Standardized Volar Silicone PIP Arthroplasty: Bilateral Proximal Collateral Release and a Structured Non-Repair...

Silicone arthroplasty of the proximal interphalangeal joint is traditionally performed through a dorsal approach, which requires violation of the extensor mechanism and may contribute to postoperative stiffness and extension lag. Volar approaches preserve the extensor apparatus and permit earlier active mobilization; however, previously described techniques differ in flexor sheath entry, volar plate management, and collateral ligament handling, limiting reproducibility. We describe a standardized volar technique that emphasizes controlled neurovascular mobilization; elevation of the A3 pulley as a laterally based flap (preserving A2 and A4); proximal disinsertion of the volar plate while maintaining its distal attachment; and bilateral complete proximal detachment of the proper collateral ligaments to achieve symmetric "shotgun" exposure. This collateral release corrects asymmetric ligament elongation or contracture in arthritic and post-traumatic deformities, restores coronal balance, and facilitates centered implant placement. Flexor tendons are retracted without division. After canal preparation and implant insertion, axial alignment and coronal and sagittal stability are assessed throughout the flexion-extension arc. The volar plate and collateral ligaments are not routinely repaired. Postoperative stability relies on implant-centered alignment and progressive peri-implant capsular fibrosis, with support from temporary buddy taping. This technique provides reproducible exposure while also serving as a structured soft-tissue rebalancing strategy. Clinical application should be limited to cases in which soft tissue balance can be restored and implant-centered stability achieved intraoperatively.