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PIP joint approach
This document outlines the surgical approaches, pearls, pitfalls, and complications for proximal interphalangeal joint (PIPJ) surgery. It discusses the volar, dorsal, and lateral approaches. The volar approach is useful for implant arthroplasty, open reduction and internal fixation, and corrective osteotomies. The dorsal approach traditionally damages the extensor tendon but can be modified. The lateral approach provides access while partially releasing surrounding structures. Complications include extensor lag, poor range of motion, and disturbance to surrounding tissues. Careful surgical technique and anatomic preservation are emphasized.
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PIP joint approach
- 2. Volume 41, published2016 Received for publication August 11, 2015 Accepted in revised form November 15, 2015 Impact Factor: 1.64
- 3. Andre Eu-Jin Cheah,MD, MBA Assistant Professor Department of Orthopaedic Surgery Yong Loo Lin School of Medicine National University of Singapore Consultant Department of Hand & Reconstructive Microsurgery University Orthopaedics, Hand & Reconstructive Microsurgery Cluster National University Health System, Singapore
- 4. Jeffrey Yao, MD AssociateProfessor Robert A. Chase Hand and Upper Limb Center, Department of Orthopaedic Surgery, Stanford University Medical Center, Redwood City, CA Affiliation International Wrist Investigators Workshop American Academy of Orthopaedic Surgeons American Society for Surgery of the Hand American Association for Hand Surgery Arthroscopy Association of North America
- 5. Outline • Surgical Anatomy •Introduction • Surgical Approach – Volar approach – Dorsal approach – Lateral approach • Pearls and Pitfalls • Complications • Recommendations
- 6. • Surgical Anatomy •Introduction • Surgical Approach – Volar approach – Dorsal approach – Lateral approach • Pearls and Pitfalls • Complications • Recommendations
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- 8.
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- 10. • Surgical Anatomy •Introduction • Surgical Approach – Volar approach – Dorsal approach – Lateral approach • Pearls and Pitfalls • Complications • Recommendations
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- 13. • Surgical Anatomy •Introduction • Surgical Approach – Volar approach – Dorsal approach – Lateral approach • Pearls and Pitfalls • Complications • Recommendations
- 14. Volar Approach Implant arthroplasty ORIF Correctiveosteomy Hemi-hamate arthroplasty Volar plate arthroplasty Bruner Bruner-midlaterral hybrid Zigzag
- 16.
- 17. 我 是 分隔 線 VP VP
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- 19.
- 20. For greater exposure,ex: arthroplasty PCL
- 21. Alternate Approach bySimmen
- 22. Dorsal Approach Implant arthroplasty ORIF Correctiveosteomy Midline longitudinal Curvilinear Lazy S
- 23. Preserve dorsal veinas much as possible Central slip insertion Lateral band
- 24. Approach by Swanson Centralslip insertion P1 head
- 25.
- 26. Central slip insertion P1head Collateral ligament
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- 28. Alternate Approach byChamay Restore tension of extensor apparatus Collateral ligament
- 29. Alternate Approach Not completedetach of central slip No repair of extensor tendon required
- 30. Lateral Approach Implant arthroplasty ORIF Middleof P1 Middle of P2
- 31. PCL ACL VP P1 head Release ofACL Proximal release of PCL VPFlexor tendon VP
- 32. Partial lateral releaseof VP Repair of VP and PCL after implant insertion VP
- 33. • Surgical Anatomy •Introduction • Surgical Approach – Volar approach – Dorsal approach – Lateral approach • Pearls and Pitfalls • Complications • Recommendations
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- 35. Single FDS sliprelease
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- 37. Dorsal Approach Conservation ofthe central slip Chamay appraoch Restore tension
- 38. Bias dissection todorsal half Lateral Approach
- 39. Shotgunned? Recession but notcomplete release Without affecting finger function or lateral stability
- 40. • Surgical Anatomy •Introduction • Surgical Approach – Volar approach – Dorsal approach – Lateral approach • Pearls and Pitfalls • Complications • Recommendations
- 43. Extensor lag of5’-20 despite approach AROM poor in arthroplasty compared with short term fracture fixation Decrease of DIP AROM disturbance to lateral band
- 45. • Surgical Anatomy •Introduction • Surgical Approach – Volar approach – Dorsal approach – Lateral approach • Pearls and Pitfalls • Complications • Recommendations
- 46. Central slip reconstruction FDStenodesis Access to base of P2 Access to head of P1 Dorsal Volar Volar Dorsal Guided by Surgeon’s experience !!!
Editor's Notes
- #4 Impact factor 0.47
- #10 lateral bands are stabilized centrally by the triangular ligament. And laterally by TRL TRL: originates from the flexor sheath at the level of the PIP joint and inserts into the lateral bands
- #15 2, 3 more surgical exposure
- #18 Left:Proximal interphalangeal joint VP (asterisk) is accessed after retracting the flexor tendons to one side. Right:Alternative route to the VP (asterisk) between the 2 slips of the FDS
- #21 the proximal attachment of the PCLs may be released proximally or distally to allow the joint to be shotgunned open
- #22 The flexor sheath and ACLs are incised between the A2 and A4 pulley on either side of the VP
- #23 2, 3 more surgical exposure
- #25 Longitudinal split of the entire central slip with elevation of the 2 halves laterally with each lateral band, to expose the articular surface and the collateral ligaments Black and red asterisks show the central slip insertion and P1 head, respectively. Dashed lines indicate the split extensor tendon. proximal release of one collateral ligament (blue asterisk). Black asterisk shows the central slip insertion; dashed line shows the intact collateral ligament.
- #26 Black and red asterisks show the central slip insertion and P1 head, respectively. Dashed lines indicate the split extensor tendon. proximal release of one collateral ligament (blue asterisk). Black asterisk shows the central slip insertion; dashed line shows the intact collateral ligament.
- #27 Black and red asterisks show the central slip insertion and P1 head, respectively. Dashed lines indicate the split extensor tendon. proximal release of one collateral ligament (blue asterisk). Black asterisk shows the central slip insertion; dashed line shows the intact collateral ligament.
- #28 2 drill holes are made at the base of P2 at the insertion of the central slip, a nonabsorbable 3-0 or 4-0 suture is passed through these holes, and a subsequent mattress repair of the central slip is done
- #29 Distally based triangular extensor tendon flap designed (dashed line). Asterisk shows the central slip attachment. The triangular tendon flap is then raised to expose the distal P1, collateral ligaments (blue asterisks), and articular surface while preserving the central slip attachment (black asterisk).
- #30 Interval between the central slip and lateral bands can be used as access to the PIP joint. The black asterisk shows the central slip attachment, the red asterisk indicates the P1 head, and the dashed line shows the tendon split.
- #31 A midlateral skin incision is made from the middle of the P1 to the middle of the P2
- #39 A window is made in the lateral surface of the flexor sheath to identify and protect the flexor tendons before the VP (black asterisk) is incised
- #40 recession but not complete release
- #42 Extensor lag of 5’-20’in every approach AROM poor in arthroplasty compared with short term fracture fixationrecurring soft tissue change in arthrosis Decrease of DIP AROM disturbance to lateral band