Perte de substance ostéo-articulaire de l’IPP des doigts longs : traitement en urgence par implant de Swanson: Étude prospective de 10 cas avec 2,7 ans de recul moyen

RésuméLes traumatismes de l’articulation inter-phalangienne proximale (IPP) avec perte de substance ostéo-articulaire, plus ou moins associée à une perte de substance tendineuse et cutanée font discuter l’arthrodèse, parfois l’amputation même sur un doigt vascularisé.Treize patients ont bénéficié d’une reconstruction en un temps de l’IPP. Dix patients, 16 implants, ont pu être revus avec un recul moyen de 2,7 ans (1-6). Aucune infection n’a été observée. Aucune arthrodèse ou amputation n’a été demandée en secondaire. Après 1 an, l’amplitude de flexion maximale était atteinte. En moyenne, la flexion active atteignait 41,8̊ (20-80). Deux implants étaient fracturés sans perte fonctionnelle au recul de 6 ans. Dans ces lésions tangentielles de la face dorsale de l’IPP, le travail du bois en loisir est responsable de la majorité des accidents. La mise en place en urgence d’implant type Swanson a permis si la reconstruction tégumentaire et tendineuse est effectuée, d’éviter l’amputation et d’obtenir une flexion utile, supérieure à 50̊ chez 5 patients (7 articulations inter-phalangiennes).

Purpose of the studyInjury of the proximal interphalangeal joint (PIP) with loss of bone and soft tissue (joint surface, tendon, skin cover) can compromise finger vascularization. Fusion or amputation is often proposed. We report our experience with another solution, emergency implantation of the Swanson implant.Material and methodsThirteen patients, mean age 47.4 years (range 18-76) underwent emergency surgery between 1997 and 2003. In twelve patients, the finger injury occurred when working with wood. For ten of the thirteen patients, the injury occurred during recreational activity. The index was involved when only one ray was injured. The thumb was spared in all patients. Joint tissue was lost in all patients. The head of P1 was injured in all cases creating a situation incompatible with fusion without loss of finger length. All patients underwent an emergency surgery for complete reconstruction of the PIP joint with Swanson implant, tendon reconstruction or suture, and skin cover performed during the same procedure.ResultsTen patients, 16 implants, were reviewed at mean 2.7 years (range 1-6 years). Mean flexion reached 41.8̊ (range 20-80̊). Maximal amplitude of flexion was achieved at one year and remained unchanged thereafter. There were no cases of infection, or secondary amputation. Two implant fractures were noted with no functional impact at six years. There were four cases of instability.DiscussionMost reports in the literature concern composite blast or firearm injuries. Ours appears to be the first series involving injuries occurring while working with wood. Most of the lesions caused by the circular saw were tangential, damaging the dorsal aspect of several PIP joints. Classically, it would be logical to propose arthrodesis if the bone and cartilage loss is not excessive, but with the loss of joint motion provided by implants. Like Nagle, we propose emergency implantation of a Swanson prosthesis if soft tissue and tendon reconstruction can be achieved, avoiding amputation.ConclusionAlthough the technique is relatively simple, implantation of a Swanson prosthesis implies certain prerequisites, particularly ligament repair and correct alignment. Oversized implants appear to be better. We did not have to perform any secondary arthrodesis.