ARTHRODESIS OF THE

METACARPOPHALANGEAL AND
INTERPHALANGEAL JOINTS OF
THE HAND:CURRENT CONCEPTS
Abstract
Metacarpophalangeal arthrodesis and interphalangeal arthrodesis are excellent
tools in the surgeon’s armamentarium to restore function of the disabled hand.
Typical indications for these procedures are pain, deformity, and/or stiffness.
Arthrodesis is generally considered a salvage procedure to be used when other
reconstructive procedures, such as arthroplasty, are not possible or would be
associated with a high rate of complication or failure.
Abstract
To determine the most functional position for arthrodesis in each patient,
the surgeon should preoperatively evaluate the compromised joint in the
context of the disease process, determine the initial cause of the joint
pathology, and assess the condition of the surrounding joints. Current
methods of achieving fusion of metacarpophalangeal and
interphalangeal joints include options for incisions, bone preparation
techniques, and surgical implants; each has advantages and associated
risks.
With the advent of new technology and research, arthro-desis of the hand
joints has undergone substantial change in the past few decades. The
development of smaller implants has made fixation more reliable but has
introduced new complications and challenges. The trend toward minimally
invasive procedures has influenced surgical techniques and concepts.
When considering arthrodesis, the surgeon must take into account the
disease process and its effect on surrounding joints and soft tissues.
Here, we review the advantages and disadvantages of different
surgical techniques and types of fixation in the context of the disease
process. Several techniques can help the surgeon avoid potential
complications and improve outcomes.
Indications
Physiologic Age and Activity
Level When choosing between fusion and arthroplasty, the surgeon must assess
the patient’s physiologic age. Physiologically younger and healthier patients put
higher loads on the joint for a longer time than do physiologically older, less
healthy patients. Because younger physiologic age increases the risk of implant
failure over time, fusion may be preferable in these patients if the loss of motion
can be tolerated. The patient’s needs must be evaluated to ensure that the
chosen procedure fulfills the patient’s expectations.
Physiologic Age and Activity

Fusion should be avoided in patients with unrealistic expectations.

Because of work or family demands, physiologically younger patients
often have greater expectations than do physiologically older patients. If
soft tissues allow, the patient’s ability to tolerate stiffness from the fusion
can be determined preoperatively by placing the patient’s finger in a
removable splint in the desired position of fusion to simulate the effect of
arthrodesis.
Physiologic Age and Activity

This method allows the surgeon to assess the patient’s satisfaction with
the chosen position and helps to manage patient expectations1 (Figure
1). The splint can be adjusted to identify the fusion angle that best suits
each patient. This process of adjustment can help ensure that the
patient will be satisfied with the outcome of the fusion and is especially
important in patients whose work or leisure activities place unusual
demands on the hand.
Joint Involvement
Which joint is affected plays a major role in the decision between arthroplasty and
fusion. Thumb metacarpophalangeal (MP) fusion tends to be well tolerated by
most patients. This finding is understandable given that thumb MP motion in the
population varies from 0 to 72. Few patients born without substantial MP motion
ever report a perceived deficit in dexterity. Fusion is also more durable than
arthroplasty and can withstand the loads and repetitive forces placed on the
thumb. In contrast to thumb MP fusion, MP joint fusion in other digits tends to be
poorly tolerated because the fusion substantially limits the function of the hand.
Joint Involvement

Proximal interphalangeal (PIP) joint fusion also limits function but to a

lesser degree than does MP joint fusion. Because of the lateral forces
applied by the thumb to the index finger, arthroplasty of the MP and PIP
joints has high failure rates in the index finger.32 Whereas the little finger
is vulnerable to unopposed forces in an ulnar direction because of its
location, the long and ring digits are relatively protected from lateral
forces because the surrounding digits act as buffers to reduce angular
deformation.
Joint Involvement

Therefore, the long and ring digits are better candidates for arthroplasty
than are the index and little fingers. The distal interphalangeal (DIP)
joints in both the thumb and the other digits are better suited for fusion
than for arthroplasty because stiffness typically is tolerated in these
joints. High loads can predispose arthroplasty and reconstructionof the
DIP joints tofailure in high-demand patients.4
Disease Process
The classic indications for arthrodesis of the MP and interphalangeal (IP) joints
are pain, deformity, and/or stiffness. Options that should be considered before
arthrodesis include osteochondral reconstruction, joint arthroplasty with or
without implant, and soft-tissue reconstruction. Important considerations in
choosing a surgical option include the cause of the initial joint destruction, the
joint involved in the specific disease process, and the condition of the
surrounding joints.
■ Osteoarthritis
Osteoarthritis is the most common type of arthritis and generally occurs in multiple
joints throughout the body in older patients who are genetically predisposed to the
disease. In the hand, the most commonly affected joints are the DIP joints of all
digits and the carpometacarpal joint of the thumb. The PIP joints are less frequently
involved than are the DIP joints. Patients tend to have pain and inflammation of the
affected joint that can last several months. The pain frequently resolves over time,
but as swelling decreases, the resulting loosened ligaments can lead to angular
deformities and joint destruction.
Osteoarthritis

Osteophytes may limit range of motion. In patients with greater stiffness,

reports of pain are less frequent. Radiographs typically demonstrate joint
space narrowing, osteophytes, bone cysts, and sclerosis of the
subchondral bone. Deciding between arthroplasty versus fusion in
patients with osteoarthritis is difficult because these patients tend to be
older and have involvement of multiple joints. The decision depends on
the joint affected, the patient’sage,and the patient’s expectations.
Osteoarthritis

Tobacco also use has been found to reduce fusion success rates in these
patients. Controversy exists concerning the management of PIP joint
osteoarthritis. Some surgeons recommend arthroplasty in the PIP joints
of the index and long fingers to maximize fine motor skills and
recommend fusion in the PIP joints of the ring and little fingers to
maximize power grip.7 Others suggest that the index PIP joint is a poor
candidate for arthroplasty because of the lateral forces placed on it by
the thumb and because of the lack of a radial border digit.3
Osteoarthritis

Many authors advocate fusion of the PIP joint in the index and little digits
and arthroplasty of the PIP joint in the long and ring digits because the
long and ring digits are well protected by the border digits. DIP joint
arthroplasty is rarely performed. This procedure is associated with
substantially higher failure rates compared with those of fusion because
of the small bone dimensions and high forces across the joint. DIP
fusions are well tolerated and are extremely durable.
Clinical photograph demonstrating
placement of a splint on the index finger.
If the soft tissues allow, preoperative
splinting can help the surgeon choose
the ideal fusion position and manage
patient expectations.

Clinical photograph demonstrating the

hand of a patient with arthritis mutilans.
■ Posttraumatic Arthritis
Patients with posttraumatic arthritis tend to have higher expectations than do
patients with other types of arthritis. Typically the goal is to return to the activity
that may have resulted in joint destruction in the first place. Posttraumatic
arthritis often occurs in younger patients with high demand. The surrounding
uninjured joints typically have excellent function, which makes these patients
suitable candidates for arthrodesis rather than arthroplasty. In these patients,
arthroplasty has higher failure rates than fusion does because of high loads and
the longevity of the patient.9
■ Septic Arthritis
Septic arthritis or associated osteo-myelitis is a relative contraindication to implant
arthroplasty or osteochondral reconstruction because of the potential for recurrent
infection. In young, active patients with septic arthritis or associated osteomyelitis,
the surrounding joints are generally in excellent condition. Therefore, fusion is a
better option than arthroplasty in these patients.
■ Psoriatic Arthritis
Psoriatic arthritis frequently involves the PIP joints and can be managed with
arthroplasty in older patients with adequate bone stock. This type of arthritis is
frequently associated with a pencil-in-cup deformity on radiography and
substantial bone loss, which may make fusion a better option.10 The patient’s age
and activity level and the involvement of other joints should be considered in the
decision. Location-based criteria for arthroplasty versus fusion are similar to those
previously discussed for osteoarthritis.
Psoriatic Arthritis

Arthritis mutilans is one of the five types of psoriatic arthritis; it is

characterized by substantial bone reabsorption around the joints, which
results in digital shortening and stiffness. Although patients with arthritis
mutilans have limited function of the hand because of multiple joint
destruction and digital shortening, they tend to be poor candidates for
arthroplasty of the PIP and DIP joints because of the low quality of the
bone stock (Figure 2). Radiographs frequently demonstrate substantial
joint destruction and resorption of bone around the affected joints and
digital shortening.
■ Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) can cause joint laxity in the hand, leading to
ulnar deviation and palmar subluxation at the MP joints associated with swan
neck defor- mities, without substantial joint destruction visible on radiography. In
these patients, osteopenia can frequently be detected on radiographs. Even when
the MP joints appear to be intact, soft-tissue procedures with joint preservation
often have poor long-term results because of recurrence of the disease process. In
patients with SLE, MP joint arthroplasty is preferable to MP joint fusion because of
the limited function of other affected joints and altered tendon function.
Systemic Lupus Erythematosus

These tendons frequently require realignment.11 Intrinsic release

andtransferscanhelpprotect the implants from lateral load. Although soft-
tissue reconstruction can be attempted in patients with PIP and DIP joint
deformities, fusion may be necessary if joint destruction has occurred.
The fusion positions of the PIP and DIP joints depend on the motion of
the MP joint. Greater PIP and DIP joint flexion can compensate for
decreased MP joint flexion.
■ Rheumatoid Arthritis
In patients with rheumatoid arthritis (RA), joint involvement is similar to that in
patients with SLE. Radiographs demonstrate more joint destruction in patients
with RA than in patients with SLE. Radiographs of patients with RA do not
demonstrate the bone cysts and sclerosis frequently seen in patients with
osteoarthritis. Arthroplasty, combined with tissue rebalancing of the extensor
mechanisms and intrinsic muscles, is preferred for management of the MP joints
in patients with RA.12
Rheumatoid Arthritis

Soft-tissue reconstruction is frequently advocated in the early stages of

the disease but can fail over time if the disease is not well controlled. In
the PIP and DIP joints, fusion is chosen when softtissue reconstruction is
not possible. As in patients with SLE, the joint fusion position is
influenced by MP motion.
Clinical photographs demonstrating the hand of a patient with
scleroderma (A), typical surgical incisions used to manage the condition
(B), pin placement (C), and the postoperative appearance of the hand
(D). During the surgical procedure, an elliptical portion of poor-quality
skin and ulcers is excised. When the proximal interphalangeal joint is
extended, the proximal and distal flaps reapproximate to allow for
primary closure. (Courtesy of C. P. Melone, Jr, MD, New York, NY.)
■ Scleroderma
Scleroderma is encountered less fre-quently than the conditions discussed earlier.
Lateral radiographs demonstrate preservation of the joint space, without cysts or
sclerosis. In patients with scleroderma, the typical hand deformity consists of a
progressive loss of MP joint flexion with stiffness in extension associated with PIP
joint flexion. Although these deformities occur in patients with progressive systemic
sclerosis and in those with the CREST (calcinosis, Raynaud phenomenon,
esophageal dysmotility, sclerodactyly, telangiectasia) variant, they are more
frequently associated with progressive systemic sclerosis and are more extreme in
these patients than in those with the CREST variant.
Scleroderma

Soft-tissue issues and healing potential are of concern because of poor

circulation and the frequent presence of ulcers and infections, which
occur over the dorsal aspects of the PIP joint more frequently than in the
DIP joints. Ischemic ulcers of the distal digital tip are more frequently
associated with the CREST variant than with progressive systemic
sclerosis.
Smoking is the greatest risk factor for amputation in patients with scleroderma.
Patients who use prod-ucts containing nicotine should be counseled to stop prior
to surgery. Although MP joint arthroplasty is frequently successful in restoring
some range of motion of the MP joints, PIP joint arthroplasty is asso-ciated with
poor results because of the poor quality of the soft tissues and damage to the
extensor mechanisms. Compared with MP joint arthroplasty, fusion of the PIP
joints and DIP joints has greater success rates and fewer complications.
The presence of ulcers should not dissuade the surgeon from proceeding
with PIP joint fusion because these lesions frequently do not heal until
the abnormally flexed PIP joint position is corrected. The PIP joint fusion
position should be determined on the basis of the MP and DIP joint
motion. Decreased flexion of the MP joint requires greater flexion of the
PIP and DIP joints. Therefore, these patients may require PIP joint fusion
in a position with much greater flexion than that needed in patients with
other diseases.
Bone shortening is frequently performed during fusion to reduce tension
of the soft tissues and vascular structures and to allow primary closure
despite preexisting soft-tissue deficits.
Meticulous handling of the soft tissues is necessary to reduce the risk of
skin necrosis. In the PIP and DIP joints, the use of permanent implants
should be avoided because of the risk of development of ulcers over
prominent implants and because of potential progression of the disease.
Fixation can be accomplished with crossed Kirschner wires (K-wires) to
allow for easy removal of the implants after fusion has been achieved13
(Figure 3).
Guidelines for Fusion Position
The choice of fusion position for any joint depends on multiple factors, including
patient vocation, hobbies, expectations, and tissue quality. To determine the ideal
joint fusion position preoperatively, the affected joint often can be splinted in the
anticipated position of fusion. Preoperative splinting in several positions can be
attempted to ensure that the patient will be satisfied with the fusion position and
understand the outcome.
Guidelines for Fusion Position

Allowing the patient to be an active participant in determining the

position of the joint is important for patient satisfaction. However,
because of contractures and soft-tissue constraints, preoperative
splinting is not always possible.
In the ideal situation, preservation of the natural cascade of the hand
results in the most aesthetically pleasing outcome (Figure 4). The natural
cascade can be calculated on the basis of the position of the resting
index finger.
Guidelines for Fusion Position

Flexion of the MP and PIP joints progresses in a radial-to-ulnar direction

by approximately 5 per digit. Flexion of the DIP joints remains relatively
constant at approximately 5. To help guide the fusion position, the
surgeon can compare the flexion of the joints with that of the opposite
hand or with the ipsilateral hand (if the other joints are well preserved).
The index MP joint is generally positioned in 25 of flex-ion, and the index
PIP joint is generally positioned in 40 of flexion.
Although aesthetics are important, function should prevail in determining the
fusion position. Patients who desire a high degree of dexterity frequently prefer a
slightly more flexed position. Position is also dictated by the health of the
surrounding joints. In patients with stiff thumbs and limited index MP joint motion,
the flexion of the PIP and the DIP joints should be adjusted to allow for pulp-to-
pulp opposition of the two digits. If other digits require fusion, the natural cascade
can be re-created by applying the formula discussed previously.
The ideal flexion of the DIP arthrodesis is controversial and has been the
focus of multiple studies. Wide use of recent technological advances,
such as smartphones and computers, has resulted in the need to
eevaluate joint position. Studies have been performed on volunteers with
their DIP joints splinted to evaluate the most functional position. One
recent study suggested that when the index DIP joint was splinted in 20
of flexion instead of 0 of flexion, dexterity scores and grip strength
improved.14 No statistically significant difference in the dexterity of the
middle finger or grip strength was found with a similar change in
position.14
Yao et al15 assessed the ideal position for thumb IP joint arthrodesis.
They found no difference in dexterity related to the use of a smartphone
with the thumb IP joint at 10 or 30 of flexion. Patient preference,
combined with the surgeon’s experience, should supersede textbook
recommendations.
Photograph demonstrating the natural
cascade of a normal hand.

Clinical photograph of the hand

demonstrating options for the skin
incision.
Surgical Techniques
Methods of achieving fusion of MP and IP joints include options for incisions, bone
preparation techniques, and surgical implants. Each option has advantages and
risks.
Exposure
Multiple options for surgical exposure are available (Figure 5). Although a few
surgeons have advocated percutaneous or arthroscopic removal of the articular
cartilage and subchondral bone followed by fixation, this option typically is
recommended only when hypertrophic bone is present, such as in patients with
osteoarthritis.16 Most surgeons advocate a curved dorsal incision in line with the
skin creases because it provides excellent exposure of the MP, PIP, and DIP joints
in most patients. A dorsal H-type incision with the transverse portion running
parallel to the skin crease is another option.
Exposure

We prefer to use this incision in patients with scleroderma because it

allows for the creation of local advancement flaps, which help in excising
nonviabletissue and performing primary closure13 (Figure 3, B). To
maximize the thickness of the flaps in patients with scleroderma, the
skin and extensor tendon are cut transversely without creating a
separate plane. Closure is accomplished by passing sutures through both
the skin and the extensor tendon in a single layer.
Exposure

In patients without vascular compromise, a plane between the skin and

tendon is created so that the transversely cut extensor tendon can be
repaired in separate layers. At the DIP joint, a transverse skin incision
over the joint with tenotomy of the underlying extensor tendon provides
excellent exposure (Figure 6). Essentially, the surgeon can cut straight
down transversely through the skin and extensor mechanism to expose
the DIP joint. After the collateral ligaments are released, the joint is easily
visible for preparation.
Bone Preparation
Multiple methods of bone preparation for fusion have been advocated. Most
surgeons recommend preparing the surface with hand tools instead of power
equipment to reduce the risk of thermal injury to the bone. Articular cartilage and
subchondral bone should be removed until healthy cancellous bone is exposed.
Removal of the subchondral bone is more difficult in patients with posttraumatic
arthritis and osteoarthritis than in other patients because of the substantial
subchondral sclerosis associated with these types of arthritis. In patients with
other types of arthritis, such as RA, SLE-related arthritis, and psoriatic arthritis,
bone removal is easily achieved because of osteopenia and the lack of sclerosis.
Bone Preparation

Overzealous removal of bone may result in loss of healthy cancellous

metaphyseal bone, which quickly becomes cortical diaphyseal bone as
one moves farther from the joint. In addition, excessive bone removal can
result in an unsatisfactorily shorter digit with a loose soft-tissue
envelope. Excess cancellous or subchondral bone removed during
preparation can be used for bone grafting after fixation has been
achieved. Occasionally, substantial bone loss may require the use of
supplemental bone graft from the distal radius or other sources. Care
should be taken to avoid distraction of the fusion mass while placing the
bone graft into the fusion site.
Bone Preparation

The most commonly used method of bone preparation is a cup-and-cone

configuration with the convexity proximal and the concavity distal. This
configuration facilitates positioning of the fusion site to maximize the contact area
and minimize bone resection. It also allows for easy adjustments of both angular
and rotational alignment to compensate for pathologic deformity, which is
frequently present. Some surgeons have used flat, angled surface cuts at the
fusion site. This technique makes slight alterations in position more difficult, and
larger amounts of bone resection may be required if the initial cuts are not
optimal.
Clinical photographs of the ring finger demonstrating exposure with an H-
type incision. A, Skin incision marked on the patient’s skin. B, Extensor
tendon exposure. C, Joint exposure after collateral ligament release.
Fixation
Several types of fixation can be used to achieve MP or IP fusion. Although biomechanical studies
have been performed to assess implant stiffness, their clinical relevance is questionable because
of the high fusion rates achieved with most fixation devices.17 Crossed K-wires have the advantage
of being technically simple to use (Figure 7). They can be removed easily if they are left
percutaneous, and they maintain position, rotation, and compression during healing. However, they
can become infected if left percutaneous and can sometimes loosen during the healing process.
This loosening results in loss of position or fusion failure. Some authors address this problem by
burying the K-wires and/or by adding cerclage wires for additional fixation. Cerclage wires can be
placed in a 90/90 configuration without K-wires to maintain reduction. Although this technique
results in more secure fixation than that achieved with K-wires and has less risk of migration during
fusion, it increases the risk of device irritation, which may necessitate removal.
The use of headless screws to stabilize the fusion site has been associated with a lower incidence
of device irritation and high fusion rates (Figure 8). A systematic review comparing K-wires,
cerclage wires, and headless screws found no difference in infection rates but higher fusion rates
with headless screws compared with the other methods.18 The disadvantage of headless screws is
that the constraints of the screw limit the degree of flexion in which the joint can be placed. When
K-wires or cerclage wires are used, a position of greater flexion is possible. The development of
cannulated screws has made fixation with headless screws technically less challenging than it was
previously. To accommodate the guidewire, cannulated screws need to be larger than
noncannulated screws. Many commercially available cannulated screws are too large for use in
the DIP joint, particularly in the index and little fingers, which have smaller dimensions than those
of the long and ring fingers. Fixation of the DIP joint with cannulated screws also can be
problematic in women because their joints are generally smaller than those in men.19
Because of the size of cannulated screws, the risk of nail plate injury is increased with this
technique. This risk has prompted some surgeons to alter the surgical technique by inserting the
screw in a proximal-todistal direction with an oblique orientation, instead of in the standard distal-
to-proximal direction. This alternative technique has been advocated to reduce the risk of implant
irritation to the nail plate by avoiding trauma to the distal digital tip.
Because cannulated screws can be inserted percutaneously, some surgeons place screws across
arthritic DIP joints without exposing and preparing the joint surfaces. This technique is less
invasive and allows for a shorter surgical time. However, the results have been disappointing.
Fibrous nonunion was found in 41% of DIP joint fusions performed with this in situ technique
compared with 8% of DIP joint fusions performed with open preparation of the joint and screw
placement.21
Plate fixation also has been used to achieve fusion. Although plate fixation is strong, plates tend to
be prominent and cause tendon adhe-sions, which can limit adjacent joint motion. The risk of
implant irritation to the soft tissue, which frequently necessitates removal, is higher with plate
fixation than with other types of fixation. With new manufacturing techniques, plates have become
smaller and stronger over the last several decades. These smaller plates have led some surgeons
to advocate this type of fixation. In a recent retrospective study using 1.3-mm plates and a lateral
approach to avoid the flexor and extensor tendons, Mantovani et al22 reported a 100% DIP joint
fusion rate in 11 patients at 12 weeks postoperatively.
A, Preoperative lateral fluoroscopic image of the hand
in a patient with systemic lupus erythematosus. Note
the minimal sclerosis, bone destruction, and joint
destruction with deformity secondary to chronic
ligamentous laxity. B, Postoperative lateral
fluoroscopic image of the hand demonstrating
fixation with Kirschner wires.
A, Intraoperative photograph demonstrating insertion of a headless cannulated screw
for fixation. A Kirschner wire is inserted as a guide wire for the screw. A second
Kirschner wire is used to prevent loss of reduction and change in rotation during
insertion of the screw. B, Postoperative lateral radiograph of the finger demonstrating
fixation with a headless screw.
Postoperative Care
Time to fusion has been found to be independent of the surgical approach, joint preparation
method, and type of fixation. Most surgeons agree that secure fixation lessens the need for
postoperative immobilization to allow healing, and higher fusion rates have been noted with more
secure fixation methods, such as screw fixation. The time to successful fusion depends on tissue
quality, disease process, and close adherence to surgical principles, but fusion typically occurs by 6
weeks.23
Complications
Complications include infection, hematoma, tissue loss, implant failure, loss of fixation resulting in
malunion or nonunion, implant irritation, nerve or vascular injury, nail plate injury, and complex
regional pain syndrome.24 Fusion in the index finger has a failure rate higher than that of fusion in
other digits because of forces applied by the opposing thumb. Although patients are routinely told
postoperatively not to use this digit until fusion is achieved, they often have difficulty complying
with this restriction. Immobilization of the thumb to prevent contact with the fused index finger
should be considered to enforce patient compliance.
Summary
When considering arthrodesis in patients with painful or deformed digits, the surgeon should
assess the entire patient, not just the affected joint. A careful history, including hand dominance,
vocation, hobbies, and expectations of surgical intervention, is necessary. A clear understanding of
the pathologic process that resulted in the joint destruction or deformity helps to determine the
appropriate surgical procedure, exposure, and fixation method. Satisfactory results can be achieved
with proper patient selection, meticulous technique, and joint fusion in an appropriate position for
the patient’s activities and expectations. Preoperative splinting can sometimes aid in selecting the
position of fusion and confirm patient satisfaction with the position before the procedure is
performed. A thorough discussion of the goals of fusion and the risks associated with the
procedure will help ensure that the patient understands the expected outcome.