Injury on PIP of right index finger

[msilva913]

Dr. Tomaino:

A few days ago, my mother Adriana asked you if you thought hemi-hamate arthroplasty could be appropriate for a severe injury I have on the PIP of the index. You responded that based on the x-rays, the only options were fusion or replacement (and that fusion was the better option).

The reason I ask is that a hand surgeon at Stanford, Jefferey Yao, said the hemi-hamate arthroplasty was a risky option that might preserve most mobility on my right index finger. The issue is that I have substantial arthritis and deviation on the finger--but I have more than 90 degrees of mobility.

I certainly understand that a fusion is definitely the "standard" procedure to use in such a situation, but given that it eliminates motion on the joint for life, I was wondering if some argument could be made for trying this procedure--with fusion as the strategy if it fails.

I understand several reasons why the procedure might not work: the overstretched collateral ligament might cause the bone to deviate; the bone from the wrist would have to bind from an articular surface.

So, is realigning and stabilizing the joint with hemi-hamate arthroplasty something of a possibility, or is it crazy? Furthermore, if the joint could be succcessfully realigned and stabilized, would this be enough to kill off most pain--enough to where writing is not problematic--or does the damage to the articular cartilage mean that much pain could remain even with realignment? (I am not talking about eliminating all pain, just enough so that writing is not an issue--since this is my writing finger).


These are tough questions. Any insights would be super, super appreciated!!

Thank you.

[mtomaino]

First, the fact that you have good motion is great, but for the index finger, the functional issue is your pain and instability. And, the functional imperative is pain relief and stability. Second, the hemi-hamate arthroplasty was designed to treat the sequelae of fracture-subluxation, and has no role in treating pip joint arthritis and radial collateral ligament incompetence. It is simply not the appropriate operation for your problem.

Because the index finger is most involved in pinch, and less dependent on range of motion for function of the hand, fusion for treatment of painful PIP joint arthritis in the index finger is the "standard" treatment----it provides pain relief and stability. It also avoids the inevitable risk of failure due to the lateral stresses on an implant that accompany pinch.

That having been said, if you are averse to fusion--understandably--there is the option of replacement. This is a "surface" replacement and bears resemblance to a "knee-replacement' design. in your case, you would also require a reconstruction of the radial collateral ligament-----and you'd have to be prepared for this to fail at some point. The key point is that failure would not burn the bridge of performing a fusion as salvage at some point in the future. Frankly, if I were in your shoes, I would probably want to try something before fusion---but I would have to embrace the absence of any guarantee.

I have attached a picture of the implant. The link below brings you to an informative site regarding this type of PIP joint replacement.

http://www.totalsmallbone.com/us/products/hand/sr_pip.php4

[msilva913]

Thank you very much for the response.

The reason I believe that trying joint replacement at all on the PIP of the index is not a good idea is that (1) the process permanently destroys some bone, and (2) the procedure is likely to fail quickly. Surgeons I have spoken with say the procedure will likely fail within a year or two. Since I do a lot of writing with my index finger, it is more likely that the procedure would fail sooner than later.

If I had good reason to think that a joint replacement would last, say, 10 years or so, that would be a completely different story--but expecting it to fail within a year or 2 indicates that--if indeed hemi-hamate arthroplasty is inappropriate--then fusion is the way to go.

Thank you very much for your insights.

Mario Silva

[mtomaino]

Mario
There is no way to predict longevity. While it could last, it may not. However, this implant does not excessively remove bone, and would not overly complicate a subsequent fusion. Good luck.