Biomechanical Characteristics of Hemi-Hamate Reconstruction Versus Volar Plate Arthroplasty in the Treatment of Dorsal Fracture Dislocations of the Proximal Interphalangeal Joint

doi:10.1016/j.jhsa.2014.10.061

The Journal of Hand Surgery

Volume 40, Issue 2, February 2015, Pages 329-332

https://doi.org/10.1016/j.jhsa.2014.10.061 Get rights and content

Purpose

To compare stability and range of motion after hemi-hamate reconstruction versus volar plate arthroplasty in a biomechanical proximal interphalangeal (PIP) joint fracture-dislocation model.

Methods

Eighteen digits from 6 cadaver hands were tested. We created defects of 40%, 60%, and 80% in the palmar base of each digit’s middle phalanx, simulating an acute PIP joint fracture-dislocation. Each defect scenario was reconstructed with a hemi-hamate arthroplasty followed by a volar plate arthroplasty. A computer-controlled mechanism was used to bring each digit’s PIP joint from full extension to full flexion via the digital tendons in each testing state, and in the intact state. During each testing scenario we collected PIP joint cinedata in a true lateral projection using mini-fluoroscopy. A digital radiography program was used to measure the amount of middle phalanx dorsal translation (subluxation) in full PIP joint extension. We recorded the angle at which subluxation, if present, occurred during each testing scenario.

Results

Average dorsal displacement of the middle phalanx in relation to the proximal phalanx was 0.01 mm for the hemi-hamate reconstructed joints and –0.03 mm for the volar plate arthroplasty, compared with the intact state. Flexion contractures were noted in each of the specimens reconstructed with volar plate arthroplasty. Degree of contracture was directly correlated with defect size, averaging 20° for 40% defects, 35° for 60% defects, and 60° for 80% defects. We observed no flexion contractures in the hemi-hamate reconstructions.

Conclusions

Surgeons can use both hemi-hamate and volar plate arthroplasty to restore PIP joint stability following a fracture dislocation with a large middle phalanx palmar base defect. Use of volar plate arthroplasty led to an increasing flexion contracture as the middle phalanx palmar base defect increased.

Clinical relevance

Clinicians can use the information from this study to help with surgical decision-making and patient education.

Section snippets

Materials and Methods

Six fresh-frozen cadaver limbs were obtained through our standard institutional protocol, and 18 digits were used in this investigation. Because of the size difference between the thumb and small finger in relation to the other digits, we did not include these digits in our protocol. We used a previously published protocol that brings each tested digit through a full simulated active ROM at the PIP joint, and captures the joint motion using live cine Digital Imaging and Communications in

Results

The mean dorsal displacement of the middle phalanx in relation to the proximal phalanx for digits reconstructed with the hemi-hamate was 0.01 mm (SD = 0.4), and for the digits reconstructed with VPA was –0.03 mm (SD = 0.6), compared with the intact specimens. This small difference in dorsal displacement (0.04 mm) between the VPA and the HHA groups was not statistically significant. None of the VPA or the HHA reconstructed PIP joints demonstrated subluxation as defined by the presence of a

Discussion

Surgeons are challenged to provide effective treatment of dorsal fracture dislocations of the PIP joint, particularly when the presentation of the injury is delayed or when the palmar aspect of the middle phalanx joint surface is not repairable. In these situations, the treating surgeon has several options for treatment, including VPA and HHA reconstruction. The reports on the outcomes of these techniques demonstrate similar values for the PIP joint ROM, with total ROM at the PIP joint between

References (21)

A.E. Cheah et al.
Volar plating for unstable proximal interphalangeal joint dorsal fracture-dislocations
J Hand Surg Am
(2012)
R.T. Ruland et al.
Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint
J Hand Surg Am
(2008)
J.Y. Lee et al.
Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results
J Hand Surg Br
(2006)
R.M. Williams et al.
Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft
J Hand Surg Am
(2003)
M.A. Deitch et al.
Dorsal fracture dislocations of the proximal interphalangeal joint: surgical complications and long-term results
J Hand Surg Am
(1999)
R.G. Eaton et al.
Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten years' experience
J Hand Surg Am
(1980)
S.C. Hamilton et al.
Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations
J Hand Surg Am
(2006)
I. Grant et al.
Internal fixation of unstable fracture dislocations of the proximal interphalangeal joint
J Hand Surg Br
(2005)
E. Dionysian et al.
The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint
J Hand Surg Am
(2000)
R.P. Calfee et al.
Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations
J Hand Surg Am
(2009)

There are more references available in the full text version of this article.

Cited by (15)

Comparison of 3 Dynamic External Fixation Devices for Proximal Interphalangeal Joint Dorsal Fracture-Dislocations in a Cadaver Model
2023, Journal of Hand Surgery
Citation Excerpt :
Using Digital Imaging and Communications in Medicine data and Paint (Microsoft Corporation), we measured the actual P2 base defects and confirmed prior to testing that none were notably different from the planned 50% resection, with a mean actual defect of 48%. For each finger, we placed the P2 and P1 parallel to each other in the lateral fluoroscopic view and measured the baseline dorsal P2 subluxation in relation to P1 (Fig. 2).8,9 The 3 prepared fingers of each hand were assigned to 1 of each of the ex-fix groups: (1) pins–rubber bands, (2) pins-only, and (3) tuberculin syringe-pins (Fig. 3).10–13
Several improvised dynamic external fixation devices are used for treating unstable dorsal proximal interphalangeal (PIP) joint fracture-dislocations. We compared the effectiveness of 3 constructs for simulated dorsal PIP joint fracture-dislocations in a cadaver model.
We tested 30 digits from 10 fresh-frozen, thawed cadaver hands. We aimed to remove the palmar 50% of the base of each digit’s middle phalanx (P2), simulating an unstable dorsal PIP joint fracture-dislocation. Each PIP joint was then stabilized via external fixation with either a pins–and–rubber-bands construct, pins-only construct, or tuberculin syringe-pins construct. We allocated 10 digits per fixation group. The finger tendons were secured to a computer-controlled stepper motor–driven linear actuator. Via this mechanism, all PIP joints were taken through 1,400 cycles of flexion-extension. With the PIP joint in neutral extension, we measured the P2 dorsal translation at baseline, after fixator stabilization, and after the motion protocol.
The actual mean P2 palmar defect created was 48% of the base. All PIP joints were unstable after creating the defect, with a mean initial P2 dorsal displacement of 3.7 mm. After application of the fixators, all PIP joint dislocations were reduced. The median residual P2 dorsal displacements were 0.0 mm for the pins–rubber bands group, 0.1 mm for the pins-only group, and 0.5 mm for the syringe-pins group. There were no cases of PIP joint redislocation after flexion-extension cycling, and the median dorsal P2 displacements were 0.0 mm for the pins–rubber bands group; 0.0 mm for the pins-only group; and 0.5 mm for the syringe-pins group.
All 3 external fixators restored PIP joint stability following simulated dorsal fracture-dislocation, with all reductions maintained after motion testing. The syringe-pins construct had significantly greater median residual P2 dorsal displacement after the initial reduction and motion testing, which is of unclear clinical importance.
This study informs surgeon decision-making when considering dynamic external fixator options for dorsal PIP joint fracture-dislocations.
The Relationship Between Hemihamate Graft Size and Proximal Interphalangeal Joint Flexion for Reconstruction of Fracture-Dislocations: A Biomechanical Study
2019, Journal of Hand Surgery
Citation Excerpt :
Consequently, in fractures that involve a substantial portion of the P2 base volar lip, HHA may be preferable to soft tissue reconstructive techniques, such as VPA. Further, biomechanical studies have demonstrated greater PIP flexion contracture with VPA than with HHA.16 Similarly, although some comminuted acute fractures may be amenable to open reduction and internal fixation, HHA may be preferable, particularly if fixation is expected to be tenuous.
The purpose of this study was to determine the relationship between hemihamate graft size and proximal interphalangeal (PIP) joint flexion in a biomechanical fracture-dislocation model.
We simulated middle finger PIP fracture-dislocations in 5 cadaver hands by resecting 50% of the palmar articular surface of the middle phalanx (P2) base. Fluoroscopy was used to confirm dorsal subluxation of the middle phalanx base after resection. A 10-mm osteochondral hamate graft was contoured to reconstruct the volar lip of the middle phalanx and was progressively downsized by 2-mm increments for each trial. A computer-controlled articulator and jig simulated active flexion and extension of the fingers. Maximum PIP flexion was measured at each graft size using fluoroscopy and digital imaging software. Clinically significant flexion block was defined as PIP flexion less than 90°.
The actual mean size of the volar defect created was 52% (3.5 mm) of the middle phalanx articular surface, which created instability and dorsal subluxation in all tested fingers. After hemihamate reconstruction, all specimens were stable throughout flexion and extension for all graft sizes. A flexion block of 90° occurred at a mean graft size of 191% of the defect (6.5 mm). With regard to the volar lip of the P2, grafts that projected an average 0.8 mm past the native volar lip position had 98° (range, 84°–107°) maximum PIP flexion. Grafts that projected an average of 3.1 mm past the native volar lip position had 90° (range, 69°–100°) maximum PIP flexion. Linear regression modeling incorporating all of the results predicted flexion block to occur at a graft size as small as 166% of the 50% volar P2 defect. In this model, for every 50% (1.7-mm) increase in graft size relative to the defect, PIP flexion decreased by approximately 6°.
Nonanatomical hemihamate grafts produce a PIP flexion block at extreme sizes, predicted to occur at greater than 166% of a 50% P2 base articular defect in our model. This suggests that relatively large grafts can be used for reconstruction of PIP fracture-dislocations without substantial biomechanical block to PIP flexion. We suggest sizing no larger than 3 mm past the native P2 volar lip position to avoid an important mechanical block to PIP flexion.
The information from this study helps surgeons understand how large a hemihamate graft can be used for P2 volar base reconstruction before having a negative impact on PIP flexion.
Injuries Around the Proximal Interphalangeal Joint
2019, Clinics in Plastic Surgery
Citation Excerpt :
Mild flexion contractures of the DIPJ 10° to 20° are common and expected, but more severe flexion contractures can occur if the joint is immobilized in excessive flexion or if the volar plate is insufficiently mobilized.81 Hemi-hamate replacement arthroplasty (HHA) has several characteristics that fulfill the treatment goals of PIPJ dorsal fracture dislocations.81 It provides a stable bony palmar lip, enables early motion through rigid fixation, and restores native hyaline cartilage.
Volar Plate Arthroplasty of the Proximal Interphalangeal Joint
2018, Operative Techniques: Hand and Wrist Surgery
Hand and foot trauma plating fixation
2017, Trauma Plating Systems: Biomechanical, Material, Biological, and Clinical Aspects
Fixation of hand and foot bone fractures is increasingly managed by plating systems. Progress in machining processes allows fabricating mini plates and screws to be implanted into the hand and foot bones to enhance open reduction and internal fracture fixation. Plating fixation has promoted fusion of bones at the joints of foot bones so that even severe fracture fragmentary fractures at the joints could be effectively treated. Higher stabilization of fracture fixation in the treatment of foot bone fractures has been reported in recent biomechanical researches, which allows further development of plating systems. The advantages of plating and transarticular screw fixations in treatment of unstable fractures at tarsometatarsal (TMT) and metatarsophalangeal (MTP) joints individually or in combination is of great interest to biomechanical-clinical researchers. Interestingly, the concept of using shape memory alloy implants with high elastic property was introduced most recently in the literature as a promising solution to enhance the contact force of bones for better joint fusion in arthrodesis treatment of severe unstable fractures or bone deformity. These concepts along with other biomechanical and clinical aspects of using trauma plating fixation for hand and foot bone fractures are reviewed in this chapter and recent developments are highlighted and discussed accordingly.
Extension Block Pinning for Unstable Proximal Interphalangeal Joint Dorsal Fracture Dislocations
2016, Journal of Hand Surgery
To evaluate the outcomes of extension block pinning used to treat unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint. The factors affecting the functional outcome were analyzed.
A series of 53 patients with 55 dorsal fracture dislocations of the PIP joint treated with closed reduction and extension block pinning were retrospectively reviewed. Additional percutaneous intramedullary fracture reduction (16 cases) or open fracture reduction (4 cases) had been performed. The radiological and clinical evaluations were included.
At a mean follow-up of 5.2 years (range, 1.0–10.6 years), 39 patients with 41 injured fingers were evaluated. The fracture fragments involved 30% to 69% (mean, 50%) of the articular surface of the middle phalanx. The mean range of motion was 80° (range, 35° to 115°) at the PIP joint with a mean extension loss of 6° (range, 0° to 50°) excluding 2 joints that were salvaged with arthrodesis. The mean range of motion of the distal interphalangeal joint was 68° (range, 5° to 90°). The mean visual analog scale for digit pain was 1.5/10. The reduction of the joint was achieved intraoperatively in all cases. However, after the hardware removal, recurrent minimal subluxation was observed in 12 cases (29%). Recurrent subluxation was associated with increased residual pain. The length of follow-up time had a positive correlation, whereas the patient age had a negative correlation with the range of motion of the injured PIP joint.
The extension block pinning technique is a simple and valuable technique for treating unstable dorsal PIP fracture-dislocation injuries producing satisfactory long-term results.
Therapeutic IV.

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: This study was funded by The Raymond M. Curtis Research Foundation, The Curtis National Hand Center, Baltimore, Maryland.

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Scientific articleBiomechanical Characteristics of Hemi-Hamate Reconstruction Versus Volar Plate Arthroplasty in the Treatment of Dorsal Fracture Dislocations of the Proximal Interphalangeal Joint

Purpose

Methods

Results

Conclusions

Clinical relevance

Section snippets

Materials and Methods

Results

Discussion

J Hand Surg Am

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J Hand Surg Am

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J Hand Surg Am

J Hand Surg Br

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J Hand Surg Am

Scientific article
Biomechanical Characteristics of Hemi-Hamate Reconstruction Versus Volar Plate Arthroplasty in the Treatment of Dorsal Fracture Dislocations of the Proximal Interphalangeal Joint