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Hemi-hamate arthroplasty for the management of chronic proximal interphalangeal joint fracture dislocations: Analysis of 21 cases in Indian population and review of the literature
Chronic fracture-dislocations involving the proximal interphalangeal (PIP) joint are challenging cases. We conducted this study to analyze the outcomes following hemi-hamate autograft reconstruction of such injuries and to compare our results with the existing literature.
Methods
A retrospective analysis of 21 patients with chronic dorsal PIP fracture-dislocations that were managed with hemi-hamate autograft reconstruction was done. The average articular surface involvement was 64%. The average duration between injury and surgery was 9.4 weeks (range, 6–16). Quick DASH (Disabilities of Shoulder and Hand) scores, VAS (Visual Analog Scale) scores, range of motion of the PIP joints, DIP (distal interphalangeal) joints, and MCP (metacarpophalangeal) joints were measured during serial follow-up visits.
Results
Union and graft incorporation was seen in all cases. The average Quick DASH score at four weeks post-surgery was 66 and it improved to eight at one year (p-value<0.05). The average VAS score at four weeks post-surgery was 7.66 and it improved to 2.09 at one year (p-value<0.05). The mean flexion of the MCP joint improved from 52.85° at the end of four weeks to 72.38° at one year (p-value<0.05). The average flexion at the PIP joint improved from 10.47° at the end of four weeks to 70.47° at one year (p-value<0.05). The average DIP flexion improved from 38.33° at the end of four weeks to 62.38° at one year (p-value<0.05). The average hand grip strength was 85% of the normal side.
Conclusion
Hemihamate autograft reconstruction is a suitable procedure for the management of chronic PIP joint fracture-dislocations, especially in cases with extensive involvement of the articular surface.
Injuries that involve less than 30% of the surface of the middle phalanx are considered to be stable. It is recommended that surgical reconstruction of PIP fracture-dislocations should be performed when the fracture has involved 30%–50% of the base of the middle phalanx or when the degree of flexion required for maintaining reduction is more than 30°.
Involvement of articular surface greater than 50% requires ORIF (Open reduction Internal fixation), while VPA (Volar plate arthroplasty) is preferred in cases with comminution.
However, there is a higher incidence of undesirable outcomes such as pain, stiffness, and recurrent dislocation when osteosynthesis and VPA are used for the surgical management of unstable PIP joint fracture-dislocations which involve more than 50% of the volar lip of the middle phalanx and hemi-hamate arthroplasty has shown to have favorable outcomes when used in such cases.
The present study aimed to analyze the outcomes of this procedure when used for the management of exclusively chronic PIP dislocations (presenting more than six weeks post-trauma) involving more than 50% of the articular surface.
2. Methods
After obtaining clearance from the Institutional Review Board and a well-written informed consent from the patients, we performed a retrospective analysis of 21 cases of chronic dorsal fracture-dislocations of the PIP joint involving more than 50% of the articular surface that were managed with hemi-hamate autograft reconstruction by a specialist-highly experienced hand surgeon over four years from 2017 to 2021 with a minimum follow-up of one year. All patients were males with an average age of 31 years (range, 18–58 years) (Table 1). The commonest digit involved was the left ring finger (seven cases) followed by the left middle finger (five cases). The common mechanisms of trauma were falls resulting in hand trauma, blunt trauma to the hand, and injury to the finger while engaging in sports activities. The patients presented to us more than six weeks after the trauma and the average duration between trauma and surgery was nine weeks (range, 6–16 weeks). The average percentage of joint involvement was 64%. The outcomes were assessed using the range of motion measured by a goniometer, hand grip strength, QuickDASH scores, and VAS scores at regular intervals of four weeks, three months, six months, and one year.
Regional anaesthesia and tourniquet were used for all cases. Bruner's skin incisions were used volarly and the digital nerves and arteries were identified. The flexor sheath was incised between the A2 and A4 pulleys and retraction of the flexor tendons was done to provide exposure of the volar plate which was then released from the accessory collateral ligaments. Exposure of the PIP joint was achieved by hyperextending (shotgunning) the PIP joint and a thorough wash was given to remove any remaining loose fragments (Fig. 1). Using a rongeur, a smooth surface was created on the distal volar margins of the middle phalanx base and the dimensions of the defect so created were measured. A longitudinal incision was taken over the fourth and fifth CMC (carpometacarpal) joint and the desired autograft was obtained from the hamate by making the cuts via a saw. The length of the obtained autograft was measured. The autograft was then placed into the bony defect created at the middle phalanx base after contouring it as per the size of the defect and then secured into the defect using two to three bicortical screws or pins under fluoroscopic guidance (Fig. 2). Relocation of the joint was done and it was confirmed that the screws or pins used for fixation were of appropriate length. Reattachment of the volar plate to the stumps of the collateral ligaments was performed and the joint was moved through a complete range of motion under fluoroscopic guidance. A thorough wash was given and the wound was closed in layers after deflation of the tourniquet and an adequate dressing was given following which the wrist and hand were immobilized using a slab in the functional position. Immobilization with the slab was discontinued after two weeks following which immobilization was provided with a splint. This was discontinued at the end of four weeks and range of motion exercises of the hand and wrist were begun under the supervision of a dedicated hand physiotherapist. Following this, a rigorous physiotherapy protocol consisting of resistive active stretching exercises was started and continued till satisfactory hand grip strength was achieved. The Quick DASH scores, VAS scores, PIP, DIP, and MCP range of motion were calculated at an interval of four weeks, three months, six months, and one year (Fig. 3). Grip strength was measured using the Jamar Hydraulic hand dynamometer (Bolingbrook, Illinois). Radiographs were obtained at regular intervals to analyze the union and status of the autograft.
Fig. 1(A) – The incision has been marked preoperatively.
(B) – Lateral radiographs show dorsal dislocation following a fracture of the index finger's middle phalanx base.
(C) – Intraoperative image of the same patient shows that the loose fragments are cleared after giving a thorough wash following hyperextension of the proximal interphalangeal joint.
(D) – Intraoperative fluoroscopy image shows the hamate graft fixed to the middle phalanx volar base with bicortical pins.
One patient was lost to follow-up due to COVID-19 restrictions. As compared to the uninjured side, the average handgrip strength was 85%. Radiographs assessed at regular intervals showed union in all cases. Resorption of the graft was not noted in any case. The average Quick DASH score at four weeks post-surgery was 66 and it improved to eight at one year (p-value<0.05). The average VAS score at four weeks post-surgery was 7.66 and it improved to 2.09 at one year (p-value<0.05) (Table 2). The average MCP joint flexion improved from 52.85° at the end of four weeks to 72.38° at one year (p-value<0.05). The average flexion at the PIP joint improved from 10.47° at four weeks to 70.47° at one year (p-value<0.05). The average DIP flexion improved from 38.33° at the end of four weeks to 62.38° at one year (p-value<0.05) (Table 3).
Table 2Detailed post-operative outcome in terms of QuickDASH scores and VAS scores.
Superficial wound infection was noted in one subject. It was managed with oral antibiotics. Swelling at the donor site was noted in two patients. Radiographs of the site did not show any abnormality. The swelling subsided within a week after being treated with anti-inflammatory medications. In one case, an iatrogenic fracture of the dorsal cortex of the middle phalanx base was noted. No additional intervention was done for the same as the hand and wrist were immobilized post-surgery. Follow-up radiographs in one case showed changes suggestive of avascular necrosis involving the head of the proximal phalanx of the involved digit. As the patient was asymptomatic and had an adequate range of motion of the involved digit, he was managed conservatively.
4. Discussion
PIP joint fracture-dislocations are challenging cases, the ideal treatment for which includes restoration of the joint congruity and early re-establishment of the range of motion.
Surgical options including ORIF, VPA, and external fixation have been tried for the management of dorsal PIP fracture-dislocations of higher grades, but hemi-hamate arthroplasty is more advantageous for managing this difficult fracture pattern. VPA is usually successful when the fracture-dislocation involves less than 50% of the articular surface
with the redislocation risk increasing when more than 50% of the articular surface is involved. Moreover, as the outcome is poorer when injuries more than six weeks old are dealt with VPA,
hemi-hamate arthroplasty is the preferred modality for the management of chronic PIP joint fracture-dislocations. ORIF is difficult in the case of articular comminution.
Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results.
The present study evaluated the functional outcomes of hemi-hamate arthroplasty when used for the management of chronic PIP joint fracture-dislocations.
A traction system using three pins has been described by Robertson et al. for the conservative management of these cases.
Although union occurred with its use, the failure to restore the congruity of the joint resulted in persistent stiffness. Wilson and Rowland introduced a method of reducing these fractures by open techniques followed by internal fixation.
In their series of 15 patients, an average of 74° of range of motion at the PIP joint was seen. The technique of volar plate arthroplasty was described in 1980
and it involved the removal of the comminuted fracture fragments involving the middle phalanx volar base followed by advancing the volar plate into the bony defect to restore the volar buttress. However, this was associated with a risk of dorsal subluxation that was proportional to the extent of comminution.
However, it was associated with only a moderate improvement in the range of motion. The use of a hemi-hamate autograft obtained from the distal aspect of the hamate for the reconstruction of these injuries was described in a series of five patients by Hastings et al.
The mean articular involvement in this series was 73% and the arc of motion of the PIP joint was 77°. The grip strength was 81% as compared to the uninjured side with union seen in all cases. In a study involving 56 PIP fracture-dislocations that were managed surgically, redislocation was seen in six cases of which three were managed with ORIF and three with VPA.
Another review concluded that ORIF was best for fractures with simple patterns because the range of motion of the PIP joint decreased as the number of involved fracture fragments increased.
They also concluded that this procedure was technically challenging and should be initially practiced in cadavers because of its learning curve.
The hamate cannot guarantee complete restoration of the articular surface and thus the aim of surgery should be the restoration of the volar buttress. Although complete restoration of the preoperative range of motion is difficult, HHA can lead to restoration of motion that would not lead to any limitation in performing activities of daily living. The findings of our study were comparable to previously described studies (Table 4). The highlight of the study was that all the cases managed were chronic injuries. There are not many studies focusing exclusively on chronic PIP joint injuries. As this study was conducted during COVID-19, most of the patients were not able to seek timely treatment due to the imposed restrictions, thereby leading to a delay in presentation. Limitations of our study included the retrospective nature, smaller sample size, and the comparatively lesser duration of follow-up. Attrition was a major problem due to the COVID-19 pandemic restrictions and hence, the follow-up duration was lesser.
Table 4Review of literature and comparison of the present study with previously published studies.
Hemi-hamate arthroplasty is a very good technique for the management of chronic PIP fracture-dislocations involving more than 50% of the articular surface. Although the technique has a longer learning curve, it is associated with favorable outcomes when performed well and when coupled with supervised dedicated physiotherapy as part of the post-operative protocol.
Funding
The author(s) received NO financial support for the preparation, research, authorship, and/or publication of this manuscript.
Declaration of informed consent
There is no information (names, initials, hospital identification numbers or photographs) in the submitted manuscript that can be used to identify patients.
Author statement
Prashant Kamble: Conceptualization, Methodology. Rudra Mangesh Prabhu: Data curation, Writing- Original draft preparation. Shubhranshu Mohanty: Supervision, Validation. Swapnil Keny- Reviewing and Editing.
Declaration of competing interest
The Authors declare that there is no conflict of interest.
Acknowledgements
None.
References
Elfar J.
Mann T.
Fracture-dislocations of the proximal interphalangeal joint.
Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results.
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