Proximal Interphalangeal Joint Level Research Articles

Clinical outcomes of salvage revision surgery following finger replantation with vascular insufficiency: A retrospective study.

The aim of this study was to analyze the outcomes of revision surgery following replantation of single digital amputations. In this study, first, a total of 403 patients (339 male, 64 female; mean age=28 years; age range=1-76) in whom a single finger replantation was performed were retrospectively reviewed, and then 60 patients with arterial or venous insufficiency in whom revision surgery was performed were reanalyzed. The second finger was observed to be the most injured one (32.8%). Injury type was classified as clean cut (25.3%), local crush (38.7), extensive crush (7.9%), and avulsion (28.1%). When taking the levels of injuries of the artery-only finger replantations into account, one finger (0.8%) was nail distal third, 70 fingers (56%) were nail distal third to lunula, 43 fingers (34.4%) were lunula to distal phalanx basis, 10 fingers (8%) were distal interphalangeal (DIP) joint, and one finger (0.8%) was middle phalanx. Operative revision was performed on 60 (14.9%) fingers. The need for operative revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The average revision time was 43 (range=6-144) hours. While the average elapsed time for artery procedures was 35.3 (range=8-110) hours, the average elapsed time for vein procedures was 47.1 (range=6-144) hours. Finger survival rates were examined. Injury mechanism, amputation level, the number of artery/vein repairs and methods were examined in all patients and revision patients separately. After the replantations, according to survival analysis, while 342 (84.9%) fingers were operated upon successfully, 61 (15.1%) fingers developed necrosis. In the patients with revision surgery, the survival rate was 78.3%. The need for revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The revision rate was significantly lower than other injury types in clean-cut cases. In terms of levels of injury, no revisions were required from distal to lunula level, and the highest revision rate was observed at the proximal interphalangeal (PIP) joint level. The results of the present study have shown that early re-exploration can provide a 78.3% success rate and can increase the survival rate from 67.6% to 84.2% following replantation of single digital amputations. Surgical re-exploration seems to be a reasonable salvage for replanted fingers with vascular insufficiency. Level IV, Therapeutic study.

Treating a subtotal degloving ring avulsion with leeches: an unusual case report with review of the literature

Subtotal deglovement injuries with delayed presentation give rise to the question: how to treat the mangled soft tissue to best keep the digit alive and functioning. We hereby present a case of a 59-year-old woman who was referred to our clinic 7 h after initial trauma from a peripheral hospital where an instant repositioning of a subtotal degloved skin envelop of her left middle finger had taken place with only minimal adhesion and circulation at the top of the finger left intact. On X-ray, a small avulsion fracture of her distal interphalangeal joint was visible but flexion and extension was intact at proximal interphalangeal (PIP) joint level on examination. On arrival, we saw a finger with minimal reconstituted blood circulation and livid skin. Further treatment consisted of onsite debridement and primary suturing of the involved skin, followed by leech therapy the next week, and consecutive split-skin grafting 6 weeks later to cover minor residual defects. Further clinical course was uneventful and showed good clinical and esthetic results. We hereby present the patient’s clinical outcome and review of the literature for further evidence of our treatment regime.Level of evidence: Level V, therapeutic study.

Application of modified pentagonal dorsal finger flap in the congenital syndactyly release

Objective To explore the clinical efficacy of modified pentagonal dorsal finger flap in the congenital syndactyly release. Methods From January 2010 to January 2014, 20 cases of simple cutaneous syndactyly were treated by modified pentagonal dorsal finger flap combined with finger Zigzag flap. The flap coverage scope, the occurrence of infection and necrosis of the skin flap and other early complications were recorded. The web depth and finger extension angle were measured and compared with the healthy side. Finger web creep and finger web scar were scored, and whether reoperation was performed due to the above complications was recorded. Questionnaire was used to evaluate parents' satisfaction. Results Twenty patients were follow-up for 30 to 75 months, with an average of 38 months. No complications such as infection and necrosis of skin flaps occurred after operation. The shape of the web was wide. The web depth of the affected side was (2.37±0.56) cm, and the finger extension angle was (24.50±4.74)°. There was no significant difference between the affected and healthy side. The reoperation rate due to web creep, web contracture and scar flexion contracture was 0. Family members were satisfied with the treatment outcome. Conclusion The modified pentagonal dorsal finger flap combined with finger Zigzag flap can reconstruct web space to the level of proximal interphalangeal joint, reduce the complications such as web creep and scar contracture after operation. Wide web is good for fingers to grasp large objects with high operative safety. Key words: Hand deformities,congenital; Syndactyly; Modified pentagonal dorsal finger flap; Web reconstruction; Web contracture

Minimally invasive correction of lesser toe deformities and treatment of metatarsalgia

Atraumatic and joint-sparing procedure for the correction of lesser toe deformities by using alinear or perpendicular osteotomy of the proximal and/or middle phalanx of the lesser toes with additional capsulotomies or tendon dissection for soft tissue realignment. Metatarsalgia is addressed via an extracapsular distal metaphyseal crescentic-like metatarsal osteotomy. Symptomatic lesser toe deformities, painful pseudoexostosis, metatarsalgia, symptomatic metatarsal malalignment, metatarsus adductus. Infection or malperfusion of the forefoot, dislocation at metatarsophalangeal joint level, noncompliance. Correction of lesser toe deformities via fluoroscopy-guided minimally invasive surgical technique. Osteotomy of the proximal and middle phalanx is combined with aplantar capsulotomy of the proximal interphalangeal joint. Condylectomy of the head of the proximal phalanx, tenotomy of the extensor digitorum longus tendon proximal to the joint line in combination with tenotomy of the short flexor tendons at the level of proximal interphalangeal joint can be necessary. Distal metatarsal osteotomies are performed with amicro-burr starting from plantar-medial parallel to the metatarsal shaft axis ending dorsally perpendicular to the metatarsal shaft axis. Taping for external stabilization of the lesser toes as well as self-adhesive bandage to stabilize the metatarsals for 6weeks; early weight-bearing is possible. Aprospective study of minimally invasive distal metaphyseal metatarsal osteotomies (DMMO; 30patients, n = 73osteotomies) and Weil osteotomies (30patients, n = 45osteotomies) showed similar results after amean follow-up of 13months. The surgery time was significantly shorter for the minimally invasive technique, but radiation exposure for the surgeon and patient were higher.

Modified toe pulp fillet flap coverage: Better wound healing and satisfactory length preservation.

BackgroundAmputation is commonly performed for toe necrosis secondary to peripheral vascular diseases, such as diabetes mellitus. When amputating a necrotic toe, preservation of the bony structure is important for preventing the collapse of adjacent digits into the amputated space. However, in the popular terminal Syme’s amputation technique, partial amputation of the distal phalanx could cause increased tension on the wound margin. Herein, we introduce a new way to resect sufficient bony structure while maintaining the normal length, based on a morphological analysis of the toes.MethodsUnlike the pulp of the finger in the distal phalanx, the toe has abundant teardrop-shaped pulp tissue. The ratio of the vertical length to the longitudinal length in the distal phalanx was compared between the toes and fingers. Amputation was performed at the proximal interphalangeal joint level. Then, a mobilizable pulp flap was rotated 90° cephalad to replace the distal soft tissue defect. This modified toe fillet flap was performed in 5 patients.ResultsThe toe pulp was found to have a vertically oriented morphology compared to that of the fingers, enabling length preservation through cephalad rotation. All defects were successfully covered without marginal ischemia.ConclusionsWhile conventional toe fillet flap coverage focuses on the principle of length preservation as the first priority, our modified method takes both wound healing and length into account. The fattiest part of the pulp is advanced to the toe tip, providing a cushioning effect and enough length to substitute for phalangeal bone loss. Our modified method led to satisfactory functional and aesthetic outcomes.

The Lateral Proximal Phalanx Flap for Contractures and Soft Tissue Defects in the Proximal Interphalangeal Joint: An Anatomical and Clinical Study.

Background: The management of contractures and soft tissue defects in the proximal interphalangeal (PIP) finger joint remains a challenge. We report a transposition flap from the lateral skin of the proximal phalanx that is based on perforating branches of the digital arteries and can be used safely for both palmar and dorsal cover defects. Methods: We first completed an anatomic study, dissecting 20 fingers in fresh cadavers with arterial injections and made the new flap in patients with dorsal or palmar defects in PIP joints. Results: In cadavers, we can reveal 4 constant branches from each digital artery in the proximal phalanx, with the more distal just in the PIP joint constituting the flap pedicle. Between February 2010 and February 2015, we designed 33 flaps in 29 patients, 7 for dorsal and 26 for palmar defects, with no instances of flap necrosis and 4 distal epidermolysis. The patients were between 4 and 69 years with no major complications, and all of the skin defects in the PIP joint were resolved satisfactorily without any relevant sequelae at the donor site. Conclusions: This flap procedure is an easy, reliable, versatile, and safe technique, and could be an important tool for the management of difficult skin defects and contractures at the PIP joint level.

Operative Treatment for Fourth Curly Toe Deformity in Adults

Curly toe deformity, a relatively common condition, occurs because of contracture of the flexor digitorum longus and flexor digitorum brevis. Numerous operative techniques have been introduced for treatment. However, there are no reports on fixed, longstanding deformity in adults. Data on 32 toes in 24 consecutive patients treated from 2003 to 2013 who underwent dorsolateral closing wedge-shaped resection arthroplasty for fourth curly toe deformity with a minimum 1-year follow-up were reviewed retrospectively. The mean follow-up period was 49 months. All patients presented preoperatively with a fixed deformity, underriding the adjacent toe. Combined surgeries were performed in 17 cases. Of 32 toes, fixed deformity presented more frequently at the proximal interphalangeal (PIP) joint, and resection at the PIP joint level was performed in 19 cases as opposed to 13 at the distal interphalangeal joint. The mean corrections of varus inclination and shortening were 31 ± 16 degrees and 3.1 ± 2.1 mm, respectively. American Orthopaedic Foot & Ankle Society scores significantly improved from 50 ± 2 preoperatively to 89 ± 8 at the final follow-up. There was 1 case of recurrence, floating toe deformity following pin tract infection in 1 case, and floating toe deformity without infection in 1 case. We introduced dorsolateral closing wedge-shaped resection arthroplasty as a simple, effective, and powerful option for treating fixed, longstanding fourth curly toe deformity in adults. Level IV, retrospective case series.

X-Ray Quiz: A Man with Finger Pain

A 55-year-old, industrial painter presented to the emergency depar tment (ED) one hour a f te r accidentally injuring his left little finger during the paint job. He complained of pain over the injured finger. The finger was swollen with areas of ecchymosis and there was a small puncture wound at the palmar surface of proximal interphalangeal joint level of the little finger. He had full range of motion of the digit and it was neurovascularly intact. Radiography of left hand was taken (Figure 1).

Using modified great toe wrap-around flap to reconstruct degloved thumb and fingers

Objective To explore the clinical outcome of using modified great toe wrap-around flap to reconstruct degloved thumb and fingers. Methods Eighteen patients were involved. Based on different types of injury, four procedures were carried on for reconstructing degloved thumb and fingers： ①Unilateral modified great toe wrap-around flap to reconstruct 9 degloved thumbs of distal proximal level and 3 degloved fingers of proximal interphalangeal joint level. ②Unilateral modified great toe wrap-around flap with second toe medial flap to reconstruct 2 total degloved fingers. ③Bilateral modified great toe wrap-around flap to reconstruct 2 thumbs. ④Bilateral modified great toe wrap-around flap and second toe medial flap with neurolized super thin anterolateral thigh flap to reconstruct 12 degloved fingers. This wrap-around flap carried with entire nail. A triangle flap was reserved at medial plantar of great toe. Results All free flaps were survived in one stage. Fifteen patients were followed up for 8 to 25 months. The contour of reconstructed digit was as same as eontralateral digit with satisfactory motion are and sensation. There was no extensive sear in donor toe. The width of medial plantar triangle flap increased significantly. All patients could walking, running, jumping without restricted. Conclusions With reconstructed by modified great toe wrap-around flap, degloved thumb or finger can be promised with excellent contour and function outcome. In the meantime, the loss of donor foot can be expected to minimal. This procedure is one of the best ways for reconstructing degloved thumb and finger. Key words: Toe ; Great toe wrap-around flap ; Finger ; Degloved digit ; Mierosurgery

The quadriga effect revisited: Designing a “safety incision” to prevent tendon repair rupture and gap formation in a canine model in vitro

Loss of experimental animals due to tendon repair failure results in the need for additional animals to complete the study. We designed a relief proximal to the flexor digitorum profundus (FDP) tendon repair site to serve as a "safety incision" to prevent repair site ruptures and maximize safety incision-to-suture strength. The FDP tendons were dissected in 24 canine forepaws. The 2nd and 5th tendons were lacerated at the proximal interphalangeal joint level and sutured using a modified Kessler technique and peripheral running suture. Tendon width was measured where the FDP tendon separates into each individual digit and a safety incision, equal to the 2nd and 5th tendon widths, was performed 3, 4, or 5 mm (Groups 1, 2, and 3) proximal to the separation. The tendons were pulled at a rate of 1 mm/s until either the "safety incision" ruptured or the repair failed. There was no gap formation at the repair site in Groups 1 and 2. However, all Group 3 tendons failed by repair site rupture with the safety incision intact. An adequate safety incision to protect repair gap and rupture and maintain tendon tension for the FDP animal model should be about 4 mm from where the FDP tendon separates.

Chronic Granulomatous Tenosynovitis Treated With Ulnar Superficialis Slip Resection

Ulnar superficialis slip resection is a procedure initially performed to treat flexor tenosynovitis in the rheumatoid finger. It was first described for treating trigger digits of children with mucopolysaccharide storage disorders and for more complex trigger digits in children. The procedure for adults with trigger finger was described for triggering with flexion contracture at the proximal interphalangeal joint level persisting after release of the A1 pulley and for trigger finger in diabetic patients.This article describes a case of chronic flexor tenosynovitis treated with ulnar superficialis slip resection. The patient was injured by the needle of a water pressure gauge. He developed chronic flexor tenosynovitis, and 1 year after the initial injury, surgery was performed due to a severe limitation of passive and active proximal interphalangeal joint flexion. Synovectomy was performed first, then the A1 pulley was divided. Passive finger flexion and extension was simulated and failed to reproduce full range of motion (ROM). The A3 pulley was then divided and still failed to reproduce full ROM. The ulnar slip of the flexor digitorum superficialis tendon was then resected from the distal margin of the carpal tunnel to the distal edge of the A3 pulley. The tendons could now move smoothly, and full passive ROM was achieved.Surgery consisting of synovectomy alone with or without resection of the A1 pulley without achieving full intraoperative ROM will likely lead to a poor result. We believe that cases like ours should be addressed with an "à la carte" procedure, starting with synovectomy and followed by A1 resection, A3 resection, and finally ulnar superficialis slip resection for achieving full intraoperative ROM.

Morphometric analysis of metacarpophalangeal and proximal interphalangeal palmar plates

Palmar plates are being used as a source of graft in radial or ulnar collateral ligament reconstruction, pulley reconstruction, and volar plate arthroplasty. The purpose of this study is to determine morphometric and major histological differences of palmar plates in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints among fingers, and supply sufficient data which would be useful in reconstruction procedures. Ninety-six MCP and 96 PIP palmar plates of 12 well-preserved formalin-fixed cadavers were measured focusing on their length, width, central thickness, and lateral thickness and statistically analyzed using ANOVA. Randomized three male and three female cadavers' specimens were examined histologically after staining with Masson's trichrome. For central thickness of the PIP joint level, there was significant difference among fingers, caused by the middle and little fingers. For lateral thickness of the PIP joint level, there was significant difference which was originated from little fingers. MCP palmar plates were significantly thicker than PIP joint levels for most of the fingers. There were thicker and denser collagen bands in MCP than PIP palmar plates. The relation of size-related parameters was not close with the thickness parameters. The predicted sizes and thicknesses of palmar plates vary according to fingers. The data collected for each finger in this study should be used as a guide in reconstructive procedures that use palmar plates as source of graft.

Denervation of the Proximal Interphalangeal Joint: A Realistic and Simple Procedure

Pain relief in osteoarthritis of the proximal interphalangeal joint is a difficult problem. Joint denervation, a technique yielding good reproducible results in wrist and first carpometacarpal joint osteoarthritis, is, at the proximal interphalangeal joint level, a good alternative to implant arthroplasty or arthrodesis. The surgical technique is simple and may be performed under local anesthesia. Results are satisfactory with about 80% pain relief.

Sensory reconstruction of the fingertip using the bilaterally innervated sensory cross-finger flap.

The authors present a series of 15 patients with large soft-tissue defects of the fingertips as a prospective, nonrandomized study. In all cases, reconstruction was achieved using a bilaterally innervated sensory cross-finger flap. This sensory fasciocutaneous flap relies on the dorsal branch of the proper digital nerves, which branch off at the level of the head of the proximal phalanx; sensory supply to the dorsal skin of the middle phalanx is thus ensured. The reconstructive procedure consists of two steps. First, the contralateral dorsal branch of the proper digital nerve is elevated with the flap at proximal interphalangeal joint level. Microsurgical coaptation is performed to the proximal nerve stump of the injured fingertip. After 3 weeks, when the pedicle is dissected, the second nerve is dissected and coapted. Clinical results were evaluated after 12 months. Because the regenerative distance is only 1.5 to 2.5 cm, good sensory regeneration should be expected. In nine of 16 flaps, sensory quality of S2+ (Highet) was present in the flap after 3 weeks. After 12 months, two-point discrimination was present in all patients, the values ranging between 2 and 6 mm (for two-point discrimination), with an average of 3.6 mm. The rate of complications was low. With acceptable additional operative action, a good functional result can be achieved. The indications of this method are discussed in comparison with other methods of fingertip reconstruction.

Anatomical consideration of reverse-flow island flap transfers from the midpalm for finger reconstruction.

Primary soft-tissue coverage for large palmar defects of the fingers is a difficult problem for cases in which homodigital or heterodigital flaps cannot be used. The aim of this study was to explore the vascular and neural anatomy of the midpalmar area to assess the possibility of reverse island flaps from this area. In 24 cadaver hands perfused with a silicone compound, the arterial pattern of the superficial palmar arch and common palmar digital artery was examined. The cutaneous perforating arteries and nerve branches supplying the midpalmar area were dissected, and the number, location, and arterial diameter of these branches were measured. In six other specimens, the common palmar digital artery was injected to determine the skin territory supplied by the artery. The superficial palmar arch contained the three common palmar digital arteries and its terminal branch coursed along the radial margin of the index metacarpus. This terminal branch had three to six cutaneous perforators (diameter range, 0.1 to 0.5 mm) and supplied the radial aspect of the midpalmar area located over the ulnar half of the adductor pollicis muscles. The midpalmar area was divided into two regions-the proximal and distal-according to the vascular distributions. The proximal region contained dense aponeurosis and thin subcutaneous tissue, and the cutaneous perforators were rather sparse (between three and nine) and had a small diameter (0.1 to 0.3 mm). The distal region, which had loose aponeurosis and abundant subcutaneous tissue, had a rich vascular supply from the common and proper digital artery. Perforating arteries of this region coursed frequently in an oblique fashion and the number of perforators (between eight and 15) and their arterial diameters (diameter range, 0.1 to 0.5 mm) were higher than those of the proximal region. The area of skin perfused by the common palmar digital artery was 5 x 3 cm at the distal midpalmar region. There were three to five cutaneous nerve branches from the palmar digital nerve supplying the midpalmar area. From this study, two different reverse flaps were proposed. First, a 5 x 2 cm flap from the distal midpalmar region was elevated on the basis of the common and proper palmar digital artery. Measurement of the rotation arc revealed that the pivot point of this flap was located at the proximal interphalangeal joint level and could cover the finger pulp of the digits. The second flap candidate was that from the radial aspect of the midpalm, which was supplied by the terminal branch of the superficial palmar arch. In studies with cadaver hands, connection of this artery with the deep arterial system enabled this flap to reach the thumb pulp. These flaps may be a useful reconstruction option for significant palmar soft-tissue loss of the fingers.

Interphalangeal joint and tendon forces: normal model and biomechanical consequences of surgical reconstruction

Soft tissue reconstructive surgery for rheumatoid-related proximal interphalangeal joint deformities frequently fails to produce the long-term predicted results. Detailed information on the biomechanics of this joint, under both normal and pathological conditions, is required to assess the efficacy of such surgical intervention. A biomechanical model of the proximal interphalangeal joint has been developed to investigate tendon and joint loading during real life three-dimensional activities. Based on a rigid body mechanics approach, the model uses high resolution MRI scans to obtain anatomical tendon and bone geometries in conjunction with three-dimensional kinematic and loading data. The model incorporates an optimisation routine which minimises overall maximum tendon stress in the eight individual elements considered. Radial and ulnar joint force components are included at the proximal interphalangeal joint level. Two simulated pathological versions of the mathematical model are developed to accommodate the altered anatomic relationships after tendon reconstructive surgery. Joint forces of up to 450 N and common usage of the extensor mechanism during normal pinching and grasping activities are predicted. The ulnar lateral bands of the extensor tendon are generally loaded to a greater extent than the radial bands. Extensor tendon and joint forces in the simulated pathological models are significantly higher than those in the normal model. Combined with the poor tendon quality of rheumatoid arthritis patients generally, these amplified internal forces may lead to further joint deformation.

Palmar Approach in Flexible Implant Arthroplasty of the Proximal Interphalangeal Joint

Joint replacement is an established method in the treatment of destroyed, painful, proximal interphalangeal joints. A palmar approach was used in which the main collateral ligaments were preserved, allowing immediate active rehabilitation with enhanced primary lateral stability. Fifty-nine proximal interphalangeal joint silicone arthroplasties in 38 patients with a minimum followup of 12 months were reviewed. Thirty-eight of the 59 joints had implantation from a palmar approach and 21 joints from a dorsal approach. The two groups were well-matched in terms of indication, preoperative range of motion, and patient age. No significant increase in the range of motion was found in either of the patient groups, with an overall average range of motion of 51 degrees postoperatively. There was also no significant difference in the postoperative stability in the two patient groups. The choice of surgical approach at the proximal interphalangeal joint level for the silastic type of implants does not appear to be important. With more sophisticated types of implants in which the integrity of the collateral ligaments is crucial, a palmar approach might be beneficial.

La dénervation articulaire, une réponse simple à des problèmes complexes de chirurgie de la main

In patients with preserved mobility and stability a painful joint remains a difficult problem, especially in elderly patients. All operations, including intracarpal arthrodesis, reduce an already limited mobility, require prolonged immobilization and have a high rate of complications. Denervation could be proposed in such cases. In our study denervation was performed on 132 wrists, 36 first carpo-metacarpal joints and 32 proximal inter-phalangeal joints. We have been disappointed in the past by partial wrist denervations. Fifty cases of complete and isolated wrist denervation were reviewed with a mean 5-year followup. Strength and mobility were only marginally improved but pain was decreased by a mean 75% (on a visual analog scale) in 74% of patients. At the proximal inter-phalangeal joint level, the mean pain improvement was 88% in 85% of patients. At the first carpo-metacarpal joint level, results of denervation were less predictable and the mean pain improvement was 67% in 81% of patients, with a mean 17-month follow-up. Joint denervation is a simple but precise operation performed under local anesthesia and on an outpatient basis. It provides good results in elderly patients, with few complications.

Spontaneous thrombosis of palmar digital veins

Five cases of spontaneous thrombosis of a palmar digital vein are presented. The patients, all female, complained of a tender and unsightly lump over the digital palmar surface at the proximal interphalangeal joint level. Two fingers were affected in one patient. None could recall any history of trauma. In four cases a surgical excision was carried out. Histology confirmed the intraoperative findings of thrombosis of a superficial digital vein in every case. All patients are free from recurrence at a mean follow-up of 2.5 years.

Infantile digital fibromas

A series of 15 digital lesions in 8 pediatric patients is presented. All infantile digital fibromas appear early in life at the distal or proximal interphalangeal joint level, characteristically involve the ulnar three digits, may be multicentric, and undergo rapid growth within a short time. Histology reveals deep dermal origin and intracytoplasmic inclusion bodies not observed in any other fibrous proliferative disorders. A viral etiology has never been proved. The lesions may recur despite wide excision followed by resurfacing with a flap or graft. This distinctive lesion has no adult counterpart and should be considered in the differential diagnosis of hard, immobile distal digital masses in children.