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PIP Joint Arthritis

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

Overview

Primary proximal interphalangeal joint arthroplasty is a reliable option for symptomatic degenerative, post-traumatic, or inflammatory arthritis when the clinical setting is appropriate [10]. Surface replacement via a volar approach yields excellent range of motion, function, and pain relief with minimal complications in active patients [1]. Anatomically neutral implants provide reliable long-term pain relief and functional maintenance for metacarpophalangeal and proximal interphalangeal osteoarthritis [4]. While utilization for primary osteoarthritis has increased, revision utilization has decreased [3].

Specific implant modalities offer distinct advantages: silicone arthroplasty remains a viable option for pain relief in osteoarthritis [13], and pyrolytic carbon hemiarthroplasty serves as a viable alternative to total joint arthroplasty [16]. Self-locking implants demonstrate good pain relief, patient satisfaction, and maintained range of motion at minimum two-year follow-up [11]. However, treatment of the long finger may represent a relative contraindication to this procedure [2].

Patients typically return to work after a median of 8 weeks [5]. Serial casting effectively corrects flexion contractures in selected patients with arthritis [6]. Minimizing postoperative complications across metacarpophalangeal and proximal interphalangeal joint arthroplasty represents a key avenue for reducing healthcare costs [7].

Anatomy & Pathophysiology

Osseous and Articular Mechanics

The internal structure and material properties of the phalanges significantly influence both the magnitude and distribution of stresses in the metacarpophalangeal (MCP) joint during common tasks [24]. In the thumb, compressive shear forces can lead over time to trapeziometacarpal joint osteoarthritis [33]. 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 serves as a model for the more general study of idiopathic osteoarthritis [31]. Thumb basal joint arthritis is a progressive disease with substantial new biomechanical and longitudinal clinical studies changing prevailing opinions on serial degenerative changes [22].

Ligamentous Stability

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 trapeziometacarpal joint [36].

Kinematics and Functional Interdependency

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]. 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].

Pathologic Progression and Outcomes

The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages [27]. Type I and III wrists had radiographic progression and ultimately underwent deformation [20]. Most of the outcome measures associated with hand osteoarthritis or rheumatoid arthritis are related to body structures and body functions or activity limitations and participation restrictions [30].

Classification

Clinical Indications: Surface replacement arthroplasty of the proximal interphalangeal joint using a volar approach yields excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis [1]. 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 provides reliable, long-term pain relief and maintenance of function [4]. 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]. Surface replacement arthroplasty using the SR PIP implant continues to be an option for patients with osteoarthritis of the proximal interphalangeal joint [45]. Pyrolytic carbon hemiarthroplasty appears to be a viable alternative to total joint arthroplasty in the treatment of proximal interphalangeal joint arthritis [16].

Contraindications and Specific Constraints: Treatment of the long finger may be a relative contraindication to proximal interphalangeal joint arthroplasty [2]. The TACTYS prosthesis should be proposed exceptionally if proximal interphalangeal joint arthritis causes invalidating functional pain [8]. The revision rate for the LPM prosthesis was higher than in published series for other proximal interphalangeal joint implants [43].

Other Considerations: 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]. 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].

Clinical Presentation

Indications and Contraindications: PIP joint arthroplasty is indicated for patients with osteoarthritis or posttraumatic arthritis [1] and serves as a good, reliable option for symptomatic degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [10]. The procedure should be proposed exceptionally if the PIP joint arthritis causes invalidating functional pain [8]. Conversely, treatment of the long finger may represent a relative contraindication to PIPJ arthroplasty [2].

Disease Progression and Outcomes: Treatment modalities for proximal interphalangeal joint arthritis are currently limited, as the disease process involves a complex interplay of biochemical, metabolic, and genetic factors rather than simple mechanical stress [40]. Patients should be advised that PIPJ range of motion deteriorates over time [9], with PIP range of motion after surface replacement arthroplasty through a volar approach showing a tendency to deteriorate with longer follow-up [15]. Regarding functional 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].

Diagnostic Evaluation and Adjuncts: 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]. 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]. Radiological osteoarthritis after a mallet finger fracture 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 patient-reported outcome measures [12]. Cortical breaks were commonly visualized in MCP and PIP joints with high-resolution peripheral quantitative CT and microCT [17].

Preoperative Management: Serial casting is an effective method to correct flexion contractures in PIP joints in selected patients with arthritis [6].

Investigations

Plain radiography: Radiological osteoarthritis following a mallet finger fracture mirrors the natural degenerative process of the distal interphalangeal joint and is accompanied by decreased range of motion, though this does not clinically affect patient-reported outcome measures [12]. In patients with established hand osteoarthritis, radiological involvement of the thumb base correlates with older age and increased structural abnormalities, whereas clinical involvement of the thumb base is associated with a higher clinical burden [49].

CT: High-resolution peripheral quantitative CT and microCT commonly visualize cortical breaks in metacarpophalangeal and proximal interphalangeal joints [17].

Other Considerations: Proximal interphalangeal joint implant arthroplasty is a good and reliable option for symptomatic degenerative, post-traumatic, or inflammatory arthritis given the proper clinical setting [10]. 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 metacarpophalangeal and proximal interphalangeal joint osteoarthritis with an anatomically neutral implant can provide reliable, long-term pain relief and maintenance of function [4]. Silicone arthroplasty for osteoarthritis of the proximal interphalangeal joint remains a good option for pain relief [13]. Pyrolytic carbon prosthesis replacing 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]. Patients should be advised that proximal interphalangeal joint range of motion deteriorates over time following pyrolytic carbon hemiarthroplasty [9]. 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]. Treatment of the long finger may be a relative contraindication to proximal interphalangeal joint arthroplasty [2]. Proximal interphalangeal joint arthroplasty with the TACTYS prosthesis should be proposed exceptionally if the proximal interphalangeal joint arthritis causes invalidating functional pain [8]. 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]. 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]. 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]. All described techniques for arthrodesis of the proximal interphalangeal joint of the finger can achieve the goal of fusing an osteoarthritic joint [47]. 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]. Type I and III wrists had radiographic progression and ultimately underwent deformation [20].

Treatment

Non-Operative

Serial casting is an effective method to correct flexion contractures in proximal interphalangeal joints in selected patients with arthritis [6].

Operative

Indications: 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]. The TACTYS prosthesis should be proposed exceptionally if the proximal interphalangeal joint arthritis causes invalidating functional pain [8]. 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 utilization has decreased [3].

Surgical Approach / Technique: 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]. Patients returned to work after a median of 8 weeks following proximal interphalangeal joint arthroplasty [5]. Minimizing postoperative complications after metacarpophalangeal and proximal interphalangeal joint arthroplasty is one avenue to decrease health care costs [7].

Implant Selection: 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]. Minimum two-year 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].

Other Considerations: Patients should be advised that proximal interphalangeal joint range of motion deteriorates over time following pyrolytic carbon hemiarthroplasty [9]. 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]. 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

Stiffness / Arthrofibrosis: Patients must be counseled that range of motion deteriorates over time following PIPJ arthroplasty [9].

Other Considerations: Treatment of the long finger may represent a relative contraindication to PIPJ arthroplasty [2]. Diabetes and surgeon experience are factors increasing the risk of postoperative complications in interphalangeal joint arthrodeses [44]. Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs [7].

Recovery

Light activity (weeks): Patients typically return to work at a median of 8 weeks following PIP arthroplasty [5].

Full activity (months): While the minimum 2-year follow-up for SLFJ implant PIP joint arthroplasty demonstrates maintained joint range of motion [11], PIP ROM after SRA through a volar approach tends to deteriorate with longer follow-up [15]. Similarly, PIPJ ROM deteriorates over time, necessitating that patients be advised of this trajectory [9].

Complete recovery / outcome plateau (months): Long-term outcomes show that 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]. Studies report 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]. Minimizing postoperative complications after MCP and PIP joint arthroplasty remains a key avenue to decrease health care costs [7].

Rehabilitation protocol: No specific rehabilitation protocols, immobilisation durations, or weight-bearing progressions are detailed in the provided evidence base.

Functional milestones: Validated functional outcomes include good pain relief and good overall patient satisfaction at a minimum of 2 years for SLFJ implants [11], alongside stable radiographic integration at 5 years [19].

Other Considerations: The deterioration of range of motion over time is a critical factor for patient counseling [9, 15].

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

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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.