In Reply

Abstract

We appreciate the authors' interest in our recent work and are encouraged to hear that others are exploring the value of the volar approach to injecting the proximal interphalangeal joint. Saito et al describe a variation on the volar approach that takes advantage of the results of their recent biomechanical study.1Saito S. Suzuki S. Suzuki Y. Biomechanical differences of the proximal interphalangeal joint volar plate during active and passive motion: a dynamic ultrasonographic study.J Hand Surg Am. 2012; 37: 1335-1341Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although we did not detect a change in conformation of the volar plate in our anatomic study,2McClelland Jr, W.B. McClinton M.A. Proximal interphalangeal joint injection through a volar approach: anatomic feasibility and cadaveric assessment of success.J Hand Surg Am. 2013; 38: 733-739Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar we did observe an increased distance between the volar plate and proximal phalanx head with passive joint flexion that increases the volar capsular volume. This increased space between the soft tissues and bones of the proximal interphalangeal joint contributes to the success of our technique. Both techniques demonstrated an equivalent rate of success (defined as injection material within the proximal interphalangeal joint capsule), but ours was done without the use of ultrasound.By the authors' own admission, their technique is more complicated. We feel that the true value of our technique is in its simplicity. This results in fewer variables to be managed by the practitioner and should lead to increased reproducibility. We believe that this could result in a quicker procedure (and therefore less patient discomfort) and one that is easier to teach, making it a desirable technique for trainees. We have concerns about the patient experience using the technique of Saito et al and would question how much patient discomfort is involved in actively flexing the digit during the process of needle insertion. If the patient is unable to maintain the digit in a flexed posture, the needle will be effectively withdrawn from the volar joint capsule.We are currently evaluating this technique clinically and will consider the active flexion modification going forward. We appreciate the authors' interest in our recent work and are encouraged to hear that others are exploring the value of the volar approach to injecting the proximal interphalangeal joint. Saito et al describe a variation on the volar approach that takes advantage of the results of their recent biomechanical study.1Saito S. Suzuki S. Suzuki Y. Biomechanical differences of the proximal interphalangeal joint volar plate during active and passive motion: a dynamic ultrasonographic study.J Hand Surg Am. 2012; 37: 1335-1341Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although we did not detect a change in conformation of the volar plate in our anatomic study,2McClelland Jr, W.B. McClinton M.A. Proximal interphalangeal joint injection through a volar approach: anatomic feasibility and cadaveric assessment of success.J Hand Surg Am. 2013; 38: 733-739Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar we did observe an increased distance between the volar plate and proximal phalanx head with passive joint flexion that increases the volar capsular volume. This increased space between the soft tissues and bones of the proximal interphalangeal joint contributes to the success of our technique. Both techniques demonstrated an equivalent rate of success (defined as injection material within the proximal interphalangeal joint capsule), but ours was done without the use of ultrasound. By the authors' own admission, their technique is more complicated. We feel that the true value of our technique is in its simplicity. This results in fewer variables to be managed by the practitioner and should lead to increased reproducibility. We believe that this could result in a quicker procedure (and therefore less patient discomfort) and one that is easier to teach, making it a desirable technique for trainees. We have concerns about the patient experience using the technique of Saito et al and would question how much patient discomfort is involved in actively flexing the digit during the process of needle insertion. If the patient is unable to maintain the digit in a flexed posture, the needle will be effectively withdrawn from the volar joint capsule. We are currently evaluating this technique clinically and will consider the active flexion modification going forward. Letter Regarding “Proximal Interphalangeal Joint Injection Through a Volar Approach: Anatomic Feasibility and Cadaveric Assessment of Success”Journal of Hand SurgeryVol. 38Issue 6PreviewMcClelland and McClinton documented an intra-articular injection technique through a volar approach for the proximal interphalangeal (PIP) joint.1 In their technique, the joint was relaxed at 45° flexion, and the needle was inserted perpendicularly on the proximal PIP joint flexion crease. Their cadaveric study showed that a total of 93% of injections were intra-articular (73%, complete; 20%, partial). Full-Text PDF