CONCLUSIONES O CONSIDERACIONES FINALES

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1. Longitudinal, slightly curved incision made over proximal interphalangeal joint

2. Central tendon incised, preserving insertion of middle phalanx, and each half retracted palmarly. Collateral ligament insertions on proximal phalanx preserved, if possible.

3. Head of proximal phalanx resected using air drill with side-cutting burr or saw

4. Proximal phalanx reamed with blunt-tip burr to avoid perforating cortex. Base of middle phalanx resected.

6. Largest implant that can be well seated inserted first into proximal and then into middle phalanx

8. Halves of central tendon drawn together and sutured through drill hole in base of middle phalanx 7. With joint extended, bone ends should

not impinge on implant midsection.

Collateral ligaments reattached, if possible.

5. Middle phalanx reamed. Sutures passed for reattachment of collateral ligaments and central slip.

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the flexor aspect of the proximal interphalangeal joint, preserving the underlying vessels and nerves. If the articular surfaces are inadequate, however, fusion of the proximal interphalangeal joint is preferred. Implant arthroplasty is rarely indicated.

Treatment of arthritic deformities of this joint includes realignment of the longitudinal arch of the digit. The joint can be treated by arthrodesis, resurfac-ing arthroplasty, or resection implant arthroplasty.

Resurfacing of the proximal interphalangeal joint is indicated for painful, degenerative, or posttraumatic deformities with destruction. When subluxation of the joint that cannot be corrected with soft tissue recon-struction alone or significant bone loss exists, implant resection arthroplasty is indicated. For deformities of the proximal interphalangeal joints of both the index and long fingers with osteoarthritis or early rheumatoid arthritis in a young person who performs heavy labor, the proximal interphalangeal joint of the index finger is fused in 20 to 40 degrees of flexion, and resurfacing or resection implant arthroplasty is performed for the proximal interphalangeal joint of the middle finger.

The more stable index finger can be used in pinch, and the more flexible long finger can be used in grasp.

Flexion of the proximal interphalangeal joints in the ring and little fingers is very important for grasping small objects, and function should be restored if possible.

Good results require adequate release of joint con-tractures. The collateral ligaments are left intact when-ever possible and if released they should be released on both sides to prevent pivoting instability on the intact side. Rebalancing and postoperative capsuloligamentous healing will stabilize the joint when the postoperative protocol below is utilized. If the joint is severely con-tracted, more bone is removed, or if too great and the joint cannot reduced, an implant resection arthroplasty

is used, allowing for even more bone resection. If the contracture persists, the palmar plate and collateral liga-ments may be incised proximally or distally, as needed.

The collateral ligaments are not required to be repaired.

Resurfacing arthroplasty may be placed either press-fit because they have a bone ingrowth surface or cemented if a tight fit cannot be achieved. Importantly, the central

tendon is advanced slightly distal on the middle phalanx, which ensures full extension postoperatively. A coexist-ing mallet deformity of the distal interproximal joint must be corrected at the time of surgery to prevent a swan-neck deformity.

The hand is dressed as in metacarpophalangeal joint surgery, and 2 or 3 days after surgery, hand-based

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This type of modular PIP joint arthroplasty has a metal proximal stem/articular surface and a polyethylene surface on a metal distal articular stem design that mimics the natural joint surface. Stable aligned joints are required for a modular implant.

Modular PIP joint arthroplasties resect minimal bone.

Radiograph demonstrating index finger PIP joint arthritis and long finger PIP joint Silastic arthroplasty.

Radiograph of failed ring finger proximal interphalangeal (PIP) joint Silastic arthroplasty that has fractured, resulting in joint subluxation

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Worn and fractured Silastic implant retrieved from patient in radiograph at left

Radiographs of modular PIP joint arthroplasty

Secure repair of the extensor mechanism by passage of suture through bone is critical to regaining normal finger extension.

Early 6-week postoperative result of patient demonstrating near full range of motion restored. A ring splint is worn to prevent hyperextension during the first 3 months.

thermoplastic splints are applied with the finger in 0 degrees of flexion for 3 to 4 weeks. Motion is initiated under supervision, and flexion is gradually increased after 3 weeks as long as full extension can be obtained.

The resting splint can be applied slightly to the radial or ulnar side of the digit to correct any residual ten-dency to deviate; it is worn at night and between exer-cise periods until adequate healing occurs.

In an alternative approach, the central tendon is pre-served and the exposure is volar, releasing the cruciate pulley, displacing the flexor tendons, releasing the volar plate, and preserving the extensor tendon insertion.

Postoperative motion is immediate and preferred for resection implant arthroplasty. However, visualization and correction of soft tissue and bony deformity for resurfacing arthroplasty is more difficult to achieve and may be incomplete.

Implant resection arthroplasty for proximal interpha-langeal joints with collapse deformity requires adjust-ment of the tension of the central tendon and lateral bands as mentioned earlier. Compared with the lateral bands, the central tendon is relatively tight in the swan-neck deformity and must be released, while in the boutonnière deformity, the central tendon is relatively loose and must be tightened.

Implant resection arthroplasty for boutonnière deformity is accompanied by reconstruction of the extensor tendon mechanism. The collateral ligaments are reefed or reattached to bone as needed. After surgery, extension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint must be maintained. The proximal interphalangeal joint is immobilized in extension with a padded aluminum splint for 3 to 6 weeks; the distal joint is allowed to flex freely. Active flexion and extension exercises are started 3 to 4 weeks after surgery, and a splint should be worn at night for about 10 weeks.

SURGERY FOR DISTAL INTERPHALANGEAL JOINT

If the distal interphalangeal joint is unstable, sublux-ated, or deviated or if there is articular damage, arthrod-esis is the treatment of choice. Contractures of the joint may be treated with soft tissue release and temporary

fixation with a Kirschner wire to allow some useful residual movement. Slight flexion movement of the distal interphalangeal joint is very important in finely coordinated activities, but if movement at the proximal interphalangeal joint is good, fixation in a functional position is acceptable.

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