Presentation for APOA Hand and Upper Limb Society 2 Oct 2021.

1. Volar Plate Arthroplasty, Fusion or
Prosthetic Replacement
Alphonsus Chong
Associate Professor, Department of Orthopaedic Surgery, NUS
Group Chief, Hand and Reconstructive Microsurgery, NUHS
Email: doscksa@nus.edu.sg
No relevant conflicts of interest to disclose

2. Scope
1. PIPJ and its importance
2. Common causes of PIPJ arthritis
3. Surgical options
1. Interpositional arthroplasty
2. Arthrodesis/Fusion
3. Implant arthroplasty
4. Summary

3. Anatomy and Function
• Function
• Locus of the finger – joint with the largest ROM
in the hand
• 85% of grasping capability of the hand
• Anatomy
• Complex: mainly hinge (with varying centres of
rotation)
• Also some lateral motion and rotation
• Osseous anatomy
• Collateral ligaments – Proper and accessory
collateral ligaments
• Volar plate & checkrein ligament
https://doi.org/10.1142/S2424835520400019

4. PIPJ Arthritis - Causes
• Post-traumatic arthritis
• Osteoarthritis
• Less common in hand compared to DIPJ
and 1st CMCJ
• Inflammatory arthritis
• Others – gout, infection etc
Jacobs, B. J., Verbruggen, G., & Kaufmann, R. A. (2010). Proximal Interphalangeal
Joint Arthritis. The Journal of Hand Surgery, 35(12), 2107–2116.
https://doi.org/10.1016/j.jhsa.2010.09.002

5. Surgical approaches (in common order)
• Dorsal
• Tendon splitting
• Chamay ‘V’
• Volar
• Lateral
Herren, D. (2019). The proximal interphalangeal joint: Arthritis and deformity. EFORT Open
Reviews, 4(6), 254–262. https://doi.org/10.1302/2058-5241.4.180042
Tendon splitting Chamay
‘Shotgun’ exposure of PIPJ from volar side. See:
AO website for step by step exposure

6. I. Interpositional Arthoplasty
• Alternative to fusion or implant arthroplasty
• Different techniques
• Advantages:
• Motion preserving
• Biological solution
• Can still do fusion (without much shortening)
• Limited data and adoption
• Selected situations – need good soft tissue,
collaterals, alignment
• Selected patients – lower demand
• ?Reliability
Lin, S.-Y., Chuo, C.-Y., Lin, G.-T., Ho, M.-L., Tien, Y.-C., & Fu, Y.-C. (2008).
Volar Plate Interposition Arthroplasty for Posttraumatic Arthritis of the
Finger Joints. The Journal of Hand Surgery, 33(1), 35–39.
https://doi.org/10.1016/j.jhsa.2007.10.020

7. Gong, H. S., Chung, M. S., Oh, J. H., Lee, Y. H., Lee, Y.-K., & Baek, G. H. (2008). Ligament Reconstruction and Tendon
Interposition for Advanced Posttraumatic Arthritis of the Proximal Interphalangeal Joint: 3 Case Reports. The Journal
of Hand Surgery, 33(9), 1573–1578. https://doi.org/10.1016/j.jhsa.2008.06.006
Pre op
Post op

8. PIPJ Arthrodesis techniques
1. Wires
a. Oblique wire and cerclage
b. 90-90 loop wiring
2. Tension band wiring technique
3. Plates and screw
4. Screw only
5. Others
a. Intramedullary screw device
b. External fixation
cerclage loop and oblique wire
(Lister’s technique)
Tension band wiring
Plate fixation (courtesy of Dr
Ellen Lee)
Screw only (Leibovic 2007)

9. Technical considerations
• Angles
• Shorter -> straighter
• Radial to ulnar
• Patient needs
• Bone cuts
Figure from: https://plasticsurgerykey.com/osteoarthritis-
in-the-hand-and-wrist/
Straight cut
Cup and cone
Leibovic, S. J. (2007). Arthrodesis of the Interphalangeal Joints With Headless Compression Screws. The
Journal of Hand Surgery, 32(7), 1113–1119. https://doi.org/10.1016/j.jhsa.2007.06.010

10. Unclear which technique is better
• Biomechanics
• Capo 2014:
• Lister’s, 90-90 wiring, Tension-band, Plate & screws, IM
device
• IM device & Plate/Screws  best Ultimate strength and
stiffness
• Kovach’s 1986:
• Cross-wire, Tension-band wiring, Lister’s technique
• Figure of 8 best in AP bending and torsion
Capo, J. T., Melamed, E., Shamian, B., Hadley, S. R., Ng Lai, W., Gerszberg, K., Rivero, S., & Caravaggi, P.
(2014). Biomechanical Evaluation of 5 Fixation Devices for Proximal Interphalangeal Joint Arthrodesis.
The Journal of Hand Surgery, 39(10), 1971–1977. https://doi.org/10.1016/j.jhsa.2014.07.035
Kovach, J. C., Werner, F. W., Palmer, A. K., Greenkey, S., & Murphy, D. J. (1986). Biomechanical analysis
of internal fixation techniques for proximal interphalangeal joint arthrodesis. The Journal of Hand
Surgery, 11(4), 562–566. https://doi.org/10.1016/S0363-5023(86)80200-3
cerclage loop and oblique wire
(Lister’s technique)

11. My favored choice – Tension band wiring
• Fast
• Reliable
• Inexpensive and non-obtrusive
implant
• For technique – see Uhl 2007 in
resources
Uhl, R. L. (2007). Proximal
Interphalangeal Joint
Arthrodesis Using the Tension
Band Technique. The Journal of
Hand Surgery, 32(6), 914–917.
https://doi.org/10.1016/j.jhsa.2
007.04.014

12. Results of PIPJ fusion
• “Surgical Results”
• Fusion rates > 85% (see Jung 2018)
• Complication rates low
• Hardware prominence ~9% (Jung
2018)
• Malunion, fracture, infection, skin
problems
• Functional Results
• Pain relief
• Better strength
• Loss of motion: average ~ 30°
(Vitale 2015)

13. Implant Arthroplasty
From Adkinson 2014
Pyrocarbon Implant Arthroplasty (A) intra-operative view of index PIP joint implant in place (B) anterior-posterior x-
ray of index finger PIP joint (C) lateral x-ray of index finger PIP joint
Silicon Implants
Surface
replacement

14. Silicone Arthroplasty
• PIPJ and MCPJ
• Many years experience
• Functions as a spacer
• Rather than a true joint
• Many patients satisfied with it
Moment about the PIP joint axis. (A) In hinged arthroplasty, flexion moment about
the PIP joint requires force (F) with moment arm (X). The moment arm from a
flexed position (X′) decreases due to dorsal displacement of the center of rotation
requiring an increase in extension force (F′) to return the PIP joint to neutral.
Zhu, A. F., Rahgozar, P., & Chung, K. C. (2018). Advances in
Proximal Interphalangeal Joint Arthroplasty. Hand Clinics, 34(2),
185–194. https://doi.org/10.1016/j.hcl.2017.12.008

15. Long term outcomes of silicone arthroplasty
• Good
• Pain relief (VAS 0.4/10)
• Patient satisfaction
• Implant survival (90% at 10 years)
• BUT
• ROM unchanged
• Radiographic changes progress
• Deformity
• Fracture
• Revisions/removal (3/38)
• For older, lower demand patients
• Average age: 60
• Mostly females
Radiographs of both hands demonstrating
subsidence, endosteal erosions, and implant failure
10 years after silicone PIP joint arthroplasties (from
Bales 2014)

16. Metal Implant Arthroplasty
• Newer than silicone
• Pain relief
• Range of motion not markedly
increased
• Complications higher than silicone
• Infection
• Squeaking
• Contractures
• Dislocation
• Subsidence
• Limited indications (Adkinson 2014)
• “Young patients with post-traumatic
arthritis, no angular deformity, adequate
soft tissue coverage”
PIP joint-Surface Replacement Implant (Courtesy of Small
Bone Innovations, Inc., Morrisville, PA). From Adkinson
2014
Proximal: cobalt-chrome
Distal: HMWPE
Titanium coated proximal stem

17. Asia-Pacific Designs
• Self Locking Finger Joint (SLFJ) (Teijin
Nakashima Medical Co, Okayama, Japan)
• Modular system
• Unique Joint anchor
• Self-tapping screw
• 2 legs
• Used since 1999 in Japan
• Results similar to other implants
• Ishizuki total finger system (Nakashima
Medical Co)
• See: Shirakawa, K., & Shirota, M. (2020). Surface Replacement Arthroplasty Using a
Volar Approach for Osteoarthritis of Proximal Interphalangeal Joint: Results After a
Minimum 5-Year Follow-up. Hand (New York, N.Y.), 15(1), 81–86.
https://doi.org/10.1177/1558944718787332
Figure from: Komatsu, I., Arishima, Y., Shibahashi, H., Yamaguchi, T., & Minamikawa,Y. (2018).
Outcomes of Surface Replacement Proximal Interphalangeal Joint Arthroplasty Using the Self
Locking Finger Joint Implant: Minimum Two Years Follow-up. HAND, 13(6), 637–645.
https://doi.org/10.1177/1558944717726136
Shirakawa, K., & Shirota, M. (2020). Surface ReplacementArthroplasty Using a Volar Approach for
Osteoarthritis of Proximal InterphalangealJoint: Results After a Minimum 5-Year Follow-up. Hand
(New York, N.Y.), 15(1), 81–86. https://doi.org/10.1177/1558944718787332

18. Summary of arthroplasty options
Type Indications Advantages Disadvantages
Silicone MCPJ and PIPJ arthritis (OA,
RA, post-traumatic)
Pain relief, technically
straightforward
Minimal improvement in range of motion
(better at MCPJ compared to PIPJ),
subsidence, implant fracture
PIP-SRA/
Nakashima
MCPJ and PIPJ arthritis (OA,
post-traumatic)
Pain relief, minimal
bone resection
(maintain collaterals)
Minimal improvement in range of motion,
subsidence, loosening, implant fracture
Pyrocarbon MCPJ and PIPJ arthritis (post-
traumatic, rarely OA) with
adequate soft tissue support
Pain relief
(controversial),
improved grip/pinch
strength
Minimal improvement in range of motion
(better at MCPJ compared to PIPJ),
subsidence, dislocation, implant fracture
Autologous Skeletally immature patients
with MCPJ and PIPJ trauma or
adults with contraindication
for prosthesis (inadequate
soft tissue support, large
bone deficit, previously failed
prosthesis)
Allows future growth
and composite
reconstruction
Minimal improvement in range of motion,
high complication rate, need for secondary
surgery, technically challenging
Adapted from Adkinson 2014

19. Fusion vs Implant Arthroplasty
• Not well studied
• Both currently have a place in
treatments – differing patients, clinical
problem, functional needs
• Outcomes studied
• Pain relief
• Range of motion
• Strength
• Better improvement in lateral pinch strength
in arthrodesis (Pelligrini 1990)
• Complications
• Implant arthroplasty late complications
Richards, T., Ingham, L., Russell, I., & Newington, D. (2020). The Long-term Results of
Proximal Interphalangeal Joint Arthroplasty of the Osteoarthritic Index Finger. HAND,
155894472092146. https://doi.org/10.1177/1558944720921468

20. Take Home Message
• Arthrodesis of PIPJ is a reliable operation for pain relief and correcting
deformity
• Main issue is total loss of motion of PIPJ
• Functional assessments comparable to implant arthroplasty
• Candidates: younger, male, strength requirement, lack of bone stock/stability
• Implant Arthroplasty
• Prioritizes motion
• Also provides good pain relief
• Motion does not increase, decreases over time
• More complications and re-operations
• Silicone implants well established; metal/surface replacement implants
evolving

21. Thank you!
References: https://bit.ly/pipj_refs

22. Komatsu, I., Arishima, Y., Shibahashi, H., Yamaguchi, T., & Minamikawa, Y. (2018). Outcomes of Surface Replacement Proximal Interphalangeal Joint Arthroplasty Using the Self
Locking Finger Joint Implant: Minimum Two Years Follow-up. HAND, 13(6), 637–645. https://doi.org/10.1177/1558944717726136
Back