Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two-year follow-up evaluation

PURPOSE: To retrospectively review the surgical technique, postoperative therapy/splinting protocols, and clinical and radiographic outcomes of patients who had pyrolytic carbon proximal interphalangeal (PIP) joint arthroplasty. METHODS: A total of 50 PIP joint replacements in 35 patients were performed with a minimum follow-up period of 27 months. Indications for surgery included pain, decreased range of motion, instability, and/or deformity. The preoperative diagnosis was osteoarthritis in 14, rheumatoid arthritis in 11, and posttraumatic arthritis in 10. There were 20 women and 15 men affected. The average age at the time of surgery was 53 years. The fingers replaced included the index (15), middle (18), ring (10), and small (7). The preoperative arc of motion averaged 40 degrees (0 degrees-60 degrees ), and the pinch and grip measurements averaged 3 and 19 kg, respectively. The preoperative pain scores averaged 6 (scale, of 0-10) on a visual analog space scale. RESULTS: The arc of motion was 47 degrees after surgery, and the average pinch and grip measurements were 4 and 25 kg, respectively. Pain scores improved to 1. At the final follow-up evaluation the overall patient satisfaction was nearly 80%. The results of index finger PIP replacements are compatible with other digits. Fourteen joints (in 14 patients) to date have required additional procedures to improve or maintain joint motion/function or pain; 5 for minor reasons and 9 for major complications. The revision arthroplasty rate was 8%. No infections were noted. Although not medically necessary, 2 patients requested and had an amputation. Radiographic subsidence and subsequent settling (in accordance with Wolff's law) without apparent loosening occurred in 20 joints. CONCLUSIONS: Our 2-year minimum follow-up evaluation of pyrolytic carbon implant arthroplasty showed improved pain relief and good overall patient satisfaction. Twenty-eight percent of patients required a second procedure and 8% required a revision arthroplasty. Radiographs showed gross changes in implant and eventual settling to a stable position in 40% of the joints. A longer follow-up period will help to better determine the efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in patients under fifty years of age

Degenerative arthritis of the elbow in patients aged under 50 years can cause disabling pain, severely restricted range of motion (ROM), and functional limitations. Open ulnohumeral arthroplasty has been demonstrated to produce satisfactory pain relief and ROM gains. We report the results of an all-arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in younger patients. Eleven consecutive patients aged under 50 years with radiographically documented degenerative elbow arthritis underwent an all-arthroscopic ulnohumeral arthroplasty as described by Savoie et al. Indications for surgery were pain and limited ROM refractory to 12 months of conservative treatment. The mean age at the time of surgery was 36 years (range, 23-47 years). The minimum postoperative follow-up was 24 months, with a mean of 26 months (range, 24-29 months). Preoperatively, mean flexion was 100 degrees (range, 70 degrees-140 degrees) and mean extension (short of neutral) was 40 degrees (range, 10 degrees-60 degrees). Postoperatively, mean flexion was 140 degrees (range, 130 degrees-150 degrees; P < .01) and mean extension was 7 degrees (range, 0 degrees-20 degrees; P < .01). The total arc of motion averaged 60 degrees preoperatively and 133 degrees postoperatively (improvement of 73 degrees, P < .01). The mean subjective pain level improved from 9.2 to 1.7 (where 10 indicates worst pain and 0 indicates no pain). Mean subjective patient satisfaction improved from 1.8 to 9.0 (where 0 indicates unsatisfied and 10 indicates completely satisfied). All-arthroscopic ulnohumeral arthroplasty provides significant short-term pain relief, as well as restoration of elbow ROM and function, in patients aged under 50 years with degenerative arthritis of the elbow. The long-term durability of this procedure with regard to preservation of ROM and radiographic progression of arthritis remains unknown.     

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.     

Pyrolytic carbon arthroplasty for posttraumatic arthritis of the proximal interphalangeal joint

PURPOSE: To prospectively evaluate the subjective and objective functional outcome of patients treated with a pyrolytic carbon proximal interphalangeal (PIP) joint arthroplasty for posttraumatic arthritis. METHODS: Five patients (7 joints) with traumatic injuries to the PIP joint were followed up for more than 1 year after pyrolytic carbon arthroplasty. All patients were treated with surgical reduction and stabilization at the time of the initial injury, but at a minimum of 6 months after the initial injury they had persistent pain, loss of motion, and functional limitations. All patients had a stable PIP joint with a satisfactory extensor mechanism but had radiographic evidence of posttraumatic arthritis. Patients were evaluated before and after arthroplasty with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and visual analog scale and by radiographic and physical examination. RESULTS: At an average of 17 months, the mean DASH questionnaire score was unchanged. The pain rating on the visual analog scale was 6 out of 10 before surgery and 4 out of 10 after surgery; this change was not statistically significant. The average range of motion of the PIP joint decreased by 10 degrees at the last evaluation. Grip strength improved from an average of 47 lb to 63 lb after surgery. CONCLUSIONS: The subjective and objective functional outcomes in 5 patients more than 1 year after pyrolytic carbon PIP joint arthroplasty for PIP joint trauma were disappointing. For posttraumatic patients, we no longer use pyrolytic carbon PIP joint arthroplasty.     

Total joint arthroplasty in the treatment of advanced stages of thumb carpometacarpal joint osteoarthritis

PURPOSE: Osteoarthritis of the thumb basal joint is a very common and disabling condition that frequently affects middle-aged women. Many different surgical techniques have been proposed for extensive degenerative arthritis of the first carpometacarpal (CMC) joint. Joint replacement has been an effective treatment of this condition. The purpose of this article is to present the outcome of a total cemented trapeziometacarpal implant in the treatment of more advanced stages of this disease. METHODS: Total joint arthroplasty of the trapeziometacarpal joint was performed on 26 thumbs in 25 patients to treat advanced osteoarthritis (Eaton and Littler stages III and IV) between 1998 and 2003. Indications for surgery after failure of conservative treatment were severe pain, loss of pinch strength, and diminished thumb motion that limited activities of daily living. A trapeziometacarpal joint prosthesis was the implant used in this series. The average follow-up time was 59 months. RESULTS: At the final follow-up evaluation, thumb abduction averaged 60 degrees and thumb opposition to the base of the small finger was present. The average pinch strength was 5.5 kg (85% of nonaffected side). One patient had posttraumatic loosening, which was revised with satisfactory results. Radiographic studies at the final follow-up evaluations did not show signs of atraumatic implant loosening. One patient complained of minimal pain, and the remaining 24 patients were pain free. CONCLUSIONS: In our series, total joint arthroplasty of the thumb CMC joint has proven to be efficacious with improved motion, strength, and pain relief. We currently recommend this technique for the treatment of stage III and early stage IV osteoarthritis of the CMC joint in older patients with low activity demands. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Surgical treatment for boutonniere deformity of the fingers. Retrospective study of 47 patients]

Disruption or laceration of the central slip of the extensor tendon at the proximal interphalangeal (PIP) joint with volar displacement of the lateral bands can result in the so-called boutonniere deformity which includes loss of extension at the PIP joint and compensatory hyperextension of the distal interphalangeal (DIP) joint. Many procedures has been described in the literature and no standard treatment can be recommended. The authors reports a series of 47 cases of posttraumatic boutonniere deformity. The mean follow-up was five years. Majority of patients were males (38 males). The mean age was 41 years-old (17-82 y.o.). The etiology was in 23 cases a missed subcutaneous disruption of the central slip of the extensor tendon and in 24 cases an inappropriate treatment of laceration of the extensor apparatus at the dorsal aspect of the PIP joint. The involved digit was in seven cases the index finger, in 14 cases the long finger, in 14 cases the ring finger and in 12 cases the little finger. It is essential to distinguish the supple boutonniere deformity without or after physical therapy (34 cases) and the stiff boutonniere deformity even after a hand physical therapy program (13 cases). Results were assessed on pain and active range of motion of the PIP joint as well as the range of motion of the DIP joint. Supple boutonniere deformities, except one treated by an isolated distal tenotomy of the extensor tendon (1/34), was treated by a procedure of reconstruction of the extensor apparatus including resection-suture of the central slip and redorsalisation of the lateral bands when there was a DIP hyperextension with a moderate flexion deformity of the PIP joint, and (33/34) with 90% of excellent and good results. Poor results (4/33) were due in two cases to the absence of physical therapy, in one case to septic osteoarthritis and in one to secondary rupture of the suture. For the 13 stiff boutonniere deformities, when the PIP flexion deformity was moderate, a distal tenotomy performed to correct the DIP hyperextension was satisfactory in three cases with a useful result (20 degrees-70 degrees). For destroyed PIP joint (osteoarthritis), two silicone spacers were implanted with also a satisfactory result (30 degrees-70 degrees). In the eight remaining cases, a teno-arthrolysis was performed combined with a reconstruction of the extensor apparatus as described. Six poor results were obtained with arthritic PIP joints (which should have required initially silicone implants), and two fair results (30 degrees-60 degrees) with non-destroyed PIP joints. Supple boutonniere deformity must always be treated by initial physical therapy. Surgical procedure with reconstruction of the extensor apparatus is satisfactory if the PIP joint is normal. When there is PIP osteoarthritis, it may be beneficial to perform a two-stage technique with tenoarthrolysis followed hand therapy and a secondary reconstruction of the extensor apparatus as these last procedure give satisfactory results on a supple boutonniere deformity.     

Reconstruction of swan neck deformities after proximal interphalangeal joint arthroplasty

Background

The authors report the use of a single slip of the flexor digitorum superficialis (FDS) as a hemitenodesis through the A2 pulley in treating swan neck deformities after previous unconstrained proximal interphalangeal joint (PIP) arthroplasty.

Methods

A retrospective chart review was undertaken to identify non-constrained PIP joint arthroplasties that underwent a subsequent soft tissue hemitenodesis for swan neck deformities. The range of motion (ROM), implant design, preoperative diagnosis, and surgical approach were collected. The Michigan Hand Outcomes Questionnaire and patient satisfaction questionnaire were collected.

Results

There were 12 patients with 14 procedures reviewed. There were seven surface replacement arthroplasties (SRA) (cobalt chrome on polyethylene) and eight pyrocarbon prostheses. The primary diagnosis for the initial joint arthroplasty was osteoarthritis (8), post-traumatic (2), and rheumatoid arthritis (5). The primary dorsal approach was a longitudinal split in eleven cases, Chamay in two, and unknown in one case. Nine of the 14 revision procedures had a concomitant dorsal approach to the joint. The average final position intraoperatively was 24.2° of flexion (range 15°–40°). Final ROM was 39° with average follow-up of 30 months. The average postoperative radiographic position was 20.3° flexion with an average of 24.8° hyperextension preoperatively. There was one failure secondary to implant loosening requiring fusion.

Discussion

For patients with a swan neck deformity after PIP arthroplasty, a FDS hemitenodesis provides a treatment option with a low revision rate, retained motion, and maintenance of the original implant with no shortening of the digit.     

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.     

Endoprosthetic surgery of the elbow

Artificial joint replacement has found a firm place in orthopaedic surgery since its first introduction in the late 1960s. While the initial fixed bearing implants tended to progress to early loosening, the development of so-called "sloppy joints" has seen a major advance in the survival and success rate of this arthroplasty. The surgical approach and technique have also been modified in such a way as to allow a complete ventral release of a flexion contracture, while at the same time preserving the integrity of the extensor mechanism. In this way, the improvement of the biomechanics of the implant combined with diligent surgical technique have enhanced this procedure dramatically. Between 1978 and 1999, 305 GSB 3-type prosthesis were implanted, with the underlying pathologies being rheumatoid arthritis (77%), posttraumatic arthritis (21%) and degenerative arthritis (2%). The range of motion could be significantly improved from the pre-operative state for extension as well as flexion. This was even more obvious in the rheumatoid than in the posttraumatic situation. The survival rate for this type of implant was 90% at 10 years, with the implants after rheumatoid surgery faring somewhat better than those of the posttraumatics. Alternative treatment options, such as resection arthroplasty, distraction arthroplasty, or arthrodesis, are nowadays employed only in rare cases where a previous infection, personal preference or an inability by the patient to co-operate in a rehabilitation program have to be considered. The overall functional results of these types of treatments seem to be inferior to that of elbow arthroplasty. Therefore, this procedure is recommended not only for advanced degenerative and rheumatoid pathologies, but also in cases of posttraumatic arthrosis.     

Treatment of chronic,traumatic hyperextension deformities of the proximal interphalangeal joint with flexor digitorum superficialis tenodesis

PURPOSE: To our knowledge, there are no reports in the literature regarding treatment of chronic, posttraumatic proximal interphalangeal (PIP) joint hyperextension deformities with flexor digitorum superficialis tenodesis. The purpose of this study was to describe the surgical treatment and results of flexor digitorum superficialis tenodesis for the treatment of chronic, posttraumatic PIP joint hyperextension deformities. METHODS: Twelve patients were reviewed retrospectively and re-examined at a mean follow-up period of 35 months (range, 6-108 mo). Evaluation included completion of a Disabilities of the Arm, Shoulder, and Hand questionnaire and range of motion (ROM) measurements. RESULTS: There were 5 excellent, 5 good, and 2 fair results. Five patients had a residual flexion contracture at the PIP joint of 5 degrees to 15 degrees, although this did not create any functional impairment as determined by responses to the Disabilities of the Arm, Shoulder, and Hand questionnaire at follow-up evaluation. The 2 patients with fair results had postoperative PIP flexion contractures of 30 degrees and 60 degrees. All 12 patients returned to their previous occupations and recreational activities. CONCLUSIONS: Flexor digitorum superficialis tenodesis is an effective method with predictable results for the treatment of chronic, traumatic hyperextension deformities of the PIP joint.     

Pyrolytic carbon proximal interphalangeal joint resurfacing arthroplasty

PURPOSE: To evaluate the clinical results of a pyrolytic carbon resurfacing proximal interphalangeal joint (PIPJ) arthroplasty in patients with osteoarthritis. METHODS: A retrospective review of 18 PIPJ arthroplasties in 8 women with severe osteoarthritis performed by a single surgeon was completed with an average follow-up period of 13 months. Clinical assessment included range of motion (ROM), stability, and deformity. Radiographs were reviewed for evidence of loosening, subsidence, fracture, and osseointegration. Six patients, representing 16 joints, answered a questionnaire regarding pain relief, appearance, and overall satisfaction with the arthroplasty. Complications also were recorded. RESULTS: The average preoperative ROM was 10 degrees to 63 degrees, and the average postoperative ROM was 18 degrees to 71 degrees. Although the average arc of motion was unchanged, 9 joints had an increase in ROM and 9 joints had a decrease in ROM. All joints were stable laterally. Radiographic review indicated 2 joints with loosening at 4 months after surgery. Complications included 8 squeaky joints, 5 joint contractures, and 2 dislocations. Pain was relieved completely in 8 joints, and the pain rating on a visual analog scale was 3.6 out of 10 for the 8 patients who had residual pain. Patients were satisfied completely with the results of 9 joints. Although there was residual deformity in 4 joints, patients believed that 15 of 16 joints had improved in appearance. Five of 6 patients responded that they would have the surgery again. There have been no secondary procedures performed by us. CONCLUSIONS: The insertion of pyrolytic carbon implants for PIPJ arthroplasty is a technically demanding procedure, but it has the potential to achieve pain relief, stability, satisfactory ROM, and correction of the deformity; however, the results in this review were unpredictable and may not be superior to those achieved with other methods of arthroplasty. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Intraoperative Fracture of a Pyrocarbon PIP Total Joint—A Case Report

Pain or dysfunction of the finger joints due to arthritis or traumatic injuries that fail medical management may necessitate arthroplasty or joint replacement. The goals of the finger joint implant arthroplasty are to relieve pain, to correct deformity, and to improve the function and appearance of the hand. Several prosthetic implants have been used for the replacement of the proximal interphalangeal (PIP) joint. Pyrocarbon materials, a form of pyrolytic carbon, a ceramic-like material, have proven to be strong, durable, resistant to wear and nonreactive in the body. The Ascension PIP pyrocarbon total joint is a bicondylar, anatomically shaped, articulating implant that allows joint flexion–extension, while providing some restriction of adduction–abduction motion. A review of the literature of pyrocarbon PIP prosthesis reveals little clinical data. The case of a 33-year-old man with posttraumatic arthritis proximal interphalangeal joint right long finger is reported. The case was treated surgically using the Ascension PIP total joint. During the insertion of the implant, the proximal component fractured at the sub-articular collar. The component was removed, and a new implant was inserted without complication. Critical evaluation revealed that there was an inadequate resection of the volar lip resulting in a stress riser on the implant during impaction. Careful attention to this technical point will hopefully minimize the occurrence of this complication as the availability and use of these implants increases.     

Long-term results of cemented Steffee arthroplasty of the thumb metacarpophalangeal joint

A retrospective evaluation of the Steffee metacarpophalangeal (MCP) thumb joint prostheses was performed to determine the long-term outcome and survivorship of the prosthesis. Fifty-four primary thumb arthroplasties (49 patients) were performed for pain, weakness, or instability involving the thumb MCP joint secondary to arthritis. Underlying etiology included rheumatoid (49 thumbs), psoriatic (1 thumb), scleroderma (2 thumbs), and degenerative (2 thumbs) arthritis. Thirty-one thumbs had concomitant interphalangeal joint instability and underwent interphalangeal joint fusions. At an average follow-up period of 57 months, the average motion of the MCP joint was 21 degrees (range, 0 degrees to 40 degrees ), with a significant improvement in position and stability. Thumb axis length was maintained or increased in 98%. Although there was not a consistent long-term improvement in grip or pinch strength, 87% of the patients reported subjective improvement in strength and function as a result of surgery. Pain was relieved in all thumbs with preoperative pain. Complications included a periprosthetic fracture, 2 late infections, and 1 gross loosening of the implant. The survivorship of the implant was 93% survivorship at 5 years and 89% survivorship at 10 years, with only 4 failures in 54 thumbs. The Steffee thumb MCP arthroplasty resulted in excellent long-term survivorship, patient satisfaction, and functional outcome.     

Silicone rubber implant arthroplasty of the metacarpophalangeal joint in rheumatoid arthritis: a follow-up study of 32 patients

A retrospective analysis of silicone rubber implant arthroplasty of the metacarpophalangeal joint in 32 patients with rheumatoid arthritis is reported. One hundred seven implants were followed in 37 hands for an average of 44 1/2 (12 to 120) months. Active motion of the metacarpophalangeal joint averaged 34 degrees, with a mean extension deficit of 7 degrees and a mean flexion 41 degrees. Ulnar deviation recurred to more than 10 degrees in 33 of 107 fingers (31%). Fracture of the spacer was confirmed in four joints (4%). One fracture of the proximal phalanx and one of the metacarpal head had occurred. Bone resorption around the stem or a hinge and migration of the implant were found in 26 (24%) fingers. Patient satisfaction was high; 27 patients experienced significant pain relief, the functioning of 31 hands (84%) was improved, and 28 patients (32 hands) thought that the cosmetic appearance of the hand was improved.     

Flexible implant arthroplasty of the radiocarpal joint. Surgical technique and long-term study

The wrist joint is frequently impaired in rheumatoid, post-traumatic, and degenerative arthritis. Stable radiocarpal motion, even limited, can improve functional hand adaptations, especially if the proximal or distal joints are disabled. A flexible silicone intramedullary stemmed hinged implant was developed in 1967 to be used as an adjunct to resection arthroplasty of the radiocarpal joint while at the same time maintaining the radiocarpal relation and allowing wrist motion in all planes. The surgical technique includes proper contracture release, bone preparation, extensor tendon repair and balancing, and dorsal and palmar capsuloligamentous repair to allow only 60 degrees of total passive flexion/extension and 10 degrees radial/ulnar deviation. This procedure can be combined with ulnar head capping. Metal bone liners (grommets) may be used to protect the radiocarpal implant from sharp bone edges. From January 1970 to April 1983, 181 wrist implant procedures had been performed in 139 patients, most of whom had rheumatoid arthritis. Stable, pain-free functional motion was obtained in the majority of cases. Roentgenograms showed the implants to be well tolerated by bone. Complications were infrequent. Because this procedure does not require cementing or significant bone resection, revision or arthrodesis procedures are facilitated.     

A preliminary report: cementless trapeziometacarpal arthroplasty

A cementless ball and socket trapeziometacarpal arthroplasty was used for the treatment of Eaton and Littler stage II and III trapeziometacarpal osteoarthritis. Forty-two joints were placed in 36 patients between 1986 and 1992. Five joints in 4 patients required revision. Thirty-four joints in 30 patients were evaluated with a mean follow-up period of 47 months (range, 15-86 months). Of the 33 monitored patients (39 joints), 79% reported good to excellent pain relief and excellent functional improvement and 12% reported poor to fair pain relief and functional improvement. Five joints required revision surgery and constituted 13% of the original arthroplasties. Thirty-three functional tests were graded before and after surgery and improvement was noted in all categories. Dramatic improvement was noted in the typical complaints for trapeziometacarpal joint disease, which are encountered in the activities of daily living. Radiolucent lines were present in 13 of 25 implants (52%), which were radiographically monitored. Radiographic loosening was present in 32%; 12 were around the trapezial component and 1 was around the metacarpal component. Radiographic loosening did not correlate with less satisfactory clinical results. Cementless trapeziometacarpal arthroplasty provides an operative alternative to arthrodesis in properly selected patients with trapeziometacarpal joint osteoarthritis. This joint is not intended to replace excisional or ligament reconstruction tendon interposition arthroplasty in lower demand patients or in those with pantrapezial arthritis. It also is not recommended in patients with rheumatoid arthritis or poor bone stock. It offers the advantages of maintaining excellent motion and stability. The cementless arthroplasty failures can be effectively salvaged by converting them to ligament reconstruction tendon interposition arthroplasty.     

Ligament reconstruction and tendon interposition for advanced posttraumatic arthritis of the proximal interphalangeal joint: 3 case reports

Although prosthetic replacement of the proximal interphalangeal (PIP) joint can restore function, it is associated with high rates of complications and is considered unsuitable for active young patients. Resection arthroplasty of the PIP joint offers an alternative, but it requires adequate soft tissue integrity and cannot correct lateral instability. The authors present an alternative resection arthroplasty technique for the PIP joint, which includes collateral ligament reconstruction and tendon interposition using a free tendon graft. This procedure can be performed in advanced posttraumatic arthritis of the PIP joint and provides acceptable motion and adequate lateral stability.     

The dorsal approach to silicone implant arthroplasty of the proximal interphalangeal joint

Silicone implant arthroplasty (SIA) has been an effective alternative in the treatment of arthritic conditions of the proximal interphalangeal (PIP) joints since its introduction into surgical practice in the early 1960s. Patients with post-traumatic, degenerative, and rheumatoid arthritis all may be candidates for PIP joint SIA. The indications for SIA of the PIP joint include pain, limited joint mobility, and angular deformity of the joint with underlying articular destruction. Contraindications include ankylosis of the joint due to bony or soft-tissue restrictions, infection, inadequate soft-tissue support for coverage, absence of flexor and/or extensor tendon function, and considerable periarticular bone loss in the proximal and middle phalanges. Proximal interphalangeal joint SIA can be accomplished by dorsal, volar, or midaxial approaches. The dorsal approach has the advantages of relative technical ease, excellent visibility of the articular surfaces for preparation of the implant canals, access to the extensor mechanism for correction of central slip abnormalities, and preservation of the collateral ligaments. The surgical technique is outlined and includes handling of the extensor mechanism and central slip attachment, mobilization of the collateral ligaments, joint surface resection, preparation of the bony canals, implant sizing, implant insertion, and repair of the soft tissues. Pearls and pitfalls of the technique are outlined. Early postoperative mobilization with hand therapy is essential but must include protection of the repaired extensor apparatus. Complications include bony changes, implant failure, recurrent angular deviation or swan-neck deformity, particulate synovitis, and rarely, infection. Complications related to implant failure are most often managed with implant replacement or arthrodesis; those related to poor mobility, angular deformity and tendon imbalance, pain, or infection are managed by arthrodesis. Although SIA of the PIP joint has a relatively high degree of success when measured both subjectively and objectively, careful patient selection is important for achieving desirable results.     

Replacement of proximal interphalangeal joints with new ceramic arthroplasty: a prospective series of 20 proximal interphalangeal joint replacements.

A prospective consecutive series of 20 proximal interphalangeal (PIP) joints replaced with a new ceramic unconstrained prosthesis (MOJE) included 13 patients with osteoarthrosis, five with rheumatoid arthritis, and one each with post-traumatic infection and traumatic arthrosis. All patients were assessed preoperatively and postoperatively at one year by an independent physiotherapist and an occupational therapist who evaluated grip strength, range of motion, activities of daily living (ADL) and occupational scores (COPM Canadian Occupational Performance Measure). The mean range of motion of the PIP joint improved from 43 degrees to 60 degrees (p=0.001), and the mean grip strength from 169-199 N (p=0.002). The patients' self-perception of occupational performance, assessed by the COPM, improved significantly from 3.6-6.6 (p<0.001) for satisfaction, and 3.8-6.3 (p<0.001) for performance. The MOJE PIP joint replacement provides significant pain relief, improved strength and range of motion, and short-term satisfaction. Further long-term studies are therefore advocated.     

Autogenous bone grafting for severe angular deformity in total knee arthroplasty

Fourteen patients with severe angular knee deformities (range, 30 degrees varus to 35 degrees valgus) had total knee arthroplasty using autogenous bone graft to the tibia. Twelve knees had osteoarthritis, one rheumatoid arthritis, and one gouty arthritis. The preoperative knee motion averaged -5 degrees of extension to 80 degrees of flexion and the average motion arc was 70 degrees. All tibial defects were greater than 25% of the tibial component support surface and more than 10 mm deep. Twelve knees were reconstructed with Insall-Burstein posterior stabilized total condylar knee implants and two knees, with severe preoperative ligamentous instability, with the constrained Total Condylar III implant. Postoperative rehabilitation was routine, and weight bearing was begun, on average, on the third postoperative day. The follow-up period averaged 4.1 years (range, 2-7.3 years). Radiographic analysis revealed no change in knee or component alignment compared with immediate postoperative position. All grafts consolidated without evidence of collapse, resorption, or prosthetic subsidence. All patients had good or excellent clinical results (Hospital for Special Surgery Knee Rating Scale). The average postoperative arc of motion was 90 degrees. There were no infections and no need for implant removal. The technique developed by the senior author (T.P.S.) utilizes bone resected from the distal femur during knee arthroplasty. An oblique planar cancellous surface is created on the recipient side, and coaptation of cancellous distal femoral graft surface to this recipient bed is ensured by vitallium screw fixation. The proximal tibia is reconstituted by the graft, and subchondral femoral bone after shaping of the graft forms the tibial periphery.