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

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

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.

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

Introduction. Injectable collagenase clostridium histolyticum (CCH) is a minimally invasive non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). In the concurrently run JOINT I and JOINT II studies, designed to follow clinical practice, we evaluated the efficacy of ?5 CCH injections in patients with DC. Methods. JOINT I and II were multicenter, 9-month, open-label studies in which DC patients with primary flexion deformities ?20° received ?3 CCH (0.58 mg) injections/joint (?5 injections/patient) at 30-day intervals into joints prioritized by extent of contracture. After the first injection, patients could opt to receive up to 2 additional injections in same cord or other cords regardless of outcome for the first joint. The primary endpoint was reduction in contracture to ?5° 30 days after the last injection. Data from JOINT I and II were pooled. Results. For the primary endpoint, 70% of MP (371/531) and 37% of PIP (128/348) joints showed a reduction in contracture to ?5° with CCH injections; 42% (223/531) of MP and 20% (69/348) of PIP joints reached success within 7 days of the first injection. Overall, 89% of MP (470/531) and 58% (202/348) of PIP joints showed clinical improvement (ie, ?50% reduction in contracture). Mean±SD percentage changes in contracture were 84±25% for MP joints and 55±41% for PIP joints. The 2 most common treatment-related adverse events (AEs) localized to the injection site were edema peripheral and contusion. Two patients had treatment-related serious AEs (deep vein thrombosis; tendonitis), but no tendon ruptures or systemic reactions were noted. Conclusions. Pooled results from the JOINT studies designed to follow clinical practice, provide support for the efficacy of CCH in correcting DC. Efficacy and safety data from this analysis are comparable to those observed in randomized, placebo-controlled trials

Normal digital flexion relies on flexor tendon pulleys to transmit linear muscular force to angular digital motion. Despite the critical role these pulleys play, there is a growing trend among surgeons to partially sacrifice or “vent” them during flexor tendon repair to improve surgical exposure. Although this new practice is reported to improve outcomes after flexor tendon repair, there is concern for the long-term effects of bowstringing, reduced finger range of motion (ROM) and altered tendon biomechanics. The objective of this study was to examine the effects of the application of a thermoplastic ring, acting as an “external” pulley, on flexor tendon biomechanics and finger ROM. We hypothesized that the application of an external thermoplastic ring would produce a centripetal force over the tendon to reduce bowstringing, improve finger ROM, and restore tendon loads following pulley venting. Twelve digits comprised of the index, long, and ring fingers from four cadaveric specimens were tested using a novel in-vitro active finger motion simulator. Servo-motors were used to generate motion. Loads induced by flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP), and joint range of motion were measured with each sequential sectioning of the A2, A3, and A4 flexor pulley, in comparison to a native healthy finger condition. At each finger condition, A2 and A4 external thermoplastic pulley rings were applied over the proximal phalanx and middle phalanx, respectively, to recreate A2 and A4 function. Results were recorded and analyzed using a one way repeated-measures ANOVA. Following venting of the A2, A3 and A4 pulley, proximal interphalangeal joint (PIPJ) ROM significantly decreased by 17.02 ± 8.42 degrees and distal interphalangeal joint (DIPJ) range of motion decreased by 17.25 ± 8.68 degrees compared to intact pulleys. Application of the external rings restored range of motion to within 8.14 ± 8.17 degrees at the PIPJ and to within 7.72 ± 8.95 degrees at the DIPJ. Similarly, pulley venting resulted in a 36% reduction in FDS load and 50% in FDP load compared to intact pulleys. Following application of the external rings, loads were almost restored to normal at 7% reduction for FDS load and 13% reduction for FDP load. Venting of flexor tendon pulleys significantly alters flexor tendon biomechanics and digit range of motion. The application of thermoplastic rings acting as external pulleys over the proximal and middle phalanges is an effective, inexpensive, non-invasive and reproducible therapeutic method to restore flexor tendon biomechanics and digit range of motion

Introduction. An educated public are becoming increasingly aware of percutaneous needle fasciotomy (PNF) for the treatment of Dupuytren's contracture. We believe that it has an important place in the management of this condition and have set up a dedicated one-stop clinic to perform this procedure. Methods. A prospective study of 61 patients with Dupuytren's, who have undergone PNF have been recruited so far. The study population includes 50 men and 11 women. The average age is 65. The senior author has operated on 81 fingers including 69 MCP joints, 62 PIP joints and 6 DIP joints. We recorded contractures prior to PNF and immediately following the procedure, as well as any complications. At follow up we recorded the Patient global impression of change (PGIC), DASH scores, degree of straightness of the operated finger and whether they would have the procedure again or recommend it. Results. For MCP joints the average pre treatment contracture was 43. o. and immediately post operatively it was 3. o. For PIP joints the average pre treatment contracture was 48. o. and immediately post operatively it was 17. o. For DIP joints the average pre treatment contracture was 41. o. and immediately post operatively it was 20. o. 8 patients had small skin tears and 2 found it too uncomfortable to continue. No nerve or tendon injuries. Mean follow up was 9 months (6–24). At follow up the average PGIC was 6 (very good) and the average DASH score was 30.9 (excellent). Subjectively the vast majority of fingers remained straight. All but 4 patients would have the procedure again and would recommend it to others. Discussion. This specialist clinic offers a very effective, safe procedure and our patients are highly satisfied withthe results. It is also cost effective for our Department

Proximal inter-phalangeal joint . (PIPJ). arthrodesis is a commonly performed procedure as a part of hammer and claw-toe correction. Conventional K-wire stabilisation has the potential disadvantages of infection; violation of DIP joint; external protrusion or the wire and necessity of removal. Newer intra-medullary stabilisation devices are also available, though tend to incur addition costs. We present our technique and results of using a single, buried 1.6 mm K-wire for proximal inter-phalangeal joint fusion. Our objectives were to assess union rates and patient satisfaction following intra-medullary K wires for PIP joint fusion. This involved reviewing 26 consecutive patients (34 toes) who had undergone hammer or claw toe correction. Case notes and radiographs were reviewed to establish results and complications and the need for revision surgery. Initial Radiographs taken at 6 weeks and a telephone survey was undertaken to assess patient satisfaction (16–44 weeks). Our findings were that of the twenty-one women and five men underwent surgery, with a mean age of 59 years (24–77), stable union was achieved in 33 of 36 toes. No patients had superficial or deep infection and no patient required wire removal or a revision procedure. In conclusion, PIPJ Arthrodesis with buried K Wires has excellent clinical outcome and high patient satisfaction

Study. This is a prospective double blind, placebo controlled trial. Collagenase Clostridium Histolyticum was effective and well tolerated used in well palpable cords of Dupuytren's Contracture. Concurrent fingers treatment with early complications have been reported. Patients reported outcome measures have been obtained. Materials & Method. 143 fingers were treated in 125 patients. Deformity of more than 30° at metacarpo phalangeal joints and more than 20° at proximal interphalangeal joints with well palpable cord were selected in this study. Finger straightening procedure was undertaken at 24–72 hours post injection. Prospectively evaluated for early complications, extent of correction, residual deformity and recurrence rate at 3 years and 6 months follow up. Concurrent fingers were treated without serious side effects. Results. Full correction was achieved in 130 fingers (91%). Residual flexion deformity noted in mainly in PIPJ with flexion 80° or more. At four years follow up, the recurrence rate was noted in Metacarpophalangeal Joints in 4(3%)fingers and Proximal Inter Phalangeal Joints in 12(9%) fingers. Patient reported outcome measures have been collected and expressed high degree of satisfaction. Conclusion. Most local complications resolved within two weeks of the injection. Isolated MPJ deformity is more likely to be corrected fully. Isolated Proximal Interphalangeal Joints and combined Proximal Interphalangeal Joints and Metacarpo Phalangeal Joints contractures are mostly end up in residual flexion. Concurrent finger treatment was uneventful

Symptomatic flexion deformity of proximal interpahalangeal joint (PIPJ) is one of the most common foot deformities and usually treated with arthrodesis. In general, percutaneous K-wires are used to stabilize the joint after excision of cartilage. K-wires projecting out of the toe need special care and can occasionally be dislodged accidentally. Furthermore issues such as cellulitis, pin tract infections, rarely osteomyelitis and need for removal make alternative fixation methods desirable. Smart toe is an intra-osseous titanium memory implant, which is stored frozen. It expands on insertion and does not require removal. 18 consecutive K-wire PIPJ arthrodesis were compared with 18 Smart toe PIP fusions with a mean follow up of 6 months. Post operative forefoot scores and complications were documented. Patient satisfaction was higher and complications were lower with Smart toe fusions than with K-wire arthrodesis. Fusion of PIP joints with smart toe is an effective and safer alternative to using K-wires. Although more expensive, higher patient satisfaction and lower complication rate may offset the extra cost of the implant

Aim. We aimed to assess the efficacy of conservative management of proximal phalanx fractures in a plaster slab. Methods. 23 consecutive patients with proximal phalanx fractures were included in this prospective study. The fractures were reduced and the position was held with a dorsal slab for three weeks. They were followed up an average of 7 weeks (range 2 to 45) after the injury. Radiographic confirmation of adequate reduction was carried out each week until union. After removal of the plaster, range of motion of the finger and radiological evidence of union, non-union or malunion was documented. Results. In united fractures, an average angulation of 4° (apex volar) was measured (range 0 to 45°). In one case (45°) this was not acceptable. All other cases measured less than 15° of angulation. On the AP radiograph the angulation was on average 2° (range 0 to 8°). On average 1.3 mm of shortening (range 0 to 5mm) were measured. In one case delayed union with rotational deformity of 20° was evident. After removal of the slab mild stiffness was noted in one case at the metacarpophalangeal joint and in two cases at the proximal interphalangeal joint. Conclusion. Most proximal phalanx fractures can be managed conservatively with acceptable results. NO DISCLOSURES

The Mathys. ¯. finger joint replacement system offers a novel fixation method into the proximal and distal medullary canals and a semi-constrained articulation. This comprises a separable, form-fit joint with a distal/proximal play of 0.7 mm, a lateral excursion of 10°, and rotation of up to 6°. This has theoretical advantages of increased radio-ulnar stability, preventing ulnar drift in patients with rheumatoid disease, and enhanced osseointegration offering implant longevity. In our unit, however, high failure rates were noted, prompting a review of cases to quantify our suspicions. Case notes of all patients who underwent finger joint replacement using the Mathys. ¯. implant between 1999 and 2005 were retrieved. Twenty-two devices were implanted by a single surgeon during this period. Four were in finger proximal interphalangeal joints, 17 in finger metacarpophalangeal joints and one in a thumb carpometacarpal joint (CMCJ). Indications for joint replacement included sixteen for rheumatoid arthritis (RA) and five for post-traumatic joint problems. The only thumb CMCJ was replaced for primary osteoarthritis. Patients were reviewed regularly and implant performance assessed critically along with survival of the implant to revision, infection or death of the patient. Mean follow up was 30 months. Sixteen implants failed including the only thumb CMCJ. Modes of failure were rotation (11), poor range of motion (two), infection (two) and dislocation (the CMCJ). Similar ball and socket designs for uncemented thumb CMCJ replacement, such as the Ledoux prosthesis, have previously shown poor survival and have been withdrawn from the market. Of the finger implants in RA patients (n=16), 12 implants failed of which ten were due to rotation. Time to failure ranged from two to 48 months (mean 15 months). The authors do not recommend the use of this implant, especially in cases of rheumatoid arthritis