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Joint replacement- Osteotec silicone PIP joint replacement

    Overview

    Learn the Joint replacement: Osteotec silicone PIP joint replacement surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Joint replacement: Osteotec silicone PIP joint replacement surgical procedure.
    This is a detailed step by step instruction for a Middle finger Proximal inter-phalangeal joint (PIPJ) replacement with the Osteotec silastic PIP joint implant, uisng a dorsal midline approach.
    This is a procedure usually performed for osteoarthritis of the PIPJ with stable collateral ligaments. It can also be performed for post-traumatic or well controlled inflammatory arthritis as long as the bone stock and soft tissue stability can support the joint. As this is a one piece joint replacement a small amount of joint instability can be tolerated pre-operatively compared with 2 component joint replacements.
    Following a period of 1 week in plaster cast the patient then starts mobilisation with a Bedford finger splint and is provided with a night resting splint at 30 degrees metacarpal-phalangeal joint (MCPJ) flexion and straight PIPJs. The patient should achieve close to their pre-operative range of movement with minimal pain by 6 weeks and at this point should start strengthening exercises. The joint will always remain enlarged and swollen after the procedure compared to the pre-operative state although the majority of post operative swelling will resolve by 3 months.
    The silastic joint replacements will usually last beyond 5 years (see results section for further details). One major advantage of the silastic versus the metal and poly implants is their ease of revision as they are not cemented. Another advantage is that if the implant itself fractures on occasion the digit may still continue to be functional with a silastic implant.
    There are a number of small joint replacements manufactured for the hand which are very similar to the Osteotec silastic PIPJ replacement. The wide range of sizes and reamers on one tray however is a significant thing in the hand. This allows the surgeon the ability with a single kit to replace the MCPJ, PIPJ and distal inter-phalangeal joints (DIPJ) and deal effectively with a wide range of phalangeal sizes.
    Readers will also find of interest the following techniques on OrthOracle: Stryker SR MCPJ Cemented Joint replacement, PIP joint replacement (Middle finger): Stryker SR Metal on Poly implant, Fractional Tendon Lengthening and Swanson Silastic Metacarpophalangeal Joint Replacement (Wright Medical) for Spasticity

    Author – Mr Mark Brewster
    Royal Orthopaedic Hospital, Birmingham

    Indications

    Indications
    Osteoarthritis, inflammatory arthritis or post-traumatic arthritis resulting in pain and functional restriction from the PIP joint that has failed conservative management.
    Ideally the joint to be replaced will be stable and have a functional range and lack significant deformity.
    Symptoms
    The symptoms experienced are pain and stiffness which leads to reduced function and grip strength. In more severe cases night pain may be a problem for the patient. The operation is carried out in the main for pain. It will usually not improve the range of movement unless there is a specific bony block to that range. This is due to the progressive tightening of the soft tissues around the joint (collaterals and volar plate) that confer stability and remain in place or are repaired once the implants are inserted. If the joint is so stiff that a functional range of movement is not present then a fusion is the preferred operation. Maintaining 30 degrees of motion however can be of benefit and during surgical decision making this needs to be balanced with the likely need for revision surgery.
    The patient’s job and hobbies often play a major role in their symptoms and therefore discussing these details and realistic expectations of the post-operative outcomes are essential in treatment selection especially if they have a very good grip strength despite the pain. Very heavy manual work is often a cause for the arthritis and exacerbation of the pain. Additionally it is not advised to continue repetitive heavy manual work after joint replacement surgery as this is likely to significant decrease the lifespan of the implant. Fusion or denervation surgery or treating the patient non-operatively until retirement are the preferred solutions.
    The most painful joints are usually treated first and it is rare to have 4 very painful PIPJs. It is not uncommon however to operate on 2 PIPJs in one sitting, more than this is possible although may make rehabilitation slower and more painful and therefore yield suboptimal results in terms of range of movement.
    Examination
    A patient with PIPJ arthritis who requires surgery will usually have a swelling around the joint which will be a combination of synovitis and osteophytes. They will often have a restricted range of movement in both flexion and extension and a reduced grip strength.
    There is often some angulation at the joint due to an uneven collapse of the proximal phalanx condyles or erosion into the middle phalanx base. This is likely to be angulation in an ulnar direction due to the forces exerted on the joint by the thumb during tripod pinch in the index and middle fingers. When assessing the stability the surgeon has to differentiate between laxity due to uneven erosion of the bone stock and instability with no clear end point where it is likely the collateral ligaments are deficient.
    The joint may be painful to palpate and certainly be painful at extremes of movement. If they have considerable joint deformity and angulation (common in inflammatory arthritis) this would suggest poor soft tissue support and they would not usually be considered for this a cemented metal on poly bi-component replacement. A single piece plastic joint replacement as described here is usually more appropriate.
    They may have other arthritic joints, however it is not uncommon to have isolated PIPJ arthritis due to trauma.
    Investigations
    Investigations include plain PA and lateral radiographs of the effected joint.
    Non-operative Management
    Non-operative management for arthritis includes, analgesia, activity modification, Bedford splinting (which may be worn during certain activities and prevent accidental deviation and pain), physiotherapy with grip strengthening and steroid and local anaesthetic injections.
    The injections treat the synovitis not the wear to the joint.
    Alternative operative Management
    Alternative procedures for PIPJ arthritis include:
    Bi-component metal on poly or Pyrocarbon replacements.
    Arthrodesis.
    Denervation.
    If the arthritic joint is very stiff or unstable, the best surgical treatment is usually a fusion, which is a reliable intervention. If however a functional range of movement is required in the joint then movement preserving operations such as denervation of the joint or a joint replacement are preferable.
    Joint denervation can be a useful adjunct in PIPJ arthritis treatment but the pain often returns to the joint after 5 years. The choice between different types of implants often depends on surgeon preference and patient demand. A single piece silastic replacement such as the one in this description is preferred for lower demand patients or those with mild joint instability. As with all joint replacements in the body, the operation is designed to maintain, not increase, the range of joint motion.
    If a PIP joint is fused this will be in a functional position with the more radial digits that need to offer pinch grips to the thumb being at 25 (index) and 30 degrees (middle). The more ulna digits used for gripping to be more flexed at 35 (ring) and 40 degrees (little). Clearly these fusion positions will prevent a tight grip or the hand being able to flatten completely.
    Contraindications
    Absolute contra-indications
    Infection, skeletal immaturity and marked joint instability, poor bone stock.
    If a joint is so unstable, as with some inflammatory arthritis patients, that it will likely remain unstable with a non-fixed joint replacement such as this then an arthrodesis is preferable. Loss of bone stock can also be a contra-indication however this usually leads to gross instability and therefore the previous point will be considered.
    Relative contra-indications
    A very stiff joint which an arthrodesis may be a better option with fewer risks (particularly of revision surgery).
    A heavy manual job – which is likely to cause early failure (often when patients are a couple of years from retirement it may be advisable for them to delay surgery until retirement to prolong the life of the implant).
    A very distorted/collapsed joint – the soft tissues may be intact but very tight in this case and may require release to insert an implant- this group of patients may be best to be also consented for joint fusion or silastic single piece replacements with the option to convert inter-operatively if excessive soft tissue release required to insert a trial has made the joint unstable.

    Setup

    Pre-operative preparations and Equipment
    The operation can be performed under local, regional or general anaesthetic. The duration of surgery is around 1 hour. An upper arm tourniquet is applied and inflated to 250mmHg (a digital tourniquet may also be used if performing the procedure under local anaesthetic and if it will not interfere with operative technique).
    A clean air flow theatre is recommended for implant surgery and a change of gloves prior to implant insertion to reduce infection risk.
    Equipment – Osteotec TM implant tray with range of implants which cover from DIPJ to MCPJ with sizes (00-9), narrow saw blade, fine bone nibblers, bone burr, an image intensifier, plaster cast.
    A single dose of antibiotics are given pre-operatively.

    Operation – 1

    Dorsal midline skin incision is marked
    The midline incision marking is extended far distal and proximal to the intended incision to aid with alignment when reaming later in the surgery.

    The skin incision extends from the middle of the proximal phalanx to the middle of the middle phalanx

    Full thickness flaps are elevated off extensor hoodThis flap elevation is best achieved with the blade facing out of the wound and tilted 45 degrees. This places the blunt side of the blade onto the tendon to protect the tendon and with tension on the skin flaps with skin hooks the connective tissue can be pushed away in a sweeping motion rather than directly cut with the blade.

    The second skin flap is elevated.
    With the tension provided by the skin hooks the fibrous tissue connections to the tendons can be seen easily and divided safely which retains the dorsal digital nerves and veins in the skin flap.

    The tendon and capsule are then split in the midline as one down to the boneAn alms retractor is used to hold the skin edges.

    The insertion of the joint capsule on the proximal phalanx is being shown with the tip of the forceps.
    The true extensor tendon splits over the proximal phalanx to provide radial and ulnar slips to the lateral bands which blend with the intrinsic tendons and then sit dorsally either side of the PIPJ and are attached via the terminal tendon to the distal phalanx.
    The central part of the true extensor continues as the central slip and inserts into the middle phalanx and it is this section which is split during the procedure. The 2 lateral bands are not incised but simply retracted to either side.

    The insertion of the central slip tendon is then elevated radially and ulnarwards, continuous with the periosteumIf the periosteum is thick enough to remain attached to the tendon the radial and ulnar slips may be simply sutured together at the end of the procedure. If the surgeon finds these tendon ends are free and not attached to the bone after elevation then they will need to be reattached with a trans-osseous suture placed before implant insertion.


    The blade points to the bony joint line of the middle phalanx, now exposed. The tendon, retracted by the skin hook, can be seen to still be attached to the middle phalanx by the periosteum in this case.

    The radial tendon insertion is sharply elevated off the bone

    The joint is now clearly exposed and can be assessed for wear and deformity.
    Reviewing the open joint at this point highlights the wear areas and any possible areas of asymmetric bone wear and therefore asymmetric bone resection required.

    With the joint fully flexed the original joint surface can be differentiated from the pearlescent dorsal osteophytes on the head of the proximal phalanx.

    The capsule and extensor tendon are bluntly elevated off the collateral ligaments.

    The insertion of the collateral ligament is identified to aid planning level of bony cutsWith the skin hook in the tendon, the limbs of the forceps are seen overlying the fibres of the collateral ligament to demonstrate the fibres direction from their proximal insertion angled towards the volar aspect of the middle phalanx.
    The collateral ligaments are a discreet, easily identifiable structure (once exposed) which are deep to the extensor tendons. Overlying them is often a thin synovial layer which hides the direction of the fibres as described and makes initial identification unclear until this is elevated.

    The capsular tissue on the neck of the proximal phalanx is elevated to expose the bony architecture

    The dorsal osteophytes are removed from the proximal phalanx head with bone nibblers

    The dorsal osteophytes are removed from the base of the middlel phalanx with bone nibblers

    The insertion of the collateral is identified and any overlying soft tissues removed
    In this case, due to the erosion of the ulnar condyle of the proximal phalanx head, the collateral insertion is almost on the joint line and therefore there is very little bone that can be removed distal to this without damaging the integrity of the collateral.

    The distal half of the collateral ligament insertion is released off the proximal phalanx head.To protect the collateral ligament and allow for enough bony resection to receive the implant the distal half of the collateral insertion is elevated off the phalanx head.

    Midline is drawn on the proximal phalanx and the perpendicular line is observed over the condyles with a McDonalds retractor, to assess the symmetry of the wear from the articular surfaces.It can be seen that with the McDonalds perpendicular to the shaft line there is more erosion of the ulnar condyle of the phalanx head, seen by the gap between the bone and the instrument. This needs to be taken into consideration when cuts are made. The bone resections need to allow enough space for the implant and be parallel to align the joint.

    A line perpendicular to the shaft of the phalanx is marked This perpendicular line is made proximal to the intended cut site. The McDonalds retractor in the image marks the cut site and the drawn line is proximal to this to act as a guide which is visible throughout the cutting process. If a line is drawn on the intended cutting point then this line will be obscured and obliterated by the saw as soon as sawing commences.
    The amount of bone resected will depend on the level of erosion and the implant used. For the PIPJ usually around 2-3mm is resected from either bone at its longest point. The very eroded areas may require no resection. As noted the resection is also mediated to the level of the collateral ligament insertions. It is always better to resect less and then recut than over-resect however if excessive resection is performed a larger implant may be used if it does not overhang the bone edges or if the resection has created joint instability then a fusion procedure may need to be required.

    The collateral ligaments are protected with retractors during sawingIf there are enough assistants then both collaterals can be protected throughout, if not then the retractors are moved to the other collateral as the saw progresses across the bone.
    The neuro-vascular bundle is volar and proximal to the saw with the PIPJ flexed in this position and therefore at minimal risk. A further retractor can be placed over the middle phalanx to protect it during sawing however with careful sawing it should not be damaged and as it still needs to be cut then a small saw mark will likely be removed by the subsequent saw resection of the joint surface.

    The proximal phalanx head is removed with a power saw.For accuracy it is best to hold the saw in one hand and rest your other hand one the table for stability and guide the saw with the thumb of your rested hand on the saws body.
    The cut must be perpendicular to the shaft in both a radial-ulnar and dorsal-volar direction to give the bone a flat top. this can be achieved holding the finger parallel to the table meaning a vertically orientated blade with be used when cutting.

    Saw blade used in this case

    The middle phalanx is inspected and soft tissues circumferentially released for 1-2mmThe deep erosion of the ulnar joint surface of the middle phalanx (A) can be seen
    With the proximal phalanx cut complete it is easier to access the middle phalanx base and therefore the time to release around it.
    The collaterals and volar plate are released for around 1-2 mm and should ideally remain attached however if a full release is required to allow bony reset (often only on the tighter side of the joint) then this can be repaired later on if elevated as a sheet with the periosteum.
    The true collateral ligaments attach to the volar third of the lateral aspects of the middle phalanx. The volar continuation of these are the accessory collaterals which insert into the volar plate. The true collaterals and volar plate therefore cover the whole volar aspect and the volar third of the radial and ulnar aspects of the middle phalanx as a U-shaped support. They all insert from the proximal edge over a few mm distally and then blend with the periosteum. This whole volar flap is therefore elevated as one during the preparation of the middle phalanx.
    The release allows safe retraction of the ligaments whilst the bony cut is performed.

    The middle phalanx base is resected with a power saw while protecting the collateral ligaments

    Operation – 2

    As with the proximal phalanx head, the middle phalanx base needs to be cut perpendicular to the shaft in both planes.
    Due to the increased erosion of the ulnar aspect of this joint the cut often is of a couple of mm on entry and then beneath the ulnar aspect of the joint the cut becomes very thin to the extent where you may see the silver of the saw blade through the bone.
    The piece of bone removed in this case will a few mm thick at the dorsal and volar aspects, 1-2mm thick in the concavity of the less eroded radial aspect and so thin that it is almost translucent in the concavity of the ulnar joint line. (Seen 2 slides ahead).

    Despite initial soft tissue release there often remains some periosteal, volar plate or collateral ligament attachments to the fragment which need to be released with sharp dissection.

    Completion of sharp dissection.
    Translucent thin ulnar joint resection seen.

    The joint space is examined in extension to assess whether adequate space exists for the implant.In this case there is clearly not enough gap between the bone ends to place the implant. If unsure a trial implant can be held over the gap. The implant can be turned on its side and the transverse limb inserted between the bones to see the fit. The gap needs to be around 1mm larger than the implant.

    Assess soft tissue to decide where more soft tissue release and bony excision should occur.
    In this case any further proximal resection would detach the collateral ligaments (indicated by the tip of the forceps).
    The decision therefore was made to further release and excise bone off the middle phalanx.

    The collateral ligaments and volar plate are further released distally to open the joint space.
    During resection the surgeon should aim to remove bone equally from the middle and proximal phalanx to maintain the joint line. This is balanced with the need to protect the collateral ligament integrity which is more important as the proximal insertion as the distal insertion if elevated with the periosteum can more easily be reattached..

    The trial implant is used to choose size requiredThe trial implant can be laid over the bone ends and the largest implant which will not overhang the bone edges is selected.
    Once selected using the cross section of the bone the trial can then be used to assess if the gap between the bones in extension is adequate.

    Joint gap is assessed in extension compared to chosen implant.The joint space here was too narrow and opened unevenly with more opening on the radial aspect.
    Further bony resection was required.

    Further resection of middle phalanx performed

    Joint space reassessed with trial implant and is seen to be even and adequate for the implant in extension.
    The implants cannot overhang the radial and ulnar aspects of the bones and therefore this determines maximum size. The implants themselves gradually increase inside both in length of the stems but also the the size of the central transverse limbs which determine the joint gap. Ideally the largest size possible is used however if the gap is slightly tight and further soft tissue release or bony resection may be detrimental then the implant can be be dropped by one size to allow for implant fit.

    Instrument and trial implant tray for the Osteotec implant.

    The starter awl is placed central dorsal-volar and central radial-ulnar in the proximal phalanxThe starter awl is a sharp spike used to find the centre of the implant entry point and then subsequent reaming.

    The awl is marked against trial implantAs the awl has a different taper to the trial implant the width of the awl and trial are not the same at a given depth. This means to make an adequate entry hole for the implant the awl needs to be advanced much further.
    Due to the different sizes of implants and the 2 different sizes of stem on the single implant (proximal stem longer) the awl could not be the same taper as all the stems it prepares holes for.
    If the awl is laid over the implant so that its width is the same as the trial at the base of the stem it can be marked as an indicator as to the depth the awl needs to be inserted.

    The difference in length of trial and awl can be seen

    A burr is used to widen the entry point for the implant trial.Due to its longer taper the awl may bottom out before creating the correct entry hole size and therefore a burr may be required. This may also be the case in sclerotic bone to help widen the hole.
    A burr is usually required for PIPJ and DIPJs however unless very sclerotic the reamers on the kit are usually sufficient when using this implant for MCPJ replacements.
    In the Osteotec TM system there are only reamers for the larger sizes used in MCPJ replacements.
    For a PIPJ only the awl is used to create the hole with a burr as an adjunct.
    The burr used here was a 3.1 x 51mm round burr.

    This trial is still a little proud and not sitting down on the bone. A burr is then used to further enlarge the entry point.

    The trial implant is seated flush to the bone in the proximal phalanx.The trial now sits easily down onto the bone with the longer of the two limbs in the proximal phalanx

    The awl is inserted into the middle phalanx, following which a burr is used to widen this entry hole.Normally the awl is inserted centrally in the radial-ulnar and volar-dorsal position however depending on the amount of deformity of the bone and the level of bone resected there may sometimes be a dorsal flare which would require a more volar than central insertion site.
    This can be assessed by examining the dorsal surface of the bone for a flare or assessing position of the awl placement on a lateral view on an image intensifier.

    A burr is used to widen the entry hole.
    This step is usually required due to the shorted length of the middle phalanx limiting the awls advancement.

    Once again the trial is standing slightly proud and therefore more burring of the entry hole is required.

    The trail is inserted into both bones, once both phalanges have been prepared.Once sitting down in the middle phalanx the trial can be fully inserted. With the longer stem in the proximal phalanx this needs to be inserted first and then NON-toothed forceps used to bend over the implant with the finger in full flexion to insert the trial into the middle phalanx.
    Is is crucial that toothed forceps are not used as these readily damage the trial and implant.
    It is also important as in all implants that the surgeon practices a slick and safe way to insert the trial with minimal handling and not allowing it to touch the skin so that when the final implant is inserted, this runs smoothly.

    Trial in-situ

    The range of movement of the joint is a assessed with the trial in situ.If the size of the implant and gap have been carefully chosen then a full range of motion is usually possible on table. Occasionally a slight loss of extension due to tight volar structures is seen pre- and intra-operatively which can be accepted. If there is a significant loss of motion compared with pre-operative state then the implant and gap size need to be reassessed.
    If the joint is very unstable in the lateral directions at this point then a fusion procedure may need to be considered however often it will be moderately unstable due to the collateral release on one side of the joint and this can be resolved by repair of these structures with a suture as demonstrated later in this procedure.

    Full extension is shown.

    Flexion achieved is artificial with the dorsal of the joint and the extensors open, however a good estimate can be achieved with simple tenodesis with an extended wrist and pressure on the flexor tendons proximal to the wrist.

    Operation – 3

    The trial is removed and bones washed out with a syringe and saline.If the extensor tendons were detached and not held with periosteum then this is the point at which a suture through the bone should be inserted.
    Two holes are drilled with 1.2mm k-wires from the dorsal of the middle phalanx into the canal with an adequate bone bridge.
    A braided suture (4/0 ethibond) is then passed from dorsal into the canal and then back into the canal and out of the second dorsal hole. This is then left free until the implant is inserted and the tendon repair is need.
    It was not required in this case.

    The final implant is inserted, its range and stability tested and joint closure undertaken.

    Non-toothed forceps are used in the same technique as the trial was inserted.

    Implant in-situ.
    As the implant is not fixed it pistons in the phalanges. In full flexion it therefore will slide out of the bone slightly and in extension should be seated on the bone as demonstrated with the trial.

    Repair of Radial collateral ligament.
    During the procedure the collateral ligament was released distally and the periosteum which remained was very friable and therefore on assessing joint stability with the implant in-situ the radial joint line was opening up. A 4/0 vicryl was therefore used to repair the collateral ligament to distal periosteum.

    If possible the capsule is be repaired separately however if not the capsule and extensor can be repaired en-mass.
    This is performed with a continuous suture of the surgeons preference (in this case 4/0 vicryl). Alternatively if a trans-osseous suture was used to reattach the tendon, this may be used to complete the repair.

    The completed extensor repair.

    Range of movement is assessed by tenodesis once the extensor is repairedExtension is assessed with full wrist flexion. In full passive wrist flexion the extensor tendons are put on stretch and the flexor tendons relaxed which extends the fingers via the tenodesis effect.

    Flexion is assess with full wrist extension.
    The passive wrist extension tightens the flexors and relaxes the extensors to flex the fingers via the tenodesis effect.

    Following skin closure with 4/0 vicryl rapide an occlusive dressing its applied, gauze, wool and volar plaster slab which is removed in a week at first appointment.

    PA pre-operative image of arthritis middle PIPJ.

    Lateral Radiograph in full extension intra-operatively.
    This allows assessment of the parallel bony cuts and the full extension of the joint.

    Lateral Radiograph in full flexion intra-operatively.
    The opaque implant can be seen between the bone ends revealing no bony impingement in flexion and the amount of flexion is assessed – around 80 degrees.

    PA Radiograph intra-operative in extension shows an acceptable finger alignment however a slightly larger joint space radially than ulnar is seen due to some slight laxity on the radial aspect and an increased bone resection on the radial middle phalanx. This is within acceptable limited.

    Post Operative

    POST OP
    The procedure is performed as a daycase where possible.
    We provide paracetamol, ibuprofen, codeine on discharge (referencing allergies and intolerances as appropriate).
    The patient will return to clinic within a week for a wound review and hand therapy. The sutures are dissolvable and the patient is instructed to keep the wound clean and dry for 14 days and then wash there hands as normal when the sutures will drop out.
    The therapists provide a Bedford finger splint for the patient to mobilise as able during the day and a night resting splint at 30 degrees MCPJ flexion and straight PIPJs for 6 weeks. The patient should see the therapist weekly for the first few weeks to check progress and encourage a range of movement exercise. It is helpful for the therapist if the surgeon documents the intra-operative range of movement on the surgical note as this will act as a target and the maximum possible for the patient to aim for.
    Strengthening exercises can begin at 6 weeks and most patients should expect to have most of their grip strength and final range of movement by 3 months.
    It will usually take patients 6-8 weeks to return to light work and 3-6 months to return to heavier work.
    The joint will always remain enlarged and swollen after the procedure compared to the pre-operative state although the majority of post operative swelling will resolve by 3 months.
    A post operative radiograph is routinely taken at 6 weeks, 6 months and 12 months post surgery.

    Recommended Reading

    Takigawa S1, Meletiou S, Sauerbier M, Cooney WP. Long-term assessment of Swanson implant arthroplasty in the proximalinterphalangeal joint of the hand. J Hand Surg Am. 2004 Sep;29(5):785-95.
    This study retrospectively reviewed PIPJ silastic implants with a mean follow up of 6.5 years. 70 joints in 48 patients were replaced for a mixture of pathologies. Range of movement (ROM) was 26 pre vs 30 degrees post-op. Swan-neck and boutonniere deformities did poorly. Extensor lag often improved ( mean 32 pre and 18 degrees post-op). Pain relief was present in almost three quarters, bone cysts at follow up in just under half. There were similar revision and fracture rates in around 15% each. Rheumatoid patients tendered to have worse outcome functionally.
    Yamamoto M1, Malay S, Fujihara Y, Zhong L, Chung KC. A Systematic Review of Different Implants and Approaches for Proximal Interphalangeal Joint Arthroplasty. Plast Reconstr Surg. 2017 May;139(5):1139e-1151e.
    This study reviewed 40 published papers on PIPJ replacements including volar and dorsal approaches, metal on poly, pyrocarbon, silicone, cemented and uncemented. They concluded that the mean post-op ROM and gain in ROM were greater for a volar than dorsal approach (58 vs 81 and 17 vs 8 degrees respectively).
    Volar approach for silicone joint was best with 6% revision at 41 months while dorsally inserted 2 piece replacements was worst with 18% revision at 51 months. All silicone replacements had lower revision rates than 2 piece replacements.
    Of the revision surgeries around a quarter were a revision to a silicone implant from bi-component implant, a seventh were arthrodesis, around 10% were revision to same implant or explantation, 5% amputation and less than 1% infection.
    This study reviewed 40 published papers on PIPJ replacements including volar and dorsal approaches, metal on poly, pyrocarbon, silicone, cemented and uncemented. They concluded that the mean post-op ROM and gain in ROM were greater for a volar than dorsal approach (58 vs 81 and 17 vs 8 degrees respectively).
    Volar approach for silicone joint was best with 6% revision at 41 months while dorsally inserted 2 piece replacements was worst with 18% revision at 51 months. All silicone replacements had lower revision rates than 2 piece replacements.
    Of the revision surgeries around a quarter were a revision to a silicone implant from bi-component implant, a seventh were arthrodesis, around 10% were revision to same implant or explantation, 5% amputation and less than 1% infection.

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