PIP JOINT ARTHRITIS
Osteoarthritis | Post-Traumatic | Silicone Arthroplasty | Arthrodesis
Eaton-Littler Classification (PIP Arthritis)
Critical Must-Knows
- PIP Anatomy: Collateral ligaments (proper and accessory), volar plate, central slip insertion.
- Bouchard Nodes: Dorsal osteophytes at PIP joint in primary OA.
- Arthrodesis Angle: 40° index, 45° middle, 50° ring, 55° small finger.
- Silicone Arthroplasty: Best for low-demand patients, preserves 60-70° arc of motion.
- Surface Replacement: For younger active patients, requires intact collaterals.
Examiner's Pearls
- "Index finger arthrodesis at 40° (pointing/pinch)
- "Middle finger can tolerate arthroplasty (motion needed)
- "Unstable joints: arthrodesis over arthroplasty
- "Check collateral ligaments before surface replacement
Critical PIP Joint Arthritis Exam Points
Arthrodesis Angles
Increasing flexion from radial to ulnar. Index 40° (pinch), Middle 45°, Ring 50°, Small 55°. Functional position for power grip.
Collateral Ligament Integrity
Essential for surface replacement success. Intact proper and accessory collaterals required. Incompetent ligaments = arthrodesis.
Silicone vs Surface Replacement
Silicone: Low-demand, elderly, multiple digits. Surface: Young, active, isolated joint. Know the indications.
Post-Traumatic Arthritis
Common after fracture-dislocation. Central slip injury leads to boutonniere. Volar plate injury leads to swan-neck. Address deformity first.
Surgical Options for PIP Arthritis
| Procedure | Best Indication | Motion Preserved | Durability | Key Limitation |
|---|---|---|---|---|
| Silicone Arthroplasty | Low-demand, elderly, multiple digits | 60-70° arc | 10-15 years | Fracture, subsidence, synovitis |
| Surface Replacement | Young, active, isolated joint | 70-80° arc | 5-10 years | Requires intact collaterals, expensive |
| Arthrodesis | High-demand, unstable, index finger | 0° (fused) | Permanent | Loss of motion, non-union risk |
IMRS 40-45-50-55PIP Arthrodesis Angle
Memory Hook:IMRS = Index-Middle-Ring-Small. Each digit increases 5° of flexion from radial to ulnar for optimal cascade and grip function.
PCAVPIP Joint Stability Structures
Memory Hook:PCAV = the 4 key stabilizers of PIP joint. All must be assessed before considering surface replacement arthroplasty.
HILUIndications for Arthrodesis over Arthroplasty
Memory Hook:HILU = when to fuse the PIP joint. High-demand, Index, Ligament injury, Unstable joint = choose arthrodesis.
Overview and Epidemiology
Why PIP Arthritis Matters
PIP joint arthritis is a common viva topic. Examiners test understanding of surgical decision-making: when to fuse vs replace, optimal arthrodesis angles, assessment of collateral ligament integrity. Know the functional demands of each finger.
PIP Joint Arthritis encompasses degenerative, post-traumatic, and inflammatory conditions affecting the proximal interphalangeal joint, resulting in pain, stiffness, and functional impairment.
Demographics
- Prevalence: 10-15% of adults over 60 years
- Gender: Female greater than male (3:1) for primary OA
- Age: Peak 50-70 years
- Digits: Middle and index most commonly affected
- Occupation: Higher in manual laborers
Post-traumatic arthritis affects younger patients (30-50 years) following fracture-dislocations.
Etiology
- Primary osteoarthritis: Idiopathic, Bouchard nodes
- Post-traumatic: Fracture-dislocation, chronic instability
- Inflammatory: Rheumatoid arthritis, psoriatic arthritis
- Crystalline: Gout, pseudogout
- Septic sequelae: Prior infection with cartilage loss
Post-traumatic is the most common surgical etiology.
Pathophysiology
PIP Joint Anatomy
The PIP joint is a hinge joint with critical soft tissue stabilizers: proper collateral ligaments (tight in flexion), accessory collateral ligaments (tight in extension), volar plate (prevents hyperextension), and central slip insertion (maintains extension). Understanding these structures is essential for surgical planning.
PIP Joint Anatomy:
- Bony Structure: Bicondylar head of proximal phalanx articulating with base of middle phalanx
- Proper Collateral Ligaments: Origin dorsal to axis of rotation, tight in flexion
- Accessory Collateral Ligaments: Insert on volar plate, tight in extension
- Volar Plate: Fibrocartilaginous structure preventing hyperextension
- Central Slip: Insertion on dorsal base of middle phalanx for extension
Pathophysiology of Primary OA:
- Progressive cartilage loss from repetitive microtrauma
- Subchondral bone sclerosis and cyst formation
- Marginal osteophyte formation (Bouchard nodes)
- Synovial inflammation and joint capsule contracture
- Progressive pain, stiffness, and loss of motion
Post-Traumatic Arthritis:
- Intra-articular fracture malunion causing incongruity
- Chronic instability from ligament injury
- Avascular necrosis of middle phalanx base
- Central slip injury leading to boutonniere deformity
- Volar plate injury leading to swan-neck deformity
Classification Systems
Eaton-Littler Classification (PIP Arthritis)
| Grade | Radiographic Findings | Clinical Features | Treatment |
|---|---|---|---|
| Grade I | Synovitis, minimal changes | Pain, mild stiffness, preserved motion | NSAIDs, splinting, activity modification |
| Grade II | Joint space narrowing, early osteophytes | Moderate pain, 20-30° motion loss | Conservative, intra-articular injection |
| Grade III | Significant joint space loss, bone-on-bone | Severe pain, stiffness, functional limitation | Arthroplasty or arthrodesis |
| Grade IV | Severe destruction with subluxation or instability | Severe pain, deformity, ligament incompetence | Arthrodesis preferred |
Clinical Application:
- Grades I-II: Trial conservative management for 3-6 months
- Grade III: Surgical decision based on patient demands and joint stability
- Grade IV: Arthrodesis preferred due to ligament incompetence
This classification system guides surgical decision-making for PIP arthritis.
Clinical Assessment
History
Chief Complaint:
- Pain at PIP joint, worse with gripping activities
- Stiffness, especially in morning or after rest
- Difficulty with fine motor tasks (buttoning, writing)
- Swelling and visible deformity (Bouchard nodes)
Associated Symptoms:
- Weakness of grip strength
- Catching or locking sensation (loose bodies)
- Cold intolerance in post-traumatic cases
- Multiple joint involvement (inflammatory arthritis)
Physical Examination
Inspection
- Bouchard Nodes: Dorsal osteophytes at PIP joint (primary OA)
- Deformity: Flexion or extension contracture, swan-neck, boutonniere
- Erythema: Suggests inflammatory or crystalline arthritis
- Muscle Wasting: Intrinsic atrophy in chronic cases
Palpation
- Tenderness: Localized to PIP joint line
- Crepitus: Grinding sensation with passive motion
- Osteophytes: Palpable dorsal or lateral bony prominences
- Joint Stability: Assess collateral ligaments with radial/ulnar stress
Range of Motion
- Active ROM: Compare to contralateral hand
- Passive ROM: Assess for fixed vs dynamic contracture
- Extensor Lag: Central slip insufficiency (boutonniere)
- Hyperextension: Volar plate incompetence (swan-neck)
Special Tests
| Test | Technique | Positive Finding | Interpretation |
|---|---|---|---|
| Collateral Stress | Radial/ulnar deviation at 30° flexion | Greater than 20° laxity or no endpoint | Ligament incompetence, arthrodesis indicated |
| Volar Plate Integrity | Hyperextension stress test | Greater than 30° hyperextension | Volar plate injury, swan-neck risk |
| Central Slip Test | Elson test (90° flexion, resist extension) | Weak or absent middle phalanx extension | Central slip disruption, boutonniere |
| Tenodesis Effect | Passive wrist flexion/extension | PIP motion less than 30° arc | Severe joint contracture or adhesions |
Red Flags
Red Flags in PIP Arthritis
- Acute inflammation with fever: Septic arthritis until proven otherwise
- Rapid progression: Consider inflammatory or crystalline arthropathy
- Severe instability: Risk of dislocation, urgent surgical planning
- Vascular compromise: Check for arterial injury in trauma cases
Investigations
Imaging
Radiographs (PA, Lateral, Oblique)
- Joint Space Narrowing: Loss of articular cartilage
- Subchondral Sclerosis: Increased bone density
- Osteophytes: Bouchard nodes on dorsal and lateral aspects
- Subchondral Cysts: Geodes from synovial fluid intrusion
- Subluxation: Joint incongruity or malalignment
Advanced Imaging
- CT Scan: Assess intra-articular fracture malunion, bone loss, surgical planning
- MRI: Evaluate cartilage loss, ligament integrity, synovitis, loose bodies
- Ultrasound: Dynamic assessment of collateral ligaments, synovitis
Laboratory Tests
For Inflammatory Arthritis:
- Rheumatoid Factor (RF): Positive in 70-80% of RA
- Anti-CCP Antibodies: Specific for RA
- ESR/CRP: Elevated in active inflammation
- Uric Acid: Elevated in gout
- ANA: Positive in systemic lupus erythematosus
For Crystalline Arthropathy:
- Joint Aspiration: Synovial fluid analysis for crystals
- Monosodium Urate: Needle-shaped, negative birefringence (gout)
- Calcium Pyrophosphate: Rhomboid, positive birefringence (pseudogout)
Management Algorithm
Conservative Management
Indications:
- Mild to moderate symptoms (Eaton-Littler Grade I-II)
- Patient refuses surgery or unfit for surgery
- Trial before surgical decision
Non-Pharmacological
Splinting:
- Buddy Taping: Tape affected digit to adjacent finger for stability
- Static Splint: Maintain joint in functional position (40-45° flexion)
- Serial Splinting: Progressive correction of contracture over 6-12 weeks
- Night Splint: Prevent flexion contracture during sleep
Occupational Therapy:
- Activity modification to reduce joint stress
- Adaptive devices for ADLs (buttonhooks, jar openers)
- Joint protection education
- Range of motion exercises to maintain flexibility
Pharmacological
NSAIDs:
- Topical: Diclofenac gel applied 3-4 times daily
- Oral: Ibuprofen 400mg TDS, Naproxen 500mg BD
- Duration: 4-6 weeks trial, use lowest effective dose
- Caution: GI bleeding, renal impairment in elderly
Intra-Articular Injection:
- Corticosteroid: Triamcinolone 10mg or methylprednisolone 20mg
- Technique: Dorsal approach, avoid extensor mechanism
- Frequency: Maximum 3 injections per year
- Efficacy: 50-70% experience pain relief for 3-6 months
Success Rate: Conservative management provides satisfactory symptom control in 40-60% of patients with mild to moderate arthritis. Failure of 3-6 months of conservative treatment warrants surgical consideration.
Conservative management is the first-line approach for most patients with PIP arthritis.
Surgical Technique
Silicone (Swanson) Arthroplasty
Indications:
- Low-demand patients (elderly, sedentary)
- Desire for motion preservation
- Stable joint with competent collaterals
- Multiple digits involved (RA)
Setup:
- Regional anesthesia (axillary block) or WALANT
- Supine position, hand table
- Tourniquet at 250 mmHg
- Fluoroscopy available
Approach:
- Incision: Dorsal curved incision over PIP joint
- Dissection: Elevate skin flaps, identify and protect digital neurovascular bundles
- Extensor Mechanism: Split central slip longitudinally or elevate radial lateral band
- Joint Exposure: Divide collateral ligaments from middle phalanx origin
Bone Preparation:
- Excise arthritic joint surfaces (proximal phalanx head and middle phalanx base)
- Resect 2-3mm of proximal phalanx distal to condyle
- Resect articular surface of middle phalanx base
- Create medullary canal in both phalanges using awls or reamers
- Trial implant to confirm appropriate sizing
Implant Insertion:
- Insert silicone spacer into proximal phalanx canal
- Reduce joint with implant stem into middle phalanx canal
- Confirm full passive flexion and extension
- Ensure no stem impingement or fracture
Closure:
- Repair central slip or lateral band with 4-0 non-absorbable suture
- Ensure extensor mechanism integrity
- Close skin with 4-0 nylon interrupted sutures
- Apply dorsal blocking splint in 30-40° flexion
Technical Pearls:
- Preserve collateral ligaments if possible for stability
- Avoid excessive bone resection (subsidence risk)
- Ensure stems fully seated in medullary canals
- Test full ROM before closure
Outcomes:
- Pain relief in 80-90% of patients
- Arc of motion 60-70° (40-110° typically)
- Implant survival 80% at 10 years, 60% at 15 years
- Complications: fracture (5-10%), subsidence, silicone synovitis
Silicone arthroplasty provides reliable pain relief and functional motion for low-demand patients.
Complications
Early Complications (less than 6 weeks)
| Complication | Incidence | Presentation | Management |
|---|---|---|---|
| Infection | 1-2% | Wound erythema, drainage, fever | Antibiotics, possible I&D |
| Hematoma | 2-3% | Swelling, ecchymosis, pain | Compressive dressing, elevation |
| K-wire Migration | 5-10% | Wire prominence, skin irritation | Wire removal and replacement |
| Neurovascular Injury | Less than 1% | Numbness, vascular compromise | Immediate exploration if acute |
Late Complications (greater than 6 weeks)
| Complication | Incidence | Presentation | Management |
|---|---|---|---|
| Non-Union (Arthrodesis) | 5-10% | Persistent pain, motion at fusion site | Revision with bone graft and rigid fixation |
| Implant Fracture (Silicone) | 5-10% | Sudden pain, deformity, crepitus | Revision with new implant or arthrodesis |
| Subsidence (Arthroplasty) | 10-15% | Progressive deformity, loss of motion | Observation vs revision |
| Silicone Synovitis | 5% | Pain, swelling, bone erosion (years later) | Implant removal, synovectomy, arthrodesis |
| Stiffness | 20-30% | Limited ROM despite therapy | Intensive therapy, possible manipulation |
| Instability (Surface Replacement) | 10% | Joint subluxation, pain with use | Revision to arthrodesis |
Prevention Strategies
Infection:
- Pre-operative antibiotics (Cefazolin 2g IV)
- Strict sterile technique
- Meticulous hemostasis
- Early post-operative wound monitoring
Non-Union:
- Maximize bone contact at fusion site
- Rigid internal fixation (screws or plate)
- Smoking cessation mandatory
- Consider bone graft in osteoporotic bone
Implant Failure:
- Appropriate patient selection (low-demand for silicone)
- Preserve bone stock (minimal resection)
- Ensure intact collateral ligaments for surface replacement
- Strict adherence to post-operative protocol
Stiffness:
- Early protected ROM (days 3-5)
- Occupational therapy for hand therapy
- Avoid prolonged immobilization
- Dynamic splinting if contracture develops
Postoperative Care
Post-Operative Protocol: Silicone Arthroplasty
Week 0-2: Protection Phase
- Immobilization: Dorsal blocking splint in 30-40° flexion
- Wound Care: Keep dry until suture removal at 10-14 days
- Edema Control: Elevation above heart level, ice packs
- Pain Management: Oral analgesics (paracetamol, NSAIDs)
Week 2-6: Early Motion Phase
- Splint: Remove for exercises, wear between sessions
- Therapy: Gentle active ROM exercises 5-10 minutes every 2 hours
- Goals: Achieve 0-60° arc by week 6
- Avoid: Forceful gripping, resistance exercises
Week 6-12: Strengthening Phase
- Splint: Discontinue daytime splint, night splint if flexion contracture
- Therapy: Progressive resistance exercises with therapy putty
- Goals: Achieve 60-70° arc, functional grip strength
- Return: Light ADLs at week 8, unrestricted light activities week 12
Month 3-6: Functional Phase
- Activities: Gradual return to pre-injury activities
- Restrictions: Avoid heavy gripping or impact activities (permanent)
- Goals: Pain-free functional range for ADLs
- Follow-Up: Clinical and radiographic at 3, 6, 12 months
Early mobilization is critical to prevent stiffness while protecting implant during healing.
Evidence Base
PIP Joint Arthroplasty Outcomes
- Systematic review of 40 studies comparing silicone and surface replacement arthroplasty
- Silicone implants: 60-70° arc of motion, 80% survival at 10 years
- Surface replacement: 70-80° arc but 15-25% complication rate
- Complications include loosening, instability, and squeaking
PIP Arthrodesis vs Arthroplasty: Patient Satisfaction
- Prospective comparison: 52 arthrodesis vs 46 arthroplasty patients
- Arthrodesis satisfaction 89% vs arthroplasty 76% (p less than 0.05)
- Better pain relief with arthrodesis despite motion loss
- Faster return to work: 8 weeks (arthrodesis) vs 12 weeks (arthroplasty)
Silicone vs Pyrocarbon Arthroplasty
- RCT of 180 joints: silicone vs pyrocarbon arthroplasty
- 5-year arc of motion: silicone 62° vs pyrocarbon 71° (p less than 0.01)
- Complication rate: pyrocarbon 18% vs silicone 8% (p less than 0.05)
- Pyrocarbon complications: squeaking, instability requiring revision
PIP Arthrodesis Functional Outcomes
- Long-term follow-up (8.4 years) of 112 PIP arthrodeses
- Union rate: screw 92% vs K-wire 78% (p less than 0.01)
- Overall patient satisfaction 88% despite motion loss
- Index finger arthrodesis: highest satisfaction at 94%
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Post-Traumatic PIP Arthritis in Index Finger
"A 45-year-old carpenter presents with chronic pain in the index finger PIP joint following a fracture-dislocation 2 years ago. He has failed 6 months of conservative management. Examination shows 30° fixed flexion contracture, bone-on-bone crepitus, and palpable osteophytes. Radiographs demonstrate severe joint space loss with subchondral sclerosis. He requests treatment to return to carpentry work."
Scenario 2: Primary OA in Multiple Digits - Low-Demand Elderly
"A 72-year-old retired woman presents with bilateral PIP joint arthritis affecting middle, ring, and small fingers. She has prominent Bouchard nodes, moderate pain, and 40° arc of motion. She struggles with buttoning clothes and opening jars. Radiographs show Grade III arthritis (Eaton-Littler) with significant joint space loss. She has tried NSAIDs and splinting for 4 months with minimal relief. She desires motion preservation and pain relief."
Scenario 3: Young Active Patient with Isolated PIP Arthritis
"A 52-year-old active male presents with isolated middle finger PIP arthritis. He plays recreational tennis and golfs regularly. Examination shows stable joint with intact collateral ligaments, 45° arc of motion, and significant pain. Radiographs show Grade III arthritis with preserved bone stock. He strongly desires motion preservation and asks about 'the most advanced implant options.' What would you recommend and why?"
Australian Context
PIP joint arthritis management in Australia follows international evidence-based guidelines with consideration of local practice patterns and healthcare system factors.
Epidemiology: PIP joint arthritis prevalence in Australian adults over 60 years is estimated at 10-15%, consistent with international data. Post-traumatic arthritis is common in manual labor occupations including construction, mining, and agricultural workers. Workers compensation claims for PIP arthritis are frequent in these industries.
Surgical Practice: Australian hand surgeons commonly perform silicone arthroplasty for low-demand patients and arthrodesis for high-demand individuals. Surface replacement arthroplasty is less frequently utilized due to cost constraints and mixed long-term outcomes. Arthrodesis remains the gold standard for index finger involvement and unstable joints.
Pharmaceutical Management: NSAIDs are first-line conservative treatment, available through the PBS. Topical NSAIDs (diclofenac gel) are preferred in elderly patients to reduce systemic side effects. Intra-articular corticosteroid injections are widely used with good short-term efficacy.
Antibiotic Prophylaxis: eTG guidelines recommend cefazolin 2g IV at induction for hand surgery prophylaxis, with vancomycin as alternative for penicillin allergy. Single-dose prophylaxis is standard for procedures under 2 hours duration.
Outcomes Data: The AOANJRR does not separately track PIP joint arthroplasty outcomes. Australian hand surgeons rely on international literature for patient counseling regarding expected outcomes and implant survival rates.
Return to Work: Average time to return to work following PIP arthrodesis is 8-12 weeks for manual laborers, compared to 12-16 weeks for arthroplasty. Workers compensation and total permanent impairment assessments account for loss of PIP joint function in occupational disability ratings.
PIP JOINT ARTHRITIS - EXAM ESSENTIALS
High-Yield Exam Summary
Anatomy (Must Know)
- •Proper collaterals: tight in flexion, origin dorsal to axis
- •Accessory collaterals: volar plate attachment, tight in extension
- •Volar plate: prevents hyperextension, critical for swan-neck
- •Central slip: dorsal base of middle phalanx, extension power
- •A2 and A4 pulleys: critical, never release with PIP surgery
Surgical Decision Algorithm
- •STABLE joint + LOW-demand = Silicone arthroplasty
- •STABLE joint + MODERATE-demand = Surface replacement arthroplasty
- •UNSTABLE joint or HIGH-demand = Arthrodesis
- •INDEX finger = Strong preference for arthrodesis
- •MULTIPLE digits = Avoid arthrodesis (cumulative stiffness)
Arthrodesis Angles (Critical)
- •Index: 40° flexion (pointing, pinch precision)
- •Middle: 45° flexion (balanced grip)
- •Ring: 50° flexion (power grip cascade)
- •Small: 55° flexion (maximum grip strength)
- •Rationale: increasing flexion radial to ulnar for optimal cascade
Silicone Arthroplasty
- •Best for: Low-demand, elderly, multiple digits
- •Motion: 60-70° arc expected (40-110° typically)
- •Survival: 80% at 10 years, 60% at 15 years
- •Complications: Fracture 5-10%, subsidence, synovitis 5%
- •Activity restrictions: Permanent avoidance heavy gripping
Surface Replacement
- •Best for: Young, active, isolated joint, intact ligaments
- •Motion: 70-80° arc if successful
- •Survival: 85% at 5 years, 70% at 10 years
- •Requires: Competent collaterals (mandatory stress test)
- •Complications: Loosening, instability, squeaking 15-25%
Arthrodesis Pearls
- •Union rate: 90-95% with screw fixation vs 78% with K-wires
- •Patient satisfaction: 88% overall, 94% for index finger
- •Fixation: Compression screw preferred, tension band or plate alternatives
- •Non-union risk: 5-10%, higher in smokers
- •Return to work: 8-12 weeks for manual labor
Viva Red Flags (Don't Miss)
- •Assess collateral stability before any arthroplasty (stress test)
- •Never recommend surface replacement with incompetent ligaments
- •Index finger arthritis: default to arthrodesis unless strong reason
- •Arthrodesis angle MUST match digit: 40-45-50-55°
- •Silicone synovitis is LATE complication (years), requires removal
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