Osteochondral autograft from the second toe for complex proximal interphalangeal joint fracture-dislocations: a case report and literature review

Introduction

Fracture-dislocations of the proximal interphalangeal (PIP) joint are notoriously challenging to manage (1), posing a significant risk of long-term stiffness and deformity regardless of the treatment method employed (2). These injuries predominantly occur in young to middle-aged males, often resulting from hyperextension or axial loading forces during sports activities (3). Fractures involving less than 30% of the articular surface can typically be managed non-surgically using closed reduction and splinting (3). However, when greater articular surface involvement and comminution are present, these injuries frequently result in instability, necessitating surgical intervention. Surgical options include dynamic traction with external fixation, palmar plate arthroplasty, and open reduction with internal fixation (4).

For fractures involving more than 30% of the articular surface with significant comminution, PIP joint reconstruction using an osteochondral autograft is often considered (5). While the original technique utilised a distal radial donor site, it has largely been replaced by the hemi-hamate autograft (6). This method enables the reconstruction of comminuted PIP joint fractures while restoring the cup-shaped contour of the middle phalangeal base. However, harvesting the hemi-hamate autograft presents challenges, particularly in recreating the anterior lip, and carries risks such as donor site instability, injury to the metacarpal bases of the ring and little fingers, and damage to the dorsal branch of the ulnar nerve (7). Furthermore, a systematic review with long-term follow-up indicates that up to 50% of hemi-hamate arthroplasty patients develop early-onset osteoarthritis (5).

While hemi-hamate arthroplasty is commonly used for reconstructing PIP joint fractures affecting the base of the middle phalanx, there is a lack of literature discussing the approach to PIP joint fractures involving the head of the proximal phalanx. The current study elucidates a nascent approach for restoring the intricate fracture-dislocation pattern of the PIP joint involving proximal phalanx head fractures. Specifically, this technique employs the head of the second toe proximal phalanx as an autograft for reconstruction. This technique has been rarely investigated and, with success noted in this case, further large-scale prospective studies are warranted.

A comprehensive literature search was conducted up to May 2024 across multiple databases, including PubMed, Embase, Cochrane Library, Scopus, and Web of Science, to identify relevant studies on osteochondral autografts for PIP joint fracture-dislocations. The search strategy employed a combination of Medical Subject Headings (MeSH) terms and keywords such as “Proximal Interphalangeal Joint”, “PIP Joint”, “Fracture-Dislocation”, “Osteochondral Graft”, “Autograft”, “Second Toe”, “Phalanx”, “Hand Surgery”, and “Joint Reconstruction”, using Boolean operators to ensure thorough retrieval of relevant articles. The search was limited to articles published in English and involved human subjects. Studies included in the review comprised case reports, case series, clinical trials, and reviews focusing on osteochondral autografts for PIP joint fracture dislocations. Exclusion criteria encompassed studies involving animals or cadaveric models, articles unavailable in English, and those focusing on other joints or non-osteochondral grafts. Details of all previous related studies can be seen in Table 1 (8,9). Written informed consent was obtained from the patient prior to the surgical procedure, which included a thorough explanation of the technique, potential risks, benefits, and alternative options. We present this article in accordance with the CARE reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-25/rc).

Case presentation

A 49-year-old, right-hand dominant male carpenter presented to the emergency department with a traumatic laceration to the dorsum of his right index finger PIP joint. The injury was sustained while using a circular saw, resulting in an open, comminuted, intra-articular fracture of the head of the proximal phalanx. The fracture involved approximately 50% of the articular surface and significant bony loss of the ulnar condyle (Figure 1).

Figure 1 Overview of the patient’s PIP joint injury. (A) Macroscopic view of right index finger dorsal PIP joint laceration with open comminuted fracture of the head of the proximal phalanx. (B) Anterior-posterior x-ray view of the right hand. (C) Lateral X-ray view of the right index finger. PIP, proximal interphalangeal.

The patient had an unremarkable medical history, was a non-smoker, and reported occasional alcohol consumption. Upon presentation, the patient was promptly taken to the operating theatre for the initial stage of a two-stage reconstructive approach, necessitated by the contaminated nature of the traumatic wound. An extensive debridement and exploratory procedure were performed. The extensor digitorum communis and central slip tendon were intact and satisfactory. The extensor digitorum communis and central slip tendon were intact and satisfactory. The further assessment confirmed an intra-articular fracture of the PIP joint of the right index finger, with a 50% bony defect located at the ulnar condyle involving the head of the proximal phalanx. The wound edges were debrided, and the wound was thoroughly irrigated, followed by temporary closure with nylon sutures. Postoperatively, the patient underwent computerised tomography (CT) guided 3D reconstruction of the right index finger to assist with surgical planning (Figure 2).

Figure 2 Computerised tomography scan with three-dimensional reconstruction of the right index finger metacarpal and phalanges.

The patient returned to the operating theatre three days later for a definitive reconstructive procedure. The reconstructive approach was via the initial dorsal wound; the extensor mechanism was incised longitudinally and retracted to provide exposure to the fracture. The fracture fragments and head of the proximal phalanx were then debrided, and the dimensions of the defect were measured to create a template for the osteochondral graft (Figure 3). The autograft procedure was conducted through a dorsal longitudinal incision over the PIP joint of the right second toe. The lateral bands were incised longitudinally and retracted, allowing the isolation of the central slip at its insertion site at the base of the middle phalanx. Following the template obtained earlier from the bony defect, an osteotomy was performed through the neck of the proximal phalanx using a bone saw and osteotome, harvesting the entire phalangeal head with a small split of the extensor tendon (Figure 4). The PIP joint was then fused in a neutral position by inserting a single percutaneous, axial 1.2-mm Kirchner wire. The lateral bands were then repositioned and repaired. The wound was closed using plain gut sutures, and the foot was immobilised in a Plaster of Paris cast with the ankle in a neutral position.

Figure 3 Exposure of the defect in the head of the index finger proximal phalanx.

Figure 4 Right second toe proximal phalanx head osteochondral graft and it’s inset into the right index finger proximal phalanx defect.

A combination of bone saws and burrs was used to shape the osteochondral graft to fit the dorsal ulnar defect in the proximal phalanx of the index finger. The graft was then fixed to the defect using two 1.2-mm cortical screws (Figure 5). The positioning of the graft was confirmed via an intraoperative image intensifier (Figure 6). The skin was closed with nylon sutures, and the hand was dressed and placed in a Plaster of Paris in a position of safe immobilisation.

Figure 5 Intraoperative imaging confirming internal fixation of the osteochondral graft.

Figure 6 Twelve months postoperative image of range of motion of right index finger.

The patient demonstrated good postoperative recovery and was discharged after two days. At the two-week follow-up, the nylon sutures were removed, and the wound exhibited satisfactory healing without any indication of infection. The patient’s active range of motion at the PIP joint was measured as 44 degrees of flexion and 72 degrees of extension, with 5 out of 10 pain reported during active range of motion and no pain at rest. At six weeks postoperatively, the active range of motion at the PIP joint improved to 34 degrees of extension and 84 degrees of flexion, with no pain at rest or during movement. The patient completed the disability of the arm, shoulder, and hand questionnaire, which resulted in a score of 29.3, indicating minimal finger disability. At eight weeks postoperatively, the Kirchner wire (Figure 7) was removed from the right second toe with no complications.

Figure 7 Postoperative X-ray of the right foot with K-wire.

The patient resumed work three months postoperatively, initially experiencing increased tenderness in the right second toe and index finger, which subsided with regular analgesia. The patient continued hand therapy as he became more active. At six months postoperatively, the patient’s active composite range of motion at the PIP joint was 24 degrees during extension and 80 degrees during flexion, and at 12 months, he was at 45 degrees extension and 100 degrees flexion. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committees and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The second toe proximal phalanx osteochondral graft represents an innovative approach to treating unstable dorsal PIP joint fracture-dislocations to achieve joint stability and rigid graft fixation. This technique involves the strategic harvest of osteochondral tissue from the base of the second toe, thereby preserving native joint stabilisers during transplantation to the compromised PIP joint. Despite its promise, the procedure necessitates meticulous patient selection and preoperative planning to mitigate risks like donor site morbidity, which may manifest as pain or stiffness. Additionally, it may not be well-suited for individuals with co-existing conditions like peripheral vascular disease or diabetes, which could complicate wound healing and elevate the risk for postoperative complications (10). While the technique may incur higher costs due to the need for specialised expertise, the ultimate choice of this method over alternative options—such as costal osteochondral grafts, hamate osteochondral grafts, or osteochondral autograft transplantation—should be predicated on an individualised assessment encompassing medical history, fracture specifics, and economic considerations. Given the procedure’s nascent stage, further research is imperative for evaluating its long-term efficacy and safety.

This study added to the evidence as a promising method of utilising the proximal phalanx from the second toe as an osteochondral autograft to reconstruct PIP joint fracture-dislocation. The patient who underwent this reconstruction achieved successful union, satisfactory range of movement, favourable hand function and patient-reported outcomes. Osteochondral autograft is a well-described method of reconstruction used for PIP joint fracture-dislocation with more than 50% involvement of the volar base of the middle phalanx. One of the primary challenges in phalangeal base fractures is the reconstruction of the anterior lip, which is critical in preventing recurring dorsal subluxation (11).

The hemi-hamate arthroplasty is typically described as the donor of choice for fractures of the PIP joint (11). Other sites for autograft donors described in the literature include the capitate (8), costal cartilage (12), and the second toe middle phalanx (8). The fracture pattern observed in this case is atypical, as it involves the head of the phalanx. Such fractures are relatively uncommon, accounting for only 6% of all phalangeal fractures. By contrast, fractures involving the base of the phalanx are much more prevalent, comprising 32% of all phalangeal fractures (13). Due to the anatomical differences between the base of the middle phalanx and the head of the proximal phalanx, considerations such as reconstructing the anterior lip were less relevant to our case. Due to their relatively low incidence, information on the reconstruction of traumatic proximal phalanx head fractures is limited, with one case series reporting the use of the base of the little finger metacarpal as a possible donor (14).

In addition to the atypical fracture pattern, an extensor surface wound was a confounding factor in the surgical approach. The usual exposure method in these cases involves placing the PIP joint in extreme hyper-flexion, so-called “shotgunning” the joint (9,10); this avoids disruption of the flimsier extensor mechanism and facilitates an earlier active range of motion (15). As the patient already had a dorsal laceration from the initial injury, we made our approach via an extension of this original wound rather than violating the intact flexor surface. The second toe proximal phalanx donor was chosen to provide greater bone stock than the hemi-hamate and costal cartilage with rib donors, which has been hypothesised to delay the development of osteoarthritis (14). Additionally, the head of the second toe proximal phalanx provides a more anatomical bony reconstruction of the ulnar condyle, allowing greater articulation with the concave base of the middle phalanx. Finally, the chosen method allowed simultaneous preparation of the recipient and harvest of the donor site, reducing total operative time. One notable disadvantage of the second toe autograft is the restriction on the patient’s mobility due to the need to immobilise the foot and ankle postoperatively. In our case, the patient had his K-wire removed at eight weeks and reported some discomfort in his toe during this period and several weeks after wire removal while gradually returning to normal daily activities.

The patient’s age, hand dominance, and occupation were significant factors that influenced the decision regarding the reconstructive approach. The primary objective was to re-establish stability in the PIP joint and enable the patient to have a functional range of motion. After accounting for the degree of flessum, the patient attained a PIP joint range of motion from 24 degrees of extension to 80 degrees of flexion, which falls well within the 71 to 94 degrees range reported in a comprehensive review of over 100 cases that utilised hemi-hamate arthroplasty (5,16). However, since the follow-up period was relatively short, it was impossible to reliably evaluate other pertinent outcomes, such as grip strength and the development of osteoarthritis.

This case report highlights using an osteochondral autograft from the second toe for managing complex PIP joint fracture-dislocations, presenting several strengths and limitations. The novel technique demonstrated successful graft integration, enhanced range of motion, and high patient satisfaction, suggesting its feasibility as a new treatment method. The report provides detailed surgical and postoperative information, offering valuable insights and contributing significantly to the current literature. Furthermore, the comprehensive literature review situates the case within the broader context of existing medical knowledge, underscoring the need for additional research. However, the study’s limitations include reliance on a single case, limiting generalizability, and the relatively short follow-up period, which may not capture long-term outcomes such as osteoarthritis. Additionally, potential donor site morbidity, including pain and mobility restrictions, poses a significant concern. The lack of comparative data with established techniques, such as hemi-hamate arthroplasty, hinders a thorough evaluation of this method’s relative advantages and disadvantages. Moreover, the specialised surgical expertise and equipment requirements may restrict the technique’s widespread adoption. Further large-scale, prospective studies with extended follow-up are essential to ascertain this novel approach’s efficacy and safety fully.

Conclusions

This report presents one of the initial documented cases of utilising a second toe osteochondral autograft for the reconstruction of an open, comminuted, intra-articular fracture of the proximal phalanx head of the index finger caused by trauma. This case exemplifies the possible advantages of utilising a second toe autograft compared to the conventional hemi-hamate autograft for fracture-dislocations of the PIP joint, mainly when the proximal phalanx head is involved, which has been scarcely studied. Although limitations exist, such as postoperative mobility restrictions, the patient achieved excellent functional outcomes and resumed daily activities and work. This case contributes to the mounting literature on osteochondral grafting, suggesting that it may be a feasible treatment approach for intricate small joint fractures of the hand. However, further research with long-term follow-up is required to determine this technique’s potential complications and outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-25/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-25/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-25/coif). I.S. serves as an unpaid editorial board member of Annals of Joint from September 2023 to August 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committees and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Kamnerdnakta S, Huetteman HE, Chung KC. Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment. Hand Clin 2018;34:267-88. [Crossref] [PubMed]
2. Elfar J, Mann T. Fracture-dislocations of the proximal interphalangeal joint. J Am Acad Orthop Surg 2013;21:88-98. [Crossref] [PubMed]
3. Freiberg A. Management of proximal interphalangeal joint injuries. Can J Plast Surg 2007;15:199-203. [Crossref] [PubMed]
4. Lee JY, Teoh LC. Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results. J Hand Surg Br 2006;31:138-46. [Crossref] [PubMed]
5. Frueh FS, Calcagni M, Lindenblatt N. The hemi-hamate autograft arthroplasty in proximal interphalangeal joint reconstruction: a systematic review. J Hand Surg Eur Vol 2015;40:24-32. [Crossref] [PubMed]
6. Faulkner H, Graham DJ, Hile M, et al. Hemi-hamate Arthroplasty for Base of Middle Phalanx Fracture: A Systematic Review. Hand (N Y) 2023;18:300-6. [Crossref] [PubMed]
7. DeNoble PH, Record NC. A Modification to Simplify the Harvest of a Hemi-hamate Autograft. J Hand Surg Am 2016;41:e99-e102. [Crossref] [PubMed]
8. Bond EC, Matenga M. B M MacLean S. Hamate vs. capitate grafting for proximal interphalangeal joint fracture-dislocation: an MRI-based study of 35 hands. J Hand Surg Eur Vol 2022;47:755-60. [Crossref] [PubMed]
9. Nizzero D, Tang N, Leong J. A novel technique for proximal interphalangeal joint fracture-dislocations: the second toe middle phalanx osteochondral graft. J Hand Surg Eur Vol 2021;46:941-5. [Crossref] [PubMed]
10. Morisaki K, Yamaoka T, Iwasa K. Risk factors for wound complications and 30-day mortality after major lower limb amputations in patients with peripheral arterial disease. Vascular 2018;26:12-7. [Crossref] [PubMed]
11. Williams RM, Kiefhaber TR, Sommerkamp TG, et al. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 2003;28:856-65. [Crossref] [PubMed]
12. Hasegawa T, Yamano Y. Arthroplasty of the proximal interphalangeal joint using costal cartilage grafts. J Hand Surg Br 1992;17:583-5. [Crossref] [PubMed]
13. Moura SP, Meulendijks MZ, Veeramani A, et al. Epidemiology and Fracture Patterns of Traumatic Phalangeal Fractures. Plast Reconstr Surg Glob Open 2022;10:e4455. [Crossref] [PubMed]
14. Cavadas PC, Landin L, Thione A. Reconstruction of the condyles of the proximal phalanx with osteochondral grafts from the ulnar base of the little finger metacarpal. J Hand Surg Am 2010;35:1275-81. [Crossref] [PubMed]
15. Duncan SFM, Smith AA, Renfree KJ, et al. Results of the Volar Approach in Proximal Interphalangeal Joint Arthroplasty. J Hand Surg Asian Pac Vol 2018;23:26-32. [Crossref] [PubMed]
16. Phan R, Xie Y, Seth I, et al. Free hemi-hamate arthroplasty: A review of donor site outcomes. JPRAS Open 2024;40:206-14. [Crossref] [PubMed]