arthroplasty of the interphalangeal and metacarpophalangeal joints. leonor fernandes, teresa...
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8/6/2019 Arthroplasty of the Interphalangeal and Metacarpophalangeal joints. Leonor Fernandes, Teresa Marques, PedroSimas, Fernando Cruz
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ArthroplastyArthroplasty of theof the InterphalangealInterphalangeal andand
MetacarpophalangealMetacarpophalangealjointsjoints
LeonorLeonorFernandesFernandes Teresa MarquesTeresa Marques
PedroPedro SimasSimas Fernando CruzFernando Cruz
UnidadeUnidade dede CirurgiaCirurgia dada momo ee membromembro superiorsuperiorHospital dosHospital dos LusLusadasadas LisboaLisboa, Portugal, Portugal
Hospital Garcia deHospital Garcia de OrtaOrta AlmadaAlmada
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HistoryHistory
19401940--Burmann: 1Burmann: 1stst IP and MCPIP and MCP arthroplastyarthroplasty
19591959--Brannon and Klein: 1Brannon and Klein: 1stst
published seriespublished series 19601960--Flatt: twin metallic stemsFlatt: twin metallic stems
19601960--Niebauer: 1Niebauer: 1stst silicone 1silicone 1--piece prosthesespiece prostheses
19681968--Swanson: SiliconeSwanson: Silicone
19791979--Linscheid:Linscheid: PyrocarbonPyrocarbon
19971997--Linscheid:Linscheid: PyrocarbonPyrocarbon --11stst resultsresults
VolarVolarplate interpositionplate interposition
OsteointegratedOsteointegrated arthroplastyarthroplasty -- TitaniumTitanium
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IP and MCPIP and MCP arthroplastyarthroplasty
IndicationsIndications
Degenerative joint diseaseDegenerative joint disease
Traumatic arthrosisTraumatic arthrosis
ReumathoidReumathoid arthritisarthritis
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IP and MCPIP and MCP arthroplastyarthroplasty
ContraindicationsContraindications
Active inflammatory diseaseActive inflammatory disease
Septic arthritisSeptic arthritis
Severe deformitySevere deformity
Loss of the extensor/flexor apparatusLoss of the extensor/flexor apparatus
Swan neckSwan neck
BoutounniBoutounnirere
LigamentousLigamentous instabilityinstability
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Small jointSmall joint arthroplastyarthroplastyPrinciplesPrinciples
Replace articular surfacesReplace articular surfaces
Balance flexor/extensor tendonsBalance flexor/extensor tendons Preserve collateral ligamentsPreserve collateral ligaments
Minimal bone removalMinimal bone removal
Intramedullary stemsIntramedullary stems
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Small jointSmall joint arthroplastyarthroplasty
CriteriaCriteria ((FlattFlatt e Fisher 1969)e Fisher 1969)
Restoration of a functionalRestoration of a functional range of motionrange of motion
IP jointsIP joints 1 degree of freedom1 degree of freedom
MCF jointsMCF joints 2 degrees of freedom2 degrees of freedom
AdequateAdequate stabilitystability
Resistance to subluxationResistance to subluxation
Constrained orConstrained orsemiconstrainedsemiconstrained prosthesesprostheses
Preservation of ligamentsPreservation of ligaments
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Small jointSmall joint arthroplastyarthroplasty
CriteriaCriteria ((FlattFlatt e Fisher 1969)e Fisher 1969)
Mechanical advantageMechanical advantage equivalent to normalequivalent to normal
Physiologic center of rotationPhysiologic center of rotation Accurate placement of stem and lengthAccurate placement of stem and length
PIP jointsPIP joints palmarpalmar/dorsal/dorsal angulationangulation
MCP jointsMCP joints
-- ulnarulnardeviationdeviation
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Small jointSmall joint arthroplastyarthroplasty
CriteriaCriteria ((FlattFlatt e Fisher 1969)e Fisher 1969)
Firm seatingFirm seating with resistance to rotational forceswith resistance to rotational forces
Intramedullary stemsIntramedullary stems AdaptativeAdaptative stems?stems?
Easy implantationEasy implantation
AccomodationAccomodation to sizeto size
Right/LeftRight/Left
4 fingers4 fingers
3232--40 models?40 models?
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Small jointSmall joint arthroplastyarthroplasty
CriteriaCriteria Biologic compatibilityBiologic compatibility
CobaltCobalt--Chrome, titanium,Chrome, titanium, pyrocarbonpyrocarbon,,siliconesilicone
AdequateAdequate material wearmaterial wear LongevityLongevity
PolyethylenePolyethylene osteolisysosteolisys??
SiliconeSilicone synovitissynovitis??
Soft tissueSoft tissue reconstructionreconstruction
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ExposureExposure -- PIPPIP
LateralLateral
PalmarPalmar
DorsalDorsal
PProsros
EasyEasy repairrepairofofthethe collateralcollateral ligamentligament
ConsCons
PrecisePrecise preparationpreparation ofofbonebone endsends isis moremore
difficultdifficult
InjuryInjury to centralto central slipslip andand palmarpalmarplateplate maymay
occuroccur
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ExposureExposure -- PIPPIP
LateralLateral
PalmarPalmar
DorsalDorsal
ProsPros
Easier preparation of bone endsEasier preparation of bone ends
Early motionEarly motion
ConsCons
Retraction of the flexor tendons and sheathRetraction of the flexor tendons and sheath
Possible injury to central slip dorsallyPossible injury to central slip dorsally
Flexor bowstringing may occurFlexor bowstringing may occur
Vascular/nervous injury riskVascular/nervous injury risk
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ExposureExposure -- PIPPIP
LateralLateral
PalmarPalmar
DorsalDorsal
ProsPros
Best exposureBest exposure
ConsCons
Possible extensor lagPossible extensor lag
Difficult bony preparationDifficult bony preparation
Delay on early motionDelay on early motion
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Dorsal (Dorsal (ChamayChamay))
Triangular incision of theTriangular incision of the
extensor apparatusextensor apparatus
Removal of dorsal capsuleRemoval of dorsal capsule
Osteotomy of the proximal andOsteotomy of the proximal and
medial phalangesmedial phalanges
MedullaryMedullary canals are reamedcanals are reamed
Appropriately sized implant isAppropriately sized implant ischosenchosen
Capsule and extensorCapsule and extensor
mechanism were repairedmechanism were repaired
TechniqueTechnique -- PIPPIP
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ExposureExposure -- MCPMCP
DorsalDorsal
ProsPros
Best exposureBest exposure
ConsCons
Repair of the extensorRepair of the extensor
mechanism is vitalmechanism is vital
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DorsalDorsal
Incision over the MCP jointsIncision over the MCP joints CapsulotomyCapsulotomy
MedullaryMedullary canals are reamedcanals are reamed
Appropriately sized implant isAppropriately sized implant ischosenchosen
Capsule and extensorCapsule and extensor
mechanism were repairedmechanism were repaired
TechniqueTechnique -- MCPMCP
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ComplicationsComplications
RadiolucenceRadiolucence (50%)(50%)
HeterotopicHeterotopic ossification (15ossification (15--20%)20%) Subluxation/Instability (19%)Subluxation/Instability (19%)
Implant fracture (12Implant fracture (12--16%)16%)
Dislocation (6Dislocation (6--8%)8%)
Infection (1Infection (1--2%)2%)
SynovitisSynovitis (rarely)(rarely)
PeriprostheticPeriprosthetic sclerosissclerosis
Revision rate at 2 years (13Revision rate at 2 years (13--50%)50%)
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RehabilitationRehabilitation
FundamentalFundamental
Early range ofEarly range of
movementmovement
ProtectionProtection
OrthotesesOrthoteses
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Surgical optionsSurgical options
ArthrodesisArthrodesis loss of movement; DIPloss of movement; DIP
InterpositionInterposition arthroplastyarthroplasty techniqualtechniqual demandingdemanding
Total jointTotal joint
arthroplastyarthroplasty
Silicone implantSilicone implant
PyrocarbonPyrocarbon implantimplant
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DiscussionDiscussion
Total jointTotal joint arthroplastyarthroplasty -- SiliconeSilicone
ProsPros
Pain freePain free
Keeps motilityKeeps motility
Long term durationLong term duration
ConsCons Instability (rheumatoid arthritis)Instability (rheumatoid arthritis)
Possibility of failure (fracture,Possibility of failure (fracture, osteolysisosteolysis))
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DiscussionDiscussion
Total jointTotal joint arthroplastyarthroplasty -- PyrocarbonPyrocarbon
ProsPros
Pain freePain free
Keeps motilityKeeps motility
ConsCons
Possibility of failure (fracture,Possibility of failure (fracture,
osteolysisosteolysis)) Better bone qualityBetter bone quality
High costHigh cost
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BrananBranan
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ConclusionConclusion
Improvement of pain with all techniquesImprovement of pain with all techniques
Improvement of strength and functionImprovement of strength and function
Failure to improve movementFailure to improve movement -- PIPPIP
Arthrodesis for distalArthrodesis for distal interphalangealinterphalangealjointjoint
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ConclusionConclusion
InterpositionInterposition arthroplastyarthroplasty -- promising resultspromising results
Silicone 1/6 price ofSilicone 1/6 price ofpyrocarbonpyrocarbon implantsimplants
Similar results silicone/Similar results silicone/pyrocarbonpyrocarbon??
Type of complications depend on implantType of complications depend on implant
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OBRIGADO!