The Volar Approach to Proximal Interphalangeal Joint

Transcription

TECHNIQUE
The Volar Approach to Proximal Interphalangeal
Joint Arthroplasty
Scott F. M. Duncan, MD, MPH,* Marianne V. Merritt, RN, RNFA,Þ and Ryosuke Kakinoki, MD, PhDþ
Abstract: Proximal interphalangeal joint arthroplasty has resulted in
good outcomes in patients treated for osteoarthritis, posttraumatic
arthritis, and rheumatoid arthritis. Most hand surgeons complete arthroplasties of the proximal interphalangeal joint through a dorsal approach.
However, for the past 7 years, we have had positive results with a volar
approach. We describe this technique, which avoids injury to the
extensor tendon and allows for a more simplified approach to postoperative therapy compared with the therapy regimen required after the
dorsal approach.
Key Words: arthritis, arthroplasty, finger joint, implant, volar plate
(Tech Hand Surg 2009;13: 47Y53)
HISTORICAL PERSPECTIVE
One of the greatest challenges for hand surgeons is the treatment
of the conditions that afflict the proximal interphalangeal (PIP)
joint. This bicondylar joint has extreme flexibility and stability
throughout its arc of motion, which are difficult to replicate
after the joint has experienced injury or degenerative changes.1
Arthroplasty is a well-established treatment option for the PIP
joint that has developed pathologic characteristics.
In the 1950s, fibrous and resection types of arthroplasties
were reported.2 These included the volar plate arthroplasty still
commonly used today for management of various PIP joint
conditions.3 Brannon and Klein4 introduced implant arthroplasty in 1959. They used a hinged prosthesis that could be
implanted in the PIP joint and in the metacarpophalangeal joint.
Early results were promising; however, long-term follow-up revealed implant loosening and fracture. Since then, several types
of implants have become available.5Y9
In 1966, silicone prostheses were introduced. The Swanson
(1969) and Sutter (1987) prostheses became 2 of the most
popular types. Numerous authors have published both shortterm and long-term results of studies examining these types of
implants.5,8 These implants were mostly placed in patients with
rheumatoid arthritis of the PIP joints. However, problems with
implant fracture, silicone synovitis, subsidence, instability, and
limited range of motion were all noted as long-term complications.3,6,10 These problems were also observed in patients with
osteoarthritis.10,11 The problems with silicone implants inspired
the development of implants made of more substantial materials.
Mechanically, the new implants have been developed in 1 of 2
ways. In the United States, an unconstrained surface replacement design is more commonly used in contrast to the constrained hinged design that is more commonly used in other
countries.
From the Department of Orthopedic Surgery, Owatonna ClinicYMayo Health,
System Owatonna, MN; †Department of Surgery, Mayo Clinic, Scottsdale,
AZ; ‡Department of Orthopedic Surgery, Graduate School of Medicine,
Kyoto University, Kyoto, Japan.
Address correspondence and reprint requests to Scott F.M. Duncan, MD,
MPH, Owatonna Clinic Southview, 134 Southview, Owatonna, MN
55060. E-mail: [email protected].
Copyright * 2009 by Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
&
Two major US suppliers of surface replacement devices
are Small Bone Innovations (Morrisville, Pa), which produces
implants with a cobalt chrome alloy on polyethylene, and
Ascension Orthopedics (Austin, Tex), which produces a
pyrocarbon-based implant. Both of these implants can be placed
using similar techniques.
First described by Swanson,12 the dorsal approach is the
most common technique for PIP joint arthroplasty. It is difficult
to challenge the dorsal technique, given its more than 40 years
of use. Numerous articles on PIP joint arthroplasty have described the dorsal technique.5Y9,11Y17 These reports have shown
it to be a reproducible technique that preserves preoperative
mobility, in general, and improves joint pain in most cases. The
dorsal approach, however, is not without problems. Whether a
midline or a Chamay18 exposure is used through the extensor
tendon, the technique can still result in considerable extensor
tendon scarring and adhesions, impairing the mobility of the
PIP joint. Furthermore, attenuation of the extensor tendon can
result in extensor lag.6,7,9,11,13,17 The central slip can also sustain disruption from its insertion due to overzealous surgical
dissection. This disruption of the extensor moment can be
problematic because it can be quite difficult to reestablish the
appropriate extensor moment postoperatively. The delicate nature of the extensor mechanism also necessitates holding the
joint in extension for a longer period of time than would be
required with the volar approach, potentially resulting in
scarring and adhesions of the extensor tendon. In addition,
protecting the extensor system requires a much more complicated postoperative therapy course that includes outrigger splints
and more supervised hand therapy. Compared with the dorsal
approach, the volar approach requires less use of these complicated splints and fewer hand therapy visits.
Despite some of the inherent advantages of the volar
approach, it is not without its detractors. Linscheid6 reported
problems in a series of 10 patients with swan neck deformities
and flexion contractures caused by flexor tendon scarring. We
have not encountered these problems to the degree that he
described in his article. Our lower rate of complications is most
likely because of our meticulous attention to repairing the flexor
tendon sheath and our application of a postoperative dorsal
blocking splint, which is an integral part of the therapy process.
In our practice, the volar approach has become the standard
approach for primary PIP joint arthroplasty.
INDICATIONS AND CONTRAINDICATIONS
The main indication for PIP joint arthroplasty is pain
caused by joint destruction. Other indications are deformity and
limited joint motion. Virtually all types of joint destruction have
been treated by PIP joint arthroplasty with varying degrees of
success.5,6,9,14,15 These include osteoarthritis, rheumatoid arthritis, other inflammatory arthritides, and posttraumatic arthritis.
Contraindications for PIP joint arthroplasty include acute
or chronic infection, substantial periarticular bone loss on each
side of the joint, irreparable flexor or extensor tendon deficits,
ligament instability that cannot be corrected with ligament
Volume 13, Number 1, March 2009
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
47
Duncan et al
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FIGURE 1. Palmar view with area marked for Bruner incision.
reconstruction or increased implant size, silicone synovitis, neuropathic arthropathy, or soft tissue defects.3,9,19 Other relative
contraindications include palmar-to-dorsal instability, sclerosis
or narrowing of the medullary canals, arthritis mutilans, ankylosis, or previous arthrodesis.3,9,19 Fusion may be better for the
PIP joint of the index finger if it is lacking a collateral ligament
or if it is in a high-demand patient.7,11 However, given the
surgical challenges involved in some of these more demanding
conditions, the patient and surgeon need to be prepared for
various possible complications during and after surgery.
TECHNIQUE
The first step in the volar approach is a Bruner incision
centered over the flexion crease of the PIP joint (Fig. 1). The
skin flap is elevated, and care is taken to protect the radial and
ulnar digital neurovascular bundles. The flexor tendon sheath is
then entered between the A2 and A4 pulleys (Fig. 2). As the
sheath is entered, it is protected so that it can be repaired at the
end of the procedure (Fig. 3). A Penrose drain is then placed
under the flexor tendons so that they can be retracted either
radially or ulnarly to allow for greater visibility of the joint
(Fig. 4). The proximal aspect of the volar plate is reflected from
the proximal phalanx (Fig. 5). Care is taken to maintain the volar
plate’s distal attachment on the middle phalanx. The volar plate
will be repaired at closure.
FIGURE 2. Tendon sheath exposed.
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FIGURE 3. A, A3 pulley incised. B, A3 pulley elevated.
The collateral ligaments are then mobilized from the proximal phalanx but are reinserted again at the end of the procedure (Fig. 6). At this point, with the volar plate and collateral
ligaments released, the joint can be shotgun opened (Fig. 7)
to expose the particular surfaces. To avoid difficulty with reattachment, the surgeon should pass the collateral ligaments
through drill holes before inserting the implants. The head (ie,
the articular surface) of the proximal phalanx is removed with
a microsagittal saw. Some systems include jigs with alignment
guides. With or without guides, extreme care should be taken to
make the cuts as perpendicular as possible to the long axis of
the proximal phalanx. Deviation from perpendicular placement
will result in the digit becoming misaligned after the components are inserted.
The surface replacement systems usually can be used to
remove approximately 2 mm of bone from the base of the
middle phalanx. The surface also needs to be cut perpendicular
to the shaft of the middle phalanx (Fig. 8). Some patients may
have large osteophytic ridges in the areas of the condyles and
around the point where the collateral ligaments originate. These
osteophytes should be carefully débrided with a rongeur. However, the surgeon should avoid damaging the collateral ligaments
of the middle phalanx. In the next step in the process, the intramedullary cavities are entered with awls or Kirschner wires
(Figs. 9 and 10). Broaches are then used to size and prepare
the proximal and distal medullary canals for the implants
(Fig. 11). With the volar approach, care should be taken to avoid
disrupting the extensor insertion on the middle phalanx by
* 2009 Lippincott Williams & Wilkins
&
Volar Approach Arthroplasty
FIGURE 6. Collateral ligaments released.
FIGURE 4. Flexor tendons retracted with a Penrose drain to show
volar plate.
motion around the digit. Trial components are usually placed
first and checked under fluoroscopy to test for appropriate size
and seating (Fig. 12). The perfect arthroplasty would have a
motion of 0 degrees of extension and 95 degrees of flexion
(Fig. 13). If the surgeon is satisfied with the position of the
trial implants, the range of motion, and the tissue tensioning
of the joint under fluoroscopy, the permanent implants can be
placed. Depending on the system, either these can be press fitted
or cemented (Fig. 14). Again, the collateral ligaments should be
reattached to the middle phalanx through drill holes, if possible, and then repaired with nonabsorbable sutures (Fig. 15).
excessively cutting with the saw. In sclerotic bone, a high-speed
burr can be helpful in initiating the broaching of the canals.
Broaching and reaming should be maintained along the long
axis of the canal. Any broaching or reaming away from this
axis could result in the angular placement of the stem of the
prosthesis.
Prosthesis size is determined by the size of the joint and
the ability of the medullary canal to hold the stem of the prosthesis. With surface replacement arthroplasty, joint instability
can result from using an implant that is too small. However, if
the implant is too large, undue tension on the tissue can impede
FIGURE 5. Volar plate elevated proximally by sharp dissection.
FIGURE 7. Proximal interphalangeal joint shotgun opened,
demonstrating the excellent exposure of joint surfaces.
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Duncan et al
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FIGURE 8. Proximal and distal phalanx cuts.
With a permanent suture, the volar plate is reapproximated to
the part of the volar plate that is left on the middle phalanx or to
the soft tissue of the middle phalanx. Finally, the A3 pulley is
repaired with a permanent suture (Fig. 16). The wounds are
thoroughly irrigated, and the incision is carefully closed with
5Y0 nylon. The digit is then splinted in 35 to 45 degrees of
flexion at the PIP joint for 3 to 4 days.
Hand therapy is then initiated, and immediate active range
of motion is started with a dorsal blocking splint (Fig. 17). This
splint keeps the PIP joint flexed at approximately 5 to 10 degrees
to prevent any hyperextension of the joint. When possible, a
buddy strap is attached to the adjacent radial digit. Splinting is
usually discontinued at 6 weeks, unless there are clinically significant extension or flexion lags. If such a complication occurs,
the therapy protocol incorporates custom dynamic splints and
static splints. Of the patients reported on, all of them received
hand therapy in the first 3 to 4 weeks. Unsupported use of
the finger is possible in most patients by 5 to 6 weeks. In some
patients, buddy strapping may be required for up to 12 weeks.
FIGURE 10. Kirschner wire placement for starting point and
canal reaming guidance.
The purpose of PIP treatment is to provide a stable congruous joint that is pain free and that has a functional arc of
motion. However, given the condition of the joints before ar-
throplasty, these goals are rarely achieved fully. For optimal
results, the patient should be checked frequently, and postoperative radiographs should be obtained to ensure that the joint
remains reduced.
Complications of PIP joint arthroplasty include deformity,
contracture, dislocation, loosening, intraoperative fracture,
infection, tendon disruption or rupture, and flexor or extensor
tendon adhesions or both. The volar approach may result in
flexor tendon bowstringing and swan neck deformities caused by
volar plate disruption. Keeping the PIP joint slightly flexed will
usually prevent a swan neck deformity. The therapist involved in
FIGURE 9. Awl to help open up bones.
FIGURE 11. Broaching of canals.
COMPLICATIONS
50
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FIGURE 12. Trial implants placed.
FIGURE 14. A, Permanent implants placed. B, Joint reduced
with permanent implants.
the patient’s care should understand that attempts to stretch the
PIP joint could result in a swan neck deformity and that extreme
stretching should be avoided. Edema control is also imperative
to achieve a satisfactory range of motion and should be addressed early on during rehabilitation. Tube wrap or selfadherent compression wrap can be used to help alleviate this
problem. Another possible problem with the volar approach is
scarring of the volar incision, which may require excision of
the scar tissue and skin grafting. We have not observed this
complication, but it has been reported.6
FIGURE 13. A, Joint reduced and alignment checked with
anteroposterior fluoroscopic imaging. B, Joint reduced and
alignment checked with lateral fluoroscopic imaging.
CONCLUSIONS
In general, PIP joint arthroplasty can be a successful treatment for the patient experiencing pain caused by an arthritic
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Duncan et al
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FIGURE 15. Repair of collateral ligaments and volar plate.
FIGURE 17. Hand therapy splint.
PIP joint. We believe that the volar approach has many advantages over the dorsal approach and have been encouraged by
our results.20 In our study, the report of which is pending
publication, we examined results of the replacements of 25 PIP
joints that had been placed through the volar approach during
a 5-year period. Follow-up averaged 33 months. The average
preoperative total arc of motion improved from 42 to 56 degrees.
Our results were as good as or better than the published results for PIP arthroplasty through a dorsal approach.20 As with
any surgery, the key to success is multifactorial. The surgeon’s
comfort level with the procedure and the patient’s compliance
with postoperative therapy both play a part in maximizing the
outcome.
REFERENCES
1. Minamikawa Y, Horii E, Amadio PC, et al. Stability and constraint
of the proximal interphalangeal joint. J Hand Surg Am. 1993;
18(2):198Y204.
2. Carroll RE, Taber TH. Digital arthroplasty of the proximal
interphlangeal joint. J Bone Joint Surg Am. 1954;36-A(5):912Y920.
3. Amadio PC. Arthroplasty of the proximal interphalangeal joint. In:
Morrey BF, ed. Joint Replacement Arthroplasty. New York: Churchill
Livingstone; 1991:147Y157.
4. Brannon EW, Klein G. Experiences with a finger-joint prosthesis.
J Bone Joint Surg Am. 1959;41-A(1):87Y102.
5. Swanson AB, Maupin BK, Gajjar NV, et al. Flexible implant
arthroplasty in the proximal interphalangeal joint of the hand. J Hand
Surg Am. 1985;10(6 Pt 1):796Y805.
6. Linscheid RL. Implant arthroplasty of the hand: retrospective and
prospective considerations. J Hand Surg Am. 2000;25(5):796Y816.
7. Sauerbier M, Cooney WP, Berger RA, et al. Complete superficial
replacement of the middle finger joint: long-term outcome and surgical
technique [Article in German]. Handchir Mikrochir Plast Chir.
2000;32(6):411Y418.
8. Mathoulin C, Gilbert A. Arthroplasty of the proximal interphalangeal
joint using the Sutter implant for traumatic joint destruction.
J Hand Surg Br. 1999;24(5):565Y569.
9. Bravo CJ, Rizzo M, Hormel KB, et al. Pyrolytic carbon proximal
interphalangeal joint arthroplasty: results with minimum two-year
follow-up evaluation. J Hand Surg Am. 2007;32(1):1Y11.
10. Foliart DE. Swanson silicone finger joint implants: a review of the
literature regarding long-term complications. J Hand Surg Am.
1995;20(3):445Y449.
11. Pellegrini VD Jr, Burton RI. Osteoarthritis of the proximal
interphalangeal joint of the hand: arthroplasty or fusion? J Hand
Surg Am. 1990;15(2):194Y209.
12. Swanson AB. Implant resection arthroplasty of the proximal
interphalangeal joint. Orthop Clin North Am. 1973;4(4):1007Y1029.
13. Stanley JK, Evans RA. What are the long term follow-up results of
silastic metacarpophalangeal and proximal interphalangeal joint
replacements? Br J Rheumatol. 1992;31(12):839.
FIGURE 16. Closure of A3 pulley.
52
14. Johnstone BR. Proximal interphalangeal joint surface replacement
arthroplasty. Hand Surg. 2001;6(1):1Y11.
&
15. Hage JJ, Yoe EP, Zevering JP, et al. Proximal interphalangeal joint
silicone arthroplasty for posttraumatic arthritis. J Hand Surg Am.
1999;24(1):73Y77.
18. Chamay A. A distally based dorsal and triangular tendinous flap for
direct access to the proximal interphalangeal joint [Article in English
and French]. Ann Chir Main. 1988;7(2):179Y183.
16. Takigawa S, Meletiou S, Sauerbier M, et al. Long-term assessment of
Swanson implant arthroplasty in the proximal interphalangeal joint
of the hand. J Hand Surg Am. 2004;29(5):785Y795.
19. Linscheid RL, Dobyns JH. Total joint arthroplasty: the hand.
Mayo Clin Proc. 1979;54(8):516Y526.
17. Tuttle HG, Stern PJ. Pyrolytic carbon proximal interphalangeal joint
resurfacing arthroplasty. J Hand Surg Am. 2006;31(6):930Y939.
20. Duncan SFM, Smith AA, Renfree KJ, et al. Results of the volar
approach in proximal interphalangeal joint arthroplasty. J Hand Surg.
Publication pending 2008.
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The Volar Approach to Proximal Interphalangeal Joint

Transcription

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