- Of 154 patients (161 joints) who had surgery for fractures involving the proximal interphalangeal joint, the reoperation rate was 16% overall and 26% for open fractures
- The odds of undergoing revision surgery were six times higher for open fractures than for closed fractures
- In bivariate analysis, nerve injury was significantly associated with reoperation, which may represent the severity of soft tissue injury
Stiffness and post-traumatic osteoarthritis are commonly reported after surgery for fractures of the proximal interphalangeal (PIP) joint. However, it's unclear how often patients undergo reoperation or which factors prompt surgeons and patients to choose reoperation.
In a retrospective study, Neal Chen, MD, chief of the Hand & Arm Center in the Department of Orthopaedics at Massachusetts General Hospital, and colleagues report in Hand that soft tissue injury is a major influence on reoperation after PIP joint fractures. They add that special attention should be paid to persistent subluxation because it may predispose to early osteoarthritis.
The researchers identified 154 patients at three urban hospitals who had surgery for fractures involving the PIP joint between January 2004 and December 2015. Some patients had multiple injuries, for a total of 161 joint fractures.
All four fingers were affected about equally often. Most fractures (61%) were caused by impaction and 50 (31%) were open. The most common surgical treatment (65% of fractures) was open reduction and internal fixation (ORIF). Forty-six PIP joints had an associated tendon injury, 11 had nerve injury and three had an associated vascular injury severe enough to need repair.
- 25 patients (16%) underwent reoperation
- Eight of those 25 patients (5% of the entire cohort) required more than one reoperation. This included two of the seven patients initially treated with ORIF, who had further revision surgery because of persistent stiffness
- 26% of open fractures underwent reoperation
- The mean time to reoperation was 7.5 months
Factors in Reoperation
The most common reasons for reoperation were joint stiffness (10 patients) and persistent subluxation (four patients).
Only seven of the 90 impact fractures (8%) underwent reoperation, compared with 64% of the 18 crush injuries. The cause of injury was significantly associated with reoperation in bivariate analysis but not multivariate logistic regression analysis.
In bivariate analysis, nerve injury was significantly associated with reoperation, which may represent the severity of soft tissue injury. Tendon and vascular injuries were not significant in bivariate or multivariate analysis.
In multivariable analysis, the only factor significantly associated with reoperation was open fracture. It was independently associated with a six times higher rate of reoperation compared with closed fracture (OR, 5.7; 95% CI, 1.1–30.0; P = .04).
Subanalysis of Closed Fractures
Twelve (11%) of the 111 closed fractures underwent surgery. The cause of injury was of borderline significance (P = .05), but in multivariate analysis, it was not independently associated with reoperation.
When counseling patients preoperatively, the researchers now emphasize that about one in six patients who have surgery for PIP joint fractures will require reoperation, usually to address stiffness and persistent subluxation.
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