Arthrodesis of the Distal Interphalangeal (DIP) Joint of the Right Ring Finger for Arthritis
Table of Contents
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.
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.
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
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
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.
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
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
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
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.
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
- 2.0–2.7-mm HCS
Nothing to disclose.
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.
- Spies CK, Langer M, Hahn P, Müller LP, Unglaub F. The treatment of primary arthritis of the finger and thumb joint. Dtsch Arztebl Int. 2018;115(16):269-275. doi:10.3238/arztebl.2018.0269.
- Favero M, Belluzzi E, Ortolan A, et al. Erosive hand osteoarthritis: latest findings and outlook. Nat Rev Rheumatol. 2022;18(3):171-183. doi:10.1038/s41584-021-00747-3.
- Wilder FV, Barrett JP, Farina EJ. Joint-specific prevalence of osteoarthritis of the hand. Osteoarthritis Cartilage. 2006;14(9):953-957. doi:10.1016/j.joca.2006.04.013.
- Heinonen A, Leppänen O, Huhtala H, Karjalainen T, Jokihaara J. Factors influencing bone union in finger distal interphalangeal and thumb interphalangeal joint arthrodesis. J Hand Surg Asian Pac Vol. 2020;25(2):184-191. doi:10.1142/S2424835520500216.
- Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis with the Herbert headless compression screw: outcomes and complications in 64 consecutively treated joints. Hand (NY). 2011;6(1):56-59. doi:10.1007/s11552-010-9295-3.
- Vedel JC, Jorgensen RW, Jensen CH. Arthrodesis of the distal interphalangeal joint and the thumb interphalangeal joint: a retrospective comparison of Kirschner wires and the Acutrak 2 headless compression screw. The Open Orthopaedics Journal. 13(1):166-169. doi:10.2174/1874325001913010166.
- Matheron AS, Gouzou S, Collon S, Bodin F, Facca S, Liverneaux P. Comparison of distal interphalangeal fusion with and without joint preparation in cases of stage IV chondropathy. Chir Main. 2015 Jun;34(3):134-40. doi:10.1016/j.main.2015.03.002.
- Renfree KJ. Percutaneous in situ versus open arthrodesis of the distal interphalangeal joint. J Hand Surg Eur Vol. 2015 May;40(4):379-83. doi:10.1177/1753193414527387.
- Han SH, Cha YS, Song WT. Arthrodesis of distal interphalangeal joints in the hand with interosseous wiring and intramedullary K-wire fixation. Clin Orthop Surg. 2014;6(4):401-404. doi:10.4055/cios.2014.6.4.401.
- Marshall M, Watt FE, Vincent TL, Dziedzic K. Hand osteoarthritis: clinical phenotypes, molecular mechanisms and disease management. Nat Rev Rheumatol. 2018;14(11):641-656. doi:10.1038/s41584-018-0095-4.
- Villafañe JH, Valdes K. Combined thumb abduction and index finger extension strength: a comparison of older adults with and without thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):238-244. doi:10.1016/j.jmpt.2013.05.004.
- Harris PA, Hart DJ, Dacre JE, Huskisson EC, Spector TD. The progression of radiological hand osteoarthritis over ten years: a clinical follow-up study. Osteoarthritis Cartilage. 1994;2(4):247-252. doi:10.1016/s1063-4584(05)80076-7.
- Paradowski PT, Lohmander LS, Englund M. Natural history of radiographic features of hand osteoarthritis over 10 years. Osteoarthritis Cartilage. 2010;18(7):917-922. doi:10.1016/j.joca.2010.04.008.
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Cite this article
Rangavajjula LP, Kachooei AR, Ilyas AM. Arthrodesis of the distal interphalangeal (DIP) joint of the right ring finger for arthritis. J Med Insight. 2023;2023(333). doi:10.24296/jomi/333.
Table of Contents
- 1. Introduction
- 2. Patient Preparation
- 3. Incision
- 4. Opening and Exposure of Joint
- 5. Debridement of Articular Cartilage down to Subchondral Bone
- 6. Confirmation of Adequate Debridement and Alignment via Fluoroscopy
- 7. Guidewire Insertion
- 8. Measurement for Screw Length
- 9. Screw Placement and Compression of Joint
- 10. Confirmation of Final Screw Position
- 11. Closure with Tenodermodesis Technique
- 12. Post-op Remarks
- Mark Incision
- Apply Finger Tourniquet
- Excision of Redundant Skin Proximally
Distal interphalangeal joint arthritis, or DIP joint arthritis, is second only to thumb basal joint arthritis in terms of the most symptomatic arthritis of the hand often necessitating surgical intervention. The technique being demonstrated here is an arthrodesis of the distal interphalangeal joint. The indication for this technique is pain, deformity, and dysfunction. The technique being demonstrated here is being performed under just local anesthesia in a wide-awake hand surgery fashion.
You'll notice the patient here has advanced arthritic changes of the ring finger DIP joint and has previously undergone index and middle finger DIP arthrodesis. Now the ring finger will be performed today. The technique requires the use of a headless compression screw. Here a 2.4 headless compression screw will be used.
Because the anesthesia being used is only a digital block with minimal lidocaine and epinephrine in the surgical site directly, a finger tourniquet is also being applied.
The exposure is achieved entirely dorsally, so the incision is placed directly across the DIP joint dorsally. The incision is placed full thickness through the skin, tendon, and the dorsal joint capsule.
The joint is then opened, and the collaterals are also taken down to fully expose the joint. Care is taken not to injure the flexor tendon deep to the joint on the volar side.
With the DIP joint fully exposed and the articular surface of the middle phalanx's head and the distal phalanx space exposed, a rongeur is used to debride off the articular cartilage down to subchondral bone. I find it as easier to debride the middle phalanx's head first before progressing to the distal phalanx space, because once the middle phalanx has been debrided the distal phalanx space is better exposed. Generally, that distal side is harder to debride of articular cartilage. It is often helpful to elevate the soft tissue off of the dorsum of the distal phalanx space as shown here, even extending the flap distally around the nail may also be helpful to fully expose the base to get the articular cartilage off.
Once debrided, the fluoroscopy machine can be brought in to confirm adequate debridement down to subchondral bone as well as to make sure adequate alignment has been restored and any deformity corrected. This should be checked on both the PA and lateral views. Extra osteophytes that have been left behind can also be assessed now and debrided away.
Once satisfied with the joint debridement and alignment of the arthrodesis site, the guidewire for the headless compression screw is prepared to be inserted. I recommend using an inside-out technique where the guidewire is first placed across the distal phalanx in the desired center, center position and then reversed into the middle phalanx. The inside-out technique is being shown here. Once happy with the alignment of the guidewire, that guidewire is then removed, flipped around, so that the blunt end is then directed into the distal phalanx until only a bit of the sharp end is showing within the arthrodesis site. This will then allow the sharp end to be then placed retrograde into the middle phalanx under direct visualization. Here, reversal of the pin and alignment of the arthrodesis site is demonstrated on fluoroscopy. Once satisfied with the alignment, the pin can then be advanced into the middle phalanx. Here the pin can be seen being advanced retrograde back into middle phalanx and then confirmed on fluoroscopy.
Next, the screw length is measured. I generally find the available cannulated depth gauges to be unhelpful, because the length of the screws should be such that it is countersunk below the head of the distal phalanx and should end within the isthmus of the middle phalanx. So oftentimes, what is more helpful is simply measuring a screw on fluoroscopy to fit that desired length.
Next, the cannulated drill is placed across the guidewire to create the path for the headless compression screw, and finally, the screw is placed across the guidewire and advance into the distal phalanx in a retrograde fashion. To achieve maximal compression across the arthrodesis site, I recommend compressing the arthrodesis site externally to achieve what I refer to as macro-compression and then allow the headless compression screw to achieve a micro-compression.
Here, final position of the screw is confirmed making sure that the screw head is adequately countersunk within the distal phalanx, and that there is good contact and compression without gapping across the arthrodesis site. Also, prior to washing the wound and closure, restoration of normal rotation of the finger should also be confirmed with active flexion of the finger by the patient to make sure that the alignment is appropriate.
If there is excessive redundancy of the skin, the proximal aspect of the skin can be excised to improve the closure. Also, I find it helpful to repair the skin in a tenodermodesis technique. That involves repairing the skin and the underlying extensor tendon in one throw. That helps bulk up the closure dorsally and cover the arthrodesis site. I use simple 4-0 nylon sutures as demonstrated here. Once closed, a soft dressing is applied. The patient is allowed to move the finger immediately. Obviously, the the DIP joint will not move, but early motion overall is encouraged. The dressing can be removed in two days, and the sutures can be removed in two weeks.
I typically check radiographs again at two weeks and 12 weeks postoperatively to confirm healing of the arthrodesis site. The patient is allowed to return to activities as tolerated immediately. The last thing to discuss is a word of warning. Sometimes fingers can be larger, and a larger screw can be used. In this case, a 2.4 screw was used. More commonly and more troublesome is that some fingers are smaller and have difficulty accepting a headless screw. I would refer you to a study published by one of our former fellows who looked at the diameter of screws and found that some fingers require smaller screws such as closer to 2.0 to meet the diameter of the canal of the distal phalanx and middle phalanx.