Renfree, Kevin J.

Background: Most hand surgeons use a dorsal approach for proximal interphalangeal (PIP) joint implant arthroplasty. However, a volar approach offers the advantage of no disturbance to the extensor mechanism, thus allowing early initiation of active range of motion. We examined our results in patients who underwent PIP joint arthroplasty via a volar approach.Methods: Using a retrospective chart review, we evaluated the outcomes of patients undergoing PIP joint arthroplasty through a volar approach between 2001 and 2005 by 3 fellowship-trained hand surgeons at our institution. The indication for surgery was PIP joint pain with radiographic evidence of joint destruction. Variables included implant type, diagnosis, affected digit(s), preoperative and postoperative range of motion, and complications. Hand therapy was initiated on postoperative day 3 or 4.Results: Over the 5 years, 25 PIP joints were replaced in 18 women and 2 men with the volar approach. Replacements consisted of 14 surface replacement prostheses, 9 pyrocarbon prostheses, and 2 silicone prostheses. The average age of patients at prosthesis implantation was 64 years (range, 39–75 years). Prostheses were placed in 1 index, 12 long, 7 ring, and 5 small digits. Average follow-up period was 33 months (range, 24–69 months). Preoperative diagnoses were osteoarthritis (14), rheumatoid arthritis (4), and posttraumatic arthritis (2). Preoperative total arc of motion averaged 42° (range, 0° extension to 80° flexion); postoperative total arc of motion averaged 56° (range, –10° extension to 90° flexion). Complications comprised 1 swan neck deformity, 1 deep infection, 1 dislocation (early), and 2 loose implants with flexion contractures. Seventeen patients had minimal or no pain at their last follow-up visit.Conclusions: PIP joint arthroplasty can be successfully implemented through a volar approach with various implant types and has outcomes similiar to the published results of the dorsal approach.

Objectives: We sought to determine the incidence of hardware removal or persistent irritation after tension band arthrodesis of the thumb metacarpophalangeal joint (MCPJ), and whether these outcomes were related to patient age, gender, body mass index (BMI), or angle of fusion. Materials and Methods: A retrospective review was performed of all (n = 39) thumb MCPJ arthrodesis done using tension band wire fixation by a single hand surgeon at a large tertiary academic medical center over a 14-year period. Thirty procedures in 28 patients (4 men, 24 women) with an average age of 65 years (range, 35-81 years) were available for long-term follow-up (mean, 82 months; range, 12-171 months). Average BMI was 26.2 (range, 17.4-35).Most were done in conjunction with a basal joint suspensionplasty. Results: One hundred percent of arthrodesis healed radiographically at a mean 3.8 months (range, 3-7 months). Mean fusion angle was 24° (range, 9°-45°). Of patients available for long-term follow-up (n = 30), 7 (23%) required hardware removal for pain at a mean of 36 months postoperatively, and another needed revision of hardware at 4 months postoperatively. An additional 3 patients (10%) expressed dissatisfaction with the hardware in place, but declined removal. There was no significant influence of the above variables on hardware removal or dissatisfaction. Conclusions: Tension band wire arthrodesis of the thumb MCPJ results in predictable bony union. Although it is a very cheap means of fixation, there is a 33% incidence of significant hardware-related pain after tension band arthrodesis of the thumb MCPJ. Twenty-five percent of patients may require a second surgery to revise or remove symptomatic hardware, which can negate any cost savings through the use of this technique. A study comparing this method with plate or single screw fixation would be beneficial.

Background: Proximal interphalangeal joint (PIPJ) arthroplasty in border digits is controversial because of unprotected external loading forces and limited canal sizes in the small finger. The use of neither a semiconstrained, surface replacement proximal arthroplasty (SRA) nor a lateral approach that preserves the external collateral ligament has been well described. Methods: Eight women (mean age, 66 years) underwent SRA of 5 index and 4 small digits for osteoarthritis. Active range of motion, deformity, and grip and pinch strengths were measured, and patients completed a visual analog pain scale, QuickDASH, and satisfaction survey. Radiographs were assessed for implant loosening or subsidence. Results: Mean follow-up was 29 months. Mean pain score decreased from 8.0 to 0.8. Mean coronal deformity decreased from 22° ulnar deviation to 6°. Average PIPJ arc of motion improved from 51° to 56°. No lateral instability was observed. Final lateral pinch averaged 4.4 kg in affected vs 4.0 kg in opposite hand. Average final grip strength was 19 kg in affected vs 16 kg in opposite hand. Postoperative QuickDASH averaged 24; postoperative satisfaction score averaged 3.7 (5-point Likert scale). Radiographic analysis showed no implant subsidence or radiolucent lines. Conclusions: PIPJ SRA appears to be a reasonable option in border digits, as is a lateral approach on the inside border of the affected digit. Pain relief and lateral stability are predictable, and motion improves slightly. If a longitudinal incision is made, placement slightly dorsal to the midaxial line away from the digital nerve may help to avoid a tender scar.

Summary This randomised, double‐blind, placebo‐controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean ( SD ) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti‐emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

We compared the results of percutaneous in situ arthrodesis with open arthrodesis of the distal interphalangeal joint with a headless compression screw. In the percutaneous in situ arthrodesis group (17 joints), the screw was inserted from the fingertip across the unprepared joint. In the open group (12 joints), flat cancellous surfaces were prepared before screw insertion. Solid fusion was found in 10/17 joints (59%) with percutaneous in situ arthrodesis and in 11/12 joints (92%) with open arthrodesis. Among the other seven joints with percutaneous in situ arthrodesis, six had fibrous union and were asymptomatic at a mean of 18 months, and one failed, requiring revision. One joint with open arthrodesis had fibrous union and was asymptomatic 12 months after surgery. We conclude that open arthrodesis is better than the percutaneous method, as a greater percentage achieve bone union. The open approach allows osteophyte removal and slightly better correction of angular deformity in the coronal plane.