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Revision of Failed Distal Interphalangeal Arthrodesis Complicated by Retained Headless Screw
SURGICAL TECHNIQUE
Revision of Failed Distal Interphalangeal Arthrodesis Complicated by Retained Headless Screw Anthony Owusu, MD, Jonathan Isaacs, MD Arthrodesis of the distal interphalangeal joint is a well-accepted treatment for painful arthritis. Although headless screw fixation across the distal interphalangeal joint is an overall effective method for achieving bony union, failures and nonunions still occur. We present a salvage technique to address both the retained headless screw within the medullary canal as well as the persistent nonunion. (J Hand Surg 2013;xx:. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.)
to treat symptomatic arthritic and traumatic conditions of the distal interphalangeal (DIP) joint; when it is successful, it relieves pain and stabilizes hand function with minimal morbidity.1 Along with proper bone surface preparation, multiple fixation techniques that have been described to facilitate predictable union include K-wires,2,3 bioabsorbable rods,4 interosseous wires with a longitudinal K-wire, and either cannulated or noncannulated transarticular screw fixation.1,5–14 Union rates are typically high for this procedure regardless of technique and have been reported to range from 80% to 100%.1,5–7,11 Unfortunately, some patients still develop nonunion of the arthrodesis site.2– 8,13,15 Some of these may develop a stable and painless fibrous nonunion and no further treatment will be necessary. For symptomatic failed arthrodesis, however, revision surgery is necessary. Cases of nonunion in which initial fixation was performed with a headless screw offer additional challenges. “Windshield wipering” can occur if there is persistent motion at the failed arthrodesis site, further complicating revision surgery. In addition, bone formation over the screw entrance site creates an additional
A
RTHRODESIS CAN BE USED
From the Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, VA. Received for publication October 26, 2012; accepted in revised form April 22, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:JonathanIsaacs,MD,DepartmentofOrthopaedicSurgery,VirginiaCommonwealth University Medical Center, 1200 East Broad Street, PO Box 980153, Richmond, VA 23298; e-mail: [email protected]. 0363-5023/13/xx0x-0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.04.018
obstacle to removing the retained intramedullary screw. We describe a technique that simultaneously addresses the retained screw and failed arthrodesis using a dorsal DIP approach, retrograde removal of the retained screw, and refixation with an iliac crest corticocancellous dowel autograft secured with cerclage wiring. CASE REPORT A 63-year-old woman with significant comorbidities including hypertension, systemic lupus erythematosus, asthma, and previous methicillin-resistant staphylococcal finger infection (in a neighboring digit) resulting in amputation, underwent middle finger DIP arthrodesis for recalcitrant painful arthritis. A dorsal approach over the DIP joint allowed “cup and cone” preparation of the joint surfaces and a 2.3-mm-diameter cannulated headless compression screw was placed across the DIP joint. Excellent compression was obtained and the arthrodesis site was stable. At 4 months postoperatively, persistent pain, swelling, and motion at the arthrodesis site was compatible with failed arthrodesis. After a short period of continued splint immobilization to see whether delayed union would occur, we noted progressive bone loss and absorption at the arthrodesis site and in the proximal aspect of the distal phalanx (Fig. 1). Concerns about ongoing symptoms as well as progressive bone loss prompted our recommendation for revision surgery. TECHNIQUE The previous dorsal surgical scar is reincorporated and extended slightly proximally (Fig. 2). A plane is created on top of the extensor tendon and split in line with the
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1
2
REVISION DIP ARTHRODESIS
FIGURE 1: A Lateral and B anteroposterior view of progressive bone loss and absorption noted at the arthrodesis site and in the proximal aspect of the distal phalanx.
FIGURE 2: Previous dorsal surgical scar is reincorporated and extended slightly proximally.
skin incision to expose the nonunion. Scar and fibrous tissue can be removed using currets and rongeurs. To remove the intramedullary screw, the proximal aspect of the screw is identified under fluoroscan imaging and marked. Two parallel longitudinal osteotomies (3– 4 mm apart) are made along the dorsal cortex of the middle phalanx from the nonunion site to about 3 mm proximal to the proximal aspect of the intramedullary screw, as identified under fluoroscan imaging using a small oscillating saw (Fig. 3A). A 1.1-mm
(0.045-in) K-wire can be used to perforate the cortex at the proximal aspect of the parallel osteotomies (because this remaining bone bridge between the cuts is too narrow for even the smallest saw blade). All cuts are performed with copious irrigation, and excess heat generation is avoided to prevent thermal bone necrosis. A wedge of dorsal cortex can now be removed from the middle phalanx, exposing the proximal half of the screw within the medullary canal. The tip of the screw can be lifted out (using a dental pick) as the unstable DIP joint is flexed down. The tip of the screw can be grasped with a large needle driver and twisted in line to advance the screw across the DIP joint and removed in a retrograde fashion (Fig. 4B). The nonunion can now be further debrided and cartilage and fibrous tissue may be scraped out of any areas of bone loss within the distal phalanx (Fig. 4C, D). The iliac crest is exposed in the standard fashion and the oscillating saw (and K-wires) is used to remove a corticocancellous wedge of bone similar in width, but about 10 to 15 mm longer than the dorsal wedge of bone removed from the dorsal cortex of the middle phalanx (Fig. 4A). Extra-cancellous bone graft can be harvested as well, to pack into any remaining lytic areas around the DIP joint and to pack into the failed arthrodesis site. The harvested corticocancellous bone peg may require further contouring, which can typically be performed using a rongeur, although careful use of an oscillating saw or burr is an acceptable alternative. The
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REVISION DIP ARTHRODESIS
3
FIGURE 3: A Two parallel longitudinal osteotomies are made along the dorsal cortex of the middle phalanx from the nonunion site to about 3 mm proximal to the proximal aspect of the intramedullary screw. A wedge of dorsal cortex can now be removed from the middle phalanx, exposing the proximal half of the screw within the medullary canal. B, C The tip of the screw is exposed and grasped with a large needle driver, which is twisted in line to advance the screw across the DIP joint, and removed in a retrograde fashion. D The nonunion can now be further debrided and cartilage and fibrous tissue scraped out of any areas of bone loss within the distal phalanx.
contoured bone peg is now impacted into the base of the distal phalanx (like a dowel) (Fig. 4B). The joint is extended so that the proximal aspect of the dowel settles into the dorsal cortical defect previously created in the middle phalanx (Fig. 4C, D). The goal is to achieve a
tongue-in-groove fit, although this should be done by fine-tuning the contouring, because attempts to forcefully impact the dowel into the middle phalanx could result in fracture. The proximal dowel is secured with 2 or 3 passes of a 24-gauge cerclage wire around the
JHS 䉬 Vol xx, Month
4
REVISION DIP ARTHRODESIS
FIGURE 4: A The harvested corticocancellous bone peg may require further contouring. B, C The contoured bone peg is now impacted into the base of the distal phalanx (like a dowel). D The joint is extended so that the proximal aspect of the dowel settles into the dorsal cortical defect previously created in the middle phalanx. E The proximal dowel is secured with 2 or 3 passes of a 24-gauge cerclage wire around the middle phalanx, whereas the distal aspect of the dowel has been secured by the impaction into the distal phalanx.
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FIGURE 5: A Anteroposterior and B lateral fluoroscopic views of the finger should confirm alignment, dowel placement, and hardware fixation.
middle phalanx (deep to all tendon and neurovascular structures), whereas the distal aspect of the dowel is secured by the impaction into the distal phalanx (Fig. 4E). Additional K-wire fixation can be used if necessary. The new arthrodesis site should now be grossly stable and any extra-cancellous bone graft can be further packed into the nonunion site. Fluoroscopic views of the finger should confirm alignment, dowel placement, and hardware fixation (Fig 5A, B). The extensor mechanism is repaired to augment the soft tissue envelope and skin is closed after obtaining hemostasis. We prefer a full dorsal hand splint in the safe position in addition to a palmar finger splint for our initial postoperative immobilization. This can be advanced to a full finger splint at 3 weeks (including the proximal interphalangeal joint) and to a DIP-only finger splint at 6
weeks. The DIP finger splint should be worn until radiographic and clinical evidence of healing is noted (Fig 6A, B). DISCUSSION Distal interphalangeal joint nonunion rates have been reported to range from 0% to 20% in the literature. In 1992, Stern and Fulton8 looked at 27 digits undergoing arthrodesis using Herbert screw (Zimmer, Inc., Warsaw, IN) fixation, with a mean follow-up of 72 months and a nonunion rate of 11%. In 2003, El Hadidi and Al-Kdah5 used Herbert screws in a similar application and observed a nonunion rate of 7% in 15 digits after a mean follow-up of 4 years. Lamas Gomez et al12 reported a nonunion rate of 5% in 20 digits over a 2-year period using the Herbert screw. In 2006, Mini-Acutrak screws (Acumed, Inc.,
JHS 䉬 Vol xx, Month
6
REVISION DIP ARTHRODESIS
FIGURE 6: A Anteroposterior and B lateral fluoroscopic views of the finger 3 months postsurgery, demonstrating early bone healing. The arthrodesis site is pain-free, stable, and clinically healed.
Hillsboro, OR) used by Brutus et al11 on 27 digits with 7-month follow-up had a similar 15% nonunion rate. Olivier et al7 reported on 28 digits using the Compact screw and Villani et al15 used the Arex SCRU 2 (Arex, Inc., Collegeville, PA) on 102 digits; both reported 100% union rates at 2-year follow-up. Failed arthrodesis of the DIP joint with a retained intramedullary screw is a rare but challenging surgical problem. Although Stern and Fulton8 recommended the use of a corticocancellous distal radius bone graft inlay for revision arthrodesis of the DIP joints, we were unable to identify a detailed description of this technique or any techniques for removal of the retained screw. We describe our technique in which both problems can be simultaneously addressed. REFERENCES 1. Faithfull DK, Herbert TJ. Small joint fusions of the hand using the Herbert Bone Screw. J Hand Surg Br. 1984;9(2):167–168. 2. Zavitsanos G, Watkins F, Britton E, Somia N, Gupta A, Kleinbert H. Distal Interphalangeal joint arthrodesis using intramedullary and interosseous fixation. Hand Surg Am. 1999;4(1):51–55. 3. Tomaino MM. Distal interphalangeal joint arthrodesis with screw fixation: why and how. Hand Clin. 2006;22(2):207–210. 4. Arata J, Ishikawa K, Soeda H, Kitayama T. Arthrodesis of the distal interphalangeal joint using a bioabsorbable rod as an intramedullary nail. Scand J Plast Reconstr Surg Hand Surg. 2003;37(4):228 –231.
5. El-Hadidi S, Al-Kdah H. Distal interphalangeal joint arthrodesis with Herbert screw. Hand Surg Am. 2003;8(1):21–24. 6. Leibovic SJ. Instructional Course Lecture. Arthrodesis of the interphalangeal joints with headless compression screws. J Hand Surg Am. 2007;32(7):1113–1119. 7. Olivier LC, Gensigk F, Board TN, Kendoff D, Krehmeier U, Wolfhard U. Arthrodesis of the distal interphalangeal joint: description of a new technique and clinical follow-up at 2 years. Arch Orthop Trauma Surg. 2008;128(3):307–311. 8. Stern PJ, Fulton DB. Distal interphalangeal joint arthrodesis: an analysis of complications. J Hand Surg Am. 1992;17(6):1139 –1145. 9. Moberg E. Arthrodesis of finger joints. Surg Clin North Am. 1960; 40:465– 470. 10. Lewis RC, Nordyke MD, Tenny JR. The tenon method of small joint arthrodesis in the hand. J Hand Surg Am. 1986;11(4):567–569. 11. Brutus JP, Palmer AK, Mosher JF, Harley BJ, Loftus JB. Use of a headless compressive screw for distal interphalangeal joint arthrodesis in digits: clinical outcome and review of complications. J Hand Surg Am. 2006;31(1):85– 89. 12. Lamas Gomez C, Proubasta I, Escriba I, Itarte J, Caceres E. Distal interphalangeal joint arthrodesis: treatment with Herbert screw. J South Orthop Assoc. 2003;12(3):154 –159. 13. Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis with the Herbert headless compression screw: outcomes and complications in 64 consecutively treated joints. Hand (N Y). 2011;6(1):56 –59. 14. Katzman SS, Gibeault JD, Dickson K, Thompson JD. Use of a Herbert screw for interphalangeal joint arthrodesis. Clin Orthop Relat Res. 1993;(296):127–132. 15. Villani F, Uribe-Echevarria B, Vaienti L. Distal interphalangeal joint arthrodesis for degenerative osteoarthritis with compression screw: results in 102 digits. J Hand Surg Am. 2012;37(7):1330 –1334.
JHS 䉬 Vol xx, Month
Revision of Failed Distal Interphalangeal Arthrodesis Complicated by Retained Headless Screw Anthony Owusu, MD, Jonathan Isaacs, MD Arthrodesis of the distal interphalangeal joint is a well-accepted treatment for painful arthritis. Although headless screw fixation across the distal interphalangeal joint is an overall effective method for achieving bony union, failures and nonunions still occur. We present a salvage technique to address both the retained headless screw within the medullary canal as well as the persistent nonunion. (J Hand Surg 2013;xx:. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.)
to treat symptomatic arthritic and traumatic conditions of the distal interphalangeal (DIP) joint; when it is successful, it relieves pain and stabilizes hand function with minimal morbidity.1 Along with proper bone surface preparation, multiple fixation techniques that have been described to facilitate predictable union include K-wires,2,3 bioabsorbable rods,4 interosseous wires with a longitudinal K-wire, and either cannulated or noncannulated transarticular screw fixation.1,5–14 Union rates are typically high for this procedure regardless of technique and have been reported to range from 80% to 100%.1,5–7,11 Unfortunately, some patients still develop nonunion of the arthrodesis site.2– 8,13,15 Some of these may develop a stable and painless fibrous nonunion and no further treatment will be necessary. For symptomatic failed arthrodesis, however, revision surgery is necessary. Cases of nonunion in which initial fixation was performed with a headless screw offer additional challenges. “Windshield wipering” can occur if there is persistent motion at the failed arthrodesis site, further complicating revision surgery. In addition, bone formation over the screw entrance site creates an additional
A
RTHRODESIS CAN BE USED
From the Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, VA. Received for publication October 26, 2012; accepted in revised form April 22, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:JonathanIsaacs,MD,DepartmentofOrthopaedicSurgery,VirginiaCommonwealth University Medical Center, 1200 East Broad Street, PO Box 980153, Richmond, VA 23298; e-mail: [email protected]. 0363-5023/13/xx0x-0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.04.018
obstacle to removing the retained intramedullary screw. We describe a technique that simultaneously addresses the retained screw and failed arthrodesis using a dorsal DIP approach, retrograde removal of the retained screw, and refixation with an iliac crest corticocancellous dowel autograft secured with cerclage wiring. CASE REPORT A 63-year-old woman with significant comorbidities including hypertension, systemic lupus erythematosus, asthma, and previous methicillin-resistant staphylococcal finger infection (in a neighboring digit) resulting in amputation, underwent middle finger DIP arthrodesis for recalcitrant painful arthritis. A dorsal approach over the DIP joint allowed “cup and cone” preparation of the joint surfaces and a 2.3-mm-diameter cannulated headless compression screw was placed across the DIP joint. Excellent compression was obtained and the arthrodesis site was stable. At 4 months postoperatively, persistent pain, swelling, and motion at the arthrodesis site was compatible with failed arthrodesis. After a short period of continued splint immobilization to see whether delayed union would occur, we noted progressive bone loss and absorption at the arthrodesis site and in the proximal aspect of the distal phalanx (Fig. 1). Concerns about ongoing symptoms as well as progressive bone loss prompted our recommendation for revision surgery. TECHNIQUE The previous dorsal surgical scar is reincorporated and extended slightly proximally (Fig. 2). A plane is created on top of the extensor tendon and split in line with the
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1
2
REVISION DIP ARTHRODESIS
FIGURE 1: A Lateral and B anteroposterior view of progressive bone loss and absorption noted at the arthrodesis site and in the proximal aspect of the distal phalanx.
FIGURE 2: Previous dorsal surgical scar is reincorporated and extended slightly proximally.
skin incision to expose the nonunion. Scar and fibrous tissue can be removed using currets and rongeurs. To remove the intramedullary screw, the proximal aspect of the screw is identified under fluoroscan imaging and marked. Two parallel longitudinal osteotomies (3– 4 mm apart) are made along the dorsal cortex of the middle phalanx from the nonunion site to about 3 mm proximal to the proximal aspect of the intramedullary screw, as identified under fluoroscan imaging using a small oscillating saw (Fig. 3A). A 1.1-mm
(0.045-in) K-wire can be used to perforate the cortex at the proximal aspect of the parallel osteotomies (because this remaining bone bridge between the cuts is too narrow for even the smallest saw blade). All cuts are performed with copious irrigation, and excess heat generation is avoided to prevent thermal bone necrosis. A wedge of dorsal cortex can now be removed from the middle phalanx, exposing the proximal half of the screw within the medullary canal. The tip of the screw can be lifted out (using a dental pick) as the unstable DIP joint is flexed down. The tip of the screw can be grasped with a large needle driver and twisted in line to advance the screw across the DIP joint and removed in a retrograde fashion (Fig. 4B). The nonunion can now be further debrided and cartilage and fibrous tissue may be scraped out of any areas of bone loss within the distal phalanx (Fig. 4C, D). The iliac crest is exposed in the standard fashion and the oscillating saw (and K-wires) is used to remove a corticocancellous wedge of bone similar in width, but about 10 to 15 mm longer than the dorsal wedge of bone removed from the dorsal cortex of the middle phalanx (Fig. 4A). Extra-cancellous bone graft can be harvested as well, to pack into any remaining lytic areas around the DIP joint and to pack into the failed arthrodesis site. The harvested corticocancellous bone peg may require further contouring, which can typically be performed using a rongeur, although careful use of an oscillating saw or burr is an acceptable alternative. The
JHS 䉬 Vol xx, Month
REVISION DIP ARTHRODESIS
3
FIGURE 3: A Two parallel longitudinal osteotomies are made along the dorsal cortex of the middle phalanx from the nonunion site to about 3 mm proximal to the proximal aspect of the intramedullary screw. A wedge of dorsal cortex can now be removed from the middle phalanx, exposing the proximal half of the screw within the medullary canal. B, C The tip of the screw is exposed and grasped with a large needle driver, which is twisted in line to advance the screw across the DIP joint, and removed in a retrograde fashion. D The nonunion can now be further debrided and cartilage and fibrous tissue scraped out of any areas of bone loss within the distal phalanx.
contoured bone peg is now impacted into the base of the distal phalanx (like a dowel) (Fig. 4B). The joint is extended so that the proximal aspect of the dowel settles into the dorsal cortical defect previously created in the middle phalanx (Fig. 4C, D). The goal is to achieve a
tongue-in-groove fit, although this should be done by fine-tuning the contouring, because attempts to forcefully impact the dowel into the middle phalanx could result in fracture. The proximal dowel is secured with 2 or 3 passes of a 24-gauge cerclage wire around the
JHS 䉬 Vol xx, Month
4
REVISION DIP ARTHRODESIS
FIGURE 4: A The harvested corticocancellous bone peg may require further contouring. B, C The contoured bone peg is now impacted into the base of the distal phalanx (like a dowel). D The joint is extended so that the proximal aspect of the dowel settles into the dorsal cortical defect previously created in the middle phalanx. E The proximal dowel is secured with 2 or 3 passes of a 24-gauge cerclage wire around the middle phalanx, whereas the distal aspect of the dowel has been secured by the impaction into the distal phalanx.
JHS 䉬 Vol xx, Month
REVISION DIP ARTHRODESIS
5
FIGURE 5: A Anteroposterior and B lateral fluoroscopic views of the finger should confirm alignment, dowel placement, and hardware fixation.
middle phalanx (deep to all tendon and neurovascular structures), whereas the distal aspect of the dowel is secured by the impaction into the distal phalanx (Fig. 4E). Additional K-wire fixation can be used if necessary. The new arthrodesis site should now be grossly stable and any extra-cancellous bone graft can be further packed into the nonunion site. Fluoroscopic views of the finger should confirm alignment, dowel placement, and hardware fixation (Fig 5A, B). The extensor mechanism is repaired to augment the soft tissue envelope and skin is closed after obtaining hemostasis. We prefer a full dorsal hand splint in the safe position in addition to a palmar finger splint for our initial postoperative immobilization. This can be advanced to a full finger splint at 3 weeks (including the proximal interphalangeal joint) and to a DIP-only finger splint at 6
weeks. The DIP finger splint should be worn until radiographic and clinical evidence of healing is noted (Fig 6A, B). DISCUSSION Distal interphalangeal joint nonunion rates have been reported to range from 0% to 20% in the literature. In 1992, Stern and Fulton8 looked at 27 digits undergoing arthrodesis using Herbert screw (Zimmer, Inc., Warsaw, IN) fixation, with a mean follow-up of 72 months and a nonunion rate of 11%. In 2003, El Hadidi and Al-Kdah5 used Herbert screws in a similar application and observed a nonunion rate of 7% in 15 digits after a mean follow-up of 4 years. Lamas Gomez et al12 reported a nonunion rate of 5% in 20 digits over a 2-year period using the Herbert screw. In 2006, Mini-Acutrak screws (Acumed, Inc.,
JHS 䉬 Vol xx, Month
6
REVISION DIP ARTHRODESIS
FIGURE 6: A Anteroposterior and B lateral fluoroscopic views of the finger 3 months postsurgery, demonstrating early bone healing. The arthrodesis site is pain-free, stable, and clinically healed.
Hillsboro, OR) used by Brutus et al11 on 27 digits with 7-month follow-up had a similar 15% nonunion rate. Olivier et al7 reported on 28 digits using the Compact screw and Villani et al15 used the Arex SCRU 2 (Arex, Inc., Collegeville, PA) on 102 digits; both reported 100% union rates at 2-year follow-up. Failed arthrodesis of the DIP joint with a retained intramedullary screw is a rare but challenging surgical problem. Although Stern and Fulton8 recommended the use of a corticocancellous distal radius bone graft inlay for revision arthrodesis of the DIP joints, we were unable to identify a detailed description of this technique or any techniques for removal of the retained screw. We describe our technique in which both problems can be simultaneously addressed. REFERENCES 1. Faithfull DK, Herbert TJ. Small joint fusions of the hand using the Herbert Bone Screw. J Hand Surg Br. 1984;9(2):167–168. 2. Zavitsanos G, Watkins F, Britton E, Somia N, Gupta A, Kleinbert H. Distal Interphalangeal joint arthrodesis using intramedullary and interosseous fixation. Hand Surg Am. 1999;4(1):51–55. 3. Tomaino MM. Distal interphalangeal joint arthrodesis with screw fixation: why and how. Hand Clin. 2006;22(2):207–210. 4. Arata J, Ishikawa K, Soeda H, Kitayama T. Arthrodesis of the distal interphalangeal joint using a bioabsorbable rod as an intramedullary nail. Scand J Plast Reconstr Surg Hand Surg. 2003;37(4):228 –231.
5. El-Hadidi S, Al-Kdah H. Distal interphalangeal joint arthrodesis with Herbert screw. Hand Surg Am. 2003;8(1):21–24. 6. Leibovic SJ. Instructional Course Lecture. Arthrodesis of the interphalangeal joints with headless compression screws. J Hand Surg Am. 2007;32(7):1113–1119. 7. Olivier LC, Gensigk F, Board TN, Kendoff D, Krehmeier U, Wolfhard U. Arthrodesis of the distal interphalangeal joint: description of a new technique and clinical follow-up at 2 years. Arch Orthop Trauma Surg. 2008;128(3):307–311. 8. Stern PJ, Fulton DB. Distal interphalangeal joint arthrodesis: an analysis of complications. J Hand Surg Am. 1992;17(6):1139 –1145. 9. Moberg E. Arthrodesis of finger joints. Surg Clin North Am. 1960; 40:465– 470. 10. Lewis RC, Nordyke MD, Tenny JR. The tenon method of small joint arthrodesis in the hand. J Hand Surg Am. 1986;11(4):567–569. 11. Brutus JP, Palmer AK, Mosher JF, Harley BJ, Loftus JB. Use of a headless compressive screw for distal interphalangeal joint arthrodesis in digits: clinical outcome and review of complications. J Hand Surg Am. 2006;31(1):85– 89. 12. Lamas Gomez C, Proubasta I, Escriba I, Itarte J, Caceres E. Distal interphalangeal joint arthrodesis: treatment with Herbert screw. J South Orthop Assoc. 2003;12(3):154 –159. 13. Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis with the Herbert headless compression screw: outcomes and complications in 64 consecutively treated joints. Hand (N Y). 2011;6(1):56 –59. 14. Katzman SS, Gibeault JD, Dickson K, Thompson JD. Use of a Herbert screw for interphalangeal joint arthrodesis. Clin Orthop Relat Res. 1993;(296):127–132. 15. Villani F, Uribe-Echevarria B, Vaienti L. Distal interphalangeal joint arthrodesis for degenerative osteoarthritis with compression screw: results in 102 digits. J Hand Surg Am. 2012;37(7):1330 –1334.
JHS 䉬 Vol xx, Month