Arthrodesis of the Distal Interphalangeal (DIP) Joint of the Right Ring Finger for Arthritis

Abstract

Osteoarthritis commonly impacts the finger distal interphalangeal (DIP) joints. The prevalence of DIP joint arthritis is high, with more than 60% of individuals older than 60 having DIP joint arthritis. Operative treatment for arthritis of the DIP joint is indicated for pain, deformity, dysfunction, and instability in patients who are recalcitrant to conservative measures. Arthrodesis, or the fusion, of the DIP joint is a widely accepted surgical treatment for DIP joint arthritis. Several surgical techniques have been historically described, with headless compression screw (HCS) fixation being a particularly common technique because of its advantages, including reliable compression, rigid fixation, lack of prominence, and no need for removal. This video demonstrates arthrodesis using HCS for arthritis in the right ring finger DIP joint.

Case Overview

Background

Osteoarthritis (OA) is the most common joint condition, with frequent involvement of the joints of the hands. OA of the hand commonly affects the distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, and the carpometacarpal (CMC) joint of the thumb, with DIP joints having the highest prevalence.¹ The most frequently involved digits are the second and third, followed by the fourth and fifth digits.² Approximately 70–90% of individuals older than age 75 are affected by some types of OA. Manifestations of OA include pain, stiffness, joint deformity, and limitation or restriction of movement.³ As a result, the impact of hand OA is far-reaching, affecting individuals’ ability to perform daily tasks.

Arthrodesis of the DIP joint is a surgical option to address pain, deformity, or instability associated with various types of arthritis or traumatic conditions after conservative treatment options have failed.⁴ In most cases, DIP joint arthrodesis dually improves the function and appearance of the digit. A recent systematic review found that union rates in DIP joint arthrodesis range between 91–96%.⁵ Several techniques have been introduced, including Kirschner wires (KW), cerclage wiring, compression screws, and headless compression screws (HCS). Arthrodesis utilizing HCS has become increasingly popular and is associated with high union rates.⁶ Central to successful union is proper preparation of the subchondral bone, strong compression and stability of the arthrodesis site, non-prominent hardware, and early mobilization.^7, 8, 9  Fundamentally, DIP joint arthrodesis aims to achieve a stable and painless DIP joint with maintenance of function and improved appearance. 

Focused History of the Patient

The patient in this case is a female who presented with advanced deformity and persistent pain of the right ring finger DIP joint due to primary OA. The patient has had prior arthrodesis of the right index and middle digit secondary to osteoarthritic changes. Patients with DIP joint arthritis often present with pain, stiffness, and limitation of movement in the affected joint. Commonly, these symptoms manifest with a decrease in grip and pinch strength. There is a high female prevalence with hand OA.¹⁰  

Physical Exam

Heberden and Bouchard nodes, firm bony swellings over the dorsal aspects of the DIP and PIP joints, are a pathognomonic finding of OA. Occasionally, a mucous cyst might be present emanating from the DIP joint with potentially chronic nail changes. Common exam findings are inflammation, bony enlargement, erythema, and warmth over the affected DIP joint.¹⁰ Individuals with DIP joint OA have reported increased pain sensitivity on movement.^10, 11

Imaging

Radiography is the imaging study of choice to evaluate OA. Although not necessary to make the diagnosis of hand OA, standard radiographs can be helpful for quantifying the extent of arthritis and for preoperative planning. Generally, advanced imaging with ultrasound or MRI is not necessary for this diagnosis and surgical treatment. 

Natural History

Without surgical intervention, individuals with hand OA may experience a gradual progression of symptoms. The literature points to radiographic progression varying from 3–23% per year, depending on the population studied and whether the definition of progression incorporates incidental OA.¹⁰ Analysis over ten years highlighted approximately 50% of individuals show degrees of deterioration, 45% remain unchanged, and 5–8% report a decrease in disease progression.¹² Overall, the prevalence of OA is cumulative with aging. Patients with hand OA frequently express aesthetic dissatisfaction because of joint deformity. This has negative effects on patient symptoms, including increased pain levels, stiffness, decreased range of motion, and satisfaction.^13, 14

Options for Treatment

The mainstay for hand OA treatment revolves around preserving function with pain relief. The management plan for each patient should be tailored on an individual basis. The management of hand OA incorporates both non-pharmacological and pharmacological approaches, with surgical intervention recommended to individuals with severe symptoms and for those who have exhausted conservative methods. Conservative management includes exercise therapy, joint mobilization, taping, and ultrasound therapy. These approaches have been recommended in the European League Against Rheumatism (EULAR) Hand OA guidelines. Topical NSAIDs are recommended as a first-line pharmacological treatment option for symptomatic hand OA, showing improved efficacy compared with oral paracetamol. Local symptomatic relief through glucocorticoid injection can be preferable in patients with multiple comorbidities.⁸ The long-term effectiveness of intra-articular injections, however, is questionable.¹ Although non-surgical modalities are palliative, surgery is the only disease-modifying intervention to date.

Arthrodesis, or joint fusion, is a reliable surgical intervention for arthritis of the interphalangeal joints.⁶ Earlier surgical techniques such as KW have provided joint stabilization but limited compression of the fusion site. Prior studies reported relatively high complication rates, with an approximate 22% having minor complications including loosening, permanent stiffness of PIP joint, and paresthesias.¹⁵ The HCS technique has garnered increasing popularity, with literature pointing to a higher union rate than the KW and cerclage wiring techniques. The advantages of the HCS are strong and stable compression along with a lack of hardware prominence and soft tissue irritation.⁵ 

Rationale for Treatment

Surgery is indicated for chronic pain, deformity, and dysfunction recalcitrant to non-operative treatment in order to establish a stable DIP joint without pain and improved alignment. ^16, 17

Special Considerations

When working with elderly patients with coexisting comorbidities, the surgeon must work with the patient to weigh the risk/benefit ratio for surgical versus non-operative interventions. To minimize anesthetic risks, DIP joint arthrodesis surgery can be performed under local anesthetic with simply a digital block. In particular, the wide-awake local anesthetic no tourniquet (WALANT) technique is becoming more popular in hand surgery because of its safety, convenience, and decreased costs while maintaining favorable results. 

Discussion

A ring finger DIP joint arthrodesis using HCS in a female patient with long-standing arthritis is demonstrated. The patient underwent DIP joint arthrodesis using a 2.4-mm HCS.

A digital block was placed, and a finger tourniquet was applied. A dorsal full-thickness incision was made through the skin, tendon, and dorsal capsule over the DIP joint. Collateral ligaments were then released to enable exposure of the joint. Care was taken not to injure the neurovascular bundles and the volar flexor tendons during the joint release. The remaining cartilage was debrided to the subchondral bone to create sufficient bony contact on both sides. Under fluoroscopic guidance, the phalanges were aligned in 0–5 degrees of flexion. The rotation should be checked using the nail and fingertip alignment relative to the neighboring fingers. The alignment is maintained using a guidewire in an inside-out fashion. The guidewire is first placed across the distal phalanx in an antegrade manner to exit at the fingertip, then reversed into the middle phalanx while the joint is held in a proper position. The screw length is measured and is placed through the guidewire in a retrograde fashion entering at the fingertip.⁵ It is important to note that the screw size should also be checked under fluoroscopy relative to the diameter of the phalanges medullary canal in both posteroanterior and lateral views. Generally, a 2.0–2.5-mm screw is sufficient, but a 3.0-mm or larger screw may be better for larger individuals. Also, the length of the screw can be determined from the distal end of the distal phalanx tuft to the isthmus of the middle phalanx. Missized screws are related to complications such as nailbed injury, screw prominence, fracture, and loss of fixation.¹⁷ The screw head is buried in the distal phalanx tuft to avoid prominence in the soft tissue.

Following fixation, a 4-0 nylon suture is used for a tenodermodesis closure, where both the skin and the underlying tendon are captured and closed together. Redundant skin can be excised to avoid bulky soft tissue over the joint. A soft dressing is placed and can be removed after two days. The sutures are removed 10–14 days after surgery, and radiographs are taken at 2 and 12 weeks postoperatively to assess the alignment and arthrodesis. Patients are allowed to use the hand per comfort immediately as tolerated. Most patients will not require physical therapy, and union is achieved at an average of 10 weeks postoperatively.¹⁸ 

An adequate bone-to-bone contact and surface compression are necessary to achieve a stable union following arthrodesis.^18, 19 There are several techniques available for DIP joint arthrodesis with varying indications, including headed screw, K-wire, cerclage wiring, external fixator, and resorbable pegs. Although the infection rate is low and comparable between the constructs, the K-wire and cerclage wiring techniques are correlated with significantly higher non-union rate, loosening.^18, 19 These techniques require more prolonged immobilization with a higher risk of stiffness. Also, external hardware prominence may interfere with the adjacent fingers' function. Nonetheless, these techniques are cheaper. The HCS allows early mobilization with a higher union rate; however, the available angles for fusion are limited with the screws, and size mismatch results in specific complications stated above. There is insufficient data to show the superiority of one technique over another; however, arthrodesis of the DIP joint utilizing HCS is becoming more popular because of reliable compression and fixation, lack of hardware prominence, consistent union, and faster patient recovery.²⁰

Equipment

• 2.0–2.7-mm HCS 
• Drill/Wiredriver
• Fluoroscopy
• Rongeur

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.