What's new in hand surgery

Surface Replacement Proximal Interphalangeal Joint Arthroplasty: A Case Series

Background: In 2012, our unit published our experience with a pyrocarbon proximal interphalangeal joint (PIPJ) implant. Due to high subsidence rates, a decision was made to change to a cemented surface replacement proximal interphalangeal joint (SR-PIPJ) implant. The purpose of this study was to assess whether the change to a cemented implant would improve the subsidence rates. Methods: Retrospective review of all patients who had a cemented SR-PIPJ arthroplasty performed from 2011 to 2013 with at least 12 months follow-up. Results: A total of 43 joints were included with an average follow-up of 26.5 months. There was a significant (P = .02) improvement in arc of motion with an average satisfaction score of 3.3 (satisfied patient). Subsidence was noted in 26% of joints with a significant difference in range of motion (P = .003) and patient satisfaction (P = .001) between the group with and without subsidence. Conclusions: The change to a cemented implant resulted in satisfied patients with an improvement in range of motion. The rate of subsidence improved but remains unacceptably high.

Treatment of complex soft-tissue defects at the metacarpophalangeal joint of the thumb using the bilobed second dorsal metacarpal artery-based island flap

BACKGROUND

The purpose of this study is to report on reconstruction of complex soft-tissue defects around the metacarpophalangeal joint of the thumb using a bilobed second dorsal metacarpal artery-based island flap taken from the dorsum of the proximal phalanges of the index and long fingers.

METHODS

From March of 2007 to October of 2009, the bilobed second dorsal metacarpal artery-based island flap was transferred in 13 patients. There were two defects on the metacarpophalangeal joint of the thumb. The mean size of the dorsal defects was 2.4 × 3.2 cm; the mean size of the volar defects was 2.6 × 4.0 cm. The mean size of the flaps taken from the index and long fingers was 2.6 × 3.4 cm and 2.8 × 3.2 cm, respectively. The mean pedicle length was 4.9 cm.

RESULTS

All flaps survived completely. At a mean follow-up of 14 months, the mean active motion arc of the thumb metacarpophalangeal joints was 42 degrees. The motion of the donor fingers was similar to that on the opposite side. The mean values of static two-point discrimination of the donor sites of the index and long fingers were 6 and 7 mm, respectively.

CONCLUSION

Transferring the bilobed second dorsal metacarpal artery-based island flap is a useful and reliable technique for reconstructing complex defects around the metacarpophalangeal joint of the thumb.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic IV.

Pyrolytic carbon resurfacing arthroplasty for osteoarthritis of the proximal interphalangeal joint of the finger

BACKGROUND

Pyrolytic carbon resurfacing arthroplasty of the proximal interphalangeal joint has been reported to provide favorable results. The purpose of this study was to evaluate the effectiveness of pyrolytic carbon joint replacement at an average follow-up of fifty-five months.

METHODS

A retrospective review of thirty-one arthroplasties of the proximal interphalangeal joint performed by a single surgeon in seventeen patients with interphalangeal joint osteoarthritis was conducted. Assessment included range of motion, patient satisfaction, and pain scores. Radiographs were evaluated for alignment, implant subsidence, and implant failure. The Michigan Hand Outcomes Questionnaire was administered at the time of the final follow-up.

RESULTS

The average follow-up period was fifty-five months (minimum, two years). No patient was lost to follow-up. The arc of motion of the interphalangeal joint decreased from 57° preoperatively to 31° (p < 0.05) at the time of the final follow-up. The average score for pain was 3 of 10 on a visual analog scale. Satisfaction averaged 3.4 points on a 5-point Likert scale, and twelve of seventeen patients stated that they would repeat the surgery. Data from the Michigan Hand Outcomes Questionnaire were compared for the involved and noninvolved hands of the fifteen patients who received implants unilaterally. Significant deficits were observed in the total outcome score, activities of daily living, function, and satisfaction for the operatively treated hand. Pain was also greater in the operatively treated hand. Complications included implant fracture (one joint), dislocation (five joints), squeaking (eleven), loosening (fifteen), and interphalangeal joint contracture (twenty). Six joints required a reoperation (an arthrodesis in four joints, a silicone arthroplasty in one, and excision of exostosis in one). Implant migration was severe for seven proximal phalanx implants and three distal phalanx implants, and one implant breached the phalangeal cortex.

CONCLUSIONS

Interphalangeal joint motion decreased significantly at the final follow-up evaluation, following short-term gains in the initial postoperative period. Complications were numerous, and implant loosening with migration was a major problem. Arthroplasty of the proximal interphalangeal joint with a pyrolytic carbon implant has a high complication rate, poor outcomes, and variable patient satisfaction. On the basis of these findings, we no longer use this implant in our practice.

Use of a bilobed second dorsal metacarpal artery-based island flap for thumb replantation

PURPOSE

An extensive traumatic defect at the level of the proximal phalanx of the thumb presents difficulty in replantation. We report bilobed second dorsal metacarpal artery-based island flap harvested from both the index and middle fingers for reconstruction of the defect and preservation of the normal thumb length.

METHODS

From March 2004 to October 2008, 15 patients (11 men and 4 women; mean age, 35 y; range, 18 to 55 y) with completely or incompletely amputated thumbs associated with extensive defects in the proximal phalanx had replantation and reconstruction. In all cases, a bilobed second dorsal metacarpal artery-based island flap was used due to the large size of the defect. After flap transfer, anastomoses between the veins of the distal part of the thumb and the flap were performed. At the final follow-up, we assessed the mean active range of motion of the metacarpophalangeal and interphalangeal joints of the thumb and the span of the first web in the thumbs that survived. Active motion of the donor fingers was also assessed.

RESULTS

In this series, 13 thumbs survived and 2 failed. All flaps survived completely. At the mean follow-up of 27 months (range, 24 to 29 mo), the mean active motion arcs of metacarpophalangeal and interphalangeal joints were 32° (range, 15° to 45°) and 31° (range, 0° to 47°), respectively. Full active range of motion was observed in all patients in both the metacarpophalangeal and the proximal interphalangeal joints of the donor index and middle fingers.

CONCLUSIONS

Bilobed second dorsal metacarpal artery-based island flap transfer is a useful and reliable technique for thumb replantation when there is an extensive defect in the proximal phalanx and when a single-digit dorsal metacarpal artery island flap is too small.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.