DIP joint arthrodesis Fusion of the DIP joint occurs similarly to the PIP joint and is typically the only viable solution to painful arthritis of this joint. Although DIP arthroplasty (i.e., replacement) procedures are possible, the DIP joints are typically unstable and become damaged easily (Rongières, 2013). Following surgical exposure of the joint using an H-shaped incision, the ligaments and terminal tendon are retracted and preserved. The DIP joint is taken apart and the joint surface is removed. The bone ends are made congruous (either flat or cup in cone) and set in a slightly flexed position (zero to 15 degrees). It is better to err on the side of too much extension than too much flexion with DIP joints. In addition, it is important to ensure that the joints align vertically without rotation. Although some surgeons prefer a type of fusion that is unfixed but allows for slight movement (i.e., intentional fibrous union), the thumb and index fingers require stable fusion with the joints in slight flexion to preserve fine pinch abilities (Rongières, 2013). As with PIP arthrodesis, the surgeon determines the method of fixation. K-wires, which are often used, are placed in longitudinal and oblique alignment to hold the joint secure. These are removed when the fusion has become solid. Other methods of fixation include tension wiring, headless screws, and specialized staples (Rongières, 2013). Although seemingly innocuous, fusion of the DIP joint can lead to the quadriga effect, a condition in which nonsurgical digits are unable to flex completely due to the lack of motion of the common flexor digitorum profundus muscle (Schreuders, 2012). As with the other methods of fusion, a client who undergoes DIP joint fusion is referred to therapy for motion exercise of noninvolved joints, edema control, and protective orthoses. Therapeutic intervention following joint arthrodesis Fusion also restores alignment of joints that are severely flexed or laterally bent—positions that lead to significant functional limitations in activities requiring fine motor skills. A joint undergoing fusion is typically immobilized in a postsurgical dressing for 10 to 14 days prior to referral to therapy. At that time, the therapist fabricates a finger-based orthosis to hold the joint in place while the fusion continues to heal. The client is instructed as needed in wound care and edema control techniques (Cannon, 2020). Edema control includes use of light compressive dressings such as gauze and Coban worn under the orthosis (Cannon, 2020). The orthoses are the same as those shown in Figures 13 and 14, and must be held securely in place to avoid displacement. Following surgery, the client is instructed to complete active and passive ROM exercises to joints surrounding the surgical joint that are stiff because of immobilization (Cannon, 2020). If pins are in place to secure the joint while the fusion solidifies, daily pin care using hydrogen peroxide (applied with a cotton swab) and antibiotic ointment can be instituted as prescribed by the surgeon. As the wound closes and the scar begins to mature, scar control using massage and silicone gel sheets can also be started 48 hours after suture removal to reduce sensitivity and improve appearance. Scar control through gentle cross-friction and circular massage assists with the reorganizing of collagen fibers of soft tissue to enhance suppleness and decrease adhesions that may contribute to pain. Massage with lotion should be conducted several times per day for about three minutes per session. Lotion or oil containing vitamin E is typically recommended for scars; however, no strong evidence exists for its use (Tanaydin et al., 2016). Silicone sheets and topical creams are meant to work by blocking moisture escaping from the skin. The buildup of pressure in the cells reduces the amount of oxygen supplied, and is thus believed to decrease the density of scar tissue. This popular method of scar reduction is supported anecdotally, but has minimal empirical evidence (O’Brien & Jones, 2013).
(Cannon, 2020). Gentle strengthening can also be initiated during this time if there is no extensor lag. Any orthoses should be discontinued at 12 to 14 weeks postsurgery; however, buddy taping/strapping may continue until week 16, especially for heavy activities, to avoid any lateral stress to the PIP joint (Cannon, 2020). PIP joint arthrodesis As stated previously, depending on the needs of the client, a joint fusion accomplishes the goals of reducing pain and preserving function that is diminished by pain. When fusing the PIP joint, the joint is placed in maximum flexion by the surgeon, who then removes the distal end of the proximal phalanx, creating a volar slope. The articular cartilage is removed from the middle phalanx. The angle of hyperflexion is reduced, and the ends of the bones are brought together (Leibovic, 2007). The PIP joint is placed in a flexed position, making it more functional for the client during grasping activities, yet not so flexed as to impair release. According to Leibovic (2007), the following degrees of flexion are appropriate, based on the digit being fused: Index finger PIP 20 to 25 degrees Long finger PIP 30 degrees Ring finger PIP 40 degrees Small finger PIP 40 to 50 degrees Joint fusion is achieved in several ways, depending on the choice of the surgeon. Longitudinal and oblique Kirschner wires (K-wires) can be used, or alternatively, Herbert screws or small dorsal plates (particularly if bone loss is present) are options (Figure 17). Following closure of the joint capsule and skin, the joint is placed in a surgical dressing. Figure 17: Arthrodesis of Distal Interphalangeal Joint
Note: OA “X-ray of distal interphalangeal joint arthrodesis, left hand” by Jmarchn, used under Creative Commons license BY-SA 3.0. Within two weeks following surgery, the client is referred to therapy for fabrication of orthoses, as well as education on orthosis use and care (Leibovic, 2007).
EliteLearning.com/ Physical-Therapy
Book Code: PTNY1024
Page 14
Powered by FlippingBook