Proximal interphalangeal joint arthrodesis with the Herbert screw

Numerous fixation techniques have been described to obtain successful proximal interphalangeal (PIP) joint arthrodesis. By use of the Herbert screw for compression, 50 (98%) out of 51 PIP joints were fused within 6 weeks. Biomechanically, PIP joint arthrodeses using the Herbert screw in cadaver joints were comparable to tension band arthrodeses evaluated by three-point bending. Herbert screw arthrodesis of the PIP joint achieves a high fusion rate with minimal external protection provided certain technical details are followed.     

Distal interphalangeal joint arthrodesis with the Herbert headless compression screw: outcomes and complications in 64 consecutively treated joints

Background  

Arthrodesis of the distal interphalangeal (DIP) joint is indicated for the treatment of arthritis. While several techniques have been recommended, the use of headless compression screws has grown in popularity. Rates of union reported vary widely, ranging from 80% to 100%, with most studies based on small series. The purpose of this study was to review the outcomes and complications associated with DIP joint arthrodesis using the Herbert headless compression screw in a large case series.     

Use of a headless compressive screw for distal interphalangeal joint arthrodesis in digits: clinical outcome and review of complications

PURPOSE: Arthrodesis of the distal interphalangeal joint (DIPJ) or thumb interphalangeal joints can be necessary to treat pain, deformity, or instability associated with arthritis. Compression and rigid fixation are thought to influence fusion rates and time to union favorably. The purpose of the study was to review the clinical outcome and complications associated with the use of a fully threaded headless compression screw for DIPJ arthrodesis. METHODS: Twenty-seven distal interphalangeal or thumb interphalangeal fusions were performed with an axial Mini-Acutrak screw in 22 patients. Charts, surgical reports, and preoperative and postoperative x-rays were reviewed to determine the incidence, time to union, and complications. The minimal follow-up period was 3 months. RESULTS: Twenty-three of the 27 arthrodeses achieved bony union. Complications included symptomatic nonunion (n=1, treated with secondary fusion), asymptomatic nonunion (n=2, left untreated), infection (n=4; 2 patients required implant removal that resulted in nonunion but declined revision) and nail bed injury (n=3). CONCLUSIONS: The Mini-Acutrak screw technique achieves healing rates that are comparable with but not superior to other techniques. Its main advantages are ease of execution, fully buried hardware, and early mobilization; however, the procedure is associated with complications and meticulous technique is required to avoid them. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

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.     

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.     

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.     

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.     

Instructional Course Lecture. Arthrodesis of the interphalangeal joints with headless compression screws

Interphalangeal arthrodesis is a reliable method of pain relief for arthritic proximal and distal interphalangeal joints in the fingers. Indications include osteoarthritis, acute trauma, chronic reconstruction for trauma, rheumatoid and other inflammatory arthritides, and at the distal interphalangeal joint, chronic mallet finger deformity and unreconstructible flexor tendon defects. Solid arthrodesis imparts stability to the digital skeleton. Headless compression screws can be reproducibly inserted and are a good method to provide fixation adequate to accomplish interphalangeal arthrodesis. Surgical technique involves a dorsal incision and preparing the skeleton for good bony apposition. Exact technique for screw insertion depends on the specific screw used. Union rates range from 85% to 100% in published studies, with time to union of 7 to 10 weeks.     

Distal interphalangeal joint arthrodesis using a minimally invasive technique with the herbert screw

The authors performed six joint arthrodeses of the distal interphalangeal joint in five patients without surface preparation of the joint using the Herbert screw. After the surgery, the joint was not splinted and the finger could be used in daily living activities, provided the patient did not attempt powerful pinching or gripping maneuvers with the affected finger. Although bony union of the joint was delayed, firm bone union was ultimately obtained in all joints. If it is acceptable to position the arthrodesis of the distal interphalangeal joint with 0 degrees of flexion, this technique can be considered very useful. Although the omission of joint surface treatment in this technique prolongs the period before bony union of the joint is attained, patients feel no inconvenience in using their fingers in daily living activities.     

Distal interphalangeal joint arthrodesis: An analysis of complications

One hundred thirty-nine patients underwent 181 arthrodeses of finger distal interphalangeal joints (144) and/or thumb interphalangeal joints (37). Techniques included (1) crossed Kirschner pins (111 joints), (2) interfragmentary wire and longitudinal Kirschner pin (43 joints), and (3) Herbert screw (27 joints). Each technique had a similar nonunion rate. There were 21 nonunions: 13 were pain free, 6 were successfully fused on the second attempt, 1 was painful (but the patient refused further surgery), and 1 was amputated. Inadequate bone stock, inadequate bone resection, premature pin removal, and infection appear to complicate the attainment of bony union. Twenty percent of the fusions had major complications (nonunion, malunion, deep infection, and osteomyelitis). Minor complications (dorsal skin necrosis, cold intolerance, proximal interphalangeal joint stiffness, paresthesias, superficial wound infection, and prominent hardware) occurred in 16% of the joints fused.     

Distal interphalangeal joint arthrodesis with a headless compression screw: morphometric and functional analyses

Introduction  

We performed radiologic measurement of the distal and middle phalanges in volunteers to determine the size of a headless compression screw suitable for distal interphalangeal (DIP) joint arthrodesis in Korean subjects and report on clinical results using an acutrak fusion screw.     

Failure of trapeziometacarpal arthrodesis with use of the Herbert screw and limited immobilization

Eighteen patients with trapeziometacarpal joint arthritis had arthrodesis with use of the 1.9 mm Herbert screw for internal fixation. Thumb spica cast immobilization was maintained for an average of 8 weeks, followed by thumb spica orthoplast splintage on a part time basis. Fourteen patients had radiographic follow-up an average of 12 months after operation. Seven had union and seven had a nonunion. There were three fixation-related complications and two nonfixation-related complications. Eleven patients had clinical follow-up an average of 12 months after operation. Four patients had no pain, five had mild pain, and two had moderate pain after operation. All had severe pain before operation. All were satisfied with the procedure. Although subgroups of patients had a higher rate of union with bone grafts or with immobilization over 8 weeks, the theory that arthrodesis with 1.9 mm Herbert screws does not require external splintage and allows early mobilization is not supported by this series.     

Tendon interposition arthroplasty versus arthrodesis for the treatment of trapeziometacarpal arthritis: a retrospective comparative follow-up study

Long-term subjective and objective outcomes of 24 tendon interposition arthroplasties in 17 patients and 32 trapeziometacarpal (TMC) arthrodeses in 26 patients were compared retrospectively in a standardized manner. Tendon interposition arthroplasty led to complications less often (27%) than TMC arthrodesis (39%). Patients in the tendon interposition arthroplasty group reported significantly less pain, less temperature intolerance, and better thumb mobility and were more satisfied with pain symptoms than patients in the arthrodesis group. Patients undergoing tendon interposition arthroplasty had better thumb opposition, interphalangeal joint mobility, and radial and palmar TMC joint range of motion. No statistically significant differences were found in tip pinch, key pinch, and grip strength between the 2 groups. Proximal first metacarpal collapse occurred in the tendon interposition patients without affecting subjective or objective outcome. Seven of 25 patients with TMC arthrodesis had pseudarthrosis. Tendon interposition arthroplasty seems to be preferable to TMC joint arthrodesis for the treatment of TMC arthritis.     

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.     

Immediate Weightbearing After First Metatarsophalangeal Joint Arthrodesis With Screw and Locking Plate Fixation: A Short-Term Review

Historically, the postoperative protocol for patients undergoing first metatarsophalangeal joint arthrodesis has included 6 weeks of non-weightbearing, followed by protected weightbearing in a below-the-knee cast boot or postoperative shoe. This prolonged period of non-weightbearing predisposes the patient to disuse atrophy, osteopenia, deep vein thrombosis risk, and, overall, a prolonged time to recovery. The present study reports a retrospective review of a patient cohort that underwent first metatarsophalangeal joint fusion with immediate full weightbearing postoperatively. Thirty consecutive first metatarsophalangeal joint arthrodeses were performed during the study period. Five patients were excluded secondary to insufficient postoperative follow-up data or a lack of adequate radiographic evaluation at regular postoperative intervals. Conical reamers were used for joint preparation. Internal fixation, consisting of a single cannulated interfragmentary compression screw and a dorsal locking plate, was used in all patients. The results showed that patients achieved clinical healing at an average of 5.92 weeks and showed radiographic fusion at an average of 6.83 weeks. The patients in the present study had an overall union rate of 96%. Complications included 1 nonunion, 1 superficial wound infection, 1 wound dehiscence, 1 case of symptomatic hardware, and 2 patients with symptomatic hallux interphalangeal joint arthralgia. The mean visual analog pain score preoperatively was 6.64 (range 4 to 8) and postoperatively was 0.6 (range 0 to 4). In conclusion, we found that immediate full weightbearing after first metatarsophalangeal joint fusion in the context of interfragmentary compression and locked plating techniques is a safe, predictable postoperative protocol that allows for a successful fusion interval and an early return to regular activity.     

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.     

Internal fixation of an unstable open fracture of a distal phalanx with a Herbert screw

A 20-year-old patient was seen with an unstable, infected, open fracture of the distal phalanx of the long finger of the right dominant hand. The patient was treated by removal of the nail, debridement of the fracture site, and stabilization of the fracture with a Herbert screw. The Herbert screw compressed the fracture site and allowed early active motion of the distal inter-phalangeal (DIP) joint. The wound healed without incident, and the fracture was radiographically united 6 weeks after the procedure. The Herbert screw is useful in the treatment of unstable fractures of the distal phalanx, since the screw maintains reduction, compresses the fracture site, and allows early active motion of the DIP joint.     

Complications of trapeziometacarpal arthrodesis using plate and screw fixation

PURPOSE: This study was designed to determine the complications associated with plate and screw fixation of thumb trapeziometacarpal arthrodesis and to compare these results with a previous report from our institution using K-wire fixation. METHOD: We retrospectively reviewed 26 trapeziometacarpal arthrodeses that used plate and screw fixation. The most common diagnosis was primary osteoarthritis and the average follow-up evaluation was 40 months. Nineteen patients were available for a clinical follow-up examination and radiographs. These results were compared with the previously published K-wire fixation group that consisted of 59 arthrodeses with an average follow-up period of 84 months. RESULTS: There were 2 (8%) painful nonunions. There were 6 (23%) hardware malpositions, most frequently associated with a screw in the trapeziotrapezoid joint. Seven (27%) arthrodeses had a second procedure, most commonly hardware removal. Twenty-one (81%) of the patients were satisfied and reported they would have arthrodesis again. In the K-wire fixation group 4 of 59 (7%) arthrodeses went on to nonunion and 2 of 59 required a secondary procedure; patient satisfaction was high (98%). CONCLUSIONS: K-wire and plate and screw fixation have comparable union rates. In the plate and screw fixation group, however, the satisfaction rate was lower and a second surgery was more common. We now recommend pin fixation when performing trapeziometacarpal joint arthrodesis.     

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.     

Subtalar joint arthrodesis using a single lag screw

BACKGROUND: This study tested the hypotheses that fusing the subtalar joint with a single lag screw from the posteroinferior calcaneus to the anterior talar neck is an effective technique and that factors affecting the time to fusion can be identified. METHODS: Between October, 1995, and July, 2002, the senior author (RAM) performed 101 isolated subtalar arthrodeses using a technique of single lag-screw fixation from posteroinferior to anterosuperior across the posterior facet of the subtalar joint combined with the application of an autograft taken from the floor of the sinus tarsi and anterior process. The average patient age was 52 (range 17 to 82) years. There were 52 women (53 arthrodeses) and 48 men (48 arthrodeses). Eight of 101 (8%) arthrodeses were revisions. The indications included posttraumatic arthritis (45), posterior tibial tendon dysfunction (18), failed prior ankle joint fusion (14), idiopathic disorders (12), hindfoot coalition (7), rheumatoid arthritis (3), and Charcot-Marie-Tooth disease (2). Fifteen of 101 patients (15%) smoked an average of 0.9 +/- 0.5 pack of cigarettes per day. RESULTS: Two of 101 joints did not fuse, resulting in an overall fusion rate of 98%. The average time to fusion was 12.3 +/- 3.4 weeks. The presence of a prior ankle fusion significantly prolonged the time to fusion of the subtalar joint (11.9 +/- 2.3 vs. 14.9 +/- 7.0, p = .003). Other factors, including smoking, revision surgery, patient age, and patient sex, did not affect time to fusion. The fixation screw was removed in 13 of 101 (13%) joints at an average of 8.8 +/- 0.5 months. CONCLUSIONS: Using a single 7.0-mm lag screw across the posterior facet of the subtalar joint results in fusion of the subtalar joint in 98% of patients. A prior ankle arthrodesis delays the time to fusion of the subtalar joint by 3 weeks. This is a simple and reliable technique for achieving fusion of the subtalar joint.