The treatment of chronic flexion contractures of the proximal interphalangeal joint

Surgical Treatment for Patients with Post-traumatic Flexion Contracture of Proximal Interphalangeal Joint: Analysis of Various Affecting Factors

Background: A flexion contracture (FC) of the proximal interphalangeal (PIP) joint can have a profound negative influence on daily activity. The outcomes of surgical release of the PIP joint in literature are based on small sample size studies done several decades ago. The aim of this study is to report the outcomes of surgical treatment for post-traumatic FC of the PIP joint and to identify factors that affect these outcomes. Methods: This single institute retrospective study included patients from 2000 to 2020. We only included patients with post-traumatic FC of the PIP joint. We evaluated the demographic characteristics, cause of FC, surgical approaches and the various procedures conducted. We surveyed postoperative complications. During the study period, we asked about their current symptoms and evaluated their operative outcomes as excellent, good, fair or poor through the phone. Results: The average FC recovery angle was 37.3°. The small finger was the most affected, and the most common cause of FC was a tendon laceration. The volar plate complex release was the most frequently conducted procedure. The FC improvement was positively correlated to the degree of preoperative FC. The more severe preoperative flexion-extension arc was presented, the more FC recovery was achieved after operation. Patients who underwent multiple procedures had a higher degree of preoperative FC, and better correction was achieved with multiple procedures than with a single procedure. The most critical complication was recurrence. Conclusions: We were able to obtain average 37.3° of extension by surgical treatment. The more severe the FC presented before surgery, the greater the need for multiple procedures, however, this resulted in a significant increase in joint extension. Nevertheless, caution should be exercised regarding recurrence and could occur even with an experienced surgeon. Level of Evidence: Level IV (Therapeutic).

Proximal Interphalangeal Joint Fractures: Various Approaches to Fixation

There are numerous operative and nonoperative options for the management of proximal interphalangeal joint fractures and fracture dislocations. The treatment of choice should be guided by the fracture pattern and joint stability. The authors highlight a contemporary option for open reduction and internal fixation techniques, but all the techniques presented are viable options under the right circumstances. It is also important to set patient expectations as most of these patients will note post-injury stiffness and potential functional limitations.

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.

The stiff proximal interphalangeal joint - an unsolved problem?

The proximal interphalangeal joint is critical for good hand function. Its anatomical complexities often predispose it to stiffness, involving damage to one or more structures. Improving or resolving the stiffness and increasing the range of motion require an accurate assessment and understanding of the pathogenesis. The surgical strategy can then be tailored accordingly. In some cases, restoration to pre-injury level may not be possible and this condition still represents an unsolved problem in hand surgery.Level of evidence: V.

Treatment practice for Dupuytren disease in Belgium before 2020: results from an online survey

The treatment of Dupuytren disease (DD) continues to evolve. New insights in risk factors for recurrence and new treatment modalities have changed the management strategies for DD over the past decades. However, several differences may remain between these insights and their clinical application. The current tendencies in management of Dupuytren disease, were investigated in a web-based survey. The survey was sent to all members of the Belgian Hand Group, the professional organisation of hand surgeons in Belgium. The participants indicated their preferred treatment for clinical cases and answered questions on the use and timing of splinting, physiotherapy, medication and adapting the management depending on fibrosis diathesis. These findings were compared to recommendations found in the literature. Forty out of 135 surveyed members of the Belgian Hand Group completed the survey and 7 responded incompletely, yielding a response rate of 35% for most questions. This is comparable to similar studies. There appeared to be still room for debate on surgical techniques for difficult cases. CCH use increased since reimbursement became available in Belgium, mainly due to satisfying clinical results for patient and surgeon. The survey demonstrated a wide variety in pre- and postoperative splinting protocols, but consensus existed with the literature on postoperative night-time application of orthoses for 7 to 12 weeks.

Prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion of the proximal interphalangeal joint: a multivariate analysis

This study aimed to identify the prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion (ROM) of the proximal interphalangeal (PIP) joint and determine which procedure actually improves the PIP joint ROM. A total of 71 fingers (57 patients: 49 men, 8 women; mean age, 41 years) with posttraumatic limited passive ROM of the PIP joint (<60°) who underwent surgical mobilisation were reviewed. Possible prognostic factors, including age, injury type, injured finger, injury in the adjacent finger, and procedure types, were assessed. We defined the PIP joint ROM improvement as the primary outcome in the linear regression analysis. To evaluate surgical efficacy, we classified the surgical treatment options into four categories (volar release, dorsal release, volar and dorsal release, and joint distraction with an external fixator) and compared their outcomes. The mean postoperative improvement in the PIP joint ROM was 12°. In the linear regression analysis, advanced age (estimate, -0.41; 95% confidence interval [CI], -0.76 to -0.06), open injury (estimate, -13.54; 95% CI -27.02 to -0.06), and skin defects (estimate, -23.22; 95% CI -34.83 to -11.61) were associated with worse outcomes; however, the volar approach was associated with favourable outcomes. Surgical mobilisation is strongly recommended when limited ROM of the PIP joint is caused by flexion site contracture. To improve the final outcome of fingers with complex injuries, a tailored treatment strategy is required to avoid dorsal release.

Etiology, Evaluation, and Management Options for the Stiff Digit

The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patient's level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors including joint, intrinsic, extensor, and flexor tendon pathology, and the patient's individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, surgery consists of open joint release, tenolysis of flexor and/or extensor tendons, and external fixation devices. Outcomes after treatment vary depending on the joint involved along with the severity of contracture and the patient's compliance with formal hand therapy and a home exercise program.

Volar plate avulsion fracture alone or concomitant with collateral ligament rupture of the proximal interphalangeal joint: A comparison of surgical outcomes

Background

Volar plate avulsion fracture of the proximal interphalangeal (PIP) joint is one of the most common hand injuries. In this study, we divided patients into two groups: patients with pure volar plate avulsion fracture, and patients with volar plate avulsion fracture concomitant with collateral ligament rupture. The purpose of this study was to compare long-term surgical outcomes between the two groups. As a secondary measure, the Mitek bone anchoring and polydioxanone (PDS) bone suturing techniques were compared.

Methods

A single-institutional retrospective review of the surgical treatment of volar plate avulsion fracture was performed. The cases were divided into those with pure volar plate avulsion fracture (group A, n=15) and those with volar plate avulsion fracture concomitant with collateral ligament rupture (group B, n=15). Both groups underwent volar plate reattachment using Mitek bone anchoring or PDS bone suturing followed by 2 weeks of immobilization in a dorsal protective splint.

Results

The average range of motion of the PIP joint and extension lag were significantly more favorable in group A (P<0.05). Differences in age; follow-up period; flexion function; visual analog scale scores; disabilities of the arm, shoulder, and hand scores; and the grip strength ratio between the two groups were non-significant. No significant differences were found in the surgical outcomes of Mitek bone anchoring and PDS bone suturing in group A.

Conclusions

Overall, the surgical outcomes of volar plate reattachment were successful irrespective of whether the collateral ligaments were torn. However, greater extension lag was observed in cases of collateral ligament injury.

Treatment of Proximal Interphalangeal Joint Contracture

Proximal interphalangeal joint (PIPJ) flexion contracture is a challenging and often frustrating problem. Treatment of PIPJ contracture begins with conservative measures. With good compliance and prolonged use, favorable results can be achieved using these modalities. For contractures that fail to respond to conservative treatment, surgical intervention can be considered. The affected structures that can be released during surgery include the accessory collateral ligaments, volar plate, checkrein ligaments, retinacular ligaments, and the flexor and extensor tendons. A stepwise approach to release is typically favored in which active motion is tested after each release to determine the need for subsequent releases.

Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment

Proximal interphalangeal joint injuries are one of the most common injuries of the hand. The severity of injury can vary from a minor sprain to a complex intra-articular fracture. Because of the complex anatomy of the joint, complications may occur even after an appropriate treatment. This article provides a comprehensive review on existing techniques to manage complications and imparts practical points to help prevent further complications after proximal interphalangeal joint injury.

Proximal Interphalangeal Joint Release in Dupuytren’s Disease of the Little Finger

We present a prospective study, with 3-year follow-up, of the role and outcome of fasciectomy plus sequential surgical release of structures of the proximal interphalangeal joint in Dupuytren’s contracture of the little finger.

Our treatment programme involves fasciectomy for all patients followed by sequential release of the accessory collateral ligament and volar plate as necessary.

Of the 19 fingers in the study, eight achieved a full correction by fasciectomy alone, and in these cases there was a fixed flexion deformity of 6° at 3 months and 8° at 3 years. The remaining 11 fingers (initial mean deformity 70° flexion) were left with a fixed flexion deformity of 42° after fasciectomy which reduced to 7° with capsuloligamentous release. This increased to 26° at 3 months but then remained relatively stable, increasing only to 29° at 3 years.

In our experience sequential proximal interphalangeal joint release has led to consistently good results with few complications in the correction of severe Dupuytren’s disease of the little finger.

Results of Operative Intervention for Finger Stiffness After Fractures of the Hand

Background: Posttraumatic finger stiffness can occur as a result of hand fractures. The purpose was to assess and quantify the improvement in range of motion (ROM) after surgical management of the stiff finger in patients who developed loss of motion following treatment for a metacarpal or phalangeal fracture. In addition, an aim was to identify possible risk factors for suboptimal improvement in ROM postoperatively. Methods: A retrospective review was performed on 18 patients who underwent surgery to improve finger stiffness following metacarpal or phalangeal fracture. Demographic data including age, initial diagnosis and treatment, health history, and worker's compensation status were collected. We determined the number of specific procedures performed at the time of surgery, the number of days between surgical release and initiation of therapy, and the total active motion (TAM) prior to surgical release and at the patient's last follow-up. Results: Mean TAM improved from 150° preoperatively (range 60°-241°) to 191° postoperatively (range 61°-271°). Most patients required multiple anatomic structures released concomitantly, with an average of 3.1. Patients who started physical therapy within 7 days of the release improved by 59°, whereas those who started physical therapy after 7 days (average 11.5 days) lost 19° of motion. Patients who had filed a worker's compensation claim improved an average of 9°, whereas nonworker's compensation patients improved an average of 58°. Degree of TAM improvement had a weak correlation with patient age or preoperative TAM. Conclusions: Surgical release for stiff fingers following hand fractures can offer modest improvements in ROM in some patients. Although the overall increase in motion as a result of these operations is generally limited, functional improvement can be obtained. Delay in initiating physical therapy is a risk factor for persistent or worsened stiffness. Patients involved in worker's compensation claims demonstrated significantly lower TAM improvement after surgical intervention.

Management of the stiff finger: evidence and outcomes

The term "stiff finger" refers to a reduction in the range of motion in the finger. Prevention of stiff fingers by judicious mobilization of the joints is prudent to avoid more complicated treatment after established stiffness occurs. Static progressive and dynamic splints are considered effective non-operative interventions to treat stiff fingers. Capsulotomy and collateral ligament release and other soft tissue release of the MCP and PIP joint are also discussed in this article. Future outcomes research is vital to assessing the effectiveness of these surgical procedures and guiding postoperative treatments.

Surgical and therapy update on the management of Dupuytren's disease

Advancements in surgical and therapy management for Dupuytren's disease are highlighted. Indications for treatment and various surgical options for Dupuytren's disease are described. Non-surgical techniques are also presented. Therapy interventions are reviewed. Treatment techniques for the management of secondary problems resulting from prolonged digit flexion are presented. The benefits, limitations and outcomes of treatments are reviewed to assist the reader to link patient specific problems and goals to the most appropriate treatment choice.

The effect of a therapy protocol for increasing correction of severely contracted proximal interphalangeal joints caused by dupuytren disease and treated with collagenase injection

PURPOSE

To determine the effect of a specific orthotic intervention and therapy protocol on proximal interphalangeal (PIP) joint contractures of greater than 40° caused by Dupuytren disease and treated with collagenase injections.

METHODS

All patients with PIP joints contracted at least 40° by Dupuytren disease were prospectively invited to participate in the study. Following standard collagenase injection and cord rupture by a hand surgeon, a certified hand therapist evaluated and treated each patient based on a defined treatment protocol that consisted of orthotic intervention to address residual PIP joint contracture. In addition, exercises were initiated emphasizing reverse blocking for PIP joint extension and distal interphalangeal joint flexion exercises with the PIP joint held in extension to lengthen a frequently shortened oblique retinacular ligament. Patients were assessed before injection, immediately after injection, and 1 and 4 weeks later. There were 22 fingers in 21 patients. The mean age at treatment was 63 years (range, 37-80 y).

RESULTS

The mean baseline passive PIP joint contracture was 56° (range, 40° to 80°). At cord rupture, the mean PIP joint contracture became 22° (range, 0° to 55°). One week after cord rupture and therapy, the contracture decreased further to a mean of 12° (range, 0° to 36°). By 4 weeks, the mean contracture was 7° (range, 0° to 35°). The differences in PIP joint contracture were statistically significant at all time points except when comparing the means at 1 week and 4 weeks. The results represent an 88% improvement of the PIP joint contracture.

CONCLUSIONS

In the short term, it appears that severe PIP joint contractures benefit from specific, postinjection orthotic intervention and targeted exercises.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Biomechanical differences of the proximal interphalangeal joint volar plate during active and passive motion: a dynamic ultrasonographic study

PURPOSE

To define the biomechanical differences of the volar plate (VP) of the proximal interphalangeal joint during active and passive motion, which may provide clues to understanding the functional importance of the volar elevation of the VP.

METHODS

We imaged the volar aspect of the proximal interphalangeal joint in 10 healthy middle fingers using ultrasonography. Cine videos recorded the movements of the VP during joint motion from full extension to more than 60° of flexion both actively and passively. We plotted 5 points on the volar surface of the VP and traced them for motion analysis. We statistically analyzed the volar distances and volar angulation of the VP in full extension, 30°, 45°, and 60° of flexion to determine the differences between active and passive flexion.

RESULTS

In active flexion, the VP showed significantly higher volar distances in 45° and 60° and changed its configuration from the original flattened figure to an inverted U shape, with a significant higher angulation at 45° compared with passive flexion. Conversely, in passive flexion, we did not observe the volar elevation of the VP and the flattened configuration was maintained throughout the motion arc.

CONCLUSIONS

From an anatomical viewpoint, volar elevation of the VP seen in active flexion could provide dynamic stresses on the adjacent ligaments and contribute to the stability and smooth gliding of the joint.

A novel splint for proximal interphalangeal joint contractures: a case report

Proximal interphalangeal (PIP) joint contractures are notoriously difficult to treat. Best results are obtained with early mobilization and splinting, though a high level of adherence is critical for a good outcome. A new roll-on splint that aims to increase motion with minimal difficulty was used. The patient described here with moderate PIP joint contractures (30°-60°) was treated successfully using this splint. The splint design and therapy protocol are described. The patient was treated for 12 weeks with good adherence to therapy and splinting. Total active motion increased by 87% in the index finger and 108% in the ring finger. Grip, pinch, and tip-pinch strengths increased. The Disabilities of the Arm, Shoulder and Hand score improved from 26.7% to 2.5%. At 3 months, the patient returned to work. Though this case illustrates some of the advantages and disadvantages of the new splint, further study is necessary to evaluate the splint and compare it with other existing forms of treatment for PIP joint contractures.

Outcome review on the percutaneous release of the proximal interphalangeal joint accessory collateral ligaments

The percutaneous release of accessory collateral ligaments was introduced in 1986 as a safe and quick procedure to be attempted before open, more extensive joint release in the treatment of proximal interphalangeal joint flexion contracture. Our study analyzed the long-term results and patient satisfaction following a percutaneous release in 30 joints after a mean follow-up period of 34 months. In one half of cases the preoperative joint flexion deformity was reduced from 78° to 34°. The best results were observed in patients with osteoarthritis and stiff, immobilized joints. In patients with inflammatory arthritides, marked intraoperative correction was maintained rarely, joint contractures recurred early, and patients were unsatisfied. There were no intraoperative complications. Percutaneous release of the accessory collateral ligaments can produce a long lasting correction of the joint contracture, but careful patient selection and strict postoperative rehabilitation are essential for favorable outcome.

[Contracture release of PIP and MP joints : classification, technique and results]

With regard to finger joint contractures, proximal interphalangeal (PIP) flexion contractures and metacarpophalangeal (MP) extension contractures are of utmost clinical importance. Exact clinical examination allows differentiation between pure joint contractures and complex cases. For PIP flexion contractures, a midlateral incision is preferable to a palmar approach, if possible. In this article, the indications, surgical techniques, and postoperative management concerning PIP flexion and MP extension contractures are addressed, and published results are discussed. Complete surgical contracture release, consistent postoperative treatment, and good compliance are the prerequisites for satisfying results.

Posttraumatic proximal interphalangeal joint flexion contractures

Normal motion of the proximal interphalangeal joint requires bony support, intact articular surfaces, unimpeded tendon gliding, and uncompromised integrity of the collateral ligaments and volar plate. Deficiency in any one of these structural requirements can lead to a loss of finger joint motion and decreased hand function. Once finger extension is lost, options include nonsurgical or surgical treatment. Nonsurgical treatment such as splinting or serial casting should be tried before attempting surgical intervention. When severe flexion deformity exists or the vascular status of the finger has been compromised, arthrodesis or amputation should be undertaken instead of procedures to regain motion. Surgical options for regaining motion include external fixators and open surgical release. Although they can lead to improved extension at the proximal interphalangeal joint, external fixators carry a risk of reduced finger flexion and pin site infection. Most clinical series of patients who have undergone surgical release document improvement in flexion contracture between 25 degrees to 30 degrees and a shift of the flexion/extension arc into a more functional range. Close follow-up after surgery is warranted, with frequent physical therapy and splinting.

Anatomy of the collateral ligaments of the proximal interphalangeal joint

PURPOSE

To study and clarify the anatomy of the proper collateral ligaments and accessory collateral ligaments of the proximal interphalangeal joint.

METHODS

The collateral ligaments of 8 proximal interphalangeal joints were dissected under an operating microscope to gain an appreciation of their fiber direction and the anatomy of their origin and insertion. Two undissected joints were studied histologically.

RESULTS

The proper collateral ligament was found to arise widely from dorsal and proximal to and from the fovea on the side of the head of the proximal phalanx and insert for some distance on most of the side of the base of the middle phalanx. The ligament is stout and its fibers are oriented parallel to the middle phalanx in all positions of the joint. The accessory collateral ligament was found to be a less substantial structure lying between the proper collateral ligament and the volar plate.

CONCLUSIONS

The anatomy shown by this study is quite different from that shown in most of the anatomic and hand surgery literature, particularly in line drawings.

Long-term results of surgical management of proximal interphalangeal joint contracture

To evaluate the long-term results of surgical treatment of proximal interphalangeal (PIP) joint contractures, 68 PIP joints were retrospectively reviewed with a minimum follow-up period of 24 months. Preoperative and intraoperative factors were studied for outcomes and subjected to statistical analysis. Among the total group the average improvement was 7.5 degrees. When grouped by diagnosis into simple (less severe diagnoses) and complex (more severe diagnoses) the average degrees gained were 17.2 degrees and 0.5 degrees, respectively. The statistically significant factors that were identified that affected results were age, number of prior procedures, preoperative flexion, removal of an exostosis, number of structures addressed, and preoperative arc of motion. The second surgery (joints requiring repeat release or salvage procedure) rates were 35% overall, 29% simple, and 39% complex; the difference was not significant. The best surgical candidate is a patient younger than 28 years with a less severe diagnosis and who has preoperative maximum flexion measurement < 43 degrees.