Proximal Interphalangeal Joint Arthroplasty for Osteoarthritis: A Long-Term Follow-Up

BACKGROUND

Previously published research describes short-term outcomes after proximal interphalangeal (PIP) joint arthroplasty; however, long-term outcomes are scarce. Therefore, the authors evaluated patient-reported outcomes and complications after a follow-up of at least 5 years following PIP joint arthroplasty.

METHODS

The authors used prospectively gathered data from patients undergoing PIP joint arthroplasty with silicone or surface replacement implants. Time points included preoperatively, 1 year postoperatively, and at least 5 years postoperatively. The authors were able to include 74 patients. Primarily, the authors focused on patient satisfaction with the treatment outcome, measured using a validated 5-point Likert scale. Secondary outcomes included the questions of whether patients would undergo the same surgery again, the assessment of factors associated with satisfaction or dissatisfaction, the Michigan Hand Outcomes Questionnaire score, and the number of reoperations.

RESULTS

The mean follow-up was 7 ± 1.2 years (range, 5 to 11 years). Patient satisfaction was excellent in 14 patients (19%), good in 17 patients (23%), reasonable in 18 patients (24%), moderate in 10 patients (14%), and poor in 15 patients (20%). Seventy-three percent of patients ( n = 54) would undergo the same procedure again. The authors found no factors associated with satisfaction or dissatisfaction. All Michigan Hand Outcomes Questionnaire scores improved significantly in the first year after surgery and did not deteriorate afterward. Sixteen fingers (16%) required a reoperation, of which 3 (4%) needed a prosthesis replacement.

CONCLUSIONS

Patient satisfaction with treatment outcomes 7 years after PIP implant surgery ranges from moderate to good for many patients, with a notable proportion expressing dissatisfaction. Patient-reported outcomes improve primarily within the first year and remain stable at 5 years or more.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, 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.

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.

Rehabilitation after proximal interphalangeal joint replacement: A structured review of the literature

Proximal interphalangeal (PIP) joint arthroplasty is an unsolved biomechanical challenge despite advances in materials and new implant designs. This leads to a high rate of complications. Moreover, there is heterogeneity in postoperative management according to the literature. The present structured review examined the therapeutic strategies utilized by physiotherapists to restore a functional finger chain and prevent postoperative complications following PIP joint replacement. Patients undergoing primary total PIP joint arthroplasty of the index, ring, middle or little finger were included. Articles published from 2008 onwards, in French or English, and reporting on PIP joint replacement and postoperative management, were included. Therapeutic strategies were organized according to the surgical approach. Details of splint strategies, mobilization and muscle strengthening and management of postoperative complications were collected. Forty-eight studies, 3 of which provided a description of surgical techniques, were included. In relation to hand function, most authors advocated joint mobilization (n = 45) and some recommended muscle strengthening (n = 4). Static (n = 43) and dynamic splints (n = 14) and buddy taping (n = 12) were frequently recommended to prevent and manage postoperative complications. Few studies (n = 13) reported wound assessment or control of postoperative edema. Precise recommendations concerning therapeutic strategies following PIP joint arthroplasty cannot be made based on available evidence. Specific protocols for rehabilitation following PIP joint replacement need to be clarified in future research.

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 Replacement Arthroplasty Using a Volar Approach for Osteoarthritis of Proximal Interphalangeal Joint: Results After a Minimum 5-Year Follow-up

Background: Surface replacement arthroplasty (SRA) through a volar approach for the proximal interphalangeal (PIP) joint can preserve the integrity of the extensor tendon, which allows early range of motion (ROM) exercise postoperatively. However, a few reports have shown that the PIP ROM tends to decline with longer follow-up. The goal of this study is to assess the results of at least 5 years of follow-up of SRA through a volar approach and also to investigate the cause of deterioration of ROM with time after SRA through this approach. Methods: Eleven fingers with degenerative osteoarthritis that underwent SRA through the volar approach were examined. ROM of the PIP joint preoperation, 1 year after the surgery, and at final follow-up was measured and statistically analyzed. Also, the relationship between PIP ROM and the osteophyte developed postoperatively was examined. Results: The average follow-up period was 7.3 years. The average PIP ROM of the PIP joints was 52.3° preoperatively, 54.1° at 1 year postoperatively, and 31.1° at the final follow-up. PIP ROM at the final follow-up was significantly decreased compared with that preoperatively or at 1 year postoperatively. Also, the development of an osteophyte was negatively correlated with the ROM of the PIP joint at the final follow-up. Conclusions: PIP ROM after SRA through a volar approach has the tendency to deteriorate with a longer follow-up. Development of an osteophyte is considered to be a main risk factor of deterioration in the cases of SRA through a volar approach.

Proximal Interphalangeal Joint Arthroplasty in Young Patients

INTRODUCTION

This investigation compares the outcomes of proximal interphalangeal (PIP) arthroplasty in patients older than and younger than 60 years.

METHODS

Overall, 299 consecutive, primary PIP arthroplasties were performed over a 14-year period, including 126 arthroplasties performed in patients younger than 60 years. In younger patients group, a higher rate of posttraumatic and inflammatory arthritis was observed.

RESULTS

In patients younger than 60 years, 32 (25%) revision surgeries occurred. Risk of revision surgery was associated with younger age. The 10-year implant survival rate was 72% for the patients younger than 60 years versus 86% for those older than 60 years. Silicone implants decreased the risk of revision surgery, although it was increased in posttraumatic arthritis. The most common complication in young patients was dislocation (n = 21). At a mean follow-up of 6.4 years, pain levels had significantly improved in patients younger than 60 years, and PIP range of motion and pinch strength were maintained. However, older patients had improved PIP motion compared with younger patients.

CONCLUSIONS

Younger age leads higher revision rates after PIP arthroplasty, particularly in the posttraumatic setting.

LEVEL OF EVIDENCE

Therapeutic, level III.

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.

Medium-Term Outcomes With Pyrocarbon Proximal Interphalangeal Arthroplasty: A Study of 170 Consecutive Arthroplasties

PURPOSE

The purpose of this study was to examine the medium-term outcomes of patients undergoing proximal interphalangeal (PIP) joint arthroplasty using a pyrocarbon implant.

METHODS

The study comprised an analysis of 170 PIP joint pyrocarbon arthroplasties in 99 patients with a minimum 2-year clinical follow-up. Diagnoses included inflammatory arthritis (n = 49), posttraumatic arthritis (n = 29), and osteoarthritis (n = 92). Univariate logistic regression and Kaplan-Meier survival analyses were performed.

RESULTS

At an average follow-up of 6 years (range, 2-14 years), 58 reoperations (34%) were required, including 36 (21%) involving implant revision surgery. The majority of revisions were performed for either dislocations (n = 16) or pain and stiffness (n = 14). The 5- and 10-year survival-free of revision surgery rates were 79% and 77%, respectively. The risk for revision surgery was higher in patients with posttraumatic arthritis. There were 15 intraoperative complications involving a fracture and 26 postoperative complications, including 21 dislocations. In unrevised implants, patients had significant improvements in their preoperative to postoperative pain levels, with no change in their PIP joint total arc of motion. At a mean radiographic follow-up of 5.4 years, there were 28% with grade 3+ loosening and 36% with progressive implant instability. Implant loosening or progressive instability was not associated with worse pain or PIP joint total arc of motion.

CONCLUSIONS

Approximately 1 in 5 PIP joint arthroplasties with a pyrocarbon implant will require revision surgery by 5 years, and 1 in 3 will undergo more than 1 operation. Furthermore, 1 in 4 PIP joint arthroplasties will have grade 3+ radiographic loosening and 1 in 3 will have progressive loosening or subsidence by 5 years. These results are particularly concerning in young patients and those with posttraumatic arthritis. Overall, in patients that do not require revision surgery, pain relief was improved and motion maintained.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

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.

MatOrtho proximal interphalangeal joint arthroplasty: minimum 2-year follow-up

The MatOrtho proximal interphalangeal replacement is a cementless cobalt-chromium metal-on-polyethylene mobile-bearing surface replacement arthroplasty. The aim of this study is to report the outcome and complications of this implant at a minimum of 2 years follow-up from a single institution. A retrospective case review was performed on all MatOrtho proximal interphalangeal joint replacements performed with a minimum of 2 years follow-up. Patient demographics, diagnosis, implant revision and other surgical interventions were recorded. Subjective and objective outcomes were evaluated at latest follow-up, including pain scores, range of motion, function and radiographic assessment. A total of 109 implants were inserted in 56 patients. Nine implants (six patients) were lost to follow-up. Of the remaining 100 implants, 75 had been undertaken in females. The mean age at time of surgery was 64 years and the principal diagnosis was osteoarthritis in 74%. The mean follow-up was 47 months (range 24-77). Within the group there was a statistically significant diminution in pain. There was also an improvement in functional scores post-operatively. Improvement in range of motion was seen in those joints with a pre-operative range of motion greater than 20°. Radiologically there was no evidence of loosening or of implant subsidence at final follow-up. The revision rate was 13%. Nine joints were revised to the NeuFlex (silicone rubber) prosthesis, three were converted to an arthrodesis and one had exchange of the MatOrtho prosthesis. The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up. Patients can be advised that the procedure achieves good pain relief, improvement in functional scores and may improve range of motion. We would, however, caution against this implant's use in joints that are either stiff or have significant deformity and/or instability pre-operatively.

Post-Operative Contracture of the Proximal Interphalangeal Joint after Surface Replacement Arthroplasty Using a Volar Approach

Background: Postoperative contracture as a major complication of surface replacement arthroplasty (SRA) remains an unresolved problem. Contracture after SRA can occur early in the postoperative period due to mechanical dysfunction, and tardy contracture where ROM declines with time postoperatively is also reported.

Methods: 13 fingers with degenerative osteoarthritis and two fingers with post-traumatic arthritis where SRA was performed using volar approach were involved. Contracture was defined as limited ROM of less than 35 degrees. Cases were then categorized into two groups according to time of onset of contracture; early contracture and tardy contracture. Characteristic findings of postoperative X-rays in each contracture group were examined. Required procedures and efficacy of any further surgery was also reviewed.

Results: Early contracture was observed in three cases, all of which suffered intra-operative fracture or fragility of the central slip insertion on the dorsal rim of the middle phalanx. This was observed in a further two cases, both of which deteriorated to tardy contracture. Tardy contracture was observed in five cases, and the average ROM was 63 degrees preoperatively, 48 degrees one year postoperatively and 21 degrees at the most recent follow-up, or at the time of the second surgery. In the three cases, development of osteophyte formation on the volar aspect of the proximal head component was observed on the follow-up X-rays. Required further surgeries were resection of the volar plate in two cases, resection of ossification in one and resection of the osteophyte in two. The results of further surgeries were mediocre in all but one case.

Conclusions: This study showed that intra-operative fracture or fragility of the central slip insertion was a risk factor for postoperative contracture after SRA, and that development of osteophyte formation can be a cause of deterioration in ROM of the PIP joint.

Revision Proximal Interphalangeal Arthroplasty: An Outcome Analysis of 75 Consecutive Cases

PURPOSE

To examine the outcomes and complications associated with revision proximal interphalangeal (PIP) joint arthroplasty.

METHODS

An analysis of 75 consecutive revision PIP joint arthroplasties in 49 patients, performed between 1998 to 2012, was performed. The mean age at the time of surgery was 58 years. Thirty-two patients had a history of prior PIP joint trauma, and 18 patients had rheumatoid arthritis. There were 12 constrained (silicone) implants and 63 nonconstrained implants (34 pyrocarbon and 29 metal-plastic).

RESULTS

Over the 14-year period, 19 (25%) fingers underwent a second revision surgery. Second revision surgeries were performed for infection, instability, flexion contracture, and heterotopic ossification. The 2-, 5-, and 10-year survival rates were 80%, 70%, and 70%, respectively, for patients requiring a second revision for PIP joint arthroplasty. Worse outcomes were seen with postoperative dislocations, pyrocarbon implants, and when bone grafting was required. Two operations were complicated by intraoperative fractures, but neither required stabilization. Sixteen patients undergoing revision surgery experienced a postoperative complication, including 2 infections, 1 postoperative fracture, 3 cases of heterotopic ossification, and 10 PIP joint dislocations. The volar approach and the use of a pyrocarbon implant was associated with increased rates of heterotopic ossification, whereas preoperative instability increased the rates of PIP joint dislocation following revision. At a mean of 5.3 years (range, 2-10 years) follow-up, 98% of patients had good pain relief but decreased PIP joint total arc of motion.

CONCLUSIONS

Proximal interphalangeal joint arthroplasty in the revision setting represents a challenge for surgeons. Revision arthroplasty was associated with a 70% 5-year survival but with a high incidence of complications. Instability was associated with worse outcomes. In this series, silicone and metal-polyethylene implants had lower rates of implant failure and postoperative complications than ones made from pyrocarbon.