What is the procedure for performing a proximal interphalangeal joint arthrotomy?

Proximal Interphalangeal Joint Arthrotomy Procedure

Surgical Approach and Exposure

The arthrotomy of the proximal interphalangeal (PIP) joint is performed through a longitudinal dorsal incision over the joint, followed by transverse extensor tenotomy and capsulotomy to expose the joint surfaces. 1

Incision Options

• Longitudinal incision across the joint provides greater exposure but carries risk of scar contracture that can elevate the toe postoperatively 1
• Elliptical incision over the PIP joint improves cosmesis but restricts surgical exposure 1
• Lateral approach can be utilized for implant arthroplasty procedures, providing good visualization while preserving the central extensor mechanism 2

Soft Tissue Management

• Perform a transverse extensor tenotomy to access the joint capsule 1
• Execute a capsulotomy to reveal the PIP joint and provide adequate exposure of the proximal phalanx head 1
• Protect surrounding soft tissues, particularly neurovascular structures, throughout the dissection 1

Joint Preparation

Articular Surface Resection

• Resect the head of the proximal phalanx proximal to the head-neck junction 1
• Remove the proximal portion of the middle phalanx to expose subchondral bone 1
• This resection can be performed using a rongeur, sagittal saw, or osteotomes 1
• Ensure adequate bone resection to allow proper osseous apposition while avoiding excessive resection that leads to cosmetically undesirable toe shortening 1

Addressing Associated Deformities

• If dorsal contracture of the metatarsophalangeal joint is present, make a longitudinal incision over that joint 1
• Perform Z-lengthening of the long extensor tendon followed by capsulectomy 1
• For angular deformities, release collateral ligaments from the metatarsal neck to balance the toe 1
• Consider metatarsal osteotomy if residual subluxation persists after soft-tissue procedures 1

Fixation Techniques

Primary Fixation Method

• Insert a smooth Kirschner wire from the middle phalanx out through the tip of the toe 1
• Drive the wire retrograde across the PIP joint, often extending into the metatarsal head and neck to hold the metatarsophalangeal joint in proper position 1

Alternative Fixation Options

• Screws, bioabsorbable pins, or intramedullary implants can be used as alternatives to Kirschner wire fixation 1
• For severe deformities, Kirschner wire fixation is preferred because it can be easily removed at bedside if excessive neurovascular bundle stretching causes toe compromise 1
• When using implants, ensure the implant is appropriately sized for the toe, as most implants are too large for fifth-toe arthrodesis 1

Critical Technical Considerations

Avoiding Complications

• Ensure adequate bone resection at the PIP joint to avoid vascular compromise 1
• Avoid excessive osseous resection that leads to cosmetically undesirable short toes 1
• In severely deformed toes, be cautious of excessive neurovascular bundle stretching during correction 1

Surgical Goals

• Achieve a congruent, stable joint, which is essential for early range of motion and favorable outcomes 3
• The main objective is to straighten the PIP joint through arthrodesis while addressing soft-tissue imbalances at the metatarsophalangeal joint 1

Postoperative Management

• Patients typically return to regular activity at 6 weeks postoperatively 1
• Wide shoes and activity modifications should be continued for several additional weeks 1
• Some patients benefit from formal physical therapy and at-home rehabilitation 1
• Persistent pain or swelling in the toe may continue beyond the initial recovery period 1

Expected Outcomes

• Osseous fusion rates range from 83% to 98% 1
• Patient satisfaction rates range from 83% to 100% 1
• Pain relief achieved in up to 92% of patients with rare complications 1
• Novel internal fixative devices provide more natural toe appearance without requiring secondary procedures for pin removal 1