Review Question - QID 218169

This young patient has a chronic, irreducible fracture dislocation of her index finger proximal interphalangeal joint (PIPJ). Of the answers provided, the most appropriate treatment involves utilizing a portion of the hamate articular surface as a non-vascularized bone graft to reconstruct the articular surface of the proximal phalanx (Answer D).

PIPJ fracture dislocations most often involve the middle phalanx dislocating dorsally with resultant fracturing of the volar articular surface of the middle phalanx (as seen in this patient). The overall long-term stability and potential need for operative intervention are predictable based on the amount of articular surface involvement (Illustration A). In cases where the joint is stable after reduction with minimal articular involvement, dorsal block splinting allows for nonoperative management with an early range of motion protocol. Closed reduction internal and trans-articular or extension block pinning are considered when there is tenuous stability of the reduction and/or a large enough middle phalanx articular fragment. Other options include open reduction internal fixation or volar plate arthroplasty, depending on the fracture morphology. In chronic, irreducible cases, reconstructive efforts are necessary. In sedentary older patients, this involves a PIPJ fusion procedure. However, younger active patients do not tolerate the loss of range of motion at the proximal interphalangeal joint as well. Therefore, hemi-hamate arthroplasty is often utilized for these patients as it affords continued range of motion with favorable patient-reported outcomes at midterm follow-up.

Elfar and Mann provided a comprehensive review article on fracture-dislocations of the PIPJ. They categorize these injuries according to three potential variants: (1) dorsal fracture-dislocation, (2) volar fracture-dislocation, and (3) pilon fractures. They discuss the anatomic causes of the deforming forces commonly encountered in these injuries. The authors conclude by discussing various treatment options and the benefits/shortfalls of each operation.

Calfee and colleagues performed a retrospective review of their outcomes when utilizing a hemi-hamate arthroplasty in 33 patients. They indicated patients who had at least 50% volar articular surface involvement and were not amenable to primary internal fixation. The authors report a mean follow-up of 4.5 years with an average active motion at the PIPJ of 70 degrees, overall improved pain scores, and significantly improved DASH scores. The authors concluded that the hemi-hamate reconstruction represents a valuable surgical procedure to address severe PIPJ fracture-dislocations with restoration of function despite modest outcome performance.

Frueh and colleagues performed a systematic review of the outcomes of hemi-hamate arthroplasty for the treatment of PIPJ reconstruction. They found 13 articles involving 71 cases with a mean follow-up of 36 months and an average of a 77-degree arc of motion. They report up to 50% of patients showed radiographic signs of osteoarthritis, however, these findings were reported to be asymptomatic in nearly all cases. The authors concluded that the hemi-hamate autograft is considered reliable for both acute and chronic PIPJ fracture-dislocation involving at least half of the articular surface.

Figure A displays a dorsal fracture-dislocation of this patient’s PIPJ involving approximately 50% of the middle phalanx articular surface. Illustration A demonstrates the commonly utilized diagram from the Calfee article to assess stability based on the degree of middle phalanx articular surface involvement. Illustration B demonstrates the dimensional planning for a hemi-hamate arthroplasty from the Elfar article. Illustration C demonstrates the shotgun approach revealing this patient’s middle phalanx volar articular surface defect. Illustration D demonstrates the dorsal approach to this patient’s hamate templated to fit the volar defect of the middle phalanx. Illustration E demonstrates this patient’s pre- and post-operative fluoroscopic imaging.

Incorrect Answers:
Answer 1: A small portion of the medial femoral condyle can be harvested as a vascularized autograft and is commonly utilized for scaphoid nonunion cases without arthritic changes. However, it does not contain the hyaline articular cartilage surface needed for this patient.
Answer 2: The iliac crest is one of the most utilized donor sites for autograft bone harvest. It can be utilized as a non-vascularized or vascularized bone graft with predictable outcomes. However, this patient requires a bone graft with a hyaline articular cartilage surface.
Answer 3: A large portion of the fibula can be harvested as a vascularized bone graft +/- a skin paddle. This is a powerful graft that can be utilized in long-bone diaphyseal defects. However, it is far too large and lacks the hyaline articular cartilage surface required for this patient.
Answer 4: The metaphysis of the distal radius can be utilized to obtain non-vascularized corticocancellous autograft. This is often performed using an inlay (Russe) or interposition (Fisk) technique for the treatment of scaphoid nonunion. However, it lacks the hyaline articular cartilage surface needed for this patient.