The Dorsal Approach to Silicone Implant Arthroplasty of the Proximal Interphalangeal Joint

Silicone implant arthroplasty (SIA) has been an effective alternative in the treatment of arthritic conditions of the proximal interphalangeal (PIP) joints since its introduction into surgical practice in the early 1960s. Patients with post-traumatic, degenerative, and rheumatoid arthritis all may be candidates for PIP joint SIA. The indications for SIA of the PIP joint include pain, limited joint mobility, and angular deformity of the joint with underlying articular destruction. Contraindications include ankylosis of the joint due to bony or soft-tissue restrictions, infection, inadequate soft-tissue support for coverage, absence of flexor and/or extensor tendon function, and considerable periarticular bone loss in the proximal and middle phalanges. Proximal interphalangeal joint SIA can be accomplished by dorsal, volar, or midaxial approaches. The dorsal approach has the advantages of relative technical ease, excellent visibility of the articular surfaces for preparation of the implant canals, access to the extensor mechanism for correction of central slip abnormalities, and preservation of the collateral ligaments. The surgical technique is outlined and includes handling of the extensor mechanism and central slip attachment, mobilization of the collateral ligaments, joint surface resection, preparation of the bony canals, implant sizing, implant insertion, and repair of the soft tissues. Pearls and pitfalls of the technique are outlined. Early postoperative mobilization with hand therapy is essential but must include protection of the repaired extensor apparatus. Complications include bony changes, implant failure, recurrent angular deviation or swan-neck deformity, particulate synovitis, and rarely, infection. Complications related to implant failure are most often managed with implant replacement or arthrodesis; those related to poor mobility, angular deformity and tendon imbalance, pain, or infection are managed by arthrodesis. Although SIA of the PIP joint has a relatively high degree of success when measured both subjectively and objectively, careful patient selection is important for achieving desirable results.