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A Hand Up In Healing!

Therapy

ManagementPIP Arthroplasty

Terri L. Wolfe, OTR/L, CHT

Hand & Upper Body

Rehabilitation Center

www. ErieHandCenter.com

Acknowledgements

Sheri Feldscher OT, CHT

Katie Froehlich, OTR/L, CHT

For handouts email: terri@eriehandcenter.com

Therapy Management –PIP Arthroplasty

Therapist must know:• Which implant used

• What surgical approach/procedure was

performed

• OA?

• Traumatic?

• RA?

PIP Joint Arthroplasty

3 basic types in US• Silicone Implant (Swanson), low demand, older pts,

most reliable, standard to which all other joint compare

• Pyrocarbon Implants – offers better wear characteristic, reproduces the normal mechanic of the PIPJ

• Cobalt Chrome Implant – convex proximal phalangeal component with bi-condylar configuration – approximated normal anatomy of PIPJ

Titanium – intramedullary stem to support distal component

3 Surgical

Approaches

• Dorsal Approach –central slip of dorsal apparatus of extensor mechanism disrupted

• Volar Approach – volar plate disrupted

• Lateral Approach –either radial/ulnar collateral ligament is disrupted

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PIP Post-op Course Dependent upon

Pre-op Condition

• Sufficient PIPJ

• PIP with lateral

deviation

• Boutonniere

deformity

• Swan neck deformity

• RA vs OA traumatic

PIP Arthroplasty

Swanson - PIP

• Flexible hinge• Acts as dynamic spacer

• Early motion• Implant stabilized by encapsulation process

• Post-op management by soft tissue reconstruction

• Goal 50 degrees index and long 70 degrees ring and small

• High patient satisfaction• Significant pain relief

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3-5 days

• A/AROM initiated

• Static PIP extension splint – maintain extension

• Edema control

• Wound care

Swanson Silicone Implant1-4 Weeks

• PROM initiated

• Dynamic flexion splinting if needed

• Scar management

• Emphasis on isolated AROM to PIPJ

• Avoid lateral deviation!

Swanson Silicone Implant

Swanson Silicone Implant

ROM goals

Index

Long 0/45

Ring 0/60

Small 0/60

Precaution

implant unable to withstand full PIP motion , functional stress

>70 ° flexion strain in implant

> 90° increases risk of implant fracture

JHT 2010

4 – 8 Weeks

• Light activities

• passive flexion if lacking

6-12 Weeks

• Nighttime extension orthosis

12 Weeks

• D/C Orthosis

• Resume full activities

Swanson Silicone Implant

Functional ROM PIPJ

Function restored – less than 20°extension lag

joint 70 to 80 ° flexion

Bain et al (2015)- used Sollerman hand grip fx test

Measured functional finger ROM needed for ADLs

Functional ADLs defined range required 90% of activities (N=20)

Results functional ROM

MPJ 19-71°

PIPJ 23-87°

DIP 10-64°

ulnar digits more functional active ROM

Feldscher Philly

Silicone Implants

Longest f/up

Most reliable, most widely used

Standard to which new approaches are compared

Systematic Review – Squitieri and Chung (2008)

average arc of AROM 44°

Foliart 1995: over time stress and wear may lead to mechanical failure/

degradation ,implant fracture, silicone synovitis, infection , recurrence of pain, stiffness, deformity

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JHS 2014

Silicone Proximal Interphalangeal Joint Arthroplasty for Primary Osteoarthritis Using a Volar Approach , Proubasta, Lamas et al

Barcelona Spain

Retrospective review 36 implants 26 patients

Average f/u 18 months

Pain pre op 7.2 to 0.4 postop

Arc of motion 33 degrees to 72 degrees

Satisfaction 4.8/5.0 all would have procedure again

All patients achieved full extension

No complications, no revisions

Surface Replacement Arthroplasty (SRA) Ascension PIP/Avanta (Feldscher)

Post operative planning

• What structure released/repaired

• What structures require protection

• Experienced hand therapist

• Problem solving approach

• Ease of communication with referring surgeon

• Constant evaluation of ROM-treatment modification

Surface Replacement Arthroplasty (SRA)

(Feldscher)

• Pyrocarbon

• Introduced in 1969 as a component of artificial heart valves• Proven strength, fatigue-resistance and wear resistance

• Pyrocarbon implant• A ceramic-like material

• Made of pyrolytic carbon

• Biologically inert with great strength• Strength and wear properties between those of graphite

and diamond

• Low-friction characteristics

Pyrocarbon Implant Fixation

• Minimally constrained

• No mechanical or chemical fixation to bone• Stabilized by insertion into the medullary canals

• Followed by appositional bone growth

• Bone-implant interface does not develop osseous in-growth

• On growth- Sclerotic bone forms up to the implant

• Bone growth constantly remodels and stabilized according to Wolff’s law

• Bone in a healthy person or animal will adapt to loads it is placed under (JHT)

Pyrocarbon Implant Stabilization

• Final implant fixation stabilization occurs 6-24 months postoperatively

• Precautions:

• Implant attains stabilization from surrounding capsuloligamentous structures• Soft tissue reconstruction must provide adequate

stabilization• If adequate stabilization is not provided

– Subluxation– Dislocation

– Lateral or longitudinal deformities

– Minimal motion or loss of motion

Ascension PIP Joint Implant

Need IRB approval

• Pyrolytic carbon coating over a graphite substrate

• Provides strength, durability, wear-resistance

• Two-component (Titanium), bicondylar, semi constrained joint prosthesis

• Designed to replace articulating surfaces of PIP joint and accommodate maximum anatomic ROM

• 2 convex articulating surfaces on the proximal component engage with and glide on 2 mating concave articulating surfaces on the distal component

From Ascention

Postoperative Therapy

Protocol

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Pyrocarbon Implant Advantages

• More accurately reproduces joint surface• Less bone is removed than with Swanson implant

• Preserves collateral ligaments for improved stability• Reduces stress on prosthesis-bone interface

• Decreases risk of loosening• Potential for better long term clinical results

• Improved biomechanics

• Mimics physiologic articulation of PIP joint• Restores more normal motion based on a virtual

axis• Has an elastic modulus similar to cortical bone

• With an assumed higher durability and wear resistance• Potentially a better option for younger active patients

Pyrocarbon Implant

Disadvantages

Pyrocarbon is brittle – susceptible to breakage during impaction

Poor bone quality may affect component fixation

(Feldscher)

From: Skie et al, Intraoperative

Fracture of a Pyrocarbon PIP

Total joint – A case report, Han, Sept. 2(3), 2007:90

Ascension Total Joint Protocol

1-877-370-5001

• Program dictated by extensor tendon status

• Splinting – forearm based/hand based

• 3-7 days post-op

• 30 degrees of PIP flexion allowed wk. 1

Ascension

• 2 wks – PIPJ flexion to 45 degrees if

no extension lag

• 4 wks – full PIP extension then flexion to 60 degrees

• 6 wks – goal of 0-75 degrees PIPJ

• 3 months – activities as tolerated

AVOID –

Extension Lag

• Hyperextension (check in splint)

• Lateral deviation/rotation

AVOID-

HYPEREXTENSION

NO!!!!!

Singh, H and Dias, J. Surface replacement

arthroplasty of the proximal interphalangeal and

metacarpophalangeal joints: The current state, Indian J Plastic Surg. 2011. 44(2)

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Modifications to program – based

on extensor tendon integrity

• Forearm vs. hand based splint

• Dynamic PIP extension vs. static

gutter splint

• Evans protocol for repaired central

slip

Evidence

• Feldscher (2010) – case report

• Wijik et al (2010) reported on 53 pyrocarbon implants in 43 patients

• Early results• Experienced joints that progressed into

hyperextension and had difficulty initiating flexion– Resulted in alteration of postoperative protocol

» Involves 15-20 degree extension block to avoid hyperextension

» Full flexion is the goal during soft-tissue healing, not full extension

Pyrocarbon Implants Outcomes

• Inconclusive

• Disappointing results• Pyrocarbon did not sig improve pain, ROM, satisfaction or

function; high complication rate (migration of components; unstable prosthesis)

– Nunlet et al (2006); Herren et al (2006)

• Potential • Conclude pyrocarbon implants have potential to relieve

pain, restore joint function, and are safe for index fingers

• Report high satisfaction, significant pain reduction, and improved ROM

– Heers et al (2006), Meier et al (2007), Stutz et al (2005), Schulz et al (2005), Bravo et al (2007), McGuire et al (2012), Mashhadi (2012)

• Dickson et al (2015) found higher implant revision rate than with other prostheses Feldscher Philly 2016

Pyrocarbon Implants Outcomes

• Inconclusive

• Potential but not Superiority

• Found no change in ROM, 50% pain relief, squeaky joints

– Tuttle and Stern (2006)

– Branam et al (2007) Compared 22 silicone implants to 19 pyrolytic carbon implants

» Concluded both implants provide excellent pain

relief and comparable ROM; Complications are implant-specific

Avanta Implant

(SR™ PIP/Small Bone Innovations)

• 2 components

• Distal component• Combines a titanium alloy stem (that

has an external surface to allow bone growth) with an ultra-high molecular weight polyethylene (UHMWPe) articulating surface

• Proximal component• Consisting of a cobalt-chromium-

molybdenum articulating surface• The components articulate on each other to form a semi-

constrained prosthetic replacement for the PIP joint

www.totalsmallbone.com

Avanta implant – Small Bone Innovations Inc.

Good stable pain free arc of motion

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Avanta Implant

(SR™ PIP/Small Bone Innovations)

• Like a little knee

• The kinematics of this implant have been found to

closely mimic that not a normal joint with well-

preserved soft tissues

• The implant is designed to allow a 90° arc of

flexion/extension

• A stable, pain-free 60° PIP joint

arc of motion is considered a

good result www.totalsmallbone.com

Complications

• Infection/joint dislocation

Postoperative Management

Journal of Hand Therapy 2010

Phase I (0-3 Weeks)

Phase II (3-6/8 Weeks)

Phase III (6/8-12 Weeks)

Postoperative ManagementPhase I (0-3 Weeks)

Protective orthotics• Dynamic orthoses, buddy tapes, Static orthoses

• Patients with RA may require up to 3 weeks immobilization to provide soft tissue stabilization

• Riggs et al (2011) compared 9 patients receiving static orthoses with 10 patients receiving dynamic orthoses following pyrocarbon implant arthroplasty in OA patients

• Found similar outcomes and concluded static protocol is promising and warrants further study

Splinting – Two Splints

• A low profile dynamic PIP

extension splint to be worn

during the day with exercise.

• A forearm based static

resting splint to be worn

at night and during rest

periods from the dynamic

splint.

Postoperative ManagementPhase I (0-3 Weeks)

• Wound care

• Scar management

• Edema control

• Avoid wrapping techniques that cause

torsion on the joint• Joint protection education

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Postoperative ManagementPhase I (0-3 Weeks)

• Protected ROM

• Depending on surgical repair• Pyrocarbon

• Avoid PIP joint hyperextension• If noted, fabricate DBO with PIP joint 30 degrees

• Flexion must not be regained at the expense of extension

• If an extension lag develops• Flexion increments are more modest• Emphasize A/AROM extension exercises and extension

orthotics

• Active PIP flexion should be limited to 30 degrees for the first week to allow for healing of the extensor repair.

• All exercises should be done hourly, 10 repetitions in the dynamic splint.

ExercisesExercises

Dorsal Extension Block PIP Joint Postoperative ManagementPhase II (3-6 Weeks)

• Protective orthoses continues nightly and between exercise sessions

• Modalities may be used

• To help facilitate exercise

• Control pain and swelling• Treatment focus

• Tendon gliding• Blocking

• Scar management

• Edema control

Postoperative ManagementPhase II (3-6 Weeks)

• Dynamic or static progressive orthoses may be initiated to increase PROM• Light functional use

• With controlled alignment• Joint protection

• Use stronger/larger joints when possible

• Avoid 1 position for prolonged periods• Avoid lateral stress to PIP joint to prevent fracture of

the prosthesis or deformities from developing

Postoperative ManagementPhase III (8-12 Weeks)

• Strengthening

• Begin gentle resistive exercise while maintaining proper joint alignment

• Progress as tolerated to full grip/UE strengthening as needed for RTW and ADLs

• Assess ADL/work status

• Provide adaptive equipment as indicated• Joint protection

• Avoiding deforming positions• Night resting orthosis

• Precautions

• Avoid lateral stress to PIP joint for a minimum of 12 weeks• Index must be closely monitored due to lateral forces

applied during pinch

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Joint Protection

Dr. Amy Ladd, Chase Hand Center, Stanford

https://www.dropbox.com/sh/3m4p1leonpsrbly/AAD4rYjhk6-Y12r8kAG6AuPia?dl=0

link for iPad pt info (also iPhone but not all videos work on phone version):

https://itunes.apple.com/us/book/thumb-cmc-

arthritis/id843455530?mt=13

Clinical Tips

As OT/PT’s• Continually evaluate splints/exercise

techniques

• Address the needs of our patients• Evaluate pts. with OA vs. RA

• Hyperextension PIP – extension block – 60 degree flexion static resting PIPJ

• Angular deformity – provide radial/ulnar support

• Extension lag DIP – mallet splint

Outcomes

JHS – Nov. 2006 (Nunley, R. Bayer, M. Goldbarl, C.)

– Pyrolytic Carbon Arthroplasty for Post-traumatic Arthritis of PIPJ (Barnes Hospital St. Louis)• 5 patients

• More than 1 yr. follow up

• Disappointing – no longer use

• Pain visual analog??? 6/10 before, 4/10 post

• Average AROM decreased by 10 degrees

• Grip strength improved 47 to 63 pounds post op

Avanta (SBI™) Outcomes

• Good gains in ROM; excellent pain relief

• Linscheid et al (1997), Johnstone (2001), Ampofo and Aerni (2011)• Complications: implant loosening, swan-neck deformities

• Mild or no significant gains in ROM; high pt satisfaction; high revision rate

• Jennings and Livingstone (2008); Luther et al (2010)• Jennings (2015) performed a long-term retrospective

analysis (9 year follow up) in 39 of 43 joints reported on in 2008

– Found ROM decreased from 64° to 56° (not stat sig); no major radiographic changes; no further revisions were required; subjective measures of satisfaction and function were unchanged

– Concluded that this procedure remains an option for patients with OA of the PIP joint but not appropriate for rheumatoid jts

Evidence comparing Implants

• Dacke et al (2012) prospectively compared outcomes of 3 implants in 43 pts (62 PIP jts): silicone, pyrocarbon, titanium-polyethylene

• No sig differences were found between the 3 implants for pain, mean ROM, strength• SRA devices showed temporary superior postop ROM but

higher postop complications and explantation rates

• Pyrocarbon integrated less into bone tissue, causing higher occurrence of progressive shaft loosening

• Chan et al (2013) performed a SR comparing outcomes of silicone and pyrocarbon arthroplasties

• Low level evidence that pyrocarbons do not demonstrate superiority over silicone implants• Both provided satisfactory pain relief, similar postop mean

ROM, and similar grip/pinch strength

• Concern over high complication rate with pyrocarbons

Outcomes cont….

JHS – 2006 (Tuttle, H. Stemp, J)

– Pyrolytic Carbon PIPJ resurfacing arthroplasty

• 8 women – average age 62

• 18 arthroplasties for OA

• 10º - 63º before surgery – average AROM

• 18-71 after surgery

• 50% had pain relief

• Demanding procedure unpredictable results

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Outcomes cont…

German Literature

– Schultz 2005• 20 patients

• Average arc of motion 50º

• Satisfactory pain relief

Stutz et al

13 patients average ROM 28-51 degrees pre-op,

22-71 post-op. 80% improved pain

Outcome Studies

• JHS 2014 – Outcomes of Proximal Interphalangeal Joint Pyrocarbon Implants,

Bales,Wall, Stern• 38 joints pain relief,preop flexionarc 50

• post of flexion arc 55 ,silicone tx of choice

• JHS 2014, Proubasta, Lamas et al

Silicone PIPJ arthroplasty for primary OA using volar approach, maintains extension integrity arc of motion 33 to 72 degrees

Outcome Studies

• Quick Dash

• SF-36

• Michigan Hand Outcomes

Questionnaire

• Arthritis Input Measure

Outcomes

JHT – 2011 – Riggs, Lynden, Ann Arbor Michigan

• Static vs Dynamic Splinting for PIPJ Pryocarbon

Conclusion

• Static splinting similar outcomes to dynamic splinting

• Static – requires less therapy & training, greater patient convenience

• Golfer with goal to achieve pain-free ROM

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Key points

1. Knowledge of normal anatomy of joint mechanics

2. OA/RA/traumatic

3. Surgical procedure/approach

(lateral/volar/dorsal)

4. Implant used

5. Soft tissue healing for stability

Summary – PIPJ Program

• Ascension Pyrocarbon Total Joint post-op

protocol

• ASHT guidelines

• JHT 2010 July-Sept, Volume 23, Issue 3

Summary – PIPJ program

Dorsal Approach

• Simple static

• PIP gutter splint

• Protect central slip

Volar Approach

Protect volar plate

30 degree of PIP flexion in splint

Summary – PIPJ Arthroplasty

• Skilled surgeon

• Skilled therapist

• Reliable, motivated patient

• Attention to detail

• No PIP hyperextension

• Precise adjustment to monitor pt progress

References

Ascension Orthopoedics PIP Pyrocarbon Total Joint Arthroplasty protocol 512-836-5001 or 1877-370-5001, Austin, TX.

Bain GI, Polites N, Higgs BG, Heptinstall RJ, and McGrath AM. The functional range of motion of the finger joints. J Hand Surg Eur Vol. 2015 May; 40(4): 406-11.

Beckenbaugh, R.D. Osseointegration and Mechanical Stability of Pyrocarbon and Titanium Hand Implants in a Load-Bearing In Vivo Model for Small Joint Arthroplasty. (2006) Letters to the Editor. J Hand Surg 31(7), 1240.

Branam BR et al.: Resurfacing arthroplasty versus silicone arthroplastyfor proximal interphalangeal joint osteoarthritis. J Hand Surg (Am) 2007, Jul-Aug 32(6):775.

Bravo CJ et al: Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two-year follow-up evaluation. J Hand Surg (Am) 2007, Jan; 32 (1): 1.

Chamay A. A Distally Based Dorsal and Triangular Tendinous Flap for Direct Access to the Proximal Interphalangeal Joint. Ann Chir Main, 1988,7(2), 179.

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 Jan;131(1):114-24

Daecke W, Kaszap B, Martini AK, Hagena FW, Rieck B, and Jung M. A Prospective, Randomized Comparison of 3 Types of Proximal Interphalangeal Joint Arthroplasty. J Hand Surg 2012: 37A: 1770-9.

Dickson DR, Nuttall D, Watts AC, Talwalkar SC, Hayton M, and Trail IA. Pyrocarbon Proximal Interphalangeal Joint Arthroplasty: Minimum Five Year Follow Up. J Hand Surg, 2015, 40(11) 2142-8.

Evans, RB –Clinical Management of Extensor Tendon injuries. In Mackin, Callahan, Skirven, Schneider and Osterman (eds). Rehabilitation of the Hand and Upper Extremity, fifth edition, St. Louis, 2002, Mosby.

Feldscher SB. Postoperative Management for PIP joint Pyrocarbon Arthroplasty. 2010. J Hand Ther. 23 (3) 315-22. Hage JJ et al (1999). Proximal Interphalangeal Joint Silicone Arthroplasty for Posttraumatic arthritis. J Hand Surg

24A(1):73-7.

Heers G et al. (2006). Z Orthop Ihre Grenzgeb. 144(6):609-13. Herren DB et al. Problematic Bone Fixation with Pyrocarbon Implants in Proximal Interphalangeal Joint

Replacement: Short-Term Results. J Hand Surg (Br), 2006, 31(6), 643.Feldscher 2015

Jennings CD, Livingstone DP. Surface replacement arthroplasty of the proximal interphalangeal joint using the SR PIP implant: long-term results. J Hand Surg Am. 2015 Mar;40(3):469-473.

References

Lubahn J., Wolfe TL., and Feldscher SB. Joint Replacement in the Hand and Wrist Surgery and Therapy. In Skirven, Osterman, Fedorczyk and Amadio (eds), Rehabilitation of the Hand and Upper Extremity (6th edition), Phila., 2011, Mosby.

Luther C, Germann G, Sauerbier M. Proximal Interphalangeal Joint Replacement with Surface Replacement Arthroplasty (SR-PIP): functional Results and Complications. Hand. 2010: 5(3): 233-40.

Mashhadi SA, Chandrasekharan L, Pickford MA. Pyrolytic carbon arthroplasty for the proximal interphalangeal joint: results after minimum 3 years of follow-up. J Hand Surg Eur Vol. 2012 Jul;37(6):501-5.

McGuire DT, White CD, Carter SL, Solomons MW. Pyrocarbon proximal interphalangeal joint arthroplasty: outcomes of a cohort study. J Hand Surg Eur Vol; 2012 Jul;37(6):490-6.

Meier R et al.(2007). Proximal interphalangealjoint replacement with pyrolytic carbon prosthesis Oper Orthop Traumatol. 19(1):1-15.

Murray, P. (2002). PIP Surface replacement arthroplasty. B. Adams (Ed.), Current techniques in hand, wrist, and elbow arthroplasties. Phoenix, AZ: American Society for Surgery of the Hand.

Nunley RM et al. (2006). Pyrolytic carbon arthroplasty for posttraumatic arthritis of the proximal interphalangeal joint. J Hand Surg31(9): 1468-74.

Riggs JM, Lyden AK, Chung KC, and Murphy S. Static vs Dynamic Splinting for PIP Joint Pyrocarbon Implant Arthroplasty: A Comparison of Current and Historical Cohorts. J Hand Ther. 2011;24:231-9.

Schulz M et al. (2005). Early results of proximal interphalangeal joint replacement with pyrolytic carbon prosthesis (Ascension) in idiopathic and post-traumatic arthritis. Handchir Mikrochir Plast Chir. 37(1):26-34.

Skie M et al (2007). Intraoperative Fracture of a Pyrocarbon PIP Total Joint-A Case Report. Hand. 2(3): 90-3.

Stutz N et al (2005). Pyrocarbon prosthesis for finger interphalangeal joint replacement. Experience after 1 year. Unfallchirurg. 108(5):365-9.

Swanson, A. et al (1995). Postoperative rehabilitation programs in flexible implant arthroplasty of the digits. In Hunter, J.M., Schneider L.H., Mackin E.J. and Callahan A.D. eds. Rehabilitation of the Hand: Surgery and therapy. (4th ed). St. Louis, MI: C.V Mosby.

Tuttle HG and Stern PJ. Pyrolytic carbon proximal interphalangeal jointresurfacing arthroplasty. J Hand Surg (Am), 2006, July-Aug 31(6)930.

Wijik U, WollmarkM, Kopylov P, Tagil M.(2010). Outcomes of Proximal Interphalangeal Joint Pyrocarbon Implants. J Hand Surg35A:38-43.

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Thank you