PIP Joint Arthroplasty Revision Using - Small Bone Innovations

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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
Page 1: Clinical Case Review: PIP Joint Art

PIP Joint Arthroplasty Revision Using - Small Bone Innovations

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