Superficial exposure:

Make a longitudinal or transverse incision dorsal to the digital interphalangeal joint to be fused. Careful and meticulous dissection is carried out to avoid violation of the neurovascular structures. (*Incision is surgeon’s preference)

Deep exposure:

Perform a release of the extensor sling and wing. A transverse or z-plasty tenotomy is then performed on the extensor tendon with reflection distally and proximally. Release the collateral ligaments laterally and medially. If fusing the DIPJ care should be taken to meticulously reflect the extensor tendon distal to the flare of the base for exposure.

Joint preparation:

Use a sagittal or oscillating saw to remove the head of the proximal phalanx and base of the middle phalanx for a PIPJ fusion or the head of the middle phalanx and base of the distal phalanx for a DIPJ fusion. Remove any soft tissue or osseous interference. Fenestration is performed at the joint ends utilizing a 0.035 Kirschner wire (k-wire) using a drill and k-wire driver.

Kirschner Wire (K-Wire) Placement:

A drill with k-wire driver is used to drive the wire in a retrograde manner centrally through the middle and distal phalanges. The wire is then driven through the proximal phalanx centrally without entering subchondral bone. *This process is performed whether fusing the DIPJ or PIPJ. Care should be taken at this stage to ensure compression of the bone ends.

After staple placement the k-wire may be removed if substantial stability for fusion is determined intraoperatively by the surgeon.

ReignMedical Clench Compression Staple Insertion:

Refer to the ReignMedical Clench staple op tech guide for insertion. The staple may be placed diagonally or parallel to the temporary k-wire fixation. A two staple parallel placement technique may be used for larger patients with increased phalange all surface areas.

Kirschner Wire (K-Wire) Utilization:

Preferably the k-wire is marked with a pin at the distal insertion point of the digit. The wire is then pulled distally 3 mm and then cut flush with the skin with a wire cutter. A mallet and tamp is used to bury the wire and the pin site closed with a non-absorbable simple interrupted stitch.

The k-wire may be driven across the metatarsophalangeal joint if an arthrotomy is performed to further maintain stability. *The wire may be bent with a frazier tip and kocher and left exposed in this scenario with a pin cap placed.

Procedure Pearls:

• Preoperative films may help determine the size of the staple utilized by measuring the distal phalanx to the flare of the proximal phalanx head. Generally a 7 mm x 5 mm staple is used.

• The staple may be placed with a straight or curved hemostat if the anatomical phalangeal size is reduced preventing placement with the staple insertion device.

• A trough to further depress the staple may be produced with a small saw if the surgeon anticipates irritation from the implant to tendon/skin interface.

Post operative management:

1. Sterile compressive dressing applied wit the fused digit or digital alignment maintained.

2. Cast boot or surgical shoe applied for 6 weeks.

3. Radiographs are taken immediately post op and at 3 and 6 weeks.

4. Stitches are removed at 14 days if appropriate.

5. K-Wire or wires may be removed at 6 weeks or held in place for 12 weeks if buried intra operatively and are unexposed.

6. Regular activity can be initiated at 6 - 8 weeks with a stable shoe.