distal interphalangeal joint arthrodesis with a headless compression screw: morphometric and...
TRANSCRIPT
HANDSURGERY
Distal interphalangeal joint arthrodesis with a headlesscompression screw: morphometric and functional analyses
Joo-Hyoun Song • Joo-Yup Lee • Yang-Guk Chung •
Il-Jung Park
Received: 1 August 2011 / Published online: 20 October 2011
� Springer-Verlag 2011
Abstract
Introduction We performed radiologic measurement of
the distal and middle phalanges in volunteers to determine
the size of a headless compression screw suitable for distal
interphalangeal (DIP) joint arthrodesis in Korean subjects
and report on clinical results using an acutrak fusion screw.
Materials and methods Radiologic measurements on the
distal and middle phalanx were performed to determine the
optimal size of screw. Five hundred fingers from 50 adult
Koreans without any abnormality on plain radiographs
were selected and anteroposterior and lateral radiographs
were obtained for measurements. For the distal phalanx,
the narrowest diameter of the cortical bone was measured
to determine the minimal diameter of the screw that would
not penetrate the cortex. For the middle phalanx, the nar-
rowest diameter of the medullary canal was measured to
determine the appropriate size of the screw for fixation.
Between May 2004 and December 2007, there were 23
fingers in 22 patients (6 male, 16 female) that had finger
DIP joint or thumb IP joint arthrodesis performed with the
acutrak fusion screws. At the final follow up, time to union,
complications, clinical fusion angle, pinch power, visual
analogue score (VAS) for pain and the Korean version of
the disabilities of the arm, shoulder and hand (DASH)
questionnaire were assessed.
Results In the distal phalanx, the narrowest diameter of
the cortex was 2.64 ± 0.51 mm for the little finger. In the
middle phalanx, the narrowest diameter of the medullary
canal was 1.83 ± 0.50 mm for the little finger and
4.17 ± 0.68 for the thumb. The mean time to union was
10 weeks (range 8–12). The mean clinical fusion angle of
the DIP joint was 11.9� (range 0–20). The VAS pain score
was 0.4 (range 0–3). Pinch power was 75% of the normal
side. The average Korean DASH score was 5 points (range
0–8). We experienced one intraoperative fixation failure for
thumb IP joint arthrodesis caused by a wide medullary
canal of the proximal phalanx.
Conclusion The acutrak fusion screw was a feasible and
adequate tool for DIP arthrodesis, particularly in Koreans.
However, meticulous attention to technique was important
to avoid complications in some little fingers. If preopera-
tive radiographs suggest the thumb has a wide medullary
canal, alternate methods of fixation should be considered.
Keywords Distal interphalangeal joint � Arthrodesis �Headless compression screw
Introduction
Arthrodesis of the finger distal interphalangeal (DIP) joint
or thumb interphalangeal (IP) joint is a commonly per-
formed procedure for the treatment of severe arthritis
accompanying pain, instability and deformity. In addition,
it can be performed for chronic mallet deformity, chronic
flexor digitorum profundus avulsions, or for nonunion in
J.-H. Song � J.-Y. Lee
Department of Orthopedic Surgery, St. Vincent’ Hospital,
The Catholic University of Korea, 93 Ji-dong,
Paldal-gu, Suwon 442-723, Korea
Y.-G. Chung
Department of Orthopedic Surgery, Seoul St. Mary’s Hospital,
The Catholic University of Korea, 505 Banpo-dong,
Seocho-gu, Seoul, Korea
I.-J. Park (&)
Department of Orthopedic Surgery, Bucheon St. Mary’s
Hospital, The Catholic University of Korea,
2 Sosa-dong, Wonmi-gu, Bucheon 420-717, Korea
e-mail: [email protected]
123
Arch Orthop Trauma Surg (2012) 132:663–669
DOI 10.1007/s00402-011-1413-3
fractures in the distal part of the middle phalanx [1]. For
successful arthrodesis, not only firm bone union should be
obtained, but also irritation caused by the hardware should
be absent, and early joint movement can be allowed to
prevent the stiffness of adjacent joints.
Early techniques such as K-wire and intraosseous wiring
provided stabilization of the joint but produced poor
compression of the fusion surfaces [2]. Complication rates
of these early techniques were relatively high involving
hardware protrusion or migration, loosening, nonunion,
pin-track infections, dorsal skin necrosis, osteomyelitis or
permanent stiffness of an adjacent joint [3]. Therefore,
several authors have recommended alternative techniques
in an attempt to avoid these complications. Based on the
expectations that compression across the joint might
accelerate the fusion rate and that buried hardware might
decrease the infection rate, various surgical techniques
using headless compression screws have been developed.
The Herbert screw, acutrak standard screw and acutrak
mini screw have been used for DIP joint fusions with rel-
atively good results [1, 2, 4–7]. However, complications
related to the medullary reaming or incompatibility of
screw size to the distal phalanx have been reported [2, 3, 5,
7]. Because Koreans are generally smaller than Caucasians,
the selection of an appropriate headless compression screw
suitable for Koreans might be important for the success of
DIP arthrodesis in our population.
There are the two viewpoints about the purpose of this
study. First, morphometric measurements of the distal and
middle phalanx of the normal population were performed
on radiographs to determine the size of headless com-
pression screws suitable for Korean hands. Second, we
evaluated the clinical and radiological outcomes of
arthrodesis of the DIP joint and thumb IP joint using
acutrak fusion screws (Acumed�, Beaverton, OR, USA).
Materials and methods
Theoretical study
To determine the optimal size of a headless compression
screw, radiologic measurements on the distal and middle
phalanx were performed. Five hundred fingers from 50
adult Koreans without any abnormality on plain radiographs
were selected and anteroposterior (AP) and lateral radio-
graphs were obtained for measurements. To reduce the
errors in magnification and estimate the real dimensions, we
used radiopaque scale markers of known size. For the distal
phalanx, the narrowest diameter of the cortical bone was
measured on AP and lateral radiographs to determine the
minimal diameter of a screw that would not penetrate the
cortex (Fig. 1). For the middle phalanx, the narrowest
diameter of the medullary canal was measured on AP and
lateral radiographs to determine the appropriate size of the
screw used for fixation (Fig. 2). Measurements were per-
formed with PACS software (Maroview�, Infinitt Health-
care Co., Seoul, Korea). Eighteen men and 32 women were
included and their average age was 46 years (range 20–72).
Differences between fingers and genders were analyzed
statistically using SPSS software (version 12.0, Chicago,
IL, USA) and P \ 0.05 was assumed significant.
Clinical study
From May 2004 to December 2007, finger DIP joint or
thumb IP joint arthrodeses were performed on 23 fingers in
22 patients using acutrak fusion screws (diameter leading
Fig. 1 The narrowest area of the cortical bone of the distal phalanx
was measured on anteroposterior (AP) and lateral radiographs for
estimating the minimal diameter that would prevent the screw thread
from penetrating the cortex
Fig. 2 The narrowest area of medullary canal of the middle phalanx
was measured on AP and lateral radiographs in assessing the
appropriate size of screw for fixation
664 Arch Orthop Trauma Surg (2012) 132:663–669
123
2.0 mm, trailing 2.5 mm, available in 14–24 mm length).
There were six male and 16 female patients and the aver-
age age was 54 years (range 22–77). The mean follow-up
time was 18 months (range 10–35). The affected digits
were two thumbs, six index fingers, six middle fingers, six
ring fingers and three little fingers. The preoperative
diagnoses included primary osteoarthritis in 12 cases,
rheumatoid arthritis in five, posttraumatic arthritis in three,
septic arthritis in two, and severe injury with soft tissue and
a terminal tendon defect in one. In all cases, arthrodesis
using the acutrak fusion screw was performed by a single
surgeon. This screw has the smallest diameter among
headless screws available on the market. Its maximum
length available is 24 mm, so it was considered suitable for
arthrodesis of the DIP joint of the fingers or the IP joint of
the thumbs. At the final follow-up observation, time to
union, complications, clinical fusion angle, pinch power,
visual analog scale (VAS) for pain, and the Korean version
of the disabilities of the arm, should and hand (DASH)
questionnaire were assessed. Bony union was defined as
radiographic trabecular bridging and clinical stability and
determined by three independent observers (one hand
surgeon and two orthopedic senior residents). Nonunion
was defined as the radiographic loosening of the screw or
radiolucency in the fusion site or clinical instability.
Operative technique
Under general or axillary anesthesia, patients were posi-
tioned supine and a tourniquet was applied to the upper arm
area. An H-shaped incision was made over the dorsal aspect
of the DIP joint, and the extensor tendon was exposed. At
that time, care was taken to avoid damage to the germinal
matrix, close to the surgical field. The tendon was divided
transversely, the joint was flexed, and the collateral liga-
ments were released. The articular cartilages and osteo-
phytes were removed with a curette and small rongeur while
minimizing injury to the subchondral bone in improving the
contact of the distal phalanx and the middle phalanx.
A 1.6 mm size K-wire was drilled antegradely through
the base of the distal phalanx out through the finger tip.
When it pressed up the skin pulp distally, a small incision
was made sufficient for exit of the wire. The K-wire was
then withdrawn and reinserted retrogradely across the joint
and into the medullary canal, while maintaining 0–10�flexion of the DIP joint. The position of the K-wire was
checked under an image intensifier. A cannulated drill bit
was used to drill the bone over the K-wire into the distal
and middle phalanx and then the screw was inserted toward
the middle phalanx. At that time, it was advanced until the
distal end of the screw was fully buried in the tuft of the
distal phalanx and its tip was located within the medullary
canal of the middle phalanx. After assessing the fixation,
the extensor tendon was repaired with nonabsorbable
sutures and the skin was closed. Immediately after surgery,
a full range of motion of the adjacent joints was started by
the patients without protective immobilization. From
6 weeks, gradual pinch movement was allowed, and rou-
tine activities were allowed from 3 months after surgery.
Results
On AP radiographs of the distal phalanx, the average nar-
rowest diameter of the thumb was 6.39 ± 0.76 mm, for the
index finger it was 4.40 ± 0.52 mm, for the middle finger
it was 4.74 ± 0.63 mm, for the ring finger it was 4.61 ±
0.56 mm and for the little finger it was 3.54 ± 0.55 mm.
On lateral radiographs, the average narrowest diameter of
the thumb was 5.04 ± 0.73 mm, for the index finger it was
3.13 ± 0.52 mm, for the middle finger it was 3.17 ±
0.55 mm, for the ring finger it was 3.05 ± 0.49 mm and
for the little finger it was 2.64 ± 0.51 mm. On AP radio-
graphs of the middle phalanx of the fingers or proximal
phalanx of the thumb, the average narrowest diameter of
the medullary canal of the thumb was 5.04 ± 0.64 mm, for
the index finger it was 3.68 ± 0.57 mm, for the middle
finger it was 3.82 ± 0.61 mm, for the ring finger it was
3.71 ± 0.50 mm and for the little finger it was 2.75 ±
0.55 mm. On lateral radiographs, the average narrowest
diameter of the medullary canal of the thumb was 4.17 ±
0.68 mm, for the index finger it was 2.09 ± 0.56 mm, for
the middle finger it was 2.10 ± 0.55 mm, for the ring
finger it was 1.95 ± 0.53 mm and for the little finger it was
1.83 ± 0.50 mm (Table 1). In all cases, the results on
Table 1 The average diameters
of the distal and middle phalanx
in healthy Koreans
Distal phalanx Middle phalanx (Proximal for thumb)
AP (mm) Lateral (mm) AP (mm) Lateral (mm)
Thumb 6.39 ± 0.76 5.04 ± 0.73 5.04 ± 0.64 4.17 ± 0.68
Index 4.40 ± 0.52 3.13 ± 0.52 3.68 ± 0.57 2.09 ± 0.56
Middle 4.74 ± 0.63 3.17 ± 0.55 3.82 ± 0.61 2.10 ± 0.55
Ring 4.61 ± 0.56 3.05 ± 0.49 3.71 ± 0.50 1.95 ± 0.53
Little 3.54 ± 0.55 2.64 ± 0.51 2.75 ± 0.55 1.83 ± 0.50
Arch Orthop Trauma Surg (2012) 132:663–669 665
123
lateral radiographs (dorsal–palmar dimension) were smal-
ler than the results on AP radiographs (medial–lateral
dimension) and no statistically significant differences
between male and female hands were detected.
During the operation, all fingers except one achieved
rigid fixation with a single screw. One thumb IP joint
required additional K-wire fixation after screw fixation for
controlling rotational instability. On plain radiographs,
bony union was observed in all cases, and the loosening or
destruction of screw was not detected. The time required
for union was an average of 10 weeks (range 8–12). The
average clinical fusion angle was 11.9� (range 0–20;
Figs. 3, 4), and no finger nail deformity was observed.
Removal of a screw because of local irritation or infection
was not required in any case. No other complications such
as dorsal skin necrosis, injury of digital nerves, or stiffness
of the proximal interphalangeal joint observed. Pinch
power was measured to be 75% of the normal side. The
VAS pain score decreased from 6.7 points to 0.4 points
after surgery (range 0–3; p \ 0.001). No patients reported
pain during resting and four reported mild pain during
routine activities. The average Korean DASH score mea-
sured after surgery was 5 points (range 0–8).
Discussion
Arata et al. [8] stated that arthrodesis is a generally
accepted operative treatment for arthritis of the DIP joint to
relieve pain, and to correct deformity and instability when
conservative measures have not improved the problem.
Arthroplasty of the DIP joint is a much less commonly
reported procedure. Silicone implants have been recog-
nized as the mainstay for small joint arthroplasty of the
hand. However, because of high rates of complications,
such as decreased range of motion, bony erosions, implant
fracture and poor patient satisfaction, it is difficult to make
strong recommendations in this regard [9–11]. Further-
more, because the successful fusion of these joints
improves the function and appearance with acceptable
morbidity, arthroplasty is not often recommended except in
special cases where greatest mobility is needed [9, 12]. For
arthrodesis of the DIP joint, a wide variety of techniques
has been used. Because each technique has its own
advantages and problems, no single technique has gained
universal popularity. Early techniques such as a single
K-wire, crossed K-wires and intraosseous wiring provided
stabilization of the joint but produced poor compression of
the fusion surfaces [13–15]. The complication rate of these
early techniques was high, with hardware protrusion or
migration, loosening, nonunion, pin-track infections, dorsal
skin necrosis, osteomyelitis, or stiffness of the adjacent
joint [3].
The principles of obtaining stable union are good bone-
to-bone contact and appropriate compression of the sur-
face. Seitz [16] suggested that compression improved
union rates, time to union, and time to return to work.
Sabbagh et al. [17] revealed that the compression across
the joint is an important factor by reporting 15% nonunion
Fig. 3 Arthrodesis in a nonflexed position. a Preoperative radio-
graphs. b Postoperative radiographs. c Last follow-up clinical
photographs
666 Arch Orthop Trauma Surg (2012) 132:663–669
123
following fixation using biodegradable smooth pegs. Based
on expectations that compression across the joint might
accelerate the fusion rate and that buried hardware might
decrease the infection rate, the use of headless compression
screws is on the rise. Despite the hope that these screws
would solve the problem, high nonunion rates have been
still reported [2–4, 7]. The exact reason is not clear, but we
suppose that the large diameter of the trailing threads break
through the cortex of the distal phalanx, resulting in loss of
purchase by the screw. In our series, successful union was
observed in all cases and the time required for union was an
average of 10 weeks. The acutrak fusion screw has the
smallest diameter among headless compression screws.
Therefore, the chance of penetration of the distal phalanx
by the screw thread was lower than for other types, which
resulted in good purchase and compression.
There are some reports on DIP joint arthrodesis with the
Herbert screw [3–7]. However, the acutrak screw has been
shown to provide greater compression [18, 19]. Because
the acutrak screw is threaded along its entire length, a
Fig. 4 Arthrodesis in a flexed
(11�) position. a Preoperative
radiographs and clinical
photograph. b Postoperative
radiographs. c Last follow-up
clinical photographs
Arch Orthop Trauma Surg (2012) 132:663–669 667
123
greater surface area is available for fixation between the
bone and the screw. The conical shape of the screw also
may provide an advantage by increasing resistance to pis-
toning within the bone [19]. Furthermore, in contrast to the
acutrak screw, the Herbert screw has a rather thin shaft that
could result in instability. We believe that these factors
might also influence the outcome.
Nail deformity as a result of dorsal cortex penetration of
the distal phalanx by the screw threads is observed fre-
quently. Brutus et al. [2] noted a 7% incidence of nail
deformity out of 27 fingers with the acutrak mini screw. In
a cadaveric study, Wyrsch et al. [20] found distal phalanx
fracture and penetration of the dorsal cortex by screw
threads in 25 of 30 specimens during joint instrumentation
with a Herbert screw. This can lead to stretching or dis-
ruption of the nail bed with deformity of the nail. When
compared with the results using other headless compres-
sion screws, our results were promising.
Distal-to-proximal placement of the screw in fusion of
the DIP joint is only possible in nearly full extension.
Brutus et al. [2] stated that arthrodesis with an acutrak mini
screw was considered very useful if it is acceptable to
positioning the DIP joint with extension and that another
technique should be performed if more than 10� of flexion
is desired. However, in our series, the mean clinical angle
of the fusion was 11.9� (range 0–20). A slight flexion
position was possible because of the small diameter of the
acutrak fusion screw, especially in the thumb. In this study,
almost all patients seemed to adapt well and they did not
complain about the fusion position.
The selection of proper headless compression screws
with the size appropriate to the distal phalanx may be one of
the most important factors for success of fusion. Koreans
tend to be smaller than Caucasians and thus the distal
phalanx is also smaller. Hence, the possibility of penetration
of the screws in the distal phalanx is higher. Wyrsch et al.
[20] dissected 30 distal phalanges from cadavers and mea-
sured the size. The average height (dorsal-palmar dimen-
sion) of the distal phalanx was 3.55 mm, smaller than the
trailing thread diameter of the Herbert screw (3.9 mm). In
their study, they found fracture and penetration of the dorsal
cortex by screw threads in 10 among 15 male cases and in
all 15 female cases during joint instrumentation with a
Herbert screw. In the study, the smallest diameter of the
distal phalanx was 2.54 mm (the little finger on lateral
radiographs). Regarding the headless compression screws
currently available on the market, the trailing thread
diameter of the acutrak standard screw is 4.2 mm; it is
3.9 mm for Herbert screws, 3.5 mm for acutrak mini
screws, 3.2 mm for Herbert mini screws and 2.5 mm for
acutrak fusion screws (Table 2). We determined that only
the acutrak fusion screw would not penetrate the distal
phalanx during the arthrodesis of the DIP joint.
The diameter of the medullary canal of the middle
phalanx might be an important factor for fixation with
headless compression screws. To the best of our knowl-
edge, this issue has not been studied in the literature. In our
study, the minimal diameter of the medullary canal was
1.83 mm (the little finger on lateral radiographs) and the
maximal diameter was 4.17 mm (the thumb on lateral
radiographs). During thumb IP joint arthrodesis, inadequate
purchase in the proximal phalanx can occur if it has a wide
medullary canal. In our series, we experienced one intra-
operative fixation loss with the acutrak fusion screw, so we
added a longitudinal K-wire for stability. Care should be
taken and alternative fixation methods should be consid-
ered for thumb IP joint arthrodesis in cases with a large
medullary canal in the proximal phalanx.
In conclusion, the acutrak fusion screw is feasible and
adequate for arthrodesis of the DIP joint and thumb IP
joint, particularly in Koreans. However, meticulous atten-
tion to the size of the distal phalanx is important to avoid
complications in some little fingers. If preoperative radio-
graphs suggest that the thumb has a wide medullary canal
in the proximal phalanx, alternate methods of fixation
should be considered.
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Screw name Diameter (mm)
Leading Trailing
Acutrak fusion (smallest) 2.0 2.5
AutoFix 2.0 2.0 3.0
Herbert mini 2.5 3.2
AutoFix 2.5 2.5 3.3
Acutrak mini 2.8 3.2–3.5
Kompressor mini 2.8 3.6
Synthes 3.0 HCS 3.0 3.5
Herbert 3.0 3.9
Acutrak 3.3 3.8–4.6
Twinfix 3.2 4.1
Kompressor 4.0 5.0
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