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INSTRUCTIONAL COURSE LECTURE Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint

Peter M. Murray, MD

From the Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL.

The first proximal interphalangeal joint (PIPJ) replacements were hinged devices with singleaxis motion. Newer implant arthroplasties of the PIPJ have anatomically designed proximal phalangeal and middle phalangeal components. A need to create balanced forces across the joint was the rationale for the semiconstrained PIPJ prosthesis, which uses an anatomic design. These low-profile implants limit bone excision while preserving the integrity of the collateral ligaments. Paramount in the success of this implant is maintaining the integrity of the insertion of the central slip as it inserts on the base of the middle phalanx. The proximal and middle phalanx should be broached such that the largest implant can be press-fit in place. Greater stability is gained with a collateral ligament-preserving implant. Patient selection should include those patients with sufficient soft-tissue integrity. In general, patients with inflammatory disorders, collateral ligament insufficiency, and acute or chronic PIPJ septic arthritis are poor candidates for PIPJ surface replacement arthroplasty. (J Hand Surg 2007;32A:899 ­904. Copyright © 2007 by the American Society for Surgery of the Hand.) Key words: Proximal interphalangeal joint, arthroplasty, surface replacement, osteoarthritis, metal on plastic.

he early proximal interphalangeal joint (PIPJ) replacements were hinged devices that allowed only single-axis freedom of motion.1­5 Newer implant arthroplasties of the PIPJ have anatomically designed proximal phalangeal and middle phalangeal surface replacement components that balance flexor and extensor tendon forces and preserve the collateral ligaments.6 ­10 Recent versions of the constrained variety of PIPJ prostheses have focused on noncemented, press-fit, intermedullary stems.5,11 A need to create balanced flexor and extensor tendon forces across the joint was the rationale for the development of the semiconstrained surface replacement PIPJ prosthesis12 (Fig. 1). These low-profile, more anatomically designed implants limit bone excision while preserving the integrity of the collateral ligaments. Greater stability is gained with a collateral ligamentpreserving implant. The silicone proximal interphalangeal spacer has been used successfully for many years and studied extensively. Limitations of the silicone PIPJ implant include its lack of resistance to valgus loading at the index and middle fingers during the pinch maneuver.13­15 It is generally believed that a PIPJ surface replacement arthroplasty (SRA) that

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preserves the collateral ligaments will achieve greater PIPJ stability.5,9,16 Burman reported the use of a Vitallium cap for PIPJ arthroplasty in 19402; this represents the first attempt at prosthetic replacement of the PIPJ of the hand. Other early digital implants used concepts similar to those already adopted in implant arthroplasty of the lower extremity. In 1959, Brannon and Klein2 published the first series of a total joint replacement for the digits. They reported encouraging results with a hinged prosthesis, which they initially used in PIPJ fractures and fracture-dislocations. Two years later, Flatt3 reported on a more rotationally stable device with 2 intermedullary prongs as opposed to the single-pronged Brannon prosthesis. Flatt indicated the use of this prosthesis in PIPJ arthritis.1,3,4 In 1979, Linscheid and Dobyns17 developed a prosthesis that they described as a "surface replacement arthroplasty" for the PIPJ. This prosthesis was designed to preserve the PIPJ collateral ligaments and unload the component stems.5 Various modifications of this prosthesis have occurred, with the most recent modification referred to as the PIP-SRA (SBI, New York, NY). Initial results with the surface

The Journal of Hand Surgery 899

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The Journal of Hand Surgery / Vol. 32A No. 6 July­August 2007

in elderly, less-active patients who desire to maintain PIPJ motion and avoid PIPJ arthrodesis. Relative indications include use in severe fractures or fracture-dislocations of the PIPJ in older, less-active patients. Generally, use of the PIP-SRA is not indicated in patients with rheumatoid arthritis or other inflammatory arthritis because of the effect of these arthritides on soft-tissue integrity. Contraindications for use of the PIP-SRA include current or chronic infection, loss of extensor mechanism or flexor tendon function, poor soft-tissue envelope, absent collateral ligament function, and incompetence of the PIPJ volar plate. Relative contraindications include the presence of a static swan-neck or boutonnière deformity.

Surgical Techniques

Figure 1. A PIPJ surface replacement arthroplasty (Small Bone Innovations, New York, NY).

replacement PIPJ were published by Linscheid et al9 in 1997. In that study, 66 PIPJ SRAs were evaluated, with the majority of digits having osteoarthritis. At a mean follow-up time of 4.5 years, 32 joints had good results, 19 had fair results, and 25 had poor results. Better results were obtained from arthroplasties performed through a dorsal approach than those performed through a lateral or palmar approach. There were complications in 19 of the 66 PIPJ arthroplasties, including instability, ulnar deviation, swan-neck deformity, flexion contracture, tenodesis, and joint subluxation. Loosening was not observed. Arc of motion at follow-up evaluation averaged ­14° of extension and 61° of flexion. There was a 12° improvement in the flexion/extension arc compared with that observed in the preoperative examination. Subsequently, a variety of semiconstrained PIPJ replacement designs were developed (including the Keesler, the Hagert, the Sibly-Unsworth, and the Ascension [Ascension Orthopedics, Austin, TX]).5,10,18,19 Other recent PIPJ prosthetic designs have focused more on improved intermedullary fixation rather than anatomic configuration of the articular surfaces5,11 (including the Saffar [Dimso S.A., Mernande, France], the Digitos [Osteo A.G., Selzach, Switzerland], the DJOA3 [Landos, Chaumont, France], and the Wecko Fingergrundgelenk prosthesis [Implant Service, Hamburg, Germany]).5,7,10,11

Indications/Contraindications

Indications for use of the PIP-SRA include primary degenerative osteoarthritis or post-traumatic arthritis

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Standard posteroanterior, lateral, and oblique radiographs of the digit are obtained before surgery. Templates are used to estimate the size of PIP-SRA to be implanted. Different surgical approaches have been used for the various PIPJ prosthetic devices, including dorsal, lateral, and palmar approaches.9 With the dorsal approach, the central slip is vulnerable; with the lateral approach, the collateral ligaments are at risk. The volar plate and the flexor tendon sheath are at risk with the volar or anterior approach. Linscheid et al9 reported late swan-neck deformities in patients having PIPJ-SRA with the volar approach. However, Lin et al15 reported no swan-neck deformities or flexor tendon bowstring with the volar approach.15 Many prefer the modified dorsal approach described by Chamay.20 This approach offers extensile exposure of the PIPJ through a distally based triangular flap of the extensor mechanism (Fig. 2). Remnants of the dorsal PIPJ capsule are also identified and incised. The radial and ulnar collateral ligaments are protected using small Homan retractors, which also bring the articular surface of the middle phalanx into view. The proximal phalangeal head is prepared by a perpendicular osteotomy performed just proximal to the most proximal extent of the articular surface. This is done perpendicular to the long axis of the proximal phalanx and while protecting the proximal origin of the radial and ulnar collateral ligaments (Fig. 3). Protection of the collateral ligament insertions can be accomplished with either small retractors or by hyperflexion of the digit. Sometimes it may be necessary to release a small portion of the proximal phalangeal origin of the collateral ligaments to facilitate the proximal phalangeal osteotomy and subsequent prosthesis insertion. Although the goal of

Peter M. Murray / PIP-SRA Surgical Technique

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Figure 2. Dorsal Chamay approach for PIPJ surface replacement arthroplasty.

Figure 4. Oblique, back cut, chamfer osteotomy of the proximal phalanx.

the PIP-SRA is preservation of the collateral ligaments, a small portion of the insertion may be undermined16 with little biomechanic effect. Minamikawa et al16 showed in a cadaver model that the PIPJ remains stable after removal of 50% of the collateral ligament substance. While protecting the volar plate with a small retractor, a 2-mm burr is used to assist in making a back cut so the proximal phalanx can accept the proximal phalangeal component. This can also be performed with the oscillating saw (Fig. 4), but use of the saw may place the volar plate, flexor tendons, digital nerves, and digital arteries at risk. A perpendicular osteotomy of the base of the middle phalanx is made with an oscillating saw (Fig. 5). The collateral ligament insertions are protected with small retractors or by hyperflexion of the digit. This osteotomy is no more than 1 to 2 mm thick and under the circumstances of severe articular erosion or bone loss may be accomplished with a small rongeur (Fig. 6). The proximal and middle phalanges are next broached. Specific proximal phalanx broaches and

middle phalanx broaches are used (Figs. 7, 8). It is sometimes necessary to initially find the intermedullary canal of the proximal or middle phalanx with a 2-mm burr (Fig. 9). It is imperative to broach the proximal and middle phalanges to the largest size accepted by these bones. Failure to do so will result in the use of undersized components, a common technical error. Undersized components result in limited motion due to boney impedance to flexion. Once the bones are satisfactorily broached, the trial components are inserted, and sizing for best largest fit ensues. Proximal and middle phalanx specific impactors are available for trial component insertion (Figs. 10, 11). The importance of using the largest possible trial and subsequent implant cannot be overstated. Five different sizes are available for implantation, and the surgeon should have some idea before surgery which size will likely be implanted. The different component sizes are not modular and are generally not interchanged. In other words, matching-sized components should be used for the proximal phalanx and the middle phalanx when possible. Under certain circumstances, such as revision surgery, it is permissible to implant unmatched sizes

Figure 3. Osteotomy of the proximal phalanx articular surface, avoiding origins of the radial and ulnar collateral ligaments.

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Figure 5. Perpendicular osteotomy of the middle phalanx.

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The Journal of Hand Surgery / Vol. 32A No. 6 July­August 2007

Figure 8. Broaching of middle phalanx in preparation for trial component implantation. Figure 6. Small bone wafer resected after middle phalanx osteotomy.

but no more that 1 size up or 1 size down. For example, in lieu of cementation, a no. 4 proximal phalanx component could be matched with a no. 3 middle phalanx component in the instance of substantial medullary bone loss in the proximal phalanx. With the components in place, the digit is examined for range of motion and stability (Fig. 12). If boney impingement occurs between the posterior cortices of the proximal and middle phalanges, the trial components are removed and the phalangeal canals rebroached. Once permanent components are chosen, they are delivered to the back table and protected. The components are implanted by press-fit with clean gloves or by the no-touch technique. The permanent components are permanently seated with the proximal and middle phalanx component-specific impactors (Fig. 13). Alternatively, cement may be used but is generally discouraged. Cement may be necessary in patients with capacious canals or in patients with substantial bone loss or articular erosion. In these circumstances, I prefer to prepare one batch of cement and simply coat the prosthetic stems and flanges. Excessive cement packing into the medullary canals is neither wise nor necessary. Another

technique is to seat the prosthesis after packing the canal with morselized allograft bone. This is analogous to the Ling technique described for revision total hip arthroplasty.21 The extensor mechanism is then repaired with 3-0 non-absorbable suture. All aspects of the procedure are performed under an upper-arm tourniquet that is released before closure. The patient leaves the operating room with a sterile dressing, splinted in extension.

Pearls and Pitfalls

Patient selection should include those patients with sufficient soft-tissue integrity. In general, patients with inflammatory disorders or collateral ligament insufficiency are poor candidates for PIP-SRA. Care must be exercised to preserve the insertion of the central slip. The Chamay approach, which requires careful repair of the extensor mechanism, is preferred. Osteotomy of the proximal phalanx should preserve the integrity of the origin of the PIPJ collateral ligaments. The osteotomy of the middle phalanx articular surface requires removal of only a small amount of bone. In many instances this can be accomplished with a rongeur.

Figure 7. Broaching of proximal phalanx in preparation for trial implantation.

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Figure 9. Location of the proximal phalanx intermedullary canal with a 2-mm round burr.

Peter M. Murray / PIP-SRA Surgical Technique

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Figure 10. Insertion of a proximal phalanx trial component with an impactor.

Figure 12. Trial components in place. Range of motion and stability of the PIPJ are tested with the trial components in place.

The proximal phalanx should be broached to the largest size that can be accommodated. Failure to implant appropriately sized implants may result in subsidence of the implants and posterior cortical impingement of the phalanges. Water-tight closure of the extensor mechanism is necessary to prevent PIPJ flexion lag or contracture.

Excessive cement packing into the medullary canals is neither wise nor necessary.

Complications

Complications after PIP-SRA are in part related to the particular surgical approach chosen. With the dorsal approach, dysfunction or failure of the central slip can occur, resulting in extensor lag or, more

Postoperative Management

After surgery, a controlled rehabilitation protocol is needed to prevent central slip failure. Initiation of formal postoperative rehabilitation is encouraged by postoperative day 5. A dynamic extension splint permitting active flexion and dynamic extension is applied at this time. The patient is instructed to animate the dynamic extension splint periodically during the day until 6 weeks after surgery. The patient is placed into a static, forearm-based digital extension splint at bedtime. During the first 2 postoperative weeks, the patient is limited by a 30° flexion block followed by a 60° block beginning at 4 weeks. By 6 weeks, the extension outrigger splint is discontinued, and unrestricted flexion and extension are permitted. The static bedtime splint is used for an additional 6 weeks. Heavy lifting or gripping are not permitted.

Figure 11. Insertion of a middle phalanx trial component with an impactor.

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Figure 13. An 87-year-old man with advanced PIPJ osteoarthritis of the ring finger. After surgery and rehabilitation, the patient was able to return to playing golf. (A) Preoperative films. (B) Radiographs taken 3 months after PIP-SRA of the ring finger.

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The Journal of Hand Surgery / Vol. 32A No. 6 July­August 2007 8. Beevers DJ, Seedhom BB. Metacarpophalangeal joint prostheses: a review of past and current designs. Proc Inst Mech Eng [H] 1993;207:195­206. 9. Linscheid RL, Murray PM, Vidal MA, Beckenbaugh RD. Development of a surface replacement arthroplasty for proximal interphalangeal joints. J Hand Surg 1997;22A:286 ­298. 10. Murray PM. New-generation implant arthroplasties of the finger joints. J Am Acad Orthop Surg 2003;11:295­301. 11. Saffar P. La fixation prothetique: generalities table ronde sur les prosthesies interphalangiennes proximales. Congres de la Societe Francaise de Chirurgie de la Main. La Main 1997;107­109. 12. Ash HE, Unsworth A. Design of a surface replacement prosthesis for the proximal interphalangeal joint. Proc Inst Mech Eng [H] 2000;214:151­163. 13. Ashworth CR, Hansraj KK, Todd AO, Dukhram KM, Ebramzadeh E, Boucree JB, et al. Swanson proximal interphalangeal joint arthroplasty in patients with rheumatoid arthritis. Clin Orthop 1997;334:34 ­37. 14. Hansraj KK, Ashworth CR, Ebramzadeh E, Todd AO, Griffin MD, Ashley EM, et al. Swanson metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis. Clin Orthop 1997;334:11­15. 15. Lin HH, Wyrick JD, Stern PJ. Proximal interphalangeal joint silicone replacement arthroplasty: clinical results using an anterior approach. J Hand Surg 1995;20A:123­132. 16. Minamikawa Y, Horii E, Amadio PC, Cooney WP, Linscheid RL, An KN. Stability and constraint of the proximal interphalangeal joint. J Hand Surg 1993;18A:198 ­204. 17. Linscheid RL, Dobyns JH. Total joint arthroplasty. The hand. Mayo Clin Proc 1979;54:516 ­526. 18. Cook SD, Beckenbaugh RD, Redondo J, Popich LS, Klawitter JJ, Linscheid RL. Long-term follow-up of pyrolytic carbon metacarpophalangeal implants. J Bone Joint Surg 1999;81A:635­ 648. 19. Cook SD, Beckenbaugh RD, Weinstein A, Klawitter JJ. Pyrolite carbon implants in the metacarpophalangeal joint of baboons. Orthopedics 1983;6:952­961. 20. Chamay A. A distally based dorsal and triangular tendinous flap for direct access to the proximal interphalangeal joint. Ann Chir Main 1988;7:179 ­183. 21. Halliday BR, English HW, Timperley AJ, Gie GA, Ling RS. Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Joint Surg 2003;85B:809 ­ 817.

commonly, a flexion contracture or boutonnière deformity.9 With the volar approach, failure of the volar plate may occur, leading to swan-neck deformity.9 Tenodesis, joint instability, and joint subluxation have also been observed.9 At a mean follow-up time of 4.5 years, Linscheid et al9 reported a total of 19 complications among 66 PIP-SRAs. Not observed in this cohort were postoperative infections or prosthetic loosening.

Received for publication February 6, 2007; accepted in revised form April 23, 2007. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Peter M. Murray, MD, Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; e-mail: [email protected] Copyright © 2007 by the American Society for Surgery of the Hand 0363-5023/07/32A06-0022$32.00/0 doi:10.1016/j.jhsa.2007.04.012

References

1. Beevers DJ, Seedhom BB. Metacarpophalangeal joint prostheses. A review of the clinical results of past and current designs. J Hand Surg 1995;20B:125­136. 2. Burman MS. Vitallium cup arthroplasty of metacarpophalangeal and interphalangeal joints of fingers. Bull Hosp Joint Dis 1940;1:79 ­ 89. 3. Flatt A. Restoration of rheumatoid finger-joint function: interim report on trial of prosthetic replacement. J Bone Joint Surg 1961;43A:753­774. 4. Flatt AE, Ellison MR. Restoration of rheumatoid finger joint function. 3. A follow-up note after fourteen years of experience with a metallic-hinge prosthesis. J Bone Joint Surg 1972;54A:1317­1322. 5. Linscheid RL. Implant arthroplasty of the hand: retrospective and prospective considerations. J Hand Surg 2000;25A:796­816. 6. Adams BD, Blair WF, Shurr DG. Schultz metacarpophalangeal arthroplasty: a long-term follow-up study. J Hand Surg 1990;15A:641­ 645. 7. Amadio PC, Murray PM, Linscheid RL. PIP Arthroplasty. In: Morrey BF, ed. Joint replacement arthroplasty. 3rd ed. Churchill Livingstone, New York, 2003:163­174.

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