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ArthroplastyArthroplasty of theof the InterphalangealInterphalangeal andand

MetacarpophalangealMetacarpophalangealjointsjoints

LeonorLeonorFernandesFernandes Teresa MarquesTeresa Marques

PedroPedro SimasSimas Fernando CruzFernando Cruz

UnidadeUnidade dede CirurgiaCirurgia dada momo ee membromembro superiorsuperiorHospital dosHospital dos LusLusadasadas LisboaLisboa, Portugal, Portugal

Hospital Garcia deHospital Garcia de OrtaOrta AlmadaAlmada

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HistoryHistory

19401940--Burmann: 1Burmann: 1stst IP and MCPIP and MCP arthroplastyarthroplasty

19591959--Brannon and Klein: 1Brannon and Klein: 1stst

published seriespublished series 19601960--Flatt: twin metallic stemsFlatt: twin metallic stems

19601960--Niebauer: 1Niebauer: 1stst silicone 1silicone 1--piece prosthesespiece prostheses

19681968--Swanson: SiliconeSwanson: Silicone

19791979--Linscheid:Linscheid: PyrocarbonPyrocarbon

19971997--Linscheid:Linscheid: PyrocarbonPyrocarbon --11stst resultsresults

VolarVolarplate interpositionplate interposition

OsteointegratedOsteointegrated arthroplastyarthroplasty -- TitaniumTitanium

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IP and MCPIP and MCP arthroplastyarthroplasty

IndicationsIndications

Degenerative joint diseaseDegenerative joint disease

Traumatic arthrosisTraumatic arthrosis

ReumathoidReumathoid arthritisarthritis

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IP and MCPIP and MCP arthroplastyarthroplasty

ContraindicationsContraindications

Active inflammatory diseaseActive inflammatory disease

Septic arthritisSeptic arthritis

Severe deformitySevere deformity

Loss of the extensor/flexor apparatusLoss of the extensor/flexor apparatus

Swan neckSwan neck

BoutounniBoutounnirere

LigamentousLigamentous instabilityinstability

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Small jointSmall joint arthroplastyarthroplastyPrinciplesPrinciples

Replace articular surfacesReplace articular surfaces

Balance flexor/extensor tendonsBalance flexor/extensor tendons Preserve collateral ligamentsPreserve collateral ligaments

Minimal bone removalMinimal bone removal

Intramedullary stemsIntramedullary stems

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Small jointSmall joint arthroplastyarthroplasty

CriteriaCriteria ((FlattFlatt e Fisher 1969)e Fisher 1969)

Restoration of a functionalRestoration of a functional range of motionrange of motion

IP jointsIP joints 1 degree of freedom1 degree of freedom

MCF jointsMCF joints 2 degrees of freedom2 degrees of freedom

AdequateAdequate stabilitystability

Resistance to subluxationResistance to subluxation

Constrained orConstrained orsemiconstrainedsemiconstrained prosthesesprostheses

Preservation of ligamentsPreservation of ligaments

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Small jointSmall joint arthroplastyarthroplasty

CriteriaCriteria ((FlattFlatt e Fisher 1969)e Fisher 1969)

Mechanical advantageMechanical advantage equivalent to normalequivalent to normal

Physiologic center of rotationPhysiologic center of rotation Accurate placement of stem and lengthAccurate placement of stem and length

PIP jointsPIP joints palmarpalmar/dorsal/dorsal angulationangulation

MCP jointsMCP joints

-- ulnarulnardeviationdeviation

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Small jointSmall joint arthroplastyarthroplasty

CriteriaCriteria ((FlattFlatt e Fisher 1969)e Fisher 1969)

Firm seatingFirm seating with resistance to rotational forceswith resistance to rotational forces

Intramedullary stemsIntramedullary stems AdaptativeAdaptative stems?stems?

Easy implantationEasy implantation

AccomodationAccomodation to sizeto size

Right/LeftRight/Left

4 fingers4 fingers

3232--40 models?40 models?

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Small jointSmall joint arthroplastyarthroplasty

CriteriaCriteria Biologic compatibilityBiologic compatibility

CobaltCobalt--Chrome, titanium,Chrome, titanium, pyrocarbonpyrocarbon,,siliconesilicone

AdequateAdequate material wearmaterial wear LongevityLongevity

PolyethylenePolyethylene osteolisysosteolisys??

SiliconeSilicone synovitissynovitis??

Soft tissueSoft tissue reconstructionreconstruction

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ExposureExposure -- PIPPIP

LateralLateral

PalmarPalmar

DorsalDorsal

PProsros

EasyEasy repairrepairofofthethe collateralcollateral ligamentligament

ConsCons

PrecisePrecise preparationpreparation ofofbonebone endsends isis moremore

difficultdifficult

InjuryInjury to centralto central slipslip andand palmarpalmarplateplate maymay

occuroccur

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ExposureExposure -- PIPPIP

LateralLateral

PalmarPalmar

DorsalDorsal

ProsPros

Easier preparation of bone endsEasier preparation of bone ends

Early motionEarly motion

ConsCons

Retraction of the flexor tendons and sheathRetraction of the flexor tendons and sheath

Possible injury to central slip dorsallyPossible injury to central slip dorsally

Flexor bowstringing may occurFlexor bowstringing may occur

Vascular/nervous injury riskVascular/nervous injury risk

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ExposureExposure -- PIPPIP

LateralLateral

PalmarPalmar

DorsalDorsal

ProsPros

Best exposureBest exposure

ConsCons

Possible extensor lagPossible extensor lag

Difficult bony preparationDifficult bony preparation

Delay on early motionDelay on early motion

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Dorsal (Dorsal (ChamayChamay))

Triangular incision of theTriangular incision of the

extensor apparatusextensor apparatus

Removal of dorsal capsuleRemoval of dorsal capsule

Osteotomy of the proximal andOsteotomy of the proximal and

medial phalangesmedial phalanges

MedullaryMedullary canals are reamedcanals are reamed

Appropriately sized implant isAppropriately sized implant ischosenchosen

Capsule and extensorCapsule and extensor

mechanism were repairedmechanism were repaired

TechniqueTechnique -- PIPPIP

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ExposureExposure -- MCPMCP

DorsalDorsal

ProsPros

Best exposureBest exposure

ConsCons

Repair of the extensorRepair of the extensor

mechanism is vitalmechanism is vital

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DorsalDorsal

Incision over the MCP jointsIncision over the MCP joints CapsulotomyCapsulotomy

MedullaryMedullary canals are reamedcanals are reamed

Appropriately sized implant isAppropriately sized implant ischosenchosen

Capsule and extensorCapsule and extensor

mechanism were repairedmechanism were repaired

TechniqueTechnique -- MCPMCP

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ComplicationsComplications

RadiolucenceRadiolucence (50%)(50%)

HeterotopicHeterotopic ossification (15ossification (15--20%)20%) Subluxation/Instability (19%)Subluxation/Instability (19%)

Implant fracture (12Implant fracture (12--16%)16%)

Dislocation (6Dislocation (6--8%)8%)

Infection (1Infection (1--2%)2%)

SynovitisSynovitis (rarely)(rarely)

PeriprostheticPeriprosthetic sclerosissclerosis

Revision rate at 2 years (13Revision rate at 2 years (13--50%)50%)

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RehabilitationRehabilitation

FundamentalFundamental

Early range ofEarly range of

movementmovement

ProtectionProtection

OrthotesesOrthoteses

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Surgical optionsSurgical options

ArthrodesisArthrodesis loss of movement; DIPloss of movement; DIP

InterpositionInterposition arthroplastyarthroplasty techniqualtechniqual demandingdemanding

Total jointTotal joint

arthroplastyarthroplasty

Silicone implantSilicone implant

PyrocarbonPyrocarbon implantimplant

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DiscussionDiscussion

Total jointTotal joint arthroplastyarthroplasty -- SiliconeSilicone

ProsPros

Pain freePain free

Keeps motilityKeeps motility

Long term durationLong term duration

ConsCons Instability (rheumatoid arthritis)Instability (rheumatoid arthritis)

Possibility of failure (fracture,Possibility of failure (fracture, osteolysisosteolysis))

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DiscussionDiscussion

Total jointTotal joint arthroplastyarthroplasty -- PyrocarbonPyrocarbon

ProsPros

Pain freePain free

Keeps motilityKeeps motility

ConsCons

Possibility of failure (fracture,Possibility of failure (fracture,

osteolysisosteolysis)) Better bone qualityBetter bone quality

High costHigh cost

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BrananBranan

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ConclusionConclusion

Improvement of pain with all techniquesImprovement of pain with all techniques

Improvement of strength and functionImprovement of strength and function

Failure to improve movementFailure to improve movement -- PIPPIP

Arthrodesis for distalArthrodesis for distal interphalangealinterphalangealjointjoint

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ConclusionConclusion

InterpositionInterposition arthroplastyarthroplasty -- promising resultspromising results

Silicone 1/6 price ofSilicone 1/6 price ofpyrocarbonpyrocarbon implantsimplants

Similar results silicone/Similar results silicone/pyrocarbonpyrocarbon??

Type of complications depend on implantType of complications depend on implant

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OBRIGADO!