of the proximal interphalangeal joint with preservation of the collateral ligaments, sufficient bone support, and intact or at least reconstructable extensor tendons. CONTRAINDICATIONS: Lack of stability, e. g., as a result of rheumatoid arthritis or destruction of the ligaments caused by an accident. Nonreconstructable extensor tendons. Florid or chronic infection. Lack of patient compliance. SURGICAL TECHNIQUE: Dorsal approach to the proximal interphalangeal joint. A triangular tendinous flap with pedicle, based distally on the insertion of the medial band, is lifted up, leaving the lateral bands intact. The joint surfaces are resected while maintaining the palmar plate and the collateral ligaments. The trial prosthesis is fitted, its position is checked, and the final unconstrained prosthetic components are inserted using a press-fit technique. The dorsal aponeurosis is reapproximated. RESULTS: 20 patients were treated for posttraumatic or idiopathic arthritis with 24 pyrolytic carbon PIP prostheses, and a follow-up examination was carried out after an average of 15 months (6-30 months). Surgical management was changed from arthroplasty to arthrodesis in three cases. For the remaining prostheses, an average range of motion of 50 degrees was achieved for the proximal interphalangeal joint. On the visual analog scale (VAS; 0: no pain, 10: incapacitating pain), the patients suffered few symptoms (VAS: 0-3). 80% of patients said they were satisfied with the outcome of the operation. In three cases (one infection, two dislocations) the prostheses had to be removed and arthrodesis performed. Migration of the distal components was observed on the radiographs in five cases, and of the proximal components in four cases, although this did not have any effect on the functional parameters. The development of a painless noise ("squeaking") was noticed in nine out of 21 prostheses. However, as with prosthetic migration, this did not cause any functional deficits.     

Treatment of boutonniere finger deformity in rheumatoid arthritis

Boutonniere finger deformities occur frequently in patients with rheumatoid arthritis. The deformity consists of flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint. Treatment decisions are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface. Treatment options can then be based on the classification of the deformity; options consist of corrective splinting, injections, synovectomy, terminal tenotomy, extensor reconstruction, or salvage surgery (arthrodesis or arthroplasty).     

Surgery of the hand in severe systemic sclerosis

Ten patients with scleroderma and severe hand problems required surgery, and seven were available for follow-up (two died from scleroderma-related complications and one was lost to follow-up). The mean duration of follow-up was 4 (range 1.5-9) years. Thirty-three procedures were carried out, including five metacarpophalangeal joint excisional arthroplasties, 13 proximal interphalangeal joint fusions, ten distal interphalangeal joint fusions, and one thumb interphalangeal joint fusion. The metacarpophalangeal joint excision arthroplasties and proximal interphalangeal joint fusions were performed for the correction of severe fixed "finger-in-palm" deformities. Lesions of cutaneous calcinosis were removed in four patients. Fixation was satisfactory in all cases of interphalangeal joint fusion, with no cases of nonunion. Wound healing was satisfactory in six of seven patients. A second surgical procedure was required in three patients for the removal of tension band wires following interphalangeal fusion. Calcinosis was effectively removed using a high-speed dental burr. The results of hand surgery for systemic sclerosis are reliable, but goals must be limited and patient expectations should be modest.     

A technique for isolated arthrodesis for inflammatory arthritis of the talonavicular joint

There are few reports in the literature documenting the efficacy of isolated arthrodesis for inflammatory arthritis of the talonavicular joint. Accordingly, we reviewed a single surgeon's experience with this procedure in twenty consecutive cases from this patient population. A technique using indirect joint distraction and the combined use of screw and staple fixation was employed. Solid arthrodesis was noted radiographically in 19 of 20 feet (95%) at an average of 11 weeks. Complications included one non-union, one deep venous thrombosis, and one superficial wound infection. Objective results were graded as excellent in 16 cases, good in 3 cases, and poor in one case. Subjectively, 18 patients were satisfied and one patient dissatisfied with the results of the procedure. It is concluded that isolated arthrodesis is an effective procedure for the treatment of inflammatory arthritis of the talonavicular joint, offering significant pain relief and improved function. Additionally, the use of indirect joint distraction and fixation with screws and staples is a reliable technique associated with an excellent fusion rate.     

Chronic palmar dislocation of proximal interphalangeal joints

Seven patients with chronic palmar dislocations of proximal interphalangeal joints are described. The duration of the dislocation ranged from 4 weeks to 19 months. Satisfactory mobility was restored in each patient after operative reduction and reconstruction of the extensor mechanism. Motion of the proximal interphalangeal joint averaged 57.1 degrees and 29.3 degrees at the distal interphalangeal joint. This method of treatment is preferable to an arthrodesis in selected patients.     

Reconstruction of the rheumatoid thumb.

Most rheumatoid patients will present with one or more thumb deformities at some stage of their clinical history. The goal of treatment is restoration and maintenance of stable and painless motion. Treatment is based on the type and stage of the deformity. The boutonniere thumb is the most common deformity. Metacarpophalangeal arthrodesis is preferred for isolated metacarpophalangeal involvement. For advanced cases in a low-demand patient, metacarpophalangeal arthroplasty with interphalangeal arthrodesis is performed. In the higher demand hand with an uninvolved carpometacarpal joint, arthrodesis of both metacarpophalangeal and interphalangeal joints may be considered. The less common swan neck is approached by treating the carpometacarpal joint with a hemiarthroplasty or a total resection with capsulodesis or arthrodesis of the metacarpophalangeal joint. Adduction contracture is treated by Z-plasty of the skin of the first web space and release of the adductor aponeurosis. Gamekeeper's deformity is treated with reconstruction of the ulnar collateral ligament. Arthrodesis is recommended for those patients with articular erosion of the metacarpophalangeal joint. Flexor pollicis longus and extensor pollicis longus tendon ruptures are common in rheumatoid patients. Extensor pollicis longus ruptures are usually treated with EIP transfer or observation. Flexor pollicis longus ruptures are more disabling and usually require a tendon transfer, tendon graft, or an interphalangeal joint fusion in patients with radiographic destruction of that joint.     

The Sauvé-Kapandji procedure: a salvage operation for the distal radioulnar joint.

The Sauvé-Kapandji procedure, a distal radioulnar arthrodesis with surgical creation of a pseudoarthrosis in the distal ulna, was used to treat 11 patients. Although all patients had had at least one previous operation on the involved wrist, they were still having pain and functional limitations. Ten patients were available for follow-up, which averaged 33 months. Of the nine patients with posttraumatic arthritis, six had excellent results (a painless wrist that averaged 82 degrees of pronation and 83 degrees of supination). Three patients had good results (mild pain during activities with an identical range of forearm rotation). One patient who had rheumatoid arthritis had an excellent result for 3 years but recently had a radiocarpal wrist fusion because of radiocarpal arthritis. We have found the Sauvé-Kapandji procedure to be a reliable treatment option for intractable disorders of the distal radioulnar joint and recommend it as a salvage procedure when previous treatment has failed.     

Metacarpal-phalangeal joint arthroplasty of the rheumatoid thumb

Fifty patients with rheumatoid arthritis had 59 Swanson implants of the metacarpal-phalangeal joint of the thumb. Eleven patients (15 implants) have since died and only 1 patient (1 implant) has been lost to follow-up leaving 43 implants available for study. The most common preoperative deformity was a boutonniere deformity with a flexible interphalangeal joint. All thumbs had less pain after operation. The average range of active motion is 25 degrees, with a flexion arc from 15 to 40 degrees. There is an average key pinch strength of 4 pounds (range, 0.5 to 10). Improvement in activities of daily living were noted in 40 hands. One thumb required reoperation for instability; the implant was removed and a metacarpal-phalangeal arthrodesis was done. Radiographic progression of disease was noted in only one thumb at the interphalangeal joint and in two other thumbs at the carpometacarpal joint. None of these have required further operations. The maintenance of motion appears to help in activities of daily living as stability and pinch strength are often adequate.