Pyrocarbon Proximal Interphalangeal Joint Arthroplasty: Minimum Five-Year Follow-Up

Incidence and Presentation of Periprosthetic Joint Infection After Primary Metacarpophalangeal and Proximal Interphalangeal Arthroplasty

PURPOSE

Periprosthetic joint infection (PJI) is a devastating complication that has been extensively investigated in large joint arthroplasty. However, this has been inconsistently reported after metacarpophalangeal (MCP) and proximal interphalangeal (PIP) arthroplasty. The objective of the study was to report the presentation and treatment of patients with PJI after MCP or PIP joint arthroplasty.

METHODS

We performed a retrospective review of 1418 primary MCP or PIP arthroplasties in 642 patients with a minimum of 180 days of follow-up (mean 9.0 years) at a single institution from 1991 to 2020. We also analyzed the association of patient (body mass index, smoking, diabetes, and immunocompromised status) and surgical (digit, implant, operative time, and reoperation) factors with infection.

RESULTS

There were six joints, all in separate patients, that developed PJI (0.4%). The median time to PJI was 91.5 days. Of the six patients with PJI, five had no systemic symptoms and a normal leukocyte count. The most common cultured organism was Staphylococcus aureus. PJI was most commonly treated with hardware removal and antibiotics.

CONCLUSIONS

PJI is uncommon after MCP or PIP arthroplasties. It commonly presents without systemic symptoms or leukocyte count and is most frequently caused by Staphylococcus aureus. More studies are needed to identify the optimal diagnostic criteria, treatment, and preventive strategies of PJI of the MCP and PIP joints.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Outcomes of Small Joint Arthroplasty for the Rheumatoid Hand

The number of patients presenting to the hand surgeon with severe rheumatoid disease has decreased with the introduction of more effective medical management. However some rheumatoid patients will undergo disease progression despite this. MCPJ and PIPJ replacement can be effective surgical treatments in these patients but patient selection is crucial. Patients undergo surgery hoping to achieve improvements in pain, hand function and appearance. Multiple types of implant have been introduced over the years; however, silicone remains the most reliable option in terms of survivorship, complications and achieving the aims of rheumatoid patients.

Proximal interphalangeal joint arthroplasty: current trends and evidence-based practice

Arthroplasty of the proximal interphalangeal joint (PIPJ) has evolved since its inception over 60 years ago. This review examines the indications for surgery, highlights the differences in current arthroplasty designs, variances in surgical techniques, clinical controversies, current implant outcomes data and salvage options for the failed implant. Overall, PIPJ implant arthroplasty is a good and reliable option for symptomatic PIPJ degenerative, post-traumatic or inflammatory arthritis given the proper clinical setting. If current techniques for implantation and rehabilitation are followed, predictable pain relief and satisfactory function can be anticipated. The purpose of this review article is to examine the current evidence-based indications for PIPJ arthroplasty and examine the reported, implant-specific outcomes of this procedure. Various techniques and rehabilitation strategies will also be outlined.

Utilization of Interphalangeal Joint Arthroplasty and Arthrodesis in the United States From 2010 to 2019

Background

Interphalangeal joint (IPJ) arthrodesis and arthroplasty are mainstay treatments for IPJ arthritis with conflicting evidence about the most efficacious choice. Our study describes case volume and incidence over the last decade (2010-2019).

Methods

The IBM MarketScan database was queried using Current Procedural Terminology codes for IPJ arthrodesis and arthroplasty from January 2010 to December 2019. Volume and incidence were estimated annually and according to sex, age, and US geographical region for 2010 and 2019.

Results

Annual volume and incidence of IPJ arthrodesis increased slightly from 2010 to 2019, though with overlapping confidence intervals for incidence. Arthrodesis tended to be higher in women versus men, especially with increasing age. When considering age, the most substantial increase in rates over increasing age was moving from the 40s to 50s age brackets. Across US regions, arthrodesis was higher in the northeast and midwest in 2010, though other rates rose and regions were similar by 2019. For IPJ arthroplasty, there was a 25%-30% decrease in case volume and incidence over the decade. Incidence was generally higher among women, with a similar jump in incidence from 40s to 50s among women, whereas men showed a more gradual rate increase with age. Regionally, arthroplasty was highest in the northeast and midwest in 2010, though it was similar across regions in 2019.

Conclusions

Although IPJ arthrodesis levels have stayed relatively stable, IPJ arthroplasty showed a general decline over the decade. Incidence of both were higher among women, and despite initial regional differences, rates became more similar by 2019.

Significantly less wear of UHMWPE rubbing against pyrocarbon than against CoCr

The history of joint replacement can be framed as a battle to reduce wear. Pyrocarbon has been shown to be a low wear material, but can low wear against an ultra high molecular weight polyethylene (UHMWPE) counterface be achieved? To investigate this research question, a 50-station, clinically validated wear screening machine was used. Half the stations tested UHMWPE pins against pyrocarbon discs, and half the stations tested UHMWPE pins against cobalt chromium (CoCr) discs. The test rig ran at 1Hz, the nominal contact stress was 2.07 MPa, and testing ran to 5 million cycles. A biomimetic lubricant was used, it was replaced every 500,000 cycles. At the end of testing, the UHMWPE pins rubbing against pyrocarbon discs had a statistically significant reduced wear, compared with the UHMWPE pins rubbing against CoCr discs (p ≤ 0.01). Analysis of the discs at the end of testing showed greater adherence of phospholipids on the pyrocarbon discs than the CoCr discs. In turn, it was also seen that far less UHMWPE was attached to the pyrocarbon discs than to the CoCr discs. Based on this evidence, it is suggested that pyrocarbon surfaces are associated with reduced adhesive wear of UHMWPE compared with CoCr surfaces. In addition, at the end of testing, the CoCr discs were found to be significantly rougher than the pyrocarbon discs. Therefore, pyrocarbon maintained a smoother surface than CoCr, likely meaning that abrasive wear of UHMWPE was reduced compared with CoCr.

Surface wear of PyroCarbon implant in metacarpophalangeal joint arthroplasty without radiographic abnormality: A case report

CASE

A 54-year-old male with osteoarthritis of the right long finger metacarpophalangeal joint underwent PyroCarbon joint arthroplasty. Seven years later the patient presented for metacarpophalangeal joint swelling and pain. The workup was benign, without signs of implant complication or osseous abnormality. He underwent washout and two-stage revision, where gross implant wear and debris not demonstrated by radiograph were found. He then returned to the operating room for reimplantation of a PyroCarbon implant.

CONCLUSION

This case demonstrates a novel presentation of aseptic PyroCarbon implant failure in the hand without radiographic abnormality that can alter operative management by reducing operating room returns.

Free neurovascular toe-(joint)-transfers compared to alternative reconstructive procedures for amputation injuries of two and tripartite fingers with substance loss

BACKGROUND

Complex injuries of the hand frequently result in loss of essential functional features. Common reconstructive procedures for soft tissue defects of the thumb or phalanges are locoregional flaps like Moberg-, Foucher-, Cross-Finger- or Littler flaps. Microneurovascular toe (joint-) transfers complete the arsenal of operative reconstructive procedures and allow for most detailed reconstructions. Our experiences with free toe transplants are reported and diversely discussed regarding contending procedures.

METHODS

From 2010 until 2019 14 patients who received emergency or elective partial or complete toe transfers were compared with a control group (n = 12) treated with contending reconstructive procedures. Aim of the reconstructions was to cover the defect with well-vascularized, sensate tissue, while preserving length and range of motion in a reliable manner.

RESULTS

The Kapandji score showed a significant difference (p- value = 0.04) with a score of 9.8 in comparison to control group (Kapandji index = 8.0).

CONCLUSION

In our heterogenic patient collective free toe transplants have proven to achieve comparable functional results for reconstruction of two and tripartite phalanxes as opposed to common local reconstructive procedures.

Proximal Interphalangeal Joint Arthroplasty for Fracture

Proximal interphalangeal joint arthroplasties can be performed in the setting of acute comminuted fracture, chronic fracture presentations, and posttraumatic arthritis. These surgeries provide excellent pain relief and patient satisfaction but patients should be cautioned not to expect an improvement in motion postoperatively. Despite high rates of minor complications and radiographic loosening, these implants have good rates of long-term survival with most revisions occurring in the early postoperative period. They provide viable alternatives to arthrodesis, osteotomy and amputation in the appropriate patient.

Reported Outcomes and Outcome Measures in Proximal Interphalangeal Joint Arthroplasty: A Systematic Review

Purpose: There is a lack of scientific consensus on the best arthroplasty implant option for proximal interphalangeal joint (PIPJ) arthritis, due to diversity in outcome reporting and measurement methods. The development of a standardized core outcome set (COS) and standard outcome measures could mitigate this issue. This study catalogs the reported outcomes and outcome measures found in PIPJ arthroplasty studies, which can be used in the first step of developing a COS. Methods: A database search of MEDLINE, EMBASE, and Web of Science (January 1, 2010, to March 10, 2021) was performed to retrieve studies that reported outcomes of the 3 most common primary PIPJ arthroplasty implants: silicone, pyrocarbon, and metal-polyethylene. The primary objectives of this study include reported outcomes and outcome measures. Secondary objectives include clinimetric properties of outcome measures, study design, and implant types. Results: Fifty articles met inclusion criteria. Of the included studies, 41 (82%) were case series, 8 (16%) were cohort studies, and 1 (2%) was a randomized control trial. Thirty-three unique outcomes were identified. Fifteen (46%) outcomes were clinician-reported and 26 (79%) were patient-reported. Eighteen unique outcome measures were identified. Of the outcome measures, 15 (83%) were patient-reported, 1 (6%) was clinician-reported, and 2 (11%) were reported by both patients and clinicians. Conclusions: Substantial heterogeneity was found in reported outcomes and outcome measures across studies evaluating PIPJ arthroplasty, impeding knowledge translation. The development of a COS for PIPJ arthroplasty is necessary to help compare and pool data across studies, and advance scientific knowledge.

Managing Difficult Problems in Small Joint Arthroplasty: Challenges, Complications, and Revisions

Small joint arthroplasty of the hand has been an established means of joint preservation and pain relief for over a half a century. Despite this, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint arthroplasty has not achieved the long-term success seen with hip and knee arthroplasty. Problems following MCP, PIP, and carpometacarpal (CMC) joint arthroplasty can include intraoperative fracture, postoperative dislocation, recurrent pain, limitation of motion, and instability. The hand surgeon needs to be prepared for these problems and their management. This article addresses the management of the most common complications seen following MCP, PIP, and CMC arthroplasty.

Small Joint Arthroplasty of the Hand: An Update on Indications, Outcomes, and Complications

Small joint arthroplasty of the hand is a well-established surgery that can preserve motion and provide reliable pain relief, joint preservation, and improvement in hand function. Soft-tissue integrity is critical in patient and implant selection to avoid postoperative joint instability. Although instability is more common in nonconstrained implants such as pyrocarbon, silicone arthroplasty is associated with high rates of late implant fracture and failure with resultant recurrent deformity and instability. Additional complications such as stiffness, extension lag, and intraoperative fractures may be mitigated by alterations in surgical technique and postoperative rehabilitation protocols. Revision arthroplasty with soft-tissue stabilization procedures have reliable outcomes and can avoid conversion to arthrodesis. This article will review the surgical indications, outcomes of small joint arthroplasty in the hand, and common complications and their management.

Proximal interphalangeal joint prosthetic arthroplasty

Surgical treatment of the painful proximal interphalangeal (PIP) joint has evolved considerably over the past century. If arthrodesis has long been the gold standard and remains so for some, prosthesis would meet patient demand: mobility and indolence. Faced with a demanding patient, the surgeon must decide the indication, the type of prosthesis, the approach, the post-operative follow-up, etc. The history of the development of PIP prostheses demonstrates the complexity of the treatment of the destroyed PIP: appearance of prostheses, evolution and sometimes disappearance from the market for commercial reasons or related to complications. The main objective of this conference is to identify the main indications for prosthetic arthroplasties and to describe the various prostheses available on the market.

Proximal Row Carpectomy Modifications for Capitate Arthritis: A Systematic Review

Introduction  Proximal row carpectomy (PRC) is a motion-sparing procedure for radiocarpal arthritis with reliable results. Traditionally, proximal capitate arthritis is a contraindication to PRC; however, PRC with modifications are proposed to circumvent this contraindication. PRC modifications can be broadly grouped into capitate resurfacing (CR) and capsular interposition (CI) procedures which could expand PRC indications. Our primary question was to characterize the outcomes achievable with various PRC modifications. Our secondary question was to determine which PRC modification was the optimal procedure when capitate arthritis was present. Methods  A systematic review was conducted to examine the outcomes of modified PRC procedures. Independent reviewers appraised multiple databases for PRC studies with modifications for capitate arthritis in adult patients (age >18 years) with a minimum of three cases and extractable outcomes. Modified PRC procedures included capsular/allograft interposition, resurfacing capitate pyrocarbon implants, and osteochondral grafting. Pertinent outcomes included patient demographics, range-of-motion, grip strength, patient-reported outcomes, and complications, including salvage rates. Results  Overall, 18 studies met the inclusion criteria-10 studies ( n  = 147) on CI and 8 studies on CR ( n  = 136). PRC with CI had the greatest flexion-extension arc and grip strength. Complications were marginally higher in the CR group (4%), while the CI group had a higher conversion to total wrist arthrodesis (10%). Conclusion  Techniques to address capitate arthritis center around resurfacing or soft tissue interposition. PRC modifications with CI produces better range-of-motion and grip strength but higher conversion to total wrist arthrodesis. Higher conversion rates may be attributable to longer follow-up periods in studies examining CI compared with CR. Level of Evidence  This is a Level III study.

Patient-Reported Outcomes 1 Year After Proximal Interphalangeal Joint Arthroplasty for Osteoarthritis

PURPOSE

Implant survival, range of motion, and complications of proximal interphalangeal joint arthroplasty have been reported often, but patient-reported outcomes are less frequently described. This study evaluated patients' experiences during the first year after proximal interphalangeal joint arthroplasty, measured with the Michigan Hand Outcomes Questionnaire (MHQ). The primary focus was the reduction of patient-reported pain after proximal interphalangeal joint implant placement and the percentage of patients who considered this reduction clinically relevant, indicated by the minimal clinically important difference (MCID).

METHODS

Data were collected prospectively; 98 patients completed the MHQ before and at 3 and 12 months after surgery. Our primary outcome was the change in the pain score. An increase of 24 points or more was considered a clinically important difference. Secondary outcomes included changes in MHQ total and subscale scores and MCIDs, range of motion (ROM), patient satisfaction with the outcome of the surgery, and complications.

RESULTS

The pain score improved significantly, from 42 (95% confidence interval, 38-46) at baseline to 65 (95% confidence interval, 60-69) at 12 months after surgery. The MCID was reached by 50% (n = 49) of patients. The ROM did not improve, reoperations occurred in 13% (n = 13) of patients, and swan neck deformities only occurred among surface replacement implants.

CONCLUSIONS

Although most patients undergoing arthroplasty for osteoarthritis experienced significantly less pain after surgery, the pain reduction was considered clinically relevant in only 50% (n = 49) of patients. Patients with high MHQ pain scores before surgery are at risk for postoperative pain reduction that will not be clinically relevant. Likewise, the other subscales of the MHQ improved after surgery, but reached a clinically relevant improvement in only 46% (n = 45) to 63% (n = 62) of patients. This knowledge can be used during preoperative consultation to improve shared decision making.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Outcome of the MatOrtho arthroplasty for PIP osteoarthritis with a minimum follow-up of two years

The aim of this study is to report the early results of the MatOrtho arthroplasty, a newer generation resurfacing implant of the proximal interphalangeal joint. We performed a prospective cohort review of all MatOrtho arthroplasties implanted between 12/2013 and 05/2018 by a single surgeon at a single institution because of primary osteoarthritis, with a minimum follow-up of two years. Patient demographics, diagnosis, implant revision and other surgical interventions were recorded. Subjective and objective outcomes were evaluated, including range of motion, Patient Reported Outcome Measures and radiographic assessment. A total of 34 implants were inserted in 25 patients. Two implants were lost to follow-up. Pain scores improved significantly (mean VAS pre- op 7, mean VAS post-op 1, p < 0.05). Active range of motion improved in 83% (25/30) of joints, with a mean improvement of the total arc of motion of 25 degrees. On radiographic assessment, no signs of circumferential lucency or subsidence were observed. Additional surgery was necessary for three out of 32 implants, including implant removal in two cases. 93.75% (30/32) implants survived after a mean follow-up of 33 months. Our results confirm that at least at short term follow up, the MatOrtho PIP arthroplasty can be a successful procedure with high patient satisfaction and functional improvement.

Total Joint Arthroplasty of a Proximal Interphalangeal Joint with Proximal Metal Surface Replacement and Distal Hemi-Hamate Autograft: A Long-Term Follow-Up

A 28-year–old female recreational athlete presented with middle finger proximal interphalangeal joint pain, stiffness, and ulnar deviation deformity 2 years after internal fixation of a middle phalanx base fracture-dislocation. Radiographs revealed posttraumatic changes on both sides of the proximal interphalangeal joint. Having failed nonsurgical measures, she elected to proceed with surgical reconstruction. Intraoperatively, we confirmed substantial articular damage on both sides of the joint. We proceeded with hemi-hamate autograft for 80% of the middle phalanx base. We used a cobalt chrome proximal phalanx component. After healing, the patient returned to all daily-living and athletic activities with resolution of preoperative pain, stiffness, and deformity. Twelve years after surgey, she had no pain or substantial limitations because of the finger. We measured 80° of proximal interphalangeal joint motion. The grip and fingertip-pinch strength were 91% and 73%, respectively, of the contralateral dominant hand. Radiographs showed no progressive changes compared to 3 years after surgery.

The Long-term Results of Proximal Interphalangeal Joint Arthroplasty of the Osteoarthritic Index Finger

Background: Arthroplasty of the proximal interphalangeal (PIP) joint is a widely performed procedure for patients with osteoarthritis. Its use in the index finger is often discouraged due to concerns over implant longevity and stability secondary to coronal forces this digit is exposed to during pinch. Methods: We analyzed 47 consecutive index finger silastic interposition arthroplasties, performed through a dorsal approach, at a mean follow-up of 5.15 years. Results: Only 2 patients had ulnar deviation greater than 15°. The reoperation rate was 12.8%, with only 1 finger requiring arthrodesis. The mean Visual Analog Scale score was 1.1; and of the whole series, only 1 patient would retrospectively have preferred a fusion. Conclusions: Our series shows that excellent functional results and patient satisfaction can be gained using silastic PIP joint arthroplasty in the index finger. We would advocate offering this procedure, especially in lower demand patients as an alternative to arthrodesis, with the benefit of providing good pain relief while preserving movement.

Systematic review of the introduction, early phase study and evaluation of pyrocarbon proximal interphalangeal joint arthroplasty

BACKGROUND

In 2002 a pyrocarbon interphalangeal joint implant was granted Food and Drug Administration approval with limited evidence of effectiveness. It is important to understand device use and outcomes since this implant entered clinical practice in order to establish incremental evidence, appropriate study design and reporting. This systematic review summarised and appraised studies reporting pyrocarbon proximal interphalangeal joint arthroplasty.

METHODS

Systematic review of MEDLINE, EMBASE, SCOPUS, Web of Science, BIOSIS, CINAHL and CENTRAL from inception to November 2020. All study designs reporting pyrocarbon proximal interphalangeal joint arthroplasty in humans were included. Data extracted included information about study characteristics, patient selection, regulatory (gaining research ethics approval) and governance issues (reporting of conflicting interests), operator and centre experience, technique description and outcome reporting. Descriptive and narrative summaries were reported.

RESULTS

From 4316 abstracts, 210 full-text articles were screened. A total of 38 studies and 1434 (1-184) patients were included. These consisted of three case reports, 24 case series, 10 retrospective cohort studies and one randomised trial. Inclusion and exclusion criteria were stated in 25 (66%) studies. Most studies (n = 27, 71%) gained research ethics approval to be conducted. Six studies reported conflicting interests. Experience of operating surgeons was reported in nine (24%) and caseload volume in five studies. There was no consensus about the optimal surgical approach. Technical aspects of implant placement were reported frequently (n = 32) but the detail provided varied widely. Studies reported multiple, heterogenous outcomes. The most commonly reported outcome was range of motion (n = 37).

CONCLUSIONS

This systematic review identified inconsistencies in how studies describing the early use and update of an innovative procedure were reported. Incremental evidence was lacking, risking the implant being adopted without robust evaluation. This review adds to evidence highlighting the need for more rigorous evaluation of how implantable medical devices are used in practice following licencing.

Poor results after pyrocarbon interpositional shoulder arthroplasty

BACKGROUND

This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA).

METHODS

The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated.

RESULTS

Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months.

CONCLUSION

High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.

Factors Associated with Reoperation after Pyrocarbon Proximal Interphalangeal Joint Arthroplasty for the Arthritic Joint: A Retrospective Cohort Study

Introduction  The rate of reoperation after pyrocarbon proximal interphalangeal (PIP) joint arthroplasty ranges from 5.9 to 37% and complications such as radiographic loosening, deformity, dislocation, and stiffness are common. Because of the limited amount of knowledge around these problems, we evaluated factors associated with reoperation after pyrocarbon PIP arthroplasty. Materials and Methods  We retrospectively included all adult patients that underwent primary PIP pyrocarbon implant arthroplasty between 2002 and 2016 at one institutional system. A total of 45 patients, with a mean age of 55 (standard deviation: 14), underwent 66 PIP arthroplasties. To address for within individual correlations, we only included fingers treated at patients' initial surgery ( n = 54) in our statistical analysis. These patients were predominantly diagnosed with noninflammatory arthritis 73% ( n = 33). Arthroplasty was performed upon 10 index, 22 middle, 20 ring, and 2 small fingers. Results  The reoperation rate after pyrocarbon PIP arthroplasty was 30% over a median follow-up of 25 months (interquartile range: 8.7-54). Indications for reoperation consisted of subluxation ( n = 6), stiffness ( n = 5), swan-neck deformity ( n = 3), and soft tissue complications ( n = 2). Younger age ( p = 0.025), male sex ( p = 0.017), and noninflammatory arthritis ( p = 0.038) were associated with a higher reoperation rate. Conclusion  In this study, our reoperation rate after pyrocarbon PIP arthroplasty was 30%. This study suggested that younger patients, males, and patients with noninflammatory arthritis are at higher risk of reoperation. We recommend considering these factors when selecting candidates for pyrocarbon arthroplasty. Future studies should focus on prospectively researching these factors in comparison with other implants.

Surface replacing arthroplasty of the proximal interphalangeal joint using the CapFlex-PIP implant: a prospective study with 5-year outcomes

The purpose of this prospective study was to evaluate the 5-year outcomes in patients after proximal interphalangeal joint arthroplasty using the surface replacing implant, CapFlex-PIP. Ninety-two prosthesis were implanted and 65 patients with 68 implants were available for follow-up. The brief Michigan Hand Outcomes Questionnaire score improved significantly from 45 (SD 15) before surgery to 71 (SD 17) at 5 years. On the numeric rating scale, pain during activities decreased significantly from 6.4 (SD 1.9) to 1.8 (SD 1.9). Range of motion of the joints increased significantly from 45° (SD 21) to 54° (SD 24). An axis deviation of more than 5° was found in 65% of the joints before surgery, but only in 25% at 5 years. Soft tissue reoperations were performed on eight patients. Four out of 92 implants underwent revision for stiffness or implant loosening. In three implants, the distal component migrated without needing revision. Overall, the CapFlex-PIP implant demonstrates favourable medium-term results in surface replacing arthroplasty of the proximal interphalangeal joint.Level of evidence: IV.

Comparison of Volar and Dorsal Approach for PIP Arthroplasty

Background: No consensus exists about whether a volar approach (VA) or dorsal approach (DA) for proximal interphalangeal (PIP) arthroplasty yields better results. Previously reported range of motion (ROM) and complications vary from study to study. This retrospective review compared the ROM and complication rates of VA and DA approaches to PIP arthroplasty. Methods: The study included 66 adults (88 digits) who underwent PIP arthroplasty from 2000 to 2015, with minimum 30-day follow-up. Demographic data, surgical approach, pre- and post-operative ROM, duration of immobilization, timing and duration of hand therapy (occupational therapy [OT]), and major and minor complications were recorded. We compared mean change in ROM, postoperative ROM, and complication rates, and examined the association of duration of immobilization and time to OT initiation with postoperative ROM. Results: While there was no difference in postoperative ROM between volar and dorsal groups (56° and 54°, respectively, P > .05), there was a greater gain in ROM in the DA group (25° vs 2.7°, P = .017). There was no statistically significant difference in overall incidence of complications (VA: 37.8%, DA: 30.3%; P > .05) or revision surgery (VA: 15.6%, DA: 17.1%; P > .05). There were no differences in duration of immobilization, time to OT initiation, or number of OT sessions between the two groups, and none of these correlated with postoperative ROM. Conclusions: We identified no statistical difference in mean postoperative ROM, incidence of complications or revision surgery between volar and dorsal approaches for PIP arthroplasty.

Two cases of pyrocarbon capitate resurfacing after comminuted fracture of the capitate bone

We present two cases of the use of a pyrocarbon capitate resurfacing implant (RCPI) after comminuted capitate fracture. Both cases were young males with a high-energy injury to the wrist. Follow-up was 21 and 29 months. Wrist ROM was decreased to about 47% and post-injury pain was limited.

Trends in Primary Proximal Interphalangeal Joint System and Revisions for Osteoarthritis of the Hand in the Medicare Database

Background: Proximal interphalangeal arthroplasty (PIPA) has been indicated for patients suffering from osteoarthritis (OA) or rheumatoid arthritis of the hand. Although there is extensive literature showing the outcomes of PIPA, there is paucity in the literature regarding trends of PIPA in patients with OA of the hand. The purpose of this study was to determine annual primary utilization and revision PIPA trends within the Medicare population with the use of an administrative database. Methods: A retrospective query was performed using the Medicare Standard Analytical Files from the PearlDiver database. Patients undergoing primary and revision PIPA with hand OA were queried using International Classification of Disease, Ninth Revision, and Current Procedural Terminology coding. Primary outcomes analyzed included annual and revision utilization of PIPA and demographic comparison of age, gender, and geographic location. Statistical analysis was primarily descriptive. An α value less than 0.05 was considered statistically significant. Results: The query returned 10 191 patients who underwent primary and revision PIPA between 2005 and 2013. Calculated annual growth rate for primary and revision PIPA was 2.40% and -0.03%, respectively (P < .001). Patients between the ages of 70 and 74 years represented most of the patients undergoing a primary PIPA, whereas patients between 65 and 69 years most commonly underwent a revision procedure. Regionally, primary and revision PIPA were most commonly performed in the South. Conclusion: The data demonstrate an increased use of primary PIPA utilization for patients with OA, whereas revision PIPA decreased. The increased use indicates the increasing demand for PIPA in the United States.

Outcome of proximal interphalangeal joint replacement with pyrocarbon implants: a long-term longitudinal follow-up study

INTRODUCTION

The aim of this study was to compare the short-, mid-, and long-term results of pyrocarbon PIPJ arthroplasty.

MATERIALS AND METHODS

Twenty-seven consecutive patients (9 males, 18 females) had arthroplasty for 32 pyrocarbon PIPJ prostheses. Two patients (two joints) were lost for follow-up. Four implants were removed during follow-up. Fifteen patients (18 implants) were available for a long-term follow-up assessment on average 9.7 (9-10.8) years postoperatively and seven patients with eight implants had telephone interviews to calculate the implant survival and complications. Of the 15 patients who came to the latest follow-up, 12 (14 implants) passed each of the three follow-up visits for short-term (ø 19 months), mid-term (ø 54 months), and long-term follow-up (ø 9.8 years) to compare functional and radiological parameters longitudinally.

RESULTS

In total, seven of the 30 joints (23%) required a revision surgery, all within the first 2 years postoperatively, including three arthrodesis due to early infection or dislocation, and one distal component removal due to primary loosening. Three patients required soft tissue revisions. The implant survival after 9 years was 87%. There was minimal pain at rest throughout the 9-year follow-up analysis; pain with activity was rated 1.9 at the short-term assessment, 1.5 at mid-term, and 1.6 at long-term. The average active range of motion was at short-, mid-, and long-term examination 49°, 50°, and 48° and grip strength averaged 24, 24, and 21 kg, respectively. The DASH score was stable with 35, 36, and 33 points. At the long-term follow-up, all evaluated implants showed radiological signs of implant loosening or migration. According to the PIP joint outcome score, 57% resulted finally in a "good" outcome.

CONCLUSIONS

Pyrocarbon PIPJ arthroplasty has a risk of early complications necessitating revision surgeries. In spite of radiological implant migration, good pain relief, grip strength, and high quality-of-life ratings are stable for a long time.

Results of proximal interphalangeal arthroplasty: border digits versus middle digits

This investigation assessed 106 consecutive primary proximal interphalangeal joint arthroplasties performed on border digits: 73 index or 33 little fingers. This was compared with 193 arthroplasties performed in non-border digits: 121 middle or 72 ring fingers. There were 20 proximal interphalangeal joint arthroplasties in the border digits that required revision surgery for pain and stiffness (10 digits), dislocation (six digits), implant fracture (one digit), and infection (three digits). Risk of revision surgery was not associated with border digit. The 5-year implant survival rate for the border digits was 81%. There was no significant difference in implant revision rate or joint dislocations between border and non-border digits. We conclude that proximal interphalangeal joint arthroplasties performed in border digits had similar pain relief, survivorship, complications, and reoperation rates compared with those performed in non-border digits.Level of evidence: IV.

Fracture of pyrocarbon humeral head resurfacing implant: a case report

We report a case of a pyrocarbon humeral head resurfacing implant fracture, occurring 6 years after its implantation, without any obvious trauma or dislocation. Initial radiographs showed a proud and oversized pyrocarbon resurfacing implant. On clinical examination, the patient had a painful and pseudoparalyzed shoulder with subscapularis insufficiency. Imaging studies confirmed implant fracture and severe fatty infiltration (Goutallier, grade 4) of the subscapularis muscle. Intraoperatively, the implant was found to be fractured with multiple pyrocarbon debris in the glenohumeral joint. The implant was loose, and gross inspection showed no visible bony adhesion or ongrowth. Histologic analysis showed multiple seats of metallosis in the synovial tissue and cancellous bone of the humeral head. Successful management of this complication was managed with a thorough débridement and irrigation and revision to reverse shoulder arthroplasty. Our observation put into question the use of pyrocarbon as a humeral head resurfacing implant. The material seems to be too fragile to be used as a resurfacing implant and cannot achieve fixation of the implant to bone.

The Optimal Position for Arthrodesis of the Proximal Interphalangeal Joints of the Border Digits

PURPOSE

This study aimed to determine the functional characteristics of various arthrodesis angles of the proximal interphalangeal (PIP) joints of the border fingers.

METHODS

The dominant hands of 48 volunteers were tested using custom orthoses to simulate PIP joint arthrodesis. For the index finger (IF), orthoses were made in 25°, 40°, and 55° of flexion (IF25, IF40, and IF55). For the little finger (LF), orthoses were made in 30°, 55°, and 70° of flexion (LF30, LF55, and LF70). Twenty-three volunteers performed grip and pinch (key, tripod, and pulp) strength testing with and without simulated arthrodeses and 25 volunteers performed the Jebsen Hand Function Test (JHFT) with and without simulated arthrodeses. Simulated conditions of arthrodesis were compared with the unrestricted state and with each other within the same finger.

RESULTS

For grip and pinch strength, there were no significant differences between simulated arthrodesis angles. Compared with baseline, grip was significantly weaker for all 6 simulated arthrodesis angles. Pinch was tested with simulated IF arthrodesis only; key pinch was significantly weaker for all tested angles and tripod pinch for IF25 and IF40. For JHFT, the 3 experimental angles for the index or ring finger did not show any statistically significant differences for any subtest. Volunteers were slower at completion times for all simulated arthrodesis angles compared to baseline times. This was significant in 5 of 7 tasks for IF25, 3 of 7 tasks for IF40, and 4 of 7 tasks for IF55. Index finger angle of flexion of 40° was significantly faster than IF55 for writing and IF25 for lifting large, light objects. For the LF, LF30 was significantly slower than baseline for 6 of 7 tasks, LF55 for 3 of 7 tasks, and LF70 for 5 of 7 tasks. Index finger angle of flexion of 55° was significantly faster than LF70 for simulated feeding and IF30 for lifting large, heavy objects.

CONCLUSIONS

No border digit PIP joint arthrodesis angle was superior for grip and pinch strength. Based on JHFT, IF40 and LF55 might be preferred arthrodesis angles.

CLINICAL RELEVANCE

Intermediate arthrodesis angles may provide the best function for patients undergoing PIP joint arthrodesis of the IF and LF.

Midterm Clinical and Radiographic Follow-Up of Pyrolytic Carbon PIP Arthroplasty

PURPOSE

The use of pyrolytic carbon arthroplasty (PCA) for the proximal interphalangeal (PIP) joint is controversial. The goal of this study was to evaluate the clinical and radiographic midterm outcomes of PIP joint PCA.

METHODS

Patients were contacted after PIP PCA at 6.4 ± 1.9 years (mean ± SD). Evaluation included grip and pinch strength and digital range of motion (ROM). Radiographs and patient reported outcomes surveys were obtained.

RESULTS

This study included 29 PIP joint PCA devices implanted in 23 hands among 19 patients. Seven devices underwent subsequent procedures. Three were removed and revised to silicone implants because of 2 dislocations and one implant migration. One underwent revision to a larger distal component. Three required soft tissue surgical revisions in which the implant was retained (one flexor digitorum superficialis tenodesis and 2 capsulectomies). At the time of latest follow-up, there was 86.2% original implant survivorship. The most recent radiographic review of the remaining 26 implants revealed 2 swan neck deformities and 2 implant migrations. Postoperative grip (38.4 ± 16.8 lb) and pinch (13.8 ± 2.7 lb) strength were 92% and 91%, respectively, of nonsurgical grip and pinch strength. Final mean ROM (range) for the metacarpophalangeal joint was 82.1° (60° to 100°) and for the PIP joint was 60.6° (20° to 110°). Mean outcome scores were: visual analog scale, 1.6 (± 2.4), Michigan Hand Questionnaire, 71.6 (± 17.6), and Disabilities of the Arm, Shoulder, and Hand, 24.7 (± 14.5).

CONCLUSIONS

Midterm follow-up (mean, 6.4 years) for 29 PCA implants in 19 patients revealed a surgical revision rate of 24.1%. Of the 29 implants, 13.8% were removed at a mean of 4.6 years (range, 1.3-7.9 years). Strength, ROM, and pain relief were all satisfactory.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Novel Use of Joint Replacement in a Thumb Interphalangeal Joint

Arthrodesis of the interphalangeal (IP) joint of the thumb is widely acknowledged as the indicated treatment for trauma and osteoarthritis of this joint. Joint replacement was offered to a young patient as an alternative treatment after traumatic joint loss of the IP joint in her thumb. This allowed her to maintain motion of the joint as she did not wish to move forward with fusion. In the present case, a Humanitarian Use Device (HUD) was utilized in an off-label manner and placed into the interphalangeal joint of the patient's thumb. The patient did well postoperatively with reasonable pain-free range of motion of the interphalangeal joint with an arc of 40 degrees. We propose that joint replacement is a viable alternative to arthrodesis in select patients who do not wish to be fused. We believe this represents the first thumb IP joint replacement using a semiconstrained joint presented in the medical literature.

Total finger joint arthroplasty with a costal osteochondral autograft: up to 11 years of follow-up

The purpose of this study was to evaluate the mid- to long-term clinical outcomes of total finger joint arthroplasty using a costal osteochondral autograft for joint ankylosis. Twenty-three joints (three metacarpophalangeal joints, 20 proximal interphalangeal joints) in 23 patients (19 men and four women) were treated with a costal osteochondral autograft and were evaluated after a mean follow-up of 77 months (60-138). Mean age was 33 years (18 to 55). Significant improvement in active finger extension/flexion was seen from a preoperative mean of -24°/26° (arc: 2°) to -13°/75° (arc: 63°) at latest follow-up. Mean preoperative Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder and Hand score was initially 24 and improved significantly to 5 at latest follow-up. Conclusion: total finger arthroplasty using a costal osteochondral autograft gave an anatomical and biological reconstruction and provided stable improvement at a mean follow-up of 77 months. Level of evidence: IV.

Complications, reoperations and revisions after proximal interphalangeal joint arthroplasty: a systematic review and meta-analysis

This systematic review and meta-analysis investigates the prevalence of complications, reoperations (surgeries without implant modifications) and revisions (surgeries with implant modifications) after proximal interphalangeal joint arthroplasty with pyrocarbon, metal-polyethylene and silicone implants. Thirty-four articles investigating 1868 proximal interphalangeal joints were included. Implant-related complications were associated with 14%, 10% and 11% of the pyrocarbon, metal-polyethylene and silicone implants, respectively, yet these rates were not significantly different from one another. Silicone implants showed more finger deviations (3%) and instabilities (2%) compared with the other implants. Reoperations were fewer for silicone arthroplasties (1%) compared with pyrocarbon (7%) and metal-polyethylene implants (10%). The revision rates of 4%, 3% and 2% were similar for pyrocarbon, metal-polyethylene and silicone implants. Our results indicate that silicone implants remain a valuable option for the treatment of stable proximal interphalangeal joints. Surface replacing implants might be better to correct unstable or deviated proximal interphalangeal joints, although they are associated with a higher risk of reoperations.

[Advances in small joint reconstruction and arthroplasty of the hand]

Since Swanson designed the silicone small joint prosthesis, the material and design of the small joint prosthesis have been constantly innovating. The number of small joint reconstruction and arthroplasty has gradually increased in the past decade. The numerous studies have focused on design and application of new material prosthesis and its long-term effectiveness analysis, in order to overcome prosthesis loosening, shift, dislocation, and poor function problem, at the same time to challenge the difficulty of the small joints revision procedures. Although the small joint prosthesis which has got the overall performance of the Swanson joints and been mature and stable like a knee joints prosthesis has not been obtained, but the small joint development has made revolutionary changes in the treatment of joint diseases, and the prosthesis selection criterion and surgical technique tendency solution have been established. In the future, digital three-dimensional printing, regenerative medicine, and translational medicine will contribute to the development of small joint reconstruction and replacement.

Implant Arthroplasty: Selection of Exposure and Implant

This review analyzes various surgical exposures and implant designs for proximal interphalangeal (PIP) joint pathology. Our literature review found that silicone implants using a volar approach had the best arc of motion, least extension lag, and lowest complication rates compared with all the other implant designs and approaches. Surface replacement arthroplasties had more frequent surgical revisions compared with silicone implants. Continued efforts toward the development of improved PIP joint implants are necessary.

Advances in Proximal Interphalangeal Joint Arthroplasty: Biomechanics and Biomaterials

Proximal interphalangeal (PIP) joint arthritis is a debilitating condition. The complexity of the joint makes management particularly challenging. Treatment of PIP arthritis requires an understanding of the biomechanics of the joint. PIP joint arthroplasty is one treatment option that has evolved over time. Advances in biomaterials have improved and expanded arthroplasty design. This article reviews biomechanics and arthroplasty design of the PIP joint.

Surgical Exposure of the Proximal Interphalangeal Joint

There are 3 main surgical approaches to the proximal interphalangeal (PIP) joint; dorsal, volar, and lateral and several described modifications to these main approaches. Historically, the dorsal approach has been the standard for the most common procedures of the PIP joint. The volar approach is advantageous for surgical interventions requiring access to the volar plate. It spares the central slip insertion from possible disruption, as does the lateral approach. This article describes the surgical approaches to the PIP joint, explains the rationale for choosing each approach, and discusses some of the most common complications.

Biomechanical evaluation of pyrocarbon proximal interphalangeal joint arthroplasty: An in-vitro analysis

BACKGROUND

Pyrocarbon proximal interphalangeal joint arthroplasty provided patients with excellent pain relief and joint motion, however, overall implant complications have been very variable, with some good outcomes at short-medium-term follow-up and some bad outcomes at longer-term follow-up. Implant loosening with migration, dislocation and implant fracture were the main reported clinical complications. The aim of the present work was to test the hypothesis that the magnitude proximal interphalangeal joint cyclic loads in daily hand functions generates stress-strain behaviour which may be associated with a risk of pyrocarbon component loosening in the long-term.

METHODS

This study was performed using synthetic proximal and middle phalanges to experimentally predict the cortex strain behaviour and implant stability considering different load conditions for both intact and implanted states. Finite element models were developed to assess the structural behaviour of cancellous-bone and pyrocarbon components, these models were validated against experimentally measured cortex strains.

FINDINGS

Cortex strains showed a significant increase at dorsal side and reduction at palmar side between intact and implanted states. Cancellous-bone adjacent to the condylar implant base components suffers a two to threefold strain increase, comparing with the intact condition.

INTERPRETATION

The use of pyrocarbon implant changes the biomechanical behaviour of the joint phalanges and is associated with a potential risk of support cancellous-bone suffer fatigue failure in mid to long term due to the strain increase for cyclic loads in the range of daily hand activities, this risk is more prominent than the risk of bone resorption due to strain-shielding effect.

A Systematic Review of Different Implants and Approaches for Proximal Interphalangeal Joint Arthroplasty

BACKGROUND

Outcomes after implant arthroplasty for primary degenerative and posttraumatic osteoarthritis of the proximal interphalangeal joint were different according to the implant design and surgical approach. The purpose of this systematic review was to evaluate outcomes of various types of implant arthroplasty for proximal interphalangeal joint osteoarthritis, with an emphasis on different surgical approaches.

METHODS

The authors searched all available literature in the PubMed and EMBASE databases for articles reporting on outcomes of implant arthroplasty for proximal interphalangeal joint osteoarthritis. Data collection included active arc of motion, extension lag, and complications. The authors combined the data of various types of surface replacement arthroplasty into one group for comparison with silicone arthroplasty.

RESULTS

A total of 849 articles were screened, yielding 40 studies for final review. The mean postoperative arc of motion and the mean gain in arc of motion of silicone implant with the volar approach were 58 and 17 degrees, respectively, which was greater than surface replacement implant with the dorsal approach at 51 and 8 degrees, respectively. The mean postoperative extension lag of silicone implant with the volar approach and surface replacement with the dorsal approach was 5 and 14 degrees, respectively. The revision rate of silicone implant with the volar approach and surface replacement with the dorsal approach was 6 percent and 18 percent at a mean follow-up of 41.2 and 51 months, respectively.

CONCLUSION

Silicone implant with the volar approach showed the best arc of motion, with less extension lag and fewer complications after surgery among all the implant designs and surgical approaches.

Pyrocarbon interposition shoulder arthroplasty: preliminary results from a prospective multicenter study at 2 years of follow-up

BACKGROUND

The concept of free interposition arthroplasty proved successful for small joints of the hand, wrist, and foot, particularly after the use of implants coated with pyrocarbon, which enhanced their tribologic and elastic properties. The present study reports preliminary outcomes of a pyrocarbon-coated interposition shoulder arthroplasty (PISA) implant.

METHODS

This was a prospective study of 67 consecutive patients who underwent shoulder PISA at 9 centers. The mean age at surgery was 51 years, with only 12 patients older than 60 years. The indications for surgery were primary glenohumeral arthritis in 42, avascular necrosis in 13, and secondary arthritis in 12 patients.

RESULTS

Revision surgery was performed in 7 patients (10.4%), 2 (3.0%) were lost to follow-up, and the outcome assessments were incomplete in 3 (4.4%). This left 55 patients, aged 49.3 ± 12.0 years, with complete outcomes assessments at a mean follow-up of 26.8 ± 3.4 months. The Constant score improved from 34.1 ± 15.1 preoperatively to 66.1 ± 19.7 postoperatively. The radiographic findings revealed erosion in 6 glenoids and thinning of 3 humeral tuberosities.

CONCLUSION

In a cohort of young arthritic patients, PISA renders clinical scores and implant survival comparable to those of hemishoulder arthroplasty but remain inferior to those results reported for total shoulder arthroplasty. The study enabled identification of contraindications and potential causes of failure that wererelated to the concept of free interposition and smaller radius of curvature of the sphere. Until long-term results are available, this type of innovative implant should remain to be tested in a few specialized shoulder centers.

Outcomes of Surface Replacement Proximal Interphalangeal Joint Arthroplasty Through a Volar Approach: A Prospective Study

BACKGROUND

The dorsal approach to the proximal interphalangeal (PIP) joint provides the advantage of improved visualization of the articular surface, while the disadvantage of a dorsal approach is the disruption of the central slip and extensor mechanism requiring a delay in range of motion exercises. A volar approach keeps the central slip and extensor mechanism intact, allowing for early range of motion. The goal of this study was to evaluate patient outcomes of surface replacement (SR) PIP joint arthroplasty performed through a volar approach.

METHODS

Twenty-one patients were evaluated with primary osteoarthritis of a single PIP joint and underwent SR arthroplasty using the Stryker SR PIP joint implants. Patients included in this study were exclusively treated through a volar approach. Preoperative range of motion, coronal plan deformity, Disabilities of the Arm, Shoulder and Hand (DASH), and patient satisfaction were measured and compared with postoperative measurements using a paired Student t test.

RESULTS

The average length of follow-up was 34 months (± 9 months). Postoperative arc of motion for the PIP and distal interphalangeal (DIP) joints measured 87° (±12°) and 36° (±11°), respectively. The average improvement in PIP arc of motion was 58°, DASH score measured 14 (±5), satisfaction measured 4 (±1), and coronal plane deviation measured 2° (±2°). No evidence of implant subsidence was found on postoperative radiographs. Four patients required an extensor tendon tenolysis, and 1 patient suffered a superficial surgical site infection.

CONCLUSION

SR arthroplasty, when performed through a volar approach, allows for early range of motion and greater improvements in arc of motion, DASH score, and patient satisfaction.