Surgical management and postsurgical occupational therapy intervention Surgical management of the PIP and DIP joints is usually undertaken as a last resort when deformities interfere with functional abilities or pain is limiting engagement in desired occupations. Proximal interphalangeal joint arthroplasty (i.e., replacement) is one surgical approach for severe OA of the PIP joint, but it can be difficult for such small joints. Arthrodesis, or fusion, of the joint is the easier surgical procedure, and the optimum choice for the DIP. It might also be the first choice for the proximal interphalangeal joint, depending on the age and lifestyle of the client. ROM is lost when a joint is fused, and although this might not be problematic for an older individual, it might interfere with function in, for example, a younger musician (Gabay & Gabay, 2013). PIP arthroplasty
of rest, the client begins hand therapy with a therapist for postsurgical management and rehabilitation of the joint(s) (Gabay & Gabay, 2013). Therapeutic intervention following PIP arthroplasty Postoperative PT/OT is of paramount importance to the success of the arthroplasty. One of the most important considerations for the practitioner is to ensure that the client is able to participate as desired in daily living tasks. During the period of recovery from PIP arthroplasty, the client might have only one hand available for use in personal self-care, work, and leisure pursuits. It is recommended that the OT complete an occupational profile to understand any areas of concern for the client and brainstorm various ways, including equipment items needed, to substitute for lost function and motion. Therapists must also consider the impact of a required protection orthosis on a client’s occupational performance. Both dynamic and static orthosis designs are recommended in postoperative protocols and the literature; however, a dynamic orthosis can involve challenges for a client such as easily threading their arm through a shirt or jacket sleeve. Clients with cognitive deficits may also have difficulty wearing a dynamic orthosis due to the complexity of donning and doffing it appropriately and concurrently maintaining postoperative restrictions. In these scenarios, it may be more feasible to use a static orthosis. In fact, researchers have noted similar outcomes in pain reduction, range of motion, and strength between clients treated with either a static orthosis or dynamic orthosis following PIP arthroplasty (Riggs et al., 2011). Furthermore, static orthoses are easier to fabricate and may be a better option for the less experienced therapist. Dynamic orthosis protocol During the first therapy visit, occurring from four to seven days following surgery, a dynamic PIP joint extension orthosis is fabricated to allow the client to flex the PIP joint to 30 degrees and allow the rubber band to return the joint to neutral. This limited movement allows time for healing of the extensor apparatus. When multiple fingers are involved, a dorsal forearm- based orthosis is fabricated that extends to the proximal phalanx, leaving the PIP joints free. A finger sling attached to monofilament and rubber bands is placed on the middle phalanx. To ensure that 30 degrees is maintained without additional flexion, a stop can be added to the monofilament as it crosses the outrigger to prevent additional movement of the joint. The client is instructed to complete 10 repetitions of flexion each waking hour. The goal of the orthosis is to provide proper protection and allow a limited arc of flexion from zero to 30 degrees at the PIP joint. Hyperextension of the PIP or extension lag (i.e., lack of full PIP extension) should be avoided, and therapy/orthosis should be adjusted immediately if either is present. Appropriate tensioning of the rubber bands, with close monitoring, minimizes development of these complications. If hyperextension is present, a small dorsal-based extension block can be secured over the PIP in a fashion similar to a gutter orthosis in order to block the PIP joint at 30 degrees or more, and active flexion to 60 degrees is then allowed. This creates a slight flexion contracture, which is more desirable than a nonfunctional hyperextended joint. Rotational deformities can occur and are treated with derotational slings affixed to an outrigger on the lateral sides of the orthosis. This traction helps avoid pronation or supination of the digits through the PIP joint (Gabay & Gabay, 2013). Lubahn and colleagues (2011) described an alternative to a dynamic orthosis, involving two static orthoses that are used as exercise templates to limit joint movement at the desired number of degrees (Figure 15). These are used throughout the day and preclude the need to create a dynamic orthosis that some clients find difficult to use.
The goal of any arthroplasty is to restore stability to the joint and thereby reduce pain (Zhu et al., 2018). When a PIP arthroplasty is indicated, surgeons can use a variety of implant types to achieve these objectives. Silicone The Swanson silicone arthroplasty implant remains the preferred option for many surgeons, as it continues to provide reliable outcomes with high client satisfaction (Lubahn et al., 2011). Used to maintain phalanx alignment and space at the joint, a silicone implant may not allow normal biomechanics at the PIP joint, leading to a limited arc of motion at only 25/75 degrees (Cannon, 2020; Lubahn et al., 2011). Even so, this type of implant may be appropriate for older clients or those with fewer occupational and task demands (Lubahn et al., 2011). Pyrocarbon Pyrocarbon is a strong, fatigue- and wear-resistant, ceramic-like material made of pyrolytic carbon. Pyrocarbon is the resurfacing arthroplasty of choice for many more experienced surgeons in comparison to the Swanson silicone implant (Lubahn et al., 2011). The pyrocarbon device is a two-component, bicondylar, semiconstrained prosthesis designed to replace the articulating surfaces of the PIP joint and accommodate maximum anatomic ROM. Pyrocarbon is superior to silicone implants because pyrocarbon reproduces the joint surface more accurately, thereby improving biomechanics. Since less bone is removed with pyrocarbon than with silastic implants, the collateral ligaments are preserved, and this aids greatly in joint stability. Unfortunately, in cases in which ligamentous tissue is minimal, reconstruction does not provide adequate stabilization, and subluxation, dislocation, lateral/longitudinal deformities, and loss of motion can occur (Lubahn et al., 2011). The surgical procedures for resurfacing arthroplasties vary greatly depending on the type and brand of implant used, as well as the client’s unique anatomy and quality of the joint and soft tissues (Lubahn et al., 2011). Surgeons can use a dorsal, volar, or lateral approach to access the involved joint. Each approach involves different released or repaired structures that will require protection during recovery. It is imperative for the OT practitioner to verify the surgical approach and explicit postoperative treatment protocol with the surgeon to ensure exercises and orthotics utilized are appropriate and necessary. For example, the collateral ligaments or even the central slip may be released during the procedure, and both require different orthotics for protection. Additionally, mobilization is delayed if the central slip was repaired, whereas immediate AROM is permitted following only collateral ligament release (Lubahn et al., 2011). One surgical technique involves a dorsal incision to the middle and proximal phalanges, which provides full exposure of the joint. The capsule is open with preservation of intact ligamentous tissue. Once exposed, the PIP joint is hyperflexed to expose the ends of each phalanx. The ends of the bone are removed and replaced with the pyrocarbon arthroplasty. Once the pyrocarbon device is in place and tested, the surrounding ligamentous capsule is sutured and the skin closed. Following several days
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