Davos Courses

Executive Editor: Jörg Auer

Authors: Jeffrey Watkins

Phalanges Middle phalanx, Degenerative joint disease (DJD)

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1 Principles top

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Complete cartilage removal

Complete cartilage removal is important to provide for maximum contact between the opposing subchondral bone plates. With compression, generated by the fixation technique, frictional forces are generated between the subchondral bone plates, which maximizes strength and stability of the fixation, providing maximum patient comfort and allowing early removal of postoperative cast support.

Plate placement enlarge

Plate placement

The implant is positioned over the proximal and middle phalanx in the sagittal plane. The distal end of the plate is placed in the proximal region of the middle phalanx. The distal end of the plate should not impinge on the proximal attachment of the distal interphalangeal joint capsule as well as the extensor process (A). The palmar/plantar position of the transarticular screws and distal plate screw should lie within the palmar/plantar eminences (B) to avoid the palmar/plantar aspect of the distal interphalangeal joint capsule and navicular apparatus.

2 Preparation and approach top


With the appropriate preparation and draping of the surgical site, this procedure is performed with the patient placed in  lateral recumbency and through the dorsal approach.

3 Plate selection and preparation top


Plate selection

A proximal interphalangeal locking plate (PIP) (right) is advocated as it is specifically designed for pastern arthrodesis. Other plate constructs have been used successfully, including narrow, 4.5 mm, 3 and 4-hole DCPs and LC/DCPs.
The technique for fixation with DCP or LC/DCP is described for uniaxial eminence fractures as an example. For more details click here.


Plate preparation

Extending the digit realigns the articulation into normal anatomic configuration.
The plate is contoured to approximate the sagittal dorsal surface of the distal proximal phalanx and proximal middle phalanx with the stacked combi-hole of the plate positioned over the proximal end of the middle phalanx.
The distal end of the plate is then bent slightly to ensure that the distal plate screw is inserted directly below the subchondral plate and into the proximal palmar/plantar aspect of the middle phalanx.

4 Fixation top

The plate is held in position... enlarge

Application of the plate

The plate is held in position and compressed to the distal proximal phalanx by placing the push-pull device in the middle combi-hole.
Check the positioning of the implant and the proposed screw position with appropriate imaging technology.

Note: It may be advantageous to prepare the glide holes and their countersinking for the two abaxial transarticular cortex screws prior to applying the plate to ensure that the plate does interfere with their preparation at a later point of time.

The hole for the first screw... enlarge

The hole for the first screw is prepared just distal to the subchondral plate and the screw length is determined. The 5.0 mm locking screw of appropriate length is subsequently inserted and provisionally tightened.

A 4.5 mm cortex screw... enlarge

A 4.5 mm cortex screw is placed in load position in monocortical fashion through the proximal most plate hole. The screw should not be fully tightened, so the plate is not yet fully compressed to the bone and dynamic compression is not engaged.
The push-pull device is now removed.

Two 5.5 mm cortex screws... enlarge

Insertion of transarticular lag screws

Two 5.5 mm cortex screws are now placed transarticularly in lag fashion extending from the dorsal distal proximal phalanx into the proximal palmar/plantar middle phalanx. They cross the joint at the junction of the palmar/plantar ¼ and the dorsal ¾.
The screws are placed medial and lateral to the plate and parallel to the sagittal plane.
It is important that first one screw hole is finished and the screw inserted before the thread hole for the second screw is prepared.
Real time imaging is useful to direct screw positioning and intraoperative imaging of some nature is necessary to confirm proper implant position.

It is very important... enlarge

It is very important that the glide holes for the transarticular lag screws in the dorsal distal aspect of the proximal phalanx are appropriately countersunk to ensure the screw heads to engage the dorsal cortex in an appropriate fashion and thereby avoid bending, weakening and potentially breaking the screw head.

It is also important, that screws of appropriate length are used. enlarge

It is also important, that screws of appropriate length are used; they should not protrude beyond the palmar/plantar cortex of the middle phalanx. For the transarticular lag screws, a screw measuring 4-6 mm less than the measured length is appropriate and prevents placing a screw, which protrudes beyond the palmar/plantar cortex of the middle phalanx.

Once the transarticular lag screws are fully tightened, the distal and proximal plate... enlarge

Applying compression

Once the transarticular lag screws are fully tightened, the distal and proximal plate screws are fully tightened, which compresses the plate to the bone and provides additional axial compression between the subchondral plates of the proximal phalanx and the middle phalanx.

Finally, the middle hole of the plate is filled using an 5.0 mm locking head screw. enlarge

Insertion of remaining screw

Finally, the middle hole of the plate is filled using an 5.0 mm locking head screw.


Confirmation of fixation

The final construct configuration is checked with appropriate imaging to ensure appropriate length and positioning of all implants.


v1.3 2013-11-20