High-yield overview

Osteoarthritis | Post-Traumatic | Silicone Arthroplasty | Arthrodesis

PIPMost affected joint

40-55°Arthrodesis angle (radial to ulnar)

40-60°Typical arc after arthroplasty

11%Silicone explantation (Daecke RCT)

Eaton-Littler Classification (PIP Arthritis)

Grade I

PatternSynovitis, minimal radiographic changes

TreatmentConservative

Grade II

PatternJoint space narrowing, early osteophytes

TreatmentConservative, injection

Grade III

PatternSignificant joint space loss, bone-on-bone

TreatmentArthroplasty or arthrodesis

Grade IV

PatternSevere destruction with instability

TreatmentArthrodesis preferred

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.

Clinical 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

Mnemonic

IMRS 40-45-50-55PIP Arthrodesis Angle

I	Index 40° flexion (precise pinch and pointing)
M	Middle 45° flexion (power grip)
R	Ring 50° flexion (power grip)
S	Small 55° flexion (maximum grip strength)

I	Index 40° flexion (precise pinch and pointing)	R	Ring 50° flexion (power grip)
M	Middle 45° flexion (power grip)	S	Small 55° flexion (maximum grip strength)

Hook:IMRS = Index-Middle-Ring-Small. Each digit increases 5° of flexion from radial to ulnar for optimal cascade and grip function.

Mnemonic

PCAVPIP Joint Stability Structures

P	Proper collateral Tight in flexion, origin dorsal to axis
C	Checkrein ligaments Prevent hyperextension
A	Accessory collateral Volar plate attachment, tight in extension
V	Volar plate Prevents hyperextension, lateral stability

P	Proper collateral Tight in flexion, origin dorsal to axis	A	Accessory collateral Volar plate attachment, tight in extension
C	Checkrein ligaments Prevent hyperextension	V	Volar plate Prevents hyperextension, lateral stability

Hook:PCAV = the 4 key stabilizers of PIP joint. All must be assessed before considering surface replacement arthroplasty.

Mnemonic

HILUIndications for Arthrodesis over Arthroplasty

H	High-demand patient Manual labor, athletes
I	Index finger Pinch stability critical
L	Ligament incompetence Collateral or volar plate injury
U	Unstable joint Deformity, subluxation, bone loss

H	High-demand patient Manual labor, athletes	L	Ligament incompetence Collateral or volar plate injury
I	Index finger Pinch stability critical	U	Unstable joint Deformity, subluxation, bone loss

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:

Reliable pain relief is the main benefit; reported patient satisfaction is high
Arc of motion typically 40-60°; motion gain over the pre-operative arc is often modest
Lower revision and explantation rates than resurfacing implants (silicone explantation 11% vs titanium 27% vs pyrocarbon 39% in the Daecke RCT)
Complications: implant fracture, subsidence, recurrent deformity, and late silicone synovitis

Silicone arthroplasty provides reliable pain relief and a functional arc 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.

Differential Diagnosis

Not all painful, swollen PIP joints are osteoarthritis. The pattern of involvement, the presence of systemic features, and the radiographic appearance distinguish the main causes.

Differential Diagnosis of PIP Joint Arthritis

Condition	Distinguishing Features	Radiographic / Lab Clues	Key Discriminator
Primary osteoarthritis	Older, female predominance, Bouchard nodes, DIP often involved	Joint space loss, osteophytes, subchondral sclerosis; normal inflammatory markers	Bouchard nodes plus normal CRP
Rheumatoid arthritis	Symmetrical, MCP and wrist involvement, morning stiffness over 1 hour, systemic features	Periarticular erosions, osteopenia; RF and anti-CCP positive, raised ESR/CRP	Erosive change with positive anti-CCP
Psoriatic arthritis	DIP predominance, dactylitis, nail and skin psoriasis	Pencil-in-cup deformity, new bone formation; RF usually negative	Skin/nail psoriasis with DIP disease
Gout / CPPD	Acute attacks, erythema, can be monoarticular	Tophi or chondrocalcinosis; urate or CPP crystals on aspiration	Crystals on polarised microscopy
Septic arthritis	Acute hot swollen joint, fever, rapid progression	Effusion, later erosion; raised WCC/CRP, organisms on aspirate	Pus on aspiration - surgical emergency
Post-traumatic arthritis	Prior fracture-dislocation or instability, younger patient	Joint incongruity, malunion, focal cartilage loss; normal inflammatory markers	Clear injury history with focal damage

Controversies and Areas of Uncertainty

Examiners reward balanced, evidence-aware answers

Stating where the evidence is weak or conflicting demonstrates consultant-level judgement. PIP arthroplasty is an area with limited high-level data, so confident nuance scores well.

Does any implant actually improve motion? The best randomized evidence (Daecke 2012) found no significant ROM gain for silicone or resurfacing implants, with resurfacing showing only a transient, non-significant advantage. The realistic goal of arthroplasty is pain relief and maintenance of a functional arc, not increased motion.
Silicone vs resurfacing. Resurfacing implants (titanium-polyethylene, pyrocarbon) were introduced to improve durability and motion, yet randomized and long-term cohort data show higher explantation and complication rates without a durable motion benefit over the silicone spacer. Their role remains contested and limited to carefully selected, stable joints.
Pyrocarbon-specific issues. Squeaking, subsidence (often subclinical and stabilising per Wolff's law) and a relatively high reoperation rate cloud interpretation; many "complications" do not require revision, so reported rates vary widely with definition.
Index finger: fuse or replace? Arthrodesis is traditionally preferred for pinch stability, but comparative data (Vitale 2015) show similar pain and satisfaction with arthroplasty at the cost of more complications. The decision is increasingly shared and goal-driven rather than dogmatic.
Optimal arthrodesis angle. The classic radial-to-ulnar progression (around 40-55°) is widely taught but not validated by high-level evidence; surgeons individualise the angle to occupation and patient preference.
Registry blind spot. Small-joint hand arthroplasty is not tracked by the major national joint registries, so long-term implant survival counselling rests on single-centre series with selection bias.

Evidence Base

Three Implant Types Compared: Silicone vs Titanium vs Pyrocarbon

Level I

Daecke W, Kaszap B, Martini AK, Hagena FW, Rieck B, Jung M • J Hand Surg Am (2012)

Key Findings:

Prospective randomized multicentre trial: 43 patients (62 PIP joints) allocated to silicone (SI), titanium-polyethylene (TI) or pyrocarbon (PY); mean follow-up 35 months
All 3 implants gave significant pain reduction at rest and load; tip-pinch slightly improved across groups
No significant ROM gain for any device; resurfacing implants showed only a transient, non-significant ROM advantage over silicone
Explantation rates: silicone 2 of 18 (11%), titanium 7 of 26 (27%), pyrocarbon 7 of 18 (39%)

Clinical Implication: Supports silicone arthroplasty as the default motion-preserving option; reserve resurfacing for carefully selected, well-counselled patients.

Verify on PubMed (PMID 22916864)

Posttraumatic Finger Joint Reconstruction: Arc of Motion and Complications

Level III

Squitieri L, Chung KC • Plast Reconstr Surg (2008)

Key Findings:

Systematic review of world literature (520 articles screened) comparing vascularized toe joint transfer, silicone, and pyrocarbon arthroplasty
Mean PIP active arc of motion: vascularized toe joint 37°, silicone 44°, pyrocarbon 43°
Major complication (revision) rates: vascularized toe joint 29%, silicone 18%, pyrocarbon 33%
No meaningful improvement in posttraumatic finger joint outcomes over 40 years

Clinical Implication: Reinforces silicone as a reliable benchmark and tempers expectations of motion gain from any current PIP implant.

Verify on PubMed (PMID 18453994)

Pyrocarbon PIP Arthroplasty: Minimum 2-Year Outcomes

Level IV

Bravo CJ, Rizzo M, Hormel KB, Beckenbaugh RD • J Hand Surg Am (2007)

Key Findings:

Retrospective series of 50 pyrocarbon PIP replacements in 35 patients (minimum 27-month follow-up)
Mean arc of motion improved only modestly from 40° to 47°; pain scores fell from 6 to 1 (0-10 scale)
Overall patient satisfaction nearly 80%; index finger results comparable to other digits
28% of patients required a second procedure; revision arthroplasty rate 8%; radiographic subsidence in 40% of joints

Clinical Implication: Counsel patients that pain relief, not large ROM improvement, is the realistic goal; expect possible reoperation.

Verify on PubMed (PMID 17218170)

Arthroplasty vs Arthrodesis for Index Finger PIP Arthritis

Level III

Vitale MA, Fruth KM, Rizzo M, Moran SL, Kakar S • J Hand Surg Am (2015)

Key Findings:

Comparative cohort of 79 index-finger PIP joints (65 arthroplasty, 14 arthrodesis) for OA or posttraumatic arthritis
No significant difference in pain relief, satisfaction, or Michigan Hand Questionnaire scores between groups
Arthroplasty preserved motion and improved opposition pinch; arthrodesis improved both opposition and apposition pinch
Arthroplasty carried a 4.3-fold higher complication risk and a shorter time to first complication

Clinical Implication: Decision should be driven by patient goals (motion vs durability) with explicit counselling on the higher complication burden of arthroplasty.

Verify on PubMed (PMID 26188383)

PIP Arthrodesis: Fixation Method and Nonunion

Level IV

Leibovic SJ, Strickland JW • J Hand Surg Am (1994)

Key Findings:

Retrospective review of 224 PIP arthrodeses fixed with Herbert screw (37), K-wire (100), tension band (69), plate (11) or other (7)
Mean clinical union at 7 weeks, radiographic union at 10 weeks; nonunion in 31 cases
Primary nonunion rate highest with K-wires, intermediate with tension band, lowest with Herbert screw
Nonunion highest in psoriatic arthritis, intermediate in RA, lowest in trauma, and absent in osteoarthritis

Clinical Implication: Favour a headless compression screw for PIP arthrodesis and warn inflammatory-arthritis patients of higher nonunion risk.

Verify on PubMed (PMID 8201177)

Surface Replacement Arthroplasty: 30-Year Single-Centre Experience

Level IV

Murray PM, Linscheid RL, Cooney WP, Baker V, Heckman MG • J Bone Joint Surg Am (2012)

Key Findings:

67 CoCr/UHMWPE surface replacements in 47 patients over 30 years; mean follow-up 8.8 years
Median total active PIP motion 40° at follow-up; median VAS pain 3 of 100
Cumulative implant failure 8% at 3 years, 11% at 5 years, 16% at 15-25 years
Volar approach failed 6.6 times more often than dorsal; failure rate similar for OA and RA

Clinical Implication: Use a dorsal approach and set realistic motion expectations; surface replacement is about durable pain relief, not increased ROM.

Verify on PubMed (PMID 22717831)

Exam Viva Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOModerate

Scenario 1: Post-Traumatic PIP Arthritis in Index Finger

CLINICAL PROMPT

"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."

PRACTICAL APPROACH

This is a case of post-traumatic PIP joint arthritis in a high-demand manual laborer involving the index finger. I would take a systematic approach. First, I would confirm the diagnosis with detailed history and examination, including assessment of collateral ligament stability and extensor mechanism function. I would review radiographs to assess severity of arthritis and bone quality. My management would be PIP joint arthrodesis at 40° flexion. The index finger requires stability for pinch and precision tasks, making arthrodesis the optimal choice. His occupation as a carpenter involves gripping and manual labor, further supporting arthrodesis over arthroplasty. I would counsel regarding loss of motion but excellent pain relief, stability for work, and high patient satisfaction with arthrodesis in index finger. I would use compression screw fixation for maximum stability and union rate. I would warn about 5-10% non-union risk, smoking cessation importance, and 3-4 month recovery before return to full carpentry duties.

KEY CLINICAL POINTS

Index finger arthritis: strong preference for arthrodesis due to pinch stability requirements

High-demand occupation (carpenter): arthrodesis provides durable pain-free stability

Arthrodesis angle 40° flexion for index finger (pointing and precision pinch)

Screw fixation offers superior union rates compared to K-wire fixation

Patient satisfaction with arthrodesis exceeds 90% in index finger despite motion loss

COMMON PITFALLS

Offering arthroplasty for index finger in carpenter (motion not worth instability risk)

Incorrect arthrodesis angle (must be 40° for index, not 45° like middle finger)

Failing to address smoking cessation (doubles non-union risk)

Not explaining trade-off: motion loss for pain-free stability and grip strength

FURTHER QUESTIONS

"What if the patient insists on preserving motion? - I would explain that motion preservation with arthroplasty in a high-demand carpenter carries significant risk of implant failure, instability, and pain recurrence. Arthrodesis provides reliable long-term function for his occupation. If he still refuses, I would consider silicone arthroplasty with clear discussion of higher failure risk and activity restrictions."

"What arthrodesis fixation method would you use and why? - I would use compression screw fixation (Herbert or headless compression screw). Evidence shows screw fixation achieves 92% union rate compared to 78% with K-wires. Screw provides rigid compression across fusion site and is buried, requiring no removal. Alternative is tension band construct if bone quality is poor."

"How would you manage a non-union at 4 months? - I would first confirm true non-union with radiographs showing no bridging callus and clinical motion at fusion site. Management includes revision arthrodesis with takedown of fibrous tissue, freshening of bone surfaces, autogenous bone graft from distal radius, and rigid plate fixation. Smoking cessation is mandatory. Union rates after revision approach 85-90%."

CLINICAL SCENARIOStandard

Scenario 2: Primary OA in Multiple Digits - Low-Demand Elderly

CLINICAL PROMPT

"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."

PRACTICAL APPROACH

This is a case of primary osteoarthritis affecting multiple PIP joints in a low-demand elderly patient. I would take a systematic approach. First, I would complete a thorough history to assess functional limitations and goals, and examination to assess range of motion, joint stability, and extensor mechanism integrity. I would confirm radiographic severity and assess collateral ligament competence with stress testing. My surgical recommendation would be silicone arthroplasty for the most symptomatic digits. Rationale includes: low-demand patient prioritizing motion, multiple digit involvement making arthrodesis less suitable, and stable joints with competent collaterals. I would counsel regarding expected outcomes: 80-90% pain relief, 60-70° arc of motion, and 80% implant survival at 10 years. I would set realistic expectations regarding activity restrictions - permanent avoidance of heavy gripping and manual labor. I would discuss potential complications including implant fracture (5-10%), subsidence, and silicone synovitis (5%). Post-operative protocol requires early protected motion beginning week 2 and hand therapy for optimal outcomes.

KEY CLINICAL POINTS

Low-demand elderly patient: ideal candidate for silicone arthroplasty

Multiple digit involvement: arthrodesis would create cumulative stiffness

Collateral ligament integrity must be confirmed before arthroplasty

Silicone arthroplasty provides reliable pain relief and motion preservation

Permanent activity restrictions necessary to protect implant longevity

COMMON PITFALLS

Recommending surface replacement in elderly patient (higher complication rate, no benefit)

Offering arthrodesis for multiple adjacent digits (excessive cumulative stiffness)

Failing to assess collateral ligament stability (unstable joint = arthrodesis indicated)

Overpromising motion outcomes (realistic expectation is 60-70°, not full motion)

FURTHER QUESTIONS

"Would you operate on all affected digits simultaneously? - I would typically limit to 1-2 digits per hand per surgery to allow functional use of contralateral hand during recovery and reduce overall morbidity. I would prioritize most symptomatic digits first. Consider staged procedures 3-6 months apart. Some surgeons perform bilateral single-digit procedures simultaneously to balance recovery."

"What if collateral ligaments are incompetent? - Ligament incompetence is a contraindication to arthroplasty due to instability risk. Options include: arthrodesis for stable pain-free function, or ligament reconstruction with volar plate advancement or tendon graft followed by staged arthroplasty. In low-demand elderly, arthrodesis is simpler and more reliable."

"How do you counsel regarding silicone synovitis risk? - Silicone synovitis occurs in approximately 5% of cases, typically many years post-implantation. Results from particulate silicone debris causing chronic inflammation and bone erosion. Presentation includes pain, swelling, and radiographic osteolysis. Management requires implant removal, thorough synovectomy, and arthrodesis. I counsel patients this is a late complication requiring regular long-term follow-up."

CLINICAL SCENARIOChallenging

Scenario 3: Young Active Patient with Isolated PIP Arthritis

CLINICAL PROMPT

"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?"

PRACTICAL APPROACH

This is a case of isolated PIP arthritis in a moderate-demand active patient with specific functional goals. I would take a systematic approach. First, I would complete detailed history regarding activity level, occupational demands, and specific functional limitations. Examination would focus on collateral ligament stability, volar plate integrity, and extensor mechanism function. I would confirm on stress testing that collaterals are competent - this is essential for surface replacement consideration. My recommendation would be surface replacement arthroplasty with pyrocarbon implant. Rationale: he is younger, moderate-demand (not manual labor), has isolated single-digit involvement, strong desire for motion, and critically - has stable joint with intact ligaments. Middle finger can tolerate arthroplasty better than index. I would counsel regarding outcomes: expected arc 70-80°, superior to silicone but higher complication risk (15-25%) including loosening, instability, and squeaking. I would emphasize strict post-operative protocol compliance is essential. Activity modifications required - avoid heavy gripping, impact activities. I would discuss alternative of arthrodesis at 45° if he prioritizes durability and pain-free function over motion, particularly important if tennis/golf involve significant grip strength. I would present both options transparently, discussing trade-offs to allow informed decision.

KEY CLINICAL POINTS

Surface replacement best for younger, moderate-demand with isolated arthritis and stable joint

Collateral ligament integrity is absolute requirement - confirm with stress testing

Pyrocarbon provides superior motion (70-80°) compared to silicone but higher complications

Strict post-operative protocol and activity modifications essential for success

Present both arthroplasty and arthrodesis options with honest discussion of trade-offs

COMMON PITFALLS

Recommending surface replacement without confirming collateral ligament integrity

Failing to discuss arthrodesis as alternative (many patients prefer pain-free stability)

Overpromising outcomes (surface replacement has 15-25% complication rate)

Not addressing activity restrictions (tennis/golf may stress implant long-term)

Assuming 'most advanced' implant is always best choice (patient selection critical)

FURTHER QUESTIONS

"What if he chooses arthrodesis instead? - This is a reasonable choice. Arthrodesis at 45° flexion for middle finger provides pain-free stability, excellent grip strength, and allows unrestricted return to tennis and golf without implant failure concerns. Many active patients ultimately prefer certainty of arthrodesis over motion preservation with activity restrictions. Counseling regarding loss of middle finger flexion but maintenance of excellent hand function."

"How would you manage early instability after surface replacement? - Early instability suggests collateral ligament failure or technical error. Initial management includes splinting and reassessment of ligament integrity. If instability persists beyond 6-8 weeks or if ligaments are incompetent, revision to arthrodesis is indicated. Attempting ligament reconstruction with arthroplasty revision has poor outcomes - arthrodesis is more reliable."

"What are contraindications to surface replacement in this case? - Absolute contraindications include ligament incompetence, severe bone loss, active infection, and patient non-compliance with post-op protocol. Relative contraindications include osteoporosis (subsidence risk), high-demand occupation (manual labor), and inflammatory arthritis (active RA). This patient has none of these, making him a suitable candidate if ligaments are intact."

Guidelines, Registries & Global Practice

PIP joint arthritis is managed similarly worldwide, guided by the same evidence base. Practice differs mainly in implant availability and resource setting rather than in core principles.

Global Epidemiology: Symptomatic interphalangeal hand OA affects roughly 10-15% of adults over 60, with a marked female predominance for primary nodal disease. Post-traumatic PIP arthritis affects younger adults and clusters in manual occupations (construction, agriculture, mining). Inflammatory arthropathy (RA, psoriatic) remains an important cause where access to disease-modifying therapy is limited.

Side-by-Side Guidance:

Body / Source	Stance on PIP Arthritis Management	Practical Emphasis
AAOS / OARSI (hand OA)	Conservative-first: topical/oral NSAIDs, hand therapy, splinting; surgery for refractory disease	Strong recommendation for topical NSAIDs and exercise before surgery
NICE (osteoarthritis, UK)	Core treatments are exercise and education; pharmacotherapy with topical NSAIDs preferred over oral; surgery reserved for severe refractory cases	Limit intra-articular steroid to short-term symptom control
AO Foundation / BSSH (hand)	Match procedure to stability and demand: arthroplasty for stable low/moderate-demand joints, arthrodesis for unstable joints and the index finger	Confirm collateral competence before any resurfacing
EFORT / European consensus	Acknowledges no implant reliably improves motion; silicone remains benchmark, resurfacing for selected stable joints	Counsel that pain relief, not large ROM gain, is the realistic goal

Registry Evidence: National arthroplasty registries (NJR UK, AJRR US, AOANJRR Australia, Swedish/Norwegian/NZ registries) focus on hip, knee and shoulder and do not systematically capture small-joint hand arthroplasty. Consequently, implant-survival counselling relies on institutional cohorts and the randomized data above rather than registry datasets — a recognised gap in the evidence.

High- vs Limited-Resource Practice: In well-resourced settings, silicone and resurfacing implants, hand therapy and image guidance are readily available, and implant choice is driven by demand and stability. In limited-resource settings, arthrodesis (K-wire, tension band or screw) and silicone spacers predominate because they are durable, low-cost and need less specialised follow-up; resurfacing implants are often unavailable. Across all settings, arthrodesis remains the default for the unstable joint, the high-demand manual worker, and the index finger.

Return to Work: Manual workers typically return after PIP arthrodesis around 8-12 weeks once union is confirmed, and somewhat later after arthroplasty owing to protected rehabilitation; exact timelines vary with occupation and local rehabilitation pathways.

PIP JOINT ARTHRITIS - EXAM ESSENTIALS

Clinical 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: typically 40-60° arc; modest gain over pre-op
•Lowest explantation rate of the implants (11% vs TI 27% vs PY 39%, Daecke RCT)
•Complications: Fracture, subsidence, late silicone synovitis
•Activity restrictions: Permanent avoidance heavy gripping

Surface Replacement

•Best for: Young, active, isolated joint, intact ligaments
•Motion: usually maintained (~40° median), not reliably increased
•Metal-PE failure ~11% at 5y, ~16% at 15-25y; dorsal approach safer
•Requires: Competent collaterals (mandatory stress test)
•Complications: Loosening, instability, squeaking, higher than silicone

Arthrodesis Pearls

•Compression screw gives lowest nonunion; K-wire highest (Leibovic)
•Reliable pain relief and grip; satisfaction high despite motion loss
•Fixation: Compression screw preferred, tension band or plate alternatives
•Nonunion higher in psoriatic/RA and smokers; absent in OA in some series
•Return to work generally 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

References

Squitieri L, Chung KC. A systematic review of outcomes and complications of vascularized joint transfer, silicone arthroplasty, and PyroCarbon arthroplasty for posttraumatic joint reconstruction of the finger. Plast Reconstr Surg. 2008;121(5):1697-1707. doi:10.1097/PRS.0b013e31816c3c5e
Bravo CJ, Rizzo M, Hormel KB, Beckenbaugh RD. Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two-year follow-up evaluation. J Hand Surg Am. 2007;32(1):1-11. doi:10.1016/j.jhsa.2006.10.017
Vitale MA, Fruth KM, Rizzo M, et al. Functional outcomes of proximal interphalangeal joint arthrodesis and arthroplasty: a prospective comparative study. J Hand Surg Am. 2015;40(10):1986-1993. doi:10.1016/j.jhsa.2015.06.108
Leibovic SJ, Strickland JW. Arthrodesis of the proximal interphalangeal joint of the finger: comparison of the use of the Herbert screw with other fixation methods. J Hand Surg Am. 1994;19(2):181-188. doi:10.1016/0363-5023(94)90002-7
Jennings CD, Livingstone DP. Surface replacement arthroplasty of the proximal interphalangeal joint using the PIP-SRA implant: results, complications, and revisions. J Hand Surg Am. 2015;40(3):469-473. doi:10.1016/j.jhsa.2014.11.023
Swanson AB. Flexible implant arthroplasty for arthritic finger joints: rationale, technique, and results of treatment. J Bone Joint Surg Am. 1972;54(3):435-455.
Bouchard C. Osteoarthritis of the hand: clinical manifestations and pathogenesis. In: Moskowitz RW, Howell DS, Altman RD, et al., eds. Osteoarthritis: Diagnosis and Medical/Surgical Management. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2007:191-210.
Eaton RG, Littler JW. Joint injuries and their sequelae. Clin Plast Surg. 1976;3(1):85-98.
Herren DB, Simmen BR. Palmar approach in flexible implant arthroplasty of the proximal interphalangeal joint. Clin Orthop Relat Res. 2000;371:131-135. doi:10.1097/00003086-200002000-00016
Chung KC, Ram AN, Shauver MJ. Outcomes of pyrolytic carbon arthroplasty for the proximal interphalangeal joint. Plast Reconstr Surg. 2009;123(5):1521-1532. doi:10.1097/PRS.0b013e3181a2059b
Daecke W, Kaszap B, Martini AK, Hagena FW, Rieck B, Jung M. A prospective, randomized comparison of 3 types of proximal interphalangeal joint arthroplasty. J Hand Surg Am. 2012;37(9):1770-1779. doi:10.1016/j.jhsa.2012.06.006
Watts AC, Hearnden AJ, Trail IA, Hayton MJ, Nuttall D, Stanley JK. Pyrocarbon proximal interphalangeal joint arthroplasty: minimum five-year follow-up. J Hand Surg Am. 2012;37(5):882-888. doi:10.1016/j.jhsa.2012.01.039
Bellemère P, Maes-Clavier C, Loubersac T, Gaisne E, Kerjean Y, Krimmer H. Proximal interphalangeal joint arthrodesis with an intramedullary screw: a review of 49 cases. J Hand Surg Eur Vol. 2011;36(5):381-387. doi:10.1177/1753193410397895
Teoh LC, Yeo SJ. Proximal interphalangeal joint fusion with Herbert screws. J Hand Surg Br. 1996;21(4):508-510. doi:10.1016/s0266-7681(96)80056-9
Stern PJ, Fulton DB. Distal interphalangeal joint arthrodesis: an analysis of complications. J Hand Surg Am. 1992;17(6):1139-1145. doi:10.1016/s0363-5023(09)91079-9
Murray PM, Linscheid RL, Cooney WP 3rd, Danahey A. Long-term outcomes of proximal interphalangeal joint surface replacement arthroplasty. J Bone Joint Surg Am. 2012;94(12):1120-1128. doi:10.2106/JBJS.K.00828
Zimmerman NB, Zimmerman SI, Clark GL, Wilgis EF. Silicone interpositional arthroplasty of the distal interphalangeal joint. J Hand Surg Am. 1989;14(5):882-887. doi:10.1016/s0363-5023(89)80096-8
Ashworth CR, Blatt G, Chuinard RG, Stark HH. Silicone-rubber interposition arthroplasty of the carpometacarpal joint of the thumb. J Hand Surg Am. 1977;2(5):345-357. doi:10.1016/s0363-5023(77)80046-8

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

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

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

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:

Reliable pain relief is the main benefit; reported patient satisfaction is high
Arc of motion typically 40-60°; motion gain over the pre-operative arc is often modest
Lower revision and explantation rates than resurfacing implants (silicone explantation 11% vs titanium 27% vs pyrocarbon 39% in the Daecke RCT)
Complications: implant fracture, subsidence, recurrent deformity, and late silicone synovitis

Silicone arthroplasty provides reliable pain relief and a functional arc for low-demand patients.

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

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

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

Condition

Distinguishing Features

Radiographic / Lab Clues

Key Discriminator

Primary osteoarthritis

Older, female predominance, Bouchard nodes, DIP often involved

Joint space loss, osteophytes, subchondral sclerosis; normal inflammatory markers

Bouchard nodes plus normal CRP

Rheumatoid arthritis

Symmetrical, MCP and wrist involvement, morning stiffness over 1 hour, systemic features

Periarticular erosions, osteopenia; RF and anti-CCP positive, raised ESR/CRP

Erosive change with positive anti-CCP

Psoriatic arthritis

DIP predominance, dactylitis, nail and skin psoriasis

Pencil-in-cup deformity, new bone formation; RF usually negative

Skin/nail psoriasis with DIP disease

Gout / CPPD

Acute attacks, erythema, can be monoarticular

Tophi or chondrocalcinosis; urate or CPP crystals on aspiration

Crystals on polarised microscopy

Septic arthritis

Acute hot swollen joint, fever, rapid progression

Effusion, later erosion; raised WCC/CRP, organisms on aspirate

Pus on aspiration - surgical emergency

Post-traumatic arthritis

Prior fracture-dislocation or instability, younger patient

Joint incongruity, malunion, focal cartilage loss; normal inflammatory markers

Clear injury history with focal damage

Body / Source

Stance on PIP Arthritis Management

Practical Emphasis

AAOS / OARSI (hand OA)

Conservative-first: topical/oral NSAIDs, hand therapy, splinting; surgery for refractory disease

Strong recommendation for topical NSAIDs and exercise before surgery

NICE (osteoarthritis, UK)

Core treatments are exercise and education; pharmacotherapy with topical NSAIDs preferred over oral; surgery reserved for severe refractory cases

Limit intra-articular steroid to short-term symptom control

AO Foundation / BSSH (hand)

Match procedure to stability and demand: arthroplasty for stable low/moderate-demand joints, arthrodesis for unstable joints and the index finger

Confirm collateral competence before any resurfacing

EFORT / European consensus

Acknowledges no implant reliably improves motion; silicone remains benchmark, resurfacing for selected stable joints

Counsel that pain relief, not large ROM gain, is the realistic goal

Patient Type	Activity Level	Surgical Preference	Rationale
Low-demand elderly	ADLs, light activities	Silicone arthroplasty	Motion preservation, pain relief
Moderate-demand	Office work, recreational activities	Surface replacement	Motion with better durability
High-demand manual	Labor, sports, gripping activities	Arthrodesis	Stable, pain-free, durable

Digit	Functional Role	Motion vs Stability	Preferred Procedure
Index	Pinch, pointing, precision	Stability critical	Arthrodesis 40° flexion
Middle	Power grip, balanced function	Motion beneficial	Arthroplasty or arthrodesis 45°
Ring	Power grip, ulnar cascade	Motion beneficial	Arthroplasty or arthrodesis 50°
Small	Power grip, ulnar support	Motion less critical	Arthrodesis 55° flexion

Patient Type	Activity Level	Surgical Preference	Rationale
Low-demand elderly	ADLs, light activities	Silicone arthroplasty	Motion preservation, pain relief
Moderate-demand	Office work, recreational activities	Surface replacement	Motion with better durability
High-demand manual	Labor, sports, gripping activities	Arthrodesis	Stable, pain-free, durable

Digit	Functional Role	Motion vs Stability	Preferred Procedure
Index	Pinch, pointing, precision	Stability critical	Arthrodesis 40° flexion
Middle	Power grip, balanced function	Motion beneficial	Arthroplasty or arthrodesis 45°
Ring	Power grip, ulnar cascade	Motion beneficial	Arthroplasty or arthrodesis 50°
Small	Power grip, ulnar support	Motion less critical	Arthrodesis 55° flexion

PIP Joint Arthritis

PIP Joint Arthritis

Eaton-Littler Classification (PIP Arthritis)

Critical Must-Knows

Clinical Pearls

Critical PIP Joint Arthritis Exam Points

Arthrodesis Angles

Collateral Ligament Integrity

Silicone vs Surface Replacement

Post-Traumatic Arthritis

Surgical Options for PIP Arthritis

IMRS 40-45-50-55PIP Arthrodesis Angle

PCAVPIP Joint Stability Structures

HILUIndications for Arthrodesis over Arthroplasty

Overview and Epidemiology

Demographics

Etiology

Pathophysiology

PIP Joint Anatomy

Classification Systems

Eaton-Littler Classification (PIP Arthritis)

Classification by Functional Demand

Digit-Specific Treatment Preferences

Clinical Assessment

History

Physical Examination

Inspection

Palpation

Range of Motion

Special Tests

Red Flags

Red Flags in PIP Arthritis

Investigations

Imaging

Radiographs (PA, Lateral, Oblique)

Advanced Imaging

Laboratory Tests

Management Algorithm

Conservative Management

Non-Pharmacological

Pharmacological

Surgical Decision-Making Algorithm

Contraindications to Specific Procedures

Silicone Arthroplasty Contraindications

Surface Replacement Contraindications

Arthrodesis Contraindications

Surgical Technique

Silicone (Swanson) Arthroplasty

Surface Replacement Arthroplasty

PIP Joint Arthrodesis

Complications

Early Complications (less than 6 weeks)

Late Complications (greater than 6 weeks)

Prevention Strategies

Postoperative Care

Post-Operative Protocol: Silicone Arthroplasty

Week 0-2: Protection Phase

Week 2-6: Early Motion Phase

Week 6-12: Strengthening Phase

Month 3-6: Functional Phase

Post-Operative Protocol: Surface Replacement

Week 0-1: Strict Protection

Week 1-3: Controlled Motion

Week 3-6: Progressive Motion

Month 2-3: Strengthening

Long-Term

Post-Operative Protocol: Arthrodesis

Week 0-2: Immobilization

Week 2-6: Continued Protection

Week 6-8: Transition

Week 8-12: Union Confirmation

Month 3-6: Full Recovery

Differential Diagnosis

Differential Diagnosis of PIP Joint Arthritis

Controversies and Areas of Uncertainty

Evidence Base

Three Implant Types Compared: Silicone vs Titanium vs Pyrocarbon

Posttraumatic Finger Joint Reconstruction: Arc of Motion and Complications

Pyrocarbon PIP Arthroplasty: Minimum 2-Year Outcomes

Arthroplasty vs Arthrodesis for Index Finger PIP Arthritis