Name:
Proximal Interphalangeal (PIP) Joint Implant Arthroplasty Using a Volar Approach
Description:
Proximal Interphalangeal (PIP) Joint Implant Arthroplasty Using a Volar Approach
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Duration:
T00H11M39S
Embed URL:
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Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e338e499-255c-4c38-a403-bb510938fe3d/Proximal Interphalangeal (PIP) Joint Implant Arthroplasty Us.mp4?sv=2019-02-02&sr=c&sig=5PJnU3ZxgclXvScjeB97jRP%2FffCOF9Nj8wm8oim87Bg%3D&st=2024-11-21T16%3A49%3A45Z&se=2024-11-21T18%3A54%3A45Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
MARTIN BOYER: This video was supported by the American Society for Surgery of the Hand, whose mission is to advance the science and practice of hand and upper extremity surgery through education, research and advocacy on behalf of patients and practitioners.
MARTIN BOYER: This is Marty Boyer speaking from Washington University in Saint Louis Department of Orthopedic Surgery and we're going to talk about PIP joint arthritis today. These are the X-rays of a 65-year-old female patient with disabling arthritis of the right index PIP joint. We've elected to treat her operatively through a volar approach and a silicone arthroplasty of the PIP joint.
MARTIN BOYER: Here's the preoperative examination. She has passive extension to about 10 degrees of flexion and passive flexion down to 45 degrees of flexion without any change in the degree of flexion based on the MP position. Again, finger doesn't quite come straight, but it, it almost does. We make a mid axial incision and we continue it as a Bruner type incision so that we have a wide base skin flap followed by mid axial extensions
MARTIN BOYER: so that exposure of the PIP joint from the volar aspect is satisfactory and extensile. We see the incisions made. I like using a 15C blade because of the precision that it affords. First thing that's done is the dissection of the neurovascular elements of the finger. We see here that we are cutting Grayson's ligament to expose the digital nerve and the digital artery that is subjacent to it.
MARTIN BOYER: This can be done fairly readily as long as the digital neurovascular bundle is found proximally and then displaced dorsally so that the entire skin flap can be elevated as a full thickness flap off of the flexor tendon sheath. Here we see the separation of the flap from the sheath and we can see nicely in this particular case, the
MARTIN BOYER: elevation all the way to the other side of the finger, sometimes even to the point where the latter branch of the digital artery that supplies the vinculum longum profundum and vinculum brevis superficialis tendons supply. I like creating a window from the distal aspect of the A2 pulley to the proximal aspect of the A4 pulley in order to avoid tendon injury. This is done from within the sheath and by displacement of the tendon,
MARTIN BOYER: we can see the volar plate, which is then transected longitudinally on the radial and ulnar side of the finger, followed by a transection off of the proximal phalanx. Displacement of the tendon shows how the entire volar plate can be elevated in a proximal distal fashion and how the joint with copious synovitis as seen here, can be exposed.
MARTIN BOYER: A gentle ronjuring of the articular content is done without any bony resection at this time. The volar plate is released slightly off of the middle phalanx and following this, a recessing of the collateral ligament is done. What I've done here is resect a little bit more synovial tissue that was not taken off with the ronjeur and what we see here is the recession of the collateral ligament on the radial and ulnar side of the finger
MARTIN BOYER: in order in this particular case. This is starting from within the joint and then elevation of the collateral ligaments off of the base of the middle phalanx and off of the concavity in the head of the proximal phalanx. Again, further gentle, ronjuring of inflammatory tissue from the content of the joint. We see here the erosion that is large in the head of the proximal phalanx, and we see also the erosion with almost a complete absence of what one might consider to be viable articular cartilage in the joint.
MARTIN BOYER: Now the blade is being placed at the dorsal base of the middle phalanx in order to free up the central tendon insertion, as long as the triangular ligament, which is more distal, is not divided or disrupted. Full digital extension at the PIP joint can be expected based on the positions of the lateral bands dorsal to the axis of rotation of the PIP joint. I prefer to not use any devices to make the bony cuts.
MARTIN BOYER: I find that these devices, at least in my hands, are unreliable and untrustworthy. I prefer to make these cuts using a ronger or at times using a saw, a oscillating saw. So as parallel cuts in both the base of the middle phalanx and the head of the proximal phalanx can be achieved directly. Following this, I like extending the finger and applying gentle traction to make sure that the bony cuts are parallel
MARTIN BOYER: to one another. And this is a nice about a 6 or a 7 millimeter wide defect into which, based on my experience, the implant can be placed. We then understand the anatomy of the PIP joint and know that the hole or the intrusion into the canal of the middle phalanx will be done dorsally
MARTIN BOYER: in the cut surface, and the reason for that, as I showed in the illustration on the surgical drape, was that the canal is located dorsally with respect to the articular surface of the middle phalanx. This is not the case in the proximal phalanx to the same extent, although there is a slight dorsal placement of the canal in the proximal phalanx. And there we see, we measure using the initial trial device or the initial canal broach.
MARTIN BOYER: The location of where we are going to broach the canal and where we're going to enter the canal on the proximal phalanx. And radiographic evaluation allows a further analysis and a further correction of the location of the, of the sound in the bone. We see here the proximal phalanx; AP on the left and lateral on the right, and we saw the middle phalanx as well.
MARTIN BOYER: Here we see the brooch being placed in order to create a slightly dorsal but intraosseous canal within both the proximal and middle phalanges to accept the trial prosthesis. Here we see an image of the middle phalanx with a center center and a proximal phalanx with a center center brooch placement of the implant.
MARTIN BOYER: Here we see the trial implant. It is a particular type of implant to which I have no financial relation, but it is a good implant in that it allows for it in my opinion in primary cases, a greater degree of flexion to be achieved in the postoperative period. That said, following sizing of the implant, we irrigate and then do final bone cuts and trimming
MARTIN BOYER: so that the finger balance is good and that there is no radial or ulnar deviation in the coronal plane. We see here that the tendons and the neurovascular elements are left intact and that the vinculum longum is present. There's the volar plate, which is displaced and there is the flexor tendon sheath which will be repaired post operatively, although it is not absolutely mandatory to do so.
MARTIN BOYER: Fluid is absorbed using our sponges and then the correct size implant is placed within the defect and then a test of stability is done. The implant should not have a tendency to pop out or dislocate in either the volar or dorsal direction. The volar plate is then replaced in the right orientation and then sewn into the remnants of the collateral ligaments subjacent to the flexor tendons.
MARTIN BOYER: I like using Ethibond suture for this. I believe this is either a 3-0 or a 4-0. Generally speaking, the smaller the suture, the better. In this particular area of the reconstruction, at this particular time of the reconstruction. So that is done on both the radial and ulnar sides of the finger with the volar plate in order to keep it in place. And following this, what you will see is you will see the flexor sheath then replaced.
MARTIN BOYER: We check range of motion following placement of the sutures in the volar plate so as to make sure that again, there is no tendency of the implant to dislocate and make sure there is no obstruction of the range of motion of the implant and of the PIP joint. Flexor sheath, you can see here is sewn to the ever present rim on the other side of the finger and this provides at least a theoretical advantage by improving the gliding surface of the flexor tendon.
MARTIN BOYER: Here we see the post-operative view still under sterile conditions and we see the interrupted horizontal mattress, nylon sutures placed. And following this, we were able to initiate therapy at two days post-op and then we see here the patient's nine week post-operative result with good flexion extension, and good coronal and sagittal alignment.
MARTIN BOYER: Thank you.
