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“PEPPER-POT” ARTHRODESIS OF THE SMALL JOINTS OF THE HAND: OUR EXPERIENCE IN 68 CASES
‘‘PEPPER-POT’’ ARTHRODESIS OF THE SMALL JOINTS OF THE HAND: OUR EXPERIENCE IN 68 CASES H. K. SHANKER, A. J. JOHNSTONE, L. RIZZO and R. B. CHESNEY From the Department of Orthopaedic Surgery, Woodend Hospital, Grampian University Hospital NHS Trust, Aberdeen, UK
Sixty-eight small joint arthrodeses were performed in the hand using a new technique. Following removal of the articular cartilage, multiple drill holes are made through the subchondral bone, connecting the medullary canal with the joint space. The final joint position is maintained with an intraosseous wire loop and a Kirschner wire. Union was achieved at a mean of 7 weeks and our results are comparable with those of other series. This technique is easy to perform but is contraindicated if there is extreme joint destruction. Its main advantages are that the position of the fusion can be adjusted as bone-to-bone congruency is maintained through an arc of flexion and the overall length and shape of the digit is preserved. Journal of Hand Surgery (British and European Volume, 2002) 27B: 5: 430–432 This technique has advantages over previously described techniques, in that it produces congruent bone-tobone contact and causes only minimal shortening of the involved digits. In addition, it is easy to perform and is sufficiently flexible to permit modification of the final position of arthrodesis prior to definitive stabilization.
INTRODUCTION Arthrodesis is used to treat pain, instability, deformity and loss of muscular control of the small joints of the hands (Weiland, 1998). Painful post-traumatic arthritis, rheumatoid arthritis, fixed joint contractures and old flexor digitorum profundus tendon ruptures are some of the conditions that can benefit from fusion of the affected joints. The aim of any joint arthrodesis is to obtain a ‘‘solid painless arthrodesis in the proper position in a reasonable time’’ (Moberg, 1960). Many techniques have been described, but successful arthrodesis relies upon maintenance of good bone-to-bone contact in the optimal functional position. Previously described techniques involve either angled resection of the bone ends, fashioning of a congruous ‘cup and cone’, a chevron osteotomy (Divelbiss and Baratz, 1999), mortise and tenon preparation of the bone ends (Lewis et al., 1986), or concave–convex preparation of the joint surfaces (Leibovic, 1997). All of these techniques result in shortening of the digit and none always provides optimal bone-to-bone contact in the desired position of fusion. In addition some of the techniques are difficult to perform and need special instrumentation. A new technique for arthrodesis of the small joints of the hand has been developed in Aberdeen.
PATIENTS AND METHODS Sixty-eight small joints have been arthrodesed in 58 patients using this technique. Forty of the patients were women with a mean age of 56 (range, 22–80) years. The mean age of the 18 men was 45 (range, 16–74) years. All of the operations were either performed by the senior surgeon (RBC), or by surgeons who had been supervised or instructed in the method by the senior surgeon. The joints arthrodesed and the indications for arthrodesis are shown in Table 1. Operative technique Through a dorsal skin incision, the extensor apparatus was split longitudinally to expose the metacarpophalangeal or proximal interphalangeal joints. The distal interphalangeal joints were approached through a Yshaped skin incision and with transverse division, and
Table 1FIndications for arthrodesis in the small joints of the hand
Post-traumatic Fractures Chronic long flexor tendon rupture Chronic rupture of volar plate Chronic ulnar collateral ligament injury Failed extensor tendon repair Osteoarthritis Rheumatoid arthritis Paralytic Dupuytrens contracture
Proximal Interphalangeal Joint
Distal interphalangeal joint
Metacarpophalangeal joint of finger
Interphalangeal joint of the thumb
2 – – – 1 2 1 – 1
5 7 1 – – 12 2 – –
2 – 1 2 – 9 10 – –
– 2 – – – 2 5 1
430
RT. SMALL JOINT FUSION
later repair, of the extensor tendon at the level of the joint. The capsule was opened to expose the articular cartilage of both joint surfaces, and this was removed using a small burr, knife or curette. The contour of the subchondral bone was preserved (Fig 1a). The denuded surfaces were then drilled with a Kirschner wire to produce multiple connections between the medullary cavity and the joint in a ‘pepper-pot’ fashion (Fig 1b). Care was taken not to remove the medullary contents that exuded into the joint space. As the joint surfaces had been retained, the surgeon was able to choose the ideal final position for joint arthrodesis without significantly altering the area of bone-to-bone contact. Stabilization was achieved using an intraosseous wire loop and an obliquely placed Kirschner wire
431
to maintain the chosen degree of joint flexion (Lister, 1978). Earlier in this series it was the practice of the senior surgeon to leave the Kirschner wire protruding through the skin to enable its removal after 2–3 months. However, later in the series, the Kirschner wire was cut short and buried under the skin. Postoperatively, the joint arthrodeses were placed in a bulky soft dressing for 24 h and early movement of the adjacent joints was actively encouraged. Power grip was discouraged until fusion, as assessed clinically or radiologically, had occurred. Clinically a joint was considered to have fused when the localized tenderness had resolved, the joint appeared stable, and there was no pain on stressing the joint in either the medial–lateral or palmar–dorsal directions (Leibovic, 1997).
Fig 1 (a) Preservation of the subchondral bone following removal of the articular cartilage. (b) ‘Pepper-pot’ preparation of the subchondral bone.
Fig 2 (a,b) Pre-operative radiograph showing an osteoarthritic DIP joint. (c,d) Post-operative radiographs demonstrating fusion of this joint.
432
RESULTS All of the proximal interphalangeal joints and thumb interphalangeal joints fused successfully. The average time to union for all of the joints that fused was 7 weeks (Figs 2a and b). We did not observe any significant difference in the union rate for rheumatoid patients taking disease-modifying drugs. Seven out of the 68 joints failed to unite (10%). The majority of the nonunions involved the distal interphalangeal joint (five of the 27 distal interphalangeal joint arthrodeses performed). Two out of the 24 metacarpophalangeal joints of the thumb also failed to unite. Of the five unsuccessful distal interphalangeal joint arthrodeses, three were symptom free, had sufficient stability and did not require further surgery. One patient underwent re-arthrodesis with a longitudinal Kirschner wire supplemented with bone graft, while the other patient required bone grafting alone as the intraosseous wire was providing good stability. Both of the metacarpophalangeal joint nonunions required re-arthrodesis with crossed Kirschner wire fixation. Of the 68 patients, four patients developed minor wound infections that resolved with oral antibiotics. Pin track infection occurred in five cases, and these settled following removal of the Kirschner wires. Four patients experienced localized tenderness over the knot of the intraosseous wire loop and had the wire removed after the joint had successfully fused. Importantly, there were no cases of malunion or excessive shortening of the digits. The total range of digital motion was not formally measured either pre- or post-operatively, but significant joint stiffness was not observed in the joints adjacent to the arthrodesed joint.
THE JOURNAL OF HAND SURGERY VOL. 27B No. 5 OCTOBER 2002
12 weeks (Leibovic, 1997) and our time of 7 weeks is comparable with these. Similarly, the incidence of nonunion after proximal interphalangeal joint arthrodesis varies from 0% (Leibovic and Strickland, 1994) to 13% (Lister, 1978), and our results are consistent with this. It is clear that nonunions are more common following arthrodeses for the distal interphalangeal joint, and in some series the rate may be as high as 20% (Engel et al., 1977). Overall, our technique of small joint arthrodesis has a similar fusion rate to previously described techniques. In addition our technique is easy to perform, maintains digital length and allows the surgeon to ‘fine tune’ the position of arthrodesis. However, it should be emphasized that this technique is not suitable for joints with marked deformities of the underlying bone ends resulting in loss of joint congruity. Acknowledgements The authors wish to thank Ms D. Bruce and Mrs L. Reid of the Records Section at Woodend Hospital for helping with data collection.
References Divelbiss BJ, Baratz ME (1999). The role of arthroplasty and arthrodesis following trauma to the upper extremity. Hand Clinics, 15: 335–345. Engel J, Tsur H, Farin I (1977). A comparison between Kirschner wire and compression screw fixation after arthrodesis of the distal interphalangeal joint. Plastic and Reconstructive Surgery, 60: 611–614. Leibovic SJ (1997). Internal fixation for small joint arthrodeses in the hand. Hand Clinics, 13: 601–613. Leibovic SJ, Strickland JW (1994). Arthrodesis of the proximal interphalangeal joint of the finger: comparison of the use of the Herbert screw with other fixation methods. The Journal of Hand Surgery, 19(A): 181–188. Lewis RC, Nordyke MD, Tenny JR (1986). The tenon method of small joint arthrodesis in the hand. Journal of Hand Surgery, 11(A): 567–569. Lister G (1978). Intraosseous wiring of digital skeleton. Journal of Hand Surgery, 39(A): 427–435. Moberg E (1960). Arthrodesis of the finger joints. Surgical Clinics of North America, 40: 465–470. Weiland AJ. Small joint arthrodesis. In: Green DP (Ed.) Operative hand surgery, 4th edn. New York, Churchill Livingstone, 1998, Vol. 1: 95–107.
DISCUSSION The position of an arthrodesed joint is of paramount importance if a good functional result is to be achieved (Leibovic, 1997). To achieve a successful arthrodesis bone ends have to be prepared to facilitate adequate apposition of cancellous bone combined with sound fixation (Divelbiss and Baratz, 1999). Time to union in other series reported in the literature varies from 6 to
Received: 17 December 2001 Accepted after revision: 11 April 2002 Dr A. J. Johnstone, Senior Lecturer and Honorary Consultant, Woodend Hospital, Eday Road, Aberdeen, AB15 6LS, UK. Tel.: +44 1224 556755; fax: +44 (0)1224 55666; E-mail: [email protected]
r 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2002.0798, available online at http://www.idealibrary.com on
Sixty-eight small joint arthrodeses were performed in the hand using a new technique. Following removal of the articular cartilage, multiple drill holes are made through the subchondral bone, connecting the medullary canal with the joint space. The final joint position is maintained with an intraosseous wire loop and a Kirschner wire. Union was achieved at a mean of 7 weeks and our results are comparable with those of other series. This technique is easy to perform but is contraindicated if there is extreme joint destruction. Its main advantages are that the position of the fusion can be adjusted as bone-to-bone congruency is maintained through an arc of flexion and the overall length and shape of the digit is preserved. Journal of Hand Surgery (British and European Volume, 2002) 27B: 5: 430–432 This technique has advantages over previously described techniques, in that it produces congruent bone-tobone contact and causes only minimal shortening of the involved digits. In addition, it is easy to perform and is sufficiently flexible to permit modification of the final position of arthrodesis prior to definitive stabilization.
INTRODUCTION Arthrodesis is used to treat pain, instability, deformity and loss of muscular control of the small joints of the hands (Weiland, 1998). Painful post-traumatic arthritis, rheumatoid arthritis, fixed joint contractures and old flexor digitorum profundus tendon ruptures are some of the conditions that can benefit from fusion of the affected joints. The aim of any joint arthrodesis is to obtain a ‘‘solid painless arthrodesis in the proper position in a reasonable time’’ (Moberg, 1960). Many techniques have been described, but successful arthrodesis relies upon maintenance of good bone-to-bone contact in the optimal functional position. Previously described techniques involve either angled resection of the bone ends, fashioning of a congruous ‘cup and cone’, a chevron osteotomy (Divelbiss and Baratz, 1999), mortise and tenon preparation of the bone ends (Lewis et al., 1986), or concave–convex preparation of the joint surfaces (Leibovic, 1997). All of these techniques result in shortening of the digit and none always provides optimal bone-to-bone contact in the desired position of fusion. In addition some of the techniques are difficult to perform and need special instrumentation. A new technique for arthrodesis of the small joints of the hand has been developed in Aberdeen.
PATIENTS AND METHODS Sixty-eight small joints have been arthrodesed in 58 patients using this technique. Forty of the patients were women with a mean age of 56 (range, 22–80) years. The mean age of the 18 men was 45 (range, 16–74) years. All of the operations were either performed by the senior surgeon (RBC), or by surgeons who had been supervised or instructed in the method by the senior surgeon. The joints arthrodesed and the indications for arthrodesis are shown in Table 1. Operative technique Through a dorsal skin incision, the extensor apparatus was split longitudinally to expose the metacarpophalangeal or proximal interphalangeal joints. The distal interphalangeal joints were approached through a Yshaped skin incision and with transverse division, and
Table 1FIndications for arthrodesis in the small joints of the hand
Post-traumatic Fractures Chronic long flexor tendon rupture Chronic rupture of volar plate Chronic ulnar collateral ligament injury Failed extensor tendon repair Osteoarthritis Rheumatoid arthritis Paralytic Dupuytrens contracture
Proximal Interphalangeal Joint
Distal interphalangeal joint
Metacarpophalangeal joint of finger
Interphalangeal joint of the thumb
2 – – – 1 2 1 – 1
5 7 1 – – 12 2 – –
2 – 1 2 – 9 10 – –
– 2 – – – 2 5 1
430
RT. SMALL JOINT FUSION
later repair, of the extensor tendon at the level of the joint. The capsule was opened to expose the articular cartilage of both joint surfaces, and this was removed using a small burr, knife or curette. The contour of the subchondral bone was preserved (Fig 1a). The denuded surfaces were then drilled with a Kirschner wire to produce multiple connections between the medullary cavity and the joint in a ‘pepper-pot’ fashion (Fig 1b). Care was taken not to remove the medullary contents that exuded into the joint space. As the joint surfaces had been retained, the surgeon was able to choose the ideal final position for joint arthrodesis without significantly altering the area of bone-to-bone contact. Stabilization was achieved using an intraosseous wire loop and an obliquely placed Kirschner wire
431
to maintain the chosen degree of joint flexion (Lister, 1978). Earlier in this series it was the practice of the senior surgeon to leave the Kirschner wire protruding through the skin to enable its removal after 2–3 months. However, later in the series, the Kirschner wire was cut short and buried under the skin. Postoperatively, the joint arthrodeses were placed in a bulky soft dressing for 24 h and early movement of the adjacent joints was actively encouraged. Power grip was discouraged until fusion, as assessed clinically or radiologically, had occurred. Clinically a joint was considered to have fused when the localized tenderness had resolved, the joint appeared stable, and there was no pain on stressing the joint in either the medial–lateral or palmar–dorsal directions (Leibovic, 1997).
Fig 1 (a) Preservation of the subchondral bone following removal of the articular cartilage. (b) ‘Pepper-pot’ preparation of the subchondral bone.
Fig 2 (a,b) Pre-operative radiograph showing an osteoarthritic DIP joint. (c,d) Post-operative radiographs demonstrating fusion of this joint.
432
RESULTS All of the proximal interphalangeal joints and thumb interphalangeal joints fused successfully. The average time to union for all of the joints that fused was 7 weeks (Figs 2a and b). We did not observe any significant difference in the union rate for rheumatoid patients taking disease-modifying drugs. Seven out of the 68 joints failed to unite (10%). The majority of the nonunions involved the distal interphalangeal joint (five of the 27 distal interphalangeal joint arthrodeses performed). Two out of the 24 metacarpophalangeal joints of the thumb also failed to unite. Of the five unsuccessful distal interphalangeal joint arthrodeses, three were symptom free, had sufficient stability and did not require further surgery. One patient underwent re-arthrodesis with a longitudinal Kirschner wire supplemented with bone graft, while the other patient required bone grafting alone as the intraosseous wire was providing good stability. Both of the metacarpophalangeal joint nonunions required re-arthrodesis with crossed Kirschner wire fixation. Of the 68 patients, four patients developed minor wound infections that resolved with oral antibiotics. Pin track infection occurred in five cases, and these settled following removal of the Kirschner wires. Four patients experienced localized tenderness over the knot of the intraosseous wire loop and had the wire removed after the joint had successfully fused. Importantly, there were no cases of malunion or excessive shortening of the digits. The total range of digital motion was not formally measured either pre- or post-operatively, but significant joint stiffness was not observed in the joints adjacent to the arthrodesed joint.
THE JOURNAL OF HAND SURGERY VOL. 27B No. 5 OCTOBER 2002
12 weeks (Leibovic, 1997) and our time of 7 weeks is comparable with these. Similarly, the incidence of nonunion after proximal interphalangeal joint arthrodesis varies from 0% (Leibovic and Strickland, 1994) to 13% (Lister, 1978), and our results are consistent with this. It is clear that nonunions are more common following arthrodeses for the distal interphalangeal joint, and in some series the rate may be as high as 20% (Engel et al., 1977). Overall, our technique of small joint arthrodesis has a similar fusion rate to previously described techniques. In addition our technique is easy to perform, maintains digital length and allows the surgeon to ‘fine tune’ the position of arthrodesis. However, it should be emphasized that this technique is not suitable for joints with marked deformities of the underlying bone ends resulting in loss of joint congruity. Acknowledgements The authors wish to thank Ms D. Bruce and Mrs L. Reid of the Records Section at Woodend Hospital for helping with data collection.
References Divelbiss BJ, Baratz ME (1999). The role of arthroplasty and arthrodesis following trauma to the upper extremity. Hand Clinics, 15: 335–345. Engel J, Tsur H, Farin I (1977). A comparison between Kirschner wire and compression screw fixation after arthrodesis of the distal interphalangeal joint. Plastic and Reconstructive Surgery, 60: 611–614. Leibovic SJ (1997). Internal fixation for small joint arthrodeses in the hand. Hand Clinics, 13: 601–613. Leibovic SJ, Strickland JW (1994). Arthrodesis of the proximal interphalangeal joint of the finger: comparison of the use of the Herbert screw with other fixation methods. The Journal of Hand Surgery, 19(A): 181–188. Lewis RC, Nordyke MD, Tenny JR (1986). The tenon method of small joint arthrodesis in the hand. Journal of Hand Surgery, 11(A): 567–569. Lister G (1978). Intraosseous wiring of digital skeleton. Journal of Hand Surgery, 39(A): 427–435. Moberg E (1960). Arthrodesis of the finger joints. Surgical Clinics of North America, 40: 465–470. Weiland AJ. Small joint arthrodesis. In: Green DP (Ed.) Operative hand surgery, 4th edn. New York, Churchill Livingstone, 1998, Vol. 1: 95–107.
DISCUSSION The position of an arthrodesed joint is of paramount importance if a good functional result is to be achieved (Leibovic, 1997). To achieve a successful arthrodesis bone ends have to be prepared to facilitate adequate apposition of cancellous bone combined with sound fixation (Divelbiss and Baratz, 1999). Time to union in other series reported in the literature varies from 6 to
Received: 17 December 2001 Accepted after revision: 11 April 2002 Dr A. J. Johnstone, Senior Lecturer and Honorary Consultant, Woodend Hospital, Eday Road, Aberdeen, AB15 6LS, UK. Tel.: +44 1224 556755; fax: +44 (0)1224 55666; E-mail: [email protected]
r 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2002.0798, available online at http://www.idealibrary.com on