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Technique: Interphalangeal joint fusion of thumb

    Overview

    Learn the Interphalangeal joint fusion of thumb surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Interphalangeal joint fusion of thumb surgical procedure.
    Arthrodesis of the interphalangeal joint of the thumb is a widely performed procedure in hand surgery.
    The most common indication is degenerative arthritis and occasionally post traumatic or inflammatory arthritides.
    A variety of other indications exist. These include severe articular disruption from trauma, irreparable tendon injury, loss of function from neurological conditions and reconstruction following tumour resection.
    A range of techniques have been described to fuse the interphalangeal joint of the thumb. These include dorsally placed low profile plates and intramedullary compression screws. Each technique has its unique advantages. Fusion rates overall are reported at 80-100%. Tension band wiring is a tried and tested, cost effective method that that remains in wide use today. The principle of tension band wiring is to convert a distracting force into a compressive one.
    Most fusions of the thumb interphalangeal joint are set at between 0-30 degrees. It is important to come to an agreement with the patient after consideration of their occupation and desired function. In this example case, the patients unique functional needs demanded that his joint be fused in a degree of flexion that would be difficult to achieve with an intramedullary device.



    Indications

    INDICATIONS:
    As mentioned above the indications include osteoarthritis, inflammatory arthritis or as in this scenario, post traumatic arthritis.
    Other indications include loss of active control of thumb IPJ position due to either a non-reconstructable tendon deficiency or neurological lesion. Trauma resulting in a non reconstructable injury to the joint may also merit arthrodesis.
    SYMPTOMS & ASSESSMENT:
    The most common complaint in degenerative arthritic conditions is pain. This initially manifests as pain upon loading the joint but in advanced disease may result in rest pain. There may be associated joint deformity and swelling. Mucous cysts are common.
    When assessing the patient a thorough history is mandatory. One must place particular emphasis on current functional limitations and expectations from surgery. Current pain levels are important to ascertain. Rest pain and night pain are both markers of severe disease.
    Response to previous treatment such as a joint injection gives some guidance as to whether operative treatment may be required or whether further non-operative measures may be feasible.
    Upon examination, the presence of tenderness, the current range of motion of the joint, any accompanying stiffness and the pattern of pain are important.
    The metocarpophalangeal joint and trapeziometacarpal joint should also be examined.

    INVESTIGATION:
    Plain anterior-posterior and lateral radiographs, centred upon the joint, are required. If the skeletal architecture is relatively well preserved and inflammatory synovitis is though to predominate, an ultrasound scan or MR scan may be useful.
    Imaging the the metacarpophalangeal joint and trapeziometacarpal joint is important to rule out more proximal joint disease that may be contributing to pain.
    OPERATIVE ALTERNATIVES:
    It is important to discuss functional demands as these will likely influence the chosen position of arthrodesis.
    0-30 degrees of fusion is the commonly accepted range. The recent study by McGowan et al. suggested that pinch grip is better at 15-30 degrees and tasks requiring precision grip are better at 15 degrees.In this patient deep thumb flexion was required to operate specific tool that required meeting the tip of the index finger and thumb. He requested 30-45 degrees of flexion. This necessitated a tension band wire or plating technique.
    A commonly used intramedulary compression screw is effective where the thumb is fused in extension.
    Other surgical techniques described include synovectomy which can be performed arthroscopically.
    Replacement arthroplasty is also described but there are few long term studies looking at outcomes.

    NON-OPERATIVE ALTERNATIVES:
    Splinting to rest the joint and relieve pain is often suitable in early disease. Steroid injections into the joint are usually performed under image guidance and may have a diagnostic value as well as offering prolonged pain relief in early disease.
    CONTRAINDICATIONS:
    Apart from general patient factors that may contraindicate surgery, the presence of infection in or around the joint are contraindications.

    Setup

    This procedure was performed under regional anaesthesia but general anaesthetic may be used. The patient is positioned supine with the hand on an arm table. An upper arm tourniquet is inflated. Intra-operative fluoroscopy is required to check wire placement. Antibiotic prophylaxis should be considered according to local protocol.

    Operation – 1

    This lateral radiograph demonstrates the arthritic change within the IPJ. There is gross disruption of joint architecture with a prominent dorsal osteophyte.
    This was a post-traumatic arthritis that presented with intractable pain 5 years after a significant injury to this joint.

    Positioning the thumb on a rolled up huck towel helps support in its semi prone position. A lead hand can provide further support to the hand.
    Various incisions are described for approaching the IPJ dorsally.
    The Y configuration shown here allows large flaps to be elevated permitting near circumferential access to the joint.

    The skin is incised.
    Large dorsal veins must be carefully ligated or cauterised.

    Full thickness skin flaps are elevated along the marked incision lines.
    The terminal extensor tendon fibres are seen crossing the joint line and the dissection plane is above its paratenon.
    Once elevated the flaps are held in position using 4/0 nylon sutures.
    The extensor tendon and capsule are split as a single layer in the midline and elevated over the joint surface.
    These tissues are degenerate where they are seated over a prominent dorsal osteophyte.

    The joint is entered. The dorsal osteophyte can give a misleading indication of the joint line, which as shown here (and on the x-ray previously) is rather more distal than where this size 15 blade is making its entry.

    Dissection into the joint continues and the radial and ulnar collateral ligaments are identified.

    The collateral ligaments are elevated sharply from their insertion into the head of the proximal phalanx.
    Release of the volar tissues may be required to completely mobilise the joint, including its volar surfaces..
    The volar neck of the proximal phalanx can be see here allowing one to access the cartilage on the volar aspect of the phalangeal head.

    A fine nibbler is now used to remove the dorsal osteophyte to improve access to the distal phalangeal joint surface.

    Now the distal phalangeal cartilage can be removed with the nibbler.
    Often a layer of hard subchondral bone remains underneath this layer. The nibbler should be used to gently remove a layer of this bone exposing some soft bleeding bone. This can be done without altering the overall contour of the joint surface.
    For this small joint surface a nibbler is effective, although a bone burr or saw is advocated by some surgeons.

    Attention is next turned to the head of the proximal phalanx.
    As previously described the nibbler is used to remove the cartilage and a layer of subchondral bone leaving bleeding bone exposed.
    The overall joint surface shape is maintained and therefore the final position of fusion can be set freely. This is because the contours of the two bone ends continue to mirror each other and can be fixed in any desired position of flexion.

    The two bone surfaces are now placed together and the desired final position of the arthrodesis is set. Good contact between the two surfaces has been achieved by ensuring the shape of the bone ends has not been altered in the previous stages. This contact is maintained throughout the range.

    Irrigation with normal saline washes out any loose bone or cartilage debris.

    A 1mm K-wire is used to place a tunnel through the distal phalanx.
    The position of this tunnel should be 8-9mm distal to the joint surface and just dorsal to the mid-axial point and should run parallel to the joint line.

    The K-wire is removed and a 0.8mm circlage wire is passed through the tunnel.

    Next two 1.1mm parallel K-wires are passed from the dorsal cortex across the fusion site.
    An alternative technique here is to use double ended wires and initially pass them retrograde from the joint surface out through the dorsal cortex before then advancing them across the fusion site into the distal phalanx.

    Once these initial passes are made an image may be taken to check the position of implants and the fusion angle.

    The lateral view here demonstrates that the desired fusion position of 30 degrees in this particular case has been achieved. Furthermore the wires are parallel and are just engaging with the volar cortex of the distal phalanx.
    The K-wires can be backed out a few mm to provide some room for them to be pushed back in at the end of the procedure after wire bending, thus leaving the dorsal wire ends closer to the bone surface.

    There is good bone contact across the fusion site on both antero-posterior and lateral views.

    The K-wires are now bent dorsally taking care to avoid any inadvertent movement within the bone.

    The wires are now trimmed short.

    The two ends of the circlage wire are now crossed taking care to ensure the cross is placed centrally across the fusion site. The ends are brought around the cut ends of the K-wires.
    A few loose twists are placed in the two ends to hold them in position.

    Further turns are then applied to this twisted end.
    To ensure that the tension added is distributed through the entire length of the circlage wire, rather than just at the twisted end, a turn is only performed after grasping the very bottom of the twisted end closest to the bone on each occasion.
    Applying twists proximal to this point merely concentrates tension within the already twisted portion of wire and results in wire breakage before an adequate amount of tension has been applied.
    There is a careful judgement to be exercised here. It is all to easy to apply too much tension and break the wire. If this occurs a new circlage may be passed.

    The K-wires are now turned 180 degrees to allow the cut end to sit next to the bone. The twisted end of the circlage is also bent to seat it close to the bone. Both steps aim to minimise soft tissue irritation.

    Final check images are recorded.
    Good bone contact across the entire construct should be evident.
    The K-wires appear prominent proximally and require further impaction into the bone to allow the proximal ends to sit closer to the bone.

    The final position of wires is checked and any prominent wire ends can be further adjusted if necessary.

    Operation – 2

    The wound is irrigated with normal saline.
    The periosteum, capsule and tendon layers are approximated over the metalwork.

    The skin here has been closed with interrupted 5/0 nylon sutures.
    The final position of the fusion is satisfactory.

    The wound is dressed with a non adherent dressing followed by a layer of gauze, wool and a protective plaster of Paris slab.
    The patient will require a Bradford sling to elevate the limb.

    Post Operative

    The patient is discharged home the same day if comfortable. With regional analgesia, careful attention is needed to ensure the patient has adequate analgesia and is warned to start taking this before the return of pain sensation. The regime used was paracetamol and codeine.
    The patient returns to clinic in one week for a wound check and completion of cast.
    Sutures are removed at 10-14 days.
    The thumb is kept immobilised in a cast for 5-6 weeks. At that point a further clinic visit with a check x-ray should demonstrate fusion across the interphalangeal joint.
    The patient can then mobilise freely and may require input from a hand therapist to overcome any stiffness in neighbouring joints.

    Recommended Reading

    Thumb Arthrodesis. Rizzo M. Tech Hand Up Extrem Surg. 2006 Mar;10(1):43-6.
    A general overview of techniques for thumb joint arthrodesis. Indications and a literature review.
    Dorsal Plate Fixation for Distal Interphalangeal Joint Arthrodesis of the Fingers and Thumb.
    Patel A, Damodar D, Dodds SD. J Hand Surg Am. 2018 Nov;43(11):1046.e1-1046.e6. doi: 10.1016/j.jhsa.2018.03.049. Epub 2018 May 24.
    Most surgeons use devices that are intramedullary and necessitate fusing the joint in full extension.
    This paper describes using a dorsal plate to achieve fusion in a degree of joint flexion.
    Acute Arthrodesis of Interphalangeal Joints of the Hand in Traumatic Injuries.
    Tan M, Ho SWL, Sechachalam S. J Hand Microsurg. 2018 Apr;10(1):1-5. doi: 10.1055/s-0037-1608691. Epub 2017 Nov 29.
    Primary fusion of the distal interphalangeal joint after severe trauma results in good return to pre-injury function and early return to work. A variety of techniques were used in this series of 11 patients.
    Functional Fusion Angle for Thumb Interphalangeal Joint Arthrodesis.
    McGowan S, Deisher M, Matullo KS. Hand (N Y). 2016 Mar;11(1):59-64. doi: 10.1177/1558944715614858. Epub 2016 Jan 14.
    This study involved splinting the IPJs of healthy volunteers to simulate various positions of fusion and discovered that a degree of flexion of 15-30 degrees was preferred for most functional tasks.

    Reference

    • orthoracle.com

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