Fracture-dislocations Of Proximal Interphalangeal Joint Research Articles

Evaluation of the clinical and radiological outcome of hemi-hamate arthroplasty in the reconstruction of proximal interphalangeal Joint fracture-dislocations.

Background: Hemi-hamate arthroplasty, a new attractive method for treatment of unstable Proximal Interphalangeal (PIP) joint fracture-dislocations, offers several advantages over the previous methods. This study was designed to evaluate the clinical and radiological outcome of this procedure. Methods: In this study, 14 patients and 15 fingers with PIP joint fracture-dislocations were evaluated, including 8 acute and 7 chronic injuries. The mean age and follow-up of the patients were 35.3 years and 29.7 months, respectively. The mean PIP joint involvement was 56.6%. Objective assessment of the outcome was performed by joint alignment, motion, stability, and grip and pinch strength. Subjective evaluation of the outcome was performed using the Visual Analogue Scale (VAS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Statistical analysis was performed using SPSS for Windows (version 16). Independent sample t test or Mann-Whitney U test were used for statistical comparison of the mean values. A p value of < 0.05 was considered significant. Results: At the final follow-up, 14 out of 15 PIP joints were clinically stable. Grip and pinch strength of the injured hand averaged 87.6% and 88% of contralateral hand, respectively. The mean PIP joint flexion, arch of motion, and flexion contracture were 82.6, 63.6, and 19 degrees, respectively. The mean DASH score was 20.33±21.87 in acute and 7.25±11.71 in the chronic group (p=0.181). The mean VAS was 2.87±2.29 in acute versus 0.42±0.78 in chronic patients (p=0.022). The degenerative joint disease was observed in 5 cases. Conclusion: Although hemi-hamate arthroplasty is a promising method for the reconstruction of severe PIP joint fracturedislocations, it is associated with minimal functional limitation and high rate of osteoarthritis.

Postoperative Dorsal Proximal Interphalangeal Joint Subluxation in Volar Base Middle Phalanx Fractures

Introduction This study was designed to assess factors associated with postoperative dorsal proximal interphalangeal (PIP) joint subluxation after operative treatment of volar base middle phalanx fractures. Our second purpose was to study the association between postoperative dorsal subluxation with postoperative arthritis.Materials and Methods We identified 44 surgically treated volar base PIP joint fractures with available pre- and postoperative radiographs between 2002 and 2015 at two academic medical systems with a median follow-up of 3.5 months. Demographic, injury, radiographic, and treatment data that might be associated with postoperative dorsal subluxation were collected. Three hand surgeons independently assessed subluxation and arthritis on radiographs. Bivariate analysis was performed to analyze our two study purposes.Results Six of 44 (14%) had postoperative dorsal subluxation after initial surgery. Bivariate analysis showed no factors with statistically significant association with postoperative subluxation, assessed independently by three hand surgeons on radiographs. Fifty per cent of the joints with postoperative arthritis had postoperative subluxation compared with 21% of joints without postoperative subluxation. No significant association was found between postoperative dorsal subluxation with postoperative arthritis.Conclusion The association of persistent subluxation and early arthrosis in dorsal PIP joint fracture dislocations needs further study. At this time, it is unclear in what ways persistent subluxation or arthrosis affects the rate of reoperation.Level of Evidence This is a therapeutic level IV study.

Evaluation of the clinical and radiological outcome of hemi-hamate arthroplasty in the ‎reconstruction of proximal interphalangeal Joint fracture-dislocations

Evaluation of the clinical and radiological outcome of hemi-hamate arthroplasty in the ‎reconstruction of proximal interphalangeal Joint fracture-dislocations

Surgical Management of Proximal Interphalangeal Joint Fracture-Dislocations: A Review of Outcomes.

Background: Treatment of proximal interphalangeal joint (PIPJ) fracture-dislocations is difficult given the potential long-term complications of the involved finger and entire hand. Several surgical methods have been utilized for management of these injuries, none of which have shown consistently favorable results. The purpose of this systematic review of the literature is to report the post-operative outcomes of multiple treatment modalities for PIPJ fracture-dislocations in various studies. Methods: A literature review of PubMed and EMBASE databases was performed for all articles on PIPJ fracture-dislocations. Outcomes of interest included PIPJ range of motion, grip strength (% of contralateral hand), and quick disabilities of arm, shoulder, hand (QuickDASH). Articles were distributed into 5 groups by surgical method: open reduction, percutaneous fixation, dynamic external fixation, extension-block pinning, and hemi-hamate arthroplasty. Results: Forty-eight of 1679 total screened articles were included. The weighted means of post-operative range of motion (ROM; degrees) at final follow-up were open reduction 84.7 (n = 146), percutaneous fixation 86.5 (n = 32), dynamic external fixation 81.7 (n = 389), extension-block pinning 83.6 (n = 85), and hemi-hamate arthroplasty 79.3 (n = 52). Dorsal fracture-dislocations, regardless of surgical method, had an average ROM of 83.2 (n = 321), grip strength 91% (n = 132), and QuickDASH of 6.6 (n = 59) while pilon injuries had an average ROM of 80.2 (n = 48), grip strength 100% (n = 13), and QuickDASH of 11.4 (n = 13). Conclusion: Percutaneous fixation yielded the highest post-operative ROM at final follow-up while extension-block pinning resulted in the greatest grip strength. While dorsal fracture-dislocations produced higher average ROM and lower QuickDASH score, pilon fractures produced a higher grip strength. No treatment method or fracture type yielded consistently better outcomes than another.

Reoperation After Operative Fixation of Proximal Interphalangeal Joint Fractures.

Background: The purpose of this study was to determine the reoperation rate and what factors are associated with reoperation of proximal interphalangeal (PIP) joint fractures. Methods: We identified 161 surgically treated PIP joint fractures between 2004 and 2015 at 2 academic medical systems. Demographic, injury, radiographic, and treatment data that might be associated with reoperation were collected. Bivariate analysis was performed. Factors identified during bivariate analysis with a P < .10 were entered into a multivariable logistic regression analysis. Results: Of the 161 fingers, 25 underwent revision surgery. Open fracture was independently associated with revision surgery. The most common indication for reoperation was joint stiffness (35%). In a subanalysis of 111 closed fractures, no factors were associated with revision surgery. Conclusions: Soft tissue injury is a major factor in reoperation after PIP joint fracture dislocation. Specific attention should be paid to persistent subluxation because this may predispose to early arthrosis.

A novel dynamic distraction external fixator for proximal interphalangeal joint fracture dislocation.

ObjectiveTo evaluate the efficacy of a novel dynamic distraction external fixator for proximal interphalangeal joint (PIPJ) fracture-dislocation.MethodsFrom March 2005 to March 2014, 20 patients with PIPJ fracture-dislocation were treated with our technique. Function scores according to the Michigan Hand Outcome Questionnaire (MHQ) score, union time, grip strength, and range of motion (ROM) were recorded before and after treatment.ResultsAll patients completed a mean follow-up of 22 months (range, 12–60 months). All patients achieved fracture union and joint reduction. The mean union time was 3 months (range, 2–6 months). The mean postoperative MHQ score was 88.00 ± 3.42 (range, 84.00–92.00). Postoperative grip strength of the affected sides was 92% of the contralateral sides. X-rays showed that the fracture line disappeared completely with a good joint contour. The range of extension in the PIPJ was −5° (range, −10°–0°). The range of flexion in the PIPJ was 89.40° ± 9.79° (range, 75°–100°). Postoperatively, four patients had slight narrowing of the joint space and two had an uneven articular surface. Pin breakage, loosening, and tract infection were not observed.ConclusionsThe novel dynamic distraction external fixator is a promising option for PIPJ fracture-dislocation.

Open Reduction Internal Fixation With Transverse Volar Plating for Unstable Proximal Interphalangeal Fracture-Dislocation: The Seatbelt Procedure.

Background: Unstable intra-articular proximal interphalangeal (PIP) joint fracture-dislocations present a difficult problem that requires congruous joint reduction and stable internal fixation or distraction. Though fractures with limited articular involvement may be treated successfully with less invasive procedures, fracture-dislocations with a volar shear component may benefit from joint reduction with subchondral support for maintenance of stability. The purpose of this article is to describe a volar transverse plate and screw technique and report the short-term postoperative results. Methods: Seventeen patients with volar shear PIP dorsal fracture-dislocations were treated with transverse plate and screw constructs at an average of 21 days (range, 2-52) after injury. Information on postoperative stability, range of motion at PIP and distal interphalangeal (DIP) joints, and radiographic outcomes and complications were retrospectively collected. Results: At a mean of 7.3 months post-operation (range, 1.5-24), there were no recurrent dislocations and an average PIP arc of 77.4° and DIP arc of 61.5°. Sixteen of 17 patients had radiographically concentric joints, with 1 patient showing slight radiographic dorsal subluxation not apparent clinically. Two of 17 patients (11.8%) had revision surgery for tenolysis and removal of hardware to improve range of motion at 4 and 9 months post-operation. Conclusions: In the setting of PIP dorsal fracture-dislocations with volar shear component >40% of the articular surface, the Seatbelt procedure allows for concentric joint and articular surface reduction with subchondral support for maintenance of stability. This volar transverse plating technique allows for highly functional range of motion without PIP dorsal subluxation clinically in the setting of comminution and delayed presentation.

Distraction ligamentotaxis for complex proximal interphalangeal joint fracture dislocations: a clinical study and the modified pins rubber band traction system revisited

BackgroundThe purpose of this study is to present our experience with the modified pins and rubber band traction system, discuss problems encountered, and make recommendations to optimize outcomes.MethodsData was collected prospectively from November 2013 to March 2017 at a tertiary referral hospital in Melbourne, Australia. Patients with closed complex proximal interphalangeal joint fracture dislocations that were considered unsuitable for other surgical options were included in the study. Patients underwent dynamic skeletal distraction using the modified (Deshmukh) pins rubber band traction system. Outcomes were measured using the Nominal Rating Scale for pain; Disabilities of the Arm, Shoulder, and Hand (DASH) score; active and passive range of motion; patient rating scale; and complications.ResultsTwenty patients underwent the procedure, and 19 were included in analyses. At the final follow-up assessment, an average of 62° and 77° was achieved for proximal interphalangeal joint active and passive range of motion, respectively. Pain levels were low (median score of 0 at rest and 1 ranging, out of 10). Four patients suffered minor pin site infections.ConclusionDistraction ligamentotaxis is a useful part of the armamentarium, especially in the absence of more suitable procedures. It is important to select appropriate patients, educate, and ensure adherence to postoperative therapy. Employing the Deshmukh frame modification streamlines the theatre processes, and removal of wires at approximately 4 weeks minimizes risk of pin site infection.

Evaluation of Articular Surface Similarity of Hemi-Hamate Grafts and Proximal Middle Phalanx Morphology: A 3D Geometric Morphometric Approach

Hemi-hamate arthroplasty has been described as a viable treatment option for unstable proximal interphalangeal joint fracture-dislocations. The procedure uses a dorsal distal hamate osteochondral graft to recreate the injured volar middle phalanx (MP) proximal base. The purpose of this study was to evaluate the similarity in shape of these articular surfaces using quantitative 3-dimensional methods. Three-dimensional virtual renderings were created from laser scans of the articular surfaces of the dorsal distal hamate and the volar MP bases of the index, middle, ring, and little fingers from cadaveric hands of 25 individuals. Three-dimensional landmarks were obtained from the articular surfaces of each bone and subjected to established geometric morphometric analytical approaches to quantify shape. For each individual, bone shapes were evaluated for covariation using 2-block partial least-squares and principal component analyses. No statistically significant covariation was found between the dorsal distal hamate and volar MP bases of the middle, ring, or little digits. Whereas the volar MP bases demonstrated relative morphologic uniformity among the 4 digits both within and between individuals, the dorsal distal hamates exhibited notable variation in articular surface morphology. Despite the early to midterm clinical success of hemi-hamate arthroplasty, there is no statistically significant, uniform similarity in shape between the articular surfaces of the dorsal distal hamate and the volar MP base. In addition, there is wide variation in the articular morphology of the hamate among individuals. The lack of uniform similarity in shape between the dorsal distal hamate andthe volar MP base may result in unpredictable outcomes in HHA. It is recommended thatthe variation in hamate morphology be considered while reconstructing the injured volar MP base in the procedure.

Accuracy and Reliability of Radiographic Estimation of Volar Lip Fragment Size in PIP Dorsal Fracture-Dislocations

Background: A cadaveric study was performed to evaluate the accuracy and reliability of radiographic estimation of the volar lip fragment size in proximal interphalangeal joint fracture-dislocations. Methods: Middle phalangeal base volar lip fractures of varying size and morphology were simulated in 18 digits. Radiographs and digital photographs of the middle phalangeal joint surface were obtained pre- and postinjury. Ten orthopedic surgeons of varying levels of training estimated the fracture size based on radiographs. The estimated joint involvement on radiograph was compared with the digitally measured joint involvement. Results: Radiographic estimation underestimated the volar lip fragment size by 9.02%. Estimations possessed high intraobserver (0.76-0.98) and interobserver (0.88-0.97) reliabilities. No differences were detected between levels of surgeon training. Conclusions: The significant underestimation of the volar lip fragment size demonstrates the lack of radiographic estimation accuracy and suggests that surgeons should be mindful of these results when making treatment plans.

Treatment of dorsal fracture-dislocations of the proximal interphalangeal joint using the shotgun approach.

IV.

Pilon Fractures of Middle Phalanx Managed with Lag Screw and Early Mobilisation

Background: Injury following proximal interphalangeal joint fracture dislocation is determined by the direction of force transmission and the position of the joint at the time of impact. Dorsal dislocations with palmar lip fractures are the most frequently encountered. The degree of stability is directly determined by the amount of middle phalangeal volar lip involvement and the degree of commination of the base of the middle phalanx.Methods: Case series of five patients who presented between Jan to June 2015 with pilon fracture of the middle phalanx. Mechanism of injury was axial loading onto to the proximal interphalangeal joint, while playing Australian football. All of them presented within 3 days of their initial injury with fracture of the volar lip of base of middle phalanx with dorsal subluxation along with commination of the base of middle phalanx appreciated on CT scan. All of them underwent open reduction via the shot gun approach and fixation with 1.3 mm lag screw. Also bone graft from the Lister`s tubercle of distal radius was used to realign the joint congruity in cases with severe comminution.Results: Post operatively they underwent early mobilisation within the volar plate protocol and good outcome in terms of proximal interphalangeal joint function and stability.Conclusion: Early intervention in the form of open reduction and internal fixation with or without bone graft in cases of pilon fractures restores the joint congruity and helps in achieving good functional outcome.

Treatment of dorsal fracture-dislocation of the proximal interphalangeal joint using the Ligamentotaxor device: clinical and radiographic preliminary results.

Fracture-dislocations of the proximal interphalangeal joint are complex injuries, often difficult to treat. Several treatment options have been described. Among them dynamic external fixation proved to be a safe technique leading to good results in many authors experience. The principles of this treatment are to avoid edema, prevent stiffness and tendon adhesions, promote joint remodelling and facilitate rehabilitation. The Ligamentotaxor® device is a simple and reproducible dynamic external fixation system that has been used in recent years to treat proximal interphalangeal joint fracture-dislocations, with favourable results. The aim of the present study is to evaluate our preliminary results with the Ligamentotaxor® device for treatment of these complex lesions. Four patients between December 2015 and January 2017 were treated at our institution with the Ligamentotaxor® device. Clinical and radiographic results were evaluated at mean 6 months follow-up. Clinical results were meanly good and appeared to be comparable to most recent literature. Mean range of motion was 60,5°, mean extension lag 18,5°. Mean QuickDASH and Michigan Hand Questionnaire scored 21.6 and 72 respectively. Radiographic evaluation showed fracture healing in all cases. No relevant complications were noted. The Ligamentotaxor® device is simple to implant, provides good stability and allows an immediate gentle active movement. According to present work the preliminary results are encouraging.

The Versatile Hook Plate in Avulsion Fractures of the Hand.

In a retrospective review of our use of hook plates in hand fractures from 2008 to 2014, a total of 63 cases were identified from the hospital data base. There were 35 cases of Mallet fractures, 16 cases of proximal interphalangeal joint fracture dislocations, 5 cases of flexor digitorum profundus avulsion fractures, 5 cases of Central slip avulsions, and 2 collateral ligament avulsions. All fractures healed well with this technique with no biomechanical failures and good functional outcome. Plates needed removal in a total of 25 cases, of which 14 were in mallet fractures. Thirteen (21%) cases suffered complications, of which the majority were again related to mallet fractures. The hook plate is a simple device that can be created quite easily with readily available materials. We have extended the use of these plates to avulsion fracture fixation in the hand and found this to be a versatile technique. The risk of fragmenting the small fracture fragment is reduced because the hooks secure it and the plate is fixed in the bone. If done meticulously, joint congruence can be achieved. It has a biomechanical advantage over current methods of fracture fixation of small but important bone fragments in the hand.

Augmented hamate replacement arthroplasty for fracture-dislocations of the proximal interphalangeal joints in 12 patients.

IV.

Unstable PIP Fracture-Dislocations

Purpose: Multiple techniques exist as part of the armamentarium for the management of Proximal Interphalangeal (PIP) joint fracture-dislocations. Of these, unstable lesions with hard reduction are the most complicated to handle. This study aims to compare the biomechanical results obtained with volar plate arthroplasty (VPA) and the hemihamate arthroplasty (HHA). Materials and Methods: We used 20 fingers from 8 cadaveric hands. We created a 50% defect on the base of the middle phalanges to simulate an unstable fracture-dislocation. The 2 techniques were assigned randomly to the different fingers (10 for each technique). A biomechanical harness was used to carry all PIP joints from extension to complete flexion. The amount of dorsal translation of the subluxation was recorded digitally at full extension. We recorded the angle at which subluxation occurred for each specimen. Results: The average of dorsal displacement of the middle phalanx did not show statistical significant difference (0.02 mm for the HHA and 0.01 mm for the VPA). All the fingers with VPA coursed with flexion contracture as opposed to the HHA. Conclusions: The VPA and the HHA are current techniques used for the management of unstable PIP fracture-dislocations. The 2 procedures manage to maintain reduction throughout the range of flexo-extension. Surgeons must choose between a little more invasive technique with double incision, hamate block bone graft with potential discomfort in the donor area and screw fixation on the recipient middle phalanx not leading to flexion contracture (HHA); versus a single surgical approach technique -dorsal or ventral- which provides stability but may course with certain flexion contracture.

Delayed treatment of unstable proximal interphalangeal joint fracture-dislocations with a dynamic external fixator

BackgroundFracture-dislocations of the proximal interphalangeal joint (PIPJ) remain a challenging problem to treat. Although there are a number of papers describing the use of dynamic external fixators and force couples for treatment of unstable PIPJ fracture-dislocations acutely, the literature is scarce on delayed treatment of PIPJ fracture-dislocations, where malunion of the articular surface may theoretically compromise postoperative range of motion (ROM) at the PIPJ. The purpose of this study was to evaluate the effectiveness of dynamic distraction external fixation (DDEF) for the delayed treatment of PIPJ fracture-dislocations at least 3 weeks after the inciting injury. MethodsTen consecutive patients were treated with delayed DDEF between 2010 and 2013. Postoperative ROM at the PIPJ was measured. Disabilities of the Arm, Shoulder and Hand (DASH) score and Michigan Hand Outcomes Questionnaire were administered to all patients postoperatively. ResultsMean time from injury to surgery was 27.5 days. The mean follow-up period was 23.7 months (range 10–36). The mean active ROM at the PIPJ on final postoperative follow-up was 83.9° (range 52–100). None of the patients experienced pin-tract infections. Mean DASH score was 3.7+3.4 and mean Michigan Hand Outcomes Questionnaire score was 97.3+3.0. All patients returned to work and resumed normal activities. ConclusionsDelayed treatment of unstable PIPJ fracture-dislocations with a DDEF is effective in restoring function to the PIPJ. Nascent malunion of the PIPJ articular surface does not compromise postoperative outcomes and the joint surface undergoes remodelling over time to restore a smooth and functional articular surface.

PIPJ reconstruction after fracture including hemihamate transfer

Proximal interphalangeal joint fracture dislocations are challenging injuries that can be managed in a wide variety of ways. The fracture dislocations of the PIP joints are classified by their mechanical stability and the percentage of joint involved in the fracture. Fracture dislocations that remain stable with less than 30 degree of flexion of the PIP Joint and those that have less than 20% of the articular surface involvement are generally considered stable and can be treated with extension block splinting. The methods of treatment that will be discussed in this presentation include extension block splinting, traction of various kinds, pinning, and open reduction internal fixation. When the PIP joint is very unstable and the fracture at the base of the middle phalanx so comminuted as to be unreconstructible, the state of the art management method is to use hemi hamate transfer that was described by Hill Hastings. This method of bringing stability to an unstable joint with the use of a unique osteochondral graft has revolutionized the management of PIP fracture dislocations. In this presentation, I will discuss the indications, detailed technique and outcomes of the hemi hamate transfer for fracture dislocations with appropriate case illustrations.

Biomechanical Characteristics of Hemi-Hamate Reconstruction Versus Volar Plate Arthroplasty in the Treatment of Dorsal Fracture Dislocations of the Proximal Interphalangeal Joint

To compare stability and range of motion after hemi-hamate reconstruction versus volar plate arthroplasty in a biomechanical proximal interphalangeal (PIP) joint fracture-dislocation model. Eighteen digits from 6 cadaver hands were tested. We created defects of 40%, 60%, and 80% in the palmar base of each digit's middle phalanx, simulating an acute PIP joint fracture-dislocation. Each defect scenario was reconstructed with a hemi-hamate arthroplasty followed by a volar plate arthroplasty. A computer-controlled mechanism was used to bring each digit's PIP joint from full extension to full flexion via the digital tendons in each testing state, and in theintact state. During each testing scenario we collected PIP joint cinedata in a true lateral projection using mini-fluoroscopy. A digital radiography program was used to measure the amount of middle phalanx dorsal translation (subluxation) in full PIP joint extension. We recorded the angle at which subluxation, if present, occurred during each testing scenario. Average dorsal displacement of the middle phalanx in relation to the proximal phalanx was 0.01 mm for the hemi-hamate reconstructed joints and -0.03 mm for the volar plate arthroplasty, compared with the intact state. Flexion contractures were noted in each of the specimens reconstructed with volar plate arthroplasty. Degree of contracture was directly correlated with defect size, averaging 20° for 40% defects, 35° for 60% defects, and 60° for 80% defects. We observed no flexion contractures in the hemi-hamate reconstructions. Surgeons can use both hemi-hamate and volar plate arthroplasty to restore PIP joint stability following a fracture dislocation with a large middle phalanx palmar base defect. Use of volar plate arthroplasty led to an increasing flexion contracture as the middle phalanx palmar base defect increased. Clinicians can use the information from this study to help with surgical decision-making and patient education.

The hemi-hamate autograft arthroplasty in proximal interphalangeal joint reconstruction: a systematic review

Palmar lip injuries of the proximal interphalangeal joint with dorsal fracture-dislocation are difficult to treat and often require major reconstruction. A systematic review was performed and yielded 177 articles. Thirteen articles on hemi-hamate autograft were included in full-text analysis. Results of 71 cases were summarized. Mean follow-up was 36 months and mean proximal interphalangeal joint range of motion was 77°. Overall complication rate was around 35%. Up to 50% of the patients showed radiographic signs of osteoarthritis. However, few of those patients complained about pain or impaired finger motion. Based on this systematic analysis and review, hemi-hamate autograft can be considered reliable for the reconstruction of acute and chronic proximal interphalangeal joint fracture-dislocations with joint involvement >50%, but longer-term follow-up studies are required to evaluate its outcome, especially regarding the rate of osteoarthritis.