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    Outcomes of PIP Joint Arthroplasty

    With advances in implant design and materials, more patients can now undergo proximal interphalangeal arthroplasty for arthritis. But more primary procedures means more revisions.

    Author

    Anthony Sapienza, MD

    Article

    ER, Luo TD, Houdek MTm Kor DJ, Moran SL, Rizzo M. Revision proximal interphalangeal arthroplasty: an outcome analysis of 75 consecutive cases.J Hand Surg Am. 2015; 40(10):1949-1955.

    Summary

    The authors report on the outcomes and complications associated with revision proximalinterphalangeal (PIP) joint arthroplasty. Patient evaluation was performed by uniformly examining the electronic medical records and total joints registry to collect:

    • Patient’s demographic
    • Comorbidities
    • Operative indications
    • Postoperative outcomes
    • Complications
    • Joint survival

    They analyzed outcomes of 49 patients who underwent 75 consecutive revision PIP joint arthroplasties over a 14-year period from 1998 to 2012, at a mean follow-up of 5.1 years (range, 1-10 years). Revision arthroplasty was defined as removal of a prior arthroplasty (any implant type) and placement of a new total joint arthroplasty.

    During the index arthroplasty, 42 implants were pyrocarbon, 19 were silicone, and 14 were metal-on-polyethylene (cobalt-chromium for proximal implant, metal-backed ultra-high-molecular-weight polyethylene for the distal implant). Most implants used in the revision surgeries were of an unconstrained design (n = 63; 84%), including pyrocarbon (n = 34) and metal-on-polyethylene (n = 29). The remaining implants were constrained silicone implants.

    Nineteen (25%) fingers in 16 patients required additional surgery. The primaryindication for a second revision surgery was dislocation (n = 7), followed by pain with limited motion (n = 4), component loosening or fracture (n = 5), and infection (n = 4), including 1 patient with both recurrent dislocations and a history of sepsis.

    The second revision surgery included revision to another arthroplasty (n = 9), arthrodesis (n = 7), and amputation (n = 3). Two amputations were performed in patients with prior septic joints with dorsal skin necrosis, and the other was performed in a patient with major bone loss secondary to recurrent dislocations.

    A greater percentage of pyrocarbon implants (n = 13; 38%) required a second revision surgery compared with metal-on-polyethylene (n = 5) and silicone (n = 1). At a mean of 5.3 years follow-up (range, 2-10 years) from the revision procedure, 98% of patients had good pain relief but decreased PIP joint total arc of motion.

    The 2-, 5-, and 10-year survival rates for the pyrocarbon implants were 66% ± 8%, 59% ± 9%, and 59% ± 9%, respectively, compared with 93% ± 5%, 78% ± 9%, and 78% ± 9% for metal-on-polyethylene implants and 88% ± 12% for all 3 survival time points for silicone implants.

    Clinical Relevance

    Small joint arthroplasty has been around for decades. With the advances in implant design and materials, primary PIP joint arthroplasty has been more commonly used as a treatment for arthritis. This has resulted in an increased prevalence of revision arthroplasty.

    There are multiple challenges with PIP joint arthroplasty in the revision setting, including bone and soft tissue deficiency and fibrous scar tissue formation. Although silicone arthroplasty is a constrained implant design, it is considered to be the reference standard for PIP joint arthroplasty. Swanson et al [1] demonstrated an 11% overall revision rate among 424 silicone PIP joint arthroplasties.

    Newer engineering designs have attempted to duplicate the native PIP joint morphology, with surface replacement arthroplasties using either metal on polyethylene or pyrocarbon surface materials.

    Most studies have found that pyrocarbon PIP joint arthroplasty provides patients with excellent pain relief overall and allow them to maintain their preoperative PIP joint motion; however, overall implant survival has been variable. In a meta-analysis by Chan et al [2] that included 718 PIP joint arthroplasties, the incidence of complications was 30% for pyrocarbon implants and 8% for silicone implants.

    Improved outcomes for the silicone prosthesis compared with metal-plastic and pyrolytic carbon in the revision setting may be due to its constrained design, which provides some inherent stability to compensate for the absence joint’s soft tissue stabilizers.

    The current article shows that revision PIP joint arthroplasty was associated with a 70% 5-year survival, but with a high incidence of complications. Instability was associated with worse outcomes. Pyrocarbon implants had a higher rate of implant failure and postoperative complications when compared with silicone and metal-polyethylene implants.

    Author Information

    Anthony Sapienza, MD, is an Assistant Professor of Orthopaedic Surgery, Division of Hand Surgery, Department of Orthopaedic Surgery, NYU Langone Medical Center – Hospital for Joint Diseases, and Co-Chief of Hand Surgery at Bellevue Hospital, New York, New York.

    References

    1. Swanson AB, Maupin BK, Gajjar NV, Swanson GD. Flexible implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg Am. 1985;10(6 Pt 1):796-805.
    2. Chan K, Ayeni O, McKnight L, Ignacy TA, Farrokhyar F, Thoma A. Pyrocarbon versus silicone proximal interphalangeal joint arthroplasty: a systematic review. Plast Reconstr Surg. 2013;131(1): 114-124.