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Proximal Interphalangeal Joint Arthroplasty

Because of the limitations of silicone spacers, a new generation of implants, composed of more durable materials, has been introduced. These recent prostheses are of two kinds: a nonconstrained surface replacement and a more constrained hinge-type design. Nonconstrained implants tend to be more commonly used in the United States, whereas both joint types are used in Europe. The procedure of implanting these prostheses is similar, with slight differences and nuances. Here we discuss implanting the pyrolytic carbon prosthesis.

Rheumatoid Hand: Boutonniere Finger Deformity

Boutonniere finger deformity is characterized by proximal interphalangeal (PIP) joint flexion, distal interphalangeal (DIP) joint extension, and hyperextension of the metacarpophalangeal (MCP) joint, with volar subluxation of the lateral bands. The deformity is common in patients with rheumatoid arthritis; however, it is not specific to this disorder and may occur following trauma or other inflammatory arthritides. Treatment of boutonniere finger is individualized and is based on the patient's current level of function, deformity, medical status, limitations of the surgeon, and expectations. Not all patients with rheumatoid hand deformities are candidates for surgery because many will adapt over time and achieve an acceptable functional level. Nonsurgical management is indicated for patients with early stage disease and consists of nighttime splinting of the PIP joint in extension. Additionally, a corticosteroid injection is useful if active PIP joint synovitis is present. A variety of surgical procedures are available for boutonniere finger deformity, including tenotomy of the terminal extensor tendon and reconstruction of the central slip. The choice of surgical treatment is based on the flexibility of the PIP joint and the status of the articular cartilage.

Rheumatoid Hand: Swan-Neck Deformity

Swan-neck deformity, characterized by proximal interphalangeal (PIP) joint hyperextension, distal interphalangeal (DIP) joint flexion, volar plate incompetence, and dorsal laxity of the lateral bands, is common in patients with rheumatoid arthritis. The deformity is the end result of synovitis of the joints, tendon sheaths, and ligaments, which disrupts the balance of flexion and extension forces across a joint and results in deformity, weakness, and loss of function. Management of swan-neck deformity is based on the flexibility of the PIP joint, integrity of the articular cartilage, and functional level of the patient. Nonsurgical treatment for swan-neck deformity, including extension block splinting, is considered for patients with preserved function. Surgical management involves procedures that limit PIP joint hyperextension and restore DIP joint extension, including DIP joint arthrodesis, tenodesis of the flexor digitorum superficialis, reconstruction of the oblique retinacular ligament, volar PIP joint dermodesis, and lateral band translocation. In late-stage disease, soft-tissue procedures alone may not result in lasting correction of deformity.

Management of Fingertip and Thumb Tip Amputations

Management of a digital tip amputation requires a thorough understanding of fingertip anatomy, vascular anatomy, and the various treatment options available. The goals of treatment include facilitating the fastest reasonable recovery, restoring volar soft-tissue pulp and contour, maintaining digital tip support, achieving a pain-free and sensate tip, and tailoring the type of reconstruction to the patient's occupational and avocational needs. Treatment options include healing by secondary intention, skin grafting, bone shortening and amputation revision, complex flap reconstruction, and replantation. The option selected will depend on the tissues involved, pathologic anatomy of the injury, personal needs of the patient, and vascularity of the fingertip. Complications of treatment include nail deformity, painful unstable scar, digital neuroma, cold intolerance, dysesthesias, hypesthesias, poor aesthetics, stiff digits with flexion contracture, and flap necrosis.