Dorsal proximal interphalangeal joint tenderness is associated with prolonged postoperative pain after A1 pulley release for trigger fingers.

BACKGROUND: In some trigger finger patients, tenderness is found in the dorsal proximal interphalangeal (PIP) joint. The etiology and prevalence of this condition are unclear. Furthermore, surgical outcomes for trigger fingers with coexisting dorsal PIP tenderness have not been reported. This study (1) determined the prevalence and risk factors for PIP joint tenderness in trigger fingers and (2) compared postoperative outcomes for trigger fingers with and without joint tenderness. METHODS: This prospective cohort study was conducted between August 2018 and March 2020. We enrolled 190 patients diagnosed with single-digit trigger fingers undergoing open A1 pulley release. The incidence, demographic data, and surgical outcomes of patients with dorsal PIP tenderness were investigated. Factors associated with tenderness were analyzed, including patient occupation, finger involvement, trigger finger grading, duration of symptoms, previous corticosteroid injections, and presence of diabetes mellitus. A numeric pain scale, a patient-specific functional scale, and the range of motion were evaluated preoperatively and 1, 2, and 6 weeks after surgery, with telephone follow-ups at 3 and 6 months. RESULTS: Of 190 patients, 46.8% had tenderness of the dorsal PIP joint. Patients with joint tenderness had significantly more overall postoperative pain for up to 6 weeks and reported residual minor pain for up to 3 months. The functional scale and range of motion of the 2 groups did not differ during follow-up. The only risk factor observed was the occupation of the patients. CONCLUSION: Dorsal PIP tenderness is more common in trigger fingers than previously thought. It is also associated with higher and prolonged levels of postoperative pain after A1 pulley release. Therefore, patients with pre-existing PIP tenderness should be informed about the possibility of sustaining residual minor pain for up to 3 months after surgery. LEVEL OF EVIDENCE: II.

Passive Manipulation for Proximal Interphalangeal Joint Extension Contractures.

PURPOSE: We investigated closed passive manipulation as an alternative to surgery for certain proximal interphalangeal (PIP) joint extension contractures. METHODS: We retrospectively reviewed all patients with PIP joint extension contractures treated with passive manipulation at our institution between 2015 and 2019. The included patients were a minimum of 12 weeks from their initial injury/surgery (median 179 days; interquartile range: 130-228 days), had plateaued with therapy, and underwent a 1-time passive manipulation. All included fingers had congruent PIP joints and no indwelling hardware that could have had direct adhesions. Most (80%) patients had a direct injury to the finger ray(s) that led to the contractures. Most (75%) patients had the manipulation performed under local anesthesia in the office. Available measures of passive range of motion (PROM) and active range of motion (AROM) immediately, within 6 weeks, between 6 and 12 weeks, and at >12 weeks after the manipulation were recorded. RESULTS: Twenty-eight patients and 46 digits met the criteria. The median PIP joint PROM improved from 50° to 90° immediately following the manipulation. The median PROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks following manipulation were 80°, 85°, and 85°, respectively. The median AROM immediately after the manipulation improved from 40° to 90°, and the median AROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks were 70°, 50°, and 60°, respectively. None of the patients experienced worsening of PIP joint range of motion. One patient who had 4 fingers manipulated had a 45° distal interphalangeal joint extension lag for one of the fingers after the manipulation. Eight fingers underwent later flexor tenolysis or reconstruction to improve AROM after the gains in PROM via manipulation were maintained. CONCLUSIONS: Passive manipulation is an alternative to surgical release for select PIP joint extension contractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Midterm clinical outcomes of collateral ligament repair of the thumb and lesser digits: a retrospective analysis of 35 cases.

BACKGROUND: Finger collateral ligament injuries are common, and conservative treatment usually works well. However, complete ruptures that lead to instability could cause painful disability. This study presents our clinical experience and a qualitative functional evaluation following the surgical repair of the thumb and proximal interphalangeal (PIP) joint collateral ligament ruptures. METHODS: Thirty-five patients (22 men and 13 women), diagnosed via a physical examination and magnetic resonance imaging (MRI) with a total collateral ligament rupture in the metacarpophalangeal thumb (16) and PIP joints of the lesser digits (19) and treated surgically, were evaluated retrospectively. The limited range of motion; functional score by Saetta; disabilities of the arm, shoulder, and hand (DASH) score; pre- and post-operative pain, deformity level; and post-operative ability to grip keys, buttons, and jars were measured. The significance of the change between the pre and post-operative visual analog scale for pain (VAS) scores were evaluated using the Wilcoxon signed-rank test. The difference between the lesser digits and thumb groups by patient age was evaluated using the Mann-Whitney-U test. All data, such as the mean, range, and standard deviation, were calculated using SPSS. RESULTS: The mean pre- and post-operative VAS scores were 4.8 (from 3 to 7) and 0.91 (0 to 4), respectively. The mean post-operative limitation in the range of motion was 9.78° (s = 14.47) for lesser digits and 6.87° (s = 12.29) for the thumb. According to Seatta et al., the final functional score was 62.5% excellent, 25% good, and 12.5% moderate for the thumb and 84.2% excellent, 10.5% good, and 5.3% poor for the lesser digits. The mean post-operative DASH score was 13.55 (SD: 8.77) for lesser digits and 14.22 (SD: 8.9) for the thumb. The mean contralateral (healthy) hand DASH score was 0.75 (SD: 1.05) for lesser digits and 0.75 (SD: 1.05) for the thumb. For the thumb and lesser digits, the z-scores were - 3.55 and - 3.787, respectively, and the progress of the VAS score was significant (p < 0.05). CONCLUSION: After a 40-month follow-up for 35 acute, subacute, and chronic cases, the results suggest that direct and suture-anchor repairs are feasible, painless treatments associated with good finger function.

The impact of various simulated arthrodesis angles of the proximal interphalangeal joint of the ring and middle finger on grip strength.

INTRODUCTION: Arthrodesis of the proximal interphalangeal (PIP) joint at 40° angle has been proposed by many authors. A smaller angle of arthrodesis results in weaker grip strength of the hand from the quadriga effect. However, arthrodesis at 40° compromises other aspects of hand function including poor aesthetic appearance. This paper aims to quantify the decrease in grip strength at 40°, 20°, and 0° of arthrodesis. MATERIALS AND METHODS: Grip strengths of the hand were measured using a BASELINE dynamometer at settings II, III, and IV. Baseline grip strength of the subjects were first measured without wearing a splint. Thereafter, subjects wore thermoplastic splints to simulate arthrodesis of the middle and ring finger PIP joint at 40°, 20°, and 0°, and grip strengths were measured again. The grip strength of the hand with simulated arthrodesis was then calculated as a ratio of the baseline. RESULTS: There were 50 subjects yielding 100 sets of results. The results show that average grip strength ratio of the hand decreases progressively from 40° and 20° and to 0° of arthrodesis for both the middle and ring finger. However, the difference in grip strength ratio between 40° and 20° of arthrodesis was minimal. Simulated arthrodesis of the middle finger affected the grip strength ratio more than arthrodesis of the ring finger, and compromised gripping of a smaller handle more than a wider one. CONCLUSION: The decrease in grip strength from 40° to 20° simulated fusion of PIP joint was minimal. Therefore, in so far as grip strength loss is concerned, arthrodesis of the PIP joint at an angle less than 40° can be considered for patients with individual functional and aesthetic concerns.

Radiographic goniometry of the PIP-joint: A reliable measurement method.

INTRODUCTION: Arthrodesis of the proximal interphalangeal joint (PIP joint) is a good treatment option for relief of arthritic pain. The angle of the fused PIP joint is considered important for postoperative digital function. It is therefore important to reliably measure the actual angle of fusion. Goniometry performed by hand therapists or hand surgeons can generate measurement errors. PURPOSE OF THE STUDY: The purpose of this study is therefore to investigate the intraobserver and interobserver reliability of measuring the angle of fusion of the PIP joint on X-rays. STUDY DESIGN: A clinimetric study was conducted investigating the reliability of X-ray goniometry. METHODS: Three blinded observers measured the angle of the PIP-joint fusion on a lateral postoperative X-ray. The intraobserver and interobserver reliability was calculated. RESULTS: Ninety-four patient X-rays were measured. The intraobserver reliability showed an intraclass correlation coefficient (ICC) of 0.94, and the ICC for the interobserver reliability ranged between 0.92 and 0.95. DISCUSSION: Because this is the first reliability study on radiographic goniometry, comparison of our data with other similar studies is difficult. The best comparison can be made to in vivo goniometry. Based on the investigation of ICC values of various studies on the reliability of in vivo goniometry, radiographic goniometry seems to be more reliable. CONCLUSIONS: These results indicate an excellent reliability, which is generally higher than the reliability for in vivo goniometry of the PIP joint performed by hand therapists or hand surgeons. We can conclude that radiographic goniometry of the PIP joint is a highly reliable measurement method.

Relative Strengths of Intramedullary K-Wire Techniques for Digital Deformities.

Hammertoe deformity correction surgery is one of the most common procedures performed by foot and ankle surgeons. Recent foot and ankle medical literature presents conflicting opinions regarding the optimal intramedullary fixation device and techniques for use in digital deformity correction. There are a number of varying fixation constructs of intramedullary Kirschner wire fixation reported for proximal interphalangeal joint arthrodesis; however, there are no reports of relative loading strength of the fixations. In this study, 90 sawbone models were divided equally into 3 groups of different intramedullary Kirschner wire fixation techniques: Group A- single straight, Group B- single bent, Group C- double bent. Each fixation construct underwent controlled axial loading and failure points were observed. Results showed no significant difference in load failure from all 3 groups with mean maximum force of Group A = 20N, Group B = 19.1N, and Group C =17.5N. We conclude that all Kirschner wire fixation options for digital deformity correction, will provide similar resistance to sagittal plane axial loads.

Washer and Post Augmentation of 90/90 Wiring for Proximal Interphalangeal Joint Arthrodesis: A Biomechanical Study.

PURPOSE: To describe a novel construct for proximal interphalangeal (PIP) joint arthrodesis using headless cannulated screws as an intramedullary washer to augment 90/90 intraosseous wiring and compare the biomechanical properties of this construct with those of the 90/90 intraosseous wiring without headless screw augmentation. METHODS: Biomechanical evaluation of augmented 90/90 intraosseous wiring with headless cannulated screws (group 1) or 90/90 intraosseous wiring without augmentation (group 2) for PIP joint arthrodesis was performed in 3 matched-pair cadaveric specimens (12 digits per group). Each group was loaded to 10 N in the sagittal and coronal planes and the resultant stiffness from the load-displacement curve was calculated. In extension, each group then underwent load to permanent deformation and load to catastrophic failure. RESULTS: The augmented 90/90 intraosseous wiring with cannulated screws construct demonstrated significantly greater stiffness by 132%, 64%, 79%, and 75% in flexion, extension, ulnar, and radial displacement, respectively. During load to permanent deformation testing, a 42% greater force was required to create permanent deformation in group 1 compared than group 2. There was no significant difference between the 2 groups during load to catastrophic failure testing. CONCLUSIONS: Augmenting 90/90 intraosseous wiring for PIP joint arthrodesis with 2 headless cannulated screws in the sagittal plane that serve as intramedullary washers for the sagittal wire and posts for the coronal wire significantly increases stiffness in all directions as well as load to permanent deformation compared with 90/90 intraosseous wiring without cannulated screw augmentation. CLINICAL RELEVANCE: Augmentation of the 90/90 intraosseous wire construct with headless cannulated screws can be considered in patients at risk for wire cutout or implant failure.

Neurovascular Advancement Flap to Release Flexion Contracture of the Proximal Interphalangeal Joint.

Various methods have been described to surgically release posttraumatic flexion contracture of the proximal interphalangeal joint. Extension of the distal digit often creates a soft tissue defect on the volar aspect of the finger. Although various flaps and skin grafting have been utilized for coverage of this defect, they can be associated with morbidity. We present our experience with a volar neurovascular advancement flap to achieve soft tissue release in proximal interphalangeal joint flexion contracture. This advancement flap is designed to include both digital neurovascular bundles and eliminates the need for a secondary procedure as it allows primary closure of the subsequent defect. It is indicated for contracture lengthening of 10 to 14 mm. Surgical considerations of flap design are discussed.

Isoforce: A new outrigger system for static progressive orthotic interventions of the proximal interphalangeal joint with constant force transmission-Results of a biomechanical study.

STUDY DESIGN: Bench research-biomechanical study. INTRODUCTION: Static progressive orthotic devices are efficient in treating contractures. However, current outriggers are unable to keep force transmission and the force application angle (FAA) constant. PURPOSE OF THE STUDY: To evaluate the biomechanical performance of the Isoforce outrigger, a novel extension orthosis. METHODS: A hand model was used to measure the required force at the outrigger and FAA, while simulating resolution of different contracture angles. We also tested feasibility in a small patient series. RESULTS: The force required with the Isoforce device never exceeded 2.4 N, and the FAA did not change more than 6°. Corresponding figures for the reference devices exceeded 16 N and 20°. The 7 patients testing the Isoforce extension device showed an extension deficit that decreased from 40° at baseline to 25° at 6 weeks. They rated the device as very comfortable to wear. CONCLUSIONS: Isoforce maintains constant force transmission and FAA throughout the full range of motion, promotes the lengthening of contracted structures, and is comfortable to wear. LEVEL OF EVIDENCE: Not applicable.

Surface replacement arthroplasty of the proximal interphalangeal joint using the SR PIP implant: long-term results.

PURPOSE: To evaluate the long-term results of proximal interphalangeal (PIP) joint surface replacement arthroplasty for arthritis using the SR PIP implant (Small Bone Innovations, New York, NY). METHODS: This is a long-term retrospective analysis of results in 39 of 43 joints first reported in 2008. Subjective results were based upon a mailed questionnaire. Active range of motion was measured by a certified hand therapist, and x-rays were obtained to analyze changes occurring since the first study. RESULTS: The average follow-up time was 9.3 years. The average active PIP joint arc of motion in the present cohort of patients went from 64° at the first report (2008) to 56° at this time. Radiographic comparisons revealed no major changes since the first study. Ten of 11 revisions were done for pain due to loosening and were performed at an average of 20 months after the primary procedure. No further revisions were necessary in the interim. Overall, subjective measures of satisfaction and symptomatic and functional improvement remained unchanged. CONCLUSIONS: Surface replacement arthroplasty using the SR PIP implant continues to be an option for patients with osteoarthritis of the PIP joint. Long-term subjective and objective outcomes are comparable to those reported using other implants. This and other studies suggest that this procedure is not appropriate for most rheumatoid joints. In the interim between studies, we saw a reduction in the average PIP joint arc of motion, although this change did not reach statistical significance. Our original revision incidence of 26% has not changed. Subjective evaluation and radiologic findings did not change between studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Prosthetic Arthroplasty Versus Arthrodesis for Osteoarthritis and Posttraumatic Arthritis of the Index Finger Proximal Interphalangeal Joint.

PURPOSE: To compare outcomes of prosthetic arthroplasty versus arthrodesis to treat index finger proximal interphalangeal (PIP) joint arthritis. METHODS: Patients with osteoarthritis or posttraumatic arthritis of index finger PIP joints were evaluated. Digit range of motion, grip and pinch strength, patient-rated pain and satisfaction scores, Michigan Hand Questionnaire scores, and complications were recorded. RESULTS: A total of 79 finger PIP joints were followed for a median of 67 months overall (72 months for arthroplasty and 8 months for the arthrodesis group). Sixty-five were treated with arthroplasty and 14 with arthrodesis. Patients undergoing arthroplasty experienced no significant postoperative change in PIP joint range of motion whereas all preoperative PIP joint motion was eliminated after arthrodesis. Patients undergoing arthroplasty experienced significant postoperative improvement in opposition pinch. In contrast, patients undergoing arthrodesis experienced significant improvement in both opposition and apposition pinch. There were no differences in pain relief, satisfaction, or Michigan Hand Questionnaire scores between treatment groups. Patients undergoing arthroplasty had a significantly greater mean number of complications per year and mean number of complications in the first year postoperatively. There was a 4.3 times increased risk of complication in patients undergoing arthroplasty versus arthrodesis, and Kaplan-Meier analysis revealed a shorter time to first complication among patients undergoing arthroplasty. CONCLUSIONS: The decision for prosthetic arthroplasty versus arthrodesis in the index finger of patients with osteoarthritis or posttraumatic arthritis must be made with patient goals in mind and in light of greater risk of complications associated with arthroplasty.

Arthrodesis of proximal inter-phalangeal joint for hammertoe: intramedullary device options.

BACKGROUND: Proximal inter-phalangeal (PIP) joint arthrodesis today represents the standard treatment for structured hammertoes; however, recently, a lot of new intramedullary devices for the fixation of this arthrodesis have been introduced. The purpose of this work is to look at the currently available devices and to perform a review of the present literature. MATERIALS AND METHODS: A literature search of PubMed/Medline and Google Scholar databases, considering works published up until September 2014 and using the keywords: hammertoe, arthrodesis, PIP joint, fusion, intramedullary devices, and K-wire, was performed. The published papers were included in the present study only if they met the following inclusion criteria: English articles, arthrodesis of PIP joints for hammertoes with new generation intramedullary devices, series with n > 10. Studies using absorbable pins or screws that are considered as another kind of fixation that involved more than one articulation, as well as comments, letters to the editor, or newsletters were excluded. RESULTS: Nine publications were included. Of the patients' reports, 93-100 % were good or excellent concerning satisfaction. Radiological arthrodesis was achieved in 60.5-100 % of cases. Three of the publications compared the new devices with the K-wire. Of these three articles, two employed the traditional technique and one the buried technique. The AOFAS score, evaluated in three publications, showed a delta of 19, 45 and 58 points. Major complications, which required a secondary surgical revision, were between 0 and 8.6 %. The complications of the K-wire and the new devices were similar; also the reoperation rate was close to equal (maximal difference 2 %). On the other hand, these kinds of devices definitely have a higher price, compared to the K-wire. CONCLUSION: The use of these new devices provides good results; however, their high price is currently a problem. For this reason, cost-benefit studies seem to be necessary to justify their use as standard treatment.

Biomechanical evaluation of 5 fixation devices for proximal interphalangeal joint arthrodesis.

PURPOSE: To determine in a cadaver model which, among 5 fixation methods for proximal interphalangeal (PIP) joint arthrodesis, has the greatest stiffness. METHODS: Thirty-five cadaver digits were randomly assigned to 1 of 5 fixation groups: oblique K-wire with coronal intraosseous wiring, tension-band wire (TBW), dorsal plate, intramedullary linked screw (IMS), and 90/90 wiring (90/90W). Testing was done by applying bending moments to the PIP joint in the sagittal and frontal planes. The force/displacement curves were used to estimate the stiffness of each construct. Ultimate strength was determined by loading to failure in extension. RESULTS: The IMS had significantly higher stiffness than all wiring constructs in all planes of motion and significantly greater stiffness in extension than the dorsal plate. The IMS stiffness exceeded 10 N/mm across all bending directions and showed an ultimate strength of 21 N. The plate demonstrated higher stiffness in radial bending than the oblique K-wire with coronal intraosseous wiring and TBW. There were no differences in stiffness between the IMS and plate in all modes of testing except extension. Load-to-failure testing of the devices showed the IMS device to be significantly stronger than the TBW, 90/90W, and plating constructs. CONCLUSIONS: The IMS resisted larger bending moments than all wiring constructs and showed the greatest ultimate strength when compared with 3 of the tested arthrodesis techniques. The plate was significantly better than 2 of the wiring constructs, but only in radial bending. No differences were found between the, TBW, and 90/90W when compared with each other. CLINICAL RELEVANCE: The stiffness necessary for a successful PIP joint fusion has not been quantified, but according to this study, the IMS was the most favorable biomechanical construct for initial stability.

Silicone proximal interphalangeal joint arthroplasty for primary osteoarthritis using a volar approach.

PURPOSE: To evaluate the short-term clinical and radiographic outcome of a silicone proximal interphalangeal (PIP) joint implant using a volar approach in patients with primary osteoarthritis. METHODS: We retrospectively reviewed 36 proximal PIP joints that were replaced with Avanta silicone implants in 26 patients. Inclusion criteria were diagnosis of primary osteoarthrtitis of the PIP joint and failure to respond to conservative treatment. Clinical asessment included range of motion, patient satisfaction, and pain scores. The Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire was administered at final follow-up. Radiographs were reviewed for alignment and implant fracture. Complications were also recorded. RESULTS: After an average follow-up of 18 months (range, 12-60 mo), pain relief was markedly reduced in all patients, decreasing from a mean score of 7.2 preoperatively to 0.4 postoperatively. The arc of active motion of the PIP joint improved from 33° to 72°. Satisfaction averaged 4.8 on a 5-point Likert scale, and all patients stated they would repeat the surgery. The median final average Quick-Disabilities of the Arm, Shoulder, and Hand score was 7 (range, 4-12). Radiograph review showed 2 implant fractures at 1 and 2 years after surgery, respectively, but without clinical changes. The average deformity in the coronal plane changed from 12° (range, 8° to 18°) preoperatively to 4° (range, 3° to 8°) postoperatively, whereas the average flexion contracture changed from 18° (range, 10° to 30°) to 0° (all patients achieved full active extension). No other complications were observed. No revision surgery has been needed to date. CONCLUSIONS: The volar approach to PIP joint silicone arthroplasty offers the advantages of maintaining the integrity of the extensor mechanism, providing pain relief, and improving postoperative range of motion with minimal complications. However, further research is needed to determine the long-term efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Early ultrasound therapy for rehabilitation after zone II flexor tendon repair.

BACKGROUND: In our Institute, most of the patients treated for hand injuries were industrial workers with poor compliance. For rehabilitation after zone II flexor tendon repair, we had tried various early mobilization protocols. As these protocols demanded a degree of commitment from the patients, our results were suboptimal. Hence, to improve the results, we implemented a new rehabilitation protocol by administering the pulsed ultrasound therapy during the early phase of tendon healing. MATERIALS AND METHODS: This is a prospective study done over a period of five years from January 2008 to January 2013. A total of 100 patients and 139 digits with zone II flexor tendon injuries were studied. After randomization, we administered pulsed ultrasound therapy of different frequencies and intensities for a total of 72 patients and 99 digits and formulated three groups. The results of ultrasound treated cases were compared with each other and with the results of cases treated by immobilization protocol. The results were analyzed using 'Original Strickland' criteria. RESULTS: 72% excellent-good results in ultrasound (Group 1) protocol, 75% excellent-good results in ultrasound (Group 2) protocol, and 77% excellent-good results in ultrasound (Group 3) protocol were achieved. There was no case of rupture in the first two groups. The rupture rate was 7% in ultrasound (Group 3) protocol. Only 25% excellent-good results were obtained in the immobilization protocol. CONCLUSION: After zone II flexor tendon repair, pulsed ultrasound therapy during the early rehabilitation phase is safe and effective. The results are comparable to early mobilization protocols.

Dorsal Approach for Management of Proximal Interphalangeal Joint Flexion Contracture.

Proximal interphalangeal (PIP) joint contracture is a common, difficult clinical problem that can arise from minor trauma. Management is difficult because outcomes are unpredictable and often poor, due to residual flexion deformities postoperatively. The dorsal approach for flexion contracture of the PIP joint is not discussed in present literature. In this technique guide, we wish to describe and explain the rationale for a dorsal approach. In our experience, a dorsal approach allows for ease of access to all pathologic structures, with simple positioning of the digit to allow access to volar structures, as well as when addressing more than one digits with a PIP contracture. Finally, similar to the midaxial approach, the dorsal approach also eliminates any volar soft tissue concerns and need for supplemental coverage.

Effectiveness of the static progressive Joint Active System splint in improving upper extremity joint stiffness.

PURPOSE: Injuries to the upper extremity often result in stiffness. The joint capsule may lose its elastic properties, limiting motion. Most modalities for increasing motion are based on capsule stretching, and usually involve physical or occupational therapy. We tested the hypothesis that the Joint Active System static-progressive splint is helpful in increasing range of motion in stiff joints after failure of other treatments. METHODS: Candidates for the Joint Active System splint were mostly patients with upper extremity trauma that required surgery, if they plateaued after therapy but still had stiffness. A retrospective review was performed of all patients from 2015 to 2019 that met our inclusion criteria. Etiologies of stiffness and patient demographics were documented. Range of motion was recorded before and after treatment and, when available, functional scores were calculated. RESULTS: Forty-four patients were treated with the Joint Active System splint; 5 were excluded, leaving 39 for analysis: 15 elbow, 14 wrist and 10 proximal interphalangeal joints. All patients had received therapy before using the Joint Active System and 11 had tried a dynamic splint in addition to therapy. All joints showed significant improvement in motion after treatment: from 66.5° to 95.7° in the elbow, 63.5° to 81.1° in the wrist and 33.2° to 51.8° in the proximal interphalangeal joint. When functional scores were available before and after treatment, there was significant improvement for both elbow and wrist. Even when the Joint Active System was started many months after injury, it was effective. CONCLUSIONS: Despite reaching a plateau with therapy, the Joint Active System static-progressive splint is effective in improving range of motion in elbow, wrist and finger joints with stiffness following injury or surgery. TYPE OF STUDY: Retrospective case series. LEVEL OF EVIDENCE: Therapeutic, level IV.

Double Stiletto Flap for Soft Tissue Cover as a Firebreak Following Contracture Release of Digits and Full-Thickness Grafting: A Surgical Technique.

Contracture release followed by full-thickness skin grafting is often performed while releasing severe contracture of the digits. We report a technique for flexion contracture of the finger, by using two triangular flaps from either side of the digit as a firebreak over the proximal interphalangeal (PIP) joint while using a skin graft following contracture release. We reviewed the medical records of patients who underwent contracture release at our institution from January 2018 to July 2021, and this technique was used for the release of flexion contracture of the five digits belonging to four patients. Our technique used triangular flaps from either side of the digit, which were rotated and brought over the PIP region, and hence, a single sheet of graft spanning the PIP joint is avoided. We believe that this acts as a firebreak and thus reduces the recurrence of contracture at the PIP joint.

Neglected Dorsal Proximal Interphalangeal Joint Dislocation Treated by Volar Plate Arthroplasty: A Case Series.

Chronic unreduced dislocations of the proximal interphalangeal joint are uncommon, and management principles for these injuries have not been defined. The dislocation can be volar or dorsal and closed reduction is rarely successful owing to soft tissue contractures. Treatment options in literature reviews for such rare injuries included open reduction of pip joint with volar plate arthroplasty, extension block pinning, hemi hamate arthroplasty, pip joint arthrodesis, Suzuki dynamic frame fixation, open reduction and repair of capsule and collateral ligaments with suture anchors. Few cases of amputation following treatment were even reported in literature emphasizing the role of meticulous soft tissue handling in such neglected cases of hand. We report six cases of neglected (more than three months old) dorsal dislocation of the PIP joint of the hand, treated with volar plate arthroplasty and extension block pinning. A functional range of motion with a stable joint can be achieved in such injuries with volar plate arthroplasty, as long as the articular cartilage is relatively preserved and bone loss is <30%.