Surgical treatment of the sequelae of intra-articular injuries of the proximal interphalangeal joint of the fingers: an umbrella review

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INTRODUCTION

The proximal interphalangeal joint (PIPJ) of the fingers plays a crucial role in the biomecha-nics of cylindrical grasp. Although the total anatomical range of motion of the PIPJ is 100-110° and accounts for approximately 35-40% of the overall range of motion of the finger joints, it is the PIPJ that makes the principal contribution to approximating the middle phalanx to the palm [1, 2, 3]. According to kinematic studies, during cylindrical grasp the PIPJ flexes more actively than the other finger joints, providing up to 75-80% of the functional flexion of the finger. This makes the PIPJ a key element in performing most daily and professional manual activities [1, 2, 3, 4].

The injuries of the PIPJ are characterized by a high rate of unfavorable outcomes after primary treatment. Even with timely management and early mobilization, a substantial proportion of patients (up to one third of cases) develop persistent contractures. In the long term, post-traumatic osteoarthritis of the PIPJ may occur, accompanied by a pronounced chronic pain [5, 6, 7]. Intra-articular fractures of the PIPJ account for up to 48% of all phalangeal fractures of the hand. Initial X-rays in most cases demonstrate marked incongruity of the articular surface and angular deformity [8, 9, 10]. Primary treatment that fails to achieve anatomical reduction and the restoration of articular congruity of the PIPJ in the acute phase is associated with an increased rate of revision procedures (15-20% in complex fracture-dislocations) and the development of persistent functional deficit [8, 11, 12, 13].

The goal of surgical treatment of the sequelae of intra-articular PIPJ injuries is to provide pain relief, joint stability, and, whenever possible, the restoration of the mobility of the affected finger [5, 14, 15]. Arthrodesis is performed in cases where achieving stability and grip strength requires sacrificing joint motion [16, 17]. Over the past decades, attempts have been made to develop effective arthroplasty techniques capable of restoring active and passive motions in the joint [18, 19]. In clinical practice, a wide range of surgical procedures is used: joint replacement with silicone, pyrocarbon, metal, and ceramic implants; hemi-hamate arthroplasty using an autologous hamate bone graft; microsurgical toe joint transfer; volar plate interposition arthroplasty; costal cartilage graft arthroplasty; mobilizing procedures for contractures (arthrolysis); and joint denervation [20, 21, 22, 23, 24]. The diversity of techniques and variability of clinical scenarios complicate the development of a unified approach to PIPJ reconstruction, making the choice of treatment method strictly individualized [25, 26].

A number of systematic reviews have been published addressing individual surgical tech-niques for the management of the sequelae of intra-articular PIPJ injuries, such as comparative analyses of pyrocarbon and silicone implants, various arthrodesis techniques, outcomes of hemi-hamate autograft arthroplasty, and joint denervation. However, we did not identify in any database a single comprehensive review directly comparing the outcomes of all major reconstructive surgical procedures for the PIPJ. Existing systematic reviews focus on specific treatment options, differ substantially in methodological quality, and often include overlapping primary studies. This results in the fragmentation of the evidence base and reduces confidence in selecting the optimal treatment strategy. The umbrella review performed in the present study aims to address this gap by summarizing and critically appraising the data from all available systematic reviews on the surgical treatment of the sequelae of intra-articular PIPJ injuries.

The aim of the review — to systematize and critically evaluate evidence from systematic reviews on the surgical treatment of the sequelae of the intra-articular injuries of the proximal interphalangeal joint of the fingers in adults.

METHODS

Study design

An umbrella review (review of systematic reviews) was performed in accordance with the PRISMA 2020 and PRIOR 2022 reporting guidelines [27, 28]. The study protocol was prospectively re-gistered in PROSPERO (ID: CRD420251165884). The review included studies that met the criteria listed below, defined using the PICO framework.

Inclusion criteria: published systematic reviews and meta-analyses (with a reproducible search strategy and quality assessment of included studies) addressing the surgical treatment of chronic intra-articular PIPJ injuries in adults. All types of surgical interventions on the PIPJ were considered, including arthrode-sis, joint arthroplasty, denervation, hemi-ha-mate arthroplasty, and other reconstructive procedures. Reviews focusing exclusively on acute trauma, nonsurgical treatment methods, and experimental studies (animal or cadaveric) were excluded.

Literature search

A comprehensive search was performed in the following databases: MEDLINE (via PubMed), Embase (Ovid), Cochrane Library (CENTRAL), the Russian Scientific Electronic Library eLIBRARY, as well as Google Scholar and refe-rence lists of relevant articles. The search cove-red the period from 2000 to 2025 (last search conducted on October 1, 2025).

The search strategy was based on the combinations of terms reflecting PIPJ pathology and surgical interventions of interest.

The keywords and their synonyms in Russian and English were used: proximal interphalangeal joint, PIP joint, intra-articular injuries, outcomes, post-traumatic arthritis, joint contracture, arthrodesis, joint arthroplasty, joint replacement, silicone implant, pyrocarbon implant, hemi-hamate arthroplasty, denervation, arthrolysis. The terms were combined using the logical operators AND and OR in various combinations depending on the database.

Primary title/abstract screening and full-text assessment were independently performed by two reviewers, with disagreements resolved by consensus. The study selection process is presented in Figure 1. A total of 17 systematic reviews (published between 2008 and 2024; more than half published in 2020-2024) on PIPJ surgery were included in the final analysis. Collectively, they encompassed 211 unique primary studies.

 

Figure 1. Flow diagram of study selection

 

Data extraction

From the included reviews, two authors independently extracted summarized data on the characteristics of the primary studies (study design, sample size, mean patient age, diagnosis), types and technical details of surgical interventions, duration of follow-up, and key outcomes: range of motion (ROM), pain intensity (VAS), functional outcomes (DASH, QuickDASH, PRWHE, MHQ scores), complication rates, re-operation rates, and implant survival. When reviews reported pooled quantitative estimates (e.g., mean change in outcome values, cumulative complication rates, or meta-analytic results), these values were extracted directly. If data on a specific outcome were available from more than one review, the findings were compared to assess consistency. If the same surgical intervention was addressed in multiple reviews, the synthesis was based primarily on the most recent and methodologically robust source.

Quality assessment of included reviews

The methodological quality of each included re-view was assessed using AMSTAR 2, and the risk of bias was evaluated with ROBIS. AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) evaluated critical domains, including the presence of a protocol, comprehensiveness of the search strategy, duplication of study selection and data extraction, appropriateness of risk-of-bias assessment in primary studies, and justification of the synthesis methods. Based on these domains, the overall confidence in the results was rated as high, moderate, low, or critically low [29, 30]. ROBIS (Risk of Bias in Systematic Reviews) was used to determine the overall risk of bias, categorized as low, unclear, or high [31].

In addition, the degree of the overlap of primary studies across reviews was assessed. A citation matrix (“review-primary study”) was constructed, and the Corrected Covered Area (CCA) index was calculated according to the method proposed by D. Pieper et al. [32]. CCA values were interpreted as follows: 0-5% — slight overlap, 6-10% — moderate overlap, and > 15% — high overlap.

Data analysis

A summary qualitative (descriptive) analysis was performed across the main outcome categories, with a focus on comparing different surgical interventions. When meta-analytic data were available within the included systematic reviews, these results were cited in the present umbrella review. Due to substantial heterogeneity in the data (differences in patient populations, study designs, terminology, and outcome assessment scales), conducting a new quantitative meta-analysis was considered inappropriate. All findings were grouped according to outcome categories and presented with reference to the corresponding sources. No statistical comparison between intervention groups was performed because of the lack of directly comparable data.

RESULTS

The characteristics of the included systematic reviews are presented in Table 1.

 

Table 1

Characteristics of the included systematic reviews

Author and year	Intervention type (category)	Intervention subtype / technique	Number of studies, n	Number of patients, n	Δ ROM, deg.	Δ VAS	Complications, %	Revisions, %	Implant survival, %	Quality (AMSTAR 2)	Risk of bias (ROBIS)
Abdiba N.V. et al., 2024 [33]	Mobilizing procedures	External fixation device	4	58	–	–	20	–	–	Moderate	Low
		Soft-tissue release	5	82	–	–	15	–	–
		Combined technique	1	30	–	–	–	–	–
Yamamoto M. et al., 2017 [34]	PIPJ arthroplasty	Silicone implant, volar approach	6	235	17	4	6	6	–	Moderate	High
		Silicone implant, lateral approach	3	120	16	3	10	10	–
		Silicone implant, dorsal approach	8	541	12	3	11	11	–
		Various prostheses, volar approach	2	12	9	4	17	17	–
		Various prostheses, volar approach	25	859	8	4	18	18	–
Squitieri L., Chung K.C., 2008 [35]	PIPJ arthroplasty	Silicone implant	9	194	–	–	19	18	–	Moderate	Unclear
		Pyrocarbon implant	2	18	–	–	33	33	–
		Microsurgical 2nd toe joint transfer	11	86	–	–	31	29	–
Millrose M. et al., 2022 [16]	Arthrodesis	Kirschner wires	13	735	–	–	–	–	–	High	Low
		Tension-band	14	293	–	–	–	–	–
		Compression screw	12	282	–	–	–	–	–
		Intraosseous wire	8	105	–	–	–	–	–
		Intramedullary pin	9	102	–	–	–	–	–
		Harrison-Nicolle peg	8	165	–	–	–	–	–
		Plate	6	93	–	–	–	–	–
Caviglia D. et al., 2021 [36]	Mobilizing procedures	Volar plate repair	4	90	10.9	–	6.7	5.6	–	Low	Unclear
		FDS tenodesis	3	32	35.4	–	18.8	0	–
Forster N. et al., 2018 [37]	PIPJ arthroplasty	Silicone implant	8	261	–	–	11	2	–	High	Low
		Pyrocarbon implant	17	955	–	–	14	4	–
		Metal-polyethylene implant	13	545	–	–	10	3	–
Mahi G. et al., 2024 [38]	PIPJ arthroplasty	Volar approach	5	150	–	–	7	7	–	High	Low
		Dorsal approach	5	160	–	–	15	7	–
Gandolfi S. et al., 2020 [39]	PIPJ denervation	Volar approach	3	51	13.00	8.60	17.6	10.6	–	Low	Unclear
Faulkner H. et al., 2023 [40]	Hemi-hamate arthroplasty	Hemi-hamate arthroplasty	22	235	48.3	5.40	26	–	–	High	Low
Milone M.T. et al., 2019 [41]	PIPJ arthroplasty	Silicone implant	3	99	–	–	18	6.1	94	Moderate	Low
		Pyrocarbon implant	2	38	–	–	33	0	100
		Metal-polyethylene implant	1	40	–	–	22.5	22.5	77.5
Faulkner H. et al., 2023 [42]	Arthrodesis	Screws	2	41	–	–	8.5	–	–	Moderate	Unclear
		Plates	1	4	–	–	4	–	–
		Kirschner wires	8	273	–	–	12.7	–	–
Adams J. et al., 2012 [43]	PIPJ arthroplasty	Pyrocarbon implant, dorsal/volar approach	4	53	1.7	4.76	31.7	14	86	Moderate	Unclear
		Ceramic implant (MOJE), dorsal approach	1	20	16.5	2.10	10	–	100
		Pyrocarbon, dorsal approach	1	7	-6.6	6.30	71	14	86
Chan K. et al., 2013 [44]	PIPJ arthroplasty	Silicone implant	21	1430	8.2	2.10	9.3	4.3	–	Moderate	Unclear
		Pyrocarbon implant	14	452	8	–	30.4	14	–
Van Der Meulen C. et al., 2023 [45]	PIPJ denervation	Classic technique	3	74	14	6.30	18	13	–	High	Low
Welford P. et al., 2021 [46]	PIPJ arthroplasty	Pyrocarbon implant	38	1434	20	4.00	40	25	75	High	Low
Frueh F.S. et al., 2015 [47]	Hemi-hamate arthroplasty	Hemi-hamate arthroplasty	8	71	–	–	35	–	–	Moderate	Low
Ibrahim M.S. et al., 2015 [48]	PIPJ arthroplasty	Silicone implant	6	330	10	5.50	15	10	85	Moderate	Low
		Metal-polyethylene implant	2	76	–	–	20	20	80
		Osseointegrated prosthesis (titanium screws with flexible spacer)	2	17	29	–	50	50	50
		Ceramic implant (MOJE)	2	30	15	–	5	0	100
		Pyrocarbon implant	2	34	12	6.30	26	26	74
		Ceramic-coated implant (LPM)	1	9	10	–	30	30	70

FDS — m. flexor digitalis superficialis.

 

The overall CCA index across all 17 reviews was 4%, indicating a low degree of overlap and overall thematic dispersion among reviews. However, analysis within specific thematic subgroups revealed a different pattern of overlap. PIPJ arthroplasty — CCA 17.3%, corresponding to high overlap, mainly due to recurring primary studies on silicone, pyrocarbon, and modular implants. Hemi-hamate arthroplasty — CCA 31%, indicating high overlap, as all included reviews analyzed a limited and largely identical set of primary studies [49, 50]. PIPJ arthrodesis — CCA 19%, corresponding to high overlap, driven by repeated inclusion of studies on Kirschner wire fixation, screw fixation, and compression systems. PIPJ denervation — CCA 56%, reflecting extremely high overlap, attributable to the small number of available primary studies and their near-complete duplication across reviews. Mobilizing procedures — CCA 5%, indicating low overlap, likely due to substantial heterogeneity of techniques and a limited number of homogeneous primary studies. These findings are summarized in Table 2. Thus, although the overall CCA suggests a minimal risk of repeatedly synthesizing identical data across the entire umbrella review, within specific clinical domains there is a high concentration of overlapping primary studies. This should be considered when interpreting results within individual intervention groups.

 

Table 2

Overlap matrix of primary studies and CCA index

 

 

Metric	Value
R — number of unique studies (rows)	211
N — total number of inclusions (all SR1...SR17)	348
C — number of reviews	17
CCA (Pieper), %	4.058056872
Overlap category (Pieper)	Low overlap

 

Thematically, the included reviews were distributed as follows: arthroplasty — 9 reviews, some of which compared different PIPJ implant types or surgical approaches [34, 35, 37, 38, 41, 43, 44, 46, 48]; various arthrodesis techniques — 2 reviews [16, 42]; hemi-hamate arthroplasty — 2 reviews [40, 47]; joint denervation — 2 reviews [39, 45], and soft-tissue release for contractures — 2 reviews [33, 36]. No systematic reviews were identified addressing volar plate interposition arthroplasty or costal cartilage graft arthroplasty.

A systematic review on microsurgical toe joint transfer was not included in the analysis due to low methodological quality [51]. According to AMSTAR 2, the methodological quality of the included reviews was distributed as follows: 6 reviews were rated as high quality, 9 as mode-rate quality, and 2 as low quality (Table 3, Figure 2). Based on ROBIS assessment, the overall risk of bias was low in 10 reviews, unclear in 6, and high in 1 review (Table 4, Figure 3). The highest methodological values were demonstrated by meta-analyses focusing on implant-related complications [37] and by more recent systematic reviews. In contrast, earlier publications showed methodological limitations, including incom-plete search strategies and the absence of a registered protocol. None of the included reviews applied the GRADE approach to assess the overall certainty of evidence.

 

Table 3

Assessment of the reviews using the 16-item AMSTAR 2 tool

Author and year

Item

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Final grade of quality

Abdiba N.V. et al., 2024 [33]

Yes

No

Yes

Yes

Yes

Partly

Yes

Yes

Yes

No

No

Partly

No

Yes

No

Yes

Moderate

Yamamoto M. et al., 2017 [34]

Yes

No

Yes

Yes

No

No

Partly

Yes

Partly

No

—

Partly

No

Yes

No

Yes

Moderate

Squitieri L., Chung K.C., 2008 [35]

Yes

No

Yes

Yes

No

No

Partly

Yes

Partly

No

Partly

Partly

No

Yes

No

Yes

Moderate

Millrose M. et al., 2022 [16]

Yes

Partly

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Yes

No

Yes

No

Yes

High

Caviglia D. et al., 2021 [36]

Yes

Partly

Yes

Yes

Yes

Yes

Partly

Yes

No

No

—

Partly

No

Yes

No

Yes

Low

Forster N. et al., 2018 [37]

Yes

Partly

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

Yes

No

Yes

High

Mahi G. et al., 2024 [38]

Yes

Partly

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Partly

Yes

No

Yes

High

Gandolfi S. et al., 2020 [39]

Yes

No

Yes

Yes

Yes

Yes

Partly

Yes

No

No

No

Partly

No

Yes

No

Yes

Low

Faulkner H. et al., 2023 [40]

Yes

Partly

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Yes

No

Yes

No

Yes

High

Milone M.T. et al., 2019 [41]

Yes

Partly

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

No

Yes

Moderate

Faulkner H. et al., 2023 [42]

Yes

Partly

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

No

Yes

Moderate

Adams J. et al., 2012 [43]

Yes

No

Yes

Yes

Yes

Partly

Yes

Yes

Yes

No

Yes

Yes

No

Yes

No

Partly

Moderate

Chan K. et al., 2013 [44]

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

No

Yes

No

Yes

Moderate

Van Der Meulen C. et al., 2023 [45]

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Yes

No

Yes

No

Yes

High

Welford P. et al., 2021 [46]

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Partly

Yes

—

Yes

No

Yes

No

Yes

High

Frueh F.S. et al., 2015 [47]

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

No

Yes

No

Yes

Moderate

Ibrahim M.S. et al., 2015 [48]

Yes

Partly

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

—

Yes

No

Yes

No

Yes

Moderate

 

Figure 2. Overall methodological quality of included reviews according to AMSTAR 2

 

Table 4

ROBIS: risk of bias across domains

Author and year	Domain 1 Study eligibility criteria	Domain 2 Identification and selection of studies	Domain 3 Data collection and synthesis	Domain 4 Interpretation of results	Overall risk of bias
Abdiba N.V. et al., 2024 [33]	Low	Unclear	Low	Low	Low
Yamamoto M. et al., 2017 [34]	Low	High	High	Unclear	High
Squitieri L., Chung K.C., 2008 [35]	Low	Unclear	Unclear	Low	Unclear
Millrose M. et al., 2022 [16]	Low	Low	Unclear	Low	Low
Caviglia D. et al., 2021 [36]	Low	Low	Unclear	Low	Unclear
Forster N. et al., 2018 [37]	Low	Low	Low	Low	Low
Mahi G. et al., 2024 [38]	Low	Low	Low	Low	Low
Gandolfi S. et al., 2020 [39]	Low	Low	Unclear	Unclear	Unclear
Faulkner H. et al., 2023 [40]	Low	Low	Low	Low	Low
Milone M.T. et al., 2019 [41]	Low	Low	Low	Low	Low
Faulkner H. et al., 2023 [42]	Low	Low	High	Low	Unclear
Adams J. et al., 2012 [43]	Low	Low	High	Low	Unclear
Chan K. et al., 2013 [44]	Low	Low	High	Low	Unclear
Van Der Meulen C. et al., 2023 [45]	Low	Low	Unclear	Low	Low
Welford P. et al., 2021 [46]	Low	Low	Unclear	Low	Low
Frueh F.S. et al., 2015 [47]	Low	Low	Unclear	Low	Low
Ibrahim M.S. et al., 2015 [48]	Low	Low	Unclear	Low	Low

 

Figure 3. Distribution of risk of bias according to ROBIS

 

Range of motion (ROM)

Pyrocarbon and other implant types demonstrate comparable final ROM values (45-55°), although the mean gain in motion is generally modest (approximately 8-10°). The surgical approach in joint arthroplasty influences motion recovery: according to some studies, the volar approach results in less extension deficit (5° with the volar approach versus 14° with the dorsal approach) and a slightly greater final ROM [38, 39]. Articular surface reconstruction using a hemi-hamate autograft allows for greater restoration of motion, with a mean active ROM reaching 74° (mean gain approximately 48°). In cases of chronic post-traumatic contractures, surgical release proce-dures (capsulotomy, arthrolysis with distraction, and others) primarily improve extension.

Pain (VAS assessment)

All reviewed interventions were associated with pain reduction. Arthrodesis and selective denervation almost completely eliminated pain; in the latter case, VAS scores decreased from 7-9 points to 0-1 (an improvement of 6-9 points). Joint arthroplasty also provided significant pain relief: pain intensity decreased on average by 4 points on a 10-point scale (e.g., from 6-7 to 2), and up to 76% of patients undergoing silicone implant arthroplasty reported being pain-free postoperatively. Hemi-hamate arthroplasty demonstrated com-parable pain outcomes. In systematic reviews addressing surgical release for post-traumatic contractures, VAS data were not reported.

Functional outcomes

Hand function was assessed using patient-repor-ted outcome measures (DASH, MHQ, PRWHE, and others). A major methodological issue in the literature is the substantial heterogeneity of outcome measures and assessment tools ranging from validated questionnaires to simple categorical scales, which may make the comparability of functional results across studies incorrect. A dedicated systematic review by K. Uhlman et al. on PIPJ arthroplasty identified 33 different outcomes assessed using 18 distinct measurement instruments, emphasizing marked heterogeneity and the absence of standardized reporting [52]. Arthrodesis provides joint stability and pain relief, enabling most patients to return to daily activities. However, the absence of motion at the PIPJ may limit fine motor function. Arthroplasty, by preserving joint motion, may improve functional outcomes. Systematic reviews report significant increases in composite functional scores; for example, MHQ scores improved on average from 45 to 72 points following silicone implant arthroplasty, representing a substantial and clinically meaningful improvement. In one randomized controlled trial cited by M. Yamamoto et al., postoperative DASH scores were lower (indica-ting fewer functional limitations) in patients with silicone implants compared with pyrocar-bon implants [34]. However, meta-analyses have not identified significant differences in final functional outcomes between different implant types or surgical approaches. Overall, provided that pain is adequately relieved, patients with preserved finger motion tend to report higher satisfaction compared with arthrodesis — mobility is valued despite the potential need for revision procedures. Hemi-hamate arthroplasty, performed under strict indications (typically in young patients with isolated post-traumatic defects of the base of the middle phalanx), demon-strates favorable functional outcomes, with a mean DASH score of approximately 9 points, which is close to normal. Joint denervation results in pain reduction, and concomitant soft-tissue release contributes to improved range of motion. Isolated soft-tissue release for PIPJ contracture also leads to functional improvement. According to categorical outcome assessments, 80-90% of patients achieve good or excellent results after such procedures.

Complications

The incidence of complications varies sub-stantially depending on the surgical technique. Arthrodesis is considered a relatively safe procedure: nonunion, infection, or other adverse events occur in approximately 5-13% of patients overall. In contrast, arthroplasty is associated with higher complication rates, depending on the implant type. Silicone implants are linked to complications in 10-11% of cases, whereas pyrocarbon implants show rates of 14-18% at a mean follow-up of 5 years. In primary studies with longer follow-up included in the analyzed reviews, complication rates for pyrocarbon implants increased to 30-40%. Reported issues include instability, implant subsidence or protrusion, and wear. Metal-polyethylene prostheses demonstrated complication rates comparable to silicone implants (approximately 10%). Typical adverse events following arthroplasty include extension contracture (including 11% of cases presenting as swan-neck deformity after a dorsal approach), implant dislocation or failure, and reactive synovitis. Overall, contemporary systematic reviews do not confirm any advantage of pyrocarbon implants over silicone implants; on the contrary, complication rates appear substantially higher with pyrocarbon implants. Hemi-hamate arthroplasty is associated with complications (e.g., graft nonunion or migration) in 26-35% of cases, although not all complications require revision surgery. Selective denervation results in complications in approximately 17-18% of patients (neuroma formation, hyperesthesia, or lack of clinical effect). For surgical release of PIPJ contracture, the reported complication rate ranges from 15% to 20%.

Re-operations and implant survival

The risk of revision surgery is a key indicator of procedural reliability. Following PIPJ arthrodesis, repeated interventions are quite rare; therefore, this procedure is generally considered a definitive solution. In contrast, after PIPJ arthroplasty, the likelihood of revision increases over time. According to pooled data, 6-10% of patients require implant replacement or conversion to arthrodesis within the first 5 years after silicone implant placement, whereas after pyrocarbon implantation this rate reaches 14-26%. The reported survival of silicone implants ran-ges from 85% to 94% at 3-5 years, compared with approximately 74-86% for pyrocarbon prostheses. Newer metal-polyethylene implants demonstrate intermediate outcomes, with 77-80% revision-free survival at 4-5 years. After hemi-hamate arthroplasty, conversion to arthrodesis was required only in isolated cases during mid-term follow-up. Similarly, after isolated joint denervation, only about 10% of patients subsequently required arthrodesis due to recurrent pain. Direct comparative studies between different surgical techniques are virtually absent. The included reviews identified only one randomized controlled trial comparing three types of PIPJ prostheses. Therefore, the above comparison of treatment modalities is based predominantly on unrelated retrospective case series. Consolidated outcome data for the various intervention types are presented in Table 5.

 

Table 5

Consolidated outcome data

Intervention	Final ROM, deg.	Δ ROM, deg.	Final VAS	Δ VAS	Complications, %	Revisions, %	Implant survival, %
Arthrodesis	0	—	0-1	6-9	5-13	Rare	—
Arthroplasty — silicone	50-60	+10-17	2	4	10-11	6-10	85-94
Arthroplasty — pyrocarbon	45-55	+8-10	2	4	14-18 (< 40%)	14-26	74-86
Arthroplasty — metal-polyethylene	45-55	—	2	—	10	14-26	77-80
Hemi-hamate arthroplasty	74	+48	2	—	26-35	Rare	—
PIPJ denervation	Improvement	—	0-1	6-9	17-18	10	—
Mobilizing procedures	Improvement	—	—	—	15-20	—	—

 

DISCUSSION

In this umbrella review, the outcomes of various surgical treatment methods for PIPJ pathology of the fingers were compared based on previously published systematic reviews.

Arthrodesis provides reliable pain relief and joint stability, confirming its role as the gold standard in cases of severe osteoarthritis, particularly in the index finger [53]. However, this benefit comes at the cost of complete loss of joint motion. In contrast, arthroplasty preserves joint mobility and may improve upper limb function (e.g., grip performance), but it is associated with a higher risk of complications and limited implant survival. Based on pooled data from systematic reviews, silicone PIPJ prostheses demonstrated the most favorable balance between effectiveness and reliability — they significantly reduce pain, restore a moderate range of motion, and show acceptable durability. Pyrocarbon implants, despite their theoretical advantages (strength, elasticity, and biocompatibility), have not outperformed silicone prostheses in clinical practice. On the contrary, there is a trend toward higher complication and revision rates with pyrocarbon devices [34, 44, 54].

Other surgical options occupy more narrowly defined indications. Hemi-hamate arthroplasty has shown favorable outcomes in patients with post-traumatic articular defects of the base of the middle phalanx, providing greater restoration of motion and, in selected cases, near-normal functional recovery [23, 40, 50]. However, this technique is applicable only in specific clinical scenarios (chronic dorsal fracture-dislocations of the base of the middle phalanx) and requires advanced surgical expertise. Joint denervation represents a palliative option for patients with osteoarthritis who retain an acceptable range of motion but experience pronounced pain and who lack clear indications for arthroplasty or arthrodesis [22, 55]. It offers substantial pain relief and may delay more radical procedures, although it does not definitively replace them. Mobilizing procedures for post-traumatic contractures are effective in improving joint motion, but their success is often limited. While extension frequently improves substantially, full restoration of flexion is rarely achieved because of irreversible soft-tissue changes. Nevertheless, in the absence of advanced osteoarthritis, such techniques may restore meaningful joint mobility.

Insufficient methodological rigor in the available literature substantially affects the interpretation of results. All included systematic reviews were based predominantly on retrospective case series (Level IV evidence according to the OCEBM). One review explicitly stated that the evidence supporting PIPJ arthroplasty is of low methodological quality. Only a single prospective randomized controlled trial comparing different types of prostheses was identified; therefore, direct comparisons between alternative approaches (e.g., arthrodesis versus arthroplasty) are lacking, and a quantitative meta-analysis is not feasible [34].

The present umbrella review is therefore based on indirect comparisons across separate bodies of evidence. Different authors used highly heterogeneous outcome measures (33 unique outcomes and 18 distinct assessment tools in one review), which prevents meaningful data pooling. Substantial heterogeneity in measured outcomes and evaluation methods has been specifically documented in studies on PIPJ arthroplasty [52]. The risk of bias must also be considered. Many reviews, particularly older ones, demonstrated methodological disadvantages, including incomplete search strategies, the lack of a registered protocol, and insufficient assessment of the quality of included studies, potentially leading to the overestimation of treatment effectiveness. More recent reviews applying ROBIS and AMSTAR 2 have identified high risks of bias in the underlying primary studies (e.g., nonblinded outcome assessment, conflicts of interest involving implant developers, etc.). Accordingly, the synthesized findings of this umbrella review should be interpreted with caution. Nevertheless, the consistency of conclusions on key issues (for example, the absence of demonstrated superiority of pyrocarbon over silicone implants) supports the formulation of certain practical recommendations.

For clinical practice, the findings of this review indicate that the management of PIPJ pathology should be individualized. There is no universally “best” procedure — each option has distinct advantages and limitations. Decision-making should consider the underlying pathology, the affected finger (for example, arthrodesis may be more appropriate for the index finger, whereas arthroplasty may be preferable for the middle and ring fingers to preserve grip function), as well as patient-speci-fic demands (level of physical activity, required range of motion). Silicone implants remain the most predictable option for PIPJ arthroplasty in osteoarthritis. Pyrocarbon prostheses have not demonstrated clear advantages and therefore should be used cautiously, preferably within further clinical research. In young patients with partial articular defects of the base of the middle phalanx, hemi-hamate arthroplasty appears to be a promising option. In cases where joint motion is not critical (or in inflammatory/rheumatoid conditions), arthrodesis provides reliable pain relief and eliminates the need for future revision procedures. It should be emphasized that PIPJ arthroplasty does not yield functional improvements comparable to large joint replacement and provides only partial restoration of joint motion.

Further high-quality research is needed to develop more definitive recommendations. In particular, prospective comparative studies (randomized controlled trials and multicenter registry-based analyses) directly comparing arthrodesis and different types of PIPJ arthroplasty in homogeneous patient popula-tions are required. There is also a clear need for the standardization of outcome assessment: the development and implementation of a core outcome set would allow meaningful compari-son and the pooling of data across studies. At present, surgeons must rely on the evidence of limited methodological strength and their own clinical experience. The present umbrella review aims to facilitate decision-making by consolidating fragmented data. It demon-strates that arthrodesis continues to provide the highest rates of pain relief and stability, whereas arthroplasty offers greater preserva-tion of motion but carries a higher risk of com-plications. The choice between these approaches should be guided by individual patient preferences and specific clinical scenario. Patients should be informed about these trade-offs: arthroplasty does not fully restore normal joint motion and may require revision in the future, whereas arthrodesis permanently sacrifices mobility but offers definitive pain relief.

CONCLUSIONS

Surgical treatment methods for the sequelae of the proximal interphalangeal joint injuries of the fingers yield heterogeneous clinical outcomes and are associated with different complication risks. Therefore, the choice of the optimal procedure depends on the spe-cific clinical scenario. Arthrodesis remains the treatment of choice in cases of advanced osteo-arthritis and low functional demands. In joint arthroplasty, silicone implants represent the most reliable option. Hemi-hamate arthro-plasty and mobilizing procedures have limited indications and should be applied in carefully selected clinical situations.

The low overall level of evidence, the absence of direct comparisons between various treatment strategies, and the heterogeneity of reported outcomes underscore the need for prospective comparative studies and standardized core outcome sets. Without such data, the optimiza-tion of treatment algorithms for chronic proxi-mal interphalangeal joint pathology remains unattainable.

DISCLAIMERS

Author contribution

Malyshev V.I. — study concept and design, data analysis and interpretation, drafting and editing the manuscript.

Rodomanova L.A. — scientific guidance, study concept and design, data analysis and interpretation, editing the manuscript.

Tsybul E.S. — data acquisition, analysis and interpretation, editing the manuscript.

Mironov A.R. — data acquisition, editing the manuscript.

All authors have read and approved the final version of the manuscript of the article. All authors agree to bear responsibility for all aspects of the study to ensure proper consideration and resolution of all possible issues related to the correctness and reliability of any part of the work.

Funding source. This study was not supported by any external sources of funding.

Disclosure competing interests. The authors declare that they have no competing interests.

Ethics approval. Not applicable.

Consent for publication. Not required.

Use of artificial intelligence. No generative artificial intelligence technologies were used in the preparation of this manuscript.

About the authors

Vladislav I. Malyshev

Vreden National Medical Research Center of Traumatology and Orthopedics

Author for correspondence.
Email: trauma@malyshevdoc.ru
ORCID iD: 0009-0003-4609-7506
SPIN-code: 7222-7263
Russian Federation, St. Petersburg

Lyubov A. Rodomanova

Vreden National Medical Research Center of Traumatology and Orthopedics

Email: rodomanovaliubov@yandex.ru
ORCID iD: 0000-0003-2402-7307
SPIN-code: 3227-4457

Dr. Sci. (Med.), Professor

Russian Federation, St. Petersburg

Evgeny S. Tsybul

Vreden National Medical Research Center of Traumatology and Orthopedics

Email: na4med@inbox.ru
ORCID iD: 0009-0001-8105-3635
SPIN-code: 4744-7478

Cand. Sci. (Med.)

Russian Federation, St. Petersburg

Artem R. Mironov

Vreden National Medical Research Center of Traumatology and Orthopedics

Email: ortopedix@yandex.ru
ORCID iD: 0009-0001-9273-8680
Russian Federation, St. Petersburg

References

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