Treatment of Chronic PIP Joint Hyperextension Injury (>12 Months Post-Injury)
Surgical Intervention is Recommended
For patients presenting more than 12 months after a PIP joint hyperextension injury, late volar plate repair should be the first-line surgical treatment, as it provides physiologic restoration of joint stability with excellent functional outcomes even years after the initial injury. 1, 2
Surgical Approach: Late Volar Plate Repair
Primary Technique
- Direct volar plate repair remains viable and effective even 8+ years after injury, contrary to traditional teaching that the volar plate becomes too retracted or attenuated for repair 1, 2
- The surgical technique involves meticulous scar lysis and advancement of the volar plate to its anatomical insertion site while preserving adjacent nutrient vessels 2
- Intraoperative findings consistently demonstrate that the volar plate can be mobilized and repaired successfully in chronic cases 1
Expected Outcomes
- Mean arc of motion achieves 6° to 92° of flexion with consistent pain relief and restoration of joint stability 2
- Grip strength returns to within 90% of the contralateral side 2
- Average PIP joint flexion of 92° (range 75-98°) with flexion contracture averaging 9° (range 0-20°) 1
- Clinical results show excellent to good outcomes in 71% of patients using Catalano's criteria 1
- All patients return to unrestricted activities with no recurrence of hyperextension deformity 1, 2
Alternative Surgical Options
When Volar Plate Repair is Not Feasible
If intraoperative findings reveal the volar plate cannot be adequately mobilized or repaired:
- Flexor digitorum superficialis (FDS) tenodesis provides equivalent biomechanical stability to volar plate repair 3
- Single lateral band transfer (SLBT) demonstrates comparable stiffness and restraint to hyperextension 3
- Double lateral band transfer and dual split lateral band transfer are additional options with similar biomechanical properties 3
Important Surgical Considerations
- All surgical stabilization techniques provide statistically equivalent restraint to PIP joint hyperextension in biomechanical testing 3
- Lateral band transfer techniques fail by massive disruption of the flexor tendon sheath, while volar plate repairs fail by suture anchor pullout or suture breakage 3
- Volar plate repair is more physiologic than reconstruction methods and should be attempted first regardless of the time interval since injury 1
Critical Pitfalls to Avoid
Common Misconceptions
- Do not assume the volar plate is irreparable in chronic cases - studies demonstrate successful repair even 8.2 years post-injury 2
- Avoid excessive scarring by performing precise anatomical repair rather than over-tightening 2
- Traditional teaching favored FDS tenodesis, but direct volar plate repair is now recognized as superior when technically feasible 1, 2
Postoperative Monitoring
- Radiographic assessment should evaluate for degenerative changes in the PIP joint, though most patients (86%) show no degenerative changes after late volar plate repair 1
- Long-term follow-up averaging 8 years demonstrates sustained stability and function 2
Why Conservative Management is Not Appropriate at This Stage
- Buddy strapping and aluminum orthoses are effective only for acute injuries treated within the first week 4, 5
- These conservative approaches show no benefit beyond 12 months when chronic instability and painful locking have developed 2
- All patients in chronic case series complained of painful locking of the PIP joint in extension, which resolved only with surgical intervention 2