Joint replacement is an established method in the treatment of destroyed, painful, proximal interphalangeal joints. A palmar approach was used in which the main collateral ligaments were preserved, allowing immediate active rehabilitation with enhanced primary lateral stability. Fifty-nine proximal interphalangeal joint silicone arthroplasties in 38 patients with a minimum followup of 12 months were reviewed. Thirty-eight of the 59 joints had implantation from a palmar approach and 21 joints from a dorsal approach. The two groups were well-matched in terms of indication, preoperative range of motion, and patient age. No significant increase in the range of motion was found in either of the patient groups, with an overall average range of motion of 51 degrees postoperatively. There was also no significant difference in the postoperative stability in the two patient groups. The choice of surgical approach at the proximal interphalangeal joint level for the silastic type of implants does not appear to be important. With more sophisticated types of implants in which the integrity of the collateral ligaments is crucial, a palmar approach might be beneficial.