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Again, referring to Tables 33-1 through 33-3, one can see that bone and joint procedures are the second most common secondary operations. With respect to joint reconstruction, Foucher has pointed out that reconstructive options for joint reconstruction seldom succeed in restoring normal motion; however, acceptable improvement in motion at key joints may allow marked improvement in global hand function.50 Capsulotomies and selective arthroplasties of the PIP joint may be performed at the same time as flexor or extensor tenolysis, as mentioned above. Ideally, one would prefer to perform silastic arthroplasties through independent dorsal incisions; however, a volar approach may be more logical when the site of the fused joint is exposed during a flexor tenolysis. Capsulotomy, capsulorrhaphy, and freeing or reconstruction of the volar plate can be simultaneously accomplished if reasonable articular surfaces remain. Autogenous vascularized joint transplants51 are indicated in selected cases to replace the MP or PIP joint with MT, PIP or DIP joints from the toes.52,53 Because of the complexity of these transplant procedures, they are used for single key joints in young people, for a flail thumb, or a fused MP or PIP of the index or another digit when several digits are injured or missing.50 Also, a fused single joint in an otherwise normal hand may warrant this approach. The results may often be dramatic from a functional and aesthetic standpoint, as can be seen in the section on vascularized joint transplants.
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Rotational osteotomies, bone grafts for nonunion, ray transpositions, and ray amputations constitute the bulk of secondary bone operations (Table 33-3).4,18 Scissoring of replanted digits is not uncommon, resulting from faulty initial bony alignment or the secondary loss of position during healing, with bony absorption, delayed union, fracture instability or reinjury.54 Initial bone stock may be poor because of the destructive force of the primary injury. Because replant survival takes precedence over bone carpentry, proper alignment and bony union must often be managed secondarily. The advent of sophisticated miniplating techniques has improved the precision of such secondary operations, particularly on the metacarpals and proximal phalanxes.47,48,55,66 Accurate secondary alignment is paramount, and results can be improved by attention to details worked out in instructional courses and cadaver dissections. The classical use of tailored intramedullary bone grafts with simple wire or screw fixation, 2,57 however, should not be abandoned for elaborate metallic devices that take up critical space and destroy periosteal blood supply.48
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