IC48-R: Acutely Unstable Proximal Interphalangeal Joint: Tools for Success Moderator: Stephen A

IC48-R: Acutely Unstable Proximal

Interphalangeal Joint: Tools for Success Moderator(s): Stephen A. Kennedy, MD

Faculty: Nicholas Paul Iannuzzi, IV, MD, Jeffrey N. Lawton, MD, Andrew R. Tyser, MD, and Lindley B. Wall, MD

Session Handouts

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

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ICL 48: Acutely Unstable Proximal Phalangeal Joint – Tools for Success Unicondylar Fractures of the Proximal Phalanx Nicholas Iannuzzi, MD Assistant Professor University of Washington, Seattle

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• No financial or non-financial relationships to disclose

Disclosures

Case 1

13y M GLF @ 5 wks

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Case 2

47y F GLF @ 1 day

Images courtesy of Stephen Kennedy

Case 3

21y M L RF Lacrosse injury @ 4 wks Buddy taped

Images courtesy of Douglas Hanel

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Case 4

Zhang, et al (2012)7 • 36y M s/p saw injury

Outline

• Anatomy • Classification • Non-operative Management • Operative Management • Approach • Fixation • Complications • Salvage

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Anatomy5,6

• Trapezoid • Torsion • Radial v. Ulnar • -2.5°  4.3° • Condylar height • 10mm MF • 8mm SF

Blood Supply

Yousif et al. (1985)1 • 3 vessels, dorsal aspect dig. a. • Proximal system (14-25mm) • Distal system (2.5-10mm) • One of each for PIP perfusion

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Classification

London (1971) 2 • I: Stable • Protected activity • II: Unstable • K-wires • III: Comminuted • Arthrodesis/amputation

Classification3

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Classification3

Indications

Weiss and Hastings (1993)3 • 5/7 initially non-displaced fractures  displacement • Worst motion in patients treated with single k-wire • 2/2 displacement

Largely operative

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Approaches

Preservation of Exposure of fracture blood supply, soft Adequate reduction tissues

Approaches4

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Approaches

Between CS and lat band • Flex to improve exposure

9 Instructional Course: IC48-R: Acutely Unstable Proximal Interphalangeal Joint: Tools for Success Moderator: Stephen A. Kennedy, MD

Your specific speaking information- Talk Title: Dorsal and Volar Fracture Dislocations of the PIP Joint

Presenter: Lindley B. Wall, MD MSc

Disclosures: None

Dorsal and Volar PIP Joint Fracture/Dislocations ASSH 2019 Lindley Wall, MD MSc

Background: PIP joint conveys 85% of digit motion Joint dislocation with associated fracture Dorsal – volar fracture of middle phalanx base Volar – central slip fracture Dorsal more common Dorsal: hyperextension or axial load with digit in flexion Volar: axial load with digit in extension

Treatment considerations: Amount of articular surface involved – joint stability Goal: obtain and maintain joint reduction Restore stability to achieve full ROM Begin early motion Anatomic reduction of joint surface – secondary to congruent joint

Treatment Methods: Reduction with immobilization Splinting and early protected motion Traction device* Closed reduction and percutaneous pinning Open reduction and fixation (K-wires versus screws) Reconstruction* Joint arthroplasty Arthrodesis

Dorsal PIP Fracture/Dislocation Stability assessment: 1) Volar lip fragment <30% - Stable 2) Volar lip 30-50% - Tenuous a. Needs <30 degrees of PIP flexion to maintain reduction 3) Volar lip 30-50% - Unstable a. Needs >30 degrees of PIP flexion to maintain reduction 4) Volar lip >50% - Unstable Treatment: 1) Volar lip <30% a. Stable – buddy tape and early motion 2) Volar lip 30-50% a. ROM under fluoro, determine amt of flexion needed for stability b. Dorsal blocking splint c. Start early ROM in splint d. Progressive extension weekly 3) Volar lip >50% a. Closed reduction and pinning b. Open reduction and fixation c. Hemi-hamate reconstruction

Volar PIP Fracture/Dislocation Stability assessment: 1) Central Slip fragment <50% - Potentially Stable 2) Central Slip fragment any % - Unstable Treatment: 1) Central Slip fragment <50% - Potentially Stable a. ROM under fluoro, determine joint congruity and fracture alignment b. PIP extension splint c. No bony apposition - fixation 2) Central Slip fragment any % - Unstable a. Fixation i. CRPP ii. ORPP iii. OR and screw or anchor fixation 3) Tips: a. Congruent joint, reduced fragment b. Transarticular pinning c. Treat acutely d. Pre-operative counseling on nature of injury i. Poor outcomes ii. High risk of early arthritis iii. Stiffness iv. Risk of salvage procedures

Results Dorsal: 1) Kiefhaber et al. JHS – mini-screw fixation 2) Cheah et al. JHS – plate fixation 3) Vitale et al. JHS – percutaneous fixation Volar: 1) Imatami et al JHS Br 1997 2) Rosenstadt el al. JHS 1998 3) Meyer et al JHS 2017

References: 1) Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am 1998;23(3):368-80. 2) Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am. 2006;31(8);1349-54. 3) Cheah AE, Tan DM, Chong AK, Chew WY. Volar plating for unstable proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am. 2012;37(1):28-33. 4) Vitale MA, White NJ, Strauch RJ. A percutaneous technique to treat unstable dorsal fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2011;36(9):1453-9. 5) Imatami J, Hashizume H, Wake H, Inoue H. The central slip attachment fracture. J Hand Surg Br. 1997;22(1):107e109. 6) Rosenstadt BE, Glickel SZ, Lane LB, Kaplan SJ. Palmar fracture dislocation of the proximal interphalangeal joint. J Hand Surg Am. 1998;23(5):811e820. 7) Meyer ZI, Goldfarb CA, Calfee RP, Wall LB. The central slip fracture: Results of operative treatment of volar fracture subluxations/dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2017;42(7):572.e1-e6.

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Pilon Fractures and Dynamic External Fixation

STEPHEN A. KENNEDY MD FRCSC ASSOCIATE PROGRAM DIRECTOR DEPARTMENT OF ORTHOPAEDICS AND SPORTS MEDICINE UNIVERSITY OF WASHINGTON

Disclosures

• Associate Editor Journal of Hand Surgery

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Pilon fractures occur from axial load, like a “pilón” (or pestle).

• The proximal phalanx drives axially into the middle phalanx and results in a complete articular fracture • No intact column of bone between the diaphysis and articular surface

An unstable fracture surrounded closely by finely balanced flexor and extensor gliding surfaces.

Karim Bakri http://www.turntillburn.ch/cms/ttb/index.php?id=93%7C0&L=1

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Often need to balance competing priorities.

• Restore articular congruity • Preserve blood supply • Correct length, angulation, rotation with adequate stability • Avoid scar from dissection and/or immobilization

Options for treatment vary:

• Buddy tape/loop (stable) • Splint • CRPP • External Fixator (Static vs Dynamic) Sarris et al JHS 2004 Mark Henry MD • ORIF +/‐ bone graft • Total joint replacement • Arthrodesis

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Surgeons generally agree on which patients need surgery, but not on which type of surgery.

Janssen et al., Science of Variation Group. CORR. 2015. 7

Several authors report variety of techniques for ORIF.

• Screws, plates

• Cerclage

• Absorbable sutures

Mark Henry MD 8

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Open reduction and internal fixation can be disappointing

“Open reduction should be approached cautiously and may result in significant complications.”

“Skeletal traction is safe and gives results that are radiographically and clinically comparable to those achieved with open reduction.”

Stern PJ et al. JHS Am. 1991. 9

Begin with the end in mind.

o Restore length and keep it.

o Achieve acceptable articular surface

o Correct angulation/translation/rotation

o Get moving by ~4 weeks

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Dynamic external fixation can achieve the end goal…

• Stable restoration of length • Articular alignment is often more than adequate • Avoids dissection/scarring of tendons • Inexpensive

…and allow for early motion.

Chris Allan MD

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Motion is often not full, because PIP joints are not simple hinges.

1. Hess F et al. Comput Math Methods Med. 2013. 2. Lawrence T, et al JHS Br. 2004 13

The best approximation of a center axis is still the optimal target.

1. Chauhan A, et al. JHS Am. 2018.

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What do you need?

• Depends on type of dynamic external fixator • Pins and rubbers (Suzuki, Slade) • 0.045” K‐wires (6‐7”) and dental rubbers • Metal only (Gaul and Rosenberg 1998) • 0.045” K‐wires only

Chauhan A et al. JHS Am. 2018.

Suzuki method steps:

Chauhan A et al. JHS Am. 2018 16

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Slade method steps (with blocking wire):

Chauhan A et al. JHS Am. 2018 17

Slade method steps (with blocking wire):

Chauhan A et al. JHS Am. 2018 18

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Metal‐only technique

Debdut Biswas MD 19

Case – 31 yo healthy M jammed small finger in basketball.

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Case – Pins and rubbers system applied, with early therapy, followed weekly in clinic.

Case – Pins removed and continued with therapy – then lost to follow‐up.

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Returns 4 years later. Reports very satisfied and “full function”

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Radiographic arthrosis and/or deformity does not correlate with function

Giugale JM et al. Open Orthop J. 2017.

Debdut Biswas MD 26

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Debdut Biswas MD

Debdut Biswas MD 28

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Metal only technique provides similar outcomes.

Debdut Biswas MD

Outcomes – pins and rubber bands

Chauhan A et al. JHS Am. 2018 30

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Outcomes – pins and rubber bands

‐ Case series of n=5‐34 patients ‐ Ex‐fix removal ranged from 2‐8 weeks ‐ Average ROM is 63‐88 degrees ‐ Most common complications are ‐ (1) post traumatic arthritis, ‐ (2) pin tract infection ‐ (3) malalignment

Chauhan A et al. JHS Am. 2018 31

Outcomes – metal only

Chauhan A et al. JHS Am. 2018 32

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Outcomes – metal only

‐ Case series of n=5‐36 patients ‐ Ex‐fix removal ranged from 3‐6 weeks ‐ Average ROM is 64‐90 degrees ‐ Most common complications are ‐ (1) pin tract infection ‐ (2) uncoupling, and ‐ (3) chronic pain

Chauhan A et al. JHS Am. 2018 33

Summary

• Pilon fractures remain a challenge • Ligamentotaxis can provide acceptable reduction • Operative options based on Level IV case series • Anticipate uncoupling, overdistraction, arthrosis • Further evidence is needed for comparison of various techniques

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Thank You!

• Stephen Kennedy MD • University of Washington

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DISCLOSURES

Jeffrey N. Lawton, MD

Consulting Fees: Innomed, Instrument Design

PIP Joint ORIF IC48: Acutely Unstable Proximal Jeff Lawton Interphalangeal Joint: Chief, Division Elbow, Hand and Microsurgery Tools for Success University of Michigan Department of Orthopaedic Surgery

Disclosures

• Innomed – Savannah, GA: Instrument Design & Development • Wolters-Kluwer – Philadelphia, PA: Publishing • AO Hand Faculty

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Objectives

• Evaluate PIP Fractures • Comprehend the Importance and Anatomy of the Injury and Surgical Exposures • Explain Relevant Reduction and Fixation Principles • Evaluate PIP ORIF as a Surgical Management Option

Treatment Options

Calfee, Sommerkamp J Hand Surg 34A:1140‐1147, 2009.

Treatment Options

Calfee, Sommerkamp J Hand Surg 34A:1140‐1147, 2009.

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Is this something I think I can fix?

ORIF: Cerclage Wiring

• Comminuted PIP Fractures • Weiss CORR (1996) • 12 pts treated with volar cerclage wiring • Avg. f/u 2.1 yrs – 11/12 pts w/ no DJD, 1/12 with some articular breakage • TAM – 89deg, no implant failure, all pts no pain with ROM

PIP Fx-28yo RHD Laborer: LMF

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PIP Fx

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• Approach

• NV bundles

• Volar Plate Incision

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28 yo RHD Laborer • Left Middle Finger

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ORIF: Screw Fixation

Bindra R. JBJS 2016

17 yo RHD Jr SS

Misjudged a grounder Previous RMF Mallet

Bindra R. JBJS 2016

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17 yo RHD Jr SS

Made it back that summer for College Scholarship looks

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46 yo + Fireworks = ? R Ring Finger

46 yo + Fireworks = ?

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46 yo + Fireworks = ?

Conjoint Lateral Tendons

Central Slip Insertion

46 yo + Fireworks = ?

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15 yo Aspiring Mechanic HS Autoshop, Rt Small Finger

15 yo Aspiring Mechanic

Can I fix this and begin early motion ?

15 yo Aspiring Mechanic

Can I fix this and begin early motion ?

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15 yo Aspiring Mechanic

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15 yo Aspiring Mechanic Never trust an intra‐op pic of a Capsulectomy

15 yo Aspiring Mechanic

ORIF Advantages: • Anatomic articular restoration • Early Motion • No additional site of morbidity - HHA • No transarticular fixation / External Fixators

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ORIF Disadvantages:

• Technically challenging • Added soft tissue dissection may result in stiffness and swelling • Requires commitment to Hand Therapy program

ORIF: Outcomes • No prospective comparative study • Full ROM rare ~10 deg Extensor Lag • ORIF has most complications

• Delayed presentation or recurrent subluxation >> poor prognosis

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Summary • Our Goal is to Return Pts to Function

• Use the technique that works best for you

• Early Active Motion.

Thank you

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Thank you

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Osteochondral Reconstruction and Arthroplasty for Acute PIP Joint Injury

©UNIVERSITY OF UTAH HEALTH, 2017

ARTHOPLASTY – RARELY REQUIRED FOR ACUTE INJURY

©UNIVERSITY OF UTAH HEALTH, 2017

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ARTHOPLASTY – RARELY REQUIRED FOR ACUTE INJURY

©UNIVERSITY OF UTAH HEALTH, 2017 3

ARTHOPLASTY – RARELY REQUIRED FOR ACUTE INJURY

©UNIVERSITY OF UTAH HEALTH, 2017

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ARTHOPLASTY OPTIONS FOR UNSTABLE PIP JOINT INJURIES

1. Volar plate arthroplasty (VPA)

2. Hemi‐hamate replacement arthroplasty (HHRA)

3. Reverse hemi‐hamate replacement arthroplasty

4. Implant arthroplasty

©UNIVERSITY OF UTAH HEALTH, 2017 5

SITUATIONS WHERE ACUTE ARTHOPLASTY MAY BE INDICATED

1. Highly comminuted fractures of the volar articular surface associated with dorsal fracture‐dislocations of the PIP joint • When other treatment options are not feasible or are unsuccessful in achieving acceptable fracture reduction.

2. Large defect in osteoarticular surface involving either the base of P2 or a significant portion the head of P1.

©UNIVERSITY OF UTAH HEALTH, 2017

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SITUATIONS WHERE ACUTE ARTHOPLASTY MAY BE INDICATED

2. Large defect in osteoarticular surface involving either the base of P2 or a significant portion the head of P1. • Implant arthroplasty: rarely indicated

SITUATIONS WHERE ACUTE ARTHOPLASTY MAY BE INDICATED

Volar Plate vs Hemi‐hamate

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