PIP Joint Arthroplasty Revision Using - Small Bone Innovations

Clinical Case Review:
PIP Joint Arthroplasty Revision Using SR PIP Implant Sytem
Small Bone Innovations, Inc. : SR PIP Implant Sytem
Before
After
Dr. Sunjay Berdia
Adjunct Assistant Professor at Uniformed Services University
of the Health Sciences in Bethesda, MD

Patient History
Patient is a 53 year old, right-hand dominant female who sustained
a distal radius fracture. She underwent open reduction
internal fixation of this fracture but she subsequently developed
severe complex regional pain syndrome in that extremity.
Although with time her wrist and digital range of motion improved,
she developed progressive degenerative arthritis in
her middle finger PIP and DIP Joints. Her PIP joint became increasely
more painful with a concomitant loss of motion. She
was initially treated conservatively with therapy, NSAIDS, and
then finally with cortisone injections.
Preoperative Write Up and X-Rays
Fig. 1: PIP Joint AP Xray
Fig. 2: PIP Joint Lateral Xray
Physical examination revealed a PIP range of motion from
5 degrees of full extension to 65 degrees of flexion. The PIP
Joint was ulnar deviated 10 degrees. Figures 1 and 2 show
the posteroanterior and lateral radiographs. As she had failed
conservative treatment, the decision was made to proceed
with a joint replacement using the Pyrocarbon PIP Joint Replacement.
A dorsal tendon splitting approach was used to carry
out the joint replacement. Figures 3 and 4 show postoperative
posteroanterior and lateral radiographs. By appropriate cuts
and tightening of the radial collateral ligament, the ulnar deviation
deformity was corrected. Although the proximal component
seems slightly proud, the stem was tightly fixed into
the canal.
The patient did well in the immediate postoperative period.
Her pain was alleviated. Her range of motion at 3 months was
from 10 degrees of full extension to 75 degrees of flexion. At
5 months, she started to exhibit signs of radiograph loosening
(See Fig. 5 - 6). Therapy on the finger was halted and she was
instructed to rest the finger as much as possible.
Fig. 3: Postoperative AP Xray
Fig. 4: Postoperative Lateral Xray
She was followed using serial radiographs. Even with these
precautions, she showed continued “windshield wiper” loosening
on these radiographs. At 12 months post-operative, (See
Fig. 7 - 8), the decision was then made to revise the arthroplasty
before imminent catastrophic implant failure. Preoperative
physical examination revealed a PIP range of motion from 15
degrees of full extension to 55 degrees of flexion. Options
that were then contemplated included using a silicone replacement
or a cemented PIP Surface Replacement Arthroplasty
(SRA) from SBi. Preference was given to the SBi SR PIP because
of the potential increase in range of motion, lack of silicone
synovitis, lack of silicone implant breakage, and patient age
and activity level.
SBi SR PIP Arthroplasty was performed on November 13,
2008.
Fig. 5: PIP Joint Loosening AP Xray
Fig. 6: PIP Joint Loosening Lateral Xray
Fig. 7: Windshield Wiper AP Xray
Fig. 8: Windshield Wiper Lateral Xray

Operative Technique
A dorsal tendon splitting approach was again utilized. In order to
gain adequate exposure, the central slip insertion was elevated periosteally
for later repair. The pyrocarbon implant was easy removed
as both components were loose (See Fig. 9).
As the collaterals were in good condition and tension, the decision
was made to proceed using the SRA implant. As the pyrocarbon
is larger than the SRA implant, no additional resurfacing cuts were
necessary. Broaching was attempted but due to loosening within
the canal no broaching was necessary. Any pseudocapsule within
the canal was cleaned with a fine curette so as to promote good
interdigitization at cement-bone interface.
Fig. 9: Intraoperative Photo: Pyrocarbon
Removal
Fig. 10: Intraoperative Photo: Repairing
the Central Slip
Trials were placed temporarily within the canal. An implant size 2 was
chosen based on the best fit to the exposed parts of the proximal and
distal phalangeal metaphysis. The length of the SRA proximal component
stem is longer than the implant. As such, the stem would be
able to go past the “windshield wiper” changes and minimize any stress
risers. Additional steps were taken to repair the central slip. Prior to cementing,
two holes were created at the insertion of the central slip and
a non-absorbable suture was passed through the holes (See Fig. 10).
Fig. 11: Intraoperative Photo: Cementing
Both components were cemented in place at the same time so that the
appropriate length could be determined (See Fig. 11). Prior to cement
hardening, a partial cement mantle was built manually on the proximal
side because of the bone deficiency (See Fig. 12).
Intra-operative radiographs were taken repeatedly including after final
implantation and they confirmed no cement extravasation, especially
on the volar aspect of the proximal phalanx at the level of the
“windshield wiper” changes. Postoperative radiographs seen in Fig. 13
and 14 show a well seated and positioned implant.
Surgery time was 60 minutes.
Fig. 12: Intraoperative Photo: Cement Mantle
Fig. 13: Postoperative AP
SR PIP Xray
Fig. 14: Postoperative Lateral
SR PIP Xray

Post-Operative Protocol
Patient started 4 days postop with a dynamic splinting protocol during the day and a resting splint at night-time. The dynamic
splinting protocol protects the central slip repair. The patient was extremely pleased with the results and was allowed to return to
full activities after 6 weeks. At 3 months, her range of motion was 0 to 65 degrees of flexion. She continued with the therapy. At
6 months follow-up (See Fig. 15 - 16) her range of motion is 10 degrees of full extension to 75 degrees of full flexion. There was no
clinical evidence of instability, loosening or subsidence.
In this case, the SR PIP implant has resolved the PIP joint pain, increased ROM, and provided a stable joint.
Fig. 15: Postoperative AP SR PIP Xray: 6 Months
Fig. 16: Postoperative Lateral SR PIP Xray: 6 Months
Small Bone Innovations, Inc.
1380 South Pennsylvania Ave.
Morrisville, PA
(215) 428-1791/ Fax (215) 428-1795
SBi Customer Service: (800) 778-8837
Technical Support: (866) SBi-TIPS
www.totalsmallbone.com
Small Bone Innovations International
ZA Les Bruyères - BP 28
01960 Péronnas, France
Tel: +33 (0) 474 21 58 19
Fax: +33 (0) 474 21 43 12
Caution: United States federal law restricts this device to sale by or on the order of a physician.
SR PIP is a Humanitarian Use Only Device.
Copyright© 2009 Small Bone Innovations, Inc. All rights reserved.
MKT 10870 Rev. A 8/09