Skip to content

PIP Joint Arthritis PDF Evidence

A hand-drawn illustration of a worn arthritic middle-finger joint.
A hand affected by arthritis — visible swelling and deformity at the finger joints. Kieran Hirpara 4.0

Osteoarthritis and inflammatory arthritis of the PIP joint — non-operative and surgical options.

What you're feeling

You likely feel pain in the middle joint of your finger, known as the proximal interphalangeal joint. This pain often comes from wear-and-tear arthritis or damage from a past injury. Your surgeon may suggest this surgery only if the pain becomes so severe that it stops you from doing daily tasks. You might notice the pain gets worse after you use your hand or when you wake up in the morning.

Simple actions can become very difficult. You may struggle to reach behind your back to fasten a bra or tuck in your shirt. The joint might feel stiff, making it hard to bend or straighten your finger fully. In some cases, the joint may not move as well as it used to, and this range of motion can get worse over time. If you have rheumatoid arthritis, early treatment with specific medicines can help improve how you feel.

While the disease process is complex, you can expect relief from pain and better function after surgery. Many patients find that surface replacement of the joint provides excellent relief with few problems. However, you should know that the movement in your finger might decrease slightly as time goes on. If you have a contracture where the finger is stuck bent, serial casting might help correct this before or after surgery. Your surgeon will review if this procedure is right for you based on your specific symptoms and joint condition.

What's actually happening

In your finger, the smooth coating on the bone ends, called cartilage, wears down over time. This wear-and-tear arthritis acts like a shock absorber that has lost its cushion. As the cartilage thins, the bones rub together, causing pain and stiffness. You may notice you move through a smaller range of motion when doing daily tasks because the joint no longer glides smoothly.

The problem goes deeper than just the bone. The tendons, which are like ropes of fibers connecting muscle to bone, change early in the disease. These tendons bridge multiple joints, so a change in one area affects how your whole finger moves. This interdependency means that when one part of your finger changes, the others struggle to keep up. Over time, these changes in the tendons and related structures lead to the deformities you see.

Your surgeon sees that this process is driven by how forces travel through your hand. Women with this condition often have significantly lower hand forces, with a mean decrease of 30% across most force types. Compressive shear forces can also damage the joint over time, leading to further wear. When the joint capsule, the sleeve around the joint, and the ligaments lose their stability, the bones shift. This shift creates the pain and limited function that bring you to see your surgeon.

What we can do about it

Your journey often begins with self-management and physiotherapy. If you have a stiff finger, serial casting is an effective method to correct flexion contractures in selected patients with arthritis. This process helps you regain movement without surgery. Your surgeon may also recommend exercises to keep the joint flexible. You should give these non-surgical options a fair chance before considering more invasive steps.

If simple care is not enough, your surgeon may discuss medical management. While the evidence does not detail specific drug names or injection types for this joint, it confirms that pain relief is a primary goal. For some, the focus remains on managing symptoms to maintain function. If arthritis causes invalidating functional pain, your surgeon might consider specific surgical options like the TACTYS prosthesis exceptionally. However, for many, the focus is on keeping the joint working well while managing discomfort.

When conservative care reaches its limit, surgery becomes a reliable option. Proximal interphalangeal joint implant arthroplasty is a good and reliable choice for symptomatic arthritis given the proper clinical setting. This procedure can provide reliable, long-term pain relief and maintenance of function. Most patients return to work after a median of 8 weeks following this surgery. While the joint may feel better, you should be advised that range of motion can deteriorate over time with certain implants. Your surgeon will help you decide if this is the right step for your specific finger.

When to see someone

Ask for a specialist review if you have persistent pain from wear-and-tear arthritis or post-traumatic arthritis that does not improve with rest. Seek help if you experience weakness, instability, or locking in your finger. Contact your doctor if symptoms interfere with your sleep or work. You should also seek advice if you notice a sudden worsening of your condition. Be aware that range of motion can deteriorate over time. If you have diabetes, discuss the higher risk of complications with your surgeon before considering surgery.

Reviewed by AI synthesis (v2) — pending human review · 2026-05-18 19:02:24.887032+00:00.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

title: "PIP Joint Arthritis" slug: pipj-arthritis region: hand audience: patient mesh_terms: ["Osteoarthritis", "Finger Joint", "Arthritis, Rheumatoid", "PIPJ arthritis", "proximal interphalangeal arthritis", "finger joint arthritis"] article_count: 174 model_used: qwen3.5-35b-a3b-q8 generated_at: '2026-05-18T13:43:42+00:00' key_articles: - title: "Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint Using a Volar Approach: Case Series" ref_num: 1 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2011.03.003 year: 2011 - title: "Prosthetic Arthroplasty of Proximal Interphalangeal Joints for Treatment of Osteoarthritis and Posttraumatic Arthritis: Systematic Review and Meta-Analysis Comparing the Three Ulnar Digits With the Index Finger" ref_num: 2 evidence_tier: paper evidence_level: 1 doi: 10.1177/1558944718791186 year: 2018 - title: "Trends in Primary Proximal Interphalangeal Joint System and Revisions for Osteoarthritis of the Hand in the Medicare Database" ref_num: 3 evidence_tier: paper evidence_level: 4 doi: 10.1177/1558944719837009 year: 2019 - title: "Anatomically Neutral Silicone Small Joint Arthroplasty for Osteoarthritis" ref_num: 4 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2008.11.005 year: 2009 - title: "Type of Work and Preoperative Ability to Perform Work Affect Return to Usual Work Following Proximal Interphalangeal Joint Arthroplasty for Osteoarthritis" ref_num: 5 evidence_tier: paper evidence_level: 3 doi: 10.1177/15589447221141485 year: 2022 - title: "Effects of serial casting in the treatment of flexion contractures of proximal interphalangeal joints in patients with rheumatoid arthritis and juvenile idiopathic arthritis: A retrospective study" ref_num: 6 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jht.2015.11.005 year: 2016 - title: "National Prevalence of Complications and Cost of Small Joint Arthroplasty for Hand Osteoarthritis and Post-Traumatic Arthritis" ref_num: 7 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jhsa.2019.11.002 year: 2020 - title: "Arthroplasty of the Proximal Interphalangeal Joint With the TACTYS Prosthesis: Clinical and Radiographic Results With a Mean Follow-up of 5 Years" ref_num: 8 evidence_tier: paper evidence_level: 4 doi: 10.1177/15589447211030962 year: 2022 - title: "Pyrolytic Carbon Hemiarthroplasty for Proximal Interphalangeal Joint Arthritis, Long-Term Follow-Up" ref_num: 9 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2023.11.007 year: 2024 - title: "Proximal interphalangeal joint arthroplasty: current trends and evidence-based practice" ref_num: 10 evidence_tier: paper evidence_level: 4 doi: 10.1177/17531934241265837 year: 2024 - title: "Outcomes of Surface Replacement Proximal Interphalangeal Joint Arthroplasty Using the Self Locking Finger Joint Implant: Minimum Two Years Follow-up" ref_num: 11 evidence_tier: paper evidence_level: 4 doi: 10.1177/1558944717726136 year: 2017 - title: "Posttraumatic Osteoarthritis of the Distal Interphalangeal Joint: A Follow-Up Study of 12 Years After Nonsurgical Treatment of Mallet Finger Fractures" ref_num: 12 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2023.03.027 year: 2023 - title: "Proximal Interphalangeal Joint Silicone Arthroplasty for Osteoarthritis: Midterm Outcomes" ref_num: 13 evidence_tier: paper evidence_level: 4 doi: 10.1177/1558944718769427 year: 2018 - title: "Reconstruction of finger joints using autologous rib perichondrium – an observational study at a single Centre with a median follow-up of 37 years" ref_num: 14 evidence_tier: paper evidence_level: 4 doi: 10.1186/s12891-020-03310-5 year: 2020 - title: "Surface Replacement Arthroplasty Using a Volar Approach for Osteoarthritis of Proximal Interphalangeal Joint: Results After a Minimum 5-Year Follow-up" ref_num: 15 evidence_tier: paper evidence_level: 4 doi: 10.1177/1558944718787332 year: 2018 - title: "Pyrolytic Carbon Hemiarthroplasty in the Management of Proximal Interphalangeal Joint Arthritis" ref_num: 16 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2014.12.016 year: 2015 - title: "Visual detection of cortical breaks in hand joints: reliability and validity of high-resolution peripheral quantitative CT compared to microCT" ref_num: 17 evidence_tier: paper evidence_level: 4 doi: 10.1186/s12891-016-1148-y year: 2016 - title: "Delphi consensus of risk factors for development and progression of finger interphalangeal joint osteoarthritis" ref_num: 18 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193419865872 year: 2019 - title: "Ten years’ experience with a pyrocarbon prosthesis replacing the proximal interphalangeal joint. A prospective clinical and radiographic follow-up" ref_num: 19 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193413479527 year: 2013 - title: "Prediction of Wrist Prognosis in Patients With Early Rheumatoid Arthritis According to Radiographic Classification" ref_num: 20 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jhsa.2009.01.016 year: 2009 - title: "Impaired intrinsic hand strength in women with osteoarthritis" ref_num: 21 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jht.2024.02.005 year: 2024 - title: "Thumb Basal Joint Arthritis" ref_num: 22 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-d-17-00374 year: 2018 - title: "A three-dimensional finite element analysis of finger joint stresses in the MCP joint while performing common tasks" ref_num: 24 evidence_tier: paper evidence_level: 5 doi: 10.1007/s11552-012-9430-4 year: 2012 - title: "Finger Deformities Caused by Rheumatoid Arthritis" ref_num: 27 evidence_tier: paper evidence_level: 4 doi: 10.2106/00004623-195739030-00006 year: 1957 - title: "Linking ICF components to outcome measures for hand osteoarthritis and rheumatoid arthritis: A systematic review" ref_num: 30 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jht.2019.12.015 year: 2020 - title: "THE ABJS 2005 NICOLAS ANDRY AWARD: Osteoarthritis and Injury at the Base of the Human Thumb" ref_num: 31 evidence_tier: paper evidence_level: 5 doi: 10.1097/01.blo.0000176968.28247.5c year: 2005 - title: "Comparison of finger kinematics between patients with hand osteoarthritis and healthy participants with and without joint protection programs" ref_num: 32 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jht.2020.10.010 year: 2022 - title: "Current Concepts of the Anatomy of the Thumb Trapeziometacarpal Joint" ref_num: 33 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2010.10.029 year: 2011 - title: "Laboratory Diagnosis of Rheumatoid Arthritis" ref_num: 35 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2011.01.036 year: 2011 - title: "Effects of the Deep Anterior Oblique and Dorsoradial Ligaments on Trapeziometacarpal Joint Stability" ref_num: 36 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2006.12.002 year: 2007 - title: "The Coordination of Finger-Joint Motions" ref_num: 39 evidence_tier: paper evidence_level: 5 doi: 10.2106/00004623-196345080-00007 year: 1963 - title: "Proximal Interphalangeal Joint Arthritis" ref_num: 40 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2010.09.002 year: 2010 - title: "Simultaneous anterograde screw arthrodesis of distal interphalangeal joint and silastic proximal interphalangeal joint replacement for osteoarthritis" ref_num: 41 evidence_tier: paper evidence_level: 4 doi: 10.1177/17531934231215790 year: 2023 - title: "TWO TO FIVE YEAR FOLLOW-UP OF THE LPM CERAMIC COATED PROXIMAL INTERPHALANGEAL JOINT ARTHROPLASTY" ref_num: 43 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193407087864 year: 2008 - title: "Arthrodesis of distal interphalangeal and thumb interphalangeal joint: a retrospective cohort study of 149 cases" ref_num: 44 evidence_tier: paper evidence_level: 3 doi: 10.1186/s12891-024-07361-w year: 2024 - title: "Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint Using the SR PIP Implant: Long-Term Results" ref_num: 45 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2014.11.015 year: 2015 - title: "Arthrodesis of the proximal interphalangeal joint of the finger – a systematic review" ref_num: 47 evidence_tier: paper evidence_level: 1 doi: 10.1530/eor-21-0102 year: 2022 - title: "Thumb Base Involvement in Established Hand Osteoarthritis" ref_num: 49 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jht.2014.01.006 year: 2014 synthesis_version: "v2" verifier_status: skipped

Overview

  • Surface replacement arthroplasty of the proximal interphalangeal joint using a volar approach can result in excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis [1].
  • Treatment of the long finger may be a relative contraindication to proximal interphalangeal joint arthroplasty [2].
  • There has been an increased use of primary proximal interphalangeal joint arthroplasty utilization for patients with osteoarthritis, whereas revision proximal interphalangeal joint arthroplasty has decreased [3].
  • Treatment of metacarpophalangeal and proximal interphalangeal joint osteoarthritis with an anatomically neutral implant can provide reliable, long-term pain relief and maintenance of function [4].
  • Patients returned to work after a median of 8 weeks following proximal interphalangeal joint arthroplasty [5].
  • Serial casting is an effective method to correct flexion contractures in proximal interphalangeal joints in selected patients with arthritis [6].
  • Minimizing postoperative complications after metacarpophalangeal and proximal interphalangeal joint arthroplasty is one avenue to decrease health care costs [7].
  • Proximal interphalangeal joint implant arthroplasty is a good and reliable option for symptomatic proximal interphalangeal joint degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [10].
  • Minimum two years of follow-up evaluation of the self-locking finger joint implant proximal interphalangeal joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion [11].
  • Silicone arthroplasty for osteoarthritis of the proximal interphalangeal joint remains a good option for pain relief [13].
  • Pyrolytic carbon hemiarthroplasty appears to be a viable alternative to total joint arthroplasty in the treatment of proximal interphalangeal joint arthritis [16].

Anatomy & Pathophysiology

  • Women with hand osteoarthritis exhibited significantly lower intrinsic hand forces compared to healthy women, with a mean decrease of 30% across most force types [21].
  • People with hand arthritis move through a smaller arc of motion when performing some functional tasks as compared with controls [32].
  • The internal structure and material properties of the phalanges play a significant role in both the magnitude and distribution of stresses in the MCP joint during common tasks [24].
  • Interdependency of joints is a primary feature of finger function [39].
  • The function of a muscle with respect to a certain joint cannot be inferred from the position of the muscle with respect to that one joint alone due to tendons bridging multiple joints [39].
  • Changes occurring in the tendons and related structures are the most important factor in the development of finger deformities, especially in early stages [27].
  • Detailed understanding of the functional anatomy and related pathologic features of the trapeziometacarpal joint complex provides the basis for treatment of acquired afflictions at the base of the human thumb [31].
  • Compressive shear forces can lead over time to trapeziometacarpal joint osteoarthritis [33].
  • In most degrees of freedom of metacarpal movement relative to the trapezium, the dorsoradial ligament (DRL) is relatively more important than the deep anterior oblique ligament (dAOL) in providing stability to the TMC joint [36].
  • Thumb basal joint arthritis is a progressive disease with substantial new biomechanical and longitudinal clinical studies changing prevailing opinions on serial degenerative changes [22].
  • Type I and III wrists had radiographic progression and ultimately underwent deformation [20].
  • Most of the outcome measures associated with hand OA or RA are related to body structures and body functions or activity limitations and participation restrictions [30].

Classification

  • Surface replacement arthroplasty of the proximal interphalangeal joint using a volar approach can result in excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis [1].
  • Treatment of the long finger may be a relative contraindication to proximal interphalangeal joint arthroplasty [2].
  • Primary proximal interphalangeal joint arthroplasty utilization has increased for patients with osteoarthritis, whereas revision utilization has decreased [3].
  • Treatment of metacarpophalangeal and proximal interphalangeal joint osteoarthritis with an anatomically neutral implant can provide reliable, long-term pain relief and maintenance of function [4].
  • Patients returned to work after a median of 8 weeks following proximal interphalangeal joint arthroplasty [5].
  • Serial casting is an effective method to correct flexion contractures in proximal interphalangeal joints in selected patients with arthritis [6].
  • Minimizing postoperative complications after metacarpophalangeal and proximal interphalangeal joint arthroplasty is one avenue to decrease health care costs [7].
  • The TACTYS prosthesis should be proposed exceptionally if the proximal interphalangeal joint arthritis causes invalidating functional pain [8].
  • Proximal interphalangeal joint implant arthroplasty is a good and reliable option for symptomatic proximal interphalangeal joint degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [10].
  • Radiological osteoarthritis after a mallet finger fracture is similar to the natural degenerative process in the distal interphalangeal joint and is accompanied by a decrease in range of motion of the distal interphalangeal joint, which does not clinically affect patient-reported outcome measures [12].
  • Pyrolytic carbon hemiarthroplasty appears to be a viable alternative to total joint arthroplasty in the treatment of proximal interphalangeal joint arthritis [16].
  • Cortical breaks were commonly visualized in metacarpophalangeal and proximal interphalangeal joints with high-resolution peripheral quantitative CT and microCT [17].
  • Expert consensus can be reached to identify putative risk factors for interphalangeal joint osteoarthritis, though the number identified was low and often required multiple Delphi rounds [18].
  • The revision rate for the LPM prosthesis was higher than in published series for other proximal interphalangeal joint implants, warranting close surveillance of all patients with this prosthesis currently in situ [43].
  • Surface replacement arthroplasty using the SR PIP implant continues to be an option for patients with osteoarthritis of the proximal interphalangeal joint [45].

Clinical Presentation

  • PIP joint arthroplasty may be a relative contraindication for treatment of the long finger [2].
  • Patients with PIP joint arthritis causing invalidating functional pain should be considered for arthroplasty [8].
  • PIPJ implant arthroplasty is a good and reliable option for symptomatic PIPJ degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [10].
  • Treatment of MCP and PIP osteoarthritis with an anatomically neutral implant can provide reliable, long-term pain relief and maintenance of function [4].
  • Silicone arthroplasty for osteoarthritis of the PIP remains a good option for pain relief [13].
  • Surface replacement arthroplasty of the PIP joint using a volar approach can result in excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis [1].
  • Surface replacement arthroplasty of the PIP joint using a volar approach has the tendency to deteriorate in range of motion with longer follow-up [15].
  • Pyrolytic carbon hemiarthroplasty for PIP joint arthritis results in good pain relief and stable radiographic integration at 5 years, with no late revisions or loosening observed, despite no improvement in range of motion [19].
  • Patients should be advised that PIPJ range of motion deteriorates over time following pyrolytic carbon hemiarthroplasty [9].
  • Minimum two-year follow-up evaluation of the Self Locking Finger Joint (SLFJ) implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion [11].
  • Autologous rib perichondrium transplants restored injured PIP and MCP joints that remained essentially pain-free and mostly well-functioning without need for additional surgeries up to 41 years after the procedure [14].
  • Serial casting is an effective method to correct flexion contractures in PIP joints in selected patients with arthritis [6].
  • Cortical breaks were commonly visualized in MCP and PIP joints with high-resolution peripheral quantitative CT and microCT [17].
  • Expert consensus can be reached to identify putative risk factors for IP joint osteoarthritis, though the number identified was low and often required multiple Delphi rounds [18].
  • Treatment modalities for PIP joint arthritis are currently limited, and the disease process involves a complex interplay of biochemical, metabolic, and genetic factors rather than simple mechanical stress [40].
  • Early diagnosis of rheumatoid arthritis is important, and referral to a rheumatologist followed by treatment with disease-modifying antirheumatic agents has been shown to improve outcomes [35].

Investigations

  • The volar approach to proximal interphalangeal joint surface replacement arthroplasty can result in excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis [1].
  • Treatment of the long finger may be a relative contraindication to proximal interphalangeal joint arthroplasty [2].
  • There has been an increased use of primary proximal interphalangeal joint implant arthroplasty utilization for patients with osteoarthritis, whereas revision utilization has decreased [3].
  • Treatment of metacarpophalangeal and proximal interphalangeal joint osteoarthritis with an anatomically neutral implant can provide reliable, long-term pain relief and maintenance of function [4].
  • Patients returned to work after a median of 8 weeks following proximal interphalangeal joint arthroplasty [5].
  • Serial casting is an effective method to correct flexion contractures in proximal interphalangeal joints in selected patients with arthritis [6].
  • Proximal interphalangeal joint implant arthroplasty should be proposed exceptionally if the joint arthritis causes invalidating functional pain [8].
  • Patients should be advised that proximal interphalangeal joint range of motion deteriorates over time following pyrolytic carbon hemiarthroplasty [9].
  • Proximal interphalangeal joint implant arthroplasty is a good and reliable option for symptomatic proximal interphalangeal joint degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [10].
  • Radiological osteoarthritis after a mallet finger fracture is similar to the natural degenerative process in the distal interphalangeal joint and is accompanied by a decrease in range of motion of the distal interphalangeal joint, which does not clinically affect patient-reported outcome measures [12].
  • Silicone arthroplasty for osteoarthritis of the proximal interphalangeal joint remains a good option for pain relief [13].
  • Perichondrium transplants restored injured proximal interphalangeal and metacarpophalangeal joints that remained essentially pain-free and mostly well-functioning without need for additional surgeries up to 41 years after the procedure [14].
  • Proximal interphalangeal joint range of motion after surface replacement arthroplasty through a volar approach has the tendency to deteriorate with a longer follow-up [15].
  • Cortical breaks were commonly visualized in metacarpophalangeal and proximal interphalangeal joints with high-resolution peripheral quantitative CT and microCT [17].
  • Expert consensus can be reached to identify putative risk factors for interphalangeal joint osteoarthritis, though the number identified was low and often required multiple Delphi rounds [18].
  • Pyrolytic carbon prosthesis replacement of the proximal interphalangeal joint reports good pain relief and stable radiographic integration at 5 years, with no late revisions or loosening observed, despite no improvement in range of motion [19].
  • Type I and III wrists had radiographic progression and ultimately underwent deformation [20].
  • All described techniques for proximal interphalangeal joint arthrodesis can achieve the goal of fusing an osteoarthritic joint [47].
  • In patients with established hand osteoarthritis, clinical involvement of the thumb base joint is associated with a higher clinical burden, whereas radiological involvement of the thumb base joint is associated with older age and more structural abnormalities [49].

Treatment

  • Surface replacement arthroplasty of the proximal interphalangeal joint using a volar approach can result in excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis [1].
  • Treatment of the long finger may be a relative contraindication to proximal interphalangeal joint arthroplasty [2].
  • There has been an increased use of primary proximal interphalangeal joint arthroplasty utilization for patients with osteoarthritis, whereas revision proximal interphalangeal joint arthroplasty has decreased [3].
  • Treatment of metacarpophalangeal and proximal interphalangeal joint osteoarthritis with an anatomically neutral implant can provide reliable, long-term pain relief and maintenance of function [4].
  • Patients returned to work after a median of 8 weeks following proximal interphalangeal joint arthroplasty [5].
  • Serial casting is an effective method to correct flexion contractures in proximal interphalangeal joints in selected patients with arthritis [6].
  • Minimizing postoperative complications after metacarpophalangeal and proximal interphalangeal joint arthroplasty is one avenue to decrease health care costs [7].
  • The TACTYS prosthesis should be proposed exceptionally if the proximal interphalangeal joint arthritis causes invalidating functional pain [8].
  • Patients should be advised that proximal interphalangeal joint range of motion deteriorates over time following pyrolytic carbon hemiarthroplasty [9].
  • Proximal interphalangeal joint implant arthroplasty is a good and reliable option for symptomatic proximal interphalangeal joint degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [10].
  • Minimum two years of follow-up evaluation of the Self Locking Finger Joint implant proximal interphalangeal joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion [11].
  • Silicone arthroplasty for osteoarthritis of the proximal interphalangeal joint remains a good option for pain relief [13].
  • Proximal interphalangeal joint range of motion after surface replacement arthroplasty through a volar approach has the tendency to deteriorate with a longer follow-up [15].
  • Pyrolytic carbon hemiarthroplasty appears to be a viable alternative to total joint arthroplasty in the treatment of proximal interphalangeal joint arthritis [16].
  • The combination of distal interphalangeal joint arthrodesis and proximal interphalangeal joint Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility [41].

Complications

  • Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty [2].
  • Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs [7].
  • Patients should be advised that PIPJ range of motion deteriorates over time [9].
  • Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in DIP and thumb IP joint arthrodeses [44].

Recovery

  • Patients returned to work after a median of 8 weeks following PIP arthroplasty [5].
  • Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs [7].
  • Patients should be advised that PIPJ ROM deteriorates over time [9].
  • The minimum 2 years of follow-up evaluation of the SLFJ implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion [11].
  • Perichondrium transplants restored injured PIP and MCP joints that remained essentially pain-free and mostly well-functioning without need for additional surgeries up to 41 years after the procedure [14].
  • PIP ROM after SRA through a volar approach has the tendency to deteriorate with a longer follow-up [15].
  • The study reports good pain relief and stable radiographic integration at 5 years, with no late revisions or loosening observed, despite no improvement in range of motion [19].

Key Evidence

  • [L4] The volar approach to PIP SRA can result in excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis. (10.1016/j.jhsa.2011.03.003)
  • [L1] Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty. (10.1177/1558944718791186)
  • [L4] The data demonstrate an increased use of primary PIPA utilization for patients with OA, whereas revision PIPA decreased. (10.1177/1558944719837009)
  • [L4] Treatment of MCP and PIP osteoarthritis with an anatomically neutral implant can provide reliable, long-term pain relief and maintenance of function. (10.1016/j.jhsa.2008.11.005)
  • [L3] Patients returned to work after a median of 8 weeks following PIP arthroplasty. (10.1177/15589447221141485)
  • [L4] SC is an effective method to correct flexion contractures in PIP joints in selected patients with arthritis. (10.1016/j.jht.2015.11.005)
  • [L3] Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs. (10.1016/j.jhsa.2019.11.002)
  • [L4] It should be proposed exceptionally if the PIP joint arthritis causes invalidating functional pain. (10.1177/15589447211030962)
  • [L4] Patients should be advised that PIPJ ROM deteriorates over time. (10.1016/j.jhsa.2023.11.007)
  • [L4] PIPJ implant arthroplasty is a good and reliable option for symptomatic PIPJ degenerative, post-traumatic or inflammatory arthritis given the proper clinical setting. (10.1177/17531934241265837)
  • [L4] The minimum 2 years of follow-up evaluation of the SLFJ implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion. (10.1177/1558944717726136)
  • [L4] Radiological OA after an MFF is similar to the natural degenerative process in the DIP joint and is accompanied by a decrease in range of motion of the DIP joint, which does not clinically affect PROMs. (10.1016/j.jhsa.2023.03.027)
  • [L4] Silicone arthroplasty for osteoarthritis of the PIP remains a good option for pain relief. (10.1177/1558944718769427)
  • [L4] Perichondrium transplants restored injured PIP and MCP joints that remained essentially pain-free and mostly well-functioning without need for additional surgeries up to 41 years after the procedure. (10.1186/s12891-020-03310-5)
  • [L4] PIP ROM after SRA through a volar approach has the tendency to deteriorate with a longer follow-up. (10.1177/1558944718787332)
  • [L4] Pyrocarbon hemiarthroplasty appears to be a viable alternative to total joint arthroplasty in the treatment of PIP joint arthritis. (10.1016/j.jhsa.2014.12.016)
  • [L4] Cortical breaks were commonly visualized in MCP and PIP joints with HR-pQCT and microCT. (10.1186/s12891-016-1148-y)
  • [L4] Expert consensus can be reached to identify putative risk factors for IP joint OA, though the number identified was low and often required multiple Delphi rounds. (10.1177/1753193419865872)
  • [L4] The study reports good pain relief and stable radiographic integration at 5 years, with no late revisions or loosening observed, despite no improvement in range of motion. (10.1177/1753193413479527)
  • [L2] Type I and III wrists had radiographic progression and ultimately underwent deformation. (10.1016/j.jhsa.2009.01.016)
  • [L3] Women with hand osteoarthritis exhibited significantly lower intrinsic hand forces compared to healthy women, with a mean decrease of 30% across most force types. (10.1016/j.jht.2024.02.005)
  • [L5] Thumb basal joint arthritis is a progressive disease with substantial new biomechanical and longitudinal clinical studies changing prevailing opinions on serial degenerative changes. (10.5435/jaaos-d-17-00374)
  • [L5] The internal structure and material properties of the phalanges were found to play a significant role in both the magnitude and distribution of stresses. (10.1007/s11552-012-9430-4)
  • [L4] The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages. (10.2106/00004623-195739030-00006)
  • [L2] Most of the outcome measures associated with hand OA or RA are related to body structures and body functions or activity limitations and participation restrictions. (10.1016/j.jht.2019.12.015)
  • [L5] Detailed understanding of the functional anatomy and related pathologic features of the trapeziometacarpal joint complex provides the basis for treatment of acquired afflictions at the base of the human thumb and a model for the more general study of idiopathic osteoarthritis. (10.1097/01.blo.0000176968.28247.5c)
  • [L3] This study demonstrated that people with hand arthritis move through a smaller arc of motion when performing some functional tasks as compared with the controls, and that with instruction on joint protection techniques, participants made significant changes in the amount of movement used to perform tasks, which supports a proof of principle of joint protection. (10.1016/j.jht.2020.10.010)
  • [L5] The resulting compressive shear forces can lead over time to trapeziometacarpal joint osteoarthritis. (10.1016/j.jhsa.2010.10.029)
  • [L5] Early diagnosis of rheumatoid arthritis is important, and referral to a rheumatologist followed by treatment with disease-modifying antirheumatic agents has been shown to improve outcomes. (10.1016/j.jhsa.2011.01.036)
  • [L5] In most degrees of freedom of metacarpal movement relative to the trapezium, the DRL is relatively more important than the dAOL in providing stability to the TMC joint. (10.1016/j.jhsa.2006.12.002)
  • [L5] The paper concludes that interdependency of joints is a primary feature of finger function, and that the function of a muscle with respect to a certain joint cannot be inferred from the position of the muscle with respect to that one joint alone due to tendons bridging multiple joints. (10.2106/00004623-196345080-00007)
  • [L5] Treatment modalities for proximal interphalangeal joint arthritis are currently limited, and the disease process involves a complex interplay of biochemical, metabolic, and genetic factors rather than simple mechanical stress. (10.1016/j.jhsa.2010.09.002)
  • [L4] The combination of DIP arthrodesis and PIP Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility. (10.1177/17531934231215790)
  • [L4] The revision rate for the LPM prosthesis was higher than in published series for other PIP joint implants, with close surveillance of all patients with this prosthesis currently in situ recommended. (10.1177/1753193407087864)
  • [L3] Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in these DIP/thumb IP joint arthrodeses. (10.1186/s12891-024-07361-w)
  • [L4] Surface replacement arthroplasty using the SR PIP implant continues to be an option for patients with osteoarthritis of the PIP joint. (10.1016/j.jhsa.2014.11.015)
  • [L1] All described techniques can achieve the goal of fusing an osteoarthritic joint. (10.1530/eor-21-0102)
  • [L3] In patients with established hand OA clinical involvement of the TBJ is associated with a higher clinical burden whereas radiological involvement of the TBJ is associated with older age and more structural abnormalities. (10.1016/j.jht.2014.01.006)

References

[1] Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint Using a Volar Approach: Case Series. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.03.003 [2] Prosthetic Arthroplasty of Proximal Interphalangeal Joints for Treatment of Osteoarthritis and Posttraumatic Arthritis: Systematic Review and Meta-Analysis Comparing the Three Ulnar Digits With the Index Finger. HAND. 2018. DOI: 10.1177/1558944718791186 [3] Trends in Primary Proximal Interphalangeal Joint System and Revisions for Osteoarthritis of the Hand in the Medicare Database. HAND. 2019. DOI: 10.1177/1558944719837009 [4] Anatomically Neutral Silicone Small Joint Arthroplasty for Osteoarthritis. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.11.005 [5] Type of Work and Preoperative Ability to Perform Work Affect Return to Usual Work Following Proximal Interphalangeal Joint Arthroplasty for Osteoarthritis. HAND. 2022. DOI: 10.1177/15589447221141485 [6] Effects of serial casting in the treatment of flexion contractures of proximal interphalangeal joints in patients with rheumatoid arthritis and juvenile idiopathic arthritis: A retrospective study. Journal of Hand Therapy. 2016. DOI: 10.1016/j.jht.2015.11.005 [7] National Prevalence of Complications and Cost of Small Joint Arthroplasty for Hand Osteoarthritis and Post-Traumatic Arthritis. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.11.002 [8] Arthroplasty of the Proximal Interphalangeal Joint With the TACTYS Prosthesis: Clinical and Radiographic Results With a Mean Follow-up of 5 Years. HAND. 2022. DOI: 10.1177/15589447211030962 [9] Pyrolytic Carbon Hemiarthroplasty for Proximal Interphalangeal Joint Arthritis, Long-Term Follow-Up. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.11.007 [10] Proximal interphalangeal joint arthroplasty: current trends and evidence-based practice. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241265837 [11] Outcomes of Surface Replacement Proximal Interphalangeal Joint Arthroplasty Using the Self Locking Finger Joint Implant: Minimum Two Years Follow-up. HAND. 2017. DOI: 10.1177/1558944717726136 [12] Posttraumatic Osteoarthritis of the Distal Interphalangeal Joint: A Follow-Up Study of 12 Years After Nonsurgical Treatment of Mallet Finger Fractures. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.03.027 [13] Proximal Interphalangeal Joint Silicone Arthroplasty for Osteoarthritis: Midterm Outcomes. HAND. 2018. DOI: 10.1177/1558944718769427 [14] Reconstruction of finger joints using autologous rib perichondrium – an observational study at a single Centre with a median follow-up of 37 years. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03310-5 [15] Surface Replacement Arthroplasty Using a Volar Approach for Osteoarthritis of Proximal Interphalangeal Joint: Results After a Minimum 5-Year Follow-up. HAND. 2018. DOI: 10.1177/1558944718787332 [16] Pyrolytic Carbon Hemiarthroplasty in the Management of Proximal Interphalangeal Joint Arthritis. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.12.016 [17] Visual detection of cortical breaks in hand joints: reliability and validity of high-resolution peripheral quantitative CT compared to microCT. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1148-y [18] Delphi consensus of risk factors for development and progression of finger interphalangeal joint osteoarthritis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419865872 [19] Ten years’ experience with a pyrocarbon prosthesis replacing the proximal interphalangeal joint. A prospective clinical and radiographic follow-up. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413479527 [20] Prediction of Wrist Prognosis in Patients With Early Rheumatoid Arthritis According to Radiographic Classification. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.01.016 [21] Impaired intrinsic hand strength in women with osteoarthritis. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2024.02.005 [22] Thumb Basal Joint Arthritis. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00374 [24] A three-dimensional finite element analysis of finger joint stresses in the MCP joint while performing common tasks. HAND. 2012. DOI: 10.1007/s11552-012-9430-4 [27] Finger Deformities Caused by Rheumatoid Arthritis. The Journal of Bone & Joint Surgery. 1957. DOI: 10.2106/00004623-195739030-00006 [30] Linking ICF components to outcome measures for hand osteoarthritis and rheumatoid arthritis: A systematic review. Journal of Hand Therapy. 2020. DOI: 10.1016/j.jht.2019.12.015 [31] THE ABJS 2005 NICOLAS ANDRY AWARD: Osteoarthritis and Injury at the Base of the Human Thumb. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000176968.28247.5c [32] Comparison of finger kinematics between patients with hand osteoarthritis and healthy participants with and without joint protection programs. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2020.10.010 [33] Current Concepts of the Anatomy of the Thumb Trapeziometacarpal Joint. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.10.029 [35] Laboratory Diagnosis of Rheumatoid Arthritis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.01.036 [36] Effects of the Deep Anterior Oblique and Dorsoradial Ligaments on Trapeziometacarpal Joint Stability. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.12.002 [39] The Coordination of Finger-Joint Motions. The Journal of Bone & Joint Surgery. 1963. DOI: 10.2106/00004623-196345080-00007 [40] Proximal Interphalangeal Joint Arthritis. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.09.002 [41] Simultaneous anterograde screw arthrodesis of distal interphalangeal joint and silastic proximal interphalangeal joint replacement for osteoarthritis. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231215790 [43] TWO TO FIVE YEAR FOLLOW-UP OF THE LPM CERAMIC COATED PROXIMAL INTERPHALANGEAL JOINT ARTHROPLASTY. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193407087864 [44] Arthrodesis of distal interphalangeal and thumb interphalangeal joint: a retrospective cohort study of 149 cases. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07361-w [45] Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint Using the SR PIP Implant: Long-Term Results. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.11.015 [47] Arthrodesis of the proximal interphalangeal joint of the finger – a systematic review. EFORT Open Reviews. 2022. DOI: 10.1530/eor-21-0102 [49] Thumb Base Involvement in Established Hand Osteoarthritis. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2014.01.006

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.