Objective. Destruction and deformity in both PIP and MP joints are not uncommon and cause sever disabilities. Arthroolasty of the MP joint combined with arthrodesis of the PIP joint are the usual choice for this condition. Some motion in ulnar digits provides great benefits for rheumatoid patients. We report implant arthroplasty of the PIP joint and also simultaneous replacement of PIP and MP joint in same finger. Material & Methods. Twenty-five joints in 15 patients underwent PIP arthroplasty either with silicone or surface replacement implant. Twelve PIP joints in 6 patients used Silicone implant (6 Swanson and 6 Avanta) alone and mean follow up was 42(6–84) months. New cementless surface implant (Self Locking Finger Joint, SLFJ) were developed and clinically used for about 3 years. Because of the stem design, SLFJ are able to use both PIP and MP joint simultaneously or combined with silicone implant. Four PIP joints in 3 patients used SLFJ alone and 6 patients underwent both PIP and MP joint with implant simultaneously. Combination of SLFJ PIP and silicone MP was 4 finger in 2 hand, SLFJ PIP and SLFJ MP was 3 finger in 2 hand, silicone PIP and SLFJ MP was 3 finger in 2 patients and silicone PIP and silicone MP was 1 finger. Mean follow up for SLFJ in either PIP or MP was 18(4–37) months. Results. Average arc of the PIP with silicone implant alone was 38(10–50 ° and SLFJ alone was 55(45–60) °. One PIP SLFJ dislocates immediate after surgery and was converted silicone later on. Of 7 SLFJ with combined PIP and MP arthroplasties, 2 PIP lost motion completely, one PIP move only 15°, 4 PIP move 75 °in average. Four silicone PIP combined with MP arthroplasties move 45°in average. One PIP SLFJ had breakage in stem legs, which believed to occur during interaction of stem insertion from both side of the basal phalanx, and was seen at immediate post op X-ray. There was one instability in index replaced with SLFJ for sever Swan neck deformity and no infection. Patient satisfaction for simultaneous replacement in PIP and MP joint were excellent except one whose age was 72. Discussion. Stability of the PIP joint in index finger is important for pinch and PIP motion of ring and little fingers are required for grip motion. Although arthrodesis of the PIP joint were performed more often and functional improvement usually obtained compared to pre-operative condition, ulnar 2 digits better to preserve some motion in the PIP joint as long as there is a possibility, and especially for the young patients. The results of the simultaneous replacement in PIP and MP joint seems discourage, however, when considering the severity of the deformities of this series, there is a good chance in the future. We will improve implant design and surgical technique as well as post-operative therapy, and continue to challenge the simultaneous replacement of PIP and MP joint

Introduction: Traditionally flexion deformities in Proximal Interphalangeal joints of lesser toes like hammer toes and curly toes are treated with fusing the PIP joint with a single Large Kwire. We describe a new technique of fusing PIP joints using two 1.1mm K wires. The advantages of this technique over single K wire are:. Less post operative complications like pain and pin tract infection. Achieving normal biomechanics of the foot by fixing the PIP joint at 15–20 degrees of flexion. Using two K wires gives more rotational stability of the toes and reduces the complications of over riding, under riding and hyperextension of the toes. 15–20 degrees flexion at PIP joint will give good digital purchase and push off in stance phase. As the K wire engages the cortex of proximal phalanx, there is almost negligible chance of loosening of K wires which is a common problem in large single K wire which usually is driven in to the medullary cavity of proximal phalanx. Aim: To compare the clinical and radiological outcomes in two pin fusions with standard single pin fusions described by Coughlin. To prove that this is a technically and biomechanical better procedure. Materials and Methods: Two pin technique was used for 36 PIP joint fusions in 25 patients with a mean age of 58 years (range–42 to 87 years) and female preponderance. Results were analysed using foot function scale, AOFAS (American Orthopaedic Foot and Ankle Society) lesser metatarsophalageal-Interphalageal scale. Post operative complications were documented. Technique: Dorsal skin incision was used to approach the PIP joint. Articular surfaces were prepared and two 1.1mm K wires were inserted from the tip of the toe and joint fixed in 15 – 20 degrees of flexion which is optimal functional position of PIP joint. Patients were mobilised non weight bearing for 6 weeks when K wires were removed and weight bearing started. Results: The results were analysed at 3–6 months post operatively. The foot function scores and objective parameters of AOFAS scores are slightly better in two pin fusions compared with single pin fusions. Objective parameters of AOFAS scale like adduction/ abduction, flexion, rotational deformities are significantly less with two wire fusions compared with single wire procedures (Coughlin et al). Radiological analysis of the foot showed that 97% had bony union compared 81% with single pin, and only 3% had fibrous union compared to 19% with single wire. Both the procedures didn’t have any non-unions. Only one patient had superficial wound infection, and surprisingly none had pin tract infection. Conclusion: Two pin PIP Joint fusion is relatively easy procedure with many technical advantages over single pin technique. The clinical and radiological outcomes are good. Results of the biomechanical studies should be available soon

Background: PIP joint surface replacement has been shown to be effective in the treatment of arthritis. We performed a retrospective review to evaluate the clinical results and functional outcome of pyrocarbon proximal interphalangeal joint replacement, motion preserving and function in selected patients. Method: The patients who underwent pyrocarbon PIP joint arthroplasty by the two senior authors were reviewed. Clinical assessment included range of motion, degree of pain and deformity pre and post operatively. Independent functional scores were collected. Radiographs were reviewed for evidence of loosening, fracture and dislocation. Patient overall satisfaction was assessed. Results: 25 patients had 27 pyrocarbon PIP joint replacements between 2004 and 2008. Of these patients, there were 21 female (84%) and 4 male (16%) with average age of 62.5 (43–78). Indications for surgery were pain and loss of function. The preoperative diagnosis was post traumatic osteoarthritis in 9 (33.3%) and primary osteoarthritis in 18 (66.7%). The average arc of motion preoperatively was 42.3 (5–60), and the average postoperative one was 74.3 (45–100). Pain was relieved in majority of patients. 23 patients (92%) were satisfied completely with the procedure. Pain was relieved in the majority of cases and we had 2 dislocations requiring revision to silicone joint replacement and 2 adhesions/stiffness requiring tenolysis. There were no infections. Conclusion: Our experience of pyrocarbon PIP joint replacement over the 4 years showed this implant is useful for relief of pain and function. A technically demanding procedure, it improves arc of motion, corrects deformity and achieves satisfactory function. We had 7 % revision rate and longer term follow-up is required

Introduction. Unstable dorsal fracture/dislocation of PIP joint is a complex injury and difficult to treat. Different treatment methods have been described with varying results. We describe a novel technique to combine fracture fixation with volar plate repair using micro anchor suture. Material and methods. Between July and December 2005, 11 consecutive patients with unstable dorsal PIP joint dislocations underwent open reduction and volar plate repair using our technique. Nine patients had dorsal fracture dislocations and two had open dislocations. All patients were males and their average age was 26 years. All patients were reviewed with the minimum follow up of 12 months. The pain score, range of movements and grip strength were recorded and compared to the normal side. Operative Technique. Volar approach was made using a semi Brunar incision. One or two micro bioabsorbable anchors (Mitek, Ethicon Ltd, UK) were used to stabilise the joint and repair the volar plate. Additional anchor was used to repair the collateral ligament when indicated. Post-operatively the hand was rested in Edinburgh functional splint for 10 days followed by active and assisted range of movements under hand physiotherapist supervision. Results. 10 out 11 patients had excellent pain relief. The average range of movement of the PIP joint was 100 degrees. One patient with neglected PIP joint fracture dislocation for 10 weeks had mild residual pain and stiffness. The mean grip strength was 87% of that of contralateral normal side. All patients returned to their same work as before. 8 out of 9 patients returned to play their regular sports at the same level. All patients were satisfied with the functional outcome. Conclusion. Combined fracture fixation and volar plate repair through anterior approach using micro bioabsorbable anchors appears to be very effective way of treating this otherwise complex unstable fracture/dislocation of PIP joint

Proximal interphalangeal joint arthrodesis for lesser toe deformity is commonly stabilised using a Kirschner wire passed through the tip of the toe. Recently, a number of all-inside intramedullary fusion devices have been developed, with the aim of decreasing infection risk through avoiding exposed metalwork. We report our early experience with Stayfuse™ (Nexa Orthopaedics). Case records of patients undergoing Stayfuse™ proximal interphalangeal joint arthrodesis between July 2009 and November 2011 were examined. Twenty-eight Stayfuse™ proximal interphalangeal joint arthrodesis procedures in 14 patients were performed. Overall, 8 (29%) procedures required revision within 6 months. Of these, 3 (11%) intraoperative failures occurred, requiring immediate revision (Kirschner wire stabilisation or excision arthroplasty). All involved bending failure of the implant clip mechanism. A further 5 (18%) toes required revision procedures within 6 months of the index procedure, 3 (11%) for dissociation of the implant clip mechanism and 2 (7%) for periprosthetic fracture. For patients perceived to be at higher risk of infective complications, all-inside stabilisation systems are an attractive concept. However, with 29% of patients undergoing revision procedures within 6 months, we question the safety of choosing Stayfuse™ implants over Kirschner wire stabilisation

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone. Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply

Aims: We present a prospective study, with three-year follow-up, of the incidence, course and influence on surgical outcome of the abductor digiti minimi cord in Dupuytren’s contracture of the PIP joint of the little finger. Methods: All patients presenting for surgery with primary Dupuytren’s contracture of the little finger over a six-month period were included in the study. Patterns of disease cords and joint involvement were noted. All fingers underwent fasciectomy of the central and pre-tendinous cords. If significant contracture remained the abductor cord was excised next, and the PIP joint itself released only if correction could still not be obtained. Contracture and range of movement of affected joints measured with goniometer pre-operatively, at each stage intra-operatively and at 3 months and 3 years post-op. Results: The abductor cord was present in twleve of the nineteen fingers in the study, including all of those with ulnar-sided disease. The ulnar neurovascular bundle was found to be deep to the cord in nine fingers, encased by diseased tissue in two and displaced superficially in only one finger. Mean initial flexion deformity in these twelve fingers was 59, corrected to only 51 by resection of the central and pre-tendinous cords. Excision of the abductor cord further improved the contracture to 25 while PIP join release improved it to 6. Flexion deformity was 18 at three months and 21 at three years. For the seven fingers in which no abductor cord was found, mean initial flexion deformity was 42, improving to 24 following fasciectomy and 4 with joint release. It was 16 at three months and 18 at three years. No significant difference in outcome could be identified between the groups at three months or three years. Conclusions: The abductor cord is present in roughly two-thirds of little fingers with contracture pf the PIP joint. The ulnar digital nerve usually lies deep to the abductor cord but in roughly one quarter of cases is either encased in or superficial to it. In affected fingers, resection of the cord accounts for more than half of the total correction obtained and three quarters of that obtained by fasciectomy. Presence of the ADM cord does not prejudice long-term outcome provided it is adequately resected

Introduction. PIPJ replacement has become increasingly popular however, there is very little clinical data available apart from small studies and those from the originators of the prostheses. We present a review of our initial experience with the Acension. (c). Pyro-carbon PIP joint. Results. Data was collected from 62 joints in 39 patients with one patient lost to follow-up. Mean age was 61.6 years. 29 patients were female and 10 male. Mean follow up was 22.3 months (range 11 to 54). 7 patients or 11% needed further surgery. The majority were for stiffness with 3 operations for dislocation or component malposition. The total complication rate was 32%, again the biggest problem was stiffness. 4 joints have subluxed or dislocated, 2 had superficial infections. There was no statistical difference in the rate of complications compared to the operated finger or the pre-operative diagnosis. Post-operatively patients had a mean fixed flexion deformity of 19° and flexed to 76° (58° arc). However patients undergoing surgery following trauma do not do as well as the other groups with a decrease in ROM of 33°. Conclusions. Subjectively patients are returning low pain scores and the majority are pleased with the outcome of their surgery. There is however a high rate of complications and re-operations. This is in part due to the complexity of the cases as patients with inflammatory arthritis, following trauma or infection or those who are undergoing revision procedures often have decreased bone stock, erosions and more complex soft tissue balancing resulting in an increase in the complication rate. We have found the early results to be encouraging and, when successful, better than the short term results for arthrodesis or silastic implants. We intend to continue with the technique but believe patients should be kept under review

Purpose: Since 1966 silicone implant arthroplasty has been used to treat arthritis of the PIP joint as an alternative to fusion. The volar approach to expose this joint spares the extensor mechanism at the cost of increased risk to neurovascular structures. In the dorsal approach, the extensor mechanism must be carefully handled, reattached and then protected during rehabilitation. Several surgical techniques have been used to handle the extensor mechanism. Swanson et al. recommended midline incision of the central tendon followed by release of the lateral insertion on the middle phalanx and then reattachment to the base of the middle phalanx. Our clinical experience led us to a new surgical technique; splitting then repairing the extensor mechanism without bone reattachment as recommended by Swanson. The purpose of this study was to biomechanically compare the strength and function of this proposed technique with that of Swanson. Method: Four pairs of fresh-frozen cadaveric hands were used. The index, long and ring finger were harvested for testing. Twelve digits (3 digits × 4 hands) were designated as control and were used to measure the fixation strength of Swanson’s procedure. The other 12 digits of the paired hands were designated as experimental and were used to measure the fixation strength of the proposed new technique. Results: The fixation strength mean ± SD were, respectively, 4.74 ± 0.46 N/mm for the control group and 4.62 ± 0.30 for the experimental group. The results were not statistically different, p=0.45. Conclusion: The simple repair of the central slip without the bone reattachment preserves the function of the extensor mechanism on the PIP joint. In our clinical cases we haven’t noticed any increase in the incidence of extensor lag or boutonnière deformity as a result of that. This technique can also be applied for fracture fixation in the area

Abstract: Although the unconstrained pyrocarbon prosthesis (Ascension®) has been presented as a new alternative in the treatment of idiopathic arthritis of the proximal interphalangeal joint of the hand a few years ago, there is still a lack of studies analyzing the results of this implant. In this study 10 patients (13 implants), that were tretated with this type of prosthesis between february 2002 and january 2005 were studied. All but one patient were satisfied with the postoperative situation and would agree to another operation. A significant pain reduction was observed. The average ROM was 58degrees. Five patients demonstrated a free extension, two patients had a swan neck defomity, which could be actively compensated for, and the remaining six patients had an extension deficit of 30–45degrees. The average flexion was 76° (+/−12°). X-ray examination was unremarkable in eight patients with a regular position of the endoprosthesis. However, in five patients significant radiolucent lines (> = 1mm) were observed. So far, a luxation of the prosthesis has not occurred and all implants are still in-situ. However, a dorsal tenoarthrolysis had to be performed in 3 patients. The results of this study show a high rate of patient satisfaction with a significant pain reduction. The radiological results have to be closely monitored in the future. Long-term results with a higher number of patients are necessary. A central registry for finger implants is recommended

Background. Evidence concerning the management of dorsal fracture dislocation (DFD) of the proximal interphalangeal joint (PIPJ) in the hand has been limited by small sample size and case heterogeneity within studies. This retrospective case control study examined clinical outcome of this specific subgroup managed by three different methods. Methods. Patients undergoing fixation of unstable DFD of the PIPJ between March 2005 and August 2011 were identified from theatre records. A retrospective review of case-notes and radiographs was undertaken to determine fracture characteristics, fixation methods and clinical outcomes. Results. 21 patients with DFD of the PIPJ were identified with a mean age of 40 years (range 22–65). The majority of patients were male (17/21, 81%) and the mean percentage articular surface involvement of fractures was 41% (Std. Dev. 11.3%). PIPJ DFD's were managed by reduction of the PIPJ and temporary transarticular K-wire fixation (12/21, 57%), hemi-hamate arthroplasty (7/21, 33%), or by open reduction and internal fixation (2/21,10%). PIPJ ROM following hemi-hamate arthroplasty was 65° (range 34–108°) and was greater than K-Wire fixation at 56. o. (range 9–85. o. ) (p = 0.82). Hemi-hamate arthroplasty and K-wire fixation resulted in fixed flexion deformity of 20° (range −12–52°) and 15° (range −6–50°) respectively (p = 0.61). Hand therapy data was available for one case undergoing ORIF with a post-operative ROM of 60° and 30° of fixed flexion. There was poor correlation between articular surface involvement and post-operative range of movement at the PIPJ (Co-efficient −0.16, p = 0.55). Conclusion. We present a relatively large series of outcomes following DFD of the PIPJ. We were unable to demonstrate any difference in post operative clinical outcomes between the fixation methods examined

Background

Traditional teaching recommends against arthroplasty in the index finger, due to concerns over failure with pinch stress, and prefers arthrodesis is for its stability. We aim to allay these fears and present the results of our series of index finger silastic PIPJ arthroplasties. Methods: Between 2007 & 2018 48 silastic index finger PIPJ arthroplasties were undertaken in 37 patients at our Hand Unit. All were performed under local anaesthetic ring block. Eleven patients underwent PIPJ arthroplasty in both Index fingers. Thirty-five women and two men made up the cohort with a mean age of 69 years. A retrospective analysis of all patients has been undertaken to determine the clinical results including patient satisfaction, grip and pinch strength and reoperation rates. Mean follow up was 5.1 years.

Aims: We present a prospective study, with three-year follow-up, of the role and outcome of fasciectomy plus surgical release of structures of the PIP joint in Dupuy-tren’s contracture of the fifth ray. Methods: All patients presenting for surgery with primary Dupuytren’s contracture of the fifth ray over a six-month period were included in the study. All underwent fasciectomy followed sequentially by release of the abductor band, accessory collateral and checkrein ligaments as necessary. Deformity and range of motion in the PIPJ were measured by goniometer preoperatively, intra-operatively (post-fasciectomy and post-PIP release) and at three months and three years postoperatively. Results: Of the nineteen fingers in the study, eight (all mild deformity) achieved a full correction by fasciectomy alone. 78% correction remained at three months and 70% at three years. The remaining eleven fingers (initial mean deformity 70o flexion) obtained only a 38% correction by fasciectomy, increased to 90% with PIPJ release. Of this correction 64% was maintained at three months and 57% at three years. These figures include one recurrence of Dupuytren’s and are comparable with those of other techniques. Conclusion: We conclude that sequential PIPJ release is a useful technique for the correction of severe Dupuytren’s of the fifth ray involving that joint

Introduction and Aims: Severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint is a difficult condition to treat; a two-stage technique has been advocated by some surgeons for such cases. The present study set out to determine the early results of this technique. Method: Thirteen patients (11 with primary and two with recurrent disease) with a severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint were treated by geometric correction (in line distraction followed by angular correction) using the OrthofixTM mini external fixator followed by its removal and partial fasciectomy (without collateral ligament or volar plate release). The mean duration of distraction was 14 days. Results: In the PIP joint the mean true fixed flexion deformity pre-operatively was 75 degrees (range 45–90). At a mean follow-up of 21 months, the mean residual flexion deformity was 35 degrees (range 10–90). The mean arc of motion increased from 26 (range 10–55) to 51 degrees (range 0–90). At follow-up, the mean arc of motion was 33 degrees (range 0–70) and 73 degrees (range 45–110) at the distal interphalangeal and meta-carpophalangeal joints respectively. There were no cases of reflex sympathetic dystrophy or neurovascular damage. One patient had a fracture of the proximal phalanx and a second patient had an early recurrence, which led to a poor clinical outcome. The rest had an excellent clinical outcome according to the Michigan Hand Questionnaire. Conclusion: Although the technique is challenging, the early results are promising and we recommend it for the management of this difficult problem

Purpose: We conducted a study of 72 hammer toes treated with proximal interphalangaeal joint (PIPJ) fusions with a Stayfuse implant. The aim of the study was to access the clinical results of PIPJ fusion carried out with Stayfuse implants.

Method: There were 10 males and 62 females. Average age was 52 years. Twelve cases had bilateral and 60 cases had unilateral foot involvement. Fifty-two second and 20 third toes were operated on. Mean follow up was twelve months. The results were assessed clinically, radiologically and with the American orthopaedic foot and ankle surgery society (AOFAS) score.

Results: All the joints fused clinically except two. There were ten PIPJ’s which did not fuse radiologically. The AOFAS score improved from 42 preoperativley to 84 post operatively. There were two cortical breeches of the proximal phalanx, one implant breakage and one case of dissociation of the components of the implant at six weeks after the surgery, with a recurrence of deformity. There were two patients who complained of over-straight toes. Fifty-two patients were very satisfied with the procedure, seventeen satisfied and three patients were unsatisfied.

Conclusion: We conclude that the Stayfuse is safe, reliable method to correct PIPJ deformity, although there is a learning curve. The main advantages of the implant are that there is no postoperative implant exposure, no violation of healthy joints, no risk of pin tract infection, rotational and angular stability, early rehabilitation and a high patient satisfaction. The disadvantages of the implant are dissociation of the components and the difficulty of removal, if this is needed.

Introduction and Objective. Zone 2 flexor tendon injuries are still one of the challenges for hand surgeons. It is not always possible to achieve perfect results in hand functions after these injuries. There is no consensus in the literature regarding the treatment of zone 2 flexor tendon injuries, tendon repair and surgical technique to be applied to the A2 pulley. The narrow fibro-osseous canal structure in zone 2 can cause adhesions and loss of motion due to the increase in tendon volume due to surgical repair. Different surgical techniques have been defined to prevent this situation. In our study, in the treatment of zone 2 flexor tendon injuries; Among the surgical techniques to be performed in addition to FDP tendon repair; We aimed to compare the biomechanical results of single FDS slip repair, A2 pulley release and two different pulley plasty methods (Kapandji and V-Y pulley plasty). Materials and Methods. In our study, 12 human upper extremity cadavers preserved with modified Larssen solution (MLS) and amputated at the mid ½ level of the arm were used. A total of 36 fingers (second, third and the fourth fingers were used for each cadaver) were divided into four groups and 9 fingers were used for each group. With the finger fully flexed, the FDS and FDP tendons were cut right in the middle of the A2 pulley and repaired with the cruciate four-strand technique. The surgical techniques described above were applied to the groups. Photographs of fingers with different loads (50 – 700 gr) were taken before and after the application. Proximal interphalangeal (PIP) joint angle, PIP joint maximum flexion angle and bowstring distance were measured. The gliding coefficient was calculated by applying the PIP joint angle to the single-phase exponential association equation. Results. Gliding coefficient after repair increased by %21.46 ± 44.41, %62.71 ± 116.9, %26.8 ± 35.35 and %20.39 ± 28.78 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. The gliding coefficient increased significantly in all groups after surgical applications (p<0.05). PIP joint maximum flexion angle decreased by %3.17 ± 7.92, %12.82 ± 10.94, %8.33 ± 3.29 and %7.35 ± 5.02 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. PIP joint maximum flexion angle decreased significantly after surgery in all groups (p<0.05). However, there was no statistically significant difference between surgical techniques for gliding coefficient and PIP joint maximum flexion angle. Bowstring distance between single FDS slip repair, kapandji pulley plasty and V-Y pulley plasty showed no significant difference in most loads (p>0.05). Bowstring distance was significantly increased in the A2 pulley release group compared to the other three groups (p<0.05). Conclusion. Digital motion was negatively affected after flexor tendon repair. Similar results were found in terms of gliding coefficient and maximum flexion angle among different surgical methods. As single FDS slipe repair preserves the anatomical structure of the A2 pulley therefore we prefer it as an ideal method for zone 2 flexor tendon repair. However, resection of FDS slip may jeopardizes nutrition to the flexor digitorum profundus tendon which weakens the repair site. Therefore the results must be confirmed by an in vivo study before a clinical recommendation can be made. Keywords: Flexor tendon; injury; pulley plasty; cadaver;

Aetiology and pathogenesis: The pathogenesis of boutonnière deformity, in the rheumatoid patient is usually quite clear, and is due to either a central slip failure or volar subluxation of the middle phalanx. This subluxation is seen more commonly in the patients with psoriatic arthropathy. The most common cause is a chronic synovitis of the proximal interphalangeal joint leading to attenuation of the sagital fibres between the central slip and the lateral bands and at a later stage disruption or attenuation of the central slip itself. Synovitis of the pip joint with separation of the lateral bands from the central slip allows the lateral bands to sublux forwards to lie anterior to the axis of rotation thus the intrinsics which extend the proximal and distal joints of the finger come to act as flexors of the proximal joint and continue to act as extensors to the distal joint. The patient will use the intrinsic muscles and they now have a flexion force upon the PIP joint and hyperextension force on the DIP joint, causing a boutonnière deformity. Volar subluxation of the middle phalanx draws forwards the lateral bands and defunctions the central slip creating the same imbalance. Scarring of the volar plate as is seen in volar plate injuries with the production of a pseudo-boutonnière deformity is sometimes seen in psoriatic arthropathy. In a boutonnière deformity the PIP joint is flexed and the DIP joint is extended. With the joints in this position, the origin and insertion of the intrinsic muscles are closer together, and as a consequence, with the passing of time, the muscles fibres will remodel in a shortened position, creating a lateral band tightness. Classification: Boutonnière deformity can be classified into four stages. Type I. The deformity is totally correctable passively, and there is full flexion of the DIP joint when the PIP joint is fully extended. The patient has a passively correctable flexion deformity of the PIP joint, and can actively flex the distal interphalangeal joint. The anatomical alterations are the following: elongation of the sagital fibres and volar displacement of the lateral bands but no secondary shortening of musculo-tendinous system. Type II. Flexion of the DIP joint is limited when the PIP joint is passively corrected. The patient cannot actively or passively flex the distal interphalangeal joint, when the PIP joint is passively corrected. Secondary shortening of the intrinsic/lateral band system because the intrinsics have remodelled in a shortened position. Type III. Stiffness of the PIP joint without joint destruction. There is no passive correction of the deformity but the joint surfaces are sound. The patient can not passively extend the PIP joint nor flex the DIP joint. Type IV. Stiffness of the PIP joint with joint destruction. In these cases, stiffness of the PIP joint is not only due to soft tissue remodelling but mainly to joint destruction. In this type, destruction of the joint cartilage should be added to the previously described anatomical deformities. X-ray examination is needed to confirm the diagnosis. Treatment: Boutonnière deformities, are both aesthetically and functionally less disabling than swan neck deformities because there is usually little loss of active PIP joint flexion. Some therapeutic options exist, and choosing the most appropriate surgical procedure will depend on the severity of the anatomical deformities which need to be corrected. Correction of PIP joint flexion. Mobilisation of the lateral bands and transposition of the lateral bands posterior to the axis of rotation of the PIP joint. Release of the volar plate of the PIP joint is often necessary because of secondary contracture. Improving active DIP joint flexion. The only way to restore loss of active DIP joint flexion is by performing a Dolphin tenotomy or formal lengthening of the conjoined lateral bands over the middle phalanx. Improving passive PIP joint extension. Passive extension of the PIP joint can usually be obtained by gentle manipulation and serial application of plaster of paris casts, as well as the use of a Capner (or armchair splint)the dorsal structures are usually quite thin and lax. If the joint can not be passively extended, a surgical release of the lateral bands is indicated,. Y-V plasty shortening of the central slip and extensor mechanism is usually necessary. A longitudinal incision at both sides of the central slip, allowing the lateral bands to displace dorsally during PIP joint extension with reefing of the lateral bands to the remnants of the central slip is needed in most cases. PIP joint arthroplasty. A PIP joint arthroplasty should be considered when the joint is destroyed. A radiological examination is essential in making the diagnosis, as many stiff PIP joints in flexion do not have their joint surfaces preserved because boutonnière deformities are often secondary to PIP joint synovitis. A full soft tissue procedure must be performed at the same time. DIP joint arthrodesis. Arthrodesis is only indicated for the treatment of uncorrectable deformity of the DIP joint with or without joint destruction, confirmed by radiological examination. The functional results of an arthroplasty are far superior for the treatment of a swan neck than a boutonnière deformity, because of the integrity of the extensor apparatus in the former, allowing for immediate postoperative motion. 7. PIP joint arthrodesis will be the treatment of choice if the finger presents a gross deformity with deteriorating function or failed surgery

Extensor tendon attachment to the dorsum of the proximal phalanx may fully extend the finger metacarpal phalangeal joint (MPJ). 15 fresh-frozen cadaveric hands were axially loaded in the line of pull to the extensor digitorum comunis of the index, middle, ring and small finger at the level just proximal to the MPJ. We measured force of extension at the MP joint in 3 groups: 1) native specimen, 2) extensor tendon release at the proximal interphalangeal (PIP) joint with release of lumbricals/lateral bands, 3) extensor tendon release at the PIP joint and dorsal proximal phalanx and lumbrical/lateral band release. Degree change of extension was calculated using arctan function with height change of the distal aspect of the proximal phalanx, and the length of the proximal phalanx. We used Student T-test to determine significant decrease in the extension of the phalanges. Extension of all fingers decreased slightly when the extensor tendon were severed at the PIP joint with release of the lateral bands/lumbricals (8deg+/−2deg). After this release, the finger no longer extended. Slight loss of extension was not statistically significant (p >.05) between group 1 and group 2. Groups 1 and 2 were significantly different compared to group 3. In summary, distal extensor tendon transection and release of lateral bands/lumbricals resulted in little change in force and degree of finger extension. The distal insertion of the extensor, released when exposing the PIP joint dorsally, may not need to be repaired to the base of the middle phalanx

Objective. To assess patterns of recurrence in patients with Dupuytren's disease after surgery for proximal interphalangeal joint (PIPJ) deformity. Methods. 81 patients (94 fingers) with Duputyren's contracture of the proximal interphalangeal joint underwent surgery to have either a ‘firebreak’ skin graft (46 fingers) or a fasciectomy (48 fingers). They were reviewed after three weeks, six weeks, 6, 12, 24 and 36 months to note the range of movement and recurrence. Both groups were similar with regard to age, gender and factors considered to influence the outcome such as bilateral disease, family history, and the presence of diabetes, smoking and alcohol intake. Results. The rate of recurrent contracture of PIP joint was 12.2%. Four patterns were identified: Group 1 (Responsive group: Immediate improvement, maintained over three years), Group 2 (Improved group: Initial mild loss of position but improvement maintained), Group 3 (Stiffness group: Immediate significant worsening but maintained), and Group 4 (Recurred group: Immediate loss of position with further progressive contracture). Time since onset of Dupuytren's disease and pre-op PEM showed significant association with recurrent contracture on regression analysis (GEE, Wald chi square test, P< 0.01). Conclusion. Four distinct patterns of recurrent contracture of PIP joint were identified three years after corrective surgery for Dupuytren's disease. Pre-operative PEM and disease duration could predict recurrence

The October 2014 Wrist & Hand Roundup360 looks at: pulsed electromagnetic field of no use in acute scaphoid fractures; proximal interphalangeal joint replacement: one at a time or both at once; trapeziometacarpal arthrodesis in the young patient; Tamoxifen and Dupytren’s disease; and endoscopic or open for de Quervain’s syndrome?