近端指间关节关节炎资料 In-depth

您的感受

疼痛位于手指的中节关节，即手指弯曲的关节。疼痛往往在手部使用后加重，且晨起时关节可能僵硬。关节周围肿胀较为常见，且可能持续较长时间。许多人会注意到关节僵硬，弯曲不如以往顺畅。

需要手指弯曲的日常任务变得困难。扣纽扣、握水壶、拧钥匙或握笔都可能引起不适。部分患者的关节会形成弯曲畸形，且无法完全伸直。如果手指既往曾脱位或受伤且未接受治疗，关节可能错位并持续处于该状态。

需要了解的一点是，X 光片上显示的关节炎程度与疼痛程度并不一致。部分患者 X 光片显示严重的磨损性关节炎但症状较少，而部分患者 X 光片改变轻微却症状严重。这种关节炎的早期阶段涉及关节内的炎症，许多人在炎症消退后实际上会感觉好转，即使在后期阶段也是如此。

如果您同时患有扳机指或卡压指，腱鞘手术后关节疼痛可能无法完全缓解。该手术后，此关节处的轻微压痛可能持续长达 3 个月。

实际发生了什么

您手指的中节关节是一个简单的铰链结构。它只能向一个方向弯曲和伸直，就像门上的铰链一样。在那里相遇的手指骨末端形状相互契合，这使得手指伸直时关节保持稳定。当手指弯曲时，关节周围的软组织带接管并固定所有结构。

覆盖在这些骨末端上的是光滑、滑溜的软骨层。可以将其视为关节的减震器和密封垫的结合体。在磨损性骨关节炎中，该层变薄并分解。关节边缘形成新骨，周围的衬里增厚。关节随后失去其光滑的滑动表面，这就是为什么弯曲时感觉粗糙、僵硬和疼痛。

关节周围的软组织带也可能收紧和缩短。关节内肿胀，随后长时间保持静止，会引发一个循环，导致组织粘连并失去弹性。这就是为什么弯曲的手指可能变成固定的挛缩，即使借助另一只手也无法伸直。

有些人会发展出一种称为钮孔状畸形的特定模式。伸直中节关节的肌腱变弱并滑脱，因此中节关节向下弯曲，而手指末端关节向后过度弯曲。早期，您仍然可以被动地伸直手指，功能基本不受影响。随着进展，弯曲位置变得固定。

如果您的关节过去受过伤，例如从未治疗的脱位，相同的软组织带可能在缩短的位置愈合。如果关节错位持续4周或更长时间，通常无法简单地将其推回原位，因为组织已围绕新位置收紧。

这也是为什么中节关节不容忍错误。它在受伤或手术后容易出现持久的僵硬和畸形，保持其活动是一个真正的挑战。

我们如何处理该问题

Mater Private Hospital Rockhampton 的上肢外科医生 Kieran Hirpara 医生会从适合您病情的微创方案入手。患者通常由全科医生（GP）转诊至我们的诊所；如果理疗师建议您就诊，您仍需获得全科医生的转诊才能符合 Medicare 报销资格。在您的首次就诊时，我们会采集病史，检查您的手指，并在必要时安排影像学检查，如 X 光。由于这是一种长期存在的磨损性问题，我们通常首先尝试非手术治疗，只有当非手术治疗未能带来足够改善时，才会考虑手术。

第一步通常是可以自行做出的简单改变。改变握持和使用手部的方式可以缓解急性发作，保持关节轻柔活动有助于防止其进一步僵硬。物理治疗或手部治疗旨在保持关节的屈曲和伸直，保护关节周围的肌腱结构，并减缓导致关节固定于屈曲位的肿胀和缩短循环。我们通常会给这种方法至少 3 个月的充分尝试，然后再考虑其他方案。

按照全科医生的建议服用止痛药和抗炎药，可以帮助您在急性发作期间继续使用手部。夹板固定也可以帮助手指在关节稳定期间保持更好的位置。我们不针对该关节使用注射治疗，因此当简单措施未能提供足够帮助时，我们会转向手术治疗。

当疼痛导致您无法使用手指，且经过 3 个月或更长时间的非手术治疗无效，同时 X 光显示存在磨损性骨关节炎时，就会考虑手术。主要有两个方向。一是关节置换术（arthroplasty），即用植入物替换磨损的关节面，以缓解疼痛同时保留一定的屈曲功能。二是关节融合术（arthrodesis），即将关节永久固定于舒适、略微弯曲的位置，使其不再疼痛，这以牺牲屈曲功能为代价，换取一个稳定、无痛的手指。哪种方案适合您取决于涉及哪根手指、关节及其肌腱的稳定性如何，以及您希望保留多少屈曲功能。例如，融合术可能适合手部的一侧，而置换术可能适合另一侧，且置换术需要肌腱完整以及至少保留一定的关节稳定性才能发挥作用。我们会与您详细讨论这两种方案，并共同做出决定。

预期情况

这种关节炎病程较长。它通常不会自行消失，僵硬感往往在数月乃至数年内缓慢加重，而非在数天内发生。部分患者在早期发作平息后会感觉好转，但关节本身的磨损依然存在。

如果关节受伤后未得到治疗，无所作为会带来实际后果。疼痛可能转为慢性，手指可能变得僵硬或形成固定的弯曲形态，关节也可能过早磨损。早期发现这些损伤并进行适当治疗，是预防许多此类问题的关键。

在管理良好的护理下，预后更为稳定。保持关节轻柔活动并在发作期加以保护，有助于减缓前文所述的肿胀和缩短循环。手部治疗可以改善手指的伸直程度，尽管手指更直并不一定意味着您在日常任务中感觉更有用。

如果您决定进行关节置换，了解现实情况会有所帮助。疼痛缓解通常是效果良好的部分，许多人能保留手指有用的屈曲功能。您获得的屈曲度通常是术前屈曲度的两倍以上。但此手指的置换关节往往会随时间推移而僵硬，因此活动范围可能随岁月流逝而减退。约五分之一的碳素（pyrocarbon）植入物使用者在5年内需要对该关节进行再次手术，约三分之一的人需要不止一次手术。其他植入物设计有其各自的记录：一种较新的表面置换植入物在2年时仍有85%的手指保持原位，硅胶植入物在10年时仍有90%的手指保持原位。手术中发生骨折的情况约占5%，但通常不会改变最终结果。此类手术后的感染并不常见。

如果置换失败，仍有其他选择。可以进行关节融合，如前所述，这能提供稳定且无痛的手指。在罕见情况下，切除手指部分是最后的手段。

何时就医

如果您的手指中间关节在休息、夹板固定或手部治疗的情况下，疼痛持续 3 个月或更长时间，且疼痛已影响手指的使用，请咨询您的全科医生。如果关节变得僵硬，或出现影响您日常活动的弯曲畸形，尤其是如果该关节仍可被动伸直，请要求专家会诊。如果您的手指曾脱位或受伤，且错位状态持续 4 周或更长时间，需要接受评估而非继续等待，因为关节可能会在该位置固定。如果您患有扳机指或卡压指，且中间关节也有压痛，请在进行任何肌腱松解手术前告知医生，因为该压痛在术后可能持续长达 3 个月。

深入探讨

Advanced reading: the deeper science (optional)

本节内容超出了您做出自身治疗决策所需的范围。手指中间关节的关节炎值得额外阅读，因为融合术与置换术的选择取决于大多数人不会想到去询问的因素——即关节是否稳定——而且具体是哪根手指与X线片显示的内容同样重要。

决定手术方式的是稳定性，而非严重程度

有两种手术可供选择。关节融合术将关节永久固定于选定位置，可靠地消除疼痛，但代价是丧失所有活动度。关节置换术则保留活动度。

基于 1,868 例患者的对比研究界定了每种手术的适用时机。对于稳定性良好的关节，硅胶假体仍是一个有价值的选择；而对于不稳定或存在偏斜的关节，表面置换假体可能更为适宜，尽管其再手术风险更高 [1]。

其中的关键变量是稳定性。硅胶假体是一种柔性间隔物，而非铰链；它通过置于骨端之间并允许骨端围绕其活动来发挥作用，这需要周围韧带提供稳定性。当这些韧带失效且关节向侧方偏斜时，间隔物缺乏可依托的结构，因此需转向表面置换设计，而这也伴随着因假体约束性更强而导致的较高再手术率。

手指位置不同，建议也不同

这一点很少被解释清楚。食指在捏握时承受较大的侧向力，该力作用于拇指，而这种力恰恰是人工关节置换术所能耐受程度最低的。无名指和小指主要用于抓握，此时负荷沿手指纵向分布，而非横向分布。

实际影响在于，关节置换通常更适合尺侧手指（无名指和小指），而在食指处，往往更倾向于选择关节融合术，因为一个稳定的支撑点用于捏握比活动度更有价值。因此，在X光片上外观相同的两个关节，仅因其在手部的不同位置，就可能获得不同的治疗建议。

融合是可靠的，且技术的重要性低于预期

在选择融合术时，关于技术的争论相对较小。在 1,923 例患者中，所有描述的技术均能实现融合骨关节炎关节的目标，且近期文献趋势倾向于加压技术 [2]。在 286 例患者中直接比较不同技术，其融合时间、不愈合率及并发症率相似，其中螺钉关节融合术的不愈合率低于钢丝融合术，尽管这些数据存在显著局限性 [3]。

关节因创伤而非磨损而破坏的情况

穿过中间骨骼基部的骨折会直接破坏关节面。当受累面积超过关节面的一半时，一种选择是使用取自腕部钩骨的移植物进行重建，因为钩骨的轮廓与丢失的关节面相似。

半钩骨自体骨移植可被认为对急性及慢性骨折脱位且关节受累超过50%的情况是可靠的，但需要更长期的随访，特别是为了确定后期关节炎的发生率 [4]。另一项针对235例患者的独立综述发现，该手术能带来症状缓解和功能恢复 [5]。

关于后期关节炎的未决问题是诚实的警示：移植物恢复了关节的形状，但重建的表面是否以与原生表面相同的速率磨损，目前尚无定论。

参考文献

[1] Forster N, Schindele S, Audigé L, Marks M. 近端指间关节置换术后的并发症、再手术及翻修：系统综述. J Hand Surg Eur Vol. 2018;43(10):1066-75. https://doi.org/10.1177/1753193418770606

[2] Millrose M, Gesslein M, Ittermann T, Kim S, Vonderlind H, Ruettermann M. 手指近端指间关节融合术，系统综述. EFORT Open Rev. 2022;7(1):49-58. https://doi.org/10.1530/EOR-21-0102

[3] Faulkner H, An V, Lawson RD, Graham DJ, Sivakumar BS. 近端指间关节融合技术：系统综述. Hand (N Y). 2021;18(1):74-9. https://doi.org/10.1177/1558944721998019

[4] Frueh FS, Calcagni M, Lindenblatt N. 半月骨自体骨移植关节成形术在近端指间关节重建中的应用：系统综述. J Hand Surg Eur Vol. 2014;40(1):24-32. https://doi.org/10.1177/1753193414554356

[5] Faulkner H, Graham DJ, Hile M, Lawson RD, Sivakumar BS. 半月骨关节成形术治疗中节指骨基底骨折：系统综述. Hand (N Y). 2021;18(2):300-6. https://doi.org/10.1177/15589447211014623

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

Clinical outcomes for PIP joint replacements with pyrolytic carbon implants are variable despite substantially good survivorship [1].
Primary PIP arthroplasty utilization for patients with osteoarthritis has increased, while revision PIP arthroplasty has decreased [2].
Reoperations following primary nonconstrained PIP joint arthroplasties are common [3, 16].
Extensor mechanism dysfunction is the most frequent cause of reoperations following primary nonconstrained PIP joint arthroplasties [3].
Surgery performed better than collagenase at early and 2-year follow-up in PIP joints affected by Dupuytren disease [4].
PIP joint arthrodesis has very few contraindications [5].
PIP joint arthrodesis has an excellent overall success rate [5].
The survival of pyrocarbon PIP joint arthroplasty was 85% at 5 years of follow-up [12].
Pyrocarbon PIP joint arthroplasty is associated with high patient satisfaction [12].
PIP joint denervation provides durable, effective pain relief despite osteoarthritis progression [13].
PIP joint denervation is associated with high patient satisfaction [13].
Ultimate salvage for a failed PIP joint arthroplasty may require arthrodesis or amputation [14].
Treatment of the long finger may be a relative contraindication to PIP joint arthroplasty [18].
Pyrocarbon PIP joint replacement provides excellent pain relief [24].
Pyrocarbon PIP joint replacement increases the arc of motion by more than double the preoperative range [24].

Anatomy & Pathophysiology

Bony Anatomy and Biomechanics

The proximal interphalangeal (PIP) joint is a simple hinge joint that allows for motion in the flexion-extension axis only [55].
In full extension, PIP joint stability is maintained by the highly congruent bony architecture [55].
In flexion, the PIP joint is stabilized by capsuloligamentous structures that envelope the joint [55].
The PIP joint has unique anatomy that predisposes it to stiffness [55].
Proper biomechanics of a joint must be restored to achieve full, functional range of motion [52].
The PIP joint anatomy remains a subject of ongoing investigation, with evolving understanding of its biomechanical properties continuing to improve treatment and reconstructive designs [53].
The complex anatomy and biomechanics of the PIP joint make classification and management of injuries difficult [36].
An understanding of the anatomy and biomechanics of the PIP joint forms the basis of analyzing patterns, mechanisms, and subsequent management of these injuries [36].

Soft Tissue Anatomy

The capsuloligamentous structures of the PIP joint include the dorsal capsule, volar plate, and collateral ligaments [55].
Unlike the metacarpophalangeal joint, the PIP joint's collateral ligaments are essentially isometric throughout the arc of motion [55].
The dorsal interossei are abductors and lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [43].
The volar interossei are adductors and lie to the ulnar side of the index finger and the radial side of the ring and little fingers [43].
The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [43].
The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint [43].
The deep head of the dorsal interosseous muscles flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [43].
Transverse fibers arch dorsally from each lateral band to join each other over the dorsum of the finger, flexing the proximal phalanx [43].
Oblique fibers (spiral fibers) from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx [43].
The oblique fibers extend the middle phalanx at the PIP joint [43].
The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [43].
The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon [43].
The terminal tendon inserts at the base of the distal phalanx to extend it [43].
The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [43].
The volar interossei send oblique or spiral fibers that insert onto the base of the middle phalanx at its lateral tubercle [43].
The flexor digiti quinti brevis forms the ulnar lateral band of the little finger [43].
The dorsal covering of the interphalangeal articulations of the digits forms a unique cutaneous unit characterized by a considerable excess of skin when the digits are in extension [42].
The fine tight skin of the dorsal aspect of the middle phalanx forms another cutaneous unit [42].
The dorsal integument of the distal phalanx is very special because of the nail bed with its matrix [42].
The integument of the palmar face of the digits may be subdivided into phalangeal units separated by digital flexion folds [42].
When a digit is completely flexed, the integument of adjacent phalanges comes into contact in the zones of the flexion creases, establishing areas of cutaneous contact in the form of a diamond [42].
The sides of the diamond-shaped cutaneous contact zones do not undergo variations in length during the movements of flexion and extension [42].
Incisions made along the level of the diamond-shaped cutaneous contact zones present a minimal chance of retraction [42].

Pathophysiology and Injury Mechanisms

The PIP joint of the finger is prone to injury and residual deformity [36].
Inappropriate management of PIP joint injuries may result in chronic pain, stiffness, deformity, or premature degenerative arthritis [36].
A review of 96 injuries about the PIP joint found a 30% poor recovery rate, characterized by joint instability, poor function, pain, or flexion deformities [36].
Suboptimal treatment of intra-articular fractures typically leads to functional impairment of the hand [29].
Maintaining motion and function following trauma and/or surgery of the PIP joint remains very challenging [6].
The pathogenesis of the PIP joint contracture is attributed to a cycle of edema, immobilization, and tissue adherence of the capsuloligamentous structures [55].
PIP joint stiffness may be the result of both traumatic and atraumatic conditions, such as Dupuytren disease, infection, and neurological injury [55].
Dorsal dislocations represent almost all PIP joint dislocations [81].
The mechanism for dorsal PIP dislocations involves forced hyperextension, axial load, and radial or ulnar deviation [81].
Dorsal PIP dislocations are characterized by volar plate rupture at its distal attachment [81].
Dorsal PIP dislocations involve a split between the accessory collateral ligament and proper collateral ligament with detachment of the proper collateral ligament from its proximal attachment [81].
In dorsal PIP dislocations, the volar plate is maintained beneath the condyle, held by intact attachment to the accessory collateral ligament [81].
When a torsional mechanism is involved in dorsal PIP dislocations, soft tissue interposition can block reduction [81].
Lateral PIP dislocations are less common than dorsal dislocations [81].
The mechanism for lateral PIP dislocations involves direct radial or ulnar stress on the PIP joint with axial load [81].
In lateral PIP dislocations, the collateral ligament on the side of the force fails under tension, avulsing from its proximal attachment [81].
Continued force in lateral PIP dislocations causes disruption of the volar plate on the side of the force [81].
Volar PIP dislocations are the least common type of PIP dislocation [81].
Volar PIP dislocations require force in two vectors: ulnar or radial deviation causing rupture of the collateral ligament and volar plate [81].
In uncomplicated volar PIP dislocations, the central slip of the extensor mechanism ruptures or avulses from the dorsal lip of the middle phalanx [80].
The intact lateral bands initially can perform joint extension even though the central slip is ruptured in volar PIP dislocations [80].
Failure to immobilize the joint in extension to allow central slip healing can eventually lead to stretching of the triangular ligament holding the lateral bands [80].
Stretching of the triangular ligament results in volar subluxation of the lateral bands [80].
Subluxated lateral bands can no longer extend the PIP joint [80].
The tightening of the terminal extensor slip leads to hyperextension of the distal interphalangeal joint, resulting in the classic boutonniere deformity [80].
Complex volar dislocations involve rotary displacement with a collateral ligament tear secondary to lateral stress combined with an anteriorly directed force [80].
In complicated volar dislocations, the central slip, lateral band, or torn collateral ligament may be interposed within the joint, necessitating open reduction [80].
A laterally directed force to the PIP joint results in avulsion of the collateral ligament from its proximal attachment on the side of the applied force [80].
With continued force in lateral dislocations, the volar plate eventually tears on the side of injury, resulting in lateral dislocation [80].
A dorsal PIP fracture-dislocation with a fracture fragment consisting of more than 40% of the middle phalanx base creates an extremely unstable configuration due to loss of bony congruity and disruption of all ligamentous stabilizers [80].

Classification

The diagnosis of PIP joint osteoarthritis is based mainly on the clinical picture and confirmed by radiographs [23].
Radiographs and symptoms do not correlate in PIP joint osteoarthritis, which is why classifications and staging based on radiographs are rarely used [23].
Radiographic evaluation of bone quality, specifically defects and cyst formation, plays a crucial role in the indication of possible surgical treatment options for PIP joint arthritis [23].
The presence of stiffness and deformity plays a crucial role in the indication of possible surgical treatment options for PIP joint arthritis [23].
Patients were considered for PIP joint arthroplasty if they had radiological signs of PIP joint osteoarthritis (Kellgren-Lawrence classification ≥grade 2) in combination with pain, despite nonsurgical treatment for at least 3 months [10].
Stiffness and deformity could be indications for PIP joint arthroplasty surgery [10].
A classification of injuries about the PIP joint is suggested to provide a practical guide to management [36].
The SCARF classification allows non-hand specialists to specify the type of every PIP joint dislocation [57].

Clinical Presentation

Diagnostic Criteria and Indications

Radiographs and symptoms do not correlate, which is the main reason that classifications and staging based on radiographs are rarely used [23].
Radiographic evaluation of bone quality, specifically defects and cyst formation, plays a crucial role in the indication of possible surgical treatment options [23].
The presence of stiffness and deformity plays a crucial role in the indication of possible surgical treatment options [23].
Patients are considered for surgery if they have radiological signs of PIP joint osteoarthritis (Kellgren-Lawrence classification ≥grade 2) in combination with pain, despite nonsurgical treatment for at least 3 months [10].
Stiffness and deformity could be indications for surgery in addition to pain [10].
The most common indications for initial PIP joint arthroplasty surgery were stiffness (28%) and pain (25%) [11].

Symptom Characteristics and Disease Progression

The initial phase of PIP joint osteoarthritis is an inflammatory process that comes to a halt at a later stage [23].
Many patients have fewer symptoms at the end stage of the disease than at the beginning [23].
Patients should be advised that PIP joint range of motion deteriorates over time [8].
It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains [19].
PIP joint pain in patients with trigger finger is mostly aching and felt on the palmar and dorsal aspect of the PIP joint [26].
PIP joint pain in patients with trigger finger worsens with joint movement, especially when the joint is actively extended, and sometimes radiates proximally [26].
Occasionally there is additional PIP joint tenderness on palpation in patients with trigger finger [26].
Patients complaining of PIP joint pain often have long-standing trigger finger requiring surgery and a variable degree of fixed extension loss [26].

Trauma and Injury Presentation

Early recognition of joint instability is essential for adequate treatment of injuries of the PIP joint [27].
Fracture dislocations of the PIP joint may rapidly develop fixed deformity, leaving an athlete with a poor outlook for complete correction [31].
Clinical results for PIP joint dislocations and fracture-dislocations vary and are often difficult to predict due to the complexity of fracture patterns and potential for sub-acute or chronic presentation [60].
Complications regularly arise after PIP joint injuries, yet they can often be prevented through early detection of injury and appropriate initial treatment protocols [7].

Functional Limitations

PIP joint stiffness remains an unsolved problem in hand surgery, with poor prognosis in complex cases even after complete arthrolysis and tenolysis [61].

Investigations

A careful physical examination is essential to direct care and future testing if indicated [22].
Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [22].
Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit [22].
A systematic method to approaching the physical examination is essential due to the number of structures in a small space [22].
Radiological signs of PIP joint osteoarthritis are defined by the Kellgren-Lawrence classification ≥grade 2 [10].
Stiffness and deformity can be indications for surgery in addition to pain [10].
Timely diagnosis is imperative if there is any persistent incongruity of the joint, as fracture dislocations of the PIP joint may rapidly develop fixed deformity [31].

Treatment

Arthroplasty

PIP joint arthroplasty is a widely accepted procedure for joints with osteoarthritis destruction or post-traumatic conditions [70].
Prerequisites for PIP joint arthroplasty include intact tendons and at least some residual joint stability [70].
Correction of lateral deviation beyond 30° in PIP joint arthroplasty is difficult and likely to fail [70].
PIPJ implant arthroplasty is a good and reliable option for symptomatic PIPJ degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [15].
Pyrocarbon PIPJ replacement is a safe and effective treatment for arthritis of the PIPJ [24].
Pyrocarbon PIPJ replacement provides excellent pain relief and increases the arc of motion by more than double the preoperative range [24].
Clinical outcomes for PIP joint replacements with pyrocarbon implants are variable despite substantially good survivorship [1].
Patients should be advised that PIPJ range of motion deteriorates over time following pyrolytic carbon hemiarthroplasty [8].
The CapFlex-PIP implant demonstrates favourable medium-term results in surface replacing arthroplasty of the proximal interphalangeal joint [37].
Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty [18].
Ultimate salvage for a failed PIP joint arthroplasty may require arthrodesis or even amputation [14].
Data demonstrate an increased use of primary PIPA utilization for patients with osteoarthritis, whereas revision PIPA decreased [2].

Arthrodesis

PIPJ arthrodesis has very few contraindications [5].
PIPJ arthrodesis has an excellent overall success rate [5].
PIPJ arthrodesis is an excellent option for surgical management of PIPJ arthritis [5].
Arthrodesis in the radial digits brings an improvement in the lateral pinch [70].
Arthroplasty in the ulnar digits gives reasonable functional mobility with good pain relief [70].
Several authors have advocated reserving PIP arthroplasty for ulnar digits and treating the index finger with PIP joint fusion [70].

Other Surgical Interventions

PIP joint denervation provides durable, effective pain relief with high patient satisfaction despite osteoarthritis progression [13].
PIP joint denervation supports its consideration as a surgical option for symptomatic PIP joint osteoarthritis [13].
External fixation is a simple and effective treatment modality for chronic traumatic PIP joint contractures [34].
External fixation for chronic traumatic PIP joint contractures has good predictable medium- to long-term results [34].
Open reduction of chronic untreated PIP joint dislocations can successfully achieve a functional range of motion with a stable joint [39].
Surgery performed better than collagenase at early and 2-year follow-up in PIP joints affected by Dupuytren contracture [4].

Rehabilitation and Postoperative Care

Patients with rheumatoid arthritis may require up to 3 weeks of immobilization before initiation of therapy following PIP arthroplasty to provide for soft tissue repair healing [32].
Therapy starting 1 week after PIP arthroplasty requires close monitoring to ensure proper alignment, rotation, and position [32].
A dynamic PIP extension-assist splint is worn during the day and limits ROM to 0° to 30° of extension-flexion for the first week following PIP arthroplasty [32].
A static resting splint is worn at night and during rest periods, with the MCP joint in 20° of flexion and the PIP and DIP joints maintained in full extension [32].
All exercises in the dynamic splint should be done hourly with ten repetitions following PIP arthroplasty [32].
Hyperextension and extension lag should be avoided, with therapy/splinting adjusted immediately when either is present following PIP arthroplasty [32].
When hyperextension of the PIP joint is present, an extension block can be added to block the PIP joint at 30° or more of flexion [32].
An extension block for PIP hyperextension includes a night static flexion block at 60° to 90° for 3 weeks [32].
After a 3-week period of flexion blocking, dynamic extension is reinstituted to zero following PIP arthroplasty [32].
Functional exercises with the index finger are begun later and functional splinting is prolonged after PIP arthroplasty to protect the radial collateral ligament [70].
The goal of index-finger rehabilitation after PIP arthroplasty is not maximum mobility but an optimized functional outcome [70].

Complications

Arthroplasty Complications

Reoperations following primary nonconstrained PIP joint arthroplasties are common, with extensor mechanism dysfunction being the most frequent cause [3].
Intraoperative fractures occur in about 5% of PIP joint arthroplasties and do not appear to influence outcomes, including revision surgery, refracture rate, or other early complications [58].
The revision rate of the LPM PIPJ prosthesis was 29%, with a further 20% rate of adverse clinical and radiological outcomes at a maximum follow-up of 6 years [63].
Periprosthetic joint infection is uncommon after PIP arthroplasties [17].

Arthrodesis Complications

PIPJ arthrodesis has very few contraindications and an excellent overall success rate [5].

Pain or locking from trigger finger may lead to secondary contracture of the PIP joint [26].

Recovery

Patients should be advised that PIPJ ROM deteriorates over time [8].
The postoperative rehabilitation protocol for PIP joint arthroplasty involves the use of two splints: a dynamic PIP extension-assist splint worn during the day and a static resting splint worn at night [32].
The dynamic PIP extension-assist splint limits ROM to 0° to 30° of extension-flexion for the first week to allow for healing of the extensor apparatus [32].
The static resting splint is forearm-based, with the MCP joint in 20° of flexion and the PIP and DIP joints maintained in full extension [32].
Exercises in the dynamic splint should be performed hourly with ten repetitions [32].
Hyperextension and extension lag should be avoided, with therapy and splinting adjusted immediately when either is present [32].
When hyperextension of the PIP joint is present, an extension block can be added to block the PIP joint at 30° or more of flexion, with a night static flexion block at 60° to 90° for 3 weeks [32].
Patients with rheumatoid arthritis may require up to 3 weeks of immobilization before initiation of therapy to provide for soft tissue repair healing [32].
Using night progressive static and daily dynamic orthoses as an exclusive treatment during the proliferative phase led to significant improvements in the PIP joint active extension [83].
Improvement in PIP joint active extension from orthotic intervention did not correlate with increased function as perceived by the patient [83].

Key Evidence

[L4] Despite substantially good survivorship, clinical outcomes for PIP joint replacements with pyrocarbon implants are variable. [1] (10.1302/2058-5241.2.160041)
[L4] The data demonstrate an increased use of primary PIPA utilization for patients with OA, whereas revision PIPA decreased. [2] (10.1177/1558944719837009)
[L4] Reoperations following primary nonconstrained PIP joint arthroplasties are common, with extensor mechanism dysfunction being the most frequent cause. [3] (10.1016/j.jhsa.2011.06.002)
[L3] Surgery performed better than collagenase at early and 2-year follow-up in PIP joints and similarly in MCP joints. [4] (10.1007/s00402-018-3034-6)
[L5] PIPJ arthrodesis has very few contraindications, with an excellent overall success rate, making it an excellent option for surgical management of PIPJ arthritis. [5] (10.1016/j.hcl.2017.12.007)
[L5] Maintaining motion and function following trauma and/or surgery of the PIP joint remains very challenging. [6] (10.1016/j.hcl.2017.12.003)
[L5] Complications regularly arise after PIP joint injuries, yet they can often be prevented through early detection of injury and appropriate initial treatment protocols. [7] (10.1016/j.hcl.2017.12.014)
[L4] Patients should be advised that PIPJ ROM deteriorates over time. [8] (10.1016/j.jhsa.2023.11.007)
[L3] [10] (10.1177/15589447221141485)
[Paper] [11] (10.1055/s-0040-1709088)
[L4] The survival of pyrocarbon PIP joint arthroplasty was 85% at 5 years of follow-up, with high patient satisfaction. [12] (10.1016/j.jhsa.2012.02.012)
[L4] PIP joint denervation provides durable, effective pain relief with high patient satisfaction, despite osteoarthritis progression, supporting its consideration as a surgical option for symptomatic PIP joint osteoarthritis. [13] (10.1016/j.jhsa.2026.01.033)
[L5] Ultimate salvage for the failed PIP joint arthroplasty may require arthrodesis or even amputation. [14] (10.1016/j.hcl.2017.12.011)
[L4] PIPJ implant arthroplasty is a good and reliable option for symptomatic PIPJ degenerative, post-traumatic or inflammatory arthritis given the proper clinical setting. [15] (10.1177/17531934241265837)
[L4] Reoperations following primary non-constrained PIP arthroplasties are common. [16] (10.1016/s0363-5023(11)60049-x)
[L4] PJI is uncommon after MCP or PIP arthroplasties. [17] (10.1016/j.jhsa.2024.12.008)
[L1] Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty. [18] (10.1177/1558944718791186)
[L4] It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains. [19] (10.1016/j.jhsa.2023.01.025)
[L5] [23] (10.1016/j.hcl.2017.04.002)
[L4] Pyrocarbon PIPJ replacement is a safe and effective treatment for arthritis of the PIPJ, providing excellent pain relief and increasing the arc of motion by more than double the preoperative range. [24] (10.1177/1753193411434053)
[L4] [26] (10.1177/1753193418809771)
[L5] Early recognition of joint instability is essential for adequate treatment of injuries of the PIP joint. [27] (10.5435/00124635-200011000-00006)
[L5] Suboptimal treatment of intra-articular fractures typically leads to functional impairment of the hand. [29] (10.1177/1753193414559464)
[L5] Timely diagnosis is imperative, especially if there is any persistent incongruity of the joint, as fracture dislocations of the PIP joint may rapidly develop fixed deformity, leaving an athlete with a poor outlook for complete correction. [31] (10.1016/j.hcl.2012.05.036)
[L5] [32] (10.5435/00124635-200703000-00009)
[L4] External fixation is a simple and effective treatment modality for chronic traumatic PIP joint contractures with good predictable medium- to long-term results. [34] (10.1016/j.jhsa.2013.07.007)
[L5] [36] (10.1016/j.hcl.2006.05.003)
[L4] The CapFlex-PIP implant demonstrates favourable medium-term results in surface replacing arthroplasty of the proximal interphalangeal joint. [37] (10.1177/1753193420977244)
[L4] This surgical technique of open reduction of chronic untreated PIP joint dislocations can successfully achieve a functional range of motion with a stable joint. [39] (10.1016/j.jhsa.2020.07.002)
[L5] Proper biomechanics of a joint must be restored to achieve full, functional range of motion. [52] (10.1016/j.hcl.2017.12.008)
[L5] Despite the wealth of knowledge regarding the anatomy of the PIPJ, it remains a subject of ongoing investigation, and evolving understanding of its biomechanical properties will continue to improve treatment and reconstructive designs. [53] (10.1016/j.hcl.2017.12.002)
[L5] [55] (10.1016/j.jhsa.2015.06.118)
[L2] Even other than hand specialists can specify the type of every PIP joint dislocation by using the SCARF classification and will have better understanding of each case. [57] (10.1016/j.jos.2019.08.007)
[L3] Intraoperative fractures occur in about 5% of PIP joint arthroplasties and do not appear to influence outcomes, including revision surgery, refracture rate, or other early complications. [58] (10.1016/j.jhsa.2015.06.101)
[L5] Clinical results for PIP joint dislocations and fracture-dislocations vary and are often difficult to predict due to the complexity of fracture patterns and potential for sub-acute or chronic presentation. [60] (10.1177/17531934231183259)
[L5] PIP joint stiffness remains an unsolved problem in hand surgery, with poor prognosis in complex cases even after complete arthrolysis and tenolysis. [61] (10.1177/17531934221143690)
[L4] The revision rate of 29% and a further 20% rate of adverse clinical and radiological outcomes for the LPM PIPJ prosthesis at a maximum follow-up of 6 years is unacceptable. [63] (10.1177/1753193408094920)
[L5] [70] (10.1302/2058-5241.4.180042)
[L5] [80] (10.1016/j.hcl.2009.05.008)
[L5] [81] (10.1016/j.hcl.2017.12.004)
[L1] Using night progressive static and daily dynamic orthoses as an exclusive treatment during the proliferative phase led to significant improvements in the PIP joint active extension, but the improvement did not correlate with increased function as perceived by the patient. [83] (10.1016/j.jhsa.2015.01.005)

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