What are the treatment options for conditions affecting the proximal interphalangeal (PIP) joint area?

Treatment Options for Proximal Interphalangeal Joint Conditions

For conditions affecting the proximal interphalangeal (PIP) joint area, surgery should be considered when other treatment modalities have not been sufficiently effective in relieving pain, with arthroplasty being the preferred surgical technique for most PIP joints, except for PIP-2 where arthrodesis may be considered. 1

Non-Surgical Management

Conservative Approaches

• Education and training in ergonomic principles, pacing of activity, and use of assistive devices should be offered to every patient with hand osteoarthritis (OA) affecting the PIP joints 1
• Exercises to improve function and muscle strength should be considered for pain reduction and functional improvement 1
• Thermal modalities (heat/cold) can provide symptomatic relief for PIP joint pain 1

Pharmacological Options

• Topical treatments are preferred over systemic treatments due to safety considerations, with topical NSAIDs being the first pharmacological treatment of choice 1
• Oral analgesics, particularly NSAIDs, should be considered for a limited duration for symptom relief 1
• Chondroitin sulfate may be used for pain relief and functional improvement in hand OA affecting the PIP joints 1
• Intra-articular injections of glucocorticoids may be considered specifically for painful interphalangeal joints, though they should not generally be used in other hand OA locations 1

Imaging for PIP Joint Conditions

• Radiography is the initial imaging modality of choice for suspected acute PIP joint trauma, with standard 3-view radiographic examination showing most fractures and dislocations 1
• When initial radiographs are negative or equivocal but clinical suspicion remains high, advanced imaging may be considered:
  • CT without IV contrast can help confirm suspected fractures 1
  • MRI without IV contrast can detect occult fractures and evaluate for concomitant ligamentous injuries 1

Surgical Management

Indications for Surgery

• Surgery should be considered when other treatment modalities have failed to provide adequate pain relief 1
• Structural abnormalities that compromise joint stability often require surgical intervention 2, 3
• For fracture-dislocations, surgical intervention is indicated when the joint is rendered unstable 2, 3

Surgical Options for PIP Joint

• Arthroplasty (typically with silicone implants) is the preferred surgical technique for most PIP joints 1, 4
• Arthrodesis (joint fusion) may be considered specifically for the second PIP joint (PIP-2) 1
• For PIP joint fracture-dislocations, multiple surgical techniques are available:
  • Open reduction 3
  • Percutaneous fixation (which yields the highest post-operative range of motion) 3
  • Dynamic external fixation 3
  • Extension-block pinning (which results in the greatest grip strength) 3
  • Hemi-hamate arthroplasty 3

Post-Surgical Considerations

• Rehabilitation is important following surgical intervention 1
• Complications of PIP joint surgery may include pain, instability, nerve dysfunction, superficial infection, and wound healing issues 1
• Long-term follow-up should be adapted to the patient's individual needs, considering factors such as severity of symptoms and presence of erosive disease 1

Special Considerations

Hammer Toe Correction

• For hammer toe deformities involving the PIP joint, arthrodesis provides reliable fixation with high patient satisfaction rates (up to 92% pain relief) 5
• Osseous fusion rates following PIP joint arthrodesis for hammer toe range from 83% to 98% 5

Long-Term Outcomes

• PIPJ implant arthroplasty provides predictable pain relief and satisfactory function for degenerative, post-traumatic, or inflammatory arthritis when proper techniques and rehabilitation are followed 4
• In long-term follow-up of DIGITOS-prosthesis for PIP joint replacement, patients maintained satisfaction with results despite some decrease in range of motion over time 6

Treatment Algorithm

1. Begin with conservative management (education, exercises, thermal modalities)
2. Add pharmacological treatment (topical NSAIDs first, then oral analgesics if needed)
3. Consider intra-articular glucocorticoid injections for painful interphalangeal joints
4. If conservative measures fail, consider surgical options based on:
   • Joint affected (PIP-2 may benefit from arthrodesis, others from arthroplasty)
   • Type of condition (fracture-dislocations may require specific surgical approaches)
   • Patient factors (age, activity level, comorbidities)
5. Provide appropriate post-surgical rehabilitation