The Relationship Between Hemihamate Graft Size and Proximal Interphalangeal Joint Flexion for Reconstruction of Fracture-Dislocations: A Biomechanical Study

Purpose: The purpose of this study was to determine the relationship between hemihamate graft size and proximal interphalangeal (PIP) joint flexion in a biomechanical fracture-dislocation model. Methods: We simulated middle finger PIP fracture-dislocations in 5 cadaver hands by resecting 50% of the palmar articular surface of the middle phalanx (P2) base. Fluoroscopy was used to confirm dorsal subluxation of the middle phalanx base after resection. A 10-mm osteochondral hamate graft was contoured to reconstruct the volar lip of the middle phalanx and was progressively downsized by 2-mm increments for each trial. A computer-controlled articulator and jig simulated active flexion and extension of the fingers. Maximum PIP flexion was measured at each graft size using fluoroscopy and digital imaging software. Clinically significant flexion block was defined as PIP flexion less than 90°. Results: The actual mean size of the volar defect created was 52% (3.5 mm) of the middle phalanx articular surface, which created instability and dorsal subluxation in all tested fingers. After hemihamate reconstruction, all specimens were stable throughout flexion and extension for all graft sizes. A flexion block of 90° occurred at a mean graft size of 191% of the defect (6.5 mm). With regard to the volar lip of the P2, grafts that projected an average 0.8 mm past the native volar lip position had 98° (range, 84°–107°) maximum PIP flexion. Grafts that projected an average of 3.1 mm past the native volar lip position had 90° (range, 69°–100°) maximum PIP flexion. Linear regression modeling incorporating all of the results predicted flexion block to occur at a graft size as small as 166% of the 50% volar P2 defect. In this model, for every 50% (1.7-mm) increase in graft size relative to the defect, PIP flexion decreased by approximately 6°. Conclusions: Nonanatomical hemihamate grafts produce a PIP flexion block at extreme sizes, predicted to occur at greater than 166% of a 50% P2 base articular defect in our model. This suggests that relatively large grafts can be used for reconstruction of PIP fracture-dislocations without substantial biomechanical block to PIP flexion. We suggest sizing no larger than 3 mm past the native P2 volar lip position to avoid an important mechanical block to PIP flexion. Clinical relevance: The information from this study helps surgeons understand how large a hemihamate graft can be used for P2 volar base reconstruction before having a negative impact on PIP flexion.