Arthroplasty of the Interphalangeal and

Metacarpophalangeal joints

Leonor Fernandes Teresa Marques

Pedro Simas Fernando Cruz

Unidade de Cirurgia da mão e membro superior

Hospital dos Lusíadas – Lisboa, Portugal
Hospital Garcia de Orta – Almada
 History
• 1940-Burmann: 1st IP and MCP arthroplasty
• 1959-Brannon and Klein: 1st published series
• 1960-Flatt: twin metallic stems
• 1960-Niebauer: 1st silicone 1-piece prostheses
• 1968-Swanson: Silicone
• 1979-Linscheid: Pyrocarbon
• 1997-Linscheid: Pyrocarbon -1st results
• Volar plate interposition
• Osteointegrated arthroplasty - Titanium
 IP and MCP arthroplasty

Indications

• Degenerative joint disease

• Traumatic arthrosis
• Reumathoid arthritis
 IP and MCP arthroplasty

Contraindications
• Active inflammatory disease
• Septic arthritis
• Severe deformity
• Loss of the extensor/flexor apparatus
• Swan neck
• Boutounnière

• Ligamentous instability
 Small joint arthroplasty
Principles
• Replace articular surfaces
• Balance flexor/extensor tendons
• Preserve collateral ligaments
• Minimal bone removal
• Intramedullary stems
 Small joint arthroplasty
Criteria (Flatt e Fisher 1969)
• Restoration of a functional range of motion
• IP joints – 1 degree of freedom
• MCF joints – 2 degrees of freedom

• Adequate stability
• Resistance to subluxation
• Constrained or semiconstrained prostheses
• Preservation of ligaments
 Small joint arthroplasty
Criteria (Flatt e Fisher 1969)
• Mechanical advantage equivalent to normal
• Physiologic center of rotation
• Accurate placement of stem and length
• PIP joints – palmar/dorsal angulation

• MCP joints
- ulnar deviation
 Small joint arthroplasty
Criteria (Flatt e Fisher 1969)
• Firm seating with resistance to rotational forces
• Intramedullary stems
• Adaptative stems?

• Easy implantation

• Accomodation to size
• Right/Left
• 4 fingers
• 32-40 models?
 Small joint arthroplasty
Criteria
• Biologic compatibility
• Cobalt-Chrome, titanium, pyrocarbon,
siliconeE

• Adequate material wear

• Longevity
• Polyethylene osteolisys?
• Silicone synovitis?

• Soft tissue reconstruction

 Exposure - PIP

Lateral
Pros
Palmar
• Easy repair of the collateral ligament
Dorsal

Cons
• Precise preparation of bone ends is more
difficult
• Injury to central slip and palmar plate may
occur
 Exposure - PIP

Lateral
Pros
Palmar • Easier preparation of bone ends
Dorsal • Early motion

Cons
• Retraction of the flexor tendons and sheath
• Possible injury to central slip dorsally
• Flexor bowstringing may occur
• Vascular/nervous injury risk
 Exposure - PIP

Lateral
Pros
Palmar
• Best exposure
Dorsal
Cons
• Possible extensor lag
• Difficult bony preparation
• Delay on early motion
 Technique - PIP
Dorsal (Chamay)
• Triangular incision of the
extensor apparatus
• Removal of dorsal capsule
• Osteotomy of the proximal and
medial phalanges
• Medullary canals are reamed
• Appropriately sized implant is
chosen
• Capsule and extensor
mechanism were repaired
 Exposure - MCP

Dorsal
Pros
• Best exposure

Cons
• Repair of the extensor
mechanism is vital
 Technique - MCP
Dorsal
• Incision over the MCP joints
• Capsulotomy
• Medullary canals are reamed
• Appropriately sized implant is
chosen
• Capsule and extensor
mechanism were repaired
 Complications

• Radiolucence (50%)
• Heterotopic ossification (15-20%)
• Subluxation/Instability (19%)
• Implant fracture (12-16%)
• Dislocation (6-8%)
• Infection (1-2%)
• Synovitis (rarely)
• Periprosthetic sclerosis
Revision rate at 2 years (13-50%)
Rehabilitation
Fundamental

Early range of
movement

Protection

Orthoteses
 Surgical options

• Arthrodesis – loss of movement; DIP

• Interposition arthroplasty – techniqual demanding

• Total joint arthroplasty

• Silicone implant

• Pyrocarbon implant
 Discussion
Total joint arthroplasty - Silicone
Pros
• Pain free
• Keeps motility
• Long term duration

Cons
• Instability (rheumatoid arthritis)
• Possibility of failure (fracture, osteolysis)
 Discussion
Total joint arthroplasty - Pyrocarbon
Pros
• Pain free
• Keeps motility
Cons
• Possibility of failure (fracture,
osteolysis)
• Better bone quality
• High cost

Branan
 Conclusion

• Improvement of pain with all techniques

• Improvement of strength and function

• Failure to improve movement - PIP

• Arthrodesis for distal interphalangeal joint

 Conclusion

• Interposition arthroplasty - promising results

• Silicone 1/6 price of pyrocarbon implants

• Similar results silicone/pyrocarbon?

• Type of complications depend on implant

OBRIGADO!