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Arthrodesis of the Proximal Interphalangeal Joint of the Finger—A Biomechanical Study of Primary Stability. J Pers Med 2023; 13:jpm13030465. [PMID: 36983647 PMCID: PMC10057979 DOI: 10.3390/jpm13030465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Background: Osteoarthritis of the proximal interphalangeal (PIP) joint of the finger often leads to global hand-function detriment. Different techniques for the arthrodesis of the proximal interphalangeal joint have been described that all lead to union in a reasonable percentage of patients and period of time. This biomechanical study aims to analyze and compare the primary stability of different techniques of arthrodesis to render postoperative immobilization unnecessary. Methods: Arthrodeses of 40° of composite cylinders were tested with different techniques in four-point bending for stability in extension as well as flexion. Results: In extension, the compression screw and the compression wires showed the highest stability—whereas in flexion, plate fusion was superior. Tension band, cerclage or compression screw fusion showed the best compromise in flexion/extension stability. Conclusions: Fusion techniques that apply compression to the fusion show superior stability. Cerclage, tension band and compression screws might be able to provide enough stability to withstand the forces exerted during unencumbered activities of daily living. Arthrodesis with plates should be limited to patients with special indications and require immobilization during consolidation.
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Bauknecht S, Mentzel M, Vergote D, Andreas M, Moeller RT. [Impact of a simulated DIPJ Arthrodesis on Movement and Force Patterns]. HANDCHIR MIKROCHIR P 2022; 54:418-426. [PMID: 36070777 DOI: 10.1055/a-1894-7002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Distal interphalangeal joint (DIPJ) arthrodesis is a well-proven therapy for osteoarthritis in the DIPJ. Since the upper limb is effectively a linked chain which is moved by interlinked, joint-overlapping muscle-tendon units, impacts on movement and force patterns are expected to occur in response to arthrodesis. In this context, a real-time quantitative analysis has not been performed to date. MATERIAL AND METHODS Finger motion and force development during grasping were dynamically measured and quantitatively analyzed in 19 healthy volunteers with a simulated DIPJ arthrodesis using a TUB (Technische Universität Berlin) sensor glove during fist closure and evaluating two types of force grips compared with the physiological grip. RESULTS Typical motion patterns were found. During physiological fist closure, the average flexion angle was 71.5° in the metacarpophalangeal joint (MPJ), 76.8° in the proximal interphalangeal joint (PIPJ) and 37.3° in the distal interphalangeal joint (DIPJ). With DIPJ arthrodesis, the flexion angle decreased to 49.6° in the PIPJ, whereas it increased slightly to 77.3° in the MPJ. During force grip I, the average physiological flexion angles were 18.3° in the MPJ, 39.6° in the PIPJ and 42.6° in the DIPJ. With simulated DIPJ arthrodesis, the flexion angle in the MPJ increased to 28.4°, whereas it decreased to 25.2° in the PIPJ. Force grip II yielded physiological flexion angles of 30.9° in the MPJ, 36.6° in the PIPJ and 29.0° in the DIPJ. In response to simulated DIPJ arthrodesis, the angle in the MPJ increased to 34.4° while it decreased to 23.3° in the PIPJ. The forces measured with force grips were almost equally distributed under physiological conditions. In response to simulated DIPJ arthrodesis, the average decrease in the measured force of a finger was no more than 1.4%. CONCLUSION This study was the first to introduce a quantitative analysis of grasping with simulated DIPJ arthrodesis. Based on this analysis, the study demonstrates the dynamic interaction of the finger joints as well as force patterns on the individual finger rays of the hand in real-time.
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Affiliation(s)
- Simon Bauknecht
- Unfall-, Hand-, Plastische u. Wiederherstellungschirurgie, Universitätsklinikum Ulm, Ulm, Germany
| | - Martin Mentzel
- Unfall-, Hand-, Plastische u. Wiederherstellungschirurgie, Universitätsklinikum Ulm, Ulm, Germany
| | - Daniel Vergote
- Unfall-, Hand-, Plastische u. Wiederherstellungschirurgie, Universitätsklinikum Ulm, Ulm, Germany
| | - Myriam Andreas
- Unfall-, Hand-, Plastische u. Wiederherstellungschirurgie, Universitätsklinikum Ulm, Ulm, Germany
| | - Richard-Tobias Moeller
- Unfall-, Hand-, Plastische u. Wiederherstellungschirurgie, Universitätsklinikum Ulm, Ulm, Germany
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Dimitrova P, Reger A, Prommersberger KJ, van Schoonhoven J, Mühldorfer-Fodor M. [Effect of a single proximal interphalangeal Joint Fusion of the Index, Middle or Ring Finger on the Grip and Finger Force and Load Distribution in the Hand]. HANDCHIR MIKROCHIR P 2022; 54:409-417. [PMID: 36037817 DOI: 10.1055/a-1750-9586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Due to the functional coupling of adjacent finger joints and the quadriga effect, arthrodesis of the proximal interphalangeal joint (PIPJ) can be assumed to lead to a different grip pattern resulting in altered force distribution of the hand. PATIENTS AND METHOD Ten patients with isolated arthrodesis of the PIPJ due to posttraumatic osteoarthritis (4×PIPJ II, 4×PIPJ III, 2×PIPJ IV) were assessed 59 (17-121) months postoperatively on average. The angle of arthrodesis was assessed by radiographs. Grip force and load distribution of both hands were measured by manugraphy using 3 differently sized cylinders. Grip force was separately assessed and compared for the whole hand as well as for each of the fingers and each phalanx. RESULTS Average total grip force of the affected hand compared to the uninjured opposite side was 74% (38-136%) for the small cylinder, 104% (68-180%) for the mid-sized cylinder and 110% (69%-240%) for the large cylinder. Arthrodesis of the PIPJ of the index finger led to a reduction of the grip force (91%) for the small cylinder, but increased grip force for the mid-sized (120%) and large cylinder (139%). Grip force was reduced for all cylinder sizes by arthrodesis of the PIPJ of the middle finger (56%, 88% and 91%). Arthrodesis of the PIPJ of the ring finger resulted in a grip force of 76%, 105% and 91%, respectively, for the different cylinder sizes.The finger force of the affected finger was reduced after arthrodesis of the PIPJ, with the exception of the index finger, which was stronger than the unaffected opposite finger when using the large cylinder. The force of the healthy fingers on the affected side was greater when compared with the same finger on the opposite side, which led to increased grip force for the mid-sized and the large cylinder of the affected hand. A reduction in load distribution was measured mostly for the middle phalanx but also for the distal phalanx of the operated-on finger. CONCLUSION Arthrodesis of the PIPJ almost always led to force reduction in the middle and distal phalanx of the affected finger. However, the total grip force of the hand was compensated by a higher force of the adjacent healthy fingers. In many cases, total grip force was even higher on the affected side. However, arthrodesis of the PIPJ resulted in a noticeable force reduction when smaller objects were gripped.
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Affiliation(s)
| | - Angela Reger
- Rhön-Klinikum Campus Bad Neustadt, Klinik für Handchirurgie
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Summer T, Erdmann J, Wüstner-Hofmann MC. [Indications and Techniques for Joint Fusion of osteoarthritic Finger Joints]. HANDCHIR MIKROCHIR P 2021; 53:454-461. [PMID: 34583406 DOI: 10.1055/a-1560-2780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The following article, by presenting patients' cases, provides an overview of arthrodesis indications and techniques of osteoarthritic finger joints.
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Klemm HT, Wittchen V, Willauschus W, Fuhrmann RA, Hohendorff B. [Joint arthrodesis in functionally favorable position : Considerations on measurement of disability in private accident insurance]. Unfallchirurg 2020; 123:988-998. [PMID: 33108480 DOI: 10.1007/s00113-020-00913-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
If an accident results in a functional disorder that persists and permanently restricts physical and/or mental capacity, this is referred to as a disability. In private accident insurance it is the task of the medical expert to assess this disability by examining the medical findings and produce an assessment taking account of the literature and comparing against generally acknowledged guidance values. The priority dismemberment disability rating schedule initially provides loss values. For the "next lowest" disability levels for arthrodesis of extremity joints, the assessment recommendations are based on a functionally favorable position although this functionally favorable position is not more precisely defined.In this article the authors have defined these functionally favorable positions based on the information available in the literature. In particular, the operatively favorable settings for arthrodesis of the affected joint that are stated in the literature on trauma and orthopedic surgery were consulted. Of course, the functional perspective has been especially emphasized.A difficulty in achieving this was that the literature on arthrodesis is now almost only of historical value due to modern endoprosthetics. The knowledge gained was checked against medical experience and is expounded here.
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Affiliation(s)
- H-T Klemm
- Freies Institut für medizinische Begutachtungen, Ludwigstraße 25, 95444, Bayreuth, Deutschland.
- Fachgesellschaft Interdisziplinäre Medizinische Begutachtung (FGIMB e. V.), Hamburg, Deutschland.
| | - V Wittchen
- Dr. Eick & Partner Rechtsanwälte Partnerschaft mbB, Hamm, Deutschland
| | - W Willauschus
- Fachgesellschaft Interdisziplinäre Medizinische Begutachtung (FGIMB e. V.), Hamburg, Deutschland
- alphaMED, Orthopädisch-unfallchirurgische Praxisklinik, Bamberg, Deutschland
| | - R A Fuhrmann
- Fachgesellschaft Interdisziplinäre Medizinische Begutachtung (FGIMB e. V.), Hamburg, Deutschland
- Klinik für Fuß- und Sprunggelenkchirurgie, Rhön-Klinikum Campus Bad Neustadt, Neustadt, Deutschland
| | - B Hohendorff
- Handchirurgie, Abteilung Hand‑, Ästhetische und Plastische Chirurgie, Elbe-Klinikum Stade, Stade, Deutschland
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Leclère FM, Haug L, Meier R, Surke C, Unglaub F, Vögelin E. Non-vascularized partial joint transfer for Finger Proximal Interphalangeal joint reconstruction: a series of 9 patients. Arch Orthop Trauma Surg 2020; 140:139-144. [PMID: 31691006 DOI: 10.1007/s00402-019-03301-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Finger proximal interphalangeal joint (PIP) reconstruction after the destruction of parts of the joint remains challenging. Surgical techniques include implant arthroplasty, arthrodesis, free vascularized joint transfer, and non-vascularized bone and joint transfer. This study analyzes our experience after non-vascularized transfer in terms of range of motion, postoperative rehabilitation, and patient satisfaction. MATERIALS AND METHODS Between 2009 and 2014, ten patients underwent non-vascularized partial joint transfer for PIP joint reconstruction. One of them was lost to follow-up. Included patients had osteochondral partial joint transplants of 25-50% of the toes (n = 4) and the hand (n = 5). Range of motion (ROM), grip-, and pinch-strength were measured at the last follow-up control and compared to the healthy side. Patients were asked to score the pain at rest/ on load on a visual scale (VAS: 0 = no pain; 10 = excruciating pain). Satisfaction self-assessment was evaluated by asking the patients to grade their postoperative result as excellent, very good, good or poor. RESULTS Mean follow-up period was 4.0 years (range 1.2-7.9 years). Mean PIP joint flexion was 93 ± 26° at the last follow-up control. Mean grip- and pinch-strength of the operated side at the last control were, respectively, 43 ± 18 kg and 8 ± 5 kg, close to the healthy side values (45 ± 15 kg and 9 ± 4 kg). Mean pain at rest/on load measured on a visual scale was, respectively, 0.3 ± 1 and 1.8 ± 2. Eight patients (89%) rated their operation as excellent, and one as poor. CONCLUSION In this study, non-vascularized partial joint transfer provides a mobile and stable PIP joint 4 years after reconstruction. The surgical technique presented herein is complex depending on additional injuries but results in great patient satisfaction.
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Affiliation(s)
- Franck M Leclère
- Department of Plastic und Hand Surgery, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Luzian Haug
- Department of Plastic und Hand Surgery, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Rahel Meier
- Department of Plastic und Hand Surgery, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Carsten Surke
- Department of Plastic und Hand Surgery, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Frank Unglaub
- Department of Hand Surgery, Vulpius Klinik GmbH, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland
| | - Esther Vögelin
- Department of Plastic und Hand Surgery, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
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Saul D, Roch J, Lehmann W, Dresing K. [Oberst's block anesthesia]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 32:18-22. [PMID: 31650198 DOI: 10.1007/s00064-019-00633-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/05/2019] [Accepted: 05/08/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Complete anesthesia of the phalanges of the fingers and toes. INDICATIONS All lesions distal to the metacarpophalangeal/metatarsophalangeal joint. CONTRAINDICATIONS Local infections at the injection site. Lesions proximal to the metacarpophalangeal/metatarsophalangeal joint. TECHNIQUE A subcutaneous deposit of a 0.5-2% local anesthetic is administered dorsoradially and dorsoulnarly at the base of the metacarpophalangeal/metatarsophalangeal joint. With the cannula advanced to palmar, an additional 0.5-1.5 ml is then administered to achieve complete anesthesia. POSTOPERATIVE MANAGEMENT The effect of the local anesthesia is self-limiting. RESULTS The Oberst block results in reliable anesthesia of the finger and toe. All surgical procedures distal to the metacarpophalangeal/metatarsophalangeal joint can be performed without pain.
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Affiliation(s)
- Dominik Saul
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Georg-August-Universität, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland.
| | - Jonathan Roch
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Georg-August-Universität, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Georg-August-Universität, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
| | - Klaus Dresing
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Georg-August-Universität, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
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Hohendorff B, Unglaub F, Spies CK, Wegmann K, Müller LP, Ries C. [Surgical approaches to the hand]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:372-383. [PMID: 31359070 DOI: 10.1007/s00064-019-0622-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/19/2018] [Accepted: 11/01/2018] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Accessibility of any anatomical structure of the hand via surgical approach. INDICATIONS Any surgical treatment of the hand. CONTRAINDICATIONS Any contraindication to surgical treatment of the hand. SURGICAL TECHNIQUE Skin incision at the hand with access to any anatomical structure. POSTOPERATIVE MANAGEMENT Postoperative treatment depends on the disease and hand surgery performed.
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Affiliation(s)
- B Hohendorff
- Abteilung für Hand‑, Ästhetische und Plastische Chirurgie, Elbe Klinikum Stade, Bremervörder Straße 111, 21682, Stade, Deutschland.
| | - F Unglaub
- Handchirurgie, Vulpius Klinik, Bad Rappenau, Deutschland
| | - C K Spies
- Handchirurgie, Vulpius Klinik, Bad Rappenau, Deutschland
| | - K Wegmann
- Unfall‑, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum zu Köln, Köln, Deutschland
| | - L P Müller
- Unfall‑, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum zu Köln, Köln, Deutschland
| | - C Ries
- Unfall‑, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum zu Köln, Köln, Deutschland
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[Open reduction and plate/screw osteosynthesis of proximal phalanx fractures]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:408-421. [PMID: 30980086 DOI: 10.1007/s00064-019-0598-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/17/2018] [Accepted: 03/23/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Anatomical open reduction and internal fixation using screw/plate osteosynthesis. INDICATIONS Extra-articular fractures with clinically evident malrotation of the finger, comminution fracture and/or loss of length, which cannot be treated non-operatively; fracture instability; intra-articular fracture with step off greater than 1 mm, which cannot be treated percutaneously but openly using plate/screw osteosythesis; failure of conservative treatment. CONTRAINDICATIONS General operative limitations. SURGICAL TECHNIQUE Dorsal, mediolateral, or palmar approach, temporary reduction using pincers or optional Kirschner wires; screw/plate osteosynthesis for internal fixation. POSTOPERATIVE MANAGEMENT Immediate mobilization facilitated by buddy loops for the first 4-6 weeks, prevention of edema using elastic dressing, physiotherapy. RESULTS Open reduction and internal fixation using screw/plate osteosynthesis provides good results in combination with immediate mobilization. Nevertheless, adhesion of tendons or capsule tissue with restriction of range of motion is observed.
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Biomechanical comparison of the proximal interphalangeal joint arthrodesis using a compression wire. Arch Orthop Trauma Surg 2019; 139:577-581. [PMID: 30684039 DOI: 10.1007/s00402-019-03119-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION/AIM Arthrodesis of the proximal interphalangeal joint of the finger is a common procedure for the treatment of osteoarthritis. The aim of this biomechanical study was to compare the primary stability of one, respectively, two compression wires to intraosseous wiring and tension band wiring for the arthrodesis. MATERIALS AND METHODS The stability of the arthrodesis was tested by applying flexion (n = 11) and extension (n = 10) force with 10° bending. Arthrodesis was achieved by one, respectively, two crossed compression wires and intraosseous wiring. In a control group (n = 11) tension band wiring was tested to 10° flexion and extension as well. RESULTS Mean values for flexion bending for intraosseous wiring were 10.94 N, for one compression wire 12.82 N, for tension band wiring 17.95 N, and for two crossed compression wires 20.42 N. Mean values for extension bending were 9.71 N for intraosseous wiring, 13.63 N for one compression wire, 21.43 N for tension band wiring and 22.56 N for two crossed compression wires. CONCLUSION The primary stability of the compression wires was statistically significant superior to intraosseous wiring. In comparison to tension band wiring which showed an intermediate stability. The application of a compression wire could be considered for further clinical testing in the arthrodesis of interphalangeal joints.
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Spies CK, Unglaub F. [Arthroplasty of the hand and wrist]. DER ORTHOPADE 2019; 48:367. [PMID: 30927026 DOI: 10.1007/s00132-019-03726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- C K Spies
- Vulpius Klinik GmbH, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland.
| | - F Unglaub
- Vulpius Klinik GmbH, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland.
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Hohendorff B, Franke J, Spies CK, Unglaub F, Müller LP, Ries C. [Operative treatment of Dupuytren's contracture : Arthrolysis of the proximal interphalangeal finger joint]. DER ORTHOPADE 2017; 46:328-335. [PMID: 28175957 DOI: 10.1007/s00132-017-3387-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the operative treatment of Dupuytren's disease, in certain cases proximal interphalangeal joint flexion contracture remains after fasciectomy due to shrinkage, shortening, and/or adhesion of the periarticular structures. OBJECTIVES How can a residual flexion contracture of the proximal interphalangeal joint after partial fasciectomy in Dupuytren's disease be treated surgically and what follow-up results can be expected? METHODS Description of anatomy, indication, surgical technique of arthrolysis of the proximal interphalangeal joint, postoperative treatment, and critical analysis of the results reported in the literature. RESULTS Arthrolysis of the proximal interphalangeal joint is performed in up to six consecutive steps. An improvement of only about 50% compared to preoperative flexion contracture can be expected. CONCLUSIONS Despite alleged unsatisfactory results arthrolysis of the proximal interphalangeal joint can be recommended in surgery of Dupuytren's disease. In certain cases, patient cooperation during lengthy postoperative treatment is necessary.
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Affiliation(s)
- B Hohendorff
- Abteilung für Hand-, Ästhetische und Plastische Chirurgie, Elbe Klinikum Stade, Bremervörder Straße 111, 21682, Stade, Deutschland.
| | - J Franke
- Klinik für Unfallchirurgie und Orthopädie, Elbe Klinikum Stade, Stade, Deutschland
| | - C K Spies
- Handchirurgie, Vulpius Klinik, Bad Rappenau, Deutschland
| | - F Unglaub
- Handchirurgie, Vulpius Klinik, Bad Rappenau, Deutschland
| | - L P Müller
- Unfall-, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum zu Köln, Köln, Deutschland
| | - C Ries
- Unfall-, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum zu Köln, Köln, Deutschland
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