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Proximal interphalangeal joint silicone arthroplasty for posttraumatic arthritis
Proximal Interphalangeal Joint Silicone Arthroplasty for Posttraumatic Arthritis J. Joris Hage, MD, PhD, Eveline P.D. Yoe, MD, Julia P. Zevering, MD, Peter J.M. de Groot, MSc, Amsterdam, The Netherlands The long-term results of 16 silicone implant arthroplasties following severe destruction of the proximal interphalangeal joint and surrounding soft tissue in 14 patients were evaluated. Two implants were revised (1 arthrodesis and 1 amputation) and are not included in the results. On a visual analog scale of 0 to 100, the subjective evaluation relating to the quality of function and the ability to perform activities of daily living scored 73 on average (range, 0 –100; median, 75). The range of active motion compared with the opposite side ranged from 0% to 100% (average, 47%; median, 56%). The lateral deviation, either radial or ulnar, averaged 4° (range, 0° to 9°; median, 4°). Rotational deformity, either radial or ulnar, averaged 8° (range, 0° to 32°; median, 4°). Pinch strength of the operated finger on average was 75% of the opposite nonoperated finger (range, 14% to 164%; median, 70%). Possible statistical correlation between objective and subjective results was evaluated. Subjectively, most patients were satisfied because they were pain free. Objectively, notable rotational deformity, alignment deviation, and loss of pinch strength and range of motion were observed, but these did not correlate well with the subjective assessment. Silicone implant arthroplasty for posttraumatic arthrosis should be used for those cases in which associated adhesions may be corrected by simple tenolysis, allowing for active range of motion shortly following arthroplasty. Even in these cases, the objective results of silicone arthroplasty may not be as good as its subjective outcome. (J Hand Surg 1999;24A:73–77. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Hand surgery, arthroplasty, implants, trauma
Implant arthroplasty is a well-established treatment for rheumatic conditions in the hand.1 Occasionally, arthroplasty may be indicated for posttraumatic disabilities with painful, destroyed, or
From the Departments of Plastic and Reconstructive Surgery and Occupational Therapy, Academisch Ziekenhuis Vrije Universiteit, Amsterdam, The Netherlands. Received for publication May 28, 1996; accepted in revised form July 13, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: J. Joris Hage, MD, PhD, Department of Plastic and Reconstructive Surgery, Academisch Ziekenhuis Vrije Universiteit, PO Box 7057, NL-1007 MB Amsterdam, The Netherlands. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0011$3.00/0
subluxated joints and for stiffened joints in which a soft tissue release alone would be inadequate.2 It may be performed either by interposition of soft tissues or other materials or by complete joint replacement.3 Silicone implant arthroplasty appears to be the most reliable and accepted form of replacement arthroplasty in the hand,3 even though an ideal prosthetic finger joint is not yet available.4 Arthrodesis is the major alternative to arthroplasty and, although effective, limits joint mobility. In 1975, both Iselin5 and Comtet et al6 introduced a classification of the indications for implant arthroplasty that correlated with the outcome of the procedure. Both series showed favorable results in cases in which the arthroplasty was performed for sequela of closed articular fractures without accompanying capThe Journal of Hand Surgery 73
74 Hage et al / Posttraumatic Use of Digital Joint Prostheses
sular damage. Less favorable results were observed in cases of isolated joint subluxation with capsular injury and in cases in which the dorsal extensor apparatus was damaged. The outcome of arthroplasty was reported to be worse when performed following severe open joint fractures with destruction of extensor tendon.5,6 We present our long-term results using silicone implant arthroplasty following severe destruction of the proximal interphalangeal (PIP) joint and surrounding soft tissue. Knowledge of the benefits and limitations of this procedure in the severe posttraumatic cases will permit patient and surgeon to approach implant arthroplasty with realistic expectations.1
Materials and Methods From 1982 to 1992, 16 Swanson implants (Wright Medical Technology Inc, Arlington, TN) in 14 patients (9 males and 5 females) with posttraumatic arthritis following isolated open intra-articular PIP joint fractures with extensive capsular injury or dorsal apparatus damage were inserted for pain or joint stiffness.3 In 11 cases, the fracture was part of a severe open dorsal joint wound with destruction of the extensor tendon. In most cases, the initial trauma was of occupational origin (Table 1). All cases were initially treated either conservatively or surgically. Arthroplasty was offered electively and as an alternative to arthrodesis in an attempt to regain some
motion of the joint. The time lapse between initial trauma and arthroplasty averaged 25 months (range, 2 weeks to 10 years; median, 12 months). The age at the time of arthroplasty averaged 34 years (range, 14 –77 years; median, 34 years). All patients were examined 1 to 10 years after arthroplasty with an average follow-up period of 4 years (median, 3 years). Hospital notes for all patients were available for evaluation. From these, possible revision procedures were scored.
Operative Technique All patients had undergone surgery according to the principles required for successful arthroplasty.1,7 The incision (dorsal or midlateral) depended on the level and extent of the pre-existing scar. The same applied to the choice between a midline longitudinal incision of the central extensor tendon and an approach between the lateral and central extensor tendon. In 1 case, arthroplasty was combined with extensor tenolysis. One patient had already undergone tenolysis before silicone arthroplasty. In 4 cases, tenolysis was performed as a secondary procedure. No flexor tenolysis was performed. After implantation, the integrity of the central tendon was maintained in all patients. No tendon grafts were performed for a deficient extensor mechanism. Implant size was selected using a sizing set.7 Grommets were not used. Five to 7
Table 1. Demographics and Outcome of Posttraumatic Proximal Interphalangeal Joint Arthroplasty Case No.
Age (yr)
Digit
Cause
1 2
29 14
3 4 5 6 7 8 9
33 43 24 34 38 22 39
10 11 12 13 14 Median
74 40 17 38 33
Index (D) Long (D) Ring (D) Ring (ND) Long (D) Index (ND) Index (D) Long (ND) Ring (D) Index (ND) Long (ND) Ring (ND) Long (ND) Ring (ND) Ring (D) Ring (D)
Crush Crush Crush Punch Crush Crush Mill Mill Saw Saw Saw Crush Saw Crush Crush Mill
ROM
RROM
20 80 45 25* 90 60 40 95 0 50* 60 35† 25*
0.19 0.73 0.75 0.23 1.00 0.57 0.35 0.83 0.00 0.56 0.63 0.33 0.23
13* 46
0.11 0.47
Pinch Implant fracture 4.0 1.5 6.0 1.5 9.0 7.0 3.0 18.0 26.5 19.5 12.5 10.0 10.0 Finger amputation 21.0 10.7
RPinch
VAS
0.57 0.21 0.60 0.14 1.64 1.17 0.21 1.64 0.88 0.70 0.78 0.50 0.50
85 85 75 0 0 100 100 60 70 70 100 100 100
0.91 0.76
70 66
D, dominant; ND, nondominant; Pinch, pinch strength in pounds; Rpinch, pinch strength expressed as a percentage of the strength of the opposite finger; VAS, visual analog scale. *Secondary tenolysis. †Tenolysis before arthoplasty.
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 75
days after surgery, the finger was placed in a dynamic splint for 6 weeks and range of motion (ROM) was initiated.8
Long-Term Objective and Subjective Assessment All patients attended the outpatient clinic for longterm assessment. The subjective assessment included daily function and pain. For evaluation of the combined function of the entire digit, a visual analog scale (Astra Pharmaceutics, Rijswijk, The Netherlands) was used as a self-report device to measure patients’ assessment of the resultant loss of function as it relates to activities of daily living and work and the more specialized hand activities.9 –11 The visual analog scale is a line, usually 10 cm in length, with anchors at each end to indicate the extremes of responses under study. The low end of the scale (0) is at the bottom of the vertically orientated scale and represents an unfavorable result. The upper end of the scale is marked 100 and reflects an excellent outcome.10 Objective assessment included relative range of active motion (RROM), this being the active ROM of the operated joint as a percentage of the ROM of the corresponding nonoperated PIP joint. The ROM was recorded using a goniometer (North Coast Medical, San Jose´, CA).9 Only the ROM of the involved joint was recorded because this more accurately corresponds with the implant-related result. Pinch strength of both the involved and the opposite nonoperated finger was tested using an Osco pinch meter (J.A. Preston Corp, New York, NY). To obtain the relative pinch strength, the outcome of the operated finger was expressed as a percentage of the strength observed in the nonoperated finger. Lateral angulation and rotation deformities were measured in degrees. To do so, both hands of all patients were photographed and compared in a standard way (Fig. 1). Statistical correlations between the various measurements were evaluated applying Pearson’s correlation coefficient.12 This correlation coefficient, r, measures the degree of straight-line association between the values of any 2 measurements. Thus, a value of 11.0 or 21.0 is obtained if all the points of a scatter diagram lie on a perfectly straight line. The correlation between 2 measurements is positive if favorable results of 1 measurement are associated with favorable results of another and negative whenever 1 result tends to be less favorable as the other gets more favorable. A correlation of approximately
0 indicates that there is no linear relationship between the results of 2 measurements, ie, they are not correlated.12 Statistical evaluation was completed for the entire series.
Results Revisions Two implants in 2 patients had been removed by the time of this writing. In 1 patient, a fracture of the implant occurred 3 years after arthroplasty. Salvage was accomplished by arthrodesis. In the other patient, the finger had been amputated at the PIP level 1 year after arthroplasty because of joint stiffness, resulting in functional disability. The results of the remaining 12 patients (14 implants) are presented below. Apart from the secondary tenolysis in 4 cases, no revisions were performed. No other implant fractures or dislocations were observed.
Subjective Assessment On the visual analog scale from 0 to 100, the subjective evaluation relating to the quality of function and the ability to perform activities of daily living averaged 73 (range, 0 –100; median, 75) (Table 1). Two patients scored 0; 1 had cold intolerance and the other experienced discomfort following heavy duty. All the other patients scored more than 50. Loss of sensation compared with preoperative findings was not observed.
Objective Assessment The active RROM ranged from 0% to 100% (average, 47%; median, 56%) (Table 1). There was no statistical correlation between RROM and subjective assessment for the whole series (r 5 .35) or the nontenolysis subgroup (r 5 .40). Even after tenolysis, RROM and subjective satisfaction did not correlate (r 5 .02). The lateral deviation, either radial or ulnar, averaged 4° (range, 0° to 9°; median, 4°). Rotation deformity, either radial or ulnar, averaged 8° (range, 0° to 32°; median, 4°). Pinch strength of the operated finger was on average 75% of the opposite nonoperated finger (range, 14% to 164%; median, 70%). Although the pinch strength in 3 of the patients was observed to be superior to that of the nonoperated side, the affected finger, in general, showed considerable loss of strength. Rotational deformity, alignment deviation, and loss of pinch strength did not correlate statistically with subjective assessment.
76 Hage et al / Posttraumatic Use of Digital Joint Prostheses
Figure 1. Lateral angulation (top) and rotation deformities (bottom) were measured in degrees using standardized photography of both hands in all patients, as illustrated here.
Discussion Proximal interphalangeal joint implant arthroplasties were performed for the sequel of comminuted intra-articular fractures, either open or complicated by destruction of the surrounding soft tissues. Although our objective results were less favorable than those obtained by others,2,4,6 these compare with those observed by Iselin5 and Comtet et al6 in similar subgroups of severe lesions. The resulting RROM was poor, but most of our patients were satisfied with the result of arthroplasty because they were pain free. Even in the cases in which tenolysis was performed, a more favorable RROM did not correlate to an increase of subjective satisfaction. On the contrary, the subjective assessment was found to be favorable in the 3 cases in which the RROM was less than 20%, resulting in a virtual ankylosis. Like us, Iselin5 found that the arthroplasty produced a well-posi-
tioned and painless fusion in patients in whom the procedure might be considered a failure because of lack of mobility.5,13 Like Michon et al,14 we found that poor results correlated with the condition of the surrounding soft tissues. Even when satisfactory passive motion is obtained during surgery, the final active ROM was limited by coexisting tendinous injury. Other factors limiting active ROM include the quality of the bone stock to receive the implant and the condition of adjacent joints.2 Early complications have been considered to be related to unfavorable soft tissue condition and vascularization at the level of the affected joint that account for necrosis, wound dehiscence, and infection.2,13,14 For these reasons, selection of patients is of utmost importance.5 When contemplating arthroplasty for posttraumatic disability of a finger joint, several factors
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 77
should be evaluated. Arthroplasty should be considered only to correct functional loss and not just a deformity, and it should be restricted to cases of isolated joint involvement.2 Favorable results can only be obtained if the tendons acting across the joint are intact; therefore, some investigators recommend tendon repair and tenolysis before joint reconstruction.4 Posttraumatic silicone implant arthroplasty should be restricted to cases in which musculotendinous integrity allows immediate active mobility.4,6 In addition, patient cooperation is mandatory to obtain a good result and some have argued that arthroplasty may not be indicated following an accident at work involving compensation.5 As the quality of surgical outcome is related to the cause of stiffness, this applies as an important factor to be evaluated before surgery. The use of silicone implants to correct posttraumatic arthrosis should be restricted to cases in which associated tendon adhesions may be eliminated by simple combined tenolysis, thus allowing for active function shortly after the procedure. Even in these cases, the objective results of silicone arthroplasty may not be as effective as its subjective outcome.
4. 5. 6.
7.
8.
9.
10.
References
11.
1. Wilson YG, Sykes PJ, Niranjan NS. Long-term follow-up of Swanson’s Silastic arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis. J Hand Surg 1993;18B: 81–91. 2. Swanson AB, Maupin BK, Gajjar NV, de Groot Swanson G. Flexible implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg 1985;10A:796 – 805. 3. Beckenbaugh RD, Linscheid RL. Arthroplasty in the hand and wrist. In: Green DP, Hotchkiss RN, eds. Operative
12.
13.
14.
hand surgery. Vol. 1. 3rd ed. New York: Churchill Livingstone, 1993:143–187. Hagert C-G. Advances in hand surgery: finger joint implants. Surg Ann 1978;10:253–275. Iselin F. Arthroplasty of the proximal interphalangeal joint after trauma. Hand 1975;7:41– 42. Comtet J-J, Monatte J-P, Machenaud A. Utilisation des implants de Swanson au niveau des articulations interphalangiennes proximales dans les se´quelles de traumatisme: voie d’abord—re´sultats—indications. Ann Chir 1975;29: 471– 474. Swanson AB. Flexible implant arthroplasty of the proximal interphalangeal joint of the fingers. Ann Plast Surg 1979; 3:346 –354. Swanson AB, de Groot Swanson G, Leonard J, Boozer J. Postoperative rehabilitation programs in flexible implant arthroplasty of the digits. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: surgery and therapy. 3rd ed. St Louis: Mosby, 1990:912– 928. Swanson AB, de Groot Swanson G, Go¨ran-Hagert C. Evaluation of impairment of hand function. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the hand: surgery and therapy. 3rd ed. St Louis: Mosby, 1990:109 –138. Gift AG. Visual analogue scales: measurement of subjective phenomena. Nurs Res 1989;38:286 –288. Luria RE. The validity and reliability of the visual analogue mood scale. J Psychiatr Res 1975;12:51–57. Altman DG. Relation between two continuous variables. In: Altman DG, ed. Practical statistics for medical research. London: Chapman Hall, 1991:277–324. Iselin F. Arthroplasties par implants de Swanson pour les se´quelles de fractures articulaires des doigts. Acta Orthop Belg 1973;39:1121–1125. Michon J, Delagoutte J-P, Jandeaux M. Les implants en Silastic de Swanson en traumatologie de la main. Ann Chir Plast 1974;19:13–21.
Implant arthroplasty is a well-established treatment for rheumatic conditions in the hand.1 Occasionally, arthroplasty may be indicated for posttraumatic disabilities with painful, destroyed, or
From the Departments of Plastic and Reconstructive Surgery and Occupational Therapy, Academisch Ziekenhuis Vrije Universiteit, Amsterdam, The Netherlands. Received for publication May 28, 1996; accepted in revised form July 13, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: J. Joris Hage, MD, PhD, Department of Plastic and Reconstructive Surgery, Academisch Ziekenhuis Vrije Universiteit, PO Box 7057, NL-1007 MB Amsterdam, The Netherlands. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0011$3.00/0
subluxated joints and for stiffened joints in which a soft tissue release alone would be inadequate.2 It may be performed either by interposition of soft tissues or other materials or by complete joint replacement.3 Silicone implant arthroplasty appears to be the most reliable and accepted form of replacement arthroplasty in the hand,3 even though an ideal prosthetic finger joint is not yet available.4 Arthrodesis is the major alternative to arthroplasty and, although effective, limits joint mobility. In 1975, both Iselin5 and Comtet et al6 introduced a classification of the indications for implant arthroplasty that correlated with the outcome of the procedure. Both series showed favorable results in cases in which the arthroplasty was performed for sequela of closed articular fractures without accompanying capThe Journal of Hand Surgery 73
74 Hage et al / Posttraumatic Use of Digital Joint Prostheses
sular damage. Less favorable results were observed in cases of isolated joint subluxation with capsular injury and in cases in which the dorsal extensor apparatus was damaged. The outcome of arthroplasty was reported to be worse when performed following severe open joint fractures with destruction of extensor tendon.5,6 We present our long-term results using silicone implant arthroplasty following severe destruction of the proximal interphalangeal (PIP) joint and surrounding soft tissue. Knowledge of the benefits and limitations of this procedure in the severe posttraumatic cases will permit patient and surgeon to approach implant arthroplasty with realistic expectations.1
Materials and Methods From 1982 to 1992, 16 Swanson implants (Wright Medical Technology Inc, Arlington, TN) in 14 patients (9 males and 5 females) with posttraumatic arthritis following isolated open intra-articular PIP joint fractures with extensive capsular injury or dorsal apparatus damage were inserted for pain or joint stiffness.3 In 11 cases, the fracture was part of a severe open dorsal joint wound with destruction of the extensor tendon. In most cases, the initial trauma was of occupational origin (Table 1). All cases were initially treated either conservatively or surgically. Arthroplasty was offered electively and as an alternative to arthrodesis in an attempt to regain some
motion of the joint. The time lapse between initial trauma and arthroplasty averaged 25 months (range, 2 weeks to 10 years; median, 12 months). The age at the time of arthroplasty averaged 34 years (range, 14 –77 years; median, 34 years). All patients were examined 1 to 10 years after arthroplasty with an average follow-up period of 4 years (median, 3 years). Hospital notes for all patients were available for evaluation. From these, possible revision procedures were scored.
Operative Technique All patients had undergone surgery according to the principles required for successful arthroplasty.1,7 The incision (dorsal or midlateral) depended on the level and extent of the pre-existing scar. The same applied to the choice between a midline longitudinal incision of the central extensor tendon and an approach between the lateral and central extensor tendon. In 1 case, arthroplasty was combined with extensor tenolysis. One patient had already undergone tenolysis before silicone arthroplasty. In 4 cases, tenolysis was performed as a secondary procedure. No flexor tenolysis was performed. After implantation, the integrity of the central tendon was maintained in all patients. No tendon grafts were performed for a deficient extensor mechanism. Implant size was selected using a sizing set.7 Grommets were not used. Five to 7
Table 1. Demographics and Outcome of Posttraumatic Proximal Interphalangeal Joint Arthroplasty Case No.
Age (yr)
Digit
Cause
1 2
29 14
3 4 5 6 7 8 9
33 43 24 34 38 22 39
10 11 12 13 14 Median
74 40 17 38 33
Index (D) Long (D) Ring (D) Ring (ND) Long (D) Index (ND) Index (D) Long (ND) Ring (D) Index (ND) Long (ND) Ring (ND) Long (ND) Ring (ND) Ring (D) Ring (D)
Crush Crush Crush Punch Crush Crush Mill Mill Saw Saw Saw Crush Saw Crush Crush Mill
ROM
RROM
20 80 45 25* 90 60 40 95 0 50* 60 35† 25*
0.19 0.73 0.75 0.23 1.00 0.57 0.35 0.83 0.00 0.56 0.63 0.33 0.23
13* 46
0.11 0.47
Pinch Implant fracture 4.0 1.5 6.0 1.5 9.0 7.0 3.0 18.0 26.5 19.5 12.5 10.0 10.0 Finger amputation 21.0 10.7
RPinch
VAS
0.57 0.21 0.60 0.14 1.64 1.17 0.21 1.64 0.88 0.70 0.78 0.50 0.50
85 85 75 0 0 100 100 60 70 70 100 100 100
0.91 0.76
70 66
D, dominant; ND, nondominant; Pinch, pinch strength in pounds; Rpinch, pinch strength expressed as a percentage of the strength of the opposite finger; VAS, visual analog scale. *Secondary tenolysis. †Tenolysis before arthoplasty.
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 75
days after surgery, the finger was placed in a dynamic splint for 6 weeks and range of motion (ROM) was initiated.8
Long-Term Objective and Subjective Assessment All patients attended the outpatient clinic for longterm assessment. The subjective assessment included daily function and pain. For evaluation of the combined function of the entire digit, a visual analog scale (Astra Pharmaceutics, Rijswijk, The Netherlands) was used as a self-report device to measure patients’ assessment of the resultant loss of function as it relates to activities of daily living and work and the more specialized hand activities.9 –11 The visual analog scale is a line, usually 10 cm in length, with anchors at each end to indicate the extremes of responses under study. The low end of the scale (0) is at the bottom of the vertically orientated scale and represents an unfavorable result. The upper end of the scale is marked 100 and reflects an excellent outcome.10 Objective assessment included relative range of active motion (RROM), this being the active ROM of the operated joint as a percentage of the ROM of the corresponding nonoperated PIP joint. The ROM was recorded using a goniometer (North Coast Medical, San Jose´, CA).9 Only the ROM of the involved joint was recorded because this more accurately corresponds with the implant-related result. Pinch strength of both the involved and the opposite nonoperated finger was tested using an Osco pinch meter (J.A. Preston Corp, New York, NY). To obtain the relative pinch strength, the outcome of the operated finger was expressed as a percentage of the strength observed in the nonoperated finger. Lateral angulation and rotation deformities were measured in degrees. To do so, both hands of all patients were photographed and compared in a standard way (Fig. 1). Statistical correlations between the various measurements were evaluated applying Pearson’s correlation coefficient.12 This correlation coefficient, r, measures the degree of straight-line association between the values of any 2 measurements. Thus, a value of 11.0 or 21.0 is obtained if all the points of a scatter diagram lie on a perfectly straight line. The correlation between 2 measurements is positive if favorable results of 1 measurement are associated with favorable results of another and negative whenever 1 result tends to be less favorable as the other gets more favorable. A correlation of approximately
0 indicates that there is no linear relationship between the results of 2 measurements, ie, they are not correlated.12 Statistical evaluation was completed for the entire series.
Results Revisions Two implants in 2 patients had been removed by the time of this writing. In 1 patient, a fracture of the implant occurred 3 years after arthroplasty. Salvage was accomplished by arthrodesis. In the other patient, the finger had been amputated at the PIP level 1 year after arthroplasty because of joint stiffness, resulting in functional disability. The results of the remaining 12 patients (14 implants) are presented below. Apart from the secondary tenolysis in 4 cases, no revisions were performed. No other implant fractures or dislocations were observed.
Subjective Assessment On the visual analog scale from 0 to 100, the subjective evaluation relating to the quality of function and the ability to perform activities of daily living averaged 73 (range, 0 –100; median, 75) (Table 1). Two patients scored 0; 1 had cold intolerance and the other experienced discomfort following heavy duty. All the other patients scored more than 50. Loss of sensation compared with preoperative findings was not observed.
Objective Assessment The active RROM ranged from 0% to 100% (average, 47%; median, 56%) (Table 1). There was no statistical correlation between RROM and subjective assessment for the whole series (r 5 .35) or the nontenolysis subgroup (r 5 .40). Even after tenolysis, RROM and subjective satisfaction did not correlate (r 5 .02). The lateral deviation, either radial or ulnar, averaged 4° (range, 0° to 9°; median, 4°). Rotation deformity, either radial or ulnar, averaged 8° (range, 0° to 32°; median, 4°). Pinch strength of the operated finger was on average 75% of the opposite nonoperated finger (range, 14% to 164%; median, 70%). Although the pinch strength in 3 of the patients was observed to be superior to that of the nonoperated side, the affected finger, in general, showed considerable loss of strength. Rotational deformity, alignment deviation, and loss of pinch strength did not correlate statistically with subjective assessment.
76 Hage et al / Posttraumatic Use of Digital Joint Prostheses
Figure 1. Lateral angulation (top) and rotation deformities (bottom) were measured in degrees using standardized photography of both hands in all patients, as illustrated here.
Discussion Proximal interphalangeal joint implant arthroplasties were performed for the sequel of comminuted intra-articular fractures, either open or complicated by destruction of the surrounding soft tissues. Although our objective results were less favorable than those obtained by others,2,4,6 these compare with those observed by Iselin5 and Comtet et al6 in similar subgroups of severe lesions. The resulting RROM was poor, but most of our patients were satisfied with the result of arthroplasty because they were pain free. Even in the cases in which tenolysis was performed, a more favorable RROM did not correlate to an increase of subjective satisfaction. On the contrary, the subjective assessment was found to be favorable in the 3 cases in which the RROM was less than 20%, resulting in a virtual ankylosis. Like us, Iselin5 found that the arthroplasty produced a well-posi-
tioned and painless fusion in patients in whom the procedure might be considered a failure because of lack of mobility.5,13 Like Michon et al,14 we found that poor results correlated with the condition of the surrounding soft tissues. Even when satisfactory passive motion is obtained during surgery, the final active ROM was limited by coexisting tendinous injury. Other factors limiting active ROM include the quality of the bone stock to receive the implant and the condition of adjacent joints.2 Early complications have been considered to be related to unfavorable soft tissue condition and vascularization at the level of the affected joint that account for necrosis, wound dehiscence, and infection.2,13,14 For these reasons, selection of patients is of utmost importance.5 When contemplating arthroplasty for posttraumatic disability of a finger joint, several factors
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 77
should be evaluated. Arthroplasty should be considered only to correct functional loss and not just a deformity, and it should be restricted to cases of isolated joint involvement.2 Favorable results can only be obtained if the tendons acting across the joint are intact; therefore, some investigators recommend tendon repair and tenolysis before joint reconstruction.4 Posttraumatic silicone implant arthroplasty should be restricted to cases in which musculotendinous integrity allows immediate active mobility.4,6 In addition, patient cooperation is mandatory to obtain a good result and some have argued that arthroplasty may not be indicated following an accident at work involving compensation.5 As the quality of surgical outcome is related to the cause of stiffness, this applies as an important factor to be evaluated before surgery. The use of silicone implants to correct posttraumatic arthrosis should be restricted to cases in which associated tendon adhesions may be eliminated by simple combined tenolysis, thus allowing for active function shortly after the procedure. Even in these cases, the objective results of silicone arthroplasty may not be as effective as its subjective outcome.
4. 5. 6.
7.
8.
9.
10.
References
11.
1. Wilson YG, Sykes PJ, Niranjan NS. Long-term follow-up of Swanson’s Silastic arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis. J Hand Surg 1993;18B: 81–91. 2. Swanson AB, Maupin BK, Gajjar NV, de Groot Swanson G. Flexible implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg 1985;10A:796 – 805. 3. Beckenbaugh RD, Linscheid RL. Arthroplasty in the hand and wrist. In: Green DP, Hotchkiss RN, eds. Operative
12.
13.
14.
hand surgery. Vol. 1. 3rd ed. New York: Churchill Livingstone, 1993:143–187. Hagert C-G. Advances in hand surgery: finger joint implants. Surg Ann 1978;10:253–275. Iselin F. Arthroplasty of the proximal interphalangeal joint after trauma. Hand 1975;7:41– 42. Comtet J-J, Monatte J-P, Machenaud A. Utilisation des implants de Swanson au niveau des articulations interphalangiennes proximales dans les se´quelles de traumatisme: voie d’abord—re´sultats—indications. Ann Chir 1975;29: 471– 474. Swanson AB. Flexible implant arthroplasty of the proximal interphalangeal joint of the fingers. Ann Plast Surg 1979; 3:346 –354. Swanson AB, de Groot Swanson G, Leonard J, Boozer J. Postoperative rehabilitation programs in flexible implant arthroplasty of the digits. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: surgery and therapy. 3rd ed. St Louis: Mosby, 1990:912– 928. Swanson AB, de Groot Swanson G, Go¨ran-Hagert C. Evaluation of impairment of hand function. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the hand: surgery and therapy. 3rd ed. St Louis: Mosby, 1990:109 –138. Gift AG. Visual analogue scales: measurement of subjective phenomena. Nurs Res 1989;38:286 –288. Luria RE. The validity and reliability of the visual analogue mood scale. J Psychiatr Res 1975;12:51–57. Altman DG. Relation between two continuous variables. In: Altman DG, ed. Practical statistics for medical research. London: Chapman Hall, 1991:277–324. Iselin F. Arthroplasties par implants de Swanson pour les se´quelles de fractures articulaires des doigts. Acta Orthop Belg 1973;39:1121–1125. Michon J, Delagoutte J-P, Jandeaux M. Les implants en Silastic de Swanson en traumatologie de la main. Ann Chir Plast 1974;19:13–21.